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Getting political with evidence-based policy

The Lancet is currently publishing a series of papers on Sexual and Reproductive Health; bringing to policy maker attention the current state of knowledge on the topic. Few people would argue, publicly at least, that they oppose evidence-informed policy. Yet, as we demonstrate in a Viewpoint published in The Lancet on December 9th, in the field of sexual and reproductive health at least, all too often affordable and cost-effective interventions which are technically feasible, in even the most resource constrained settings, are not implemented due to passive or active resistance. This is not surprising given that policy change usually entails the reallocation of scarce resources, the redefinition of roles and responsibilities, the presaging of new ideas, among other potentially threatening activities. Thus policy – irrespective of the quality and scope of the evidence base – is inherently political. As a result, it is important that those who hope to see the results of research implemented in the field, to achieve pro-poor health results, need to become more strategic and proactive in their engagement with the underlying politics.

In the Viewpoint, we highlight a number of examples illustrating that, due to political factors, policies are sometimes adopted in contradiction to the prevailing evidence and even when the data suggest that the proposed intervention might not work. For example, systematic reviews of interventions that focus on the promotion of abstinence for reduction of unintended pregnancies, sexually transmitted infections, and HIV risk in young people have shown that when abstainers become sexually active they are less likely to use condoms than those who have not taken part in such programmes. Nonetheless, abstinence-only programmes have been widely adopted in international development cooperation—often as a result of influence and funding that stem from consideration of domestic political interests.  In this case, one can think of the politically motivated cuts in 2002 by the US Government to WHO’s Department of Reproductive Health Research and the cancelling of its funding of the UN Population Fund. The Administration’s assault on sexual and reproductive health continues; one recent manifestation involving the US Centres for Disease Control insisting that one of its employees remove their name from the authorship of a scientific review of the evidence on the control of sexually transmitted diseases.  See Lancet Comment ‘Reviving Reproductive Health’ (text available free after registration).

Yet politics of a more pedestrian form play themselves out far from the headlines as well. Consider the case of syphilis – which, owing to its relative ease of transmission from mother to unborn child, continues to exert a substantial and, yet, entirely preventable burden of disease on babies and infants in high prevalence areas. Curbing the epidemic of congenital syphilis is feasible and affordable in most settings – screening is cheap, treatment (with penicillin) even cheaper. Nonetheless, although most countries in sub-Saharan Africa have adopted the policy of universal screening of pregnant women for syphilis, these policies have not been effectively implemented, and rates of congenital syphilis remain unacceptably high. The scarcity of champions or supportive coalitions for this intervention has hampered implementation. Another intervention that could prevent an estimated 50,000 maternal deaths per year is the use magnesium sulphate which is recommended to prevent and treat eclamptic seizures. This is not routinely done as there is no industrial advocate for the drug and health care providers are reluctant to change their practices.

That evidence rarely ‘speaks for itself’ or that it is sometimes not heard by those who make decisions is a fate that affects all policies. Yet policies that are explicitly pro-poor suffer from a further hurdle – their benefits are widely dispersed across populations at the margins of society who are poorly organized while their costs are often concentrated on well organized groups – such as the pharmaceutical industry and professional associations.

Nonetheless, there are examples of pro-poor, evidence-based interventions successfully reaching policy-maker attention and being implemented – some of which are mentioned in our article. The key to success appears to be systematically understanding the underlying political dimensions of the proposed policy change and using that information to craft strategies and tactics to improve the prospects for success. Often this will involve developing strategic coalitions, sometimes international in scope, between sympathetic government officials, researchers, advocates, professional groups, the media, and other actors depending on the issue.  The coalitions will use a variety of means to change the balance of power, the perception of the problem and its solution, the number of stakeholders active in the policy process as well as their positions on the issue. Usually these coalitions will require support from external donors to gather information, engage in strategy development and implementation. More details on the approach can be found in the book ‘Making Health Policy’.

To reiterate, policy change is inherently political. Pro-poor policy change will inevitably be blocked by a variety of national and international groups with an interest in maintaining the status quo or altering it in a way that may further their interests. We argue that facilitating evidence-informed policy will require directly addressing those underlying political dimensions. One way of doing so is to empower national groups who are pursuing technically appropriate, globally accepted, evidence-informed interventions. Without external support, both financial and technical – which we submit should include good policy analysis tools – the goals of these groups are unlikely to be met in many countries. For this reason, it is not only ethical but imperative for external partners to support the efforts of pro-poor groups to remove obvious obstacles to the attainment of their goals.

Please add your comments if
• You disagree with our proposed approach - we are keen to know why.
• You can share learning from success stories of engaging in the politics of evidence-based policy change.

We are also keen to enter into collaborative projects to move evidence-informed policy processes forward – particularly in the health sector.  Email [email protected]