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EVIDENCE USE
IN HEALTH POLICY MAKING
A N I N T E R N AT I O N A L
P U B L I C P O L I C Y P E R S P E CT I V E
EDITED BY
JUSTIN PARKHURST,
STEFANIE ETTELT,
AND BEN JAMIN HAWKINS
International Series on Public Policy

Series Editors
Guy Peters
Department of Political Science
University of Pittsburgh
Pittsburgh, PA, USA
Philippe Zittoun
Research Professor of Political Science
LET-ENTPE, University of Lyon
Lyon, France
The International Series on Public Policy—the official series of International
Public Policy Association, which organizes the International Conference on
Public Policy—identifies major contributions to the field of public policy,
dealing with analytical and substantive policy and governance issues across a
variety of academic disciplines. A comparative and interdisciplinary venture,
it examines questions of policy process and analysis, policymaking and
implementation, policy instruments, policy change and reforms, politics and
policy, encompassing a range of approaches, theoretical, methodological,
and/or empirical. Relevant across the various fields of political science,
sociology, anthropology, geography, history, and economics, this cutting
edge series welcomes contributions from academics from across disciplines
and career stages, and constitutes a unique resource for public policy scholars
and those teaching public policy worldwide.
More information about this series at

http://www.palgrave.com/gp/series/15096
Justin Parkhurst • Stefanie Ettelt
Benjamin Hawkins
Editors
Evidence Use in
Health Policy Making
An International Public Policy Perspective
Editors
Justin Parkhurst Stefanie Ettelt
London School of Economics London School of Hygiene
and Political Science and Tropical Medicine
London, UK London, UK
Benjamin Hawkins
London School of Hygiene
and Tropical Medicine
London, UK

ISBN 978-3-319-93466-2 ISBN 978-3-319-93467-9 (eBook)
https://doi.org/10.1007/978-3-319-93467-9
Library of Congress Control Number: 2018950835
© The Editor(s) (if applicable) and The Author(s) 2018. This book is published open access.
Open Access This book is licensed under the terms of the Creative Commons Attribution
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Preface
There have been many calls for better evidence and better use of evidence
in health policy making in specific countries and internationally. Much
attention has been paid to the variable quality of policy-relevant research,
the claims to validity of different research designs, and the independence
and conflicts of interest of researchers (Cartwright and Hardie 2012;
Evans 2003; Marmot 2004; Petticrew and Roberts 2003). However, dif-
ferences in the availability of independent, high quality, research only pro-
vides one of several possible answers to the complex problem of explaining
why some policies in particular contexts, and at certain points in time,
appear to be more aligned with evidence from research than others.
It is an empirical observation that the idea and rhetoric of ‘evidence-
based’, or ‘evidence-informed’ policymaking are more prevalent in some
countries and in some policy fields than others. In Britain, for example,
evidence-informed policy became an official government aspiration since
the 1999 White Paper “Modernising Government” (HM Government
1999), while in Germany official discourse is largely unaffected by explicit
appeals to evidence per se; although in practice there are many examples
in which experts, expertise and research contribute to policy decisions.
The health sector particularly embraces the language of evidence use,
given its successful history of shaping clinical practice through the embrace
of the methods of ‘evidence based medicine’ (Klein 2000; Berridge and
Stanton 1999) – and the experience of the medical field has led to calls for
other sectors to emulate its methods and approach to evidence use (HM
Government 2013). Indeed, global health advocacy is often built around
scientific expertise and evidence in the form of research findings, which
v
vi PREFACE
play a crucial role in informing decisions of international organisations

such as the World Health Organization (Oxman et al. 2007; D’Souza and
Newman 2012). Similarly, international donor agencies often utilise the
rhetoric of evidence use to justify their aid expenditures or policy choices
in the health sector, often presenting the image of a comprehensively
rational ideal by which health policy decisions can or should be made.
Yet at national level, the picture is often vastly different, with local prac-
tices, partisan interests and national politics seen to stand in the way of
better uses of evidence. In this respect, the health sector may appear no
different from other policy fields, despite the idea that health policy deci-
sions can use evidence to guide choices the same way that clinical practice
has done through the methods of evidence based medicine. This raises
important questions such as: Why are some countries more likely than
others to take account of findings from research in the development of
health policy? Why are some more successful than others in creating, and
institutionally embedding, an architecture that supports long-term evi-
dence use and a wider norm of evidence informed policy making? Does it
matter whether governments have more or less executive power, com-
pared to parliaments and the judiciary, to oversee and shape policy deci-
sions? And how do we explain these differences and analyse the ‘bigger
picture’ of evidence use in national policy and politics?
For many advocating for ‘evidence-based policymaking’ today, politics
is conceptualised as something detrimental to evidence use. From this per-
spective, political concerns, priorities and timetables, along with party
political interests, are hurdles that derail efforts of making policy more
evidence informed or even more ‘rational’. However, there is often little
clarity as to what is meant by ‘politics’ in those authors who simplify the
concept as a ‘barrier’ to evidence use.
Increasingly, however, a number of authors investigating the relation-
ship between evidence and policy have concluded that we need to engage
with the nature of the policy process more fully and, in particular, the
political nature of the policy making process (Ettelt and Mays 2011; Oliver
et al. 2014; Strassheim and Kettunen 2014; Cairney 2016; Parkhurst
2017). Often starting from a policy studies or public policy perspective,
these works argue that to see politics as a simple ‘barrier’ to evidence use
presents a false dichotomy between political and rational-technocratic
forms of decisions making. It is also to engage in a form of wishful think-
ing that we can somehow step outside of ‘politics’ to arrive at optimal,
evidence-led policy decisions. Politics is not the barrier to identifying the
PREFACE
vii
correct policy path to follow (a path presumably indicated by the evidence),

