Prescription without diagnosis: Why LMICs must lead with evidence in healthcare

About the author 

Dr Cosmas Mugambi is a student on the MSc in Global Healthcare Leadership programme, run jointly by the Nuffield Department of Primary Care Health Sciences and the Saïd Business School. His areas of interest are healthcare leadership in LMICs, healthcare financing and reverse innovations from LMICs to HICs. 

Imagine a neurosurgeon performing brain surgery without first reviewing the patient’s medical images or a policymaker designing a national policy by ‘gut feeling’. In many low- and middle-income countries (LMICs), this is not a metaphor – it is the modus operandi. The absence of institutionalised evidence synthesis in health decision-making has left policy at the mercy of politics, donor whims, charisma and chaos. 

The 'Leading with evidence-based healthcare' module on the MSc in Global Healthcare Leadership programme equips healthcare leaders with the knowledge and practical skills to apply evidence-based principles to real-world decision-making. Participants learn how to identify and frame research questions relevant to their practice, search for and critically appraise evidence for quality and bias, and integrate findings into clinical and organisational contexts.

Dr Cosmas Mugambi attending one of the MSc in Global Healthcare Leadership modules

Through case studies and applied exercises, we explored how evidence, professional expertise and patient or community values intersect to inform effective decisions. The module also connects evidence-based practice to broader systems of quality improvement, implementation science and health policy empowering leaders to champion informed, data-driven change across their organisations. 

Without strong evidence synthesis, LMICs risk wasting resources on unproven interventions, copying ill-suited models, and harming essential health services. Evidence synthesis frameworks such as RAMESES, RETREAT, and realist review approaches help ensure that policies and interventions in LMICs are grounded in rigorous, context-sensitive understanding of what works, for whom and why. By leading with evidence through these frameworks, decision-makers in resource-constrained settings can allocate limited resources more effectively, design interventions that fit local realities and strengthen trust in policy outcomes. 

Evidence exists; synthesis doesn’t

Contrary to popular belief, LMICs do not suffer from a lack of data. What they lack is the political will, institutional mechanisms and culture to synthesise that data into meaningful evidence for policymaking. Policy decisions are often made in silos, bypassing systematic reviews, economic evaluations and implementation science.

Health Technology Assessment (HTA) is a staple in high-income countries to evaluate cost-effectiveness and value for money. However, it is either sporadically used or completely absent in most LMICs, even as they expand benefit packages under Universal Health Coverage. This leads to a disconnect between research and reform. Ministries of Health often rely on outdated guidelines, donor preferences or anecdotal ‘best practices’ to make life-altering decisions for millions.

In resource-constrained settings, where every shilling or naira matters, it is malpractice to allocate health resources without asking: What works? For whom? At what cost? Under what conditions? By embedding evidence synthesis into decision-making, LMICs can:

• Prioritise high-impact Interventions. For instance, Pakistan’s Lady Health Worker Programme, backed by rigorous evidence, has significantly improved maternal and child health outcomes and informed similar models elsewhere.
• Avoid policy fads and pilots with no exit plan. A quick search in donor-funded archives shows hundreds of ‘innovations’ in Mobile-Health and community health financing that had no measurable impact but drained millions.
• Strengthen local ownership. Evidence use fosters contextualisation. Ethiopia’s Health Extension Program, refined through continuous feedback loops and local evaluations has been globally celebrated because it led with evidence.

So why isn’t evidence synthesis mainstream in LMIC health systems? There are several reasons:

1. Fragmented institutions – research and policy units rarely speak. Universities are disconnected from ministries. Decision-makers lack access to synthesised, actionable evidence.
2. Donor-driven funding often comes with pre-packaged ‘solutions’ that override local research and expertise.
3. Capacity reviews, cost-effectiveness analyses and HTAs require skills that are still thin in many public institutions.
4. Politicians often want quick wins, but evidence takes time, nuance and sometimes offers inconvenient truths.

What can LMICs do?

• Establish or strengthen national evidence synthesis centres embedded within Ministries of Health or national research councils.
• Institutionalise health technology assessment (HTA) as a mandatory gatekeeping process for new policies or technologies.
• Promote knowledge brokering, enabling professionals to translate complex research into clear, actionable briefs for policymakers.
• Incentivise collaboration between academia, frontline practitioners and decision-makers.
• Invest in capacity-building for evidence appraisal and use at national and subnational levels.

A promising model is South Africa’s National Essential Medicines List Committee, which uses evidence synthesis to decide on medicines procurement and inclusion, balancing affordability, efficacy and equity. Another is Thailand’s HITAP (Health Intervention and Technology Assessment Program), which informs Universal Health Coverage policy and has been instrumental in cost containment and prioritisation.

In conclusion, we must lead with evidence or risk following failure. The Oxford Master’s in Global Healthcare Leadership reinforces that leadership in health systems must be grounded in rigorous evidence, critical thinking and adaptive learning. Frameworks such as the Evidence-Based Health Care (EBHC) model, systems thinking and implementation science remind us that effective decision-making integrates the best available research, contextual realities and stakeholder values.

Cosmas speaking to his peers on the MSc in Global Healthcare Leadership programme

Theories of complex adaptive systems and distributed leadership further highlight that sustainable change emerges from collaboration, reflexivity and the intelligent use of data. For LMICs, these lessons are urgent. We cannot afford to continue shooting in the dark. When we fail to use evidence, we don’t just waste money, we erode public trust, widen inequities and compromise lives. Building leadership capacity to translate evidence into action is not optional; it is essential for health systems that are equitable, resilient and accountable.

Let us end the era of health policy based on ‘this is how we’ve always done it’ and begin one led by ‘what does the evidence say?’

Without this shift, health systems in LMICs will remain reactive, underperforming and ultimately unsustainable. Because in healthcare, guessing is not a strategy – it’s a liability.