Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, United States.
Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, United States.
Soc Sci Med. 2017 Mar;177:150-157. doi: 10.1016/j.socscimed.2017.01.056. Epub 2017 Jan 30.
Calls to enhance the use of scientific evidence in international health and development policy have increased in recent years; however, analytic frameworks for understanding evidence use focus narrowly on scientific research and were created using data and observations nearly exclusively from Western countries. We examine processes of health policy development in a case study of Niger, a low-income West African country that adopted integrated community case management of childhood illness (iCCM) beginning in 2007, resulting in measurable declines in child mortality. Data collection included in-depth interviews with policy actors in Niger (N = 32), document review (N = 103) and direct observation of policy forums (N = 3). Data analysis used process tracing methodology and applied an Aristotelian definition of "knowledge" as 1) episteme (facts), 2) techne (skills) and 3) phronesis (practical wisdom), while also using a critical perspective to understand issues of power. We found sharp differentials in policy-makers' possession and use of codified forms of knowledge (episteme), with Nigerien policy officers' access highly mediated by actors at international agencies. Government policy-makers possessed skills and capacities (techne) to negotiate with donors and deliberate and weigh conflicting considerations; however they lacked capacity and resources to formally evaluate and document programs and thus reliably draw lessons from them. Practical wisdom (phronesis) emerged as key to the iCCM policy enterprise, particularly among Nigerien government actors, who used logical and ethical arguments to make decisions later found to be critical to iCCM's success. While codified knowledge confers power on members of policy discussions who can access it, this represents only one form of knowledge used in the policy process and perhaps not the most important. Future research on evidence-based policy should use broader definitions of evidence or knowledge, examine on how power conditions the use of knowledge, and examine challenges specific to low-resource policy environments.
近年来，呼吁在国际卫生和发展政策中加强科学证据的使用有所增加；然而，用于理解证据使用的分析框架狭隘地关注科学研究，并且是使用几乎完全来自西方国家的数据和观察结果创建的。我们通过对尼日尔的案例研究来考察卫生政策制定过程，尼日尔是一个低收入的西非国家，于 2007 年开始采用综合社区儿童疾病管理（iCCM），导致儿童死亡率可衡量地下降。数据收集包括对尼日尔政策制定者（N=32）进行深入访谈、对文件进行审查（N=103）以及对政策论坛进行直接观察（N=3）。数据分析采用过程追踪方法，并应用亚里士多德对“知识”的定义，即 1）episteme（事实），2）techne（技能）和 3）phronesis（实践智慧），同时还使用批判性视角来理解权力问题。我们发现，政策制定者对编码形式的知识（episteme）的掌握和使用存在明显差异，尼日尔政策官员对国际机构行为者的参与度很高。政府政策制定者拥有与捐助者谈判、审议和权衡相互冲突的考虑因素的技能和能力；然而，他们缺乏能力和资源来正式评估和记录方案，因此无法从中可靠地吸取经验教训。实践智慧（phronesis）是 iCCM 政策企业的关键，特别是在尼日尔政府行为者中，他们使用逻辑和伦理论据做出后来被发现对 iCCM 成功至关重要的决策。虽然编码知识赋予能够获取它的政策讨论成员权力，但这只是政策过程中使用的一种知识形式，也许不是最重要的。关于循证政策的未来研究应该使用更广泛的证据或知识定义，研究权力如何影响知识的使用，并研究针对资源匮乏的政策环境的挑战。