but the process through which societies identify and agree upon which
path to take in the first place. It is a process through which policy objec-
tives, solutions to problems and resource allocation are debated, consid-
ered, agreed, or disputed. Instead of a barrier to evidence use, politics
must be accepted as a necessary and inevitable condition of the policy
making domain. Political contestation over values, ideas and political pri-
orities thus characterise all forms of policy decision. This is particularly so
in the context of squeezed public finances and limited time in which not
all demands can be met and choices must be made, between often highly
worthy claims to public resources.
It is therefore of critical importance to health sector actors to realise
that health policy decisions are not placed outside political systems, but
rather made within existing political systems and institutional settings. In
this volume we argue that it is equally critical to consider the nature of
political systems influencing the use of, and opportunities for, evidence to
inform health policy decisions. A public policy lens thus not only requires
recognition of the multiplicity of social concerns at stake within a health
policy decision, it also mandates consideration of the structures, rules,
processes and norms, i.e. the political institutions, in place in different
country settings to understand when, why, and how pieces of evidence
may be used to inform health decisions.
The book is based on a five-year research project supported by the
European Research Council entitled ‘Getting Research into Policy in
Health’ (the GRIP-Health project) which aimed to improve the under-
standing and practices of evidence use by examining health policy pro-
cesses in six different countries. These countries were selected to allow for
a number of comparisons both in relation to different regime types, differ-
ent levels of socio-economic development and different approaches to
health policy-making. The book investigates how governments in these
countries used evidence to inform policy decisions, the type of contesta-
tion policy-makers are exposed to, and the scope of actors that have an
influence on health policy-making in various institutional forms, both
within and beyond government. By examining evidence use in different
country contexts we can better understand the institutional factors and
settings that shape policy processes and therefore shape the opportunities
for building and embedding mechanisms that institutionalise the use of
evidence in policy processes.
viii PREFACE
It is in the nature of these types of research endeavours to start with a

broad perspective which then becomes more focused on individual case
study analyses. This book attempts to combine both perspectives: The first
part brings together a number of in-depths analyses of health policy deci-
sions in individual countries, using a spread of health policy topics to
explore the institutional dynamics in high-income countries (Germany,
England), middle-income countries (Ghana, Colombia) and lower-income
countries (Ethiopia, Cambodia1).
The second part provides an overview of the dynamics within relevant
institutional settings such as the structures in which evidence use is embed-
ded in Ministries of Health, the role of parliaments and the judiciaries as
key institutions of the (democratic) state in relation to evidence use, and
the power divergence associated with aid dependency in low income coun-
tries and its potential impact on research uptake in policy decisions.
Chapters share a public policy perspective that is concerned with the
political nature of contested decisions and/or the institutional structures
in which decisions are made. Cases in each chapter apply these ideas to
analyse or reflect on evidence use for health decision making in each set-
ting. The directions each case study or country analysis takes, however, is
unique and a reflection of the realities of the nature of the problems and
issues emerging in each situation. Ultimately, then, the book applies a
multidisciplinary lens to institutional analysis of the role of evidence in
health policy, which we hope our readers will find interesting and
illuminating.
London, UK Stefanie Ettelt
Benjamin Hawkins
Justin Parkhurst
References
Berridge, V., and J. Stanton. 1999. Science and policy: Historical insights. Social
Science & Medicine 49: 1133–1138.
Cairney, P. 2016. The politics of evidence-based policy making. London: Palgrave
Macmillan.
1
At the time of the research programme’s initiation, Cambodia was classified as a low
income country according to the World Bank, but subsequently its national income rose to
current classification as lower-middle income.
PREFACE
ix
Cartwright, N., and J. Hardie. 2012. Evidence-based policy: Doing it better. A

