Professional Documents
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Evidence-Based
Policymaking
a critique
ABSTRACT The idea that policy should be based on best research evidence might
appear to be self-evident. But a closer analysis reveals a number of problems and para-
doxes inherent in the concept of “evidence-based policymaking.” The current conflict
over evidence-based policymaking parallels a long-standing “paradigm war” in social
research between positivist, interpretivist, and critical approaches. This article draws
from this debate in order to inform the discussions over the appropriateness of evi-
dence-based policymaking and the related question of what is the nature of policy-
making. The positivist, empiricist worldview that underpins the theory and practice of
evidence-based medicine (EBM) fails to address key elements of the policymaking
process. In particular, a narrowly “evidence-based” framing of policymaking is inher-
ently unable to explore the complex, context-dependent, and value-laden way in
which competing options are negotiated by individuals and interest groups. Sociolin-
guistic tools such as argumentation theory offer opportunities for developing richer
theories about how policymaking happens. Such tools also have potential practical
application in the policymaking process: by enhancing participants’ awareness of their
own values and those of others, the quality of the collective deliberation that lies at the
heart of policymaking may itself improve.
Just as no one would argue that clinicians should practice medicine without regard to evidence,
so it would seem an incontestable, self-evident proposition that policymakers should base their
decisions on evidence. . . . Once we move away from platitudinous generalizations and start
Research Department of Primary Care and Population Health, University College London.
Correspondence: Trisha Greenhalgh, Research Department of Primary Care and Population
Health, University College London, 206 Holborn Union Building, Highgate Hill, London N19 5LW,
United Kingdom.
E-mail: p.greenhalgh@pcps.ucl.ac.uk.
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unpacking the notion of EBP—modeled on EBM—it turns out to be highly contestable and
misguided.
— R. Klein (2000)
Evidence-Based Policymaking
were readily distinguishable from one another (the latter, for example, often took
a Marxist or feminist worldview and were published in “alternative” journals),
but the boundaries between these perspectives have blurred considerably over
the last few years. Note that classifying a study as “critical” in the philosophical
sense (in other words, as searching for hidden meanings and power struggles)
does not mean that the authors are necessarily “critical thinkers” (that is, com-
petent scholars). Many positivist studies are highly critical in the latter sense, and
some philosophically “critical” studies represent poor scholarship.
1 For additional examples of the naïve rationalist perspective on the policymaking process, see de-
tailed critiques by Sanderson (2003) and Wells (2007).
Source: Based on empirical studies and reviews of the policymaking process in health care; for detailed references,
see Russell et al. 2008.
Iteration: dialogical model Interpretivist:Weiss’s theory • Research evidence is one of several knowledge sources which policymakers draw on in an iterative
(Elliott and Popay 2000) of policy as enlightenment process of decision making. Other sources include their own experience, the media, politicians,
(Weiss 1977) colleagues, and practitioners.
• The influence of research on policymaking is diffuse, providing fresh perspectives and concepts as
well as data.
• Social knowledge is jointly constructed from the interactions between researchers and others.
Collective understanding Interpretivist:Wenger • The acquisition, negotiation, adoption, construction, and use of knowledge in decision making is
(Gabbay et al. 2003) communities of practice unpredictably contingent on group processes.
Enactment of knowledge Critical-interpretivist: Use of evidence depends on a set of social processes, such as:
(Dopson and Fitzgerald Polanyi personal knowl- • Sensing, interpreting, and integrating new evidence with existing (including tacit) evidence;
2005) edge (Polanyi 1962; • Relating new evidence to the needs of the local context;
Wenger 1996) • Reinforcement or marginalization by professional networks and communities of practice;
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These realities do not, of course, negate the hierarchy of evidence or the need
for adequately funded, well-designed research studies. Yes, we need robust epi-
demiological and clinical trial evidence to inform policy. But no, this evidence
will not, in and of itself, tell us what the right policy is for any particular situation.
Political theorists have also questioned the desirability of “evidence-based pol-
icy.” The very idea of evidence-based policy unduly elevates the role that science
can ever play in solving sociopolitical problems. Schwandt (2000), for example,
has argued that “as we increasingly look to science for guidance in overcoming
the quotidian problems of social life, there emerges the expectation of the mas-
tery of society by scientific reason” (p. 225).
The overriding emphasis in evidence-based policy on “what works” arguably
eclipses equally important questions about desirable ends and appropriate means.
What matters is not merely what works, but what is appropriate in the circum-
stances, and what is agreed to be the overall desirable goal (Sanderson 2003).The
problem, as critics of the evidence-based policy movement see it, is that politi-
cal problems are turned into technical ones, with the concomitant danger that
political programmes are disguised as science (Saarni and Gylling 2004).
Should we spend limited public funds on providing state-of-the-art neonatal
intensive-care facilities for very premature infants? Or providing “Sure Start”
programs for the children of teenage single mothers? Or funding in vitro fertil-
ization for lesbian couples? Or introducing a “traffic light” system of food label-
ing, so that even those with low health literacy can spot when a product con-
tains too much fat and not enough fiber? Or ensuring that any limited English
speaker is provided with a professional interpreter for health-care encounters?
