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Please peruse the attached article, Evidence-Based Policymaking is Not Like Evidence-Based Medicine, So How Far Should You Go to Bridge the Divide Between Evidence And Policy?
Discuss insights gained from the reading.
Cairney and Oliver Health Research Policy and Systems (2017) 15:35
DOI 10.1186/s12961-017-0192-x
OPINION
Open Access
Evidence-based policymaking is not like
evidence-based medicine, so how far
should you go to bridge the divide
between evidence and policy?
Paul Cairney1,2*
and Kathryn Oliver3,4
Abstract
There is extensive health and public health literature on the ‘evidence-policy gap’, exploring the frustrating
experiences of scientists trying to secure a response to the problems and solutions they raise and identifying
the need for better evidence to reduce policymaker uncertainty. We offer a new perspective by using policy
theory to propose research with greater impact, identifying the need to use persuasion to reduce ambiguity,
and to adapt to multi-level policymaking systems.
We identify insights from secondary data, namely systematic reviews, critical analysis and policy theories relevant
to evidence-based policymaking. The studies are drawn primarily from countries such as the United States, United
Kingdom, Canada, Australia and New Zealand. We combine empirical and normative elements to identify the ways in
which scientists can, do and could influence policy.
We identify two important dilemmas, for scientists and researchers, that arise from our initial advice. First, effective actors
combine evidence with manipulative emotional appeals to influence the policy agenda – should scientists do the same,
or would the reputational costs outweigh the policy benefits? Second, when adapting to multi-level policymaking, should
scientists prioritise ‘evidence-based’ policymaking above other factors? The latter includes governance principles such the
‘co-production’ of policy between local public bodies, interest groups and service users. This process may be based
primarily on values and involve actors with no commitment to a hierarchy of evidence.
We conclude that successful engagement in ‘evidence-based policymaking’ requires pragmatism, combining scientific
evidence with governance principles, and persuasion to translate complex evidence into simple stories. To maximise the
use of scientific evidence in health and public health policy, researchers should recognise the tendency of policymakers
to base judgements on their beliefs, and shortcuts based on their emotions and familiarity with information; learn ‘where
the action is’, and be prepared to engage in long-term strategies to be able to influence policy; and, in both cases, decide
how far you are willing to go to persuade policymakers to act and secure a hierarchy of evidence underpinning policy.
These are value-driven and political, not just ‘evidence-based’, choices.
Keywords: Evidence-based medicine, Evidence-based policymaking, Implementation science, Improvement science,
Storytelling, Policy ambiguity, Complex government, United Kingdom government, Scottish government
* Correspondence: p.a.cairney@stir.ac.uk
1
Politics and Public Policy at the University of Stirling, Stirling, United
Kingdom
2
Division of History and Politics, University of Stirling, Stirling FK9 4LA, United
Kingdom
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Cairney and Oliver Health Research Policy and Systems (2017) 15:35
Background: the limits to a focus on ‘barriers’
between evidence and policy
The health sciences are well represented in studies of
the ‘evidence-policy gap’, in which academics describe
their attempts to overcome ‘barriers’ between the production of evidence by scientists and its use by policymakers. Oliver et al.’s [1, 2] systematic reviews draw
insights from 126 health policy studies published from
2000–2012. The most frequently-reported barriers relate to problems with disseminating high quality information effectively, namely the lack of time, support,
resources and incentives for scientists to engage in
dissemination. These studies suggest that scientific
evidence is often not presented at the correct time and
scientists are unable to anticipate a demand for
information to solve a very specific problem quickly.
Further, policymakers lack the research skills to understand scientific evidence. More generally, there are different scientific and policymaker cultures [3]. These
insights generally come from a small number of countries, including the United States, United Kingdom,
Canada, Australia and New Zealand.
There are two key problems with this literature. First,
very few studies draw on policy theory or other forms of
knowledge of the policy process [4]. Most are based on
personal practitioner perspectives generated through, for
example, surveys, focus groups and academicpolicymaker workshops. They generally have a particular
reference point, namely evidence-based medicine (EBM)
[2]. The EBM agenda is (1) to gather the best evidence
on health interventions, based on a hierarchy of
methods, in which randomised control trials and their
systematic review are at the top, and (2) to ensure that it
has a direct impact on practice, to exhort practitioners
to replace bad interventions. Individual clinicians have
high discretion on how to use the evidence, but based
on a common ideal and understanding of evidence quality. Consequently, the studies present limited findings
because (1) their source material is restricted primarily
to interviewees with minimal knowledge of policymaking, and (2) potential solutions are based on a misperception of the policy process, built on EBM
assumptions, not policy theory [5].
The most-frequently stated solutions to ‘barriers’ highlight the limits to such a theoretical analysis. For example, to address the problem of supply, studies
highlight the need for ‘improved dissemination’ to ensure that policymakers pay attention to, and understand,
the best evidence [1]. Too few studies recognise that
policymakers will not share the sense that there is a hierarchy of evidence. Too many assume that better dissemination will prompt policymakers to think, like
scientists, that the scientific evidence alone is persuasive
or self-evident.
Page 2 of 11
To address demand, the most-proposed solution is
to develop scientific competence in government. Too
many studies assume that it is realistic to produce
a captive audience of policymakers willing to invest
the time to prioritise and understand scientific
evidence. This approach is at odds with the less rigid
ways in which policymakers use many forms of
evidence [3, 6–9].
Second, too few studies recognise the role of values in
politics. Instead, an often implicit and untested assumption is that policymaking should be as ‘evidence based’
as medicine, which is at odds with the more common
starting point, in the study of politics, to produce a
democratic system which translates competing societal
values and preferences into policy solutions. One may
desire a political system based on value judgements and
evidence, but should recognise and address the tradeoffs between these aims, and that the production of
evidence is also an inherently value-driven process.
New directions for evidence-based policy research:
two foundational questions
We address these gaps in the literature by raising two
questions designed to promote discussion about pragmatic policy strategies. Each question identifies a central
insight from policy studies and prompts scientists to
consider how they would combine an attachment to
evidence-based policymaking with other values to produce a realistic way forward.
1. How far should scientists go to persuade
policymakers to act on their evidence?
