As rising COVID-19 cases continue to overwhelm countries and their healthcare systems, it is becoming more apparent that health institutions need to develop and adopt more robust health policies and programs. Keeping large populations healthy is a constant challenge—one only aggravated by the COVID-19 pandemic.
With decision-makers from various sectors involved, healthcare systems can be likened to delicate machines with every cog and gear affecting the entire operation. A key component in this process is the translation of research into actionable policies, which entails collaboration between the academe and policymakers.
Such elements of health policymaking were discussed last July 13, 15, and 17 in Introduction to Evidence-Informed Policymaking for Health, a webinar series spearheaded by the Department of Science and Technology-Philippine Council for Health Research and Development (DOST-PCHRD) and Ateneo de Manila University-Institute of Philippine Culture (ADMU-IPC). Dr. Dennis Batangan, a research associate from ADMU-IPC, served as the event’s moderator
A tale of two worlds
In his first lecture, Dr. Harvy Liwanag, a DOST Balik Scientist, described public health policymaking as “a tale of two worlds”—involving the “world of evidence generation” and the “world of policies and programs”. The former concerns itself with scientific research: its primary actors are scientists in academic institutions and research centers who publish papers and reports that inform policies and interventions. Meanwhile, the latter entails using the evidence provided by the researchers to formulate the appropriate policies and programs in improving the healthcare of communities.
These two worlds are heavily intertwined, with one begetting the other. Liwanag described the relationship as a two-way street, maintaining, “While we need evidence to inform policies, we also need practice to inform health research.”
There can, however, be friction between researchers and policymakers as empirical evidence is often not the sole basis for policymaking. Various other decisive factors are taken into consideration such as insights from health workers, special interests groups, and affected constituents; budgetary restraints; and media publicity. In this way, scientific endeavors inevitably “engage with minds that have strong views about how things are and ought to be,” said Liwanag, quoting Michael G. Marmot—an Epidemiology professor at the University College London.
Despite their conflicts, the two worlds must nevertheless cooperate in a “push and pull” manner, as Liwanag described it. “Researchers [push] policymakers to adopt their research findings and [pull] them to support evidence generation. And on the other hand, policymakers [push] researchers to do relevant research and [pull researchers] to work with them,” he remarked.
A work in progress
On the second day of the webinar series, Liwanag tackled research methods and study designs appropriate for investigating new policies. He introduced the idea of a hierarchy of evidence—a scale that ranks each type of research methodology according to risk of bias and quality of presented evidence. At the bottom of the hierarchy are case studies, which focus more on a specific situation involving a certain person or group, while at the top are randomized controlled trials, a study design typically used for drug testing that assigns participants into groups subjected to different forms of treatment.
There is, however, “no perfect study design”, Liwanag admitted, stressing that researchers must take into account policy questions when choosing a method to use in their studies.
“Science is a work in progress. What we know as true today may not be true in the future,” he noted, concluding his lecture with a reminder to be open to change and to remain vigilant for new breakthroughs.
Dr. Jason Ligot—head of Organic Intelligence Health, a subgroup of consulting firm Organic Intelligence that aims to improve health services—emphasized the importance of communicating the results of a study to policymakers in order to develop effective strategies to address societal problems. According to the public health and health promotion specialist, different factors are involved in effective communication, including the identification of one’s purpose, audience, message, and communication method.
Also illustrated were the pitfalls of a “post-truth world”—one where appeals to emotion are more productive than objectivity—with Ligot noting that policymaking has largely become interested in the elaborate process of persuasion, rather than relying on the presentation of facts. As such, he explained that research ought to inform potential solutions, aiding in decision-making by describing pertinent issues, benefits, and risks especially during a large-scale health emergency.
Order from chaos
“Policymaking seems neat on paper…but it’s messy, it’s iterative, it’s unpredictable,” stated Dr. Manuel Dayrit, an adjunct professor from Ateneo School of Medicine and Public Health.
He introduced a framework that considers nine questions or “lenses” that policymakers can use as a guide—urgency, scientific evidence, benefits and trade-offs, sponsors, stakeholder support, controversy, public money, issuing authorities, and implementational arrangements. To understand how these lenses can be integrated with policymaking, Dayrit cited as an example the concurrent use of real-time reverse transcription polymerase chain reaction-based (RT-PCR) test, touted by medical experts as the “gold standard” for detecting COVID-19 cases with sufficient scientific evidence to back this method.
Dayrit stated that having wider RT-PCR testing was indeed “very urgent” as it would benefit high-risk groups. Though the policy “doesn’t seem controversial,” he brought up several queries and implications such as whether PhilHealth should be the one to shoulder testing expenses and if so, how much and for whom such subsidies would be applied.
With all these lenses or factors to consider, Dayrit related the process of policymaking to writing a script—an interplay between the roles of stakeholders, beneficiaries, and sponsors—culminating in a complex process that “is not linear, is not straightforward, nor is it neat.”
“[Effective policymaking] puts order in what would otherwise be a very chaotic situation,” he concluded.