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Evaluating the claim of Greenhalgh and Russell that policy-making is about the negotiation of social values and not simply a rational and scientific process.
Much emphasis has been placed on the idea of using evidence to inform policy over the last decades. Policy decisions are expected to be made from accurate and robust use of scientific evidence with believing that evidence tells us what works. Evidence-based policy making is seen as a linear process where an identified policy problem has been solved by selection, synthesis, and evaluation of best research evidence. Despite this seemingly self-evident concept, some have been highly critical about the idea of social policy making only based on scientific evidence alone neglecting the complexity of the policy process. This notion has been criticized as naïve rationality. And this criticism challenges many policy decisions taken by simply counting evidence without recognition of multiple social values and concerns. This conflict has divided individuals into two groups; one is positivist who believes in Evidence-based policy and other is critical interpretivist who doubts its feasibility.
According to Greenhalgh and Russell, policy process is complex, context-based and value-driven where multiple actors negotiate their competing interest as an individual or in a group. And positivist view of simply narrowing the policy process as evidence-based makes it impossible to explore the main elements of policymaking. They also noted that the argumentation and debate offer insights about policy-making process and have the potentiality to improve it through understanding social values and collective reflection of multiple stakeholders (Greenhalgh and Russell, 2009).
I also think these claims are important to address to improve the use of evidence in policymaking. Neither simply answering what works by doing more research nor can the careless administration of evidence hierarchies improve the use of evidence in policymaking. It demands a deeper exploratory investigation of political realities, social values, and policy goals. The current practice of single framing of evidence-based policy, exercises the quantification forms to prioritize option distract the alternatives. Only using extensive mathematical modeling remove the alternatives from the policy process considering as de facto. However, alternatively, qualitative storytelling would offer different lenses to perceive what the problem is and will open the universe of possible frames sensitive to the different actors, interests, and norms.
Greenhalgh and Russell’s claim:
Greenhalgh and Russell (2009) claim that policymaking does not mean the application of scientific evidence to solve problems rather it raises the problems through contemplation and negotiation and determine context and value sensitive choices in the reality of uncertainty.
Evidence-based Policy (EBP)
To realize their claim at first we need to understand the evidence-based policy. Evidence-based Policy (EBP) is an approach that ‘helps people make well-informed decisions about policies, programmes, and projects by putting the best available evidence from research at the heart of policy development and implementation’ (Davies, 2004). EBP is a rational, rigorous and systematic approach or a mechanism to inform policy process which does not directly affect the policy goals.
EBP making is not a new concept. In ancient Greece, Aristotle introduced that different kind of information should be used in rulemaking. However, after the Second World War, the use of evidence to make social policy grew significantly (Nutley, Walter and Davies, 2007). Yet, many assume that it was 1990 that modern EBP movement took shape when the UK government embraced the concept (Parson, 2002).
The assumption of evidence-based policy:
Greenhalgh and Russell (2009) pointed out that the concept of EBP is established on the assumption of the hypothesis that policy decisions should be taken by using the best available evidence and incorporating rational analysis. EBP assume that policy is a purposive course of action by setting up specific objectives following a careful assessment of different ways of gaining those objectives and implementation of the selected plan of actions. Within this rational model, EBP preferred quantitative studies over qualitative through putting emphasize on analysis on more and better data which is empirically tested and validated and produce context neutral and value-free evidence. Hence, with the notion of the increasing use of scientific evidence randomized control trials, systemic review or meta-analysis are placed at the top of hierarchies of evidence as they considered as gold standard due to their controlled experiments and known effect size and as such produce the best evidence of “what works”. And current EBP also assumes that reliable and validated evidence can determine a perfect course of action. And the deficiency can only occur if there are methodological flaws in the design or execution level.
Limitation of evidence-based policy:
No matter how much appealing the idea of what works” seems numerical empirical studies on policy making process highlight the problems of this idea (Parkhurst, 2017). Greenhalgh and Russell’s (2009) critical analysis challenges the epistemological principle of current evidence-based practices as they demonstrated that evidence is not the only issue that can be faced by the policy makers ethically or morally; that undertaking more or bigger studies are not going to resolve the deficiencies in evidence; that only a number of technical solutions cannot make appropriate policy. Cairney and Oliver (2017) also demonstrated that policy decisions are not only about evidence-based choices rather they are value driven, context-specific and politically influenced judgments. Sanderson (2002) stated that this constructivist perception may emphasize the need of developing sound evidence for the policy through long-term impact evaluation using multi-methods approach.
