PBRS
1.14 Significance of evidence-based health policy and practice in Botswana
Quoting the Oxford English Dictionary, Solesbury (2001:7) defined evidence as „the available body of facts or information indicating whether a belief or proposition is true or valid.‟
Nutley (2003:4) quotes the UK Government Cabinet Office which defined evidence as ‘Expert knowledge; published research; existing statistics; stakeholder consultations; previous policy evaluations;
the Internet; outcomes from consultations; costings of policy options; and output from economic and statistical modelling.‟
Bowen and Zwi (2005:2) observed that the term „evidence-based policy‟, when used in the literature largely refers to a single type of evidence, that is, research-based evidence. From the UK Government Cabinet Office definition, however, it is apparent that evidence is not only limited to the type of information contained in research documents since this is just one source of evidence. Dealing with everyday issues, therefore, calls for the use of the best available evidence which will be context specific.
Besides research-based evidence, knowledge necessary for decision making can be obtained through sources like „histories and experience, beliefs, values, competency/skills, legislation, politics and politicians, protocols, …‟ (Bowen and Zwi 2005:601).
In Botswana, with its chosen democratic system of governance and a quest, after independence, for a growth of the economy, poverty alleviation, human resources development, gender equality and empowerment, environmental conservation and sustainable development, as well as a sustainable health sector, the need for evidence or factual information in policy making is of utmost importance. The observation by Allen (2007:6) that „Social science is bad at the accumulation and re-use of past data/findings‟ need not be true for Botswana.
In a political system as exists in Botswana, the need for evidence, from whatever source, to inform health policy is necessary to increase transparency so citizens can be informed of how decisions that affect their health status have been arrived at. Accountability is one of the corner-stones of a democratic government; hence, evidence influenced health policy will increase such accountability. It is noted that there are other influences like political expediency, stakeholders, the public and the media that may determine the nature of policy decisions. (Campbell et al 2007:13).
There is congruency between the political, ideological and economic factors that influence policy development and decision-making and the use of evidence in support of those decisions. In stating this, it is recognised that more conflicts would be expected in a country with systems based on undemocratic ways of governance. Botswana should, therefore, take advantage of the enabling environment that already exists. There is already a fertile ground for the use of evidence in the health sector and the country should take advantage of it.
The observation by Pang (2003:2) that „in the face of continuing global health challenges, times of scarce resources and competing priorities, the use of evidence to inform policy-making ……. should be the key driver for improving health system performance‟ is pertinent for Botswana. The much acclaimed democratic political system of Botswana appears to be conducive for the use of evidence in policy formulation, implementation and evaluation. Dictatorships, in contrast, tend to be more restrictive and are not open to free discussion of ideas.
Solesbury (2001:9) argues that the commitment to evidence-based policy and practice is more demand than supply-driven. This is in contrast to the „top-down supply-driven approach‟ that Tsie (cited in Hope, Sr. and Somolekae 1998) describes as having been a feature of the Botswana public service after the attainment of independence. Since evidence is crucial at all the stages of policy formulation, implementation and evaluation, upholding the value of evidence will improve health policy making through well informed government decisions and enhanced effectiveness of health policy implementation.
Oxman et al (2006:2) wrote that health decisions in many countries have tended to „rely heavily on the opinions of experts.‟ It is necessary in the Botswana setting to determine the extent to which there is consistency between the available evidence and the recommendations of experts at the level of policy formulation, implementation and evaluation. Well documented evidence will also facilitate effective feedback to influence future Botswana health policies and programmes.
The number of complaints in the Botswana media attests to the fact that the public has a poor perception of the quality of service delivery. With the purposeful use of evidence, however, authorities in government and the health sector would be in a better position to provide the rationale for health policy initiatives. Evidence-based information would also enhance the way in which the relevant authorities understand the nature and extent of health sector problems and assist in proposing more workable solutions. Armed with appropriate evidence, Government Ministers, policy makers and health sector authorities would be well placed to communicate their policy decisions to the public as well as defend such decisions. Evidence-Based Policy and Practice, which stresses „the primacy of client and user needs
and helpfulness‟ (Allen 2007:5) is significant for Botswana, where advocacy for customer care is on the increase.
It is noted that world-wide, there is general consensus among health service planners that evidence-based policies and practices should be the guiding principle wherever possible. Studies abound attesting to the advantages of having policies that are grounded in proven results and measurable outcomes. There are, however, various notable challenges to the effective implementation of evidence-based policies and practices. Davoudi (2006) writes that some of the challenges arise because of practical and institutional short-comings in decision-making processes which differ from the perfect rational planning model as is presented by the rhetoric of evidence-based planning. Various studies have indicated that much research- based evidence tends to be shelved by policy-makers because planning in the real world is also influenced by „political and social ideologies and laden with value judgements‟ (Davaoudi 2006:5). Davoudi also refers to a UK Cabinet Office report which pointed out that not much of the research commissioned by government departments or other academic research was put to use by policy-makers.
