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Decision-makingUsing evidence forpolicy-making in healthArticle by Tikki PangHow is evidence used in policy-making in health? Theanswer to this fundamental question requires anappreciation of the different mindsets, mentalitiesand “world views” of researchers and public policy-makers,and how these conditions influence the way they work, or donot work, together. An insight into this key dynamic thenallows consideration of various possible solutions on how toimprove this critical relationship so that scientific evidencemay truly drive and inform health decision- and policy-making.Goals, priorities, attitudes towards information, timepressures, accountability mechanisms and career paths tendto be different between researchers and policy-makers. Theyoften distrust one another’s motives, lack respect for eachother, have different views on the production and use ofevidence, different accountabilities, and disagree on thefundamental issue of whether there should be a link betweenscience and policy. Some possible solutions can be putforward to improve the use of evidence in policy-making:using knowledge “brokers” (translational researchers), newand better incentives to encourage researchers and policymakersto work together, organizational capacity-building andembedding research in implementation, utilizing a broaderdefinition of research, re-defining the starting point forknowledge transfer, and, finally, acknowledging that policymakingis a highly complex process.In the face of continuing global health challenges, times ofscarce resources and competing priorities, the use ofevidence to inform policy-making becomes a moral andethical responsibility and should be the key driver forimproving health system performance.Researchers and policy-makers are differentcreatures living in different worldsDespite the intuitive, logical assumption that scientificevidence should automatically inform policy, there areproblems in implementation and evidence-based policy is agoal which is not always reached 1-5 . Many researchers aresceptical about the extent to which research is used, and, inturn, many policy-makers are sceptical about the usefulnessof research in general. The causes for the disconnect arecomplex but are probably related to some key factorsincluding the fact that researchers and policy-makers havedifferent goals, speak different “languages” and have differenttime frames for their work.A researcher has, as his primary goal, the generation ofnew knowledge and the advancement of science. She/heoften measures success through the publication of scientificpublications in peer-reviewed academic journals, with thisactivity often used as the primary criteria for careeradvancement (the “publish or perish” syndrome). They areoften less interested in broader issues, for example, the “bigpicture”social or policy aspects and impact of their work. Theobjective in the research world is “publications, patents, andprofessorships” 6 . Given the unprecedented rate of increase inknowledge, researchers tend to become extremely specializedand narrow in their field of research, often resulting in others(researchers and non-researchers alike) not able to fullyunderstand or appreciate the importance of their work. Theyaspire to become an “expert/professor/specialist” and worklargely according to a rational, intellectual model.In contrast to this desire for recognition by peers, the goalof policy-makers is to obtain popular support. Much of theirdaily work is to “put out fires” and manage political crises andthey are thus more interested in broader issues, e.g. solutionsthat can be generally applied to a wide variety of problemsand which are politically acceptable. So, in contrast to theresearch community, the key considerations in the policyworld is “policy, practice, and people” 6 . Because of timepressures and lack of necessary skills policy-makers havevery little time to read or evaluate original scientificpublications of primary research. Instead, they prefer to readshort summaries or even just “bullet points”. They striveto become a “Mr/Ms Fix-it and Jack of all trades”, and betterstill is if they can do this across different portfolios. Theysearch for compromise and rapid fixes, by using an intuitive,visceral model.Research researchers speak their own language whichnormally consists of at least some Greek letters andmathematical symbols. Their language often requires“translation” before it can be understood by non-researchers,154 ✜ Global Forum Update on Research for Health Volume 4
Decision-makingPolicy-makersComplex policy problemsFocused solutionsReducing uncertaintiesSpeedControl and delayManipulationFeasible and pragmatic solutionsResearchersSimplification of the problemInterest in related but separatedissuesFinding the truthTime to thinkPublish or perilExplanationThoughtful deliberationsSource: Bensing JM. Doing the right thing and doing it right: toward a framework forassessing the policy relevance of health service research. International Journal ofTechnology Assessment in Health Care, 2003, 19:604-512.Table 1: Conflicting interests of policy-makers and researchersor even fellow researchers in a different field. Researchersoften add a standard clause at the end of their papers statingthat “our research indicates that more research is needed”.This is, of course, both exculpatory (“don’t blame me if thisisn’t correct”) and self-serving (“but if you give me moremoney I might be able to give you a better answer”). Hereinlies a key point of distrust: policy-makers believe thatresearchers do research primarily to generate more fundingfor more research, and not for the potential value of theresearch to society.