Though, we need a robust clinical trial to inform policy that only is not enough to make right policy in a particular context. The difference in context, social values, and social desirability as well as budget or time constraints caused evidence-based policy making diffuse, haphazard process. According to Greenhalgh and Russell, the notion of “what works” conceal the other important concern. Sanderson (2003) also argued that in addressing complex and puzzling problems the concern should be extending from “what works” to “what is appropriate”. As Hammersley’s (2001) Greenhalgh and Russell argue that application of evidence to policy also impair the practical wisdom or Aristotle’s praxis and diminish the confidence among practitioners’ to use professional knowledge and experience to make decisions. Research evidence can also be debatable due to the underlying issue of uncertainties, framing or preoccupied assumptions of research questions.
In reverse to these claims, positivist argue that the way medical policies have decided using evidence from rigorous research or systemic reviews so too should policy in other social realms. Indeed. Due to the development of evidence-based medicine the health sector is referred to as a leading inspiration for EBP. The use of robust experimental methods to estimate effect and evaluate interventions has been revolutionized the clinical field by providing the answer of what works in clinical treatment and that took evidence-based policy movement in one step further. From the cancer treatment to heart disease to treat diarrhea which saved 50 million lives in developing countries, everything has been evaluated through experimental studies. The EBP champions would also argue that along with new intervention EBP can also stop the use of harmful treatments (Howick, 2011).
Nevertheless, critical interpretivist thinks evidence-based policy movements’ offer technical fix to complex problems of priority settings in the health sector. According to Klein and Williams (2000), setting priorities for health care is a discursive process which involves argument and debate where policymakers not always respond to the “problems” that exist, rather frame problems and thereby shape what can be thought about and acted upon. Interpretivists consider evidence as a critical analysis of the political, social, and economic conditions reproduce through different perceptions, social interactions, adaptations and negotiations of various actors involved in policy making. Greenhalgh and Russell (2009) inspire us to think about policymaking as iteration, developing collective understanding or enactment of knowledge.
Political theorists have also pointed out that the idea of evidence-based policy inordinately raises the role of science in solving diffuse sociopolitical problems. While the rationalists’ drop “political context” as a distressing side issue.
Analysis of a qualitative study:
This part of the writing is based on the analysis of a study “Understanding the Normalization of Telemedicine Services through Qualitative Evaluation” (May et al., 2003). This study highlighted that the rationalized linear model is insufficient to assess the implementation and normalization of telehealth care and the political, organizational, and ‘‘ownership’’ problems need to be taken into consideration for the better outcome. Analysis of qualitative data from three studies through observation and semi-structured interviews gave a fair understanding of what is appropriate for the successful normalization of telemedicine systems. In spite of increased interest in the use of telecommunications in clinical practice, a large number of quantitative data regarding interventions does not explain the failure of normalization of telemedicine systems across different applications. To understand this failure qualitative data is needed which can answer the question of why and how many services fail to endure.
This study showed that the implementation of telemedicine services depends on political factors such as linkage between local and national level, funding conflict and the development of appropriate infrastructure. It also depends on the structural dynamics of the settings. The study showed that the tele healthcare can be effectively implemented if the local actors possess sufficient institutional power. Inter-organizational conflict regarding the legality of the appropriateness of telemedicine is also hampering the normalization of it. Quantitative approach fails to assess these factors and this rigorous qualitative study has filled the conceptual vacuum produce by such failure.
This study revealed that the clinicians found it hard to integrate this new model into their practice due to practical and logistics barrier where the implementers and policymakers underestimate this challenge. Whereas this different view about reality is important for suitable policy making it can only be disclosed through a critical interpretive study. This supports the interpretivist argument about the shortcoming of quantitative study in order to understand the socially constructed reality.
The study showed that evidence obtained from earlier RCTs did not translate into clinical practice because they do not tell the whole story about what is needed to make telemedicine systems work. In contrast to that this qualitative study demonstrated that translation of telemedicine technologies into clinical practice relies on the engagement of divergent actors collectively where their professional identities and power are well defined through negotiations.
Another barrier for normalization of telemedicine is the concept of co-presence during clinical assessment among both the clinicians and patients. Due to this deeply rooted value clinicians are not considering telemedicine as good practice nor do the patients perceive this as satisfactory experience. This showed us that individual’s perception and views need to be taken into consideration during undertaking a policy and should be evaluated through interpretive studies.
