Better evidence: prospective cohort study assessing the utility of an evidence-based clinical resource at the University of Rwanda.

OBJECTIVE: Evidence-based clinical resources (EBCRs) have the potential to improve diagnostic and therapeutic accuracy. The majority of US teaching medical institutions have incorporated them into clinical training. Many EBCRs are subscription based, and their cost is prohibitive for most clinicians and trainees in low-income and middle-income countries. We sought to determine the utility of EBCRs in an East African medical school. SETTING: The University of Rwanda (UR), a medical school located in East Africa. PARTICIPANTS: Medical students and faculty members at UR. INTERVENTIONS: We offered medical students and faculty at UR free access to UpToDate, a leading EBCR and conducted a cohort study to assess its uptake and usage. Students completed two surveys on their study habits and gave us permission to access their activity on UpToDate and their grades. RESULTS: Of the 980 medical students invited to enrol over 2 years, 547 did (56%). Of eligible final year students, 88% enrolled. At baseline, 92% of students reported ownership of an internet-capable device, and the majority indicated using free online resources frequently for medical education. Enrolled final year students viewed, on average, 1.24 topics per day and continued to use UpToDate frequently after graduation from medical school. Graduating class exam performance was better after introduction of UpToDate than in previous years. CONCLUSIONS: Removal of the cost barrier was sufficient to generate high uptake of a leading EBCR by senior medical students and habituate them to continued usage after graduation.

Evidence-based medicine for all: what we can learn from a programme providing free access to an online clinical resource to health workers in resource-limited settings.

The rapidly changing landscape of medical knowledge and guidelines requires health professionals to have immediate access to current, reliable clinical resources. Access to evidence is instrumental in reducing diagnostic errors and generating better health outcomes. UpToDate, a leading evidence-based clinical resource is used extensively in the USA and other regions of the world and has been linked to lower mortality and length of stay in US hospitals. In 2009, the Global Health Delivery Project collaborated with UpToDate to provide free subscriptions to qualifying health workers in resource-limited settings. We evaluated the provision of UpToDate access to health workers by analysing their usage patterns. Since 2009, ∼2000 individual physicians and healthcare institutions from 116 countries have received free access to UpToDate through our programme. During 2013-2014, users logged into UpToDate ∼150 000 times; 61% of users logged in at least weekly; users in Africa were responsible for 54% of the total usage. Search patterns reflected local epidemiology with 'clinical manifestations of malaria' as the top search in Africa, and 'management of hepatitis B' as the top search in Asia. Our programme demonstrates that there are barriers to evidence-based clinical knowledge in resource-limited settings we can help remove. Some assumed barriers to its expansion (poor internet connectivity, lack of training and infrastructure) might pose less of a burden than subscription fees.

Addressing the challenges of diagnostics demand and supply: insights from an online global health discussion platform.

Several barriers challenge development, adoption and scale-up of diagnostics in low and middle income countries. An innovative global health discussion platform allows capturing insights from the global health community on factors driving demand and supply for diagnostics. We conducted a qualitative content analysis of the online discussion 'Advancing Care Delivery: Driving Demand and Supply of Diagnostics' organised by the Global Health Delivery Project (GHD) (http://www.ghdonline.org/) at Harvard University. The discussion, driven by 12 expert panellists, explored what must be done to develop delivery systems, business models, new technologies, interoperability standards, and governance mechanisms to ensure that patients receive the right diagnostic at the right time. The GHD Online (GHDonline) platform reaches over 19 000 members from 185 countries. Participants (N=99) in the diagnostics discussion included academics, non-governmental organisations, manufacturers, policymakers, and physicians. Data was coded and overarching categories analysed using qualitative data analysis software. Participants considered technical characteristics of diagnostics as smaller barriers to effective use of diagnostics compared with operational and health system challenges, such as logistics, poor fit with user needs, cost, workforce, infrastructure, access, weak regulation and political commitment. Suggested solutions included: health system strengthening with patient-centred delivery; strengthened innovation processes; improved knowledge base; harmonised guidelines and evaluation; supply chain innovations; and mechanisms for ensuring quality and capacity. Engaging and connecting different actors involved with diagnostic development and use is paramount for improving diagnostics. While the discussion participants were not representative of all actors involved, the platform enabled a discussion between globally acknowledged experts and physicians working in different countries.

Strategic, value-based delivery in global health care: innovations at Harvard University and Brigham and Women's Hospital.

Investments in global health have more than doubled over the past decade, generating a cadre of new institutions. To date, most of the funded research in global health has focused on discovery, and, more recently, on the development of new tools, which has tightened the implementation bottleneck. This article introduces the concept of global health delivery and the need to catalog and analyze current implementation efforts to bridge gaps in delivery. Global health delivery is complex and context-dependent and requires an interdisciplinary effort, including the application of strategic principles. Furthermore, delivery is necessary to ensure that the investments in research, discovery, and development generate value for patients and populations. This article discusses the application of value-based delivery to global health. It provides some examples of approaches to aggregating implicit knowledge to inform practice. With global health delivery, the aim is to transform global health scale-up from a series of well-intentioned but often disconnected efforts to a value-based movement based upon 21st-century technology, standards, and efficiency.