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Introduction to the public health policy process the role of evidence in policy making with audio files (Mays Boaz), 3 Oct 22.pptx
- 1. Introduction to thepublic health policy process and to the role of evidence in policy making Nicholas Mays and Annette Boaz Department of Health Services Research and Policy DrPH EBPHP, 3 October 2022
- 2. Outline − Defining ‘policy’and ‘policy making’ (NM) − Main approaches from political science to thinking about the policy process (NM) − Different ways of understanding the relationship between evidence, research and policy (AB) − The ‘uses’ of evidence and research (AB recording) − Group analysis ofTrostle et al. (1999) (NM) − Facilitators of use of research in policy that are widely promoted (NM) − Evidence and research as one input to policy making (NM)
- 3. Part 1: Defining‘policy’ and ‘policy making’
- 4. What is ‘policy’? Whatsprings to mind when you hear the word ‘policy’? What different types of ‘policies’ can you think of? What characterises them?
- 5. Hogwood and Gunn’s(1984) classification of types of policy Label for field of activity (e.g. UK’s defence policy) Expression of general intent (e.g. end global poverty) Specific proposals (e.g. N on anti-retroviral treatment by time t) Decisions of government branches (e.g. government of Botswana to include Hepatitis B in routine immunisation package) Formal legislation (e.g. regulating tobacco sales) Programme/project (e.g. establish a STI treatment programme) Output or outcome (e.g. increasing patient throughput or improving patient QoL) Underlying model or theory (action x is known to achieve result A – ‘reducing the minimum wage will lower unemployment’ or vice versa)
- 6. Different levels ofpolicy (in the health care field) ‘Practice’ micro, clinical, professional, individual service or intervention ‘Organisational’ meso, programmatic ‘System’ macro, constitutional, governmental (plus multi-level governance)
- 7. What is publicpolicy? A possible definition – ‘the sum total of government action on an issue, from signals of intent to final outcomes’ Degree of formality (‘government action’) Degree of generality ( affects the ‘public’)
- 8. Characteristics of manyformal public ‘policies’ (after Knoepfel et al, 2007) − Respond to a perceived problem − Identify a target group − Clarify and express intent/sense of direction − Have an assumed ‘theory of change’/mechanism of action − Describe a set of actions/interventions − Involve a group of actors/implementers − Focus on achieving results (outputs, processes, outcomes) − Build support or consensus − Determine allocation of resources − Exercise control/authority − Establish standards/imposes order − Can include incentives
- 9. What is missingor underplayed in the preceding definitions and descriptions? ?
- 10. What is missingfrom the preceding definitions and descriptions? Answer Acknowledgement of the likelihood of conflicting values and opinions on what should be done and how it should be done Any sense of trade-offs and tensions between goals (e.g. equity and efficiency) Any sense of choices between different potential actions/means with uncertain consequences That is, little sense of politics as partisan political competition or the process through which policies come into being
- 11. Part 2: Mainapproaches from political science to thinking about the policy process
- 12. The policy ‘stages’heuristic Issue search Issue filtration Issue definition Forecasting Setting objectives Options analysis Implementation Evaluation Succession/termination • Problem recognition • Agenda setting • Policy formulation (consideration & choice of options) • Policy implementation • Policy evaluation
- 13. Some limitations ofthe stages heuristic Assumes perfect or at least very good information is available at all stages Not a ‘causal theory’ – Describes a series of activities – Sequence of stages may be inaccurate and some may not occur – Risk of top-down bias Does not recognise multiple levels of policy making or inter-sectoral policymaking Implies that ‘policy’ is a decision(s) Cannot explain why issues come onto and leave the policy agenda Rarely a good description of reality – Reality tends to be more muddled, less hierarchical, less predictable – Policy-making takes place in an environment with a wide range of actors, rules, relationships, beliefs, changing conditions (e.g. shocks)
- 14. A very differentconception: the ‘political’ approach to health policy making ((Kickbusch, 2015) • Sees all health (and health policy) as a product of political choices, involving ideology • No distinction between ‘instrumental’ and ‘normative’ policymaking • Health as integral to human rights and citizenship • Health increasingly important to political legitimacy • Health policy making is thus political involving interests, institutions, processes, power distribution, etc. throughout societies • Politics (and thus policy) seen as ‘a continuous struggle for power among competing interests’ • Public health professionals need to understand these political complexities, not just the evidence
- 15. Where do yousit in the political world of health policy? What is your perspective on public health and health policy? What are your positions, assumptions, values? How do these affect your involvement in influencing policy? Should they?
