Transcript Health System - Kerman Medical University

Decision Making and Policy Setting in
Healthcare System
Dr. Shahram Yazdani
Definition of evidence-based policy
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The advice and decisions of policy
makers are based upon the best available
evidence from a wide range of sources ;
all key stakeholders are involved at an
early stage and throughout the policy’s
development. All relevant evidence,
including that from specialists, is available
in an accessible and meaningful form to
policy makers.
General Consensus
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Evidence-based policy is a meaningful concept
(to both theorists and practitioners);
Evidence can and should be available to policymakers, in a timely and appropriate format;
This evidence can be interpreted and used in
such a way as to inform policy development;
That policies based on evidence are better than
policies which are not based on evidence.
Why isn’t policy evidence-based?
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Research is not perceived as useful in the real-politic of
office life (Davies et al 2000)
Policy-makers are biased against using it (Leicester
2000)
Research is not good quality or accessible to policymakers (Parry 1999)
Policy-makers prefer to be led by ideology and
pragmatism (Brown 2001)
Discrepancies of timing;
The low status of researchers compared to those they
are trying to influence;
Different ways of viewing the world (values, language,
interests etc.)
‘Enemies of evidence-based policy’
Leicester (1999)
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Timing (lacking the luxury of being able to do
things thoroughly),
Bureaucratic logic (doing things the way that
they have always been done)
Civil service culture (in particular, a strong
distrust of information generated from outside
the system);
Politics (doing what one can, rather than what is
rationally best).
Lack of relevant research
The need to weigh up the relative value of
different forms of evidence
Difficulties
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Evidence-based policy-making strongly predicated on
the model of evidence based medicine (Solesbury
2001).
However, there is no easy ‘read across’ from medical
research to social research.
This is because social research cannot rely on the goldstandard of the random-controlled trial (RCT);
The possible explanatory variables are much more
complicated and the interpretation of the research may
always be disputed.
In addition, “agreed criteria for evaluating evidential
quality are as far away as ever” (Young et al 2002: 223).
Evidence as:
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“Expert knowledge; published research;
existing statistics; stakeholder
consultations; previous policy evaluations;
the Internet; outcomes from consultations;
costings of policy options; output from
economic and statistical modelling.”
Impact Evaluation
Policies
Public, Administrative, Clinical
Health Research
Operation
Monitoring
HIS
MIS
Intrasectoral Governance
Intersectoral Leadership
Intrasectoral Operations
Intersectoral Operations
Health Outcomes
Evidence Based Policy Making
Impact Evaluation
Policies
Public, Administrative, Clinical
Health Research
Operation
Monitoring
HIS
MIS
Intrasectoral Governance
Intersectoral Leadership
Intrasectoral Operations
Intersectoral Operations
Health Outcomes
The rational decision model
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At a more fundamental level, these narratives about
evidence-based policy seems to imply a particular
model or theory of policy-making: the rational decision
model.
This is because they all imply that if only research were
accessible, timely, relevant, comprehensive, reliable
and replicable, and if only policy-makers could be
converted to using it, then research could be rationally
fed into the policy-making process and would make a
discernible improvement to policy decisions and
outcomes.
Janowitz (1972) describes this relationship between
research and policy in the ‘engineering model’, where
applied research has a direct and specific influence on
policy-making, in that it supplies resources which are
then used to solve practical problems.
The rational decision model
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This model sees policy-making as
coherent, scientific, objective, rational,
within a controlled climate without
interference from outside. In particular,
the process obviously takes place within a
climate of elegant consensus, in which
the problem, objectives and potential
policy solutions, even if initially unclear,
are shared and agreed.
The rational decision model
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Shared knowledge is an important creator of
this consensus.
Research and information would be vital at
several different stages:
Analysis of the problem (to allow objectives to
be set),
Analysis of the solutions (to find and analyze
the ‘best solution to the problem’)
Analysis of implementation (to follow through
and evaluation progress after the policy
recommendation has been made).
The rational decision model
Platt (1972)
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…all the work which I have placed within the
‘dominant’ tradition of policy-related research
demonstrated faith in a [rather straightforward
and] rationalist model of research input to
policy, where empirical data can be fed in at
appropriate stages to guide the course of
policy-making: to document the existing state of
affairs, to assess the feasibility of alternative
outcomes, and to design the mechanisms for
bringing about change.
The rational decision model
Lane (1993)
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This model lacks behavioral realism: “In certain
choice situations it may be normatively relevant
to policy-makers; however, it fails to offer
guidance to the understanding of policy-making
characterized by choice situations involving
multiple imprecise goals and extensive
uncertainty”.
