Strategy for change

The Cochrane Strategy for Change is an organizational strategic framework which will guide Cochrane from 2021 onwards, as we strive toward realizing our vision of a world of better health for all people. Cochrane is now operating in more challenging strategic environment – characterised by less secure funding, an increasingly competitive evidence marketplace, increasing calls for open access from governments and other funders and global health and environmental crises. The new framework focuses particularly on the changes Cochrane needs to make in the next two years to remain sustainable.

The new model for synthesizing evidence in Cochrane is anchored firmly in Goal 1. Producing trusted evidence but also in Goal 2. Advocating for evidence and Goal 3. Informing health and care decisions. From start to finish our production model must support the creation of relevant, high quality health and care evidence that is accessible to people when they need it most. All three strategic goals are underpinned by four enabling principles, and these must be the foundation of any future production model: 

Improved efficiency
The organic growth of Cochrane has led to complex and cumbersome processes and systems that threaten to overwhelm our workforce and can make Cochrane seem impenetrable. The new evidence synthesis model must make use of our existing content and methodological expertise, provide clear pathways for participation in Cochrane evidence synthesis, streamline our processes, ensure our content is consistently high quality and reduce duplication of effort.

Increase sustainability
Our traditional funding sources – public funds and license fees – are shrinking, so Cochrane must expand and diversify its funding options if it is to survive and thrive. The new evidence synthesis model must encourage and support investment from a more diverse range of funders. A more agile, responsive model helps to ensure sustainability because it enables us to deliver the high impact reviews our stakeholders need.

Increased awareness and impact
Cochrane evidence must be valued and used for us to realize our vision of a world of better health for all people, so effective dissemination must be built into the new evidence synthesis model. Cochrane’s reputation for quality is precious commodity that can be leveraged to increase our profile globally, but it must also be guarded and strengthened as part of the new model. By demonstrating our value and value for money we also potentially expand our horizons in terms of new funding sources.

Enhance accountability
The new evidence synthesis model must be built along clearer lines of accountability to ensure performance standards are met and that all those engaged in the Cochrane endeavour understand their roles and responsibilities. 

The struggle to decolonize global health and make healthcare fairer is more important than ever. In some parts of the world conflict and displacement lead to terrible health consequences for citizens and the healthcare workers who are trying to protect them. People with disabilities continue to struggle for access to health and care services and treatment options are sometimes scarce. Governments seek to ensure that the health of women and children is protected, infectious diseases are controlled, important chronic diseases are not left behind, that their citizens age in a healthy way and at the same time they are prepared for future pandemics. Looming over all of this is the threat of climate change and the devasting impact this is having on human health

In defining a new model for evidence synthesis in Cochrane we have an opportunity to respond to global health and care challenges in a different way. This would be an important change to the way we prioritize Cochrane evidence syntheses currently, but it can also be an opportunity to respond to our vision of better health for all. By taking an organization-wide approach be can better position ourselves to respond to the most important global challenges. The themes proposed in the model are high-level and will help focus to our efforts and provide a coherent framework for deciding the broad areas in which Cochrane should be providing evidence. Priority-setting at a more granular level (e.g., title level) will still be necessary but it will be contained within the overarching global priorities which are designed to maximise impact and demonstrate value to funders. 

Stakeholders

Cochrane evidence can be used by a wide range people – funders, policy makers, consumers, clinicians, researchers. All these people are our stakeholders, but they come to the Cochrane Library with different evidence needs, from macro-level public health decision-making to micro-level, individual health and care decisions. It has been a long-standing challenge for Cochrane to meet such a wide range of stakeholder needs through the single format of a Cochrane review.

The new model provides an opportunity for us to be clear about who are stakeholders are, what they need from Cochrane evidence syntheses and look at new ways to respond to those diverse needs and identify the points at which stakeholders can help in setting the direction for Cochrane. 

Review development

In Cochrane people are our strength and the reason we have, for nearly 30 years, set the gold standard worldwide for evidence synthesis in healthcare. In our current model of production Cochrane Review Groups provide intensive support to authors during the development of evidence synthesis through direct guidance, training, and resources. This typically occurs at two distinct times (1) pre-submission (production of the evidence synthesis), which includes advising of different parts of the review production process, use of technology and tools and Cochrane standards, and (2) post-submission (editorial stages leading to publication), which includes quality assurance, peer review and manuscript development. Under a new model, we are looking to draw a clearer distinction between Cochrane as the producer and Cochrane as the publisher of evidence syntheses. 