The use of evidence in policy-making has to contend with factors such as ideological values and institutional beliefs which can determine the outcome of the policy-making process. In some instances, evidence may be used to justify pre-conceived policy directions, in which case policy becomes the outcome of a political process whereby evidence that is contrary to the chosen direction is disregarded.
The institutional pressures for quick decisions make it difficult for policy-makers to review evidential documents which may be voluminous or too technical for them to make sense of. The challenge to the use of evidence in policy-making may be compounded by occasions where the available evidence is of poor quality as when it is incomplete or contradictory.
There are challenges, however, with the requirement that decisions be evidence-based, for example, the issue of what counts as evidence and who counts it as evidence. Nutley et al (2003) noted that there is no agreement as to what counts as evidence with research-based evidence being just one source amongst many. This has the attendant problems of selection as well as assessment and prioritisation of evidence in social sectors such as the health sector where the outcomes of interventions tend to be multiple and of a contested nature. It is noted that even in the medical field where evidence is said to be scientifically based, there is still some controversy as to whether this is not more of assumption than fact (Borgerson, 2003). Definitions of evidence in the social sector, therefore, tends to be context specific. Nutley et al (2003) aptly observed that there are gaps and ambiguities in research-based knowledge which makes it insufficient to inform policy and practice in the public sector. The fact that what counts as evidence is
decided on by experts or those that produce research documents, which are in themselves of dubious methodological quality, rather than the needs of the users of the research compounds the problem.
Chapman (2004), commenting on the public sector policy making process, argued that some approaches, such as the evidence-based approach, had presumptions that are not universally true. He contended that, firstly, evidence-based methods of policy making presume that the evidence that one collects in one context will necessarily apply in another yet contexts of policy making differ. Secondly, the evidence- based approach, he also argued, presumes a linear relationship between cause and effect whereas complex systems involve a number of feedback loops which contribute to non-linear behaviour. Thirdly, he stated, the evidence on which policy is based is quantitative and the unintended consequences of public policy are systematically ignored because the evaluation only measures outcomes which are intended.
Although much of the literature on evidence-based policy and practice acknowledges that there may be other factors like political and economic expediency that shape the formulation and implementation of policy, it is generally agreed that the use of evidence has potential advantages. Davies and Nutley (2002:3) suggest, as one way of improving evidence use in policy and practice, „a strategic approach to the creation of evidence, together with the development of a cumulative knowledge base.‟
Notwithstanding the challenges faced by policy-makers in utilising evidence for policy-making, it is necessary for policies elsewhere and in Botswana to be based on transparent approaches so that they can be defensible. The outcome of policies has to be effective and this can be facilitated by policies based on realistic assumptions.
1.15 Need for realistic assumptions about conditions necessary for the implementation of performance improvement initiatives
This study assessed the extent to which the process of implementing performance improvement initiatives in Botswana avoided pitfalls of copying wholesale international cases that were reported as having worked exceptionally well elsewhere, for example, in Singapore. The objective of introducing performance improvement initiatives in an organisation is not to mimic international success stories, since conditions for implementation are not identical, but to adapt reforms so that they are implemented in the most efficient way. Merely adopting or transplanting initiatives tends to have implementation problems since conditions in the new setting may not be identical to those where the initiatives originated from.
Assumptions about conditions necessary for successful implementation of performance improvement initiatives need to be realistic. The new initiatives needed to be matched with the specific conditions of the health institutions in Botswana in order to attune the initiatives to the environmental reality or culture of the institutions so as to enhance the chances of success. The introduction of the initiatives was not an end in itself but a means to an end which was to improve customer satisfaction, a mission achievable through the generation of creative ideas, not mere replication of best practices. It was borne in mind in this study that the creation of much activity, such as the establishment of various teams in institutional departments or units, with respect to the new initiatives, was not necessarily an indicator of successful implementation. The value added by the initiatives to the work output counted more than the mere process of introducing the initiatives.
The study assessed evidence that suggested the failure by health service managements in the health sector to think critically about the requisite conditions for effective implementation of performance improvement initiatives. Such assessment of unrealistic expectations regarding the initiatives shed light on institutional decisions taken to either continue with initiatives or lose interest in them, after some period of intense introductory activity. The literature indicates that in instances where particular initiatives are deemed to have fallen short of meeting expectations the problem does not always lie in faults inherent to the initiatives themselves but in the institutions embracing initiatives without a rigorous interrogation of the environment in which they were to be applied. In such cases, a cycle of implementing different initiatives would begin anew, making the attempts at introducing subsequent improvements more difficult. The results of such short-comings are cynicism in the employees, a loss of management credibility and, overall, a wasted effort and resources.