It also does not take into account collective,
rather than individual, decision-making. As an
idealized model, it is virtually impossible to find
examples of decisions which are made in this
way.
Alternatives
‘Science of muddling through’
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One of the earliest challenges to the rational
decision model came from Lindblom, who is
perhaps most famous for his description of the
‘science of muddling through’ (or
incrementalism).
Lindblom describes an irrational and complex
model of policy-making, going beyond the
actions of individuals and groups.
He suggests that policy-making is when
“somehow a complex set of forces together
produces effects called ‘policies’ “
‘Garbage-can’
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A similar model is set out by Cohen,
March and Olsen (1979), who describe
the ‘garbage-can’ model.
Outcomes are separated from the
intentions of the actors and no individual
actor or group of actors can guide the
process through to the desired result.
This is a much more anarchic process, in
which decisions are less “made” than
“come about”.
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Mulgan, who suggests that civil servants
tend to “muddle through” in order to “get
by”.
Parry and Morriss ask ‘When is a
decision not a decision?’.
They describe “decisionless decisions” as
situations of drift where a series of smaller
decisions commits each actor towards a
bigger decision which he would not have
independently contemplated.
Dependence of decision-making
on power-bargaining Minogue (1993: 16)
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Choices… are made: but they are made
through political processes in which groups
representing different policy areas bargain, and
construct trade-offs; or, alternatively, where
some groups, or one group, succeed in
imposing their political power (however based)
to the extent of winning a larger share of
resources than other groups.
Moreover similar competitive struggles take
place not only between policy arenas but within
specific policy areas. The outcomes of such
struggles are not determined by rational
techniques of decision-making.
Heroic model of policy-making Edwards (2000)
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Policy makers are who know what they want
and set out to get it without recourse to
supporting or opposing evidence... And the
nuisance from the researchers’ point of view is
that this is a legitimate point of view in a
democracy: election legitimizes the weakest
and craziest of policy beliefs. They derive from
value preferences that can, but need not be,
affected by knowledge.
The heroic model is guided by ideological
conviction, and the policies are very often
intended to be vote-winners.
The indirect effect of research
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Rein (1976) stated that social science did influence
public policy; but the link was rarely consensual, elegant
or self-evident. The link is not elegant or self-evident,
because the policy- making process is too complex to
point to particular pieces of data as ‘leading to’ policy
decisions.
The research does in fact find its way into the politicoadministrative decision-making process in a
“roundabout and murky” way .
“Scientifically generated knowledge constitutes an
important, but on the whole unquantifiable part of the
enormous store of knowledge which participants in the
politico-administrative decision-making process apply to
their practical tasks” (1995).
Sibeon (1996)
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Policy outcomes may to some extent be
affected by social science knowledge, but even
when this happens, outcomes involve a great
deal more than the straightforward application
of social science knowledge.
The operation of values, judgments, resource
limits, organizational and professional interests,
changes in the conditions of action, shifting
configurations of power in actor networks, etc,
are all factors that combine in complex and
sometimes unpredictable ways to influence
policy decisions and outcomes.
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Here, research is part of this complex,
pressured and shifting policy process, not
merely an input into it (Bulmer 1982).
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The rational decision model assumes that facts
are the most essential arguments in any case,
and that decision-making can be made more
rational if the facts are clearer.
However, as Parsons argues against positivism,
“it is important to note … that there are no
‘facts’ out there.
Data is not neutral, but is the result of an
exercise of values, beliefs and assumptions.
(Parsons 1995)
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“The crucial issues in a policy debate are
not so much matters of fact as questions
of interpretation.”
“Policy analysis is really about persuasion
and argument rather than neutral expert
advice” (Parsons 1995).
Marshall (2001)
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Politicians may prefer to ignore evidence
in preference for ideological or politically
popular choices about ways to tackle
problems
“it was a politically motivated decision”
“This is what the government was doing
and who cares about research? That’s the
government’s attitude.”
“Intuition beats proven causality every
time”.
Four different models of situations in which
groups of policy makers act and use information,
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Poker players (where competitive policy makers keep
control of valuable information, especially that which
would bolster their own position)
Chess players (where professional policy analysts value
and share formal data, according to tightly defined rules,
within their own unit or department)
Snap! players (where policy makers make essentially
opportunistic use of unstructured information and
evidence, in order to enhance their own influence)
Football players (where faction members use evidence
opportunistically, particularly evidence which supports
their ideology and will help to bind them together as a
team).
Types of research utilization
1. Instrumental use
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Research feeds directly into decision-making for policy and practice.
2. Conceptual use
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Even if policy makers or practitioners are blocked from using findings, research
can change their understanding of a situation, provide new ways of thinking
and offer insights into the strengths and weaknesses of particular courses of
action. New conceptual understandings can then sometimes be used in
instrumental ways.