“Policy speak” is often used to describe the language whichpolicy-makers use and it often contains acronyms, which inturn are defined by other acronyms. Much of thecommunication is confidential in nature and for a closedaudience, and driven by unpublicized political agendas. Theyoften include multiple signatures or are anonymous(containing no signatures), and are often stamped as“confidential”. While policy-makers do sometimes conductresearch, it is rare to see their findings published in peerreviewedscientific journals, if released at all. In general, theculture of open sharing of knowledge and information is notpart of the policy-making world.Scientific research in general is driven by fairly long timeframes. Researchers want time for contemplation, thinking,formulating hypotheses, analysis, syntheses, talking tocolleagues and more reflection. In general, it is believed thatthe longer it takes to do a research study, the better theresearch quality. It is also a fact that the process of science isa cumulative one and builds on the previous work of others.Many researchers spend their entire research career in onenarrow subject area, in order to build up their expertise andtrack record, as well as national and international reputationin that area – to many, this is an end in itself.In contrast, policy-makers work to a very different, muchshorter time scale, often a matter of days or weeks. Answersare always needed instantly and the time pressures often takeprecedence over quality, since they must have prompt andfirm opinion to look credible. This is reflected in the classicpolicy-makers’ sentiment, “I have made up my mind, don’tconfuse me with the facts”. Policy-makers usually haveshort tenure managing projects, and will move on quicklyto other responsibilities, in order to build up their repertoireof expertise in a wide variety of different areas. Theconflicting interests of policy-makers and researchers is givenin Table 1.Why are they different?The incompatibilities between researchers and policy-makerslead to very real problems in terms of promoting better useof evidence for health policy development. If they are towork together, researchers and policy-makers must knoweach other’s strengths and weaknesses, as well as likes anddislikes. There are a number of key issues that must thereforebe addressed.Researchers and policy-makers often lack trust and respectfor the respective roles that they play. Researchers often havea “superiority complex” which translates into acondescending attitude and a lack of respect for those whoare not researchers. They often take the view that theirresearch is to be reviewed only by their peers and find itdifficult to conduct “directed” or “applied” research,regardless of the potential benefits to society in general. Theyconsider “academic freedom” to be sacrosanct and expect tobe allowed to pursue their interests with no constraints.Therefore, they often resent the power of policy-makers tocontrol research funding and the frequent misuse that ismade of scientific data to fulfil a politically-driven policyagenda. At the same time, policy-makers resent the arroganceof researchers, the seeming self-fulfilment and self-servingnature of much of their research, and their narrow, tunnelvision approach to the world. Scientific input is oftenuntimely, less-than-relevant, abstract and impossible tounderstand or contextualize. In extreme situations, they viewscientific evidence as being detrimental to political andeconomic considerations, e.g. when evidence of an infectiousdisease outbreak can lead to economic loss as a result ofreduced numbers of tourists.In addition, researchers and policy-makers often havedifferent views as to what constitutes evidence. Manyscientific results are quantitative and can be assessed inrigorous, repeatable ways. Researchers obsess aboutresearch methodology and the “levels of evidence” gatheredthrough different study designs, such as clinical trials andobservational studies. Policy-makers, on the other hand, areoften more informal in their assessment of information, eventhat of a quantitative nature. They look for importantinformation based on quick reflections of reality for policymaking,e.g. poll results, opinion surveys, focus groups inmarginal electorates, anecdotes and real-life stories. Theyoperate on a different hierarchy of evidence – their “levels ofevidence” may range from “any information that establishes afact or gives reason for believing in something” to “availablebody of facts or information indicating a belief or propositionis true or valid”.Should researchers cater to the needs of policy-makers?Policy-makers are often frustrated because researcherscannot give them a quick, clear and simple answer.Researchers are frustrated because required data may notexist, or they do not know the answer or want to admitproblems with their studies, or they cannot explain theircomplex findings in a simple language. Policy-makers believethat much of the research being conducted is pointless andlacks relevance, which is probably right as the motivation onthe part of the researchers is often scientific curiosity and theGlobal Forum Update on Research for Health Volume 4 ✜ 155
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Contents096 Child immunization: acc
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IntroductionResearch contributions
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IntroductionType IType IIType IIIPr
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Introductionmaking), takes account
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