- 16. Questions raised bythe ‘political’ approach Are you comfortable with the following? ‘..politically neutral interventions for better public health outcomes are fictitious and … health promotion research is inherently political.’ (Bernier & Clavier, 2011: 110) Shouldn’t public health policy proceed simply from expertise and evidence to policy change?
- 17. Seeing ‘policy’ asa process I Policy is fundamentally shaped by (mostly enduring) sets of inter-organisational and inter-personal relations, values and norms Policy making usually involves argument (reciprocal persuasion) and struggle (as well as more covert exercise of power) Seeing policy as a continuous process clarifies why, for example, evidence is only one of many contributors to policy
- 18. Seeing ‘policy’ asa process II Not a distinct or unambiguous ‘thing’ since it does not have a beginning, middle or end, objectives can be hard to distinguish and are not fixed May involve decisions but is far more than discrete decisions Policy process is a social activity involving many players, not just a single, unified actor Not the exclusive preserve of governments and ‘experts’ – NGOs and business have and make ‘policies’, and attempt to influence governments Inherently political, involves power relations, ideas
- 19. Closer to realitythan the stages heuristic and/or policy cycle? Martin Stanley (2013) How to be a civil servant. Second edition. Politico’s Publishing
- 20. Main explanatory theoriesin policy science Tend to emphasise one of the following: –Interests –Ideas –Institutions –Networks More ambitious ‘integrated’ theories bring these together See: Peter John (1998) Analysing Public Policy
- 21. Integrated approaches Critique isthat theories are overly specific – focus on only one factor as the ‘foundation of the political system’. – Clearly all factors can be important Some authors have attempted to provide more integrated theories to understand processes better – ‘Three Streams’ (Kingdon) – Advocacy Coalition Framework (Sabatier)
- 22. ‘Multiple Lenses’ forcomplex problems (Cairney, 2007) Multiple lenses approach –No one approach will explain all cases –Risk of fitting the case study to the pre-selected theory –Multiple important insights • ‘A series of perspectives’ to view an issue • Some will provide more insights for action, more useful to guide policy development –Not searching for the ‘best’ theory/model, but instead trying to see what different ones can contribute to our understanding
- 23. Part 3: Differentways of understanding the relationship between research and policy
- 24. Ways of understandingthe relations between research and policy 1. Rationalist, instrumental use – Knowledge-driven model – Problem-solving model 2. Strategic use – Research used ideologically to support policies already decided on – Research used to delay decision-making 3. ‘Two communities’ – underpins current efforts to increase use of evidence 4. Interactive, political model – research is only one input in a complex (chaotic?) process 5. Enlightenment (conceptual) model
- 25. 1.Rationalist arguments: theorigins of the ‘evidence-based’ movement Cochrane’s Effectiveness and Efficiency (1972)
- 26. 1. The rational,‘evidence-based’ approach Sometimes referred to as the ‘knowledge driven’ or ‘problem solving’ or ‘engineering’ or ‘retail’ model The research policy arena is assumed to be a ‘retail store in which researchers are busy filling shelves of a shop front with a comprehensive set of all possible relevant studies that a decision maker might some day drop by to purchase.’ Lomas (2000)
- 27. 2. Strategic modelof use of research Views research as ammunition to support predetermined positions or to delay or obstruct politically uncomfortable decisions (Weiss, 1979) Highly compatible with the empirical evidence of the politics of policy making (i.e. policy makers’ motivations for using evidence) Question: When does evidence-based policy become policy-based evidence?
- 28. 3. ‘Two communities’model Emphasises a ‘cultural’ and structural gap between researchers and policy makers Underpins most analysis of difficulties in ‘transferring’ or ‘translating’ or ‘using’ ‘knowledge’, ‘research’ and ‘evidence’ Overlooks other potentially important actors, e.g. consultants, think tanks, lobbyists, journalists
- 29. How apt ametaphor?