3. Mobilisation of support
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Here, research becomes an instrument of persuasion. Findings – or simply the
act of research – can be used as a political tool and legitimate particular
courses of action or inaction.
4. Wider influence
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Research can have an influence beyond the institutions and events being
studied. Evidence may be synthesised. It might come into currency through
networks of practitioners and researchers, and alter policy paradigms or belief
communities. This kind of influence is both rare and hard to achieve, but
research adds to the accumulation of knowledge that ultimately contributes to
large-scale shifts in thinking, and sometimes action.
Improving dissemination
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Recommendations for research
commissioners
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Time research to deliver solutions at the right time to
specific questions facing practitioners and policymakers.
Ensure relevance to current policy agenda.
Allocate dedicated dissemination and development
resources within research funding.
Include a clear dissemination strategy at the outset.
Involve professional researchers in the
commissioning process.
Involve service users in the research process.
Commission research reviews to synthesize and
evaluate research.
Improving dissemination
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Recommendations for researchers
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Provide accessible summaries of research.
Keep the research report brief and concise.
Publish in journals or publications that are user friendly.
Use language and styles of presentation that engage interest.
Target material to the needs of the audience.
Extract the policy and practice implications of research.
Tailor dissemination events to the target audience and evaluate
them.
Use a combination of dissemination methods
Use the media.
Be proactive and contact relevant policy and delivery agencies
Understand the external factors likely to affect the uptake of
research.
Encouraging better use of
evidence in policy making
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Increasing the pull for evidence
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Require the publication of the evidence base
for policy decisions
Require departmental spending bids to
provide a supporting evidence base
Submit government analysis (such as
forecasting models) to external expert
scrutiny
Provide open access to information – leading
to more informed citizens and pressure
groups.
Encouraging better use of
evidence in policy making
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Facilitating better evidence use
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Encourage better collaboration across internal
analytical services (e.g. researchers, statisticians
and economists)
Co-locate policy makers and internal analysts
Integrate analytical staff at all stages of the policy
development process
Link R&D strategies to departmental business plans
Cast external researchers more as partners than as
contractors
Second more university staff into government
Train staff in evidence use
Decision Makers
Policy Makers
Politicians
Board Members
Managers
Institutional CEOs
Program Managers
Service Professionals
Physicians
Nurses
Problems
Solutions
Researchers
Mission Oriented
In-house Employees
Management Consultants
Applied Research Institutes
Insulated Academics
Discovery Driven
Decision Makers
Issues and Priorities
Policy Makers
Research
Funders
Service Delivery
Problems
Managers
Service Professionals
Dx, Tx, Px
Applications
Commercial R&D
Grant Agencies
Self-funding
Solutions
Problems
Discovery
Researchers
Incentives
Mission Oriented
Researchable
Questions
Discovery Driven
Decision Makers
Ideas
Knowledge
Purveyors
Policy Makers
Best Practice
Stories
Research
Funders
Applications
Interventions
Service Professionals
Dx, Tx, Px
Discovery
Problems
Facts
Personal
Experiences
Anecdotes
Interests
Wants
Values
Myths
Assumptions
Service Delivery
Problems
Managers
Solutions
Public Relations
Media
Think Tank
Conferences
Journals
Books
Issues and Priorities
Researchers
Incentives
Mission Oriented
Researchable
Questions
Evidences
Discovery Driven
Decision Makers
Ideas
Knowledge
Purveyors
Stories
Issues and Priorities
Policy Makers
Best Practice
Service Delivery
Problems
Managers
Research
Funders
Applications
Interventions
Service Professionals
Dx, Tx, Px
Discovery
Anecdotes
Interests
Wants
Values
Myths
Problems
Solutions
Facts
Researchers
Incentives
Mission Oriented
Researchable
Questions
Evidences
Discovery Driven
Decision Makers
Ideas
Knowledge
Purveyors
Stories
Issues and Priorities
Policy Makers
Best Practice
Service Delivery
Problems
Managers
Applications
Interventions
Service Professionals
Researchers
Problems
Knowledge Brokers
Solutions
Anecdotes
Interests
Wants
Values
Myths
Dx, Tx, Px
Discovery
Solutions
Facts
Research
Funders
Incentives
Mission Oriented
Researchable
Questions
Evidences
Discovery Driven
Questionable Quality
Irrelevant
1-Ethical Expert
1-Knowledge Purveyor
2- Knowledge Creator
3-Knowledge Broker
Evidence
1-Political Bargainer
Ambiguous
Loose
Ethics
Always Important !
Policies
Role of Gifted and Talented:
Politics
Thank You !
Any Question ?