Evidence-based Policymaking
During the interviews with participants, it was revealed that three factors are playing a major role in setting national policy agendas i.e. government and its entity, political influence, and external developmental partners (EDPs). Typically any government entity that realizes the need for a certain policy works to develop it and uses the template provided by National Planning Commission (NPC). When viewed superficially, the process looks fairly systematic and appropriate but in reality, it is either bureaucrats or the EDPs who influence these government entities behind the scenes.
“Entity of ministry that works for the issue and takes the responsibility for implementation of policy and its execution will decide and bring out the policy for example if it is related to maternal health, it will be family health division.” P01
Most of the health policymakers highlighted that past policy reviews are often used to set the agenda. Similarly, evidence such as prevalence studies, data from routine information systems, and various surveys along with the international commitment helps to guide national agendas and decision making.
When looking at the perception of health researchers on policy, most of them perceive it as a form of commitment from the government and reflected through their actions. In addition, researchers perceived that the policies have a role in every step of research, and few even considered policies to increase scopes for research opportunities.
“Policy I think it defines research. For example, there’s a policy addressing child health but some of its components are not being implemented then, research helps to find out the reasons behind it and ways forward. So looking policy from the research aspect, it provides research opportunities and increases its scope.” R02
Barriers Generated by Policymakers
Table 1 provides a summarized list of the barriers and facilitators from the sides of both research push and pull. As mentioned earlier, political leaders have a major influence on the policy formulation process and ultimately, on how the evidence is to be utilized in the due process. But unfortunately, in recent years, we have observed the proliferation of policies with support from policymakers, not as a measure to solve health problems of the country rather, as a means to strengthen their resume and boast about the number of policies developed during their leadership. As a result, these policies do not capture the real need of the population. Moreover, participants highlighted that the relationship between bureaucrats and the vision of the leading political party also influences the evidence utilization for decision making.
“In these recent years, there is a race among ministers to implement the maximum number of policies to show it as their success, rather than developing policies based on actual needs. The policy developed in such a way has no implementation and costing plans. We term this trend as “policy ko kheti” (developing policies as sowing the field).” P01
Table 1
Barriers and facilitators identified by Health Policymakers and Researchers
| Barriers | Facilitators |
Health Policymakers | • Political influence • Poor culture of evidence utilization • Preference of anecdotal evidences • Donor agency’s influence • Poor expenditure for research | • Targets and commitments made at international conferences • Expert/ Stakeholder’s consultation |
Health Researchers | • Issues of generalizability and credibility of evidences • Poor quality and trust of evidences • Low availability of priority-based researches • Poor targeted dissemination | • Few priority-based researches • Availability of nationally representative surveys • Publication of one-pager research • Partial CE study |
One of the most common statements used by the participants was that evidence is being utilized but not in the amount it should be. The poor technical competency of policymakers to understand research findings lead to a poor culture of scientific evidence utilization and increased preference towards anecdotal evidence.
“It’s about our practice of preference towards anecdotal evidence, for example, if a certain policymaker had visited Rukum once and had seen a certain situation and the factors behind it, they tend to generalize the context into national level but in reality, it may or may not be true because in another district some other factors might be creating that very situation.” R02
This scenario further demotivates researchers to conduct research on priority areas and due to the lack of such researches, anecdotal evidence will be preferred again. Furthermore, donor agencies tend to push their agendas to the government through partnerships and implement novel projects prior to conducting impact studies in the local context leading to less promotion for evidence generation.
“People get motivated to generate quality data if the generated data is used and vice versa. So, the use of data is one of the barriers to new research. If there is a good practice of utilizing data in decision making, definitely that will drive more research and surveys. Thus, we need to analyze the data availability; where the data gap is, and how to fill the gap.” R06
Moreover in Nepal, research is taken as a luxurious commodity so, the level of priority placed on it, allocated resources and future growth plans are poor.
“When talking about evidence, we need to look at our system, how it has been running since past, for example, the plans are prepared at the central level and budget is decided before plans are finalized and as research is not a priority, it gets a very low budget.” R01
Barriers Generated by Researchers
Most policymakers and few researchers felt that small-scaled researches are not preferred for evidence utilization as these raise some serious issues of generalizability. Similar to the issue of generalizability, is the question on the credibility of the evidence and the researchers producing it, for instance, researcher’s skills, vague recommendations, and most importantly researcher’s tendency to highlight positive results while hiding the negative ones. This leads to the development of mistrust among policymakers towards researchers, making it even more difficult to convince them. As a result, policymakers prefer large-scale surveys conducted by the institutions working closely with them. It is a good practice by policymakers as they are trusting quality evidence but this also means that they are overlooking quality findings obtained from researches, both large and small-scale, conducted by organizations or individuals unfamiliar to them.
“Sometimes quality and trust of evidence also play a factor. For example, Global Burden Disease is calculated by both WHO and IHME but Nepalese policymakers prefer WHO’s data than IHME’s data even though these two organizations use the same methodology because WHO has been working as a partner of government for a long time and policymakers have developed trust towards them.” R03
In addition, the poor culture of targeted dissemination by researchers is another barrier to evidence utilization. Every day numerous researches are being conducted at the either organizational or individual level but their potential is limited in the form of reports collecting dust on shelves, thus leaving policymakers oblivious of the evidence pool.