Policy studies suggest that actors are influential
when they ‘frame’ their evidence in simple,
manipulative and/or emotional terms to generate
policymaker attention. Should scientists also
combine evidence with emotional appeals to
influence the policy agenda? Should they deny
scientific uncertainty and make unequivocal claims
about the implications of their evidence? Or, does
this strategy produce an ethical dilemma and/or the
potential to reduce long-term scientific credibility?
2. How far should scientists go to defend a hierarchy
of evidence to deliver policy solutions?
Initially, policy studies prompt us to identify where
‘the action’ is, to know where to engage in a
complex and multi-level system in which many
actors make policy in many venues. However, it does
not identify the main aim of engagement. Is it to
make sure that all actors prioritise ‘evidence-based’
policymaking above other factors, or to cooperate
with other actors with different ideas about ‘good’
policymaking? The latter can include governance
principles such as ‘localism’ and the ‘co-production’
Cairney and Oliver Health Research Policy and Systems (2017) 15:35
of policy between local public bodies, interest groups
and service users. This process may be based primarily on values and involve actors with no commitment to a hierarchy of evidence when they
implement policy solutions.
Consequently, insights from policy studies provide practical advice and raise new dilemmas (summarised in
Table 1). Our discussion takes us beyond existing debates
on the hierarchy of evidence and primary role of randomised control trials (RCTs) in policy evaluation. Initially, it
invites us to reflect on the extent to which a commitment
to a hierarchy prompts the need for ‘fidelity’ to evidencebased solutions, limiting local policymaking discretion to
ensure the correct ‘dosage’ of an intervention and maintain continuous RCT-based evaluation. Then, we should
consider the role of governance principles – such as ‘localism’ and ‘co-production’ – which encourage local practitioners to modify policy solutions to meet the specific
circumstances of communities and preferences articulated
by service users. If we accept the value of these principles,
what are the implications for ‘evidence-based’ policymaking (at least in the countries usually covered by this
literature) and how might we design a process to manage
the trade-offs between scientific evidence and values?
To develop new perspectives on these questions, we
identify insights from secondary data, namely systematic
reviews [1], critical analysis [2] and policy theories relevant to evidence-based policymaking [3, 10, 11]. The
studies are drawn primarily from countries such as the
United States, United Kingdom, Canada, Australia and
New Zealand. We combine empirical and normative elements to identify the ways in which scientists can, do
and should try to influence policy. Our case study draws
partly from an ESRC-funded study based on 30
Page 3 of 11
anonymous semi-structured interviews with civil servants in the Scottish and United Kingdom governments.
We use this this data to produce models of evidencebased policymaking (described in more depth in [12]),
then analyse the dilemmas that they present for
scientists.
To provide context for the second question, we place the
possible responses that scientists could make on a
spectrum, from ‘purist’, or the insistence on the primacy of
RCT evidence and fidelity to successful interventions during policy implementation, to the ‘diplomatic’, treating evidence as part of a success story, encouraging the autonomy
of practitioners to ‘co-produce’ and modify policy solutions
to meet the values and specific circumstances of service
users. We examine the implications of these practices on
scientific research, outlining pragmatic responses to combine scientific evidence with governance principles.
How to maximise the use of evidence in policy
Most policy theories explore the implications of two
basic insights, namely that policymakers are limited
by ‘bounded rationality’ [13] and share power with
many actors in complex policymaking systems [3, 10,
14]. In part, bounded rationality relates to the fact
that policymakers do not have the ability to gather
and consider all evidence relevant to policy problems.
Instead, they employ two shortcuts – ‘rational’, pursuing clear goals and prioritising certain sources of information, and ‘irrational’, drawing on emotions, gut
feelings, beliefs and habits to make decisions quickly.
The key problem with many health studies is that they
focus on the first short cut. They identify the problem of
uncertainty and incomplete information, seeking to solve
it by creating hierarchies of evidence and improving the
supply of information to policymakers. They ignore the
Table 1 New insights from policy studies raise new advice and dilemmas
New advice based on such insights
New dilemmas arising from such advice
How to maximise the use of Too many studies focus on
supplying scientific evidence to
evidence in policy
reduce uncertainty; focus
instead on increasing demand
for evidence by reducing
ambiguity
New insight from policy studies
Successful actors reduce ambiguity by,
for example, framing issues in
manipulative ways, using emotional
language
How far should scientists go to persuade
policymakers to act on their evidence?
Should they be manipulative? This
strategy may be effective, but it
presents moral dilemmas and
challenges a politically effective image
of science as objective
We identify several current responses
to this dilemma
How best to understand
and act effectively within
the policy process
Successful actors take the time to
identify which responsibilities are
delegated, ‘where the action is’ and
the ‘rules of the game’ in each
policymaking venue
How far should you go to defend a
hierarchy of evidence to deliver policy
solutions?
Should scientists object to ‘localism’
if it undermines policies based on
RCTs? Or, should they embrace the
‘co-production’ of policy with actors
who reject their ‘hierarchy’ of
evidential methods?
We identify three main responses to
this dilemma
Too many studies assume that there
is a policymaking ‘centre’, making
policy via linear stages in a cycle;
focus instead on a complex multilevel system or environment
Cairney and Oliver Health Research Policy and Systems (2017) 15:35
role of manipulation and persuasion to reduce ambiguity
by establishing a dominant way to ‘frame’ policy problems. The latter can determine the demand for evidence.
From such discussions, we can provide a first key message for scientific advocates, namely to recognise the
tendency of policymakers to base judgements on their
well-established beliefs and shortcuts based on their emotions and familiarity with information. On that basis,
consider how to reduce ambiguity, to persuade policymakers to frame a problem primarily in one particular
way and, therefore, to demand scientific evidence to help
solve that problem.
Persuasion or ‘framing’ strategies are effective because
they appeal to the emotions and the familiar, combining
facts with emotional appeals to prompt lurches of attention;
telling simple and easily understood stories which manipulate people’s biases, apportioning praise and blame and
highlighting the moral and political value of solutions; and
recognising the importance of interpreting new scientific
evidence through the lens of the beliefs and knowledge of
influential actors.
Without this focus on the ways in which policymakers
understand and respond to problems, scientists will be
unable to exert influence, responding only to sudden
policymaker demand for evidence-based solutions to a
pre-defined problem [10, 15–27].
However, this first message also produces the first practical or ethical dilemma – how far should scientists go to
persuade policymakers to act on their evidence? This
knowledge allows us to decide how far we should go to secure influence, from the ‘pure scientist’ providing evidence
with little thought for its application and the ‘honest broker’
prepared to engage with stakeholders to define policy problems [28], towards engaging in persuasion and/or manipulation to generate attention for problems and evidencebased solutions [29].
