Elsevier

Social Science & Medicine

Volume 51, Issue 6, 15 September 2000, Pages 859-869
Social Science & Medicine

The evidence-based approach in health policy and health care delivery

https://doi.org/10.1016/S0277-9536(00)00066-6Get rights and content

Abstract

Evidence-based approaches are prominent on the national and international agendas for health policy and health research. It is unclear what the implications of this approach are for the production and distribution of health in populations, given the notion of multiple determinants in health. It is equally unclear what kind of barriers there are to the adoption of evidence-based approaches in health care practice. This paper sketches some developments in the way in which health policy is informed by the results from health research. It summarises evidence-based approaches in health at three impact levels: intersectoral assessment, national health care policy, and evidence-based medicine in everyday practice. Consensus is growing on the role of broad and specific health determinants, including health care, as well as on priority setting based on the burden of diseases. In spite of methodological constraints, there is a demand for intersectoral assessments, especially in health sector reform. Initiators of policy changes in other sectors may be held responsible for providing the evidence related to health. There are limited possibilities for priority setting at the national health care policy level. Hence, there is a decentralisation of responsibilities for resource use. Health care providers are encouraged to assume agency roles for both patients and society and asked to promote and deliver effective and efficient health care. Governments will have to design a national framework to facilitate their organisation and legal framework to enhance evidence-based health policy. Treatment guidelines supported by evidence on effectiveness and efficiency will be one essential element in this process. With the increasing number of advocates for the enhancement of population health in the policy arenas, evidence-based approaches provide the information and some of the tools to help with priority setting.

Introduction

Evidence-based approaches in health can be described as health policy and health care delivery driven by systematically collected proof on the effects of health-related interventions from the social and health sciences. During the 1990s, evidence-based approaches have become prominent on the national and international agendas for health policy and health research. Yet, it is unclear what the implications of this rational approach are for the production and distribution of health in populations, given the notion of multiple determinants of health. It is equally unclear what kinds of barriers there are to the adoption of evidence-based approaches in health care practice. Depending on political vision, breadth of causal thinking, and the amount of accumulated evidence on the causes of ill health, health policy addresses health issues at different levels of impact. First, this paper will sketch general developments in the way in which health policy is informed by the results from health research. Next, the paper summarises evidence-based approaches in health at three impact levels: intersectoral assessment, national health care policy, and evidence-based medicine in everyday practice.

Section snippets

Informed health policy

Health policy in the broadest sense can be defined as those actions of governments and other actors in society that are aimed at improving the health of populations. Ideally, there would be a cycle of policy formulation, implementation, and assessment. In the assessment of policy outcomes, scientific evidence should play an important role (MOH, 1986, Ruwaard, 1994, Tugwell et al., 1985, US Congress, O. o. T. A., 1994, McGinnis and Lee, 1995). Over the past two decades, national and

Intersectoral assessment

National health status documents recognise the role of multiple determinants of health. It includes the influences of other societal sectors of governmental concern. Research, however, is still scarce. Some econometric research deals with entangling the relationship between economic development, or health care development, and mortality change at the national level (Pritchett and Summers, 1997, Kwakani, 1993, Preston, 1975, Mackenbach, 1988, McGuire et al., 1993). In these kinds of studies, one

Evidence-based health care policy

Several objectives of health care policy are mentioned in policy documents as universal access, comprehensive and uniform benefits, equitable financing, value for money, public accountability and freedom of choice by consumers and providers (Daniels, Light & Caplan, 1996). When attempting to support health policy, it is important to understand how these objectives can be defined, operationalised and measured. This is by no means straightforward. At the start of an EC-funded programme on equity

Evidence-based medicine in practice

Clinical guidelines can be defined as systematically developed statements to assist clinicians and patient’s decisions about appropriate health care in specific clinical circumstances. If evidence-based, they may contribute to further defining and improving the quality of health care delivery (Sackett, Rosenberg, Gray, Haynes & Richardson, 1996) and enhance population health (Field and Lohr, 1990, Burnand, 1999). They may promote resource efficiency by identifying sources of inappropriate use

Conclusion: the near future of evidence-based health policy

Consensus is growing on the role of broad and specific health determinants, including health care, as well as on priority setting based on the burden of diseases and the opportunities to reduce such burden in a cost-effective way. There will be a demand for intersectoral assessments, in spite of methodological constraints, especially in the area of health sector reform. Initiators of policy changes in other sectors might be held responsible for providing the evidence related to health. Due to

Acknowledgements

We thank Ken Redekop, Chris de Laet and the unknown referee for their comments on the manuscript. The Institute for Medical Technology Assessment is conducting a programme on the economic evaluation of Dutch medical guidelines, funded by the Ministry of Health.

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