“Dissemination happens and researchers try to disseminate in different forums but targeted dissemination is lacking. Also, researchers disseminate findings using technical terms that are difficult for policymakers to understand.” R07
Different Operating Sphere of Policymakers and Researchers
Ultimately, all these above-mentioned barriers have resulted in two different spheres of health researchers and policymakers or as termed by a participant “Two Culture Hypothesis”. The two culture hypothesis is the concept where researchers and policymakers operate in a different environment with a frail link connecting them. Researches are being conducted based on the researcher’s self-interest, without consideration of the nation’s priority, and to make the condition worse policymakers are formulating national policies based on political influence and anecdotal evidence. This practice is further weakening the frail link between policymakers and researchers leading to the formation of evidence-free policy.
Facilitators Generated by Policymakers
The international commitment was identified by most participants to be a major factor to set the national policy agenda and identify policy areas. Being signatories of these commitments, the government has to implement its strategies which may include but are not limited to an increased budget for research, the compulsion to use evidence during policy formulation, and such.
“Well, these international commitments give us target such as where to reach in-terms of certain issues such as MMR. Also, these provide us some guidelines, for example, due to SDG commitment a minimum of 2% of the health budget is allocated for research and due to partnership with WHO, the Nepal government needs to gradually increase the budget in the health sector to 10%.” P05
Similarly, few Nepalese researchers and policymakers identified experts/ stakeholder’s consultation as one of the factors that could generate facilitation.
Facilitators Generated by Researchers
Most policymakers, as well as researchers, identified that the researches that are done based on the government’s priority and with the involvement of policymakers increases the chance for the evidence to be utilized in the policymaking process.
“Lawrence Green once said for evidence-based practice we need practice-based evidence thus, for the evidence-based policy we first need a practice of policy-based evidence. We think that if we present research evidence, it should guide policy but in reality, it does not occur. It is difficult to go that route from the beginning so first, we need to practice research to be guided by policy and policy priority identified by government and gradually move towards guiding policy by research evidence.” R03
These priority areas can be identified by holding close discussions between researchers and policymakers. Furthermore, this nature of collaboration increases ownership among policymakers.
“Those researches conducted under guidance from the ministry are easy to translate into policy but those conducted at an individual or organizational level are hard to translate and is time consuming mainly due to the issues of trusting the finding from the research.” R01
Another facilitator to evidence use identified by the participant was the availability of nationally representative surveys such as NDHS, STEPs, and MICS. These surveys are usually conducted with the involvement of policymakers at some level, thus they are aware of it and most likely utilize it during policy development.
In the previous section, lack of targeted dissemination was identified as a barrier, thus we need to find an appropriate approach to communicate our findings so that it reaches the right audience at the right time. Few researchers indicated that a one-pager policy brief in the Nepali language can solve the issue. These briefs provide a short description of the findings and specific recommendations with minimal use of technical terms. This initiative can help policymakers understand the evidence and utilize them during policy development.
“One-pager research brief will benefit as well because no policymaker has time to read 40–50 pages report. So one-pager with key findings and recommendations will help them understand the situation and will be easier to discuss as well.” R02
Moreover, there have been few instances in Nepal where findings from cost-effectiveness studies for certain programs have been utilized. These effectiveness studies gave insights on the feasibility of the programs and implementation module.
“While developing nursing and midwifery policy, we decided to have a nurse in each ward and thus performed cost analysis where we found that cost for producing a single ANM is about 5–6 lakhs and we have about 300 wards so the cost came huge and on top of that we also need to provide the salary. Another example is of placing school health nurse, there are 36,000 schools in Nepal, and the basic salary of staff nurse is 23,500 so the cost for the single year came to about 9 Arba, which we cannot bear every year thus, in these cases we decided to go phase-wise based on data from costing.” P04
Existing Strategies to promote Evidence-based Policymaking
Desk review has been a compulsory process during policy development so this has helped to reduce the gap between evidence not being utilized and their utilization.
“The trend of desk reviews is prevalent in the health sector. For example, if the policy is going to be developed on certain themes, then available literature is collected through desk reviews. We do not have a specific guideline for a literature review so we look for published and unpublished researches in Nepalese context that are available to us.” P01
Many policymakers identified policy reviews to be one of the factors used to determine the country’s priority goals. These policy reviews, though often irregular in practice, give priority areas and there have been instances of researches, large and small-scale, being conducted based on these priorities.
“While developing health policies, it’s not like that we don’t have any policies till date, we do have some which are reviewed may be in 5 years, 7 years or 10 years and based on review finding we either update the existing policy or develop new policy. Similarly, we come across new policy issues during the yearly review as well.” P03
At present, the concept of evidence facilitators or “knowledge broker”, a term used by a participant, is rising. A knowledge broker may be an institution or an employee of a certain institution whose job is to make current evidence available at the policymaker’s table. Because of these knowledge brokers, the policymakers are easily getting their hands on quality and updated information to make evidence-based decisions.
The practice of regular updates and uptake of the computerized routine information system in Nepal, recently DHIS 2, helps the very ground level health facility to get quality information in real-time. This ease in accessibility of quality information enables local government to plan programs accordingly. Moreover, the implementation of a new federal structure provides an opportunity for local government to exercise more power to plan programs based on their context and quality information provided by the routine information system.