There is no definitive answer to this question. Instead,
there are factors to consider, including the trade-off
between (1) being manipulative and hyperbolic, to generate attention in the short term, and (2) maintaining an
image of objectivity, to generate strong relationships in
government based on reliability, expertise, trust and ‘independence’. Further, there are many compromise solutions,
including a strategy built on framing the implications of
evidence according to the stated beliefs of policymakers
and building up a reputation for reliability within many
policymaking venues.
Issues with existing approaches: the focus remains on
research over policy impact
In health science, many models of research impact are
built on strategies which make minimal reference to policymaking, namely identifying the research question, developing a research methodology, implementing data
Page 4 of 11
collection, analysis and synthesis, interpreting findings,
and developing research and then policy/practice recommendations. In this patrician model, the process is
owned and controlled by researchers, who then advise
or disseminate their work in the general direction of policymakers [30].
There is also the advocacy model, where researchers
develop policy solutions and attempt to convince policymakers to adopt them [31, 32]. Most of this literature focuses on techniques (e.g. [33]) rather than risks. Gilbert
[34] describes advocacy research as aiming to create social change, usually for excellent reasons, but involving
tactics which can lead to researchers distorting the data
(for example, giving inaccurate estimates of child abuse
statistics) or presenting overly emotive cases which can
‘powerfully shape’ media coverage (for example, on rape
cases). Advocacy can obscure and distort policy discussions but most discussions do not address this problem
or the underlying issues of power and policy processes.
A more collaborative kind of advocacy is ‘facilitational’,
in which researchers attempt to share power, responsibility and accountability for research with stakeholders. ‘Coproduction’ was originally used to describe a model of
public service delivery which rested on the belief
that using a broad range of perspectives lead to better,
fairer, more useful and more used products and services
[35–38]. These beliefs have transferred to the production
of knowledge through collaborative or participatory
methods, which may lead to more egalitarian policymaking, through shared responsibilities [39–48].
New collaborations between scientists and policymakers
There are many models for collaborative interactions between scientists and policymakers (e.g. [49–54]). The
James Lind Alliance [55] has long been active in the ‘coproduction’ of research agendas between patients, clinicians and researchers; the National Institute for Health
and Clinical Excellence (NICE) has used stakeholder
groups to generate clinical and research recommendations and priorities for nearly two decades [56]. Collaborative research practices tend to fall into two groups –
using each other’s skills and expertise for relatively
discrete sections of the research process (collaborative)
and engaging in a whole process of equal control and
decision-making (co-productive) – although these labels
are not consistently applied. Both describe a ceding of
control by researchers, over some or all of the research
process, to stakeholders, including policymakers, to a
greater or lesser degree [57, 58].
Little research has been performed on the strengths,
risks and implications for research, researchers and policy of these models of interactions [34, 43]. Proponents
tend to promote their models as more democratic or as
producing higher quality research, although generally
Cairney and Oliver Health Research Policy and Systems (2017) 15:35
this is an ideological rather than empirically-grounded
stance. Proponents of the patrician or neutral models
are presumably wary about stating their position, as coproductive research is increasingly claimed as the vehicle
for research ‘impact’. Some commentators identify risks to
researchers in lessening control or increasing advocacy
[59, 60], but this has not translated into a considered discussion of the implications for the evidence-based policy
movement. Few studies consider the insights we highlight
about the roles of policy actors, the consequent judgments
about what counts as evidence and why, and how decisions are made.
What most of these models have in common is that
they are modifications of the research process, not responses to the policy process. The disinclination of many
scientists to engage with the policy world, even amongst
the most collaboratively minded, is revealing. It highlights an unresolved issue about the extent to which a
systematic research-driven model can be adapted and
improved to reflect the need to compete with advocates
of other forms of evidence to secure the attention and
support of policymakers.
In summary, scientists have developed different answers to the question ‘how far should you go?’ These
answers correspond to ways in which scientists and
policy actors interact, from disseminator/receiver to
equal co-producers. However, these interactions have
not yet been examined through the lens of policy
theory, nor have empirical comparative descriptions
enabled us to determine what types of interactions
work best, for which purposes and under which
circumstances.
How best to understand and act effectively within
the policy process
Any competition to frame issues takes place in a complex
policymaking environment or system [61]. This context is
not described well by the ‘policy cycle’ – an understanding
built on the idea that policymaking can be separated into
discrete stages (agenda setting, policy formulation, implementation, legitimation, evaluation and succession) –
which remains popular within health scholarship despite
being rejected by policy scholars as a poor explanation of
policymaking [2, 3, 10, 14, 62–66].
In its place are theories which identify a policy ‘environment’ which relates to the interaction between
five factors, namely the many policy actors operating
in multi-level systems, pursuing ideas (using their beliefs and knowledge to influence how policymakers
think), adapting to institutions (the formal and informal rules of political systems and organisations), networks (between policymakers and influential actors),
and the impact of socioeconomic context and events
[3, 27, 67–71]. Further, some theories identify
Page 5 of 11
complex policymaking systems in which, for example,
the same inputs of evidence can receive no, or disproportionate attention, and policy outcomes often
‘emerge’ in the absence of central government control, which makes it difficult to know how, and to
whom, to present evidence [3, 72].
This analytical shift from cycles to environments and
systems helps us reject the notion that there is a core
group of policymakers at the heart of the process,
analysing and making policy from the ‘top down’, and
that scientists promoting evidence can focus their efforts
at a single point of problem definition or policy
formulation [3].
Rather, scientists compete with many influential actors
to present evidence to secure a policymaker audience at
many levels of government. Support for evidence-based
solutions varies according to which organisation takes
the lead and how its rules encourage policymakers to
understand the problem. Some networks are close-knit
and difficult to access because bureaucracies have operating procedures that favour some sources of evidence
and participants over others. There is a language in institutions and networks that takes time to learn. It indicates which ways of thinking are in good ‘currency’,
including a dominant way to ‘frame’ a problem and limit
discussion to certain solutions. Well-established beliefs
provide the context for policymaking – new evidence on
the effectiveness of a policy solution has to be accompanied by a shift of attention and successful persuasion.