Of course, all these questions require “evidence”—but an answer to the question
“What should we do?” will never be plucked cleanly from massed files of scien-
tific evidence. Whose likely benefit is worth whose potential loss? These are
questions about society’s values, not about science’s undiscovered secrets.
Hammersley (2001) has argued that the effect of the dominant culture of evi-
dence-based policy devalues democratic debate about the ethical and moral
issues faced in policy choices and erodes practitioners’ confidence in their abil-
ity to make judgments by marginalizing professional experience and tacit
knowledge (Hammersley 2001). The application of scientific method to con-
temporary life has led to the deformation of what Aristotle called praxis (practi-
cal wisdom or, in contemporary terms, embodied knowledge): “the ailment is
the growing inability to engage in decision making according to one’s own re-
sponsibility as we continue to concede that task to experts in all social institu-
tions” (Schwandt 2000, p. 225).
Interpretivist and Critical Perspectives on Policymaking
Table 2 shows a number of alternative framings of what policymaking is. In
contrast to “policymaking as getting [research] evidence into practice” (positivist
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Given conflicting values, the process of setting priorities for health care must
inevitably be a process of debate. It is a debate, moreover, which cannot be
resolved by an appeal to science and where the search from some formula or set
of principles designed to provide decision-making rules will always prove elusive.
Hence the crucial importance of getting the institutional setting of the debate
right . . . the right process will produce socially acceptable answers—and this is
the best we can hope for. (Klein and Williams 2000, 20–21)
A critical reading of this debate suggests that setting priorities for health care is
a discursive process (that is, it involves argument and debate).The policy-as-dis-
course perspective embraces a number of approaches that are centrally con-
cerned with how policy problems are represented. Policymakers are not simply
responding to “problems” that exist in the community, they are actively framing
problems and thereby shaping what can be thought about and acted upon.
According to Stone (1988): “The essence of policymaking in political com-
munities [is] the struggle over ideas. Ideas are at the centre of all political con-
flict. . . . Each idea is an argument, or more accurately, a collection of arguments
in favour of different ways of seeing the world” (p. 11).Within this conceptual-
ization of policymaking, the understanding of “what evidence is” takes on a very
There is no such entity as “the body of evidence.”There are simply (more or less)
competing (re)constructions of evidence able to support almost any position.
Much of what is called evidence is, in fact, a contested domain, constituted in
the debates and controversies of opposing viewpoints in search of ever more
compelling arguments. (Wood, Ferlie, and Fitzgerald 1998, p. 1735)
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Conclusion
Expressions such as “knowledge translation” and “getting evidence into practice”
are, as Klein suggested, seductive metaphors for the policymaking process. But
they are fundamentally inaccurate, because policymaking is not about applying
objective evidence to solve problems that are “out there” waiting for solutions.
It is about constructing these problems through negotiation and deliberation, and
using judgements to “muddle through”—that is, to make context-sensitive
choices in the face of persistent uncertainty and competing values (Lindblom
1959; Parsons 2002). Policymaking in health care, as in other fields of public pol-
icy, is thus about “framing and taming ‘wicked’ problems” (Gibson 2003).
As many leading protagonists of evidence-based clinical medicine and public
health have argued, research evidence can and should inform policy judg-
ments—but this evidence does not in and of itself provide the answer to the eth-
ical question of “what to do” (and in particular, “how to allocate resources”)
(Black 2001; Davey Smith, Ebrahim, and Frankel 2001; Gabbay and le May 2004;
Giacomini et al. 2004; Lomas 2005; Mulrow and Lohr 2001).Yet despite a strong
mandate from within EBM to extend beyond naïve rationalism, technical fixes
remain the holy grail of many government departments (Syrett 2003), and some
sectors of the EBM community have gone on the defensive (Rosenstock and
Lee 2002). An exploration beyond the Medline-indexed literature reveals a
wealth of insights in the interpretivist and critical philosophical traditions, most
notably from political science, which promises to enrich and extend the analysis
of health-care policymaking, especially in relation to the application of argu-
mentation theory to its empirical study. We are both reassured and excited that
researchers in this field have begun to break free from their positivist shackles
and to embrace broader philosophical foundations.
References
Bacchi, C. 2000. Policy as discourse: What does it mean? where does it get us? Discourse
21(1):45–57.
Black, N. 2001. Evidence based policy: Proceed with care. BMJ 323:275–79.
Evidence-Based Policymaking
Weiss, C. 1977.The many meanings of research utilization. Public Admin Rev 39:426–31.
Wells, P. 2007. New Labour and evidence based policy making: 1997–2007. People Place
Policy Online 1(1):22–29.
Wenger, E. 1996. Communities of practice: Learning, meaning and identity. Cambridge:
Cambridge Univ. Press.
Wood, M., E. Ferlie, and L. Fitzgerald. 1998. Achieving clinical behaviour change: A case
of becoming indeterminate. Soc Sci Med 47(11):1729–38.
Young, I. M. 2000. Inclusion and democracy. Oxford: Oxford Univ. Press.
All in-text references underlined in blue are linked to publications on ResearchGate, letting you access and read them immediately.