De la evidencia... a la toma de decisiones Reflexiones desde el Observatorio Seminarios de Innovación Sanitaria Madrid, 16 Abril 2010 Josep Figueras
Evidence base health policy Limited availability of evidence When available it is not always relevant And/or.does not always affect decision making Lack of evidence transfer to policy But when it is adopted into policy. it does not always gets implemented Reform failure often to do with process than content Need evidence on process and implementation
Broader understanding of evidence Other types of less scientific evidence Findings from research and any other analytical information that serves as a useful lbasis for decision i making in public health and health care WHO EURO
Improving evidence use relies heavily on understanding the policy decision making process
In an ideal world New Knowledge Policy Makers Policy Change
Policy process Decision making process rarely clear cut, never a simple linear process; lots of factors/ influences to take into account [Lavis 2008, Popay & Elliot 2000] E.g. Political, Equity, Ethics, Consumer and Industry Lobbying, Media, Decision making may be more influenced by ideas not data. [Weiss 1979]
A (very) basic decision making framework Assess health needs Burden of disease Risk factors EU Health Policy Objectives (Values) EU Con ntext Evidence on interventions Subsidiarity EU value added Implementation Political economy Stakeholders
there is no more delicate matter to take in hand, nor more dangerous to conduct, nor more doubtful in its success, than to set up as a leader in the introduction ti of changes For he who innovates will have for his enemies all those who are well off under the existing order of things, and only lukewarm supporters in those who might be better off under the new (.) partly from the incredulity of mankind, who will never admit the merit of anything new, until they have seen it proved by the event
Outline Investigadores vs tomadores de decisiones: la historia de dos comunidades Transferir evidencia: lecciones Estrategias para una transferencia efectiva Ejemplos: Observatorio, Bridge, Evidence ambassadors, HEN network. Knowledge brokers
Researchers vs decision makers in public policy making, many suppliers and users of social research are dissatisfied, the former because they are not listened to, the latter because they do not thear much what tthey want tto listen to Lindblom, 2002
Because what you Yes, told me is l You how absolutely must did Where correct but be you a am researcher know? completely I? useless The problem Because you don t know where you are, You re you Yes. 30 don t know You must be a policy metres where you re going, How above and did you the now maker you re ground know? in a blaming balloon me Martin McKee, 2003
From the academic ivory tower Rational, objective &interested t on new ideas Ask questions of little concern and that we already know the answer But does not ask questions difficult to answer Speak their own language ridden with jargon Ignore context More research is required The jury is still out..
From the academic ivory tower Rational, objective &interested t on new ideas Should we be doing this sort of thing in an academic environment? Doesn t it detract from doing real research? Isn t it enough just to publish a paper? Interacting ti with policy-makers doesn t pay the bills.
To the day to day of reactive politics Pragmatic, action oriented and societal responsive Want answers in bullet points.and quickly (usually yesterday!) Push for the quick and dirty Swayed by factors unrelated to evidence Driven by politics (& mostly) political ambition
Lessons in evidence transfer Personal contact Trust Directly linked to personal contact Credibility (quality of research/experts) Objective: neutral (non normative) Timeliness Political agenda windows of opportunity Key in evidence s relevance Provide summary & recommendations Based on Innvaer et al, 2002
Lessons in evidence transfer Client and policy question (not research) driven Translation into research questions How many beds do we need? How many beds do different countries have? Why do we need beds? What are the alternatives to beds? Will changing the number of beds increase or reduce costs? What can we learn about introducing i change?