- 30. 4. Interactive, politicalmodel Policy makers receive information (including research findings) from a wide range of participants engaged in a messy, interactive process in which ideas travel back and forth between a wide range of interest groups Draws attention to the importance of understanding the public policy making process to understand if/how research is used in and for policy
- 31. 5.Enlightenment model ‘Limestone’ model(PatriciaThomas) – sedimentation of evidence Carol Weiss’ enlightenment theory ‘generalisations and ideas from numbers of studies come into currency … through articles in academic journals, journals of opinion, stories on the media, lobbying by special interest groups, conversations of colleagues, attendance at conferences … and other uncatalogued sources.’ Ideas associated with a body of research influence policy rather than specific findings
- 32. A research usecontinuum Awareness 1. Knowledge Attitudes, perceptions, ideas Knowledge & understanding 2. Persuasion Practice & policy change 3. Decision 4. Implementation 5. Confirmation CONCEPTUAL USE INSTRUMENTAL The “enlightenment” role of research (Weiss, 1979)
- 33. Different models assumedifferent mechanisms The Academy: stocks and flows of research-based knowledge Policy, organisational and professional environments, and the media and society at large Knowledge impels action Percolation Knowledge grabbing Problem solving or tactical Interaction Co- production of knowledge
- 34. Part 4:The ‘uses’of research and evidence
- 35. Impact Evidence Implementation Evidence Descriptive Analytical Evidence Economic and Econometric Evidence Ethical Evidence Experimental Quasi-Experimental Counterfactual Surveys Admin Data Comparative Qualitative Cost-Benefit Cost-Effectiveness Cost-Utility Econometrics Experimental Quasi-Experimental Qualitative Theories ofChange Social Ethics Public Consultation Statistical Modelling Linear and Logistic Regression Attitudinal Evidence Surveys Qualitative Many types of evidence can be ‘used’ including research
- 36. And there canbe many different reasons to undertake research
- 37. Some common ‘uses’of research in policy Can help bring an issue nearer to, or onto, the policy agenda – that something is a ‘problem’ worthy of attention Can contribute to the stock of ideas on possible responses – In both these cases owes its influence to its ability to be turned into arguments and advocacy rather than its ability to reveal uncontested ‘truth’ (Smith, 2014) – Often used to boost persuasiveness of arguments
- 38. But is ‘use’of research always a helpful focus of attention? Tendency to see a process in which research influences policy but not the other way round – clearly policy can influence research Is there be ‘policy-based evidence’? Can it lead to the ‘misuse’ of research? Would it be better (more realistic) to talk of the ‘interplay’ of research and policy?
- 39. Part 5: Groupanalysis of Trostle J, Bronfman M, Langer A. How do researchers influence decision makers? Case studies of Mexican policies. Health Policy and Planning 1999; 14: 103-14
- 40. Guiding questions 1. Howwould you describe the obstacles to evidence use as reported in the analysis of the four case studies? 2. Which facilitating factors helped to make research relevant to policy-makers? 3. Can you apply any of the models of research and policy discussed to the case studies in this paper? 4. Are there things that could have been done differently to overcome barriers and/or ‘improve’ the use of research findings?
- 41. Relation to the‘policy triangle’ (Walt & Gilson) Obstacles to evidence use Facilitators of evidence use Content Language, jargon, technical language Consistent direction of findings – consensus Disciplines e.g. social science Concrete recommendations for action e.g. CEA Status of authors Low cost –high benefit recs Conflict between researchers Actors Lack of technical knowledge of policy makers Joint processes to identify research priorities Policy advisers constrained by political priorities International actors – donors, expertise Experience over research evidence Rotation of researchers into government Conflicting interest groups Funders of research Mutual disdain Process Lack of communication Good relationships between policy makers and researchers Access to policy process by researchers Evidence review in a timely fashion Turn over of policy advisers Fast dissemination of evidence Pace of policy making Context Priorities and health threats in the country context Shared elite membership Media Media Centralized, confidential decision making Political continuity Lack of resources Urgency High priority subject area Influence of research on policy: analysis grid
- 42. Ways of reducingor overcoming barriers to use of evidence or improving use List your suggestions
- 43. Part 6: Facilitatorsof use of research in policy that are widely promoted
- 44. Widely supported waysof increasing use of research in policy and practice 1. Make research accessible – e.g. summaries, presentation tailored to specific audiences 2. Develop ongoing, collaborative relationships between researchers and potential users 3. Improve communication channels – e.g. ‘knowledge brokers’, KT training 4. Increase incentives and minimise costs to researchers and research users to engage in knowledge transfer activities
- 45. Other popular recommendations 5.Ensure research is relevant, timely and actionable 6. Researchers identify relevant networks and allies when policy debates are highly polarised 7. Use ‘opinion leaders’ or ‘champions’ to promote particular ideas from research
- 46. Part 7: Rememberingthat evidence is only one input to policy making
- 47. Prime Minister’s StrategyUnit Other (more significant) factors contributing to policy making than evidence Evidence Experience & Expertise Judgement Resources Values Habits & Tradition Lobbyists & Pressure Groups Pragmatics & Contingencies
- 48. Would it bebetter to aim for ‘evidence- informed’ policy making? Seen as more realistic than ‘evidence-based policy’ by some (Boaz et al, 2008) And by others as less elitist, given that ‘the people, and the politicians who represent them, have every right to ignore evidence’ (Mulgan, 2005, p224) But not by others - ‘a horrible expression, all thin- lipped, prissy and politically correct’ (Pawson 2006, pviii) Question: What difference does it make?