Social or economic ‘crises’ can prompt lurches of attention from one issue to another, and some evidence can
be used to encourage that shift. However, most policy
change is minor; it is rare for events to combine with
new evidence to produce quick and radical policy
change [10].
From such discussions, we can provide a second key
message for scientific advocates – learn ‘where the
action is’, and be prepared to engage in a long-term
strategy to be in a position to influence policy. In other
words, identify ‘the action’ at several levels of government, learn the ‘rules of the game’ in institutions and
networks (or the ‘venues’ in which policymaking takes
place), form coalitions with like-minded actors, and
work with the ‘policy entrepreneurs’ possessing the skills
to exploit ‘windows of opportunity’ to give policymakers
the motive and opportunity to adopt new solutions [3, 8,
23, 24, 27, 73–78].
In most cases, these coalitions will be with many
actors with different ways of thinking about policymaking, engaging in politics to turn their beliefs and
values into policy, often unaware or unsupportive of
EBM’s hierarchy of evidence, and likelier to refer to
governance principles other than evidence-based
policymaking.
Cairney and Oliver Health Research Policy and Systems (2017) 15:35
Consequently, this second message produces a second
practical and ethical dilemma – how far should you go
to defend a hierarchy of evidence to deliver policy solutions? It involves the extent to which policy actors
should accept and adapt to policymaking complexity and
the diffusion of power, or seek to change some aspects
and assert their claim for greater power.
For example, central governments have some incentives to try to reassert central control because they are
held accountable in elections and parliaments for policy
outcomes, regardless of their responsibility [14]. Yet,
they also recognise the need to share decision-making
with actors at multiple levels of government, including
at the point of policy delivery. This produces a form of
government in which the co-production of policy
solutions is based partly on evidence and partly on the
principles underpinning local governance, including
‘localism’ (central governments recognise the role of
partly autonomous local authorities or partnerships)
and service user-driven services (based on their values
and preferences) [12].
In that context of multi-level and delegated policymaking, scientists may support phrases such as ‘co-production of research’ superficially (who would not want to
involve all relevant actors in the production of knowledge?), but also recognise the need for tough choices to
ensure the application of evidence-based policy solutions. They need to engage with two debates simultaneously, on EBM and localism.
First, not all actors adhere to the EBM ideal [79–83].
There are several different reasons to expect a different
approach, as described below.
Policymakers may not care that evidential hierarchies
exist, preferring a variety of sources of knowledge [3,
6, 84]. While RCTs enjoy high status in some units in
government and key champions [85], in others they
may be used primarily to reinforce existing agendas
[8]. Indeed, policymakers can appropriate research
findings and reduce academic criticism of evidence
use by commissioning evidence directly and/or
seconding academics to government roles [86].
Or, policymakers may accept scientific evidence on
the size of a problem and recognise the potential
value of solutions from the same academic source,
without finding a politically feasible way to introduce
them (see, for example, [87] on the limited
receptivity to measures to reduce health inequalities).
Some advocates of RCTs recommend greater
reflection on scientific values in politics rather than
the assumption that hierarchies of evidence are
necessarily valid [88, 89].
EBM contrasts with an adherence to practice-based
evidence, which includes the experiential knowledge
Page 6 of 11
of practitioners, feedback from service users and
a greater focus on supporting different voices
([41, 44]).
Some scholars argue that complex policymaking
systems defy control and, therefore, are not
conducive to the use of RCTs (see [61]). Instead,
we use other methods, such as process tracing [90],
large-scale quantitative evaluation designs like
difference in differences, or case studies, to highlight
the interaction between a large number of factors
which combine to produce an outcome, the result
of which cannot be linked simply to the independent
effects of each factor.
Second, central governments face the trade-off
between national and local policymaking [91]. Their
national strategies can include reference to uniform
delivery standards, to avoid a ‘postcode lottery’, and
encourage local autonomy and policy flexibility, to
recognise the legitimacy of local policymaking and
encourage community or service user participation. For
some interventions, they may favour uniformity of delivery and fidelity to a programme. For others, they express a preference for localism built on arguments,
including one size does not fit all, local authorities have
their own electoral mandates, a policy will not succeed
without local ‘ownership’, and/or local public bodies
need to adapt to quickly changing local circumstances.
Consequently, there is an inextricable link between
debates on the selection of evidence-based solutions/interventions and the correct choice of governance arrangements. This involves a two-part decision in which
policymakers combine (1) their chosen method to identify and gather knowledge of successful policy solutions,
with (2) their judgement on how to work with other
actors to ‘scale up’ success.
In this context, consider the scale of the task to ensure
the primacy of RCTs and/or a hierarchy of evidence in
policymaking. It involves (1) persuading many actors in
many central and local venues that (2) there is a wellestablished best way to produce scientific evidence, and
therefore (3) that scientific forms of knowledge should
be prioritised in policymaking. This is a two-pronged
dilemma – should you devote necessarily high resources
to this line of persuasion, and should you go to great
lengths to dismiss competing understandings of good
policymaking?
Three responses to this dilemma
To demonstrate the issues central to dilemma 2, we outline a spectrum of approaches to answer the ‘how do
you scale up success?’ question (see [12] for a summary
table). It allows us to demonstrate the implications for
evidential hierarchies when power is spread across
Cairney and Oliver Health Research Policy and Systems (2017) 15:35
multiple levels of government. We show the constraining effect of a rigid attachment to ‘fidelity’ to policy interventions on the ability of local communities to
modify policy solutions to reflect their values and preferences. This outcome may only be appropriate in some
cases. We compare it with an approach that favours
local flexibility and governance principles at the expense
of scientific evidence. The contrast allows us to highlight the political choices with which advocates of evidential hierarchies need to engage. We use examples of
initiatives pursued by the United Kingdom and Scottish
central governments, each of which enact or negotiate
the delivery of policy interventions with a variety of
elected local authorities and unelected health and social
care organisations.
Approach 1: prioritise RCTs and focus on fidelity and
dosage
The primary aim of movements such as ‘implementation
science’ is to gather the best evidence on health interventions and ensure that it has a direct impact on practice [1, 92]. One should not exaggerate the top-down
nature of EBM [93, 94]. However, we can use its key
tenets to produce one ideal-type approach:
Page 7 of 11
benefits to participants and/or society”. Trials have been
conducted since 1977, producing 18 peer-reviewed articles in elite journals (such as Journal of the American
Medical Association), with at least two non-United
States studies [96]. It was rolled out in England to 9000
mothers, with reference to its high cost effectiveness and
‘strong evidence base’, which would be enhanced by
DOI 10.1186/s12961-017-0192-x
OPINION
Open Access
Evidence-based policymaking is not like
evidence-based medicine, so how far
should you go to bridge the divide
between evidence and policy?