Lessons in evidence transfer Client and policy question (not research) driven Context specific A confounding variable or the objective of research Context tends to be what is left over when the obvious factors have been dealt with Key in policy transfer
SHI is first and foremost a way of life, a stable, tradition-bound social institution in which h economic implications play an important role but do not exercise primary influence over decision making Saltman, Busse & Figueras, 2004
The specific structure and organization of social health insurance is grounded in the bedrock of social solidarity, of a system of social cohesion that reflects national culture and social preferences Saltman, Busse & Figueras, 2004
Policy settings / contextual factors For both: exporters & importers (lenders & borrowers) Culture (Weltanschauung, Checkland, 1991) Political structures and administrative arrangements Political cycle ( window of opportunity ) Ideology (relative to policy proposed) Problem severity Resource availability (political, financial, technical,..) Role of internal policy entrepreneur Geographic / cultural proximity e.g. competition, communication channels
Lessons in evidence transfer Client and policy question (not research) driven Context specific Acknowledge limitations of evidence Ceiling on impact Aim: evidence informed decision i making Decision based on (not made by) evidence The role of value trade-offs i.e. higher impact of research when confirms political self interest
Activities and mechanisms Linkage & exchange Support to research uptake Active dissemination Passive dissemination (e.g. publication in journals) Ettelt and Mays 2010
A Need to Disseminate Clear Actionable Messages Need to disseminate clear actionable messages to different stakeholder groups from a range of knowledge Yet surveys indicate that researchers continue to spend time identifying questions, conducting evaluations and refining methodologies rather than communicating with decision i makers. [e.g. Stryer et al 2000]
Activities and mechanisms Active research dissemination As requirement for research funding Knowledge centres promoting dissemination & providing syntheses of evidence; Databases of studies Support of research uptake tk by policy makers Policy staff trained in research appraisal Research use as a decision making requirement (e.g. HTA) Policy advisory committees involving researchers Ettelt and Mays 2010
Activities and mechanisms Linkage and exchange Defined as the process of ongoing interaction, collaboration, and exchange of ideas between the researcher and decision making communities (CHSRF) The few examples include Multi professional networks (again largely HTA) Secondments and exchanges Intermediaries Ettelt and Mays 2010
Interpersonal networks Central actors & source of knowledge Networks that share professional background, experience, political similarity, psychological identification, geographical proximity Face to face network exchanges are key. most tindividuals id do not evaluate an innovation on the basis of scientific studies of its consequences instead, most people depend mainly upon a subjective evaluation of an innovation that is conveyed to them from other individuals like themselves who have previously adopted the innovation. ( ) So diffusion is a very social process. Rogers, 2003, Diffusion of Innovations
Intermediaries Organisations Government related research institutes/agencies /g Health sector related research institutes/agencies International/European organisations Private non profit bodies (e.g. foundations) Individuals Research liaison staff in policy organisations Ettelt and Mays 2010
Information packaging g mechanisms e.g. policy briefs Interactive knowledge sharing mechanisms e.g. policy dialogues Organization models for knowledge brokering e.g. attachment to ministries?
The Observatory: a partnership that reflects evidence-based policy-making International agencies WHO Regional Office for Europe, the World Bank, the European Investment Bank, the European Commission, the Open Society Institute National and regional governments Belgium, Finland, France, Greece, Ireland, Norway, Spain, Sweden and Slovenia, the Netherlands as well as the Veneto Region of Italy Academia the London School of Economics and Political Science (LSE), the London School of Hygiene & Tropical Medicine (LSHTM)
The Observatory s s core mission We support and promote evidence-based health policy-making through comprehensive and rigorous analysis of the dynamics of health care systems in Europe. Country monitoring Health systems and policy analysis Disseminating the evidence Assessing performance (new!)
3. Dissemination: Reaching policy makers Web Listserve Publications Eurohealth Eurobserver OUP series CUP Series Occassional series Policy briefs Journals Joint series BMJ Conferences EHMA, Gastein, EUPHA,.. Policy dialogues
Policy briefs HEN WHO and Observatory series Focus to policy makers needs Address practical (key) policy questions Targeted and opportunistic Implementation considerations Not normative / lessons on policy options 1 /3 / 25 structure Timing Briefs for the Belgium and Spanish presidencies
Face to face International expert conferences E.g. Annual sessions in EUPHA, EHMA, Gastein Participation in key networks National conferences & country meetings Workshops and seminars for policy makers HiT and study launches
Policy dialogues Key strategic questions / policy windows Rapid reaction triggers Demand driven / supply induced Co-organised with policy makers Target small group of senior policy makers Evidence on alternative options Emphasis on implementation Evidence as a neutral platform for consensus
Peer Dissemination :The Ambassador Programme Initiated in 1996: SBU Swedish Council on Health Technology Assessment conducts evidence based reviews 40 Ambassadors, at least one in each of Sweden's counties used to help disseminate message Clinicians who are also local opinion leaders; receive initial and on-going centralised seminar-based training Impact: Evaluations in Sweden and Canada indicate approach can help peers become aware and make use of knowledge Impact: Led to some recognition of need for more capacity to understand and interpret information from reports Rashiq et al 2006, Jonsson & Britton 2002
In conclusion Still too little emphasis on bridging research and policy It is a full time activity; needs strategic approach Need to be much more active but start with easy to achieve objectives Recognise that takes time; constant dialogue;building grelationships etc Learn from others / including commercial sector
Outline Investigadores vs tomadores de decisiones: la historia de dos comunidades Transferencia de la evidencia: lecciones Estrategias para una transferencia efectiva Ejemplos: Observatorio, Bridge, Evidence ambassadors, HEN network. Knowledge brokers