Evidence use, capacity, and perspectives in policymaking about public health and health systems: an investigation with a focus on health administrations and health services in Switzerland

BACKGROUND:
Limited resources, the pursuit of high-quality and efficient health care, and the vision of a ‎healthy population require the continuous consultation and integration of evidence, that is, ‎verifiable data and analyses, in health policy making. Despite intensive research on evidence-‎informed policymaking (EIPM), there are many unanswered questions, in part because findings ‎are context-specific, and studies to date have focused predominantly on a few countries or ‎specific forms of evidence, such as evaluations. An overview of qualitative studies on EIPM ‎has been lacking, yet qualitative research approaches in particular can help address the ‎complexity of policymaking. Further lacking are case studies that trace the role of evidence in ‎decision-making processes and deepen understanding of EIPM by policymakers at the ‎cantonal level. Because cantonal administrations have a central role in the governance of ‎health care, it is also important to understand what perspectives and needs administrators ‎have regarding EIPM, how they themselves deal with verifiable data and analyses, and what ‎supports them in their use.‎
AIM AND OBJECTIVES:
The presented dissertation aims to contribute to a better understanding of the use, capacity, ‎and perspectives regarding EIPM, focusing on policymaking in Switzerland and cantonal health ‎administrations.‎ The specific objectives are to 1) identify and describe existing qualitative literature on EIPM; 2) ‎analyze and describe the role of evidence in the shift from inpatient to outpatient care in ‎Switzerland; 3) assess capacity and understand the perspectives and needs of cantonal health ‎administrations regarding EIPM; 4) outline the relevance of evidence for addressing ‎inefficiencies in health care and the health system in the context of cost containment ‎measures; 5) formulate recommendations for interventions to build EIPM capacity in the ‎administration.‎
METHODS:
The thesis consists of three empirical research papers, an editorial, and a policy brief framed ‎by an overarching introduction and discussion.‎
OBJECTIVE 1) was addressed through a systematic review of peer-reviewed academic ‎literature. Qualitative studies that examined the use of research evidence in public health and ‎health system policymaking were included. Nine electronic databases were searched, 11 ‎journals were hand-searched, and references of included studies and previous reviews were ‎systematically reviewed. No restrictions were made based on the language, publication date, ‎or geographic focus of the studies.‎
OBJECTIVE 2) Employing a case study, the regulatory policy measures introduced in Swiss ‎cantons since 2017 to substitute inpatient for outpatient care were described and examined in ‎terms of their content, policymaking process, and role of evidence. The data basis consisted of ‎publicly available information and studies as well as two expert interviews.‎
OBJECTIVE 3) Using an existing and translated questionnaire instrument, six general-‎secretaries of cantonal health administrations were interviewed on capacity at the ‎administration level regarding available tools and systems to support the engagement with ‎evidence. Semi-structured in-depth interviews with 12 policymakers in leadership positions in ‎health services and planning were used to explore perspectives and needs regarding EIPM.‎
RESULTS:
Systematic review;
A total of 319 studies were identified, revealing a thematically diverse and rapidly growing ‎research landscape. Although the geographic focus is on a few affluent countries, a growing ‎proportion of EIPM research focuses on low- and middle-income countries. A small but ‎substantial number of in-depth and explanatory case studies were found, as well as analyses ‎that draw on political science theories or frameworks. Few studies with ethnographic research ‎designs were identified, and a minority of studies had elected policymakers as the study's ‎target population. Studies on barriers and facilitators related to EIPM make up a significant ‎portion of the work in this area but by no means the majority. Few studies examined the ‎symbolic use of evidence in policymaking.‎
Case study;
The case study revealed that policy measures taken by health administrations to address ‎inpatient overuse were motivated by pressure to save costs and that long-standing ‎international evidence on inpatient substitution potential was first used to legitimize the ‎measures. The study underscores that simple, evidence-informed messages can draw ‎attention to the need for reform and that proactive engagement with comparative health care ‎data and evidence from health observatories can be critical for health care governance.‎
Interview Study;
Swiss health administrations showed moderate capacity for EIPM in with limited ‎organizational ‎support and guidance for EIPM. Internal capacity deficits are compensated ‎with external ‎capacity, for example, through the Swiss health observatory. Administrations ‎seem to place the ‎focus and responsibility for EIPM on individual staff, which are ‎committed to evidence use and ‎need evidence, especially medical data, and statistics, for ‎health services management and ‎planning.
Editorial;
It has been demonstrated that reforms should aim to improve the quality of care and reduce ‎inefficiencies rather than focusing on cost containment. To support this, the conditions for ‎generating and using quality and outcome data and evidence from health services research ‎need to be established, and the EIPM capacity of administrations strengthened.‎
Policy Brief;
Interventions to build the capacity for EIPM in administrations should be tailored and adapted ‎to the local context. In principle, simple interventions can be as effective as complex, multi-‎component measures, such as incentives or infrastructure to access scientific literature. An ‎enabling environment for capacity building should be created, and, where possible, ‎participatory approaches should be used to develop and implement interventions.‎
DISCUSSION:
This dissertation provided insights on the use, capacity, and perspectives regarding evidence, ‎‎with a focus on the Swiss policymaking context and cantonal health administrations. This ‎thesis was able to reveal a descriptive overview of the geographic, temporal, methodological, ‎and theoretical characteristics of the existing qualitative body of literature, both confirming ‎findings of previous research and unearthing studies that show the field of EIPM research to be ‎broader in scope, more theoretically grounded, and less descriptive than previously thought. ‎The findings of this thesis underscore the importance of new methodological approaches to ‎studying the EIPM field, including qualitative observational methods and meta-syntheses of ‎qualitative studies, as well as quantitative designs to assess the extent to which evidence is ‎used and the capacity to use it. In terms of content, future research efforts could address ‎previously less studied areas of the value of EIPM to elected politicians, the symbolic use of ‎evidence, or the role of health observatories in generating and using evidence.‎ For the Swiss context, the results suggest a moderate level of capacity to engage with ‎evidence in health administrations, but these findings require a more in-depth review. The ‎results also point to a modest role of academic research, particularly international comparative ‎health systems research. On the other hand, local statistics and health care data are of great ‎importance for the design and planning of health care. Still, their availability is partly limited and ‎in need of improvement. The thesis underlines the relevance of symbolic motivation for the use ‎of evidence for administrations, for the legitimization of measures, and for argumentation in ‎political discourse.‎ Given the pressure to save money in the health system and the deadlock in policy reforms, ‎health administrations should make more use of their room for maneuver in policymaking. The ‎governance of the health system should be more proactively aligned with evidence and ‎international developments.‎ To this end, investments to build capacity in the use of evidence are essential, both at the ‎individual level of policymakers and at the organizational level, e.g., through institutionalized ‎exchange with research or embedding the importance of evidence for policymaking in strategic ‎documents and guiding principles of administrations. In addition, conditions must be created ‎for the generation and use of quality and outcome data on health care to be used for ‎governance. This development can be supported by a better exchange between cantons, ‎ensuring access to scientific publications and existing data and statistics, or supporting ‎knowledge generators and brokers like the Swiss health observatory. The examples examined ‎in this thesis in the context of EIPM highlight fundamental issues facing modern health ‎systems: the need for innovation, the quest for data and evidence to monitor and manage ‎health care, and the goal of delivering it in a high-quality, effective, and efficient manner. ‎Investing in EIPM, therefore, is a promising way to strengthen health systems.‎