Paul Cairney1,2*
and Kathryn Oliver3,4
Abstract
There is extensive health and public health literature on the ‘evidence-policy gap’, exploring the frustrating
experiences of scientists trying to secure a response to the problems and solutions they raise and identifying
the need for better evidence to reduce policymaker uncertainty. We offer a new perspective by using policy
theory to propose research with greater impact, identifying the need to use persuasion to reduce ambiguity,
and to adapt to multi-level policymaking systems.
We identify insights from secondary data, namely systematic reviews, critical analysis and policy theories relevant
to evidence-based policymaking. The studies are drawn primarily from countries such as the United States, United
Kingdom, Canada, Australia and New Zealand. We combine empirical and normative elements to identify the ways in
which scientists can, do and could influence policy.
We identify two important dilemmas, for scientists and researchers, that arise from our initial advice. First, effective actors
combine evidence with manipulative emotional appeals to influence the policy agenda – should scientists do the same,
or would the reputational costs outweigh the policy benefits? Second, when adapting to multi-level policymaking, should
scientists prioritise ‘evidence-based’ policymaking above other factors? The latter includes governance principles such the
‘co-production’ of policy between local public bodies, interest groups and service users. This process may be based
primarily on values and involve actors with no commitment to a hierarchy of evidence.
We conclude that successful engagement in ‘evidence-based policymaking’ requires pragmatism, combining scientific
evidence with governance principles, and persuasion to translate complex evidence into simple stories. To maximise the
use of scientific evidence in health and public health policy, researchers should recognise the tendency of policymakers
to base judgements on their beliefs, and shortcuts based on their emotions and familiarity with information; learn ‘where
the action is’, and be prepared to engage in long-term strategies to be able to influence policy; and, in both cases, decide
how far you are willing to go to persuade policymakers to act and secure a hierarchy of evidence underpinning policy.
These are value-driven and political, not just ‘evidence-based’, choices.
Keywords: Evidence-based medicine, Evidence-based policymaking, Implementation science, Improvement science,
Storytelling, Policy ambiguity, Complex government, United Kingdom government, Scottish government
* Correspondence: p.a.cairney@stir.ac.uk
1
Politics and Public Policy at the University of Stirling, Stirling, United
Kingdom
2
Division of History and Politics, University of Stirling, Stirling FK9 4LA, United
Kingdom
Full list of author information is available at the end of the article
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Cairney and Oliver Health Research Policy and Systems (2017) 15:35
Background: the limits to a focus on ‘barriers’
between evidence and policy
The health sciences are well represented in studies of
the ‘evidence-policy gap’, in which academics describe
their attempts to overcome ‘barriers’ between the production of evidence by scientists and its use by policymakers. Oliver et al.’s [1, 2] systematic reviews draw
insights from 126 health policy studies published from
2000–2012. The most frequently-reported barriers relate to problems with disseminating high quality information effectively, namely the lack of time, support,
resources and incentives for scientists to engage in
dissemination. These studies suggest that scientific
evidence is often not presented at the correct time and
scientists are unable to anticipate a demand for
information to solve a very specific problem quickly.
Further, policymakers lack the research skills to understand scientific evidence. More generally, there are different scientific and policymaker cultures [3]. These
insights generally come from a small number of countries, including the United States, United Kingdom,
Canada, Australia and New Zealand.
There are two key problems with this literature. First,
very few studies draw on policy theory or other forms of
knowledge of the policy process [4]. Most are based on
personal practitioner perspectives generated through, for
example, surveys, focus groups and academicpolicymaker workshops. They generally have a particular
reference point, namely evidence-based medicine (EBM)
[2]. The EBM agenda is (1) to gather the best evidence
on health interventions, based on a hierarchy of
methods, in which randomised control trials and their
systematic review are at the top, and (2) to ensure that it
has a direct impact on practice, to exhort practitioners
to replace bad interventions. Individual clinicians have
high discretion on how to use the evidence, but based
on a common ideal and understanding of evidence quality. Consequently, the studies present limited findings
because (1) their source material is restricted primarily
to interviewees with minimal knowledge of policymaking, and (2) potential solutions are based on a misperception of the policy process, built on EBM
assumptions, not policy theory [5].
The most-frequently stated solutions to ‘barriers’ highlight the limits to such a theoretical analysis. For example, to address the problem of supply, studies
highlight the need for ‘improved dissemination’ to ensure that policymakers pay attention to, and understand,
the best evidence [1]. Too few studies recognise that
policymakers will not share the sense that there is a hierarchy of evidence. Too many assume that better dissemination will prompt policymakers to think, like
scientists, that the scientific evidence alone is persuasive
or self-evident.
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To address demand, the most-proposed solution is
to develop scientific competence in government. Too
many studies assume that it is realistic to produce
a captive audience of policymakers willing to invest
the time to prioritise and understand scientific
evidence. This approach is at odds with the less rigid
ways in which policymakers use many forms of
evidence [3, 6–9].
Second, too few studies recognise the role of values in
politics. Instead, an often implicit and untested assumption is that policymaking should be as ‘evidence based’
as medicine, which is at odds with the more common
starting point, in the study of politics, to produce a
democratic system which translates competing societal
values and preferences into policy solutions. One may
desire a political system based on value judgements and
evidence, but should recognise and address the tradeoffs between these aims, and that the production of
evidence is also an inherently value-driven process.
New directions for evidence-based policy research:
two foundational questions
We address these gaps in the literature by raising two
questions designed to promote discussion about pragmatic policy strategies. Each question identifies a central
insight from policy studies and prompts scientists to
consider how they would combine an attachment to
evidence-based policymaking with other values to produce a realistic way forward.
1. How far should scientists go to persuade
policymakers to act on their evidence?
Policy studies suggest that actors are influential
when they ‘frame’ their evidence in simple,
manipulative and/or emotional terms to generate
policymaker attention. Should scientists also
combine evidence with emotional appeals to
influence the policy agenda? Should they deny
scientific uncertainty and make unequivocal claims
about the implications of their evidence? Or, does
this strategy produce an ethical dilemma and/or the
potential to reduce long-term scientific credibility?