This paper pointed out that in any tele healthcare context complexity exists in different level among different stakeholders and due to framing simplicity by underestimating the complexity over the name of evidence-based policy is hampering the telemedicine programs to become normalize within its settings. Of course one can argue that qualitative research technique that has used is not statistically generalizable. But the counterclaim is that generalizations and statistical realities do not certainly coexist with cultural or contextual realities. Due to the complex nature telemedicine programs are implementing in ways completely different than anticipated. Hence the quantitative approach is unable to answer the concern of policymakers because the null hypothesis cannot be easily proven.
The problem is not that all the experimental studies are inherently flawed; rather they are being applied inaccurately, used to prioritize policy choices or fail to address the question of applicability across context. Several authors have noted the limitation of hierarchies of evidence in policy decisions taking the EBP debate further (Cartwright and Hardie, 2012; Parkhurst and Abeysinghe, 2016). The policy process is incremental and interactive. Understanding this dynamics of policy process will call upon a long-term engagement to the in-depth study of multiple social programs and thus the need for qualitative work. Tierney also demonstrates that interpretive research using narrative have the potentiality to provide context-sensitive, depth understanding usually quantitative studies would miss out (Tierney, 2011).
Furthermore, only Scientific” evaluation can assume the relationship between variables but the process of creating those variables may remove necessary contextual features need to explain the policy process. It can also draw attention from the actors involved in the play who express emotions, perform power relationships, and produce and act with conflict. Hence critical interpretive research is essential for producing appropriate evidence in a real world to capture the multiple conflicting framings and inherent tensions.
According to Greenhalgh and Russell (2009), interpretivist and critical research on the nature of policymaking shows that a theoretical framework with focusing on language, argumentation, and discourse is required to understand the deliberative policy process. Their analysis argued that Aristotle’s processes of rhetorical argumentation will more effectively address the policy questions whereas the EBP on healthcare policymaking tends to define the policy process only as evidence in an objective, dispassionate way. Rhetorical theory reminds us of the necessity of shifting equating rationality with current EBM-practices to consider rationality as a placed, possible human structure. Sanderson (2004) suggests that this alternative perception of rationality and concentration on the reason giving, argument, and judgment will make the policy process more vigorous.
Several other academics prioritize the idea of use theories to look into deeper in the policy studies. Smith (2013) noted that “it makes more sense to study the political influence of ideas than evidence”. Lewis (2003) also talked about argumentation and framing theories to signify the importance of discursive policy practices informing evidence use. However, John (2013) and Carney (2007) both have argued that among a large number of theories that are drawn to help us understand policy process, no single one of these can describe all form of policy making, rather they give multiple lenses by which different aspects of policy process can be analyzed.
The atheoretical approach taken by the positivist produced a number of predetermined steps that are mechanically applied to various interventions without considering the content, setting, participants or implementing organizations of the interventions. Rather theory can provide a framework to understand the process, outcome, context, and actors involved in the intervention and thus influence the effectiveness of the intervention. Moreover, the notion of using theory doesn’t necessarily negate the implication of experimental studies rather theory can also be used to help hypothesis development and guide on strategic design issues.
The policy process is intricate and complex and such processes cannot be viewed in a linear approach. Qualitative and interpretive research facilitates a profound, sophisticated understanding through grasping the immensity and complexity of such policy processes. For better policy implementation relying only on experimental studies will lead to failure. The realistic policy must require the understanding of contextual factors and the process by which policy act in addition to calculating outcomes. The question “what works”’ needs to be supplemented by a whole range of further questions like “what is appropriate”, what is applicable”, what is desired” or “how/where/why it works” to address the full complexity of most policy scenarios. And also applying theories through the process of argumentation will help answer the research questions more appropriately which will generate better policy decisions.
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- May, C., Harrison, R., Finch, T., MacFarlane, A., Mair, F. and Wallace, P., 2003. Understanding the normalization of telemedicine services through qualitative evaluation. Journal of the American Medical Informatics Association, 10(6), pp.596-604.
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- Parkhurst, J.O. and Abeysinghe, S., 2016. What constitutes “good” evidence for public health and social policy-making? From hierarchies to appropriateness. Social epistemology, 30(5-6), pp.665-679.
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