by Justin Parkhurst
For many, the idea that health policy should be informed by evidence is an obvious goal. And indeed, the global health community has widely called for increased use or uptake of research and evidence, in health policymaking. However, a vast majority of these calls have been made without explicit recognition of the decidedly political nature of policymaking, and without consideration of how this may affect the use of evidence to inform decisions.
Indeed, calls for ‘evidence-based’ policymaking have become ubiquitous in recent years, applied in social sectors such as health, education, crime prevention and many others. Many have seen these calls deriving from the successes of the ‘evidence based medicine’ movement – a movement that has helped to ensure that clinical practice is informed by rigorous assessments of evidence of effects of different treatment options.
Yet, while medicine has apparently achieved great success through its systematic approach to utilising evidence to inform clinical decisions, the idea that policymaking can simply copy this approach raises a number of challenges. Policy scholars for decades have noted that policymaking is a decidedly political exercise, not a simple process of technical decision making and evidence review. Simply put, the effectiveness of an intervention is often only a minor or partial consideration in many policy decisions – including health policy decisions. While medical decisions have a clear and shared goal for all involved (reduction of patient morbidity or mortality), policymaking typically involves multiple contested concerns – including relative priorities, concerns over rights and norms, and different social values promoted by competing interest groups. As such, there typically isn’t an easy answer to the simple question of ‘what does an evidence based policy actually look like?’
The GRIP-Health research programme was funded by the European Research Council to bring an explicitly political lens to the study of evidence use for health policymaking in low, middle and high income countries. It draws particularly on policy studies theories to consider how the nature of the policy process, the politicised features of health decisions, and the existing institutional arrangements for policymaking in different countries all can work to shape which evidence is utilised, and how it is utilised to inform or shape health policy decisions.
An initial systematic review (available here) helped to map out the field of knowledge in this area, and particularly flagged up that very few studies of evidence use for health policymaking include any explicit consideration of the nature of political debate or the roles of different political institutions in shaping the nature of health policy. This helped to inform further conceptual development about the nature of political institutions and how they may serve important roles in shaping or influencing issues such as which evidence is seen to be relevant for policy decisions, as well as how different bodies of evidence end up being used.
Country case studies in Cambodia, Colombia, England Ethiopia, Ghana, and Germany were then conducted to explore the nature of policymaking for health, to map out the evidence-advisory systems in place to inform ministries of health in particular, and to explore the use of evidence in recent health policy issues in local country settings. These country cases provide a number of insights into the political nature of evidence use for health policy that has often been ignored or simply dismissed under a broad brush heading of ‘politics’ seen to undermine a techno-rationalist ideal type of evidence for policy making which does not, in fact, reflect the vast majority of health policy decision situations.
For example in Colombia, we explored how the judcialization of key decisions about which health services to provide under insurance programmes led to uses of evidence very different from what the public health community might consider to be ‘rational’ in terms of cost-effectiveness analysis or priority setting. Alternatively in lower income settings such as Ghana, Ethiopia, and Cambodia, we explored the importance of the international community and international donors in shaping which evidence was used to inform health decisions, when and how – with potential donor influence apparent not only in which health issues were funded, but also in the choice of research to undertake or the application of routine data to evaluate national policy and plans. In higher income settings, such as in England and Germany, we studied how ideological and institutional differences could lead to very different expectations and roles of evidence use, with a comparative exploration of recent e-cigarette policy providing one example.
Ultimately our work illustrates that evidence use in health policymaking rarely reflects an ideal ‘rational-linear’ archetype. Rather the politicised construction and framing of policy issues, the multiple competing interests and stakeholders involved in decisions, and the institutional arrangements through which policy decisions must be made, all work to shape what evidence use or utilisation looks like in these cases. For a global public health perspective, our work highlights the need to move beyond oversimplified models of evidence ‘use’ being simple one of ‘uptake’ of research in a simple linear way. As a result, the work raises a number of conceptual questions, for which we have developed publications, including:
- What are the nature and origins of bias in evidence use for policy?
- What does ‘good evidence’ for policymaking look like?
- What might the ‘good use’ of evidence look like from a political perspective?
- How might we conceptualise ‘good governance’ of evidence in health policymaking?
These conceptual themes are ultimately drawn together in a single volume: ‘The Politics of Evidence: From Evidence Based Policy to the Good Governance of Evidence’ – available free to download and share as a pdf (or also freely available on e-book formats such as Amazon Kindle). The book speaks to an audience beyond health alone, attempting to move the field of evidence use and uptake forward by reconsidering what ‘improved’ uses of evidence might look like from a political perspective; particularly in terms of how to build institutional structures that might help support the ‘good governance of evidence’ – a concept that represents the use of rigorous, systematic and technically valid pieces of evidence within decision-making processes that are representative of, and accountable to, the multiple political needs of populations.
All outputs of the GRIP-Health programme are available Open Access and free to download and share, with most available at the programme website here. The GRIP-Health programme was supported by the European Research Council (project ID#: 282118).
About the author
Dr Justin Parkhurst is Associate Professor of Global Health Policy within LSE Health at the LSE.