The evidence synthesis development phase can be iterative, but it should not create negative feedback loops. It should recognise and respect the skills of people playing different roles in the process and provide clear mechanisms for how expertise can be sought, incorporated, and recognised. The pursuit of quality should not introduce complexity unnecessarily, and we need to find ways of bridging the implementation gap between theory and practice. 

The new model must support diversity in all its forms throughout the development process – through people, methods, and types of evidence synthesis. Cochrane has wealth of content and methods expertise and it is critical that we keep and incentivize our talented Cochrane members. One way of achieving this could be to create a board (possibly named Cochrane Board of Fellows), made up of Cochrane fellows who would contribute their methods, clinical and lived experience expertise to evidence synthesis development. 

The sorts of contribution the fellows could make might include: 

• Scoping work such as gap analysis and horizon scanning

• Topic prioritisation at a more granular level

• Identifying potential author collaborations

• Advising on knowledge translation activities

• Identifying and recommending peer reviewers

• Acting as a Sign-off Editor for peer reviewed manuscripts

There would be a simple application or nomination process for fellowship. Fellows could be people who are earlier in their careers or engagement with Cochrane but who have demonstrated a strong interest in evidence synthesis and evidence-based decision making in a specific content area. These ‘early career’ fellows could be mentored by senior fellows to ensure continuity and the maintenance of high standards within a content area.

 The term of service for senior fellows on the board would be fixed but following this term senior fellows could become emeritus Cochrane fellows. We would consider whether emeritus fellows could still contribute in an advisory or mentorship capacity to support succession planning. We would strive for geographical diversity and strong representation of lower- and middle-income settings on the board. 

Evidence synthesis units

The creation of Cochrane Networks in 2018 rearranged the 52 current Review Groups into eight larger networks.  While this reorganization made it easier to provide support and implement new tools, it did not achieve the streamlining that Cochrane needs.

This has led to the current proposal to change the model of production in Cochrane. In the new model the existing Cochrane Review Group and Network structure will be replaced by eight to 10 larger, multi-topic, multidisciplinary evidence synthesis units that will be responsible for preparing Cochrane evidence syntheses, which will be handled by an independent editorial service. These units will follow the strategic direction of the organization, be outward-looking and comprised of people who are highly skilled in evidence synthesis methods. Cochrane leaders from within and outside the central team, will work with funders to identify core funding for the units. On a parallel track the central team will focus on fundraising to support suites of evidence syntheses. 

We recommend that the units be organized geographically to maximise the possibility of securing funding from national governments. However, it is important that the units are also able to respond to funding calls for evidence synthesis in specific areas. We envisage that the units will work closely with the Geographic groups and Cochrane leadership to leverage local connections in a way that supports different funding streams. In the transition period the evidence synthesis unit structure will accommodate Cochrane Review Groups that have stable funding beyond March 2023, ensuring that there is a publication pathway for these groups and existing funding arrangements are not jeopardized.

We propose that each unit will be led by a Cochrane expert who will be responsible for setting yearly plans and meeting key performance indicators in line with a tripartite contractual agreement between the unit, the funder and Cochrane. Quality assurance will be a key component of the units and the unit leader will ultimately be responsible for the work submitted to the Central Editorial Service. Annual reports of activities, funding and expenditure will be submitted to Cochrane and the funders. 

Evidence syntheses will be prepared by diverse author teams with sufficient knowledge and expertise to guarantee high-quality, timely delivery. Authors will be supported by a skilled and experienced, core team of Managing Editors, Information Specialists, Statisticians, Consumers and Systematic Reviewers. In some cases, the core team members may take an authorship role; in all cases they will be responsible for managing the development of evidence syntheses according to agreed processes and standards.  To ensure that Cochrane can deliver different types of evidence syntheses in all the topic areas of interest to funders, there will be scope for sharing content and methods expertise between units. 

This pathway has been in operation via the Central Editorial Service on a smaller scale over the past two years, and several of Cochrane’s COVID-19 reviews have been published via this direct route. This means our editorial processes have been tried and tested and we are confident we can maintain Cochrane’s high standards using a direct submission process. We current editorial process is described in Figure 1.