2. How far should scientists go to defend a hierarchy
of evidence to deliver policy solutions?
Initially, policy studies prompt us to identify where
‘the action’ is, to know where to engage in a
complex and multi-level system in which many
actors make policy in many venues. However, it does
not identify the main aim of engagement. Is it to
make sure that all actors prioritise ‘evidence-based’
policymaking above other factors, or to cooperate
with other actors with different ideas about ‘good’
policymaking? The latter can include governance
principles such as ‘localism’ and the ‘co-production’
Cairney and Oliver Health Research Policy and Systems (2017) 15:35
of policy between local public bodies, interest groups
and service users. This process may be based primarily on values and involve actors with no commitment to a hierarchy of evidence when they
implement policy solutions.
Consequently, insights from policy studies provide practical advice and raise new dilemmas (summarised in
Table 1). Our discussion takes us beyond existing debates
on the hierarchy of evidence and primary role of randomised control trials (RCTs) in policy evaluation. Initially, it
invites us to reflect on the extent to which a commitment
to a hierarchy prompts the need for ‘fidelity’ to evidencebased solutions, limiting local policymaking discretion to
ensure the correct ‘dosage’ of an intervention and maintain continuous RCT-based evaluation. Then, we should
consider the role of governance principles – such as ‘localism’ and ‘co-production’ – which encourage local practitioners to modify policy solutions to meet the specific
circumstances of communities and preferences articulated
by service users. If we accept the value of these principles,
what are the implications for ‘evidence-based’ policymaking (at least in the countries usually covered by this
literature) and how might we design a process to manage
the trade-offs between scientific evidence and values?
To develop new perspectives on these questions, we
identify insights from secondary data, namely systematic
reviews [1], critical analysis [2] and policy theories relevant to evidence-based policymaking [3, 10, 11]. The
studies are drawn primarily from countries such as the
United States, United Kingdom, Canada, Australia and
New Zealand. We combine empirical and normative elements to identify the ways in which scientists can, do
and should try to influence policy. Our case study draws
partly from an ESRC-funded study based on 30
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anonymous semi-structured interviews with civil servants in the Scottish and United Kingdom governments.
We use this this data to produce models of evidencebased policymaking (described in more depth in [12]),
then analyse the dilemmas that they present for
scientists.
To provide context for the second question, we place the
possible responses that scientists could make on a
spectrum, from ‘purist’, or the insistence on the primacy of
RCT evidence and fidelity to successful interventions during policy implementation, to the ‘diplomatic’, treating evidence as part of a success story, encouraging the autonomy
of practitioners to ‘co-produce’ and modify policy solutions
to meet the values and specific circumstances of service
users. We examine the implications of these practices on
scientific research, outlining pragmatic responses to combine scientific evidence with governance principles.
How to maximise the use of evidence in policy
Most policy theories explore the implications of two
basic insights, namely that policymakers are limited
by ‘bounded rationality’ [13] and share power with
many actors in complex policymaking systems [3, 10,
14]. In part, bounded rationality relates to the fact
that policymakers do not have the ability to gather
and consider all evidence relevant to policy problems.
Instead, they employ two shortcuts – ‘rational’, pursuing clear goals and prioritising certain sources of information, and ‘irrational’, drawing on emotions, gut
feelings, beliefs and habits to make decisions quickly.
The key problem with many health studies is that they
focus on the first short cut. They identify the problem of
uncertainty and incomplete information, seeking to solve
it by creating hierarchies of evidence and improving the
supply of information to policymakers. They ignore the
Table 1 New insights from policy studies raise new advice and dilemmas
New advice based on such insights
New dilemmas arising from such advice
How to maximise the use of Too many studies focus on
supplying scientific evidence to
evidence in policy
reduce uncertainty; focus
instead on increasing demand
for evidence by reducing
ambiguity
New insight from policy studies
Successful actors reduce ambiguity by,
for example, framing issues in
manipulative ways, using emotional
language
How far should scientists go to persuade
policymakers to act on their evidence?
Should they be manipulative? This
strategy may be effective, but it
presents moral dilemmas and
challenges a politically effective image
of science as objective
We identify several current responses
to this dilemma
How best to understand
and act effectively within
the policy process
Successful actors take the time to
identify which responsibilities are
delegated, ‘where the action is’ and
the ‘rules of the game’ in each
policymaking venue
How far should you go to defend a
hierarchy of evidence to deliver policy
solutions?
Should scientists object to ‘localism’
if it undermines policies based on
RCTs? Or, should they embrace the
‘co-production’ of policy with actors
who reject their ‘hierarchy’ of
evidential methods?
We identify three main responses to
this dilemma
Too many studies assume that there
is a policymaking ‘centre’, making
policy via linear stages in a cycle;
focus instead on a complex multilevel system or environment
Cairney and Oliver Health Research Policy and Systems (2017) 15:35
role of manipulation and persuasion to reduce ambiguity
by establishing a dominant way to ‘frame’ policy problems. The latter can determine the demand for evidence.
From such discussions, we can provide a first key message for scientific advocates, namely to recognise the
tendency of policymakers to base judgements on their
well-established beliefs and shortcuts based on their emotions and familiarity with information. On that basis,
consider how to reduce ambiguity, to persuade policymakers to frame a problem primarily in one particular
way and, therefore, to demand scientific evidence to help
solve that problem.
Persuasion or ‘framing’ strategies are effective because
they appeal to the emotions and the familiar, combining
facts with emotional appeals to prompt lurches of attention;
telling simple and easily understood stories which manipulate people’s biases, apportioning praise and blame and
highlighting the moral and political value of solutions; and
recognising the importance of interpreting new scientific
evidence through the lens of the beliefs and knowledge of
influential actors.
Without this focus on the ways in which policymakers
understand and respond to problems, scientists will be
unable to exert influence, responding only to sudden
policymaker demand for evidence-based solutions to a
pre-defined problem [10, 15–27].
However, this first message also produces the first practical or ethical dilemma – how far should scientists go to
persuade policymakers to act on their evidence? This
knowledge allows us to decide how far we should go to secure influence, from the ‘pure scientist’ providing evidence
with little thought for its application and the ‘honest broker’
prepared to engage with stakeholders to define policy problems [28], towards engaging in persuasion and/or manipulation to generate attention for problems and evidencebased solutions [29].