- 49. Problems with thepopular models of improving research use in policy (Smith 2014) Tend to see policy makers and researchers as relatively homogeneous and distinct – ignores evidence of conflicts within the ‘two communities’ and links between them Assume that research can respond directly to policy makers’ questions and concerns Tend to present the process as one way rather than interactive Overlooks that research and policy agendas are simultaneously shaped by particular ideologies – affects what is regarded as worth researching & how – affects what ‘counts’ as research, evidence, etc.
- 50. Questions to thinkabout Is the focus on making evidence more influential the right one? Is ‘policy-based evidence’ to be encouraged or not? Is it (ever) helpful to think of researchers and policy makers as ‘two communities’? Are policy makers uninterested in evidence or is it that their needs cannot be met entirely by evidence? Can better relationships/linkages overcome institutional, political & other factors? Will more use of evidence necessarily improve policy? Should researchers get involved in policy debate or remain dispassionate and uninvolved?
- 51. Summary 1. Wider rangeof research impacts/uses than EBP advocates often recognise 2. The relationship is a complex one and different theories can be useful to understand it 3. To use research and other evidence to inform policy requires understanding the nature of policy and what shapes it 4. ‘Policy’ is inherently ‘political’ since one classic definition of politics is ‘Who gets what’ (Lasswell, 1936) and policies are designed to influence this
- 52. Evidence and policycase study small group presentations, 6 December Analysis of case studies of evidence interpretation and use • Carefully read the description of the task in the handbook • Agree how to work as a group (e.g. who does what, who presents what, etc.) • Locate and read further literature to become familiar with the case study • Summarise the main differences of interpretation of the evidence on the topic • Identify whether different policy advice and decisions have been made in different countries and, if so, why • Suggest which theory/theories related to the use of evidence for policy best fit the case • Identify the main barriers and facilitators of evidence ‘use’ in the case • Work out whether evidence use and the relationship of evidence to policy could be ‘improved’ in the case • Briefly read about the other case studies that you are not presenting
- 53. References Boaz A, etal (2008) Does evidence-based policy work? Learning from the UK experience. Evidence & Policy 4: 233-53. Baumbusch JL, Kirkham SL et al. (2008): Pursuing common agendas: a collaborative model for knowledge translation between research and practice in clinical settings. Research in Nursing and Health 31: 130-140. Caplan N. (1979)The two-communities theory and knowledge utilization. American Behavioral Scientist 22: 459-70. Cochrane A. (1972) Effectiveness and efficiency. London: Nuffield Provincial Hospitals Trust. Green J,Thorogood N. (1998) Qualitative methods for health research. London: SAGE. Lasswell HN. (1936) Politics: who gets what, when, how. NewYork: McGraw-Hill Lavis JN. (2006) Research, public policymaking, and knowledge-translation processes:Canadian efforts to build bridges. Journal of Continuing Education in the Health Professions 26: 37-45.
- 54. References Lomas J. (2000)Connecting research and policy. Isuma - Canadian Journal of Policy Research 1: 140-44. Majone, G. (1989). Evidence, Argument, and Persuasion in the Policy Process. New Haven, CT:Yale University Press. Mulgan G (2005) Government, knowledge and the business of policy making. Evidence & Policy 1: 215-26. Nutley S,Walter IC, Davies HTO. (2007) Using evidence: how research can inform public services. Bristol: Policy Press. Pawson R. (2006) Evidence-based policy: a realist perspective. London: SAGE Smith K. (2014) Beyond evidence-based policy in public health: the interplay of ideas. Basingstoke: Palgrave Macmillan. Thomas P. (1987) Use of social research; myths and models. In:Walter I, Nutley S, Davies H. (2005)What woks to promote evidence-based practice? Evidence & Policy 1: 335-63. WeissC. (1979)The many meanings of research utilization. Public Administration Review 39: 426-31.