Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
National Institute of Public Health, Phnom Penh, Cambodia.
Health Res Policy Syst. 2017 Nov 10;15(1):95. doi: 10.1186/s12961-017-0260-2.
Discussions within the health community routinely emphasise the importance of evidence in informing policy formulation and implementation. Much of the support for the evidence-based policy movement draws from concern that policy decisions are often based on inadequate engagement with high-quality evidence. In many such discussions, evidence is treated as differing only in quality, and assumed to improve decisions if it can only be used more. In contrast, political science scholars have described this as an overly simplistic view of the policy-making process, noting that research 'use' can mean a variety of things and relies on nuanced aspects of political systems. An approach more in recognition of how policy-making systems operate in practice can be to consider how institutions and ideas influence which pieces of evidence appear to be relevant for, and are used within, different policy processes.
Drawing on in-depth interviews undertaken in 2015-2016 with key health sector stakeholders in Cambodia, we investigate the evidence perceived to be relevant to policy decisions for three contrasting health policy examples, namely tobacco control, HIV/AIDS and performance-based salary incentives. These cases allow us to examine the ways that policy-relevant evidence may differ given the framing of the issue and the broader institutional context in which evidence is considered.
The three health issues show few similarities in how pieces of evidence were used in various aspects of policy-making, despite all being discussed within a broad policy environment in which evidence-based policy-making is rhetorically championed. Instead, we find that evidence use can be better understood by mapping how these health policy issues differ in terms of the issue characteristics, and also in terms of the stakeholders structurally established as having a dominant influence for each issue. Both of these have important implications for evidence use. Contrasting concerns of key stakeholders meant that evidence related to differing issues could be understood in terms of how it was relevant to policy. The stakeholders involved, however, could further be seen to possess differing logics about how to go about achieving their various outcomes - logics that could further help explain the differences seen in evidence utilisation.
A comparative approach reiterates that evidence is not a uniform concept for which more is obviously better, but rather illustrates how different constructions and pieces of evidence become relevant in relation to the features of specific health policy decisions. An institutional approach that considers the structural position of stakeholders with differing core goals or objectives, as well as their logics related to evidence utilisation, can further help to understand some of the complexities of evidence use in health policy-making.
在卫生界的讨论中，经常强调证据在为政策制定和实施提供信息方面的重要性。对循证政策运动的支持很大程度上源于对政策决策往往缺乏对高质量证据的充分参与的关注。在许多这样的讨论中，证据仅在质量上有所不同，并假定如果能够更多地使用证据，就可以改善决策。相比之下，政治科学学者将这种观点描述为对决策过程过于简单化的看法，并指出研究“使用”可能意味着各种不同的事情，并依赖于政治系统的细微方面。一种更能认识到政策制定系统在实践中运作方式的方法是，考虑机构和思想如何影响哪些证据似乎与不同的政策过程相关，并在这些过程中得到使用。
本研究借鉴了 2015 年至 2016 年在柬埔寨与卫生部门主要利益攸关方进行的深入访谈，调查了三个截然不同的卫生政策案例（即烟草控制、艾滋病毒/艾滋病和基于绩效的薪酬激励）中被认为与政策决策相关的证据。这些案例使我们能够研究在问题的框架以及考虑证据的更广泛机构背景下，政策相关证据可能因情况而异的方式。
尽管所有这些案例都在广泛的循证政策制定政策环境中进行讨论，但三个卫生问题在政策制定的各个方面使用证据的方式很少有相似之处。相反，我们发现，通过绘制这些卫生政策问题在问题特征方面的差异，以及在结构上被确定为对每个问题具有主导影响的利益攸关方方面的差异，就可以更好地理解证据的使用。这两个方面对证据的使用都有重要的影响。关键利益攸关方的不同关切意味着，可以根据证据与政策的相关性来理解与不同问题相关的证据。然而，可以进一步看到，所涉及的利益攸关方在实现其各种结果的方式上具有不同的逻辑——这些逻辑可以进一步帮助解释证据利用方面的差异。
比较方法重申，证据不是一个统一的概念，不是越多越好，而是说明了不同的结构和证据如何与特定卫生政策决策的特征相关。一种考虑具有不同核心目标或目的的利益攸关方的结构地位以及他们与证据利用相关的逻辑的机构方法，可以进一步帮助理解卫生政策制定中证据利用的一些复杂性。