There is no definitive answer to this question. Instead,
there are factors to consider, including the trade-off
between (1) being manipulative and hyperbolic, to generate attention in the short term, and (2) maintaining an
image of objectivity, to generate strong relationships in
government based on reliability, expertise, trust and ‘independence’. Further, there are many compromise solutions,
including a strategy built on framing the implications of
evidence according to the stated beliefs of policymakers
and building up a reputation for reliability within many
policymaking venues.
Issues with existing approaches: the focus remains on
research over policy impact
In health science, many models of research impact are
built on strategies which make minimal reference to policymaking, namely identifying the research question, developing a research methodology, implementing data
Page 4 of 11
collection, analysis and synthesis, interpreting findings,
and developing research and then policy/practice recommendations. In this patrician model, the process is
owned and controlled by researchers, who then advise
or disseminate their work in the general direction of policymakers [30].
There is also the advocacy model, where researchers
develop policy solutions and attempt to convince policymakers to adopt them [31, 32]. Most of this literature focuses on techniques (e.g. [33]) rather than risks. Gilbert
[34] describes advocacy research as aiming to create social change, usually for excellent reasons, but involving
tactics which can lead to researchers distorting the data
(for example, giving inaccurate estimates of child abuse
statistics) or presenting overly emotive cases which can
‘powerfully shape’ media coverage (for example, on rape
cases). Advocacy can obscure and distort policy discussions but most discussions do not address this problem
or the underlying issues of power and policy processes.
A more collaborative kind of advocacy is ‘facilitational’,
in which researchers attempt to share power, responsibility and accountability for research with stakeholders. ‘Coproduction’ was originally used to describe a model of
public service delivery which rested on the belief
that using a broad range of perspectives lead to better,
fairer, more useful and more used products and services
[35–38]. These beliefs have transferred to the production
of knowledge through collaborative or participatory
methods, which may lead to more egalitarian policymaking, through shared responsibilities [39–48].
New collaborations between scientists and policymakers
There are many models for collaborative interactions between scientists and policymakers (e.g. [49–54]). The
James Lind Alliance [55] has long been active in the ‘coproduction’ of research agendas between patients, clinicians and researchers; the National Institute for Health
and Clinical Excellence (NICE) has used stakeholder
groups to generate clinical and research recommendations and priorities for nearly two decades [56]. Collaborative research practices tend to fall into two groups –
using each other’s skills and expertise for relatively
discrete sections of the research process (collaborative)
and engaging in a whole process of equal control and
decision-making (co-productive) – although these labels
are not consistently applied. Both describe a ceding of
control by researchers, over some or all of the research
process, to stakeholders, including policymakers, to a
greater or lesser degree [57, 58].
Little research has been performed on the strengths,
risks and implications for research, researchers and policy of these models of interactions [34, 43]. Proponents
tend to promote their models as more democratic or as
producing higher quality research, although generally
Cairney and Oliver Health Research Policy and Systems (2017) 15:35
this is an ideological rather than empirically-grounded
stance. Proponents of the patrician or neutral models
are presumably wary about stating their position, as coproductive research is increasingly claimed as the vehicle
for research ‘impact’. Some commentators identify risks to
researchers in lessening control or increasing advocacy
[59, 60], but this has not translated into a considered discussion of the implications for the evidence-based policy
movement. Few studies consider the insights we highlight
about the roles of policy actors, the consequent judgments
about what counts as evidence and why, and how decisions are made.
What most of these models have in common is that
they are modifications of the research process, not responses to the policy process. The disinclination of many
scientists to engage with the policy world, even amongst
the most collaboratively minded, is revealing. It highlights an unresolved issue about the extent to which a
systematic research-driven model can be adapted and
improved to reflect the need to compete with advocates
of other forms of evidence to secure the attention and
support of policymakers.
In summary, scientists have developed different answers to the question ‘how far should you go?’ These
answers correspond to ways in which scientists and
policy actors interact, from disseminator/receiver to
equal co-producers. However, these interactions have
not yet been examined through the lens of policy
theory, nor have empirical comparative descriptions
enabled us to determine what types of interactions
work best, for which purposes and under which
circumstances.
How best to understand and act effectively within
the policy process
Any competition to frame issues takes place in a complex
policymaking environment or system [61]. This context is
not described well by the ‘policy cycle’ – an understanding
built on the idea that policymaking can be separated into
discrete stages (agenda setting, policy formulation, implementation, legitimation, evaluation and succession) –
which remains popular within health scholarship despite
being rejected by policy scholars as a poor explanation of
policymaking [2, 3, 10, 14, 62–66].
In its place are theories which identify a policy ‘environment’ which relates to the interaction between
five factors, namely the many policy actors operating
in multi-level systems, pursuing ideas (using their beliefs and knowledge to influence how policymakers
think), adapting to institutions (the formal and informal rules of political systems and organisations), networks (between policymakers and influential actors),
and the impact of socioeconomic context and events
[3, 27, 67–71]. Further, some theories identify
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complex policymaking systems in which, for example,
the same inputs of evidence can receive no, or disproportionate attention, and policy outcomes often
‘emerge’ in the absence of central government control, which makes it difficult to know how, and to
whom, to present evidence [3, 72].
This analytical shift from cycles to environments and
systems helps us reject the notion that there is a core
group of policymakers at the heart of the process,
analysing and making policy from the ‘top down’, and
that scientists promoting evidence can focus their efforts
at a single point of problem definition or policy
formulation [3].
Rather, scientists compete with many influential actors
to present evidence to secure a policymaker audience at
many levels of government. Support for evidence-based
solutions varies according to which organisation takes
the lead and how its rules encourage policymakers to
understand the problem. Some networks are close-knit
and difficult to access because bureaucracies have operating procedures that favour some sources of evidence
and participants over others. There is a language in institutions and networks that takes time to learn. It indicates which ways of thinking are in good ‘currency’,
including a dominant way to ‘frame’ a problem and limit
discussion to certain solutions. Well-established beliefs
provide the context for policymaking – new evidence on
the effectiveness of a policy solution has to be accompanied by a shift of attention and successful persuasion.
Social or economic ‘crises’ can prompt lurches of attention from one issue to another, and some evidence can
be used to encourage that shift. However, most policy
change is minor; it is rare for events to combine with
new evidence to produce quick and radical policy
change [10].
