Senior Lecturer in Health Policy, Planning and Management at Makerere University, Uganda
According to Hyrum W. Smith, wisdom is knowledge, rightly applied. In order to promote knowledge uptake in a rapidly changing world, the coming decade should be seen to challenge the sanctity of what has been, in many instances, lauded as the hierarchy of evidence. I absolutely concur that evidence hierarchies enable one to appreciate the complex array of evidence generated by a variety of research methods, gauge the trustworthiness that can be placed in the recommendations and, in some instances, alert the practitioner when caution is required. Many proponents of knowledge uptake are, in my opinion, still too heavily biased towards the use of evidence hierarchies determined through the lens of effectiveness. This means evidence used for policies and practices should be based on systematic reviews, randomized controlled trials (RCTs), and other rigorously evaluated studies conducted in controlled settings. Oftentimes this evidence on effectiveness is only scantily clad with information on ‘how it works’ in different settings. Efforts around knowledge management should go beyond effectiveness to embed measures of appropriateness and feasibility when considering hierarchies. There were no randomized controlled trials conducted during the last Ebola outbreak in Africa, yet priceless lessons were gleaned from this experience. Why should the weight of effectiveness always trump appropriateness or feasibility? Especially since this effect is measured in a highly controlled environment. Clearly, policy and programmes are hardly ever implemented in controlled environments. Why should the tacit knowledge of experts be considered ‘weak evidence’? Evidence hierarchies firmly based on effectiveness, appropriateness and feasibility should be promoted as a gold standard for evaluating healthcare interventions because they acknowledge the many facets that have an impact on the success of an intervention. Indeed, the most effective intervention will fail if it cannot be adequately implemented or is unacceptable to the consumer.
Knowledge management will progress if a shift is made from the singular focus on effectiveness towards a holistic incorporation of evidence on the appropriateness or feasibility of interventions even though these (seen through a different lens) are erroneously perceived to be lower-level evidence. Besides, without wisdom, one can swim all day in the Sea of Knowledge and still come out completely dry. Knowledge management will progress if it draws from the wise, who have rightly applied knowledge. If this takes place, wisdom management will soon become the buzz word.