From such discussions, we can provide a second key
message for scientific advocates – learn ‘where the
action is’, and be prepared to engage in a long-term
strategy to be in a position to influence policy. In other
words, identify ‘the action’ at several levels of government, learn the ‘rules of the game’ in institutions and
networks (or the ‘venues’ in which policymaking takes
place), form coalitions with like-minded actors, and
work with the ‘policy entrepreneurs’ possessing the skills
to exploit ‘windows of opportunity’ to give policymakers
the motive and opportunity to adopt new solutions [3, 8,
23, 24, 27, 73–78].
In most cases, these coalitions will be with many
actors with different ways of thinking about policymaking, engaging in politics to turn their beliefs and
values into policy, often unaware or unsupportive of
EBM’s hierarchy of evidence, and likelier to refer to
governance principles other than evidence-based
policymaking.
Cairney and Oliver Health Research Policy and Systems (2017) 15:35
Consequently, this second message produces a second
practical and ethical dilemma – how far should you go
to defend a hierarchy of evidence to deliver policy solutions? It involves the extent to which policy actors
should accept and adapt to policymaking complexity and
the diffusion of power, or seek to change some aspects
and assert their claim for greater power.
For example, central governments have some incentives to try to reassert central control because they are
held accountable in elections and parliaments for policy
outcomes, regardless of their responsibility [14]. Yet,
they also recognise the need to share decision-making
with actors at multiple levels of government, including
at the point of policy delivery. This produces a form of
government in which the co-production of policy
solutions is based partly on evidence and partly on the
principles underpinning local governance, including
‘localism’ (central governments recognise the role of
partly autonomous local authorities or partnerships)
and service user-driven services (based on their values
and preferences) [12].
In that context of multi-level and delegated policymaking, scientists may support phrases such as ‘co-production of research’ superficially (who would not want to
involve all relevant actors in the production of knowledge?), but also recognise the need for tough choices to
ensure the application of evidence-based policy solutions. They need to engage with two debates simultaneously, on EBM and localism.
First, not all actors adhere to the EBM ideal [79–83].
There are several different reasons to expect a different
approach, as described below.
Policymakers may not care that evidential hierarchies
exist, preferring a variety of sources of knowledge [3,
6, 84]. While RCTs enjoy high status in some units in
government and key champions [85], in others they
may be used primarily to reinforce existing agendas
[8]. Indeed, policymakers can appropriate research
findings and reduce academic criticism of evidence
use by commissioning evidence directly and/or
seconding academics to government roles [86].
Or, policymakers may accept scientific evidence on
the size of a problem and recognise the potential
value of solutions from the same academic source,
without finding a politically feasible way to introduce
them (see, for example, [87] on the limited
receptivity to measures to reduce health inequalities).
Some advocates of RCTs recommend greater
reflection on scientific values in politics rather than
the assumption that hierarchies of evidence are
necessarily valid [88, 89].
EBM contrasts with an adherence to practice-based
evidence, which includes the experiential knowledge
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of practitioners, feedback from service users and
a greater focus on supporting different voices
([41, 44]).
Some scholars argue that complex policymaking
systems defy control and, therefore, are not
conducive to the use of RCTs (see [61]). Instead,
we use other methods, such as process tracing [90],
large-scale quantitative evaluation designs like
difference in differences, or case studies, to highlight
the interaction between a large number of factors
which combine to produce an outcome, the result
of which cannot be linked simply to the independent
effects of each factor.
Second, central governments face the trade-off
between national and local policymaking [91]. Their
national strategies can include reference to uniform
delivery standards, to avoid a ‘postcode lottery’, and
encourage local autonomy and policy flexibility, to
recognise the legitimacy of local policymaking and
encourage community or service user participation. For
some interventions, they may favour uniformity of delivery and fidelity to a programme. For others, they express a preference for localism built on arguments,
including one size does not fit all, local authorities have
their own electoral mandates, a policy will not succeed
without local ‘ownership’, and/or local public bodies
need to adapt to quickly changing local circumstances.
Consequently, there is an inextricable link between
debates on the selection of evidence-based solutions/interventions and the correct choice of governance arrangements. This involves a two-part decision in which
policymakers combine (1) their chosen method to identify and gather knowledge of successful policy solutions,
with (2) their judgement on how to work with other
actors to ‘scale up’ success.
In this context, consider the scale of the task to ensure
the primacy of RCTs and/or a hierarchy of evidence in
policymaking. It involves (1) persuading many actors in
many central and local venues that (2) there is a wellestablished best way to produce scientific evidence, and
therefore (3) that scientific forms of knowledge should
be prioritised in policymaking. This is a two-pronged
dilemma – should you devote necessarily high resources
to this line of persuasion, and should you go to great
lengths to dismiss competing understandings of good
policymaking?
Three responses to this dilemma
To demonstrate the issues central to dilemma 2, we outline a spectrum of approaches to answer the ‘how do
you scale up success?’ question (see [12] for a summary
table). It allows us to demonstrate the implications for
evidential hierarchies when power is spread across
Cairney and Oliver Health Research Policy and Systems (2017) 15:35
multiple levels of government. We show the constraining effect of a rigid attachment to ‘fidelity’ to policy interventions on the ability of local communities to
modify policy solutions to reflect their values and preferences. This outcome may only be appropriate in some
cases. We compare it with an approach that favours
local flexibility and governance principles at the expense
of scientific evidence. The contrast allows us to highlight the political choices with which advocates of evidential hierarchies need to engage. We use examples of
initiatives pursued by the United Kingdom and Scottish
central governments, each of which enact or negotiate
the delivery of policy interventions with a variety of
elected local authorities and unelected health and social
care organisations.
Approach 1: prioritise RCTs and focus on fidelity and
dosage
The primary aim of movements such as ‘implementation
science’ is to gather the best evidence on health interventions and ensure that it has a direct impact on practice [1, 92]. One should not exaggerate the top-down
nature of EBM [93, 94]. However, we can use its key
tenets to produce one ideal-type approach:
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benefits to participants and/or society”. Trials have been
conducted since 1977, producing 18 peer-reviewed articles in elite journals (such as Journal of the American
Medical Association), with at least two non-United
States studies [96]. It was rolled out in England to 9000
mothers, with reference to its high cost effectiveness and
‘strong evidence base’, which would be enhanced by
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