practical guide to predicting if a policy will work for you. Oxford, UK: Oxford
University Press.
D’Souza, B., and R.D. Newman. 2012. Strengthening the policy setting process
for global malaria control and elimination. Malaria Journal 11: 1–3.
Ettelt, S., and N. Mays. 2011. Health services research in Europe and its use for
informing policy. Journal of Health Services Research and Policy 16: 28–60.
Evans, D. 2003. Hierarchy of evidence: A framework for ranking evidence evaluat-
ing healthcare interventions. Journal of clinical nursing 12: 77–84.
HM Government. 1999. Modernising government. London: The Stationery
Office.
HM Government. 2013. What works: Evidence centres for social policy. London:
Cabinet Office.
Klein, R. 2000. From evidence-based medicine to evidence-based policy? Journal
of Health Services Research & Policy 5: 65.
Marmot, M.G. 2004. Evidence based policy or policy based evidence? Willingness
to take action influences the view of the evidence – Look at alcohol. BMJ 328:
906–907.
Oliver, K., T. Lorenc, and S. Innvær. 2014. New directions in evidence-based pol-
icy research: A critical analysis of the literature. Health Research Policy and
Systems 12: 34.
Oxman, A.D., J.N. Lavis, and A. Fretheim. 2007. Use of evidence in WHO rec-
ommendations. The Lancet 369: 1883–1889.
Parkhurst, J. 2017. The politics of evidence: From evidence-based policy to the good
governance of evidence. Abingdon: Routledge.
Petticrew, M., and H. Roberts. 2003. Evidence, hierarchies, and typologies:
Horses for courses. Journal of Epidemiology and Community Health 57:
527–529.
Strassheim, H., and P. Kettunen. 2014. When does evidence-based policy turn
into policy-based evidence? Configurations, contexts and mechanisms. Evidence
& Policy: A Journal of Research, Debate and Practice 10: 259–277.
Acknowledgements
This work is part of the Getting Research Into Policy in Health (GRIP-
Health) project, supported by a grant from the European Research Council
(Project ID#282118).
xi
Contents
1 Studying Evidence Use for Health Policymaking

from a Policy Perspective 1
Justin Parkhurst, Stefanie Ettelt, and Benjamin Hawkins
2 The Many Meanings of Evidence: A Comparative Analysis

of the Forms and Roles of Evidence Within Three Health
Policy Processes in Cambodia 21
Helen Walls, Marco Liverani, Kannarath Chheng, and Justin
Parkhurst
3 The Role of Evidence in Nutrition Policymaking

in Ethiopia: Institutional Structures and Issue Framing 51
Helen Walls, Deborah Johnston, Elisa Vecchione, Abdulfatah
Adam, and Justin Parkhurst
4 The Use of Evidence in Health Policy in Ghana:

Implications for Accountability and Democratic
Governance 75
Elisa Vecchione and Justin Parkhurst
5 Using Evidence in a Highly Fragmented Legislature:

The Case of Colombia’s Health System Reform 91
Arturo Alvarez-Rosete and Benjamin Hawkins
xiii
xiv Contents
6 The Politics of Evidence Use in Health Policy Making

in Germany: The Case of Regulating Hospital Minimum
Volumes 111
Stefanie Ettelt
7 Electronic Cigarettes Regulation in the UK: A Case Study

in Evidence Informed Policy Making 137
Benjamin Hawkins
8 Ministries of Health and the Stewardship of Health

Evidence 155
Justin Parkhurst, Arturo Alvarez-Rosete, Stefanie Ettelt,
Benjamin Hawkins, Marco Liverani, Elisa Vecchione, and
Helen Walls
9 Evidence Use and the Institutions of the State: The Role

of Parliament and the Judiciary 185
Stefanie Ettelt
10 Evidence and Policy in Aid-Dependent Settings 201

Justin Parkhurst, Siobhan Leir, Helen Walls, Elisa Vecchione,
and Marco Liverani
11 Conclusion: Reflecting on Studying Evidence Use

from a Public Policy Perspective 221
Justin Parkhurst, Benjamin Hawkins, and Stefanie Ettelt
Index239
CHAPTER 1
Studying Evidence Use for Health

Policymaking from a Policy Perspective
Justin Parkhurst, Stefanie Ettelt, and Benjamin Hawkins
Introduction
Individuals working within the health sector very often see their work as
guided by collectively shared normative values. In particular there is an
overarching goal of improving people’s health. Indeed the field of public
health has been defined as “the science and art of preventing disease, pro-
longing life and promoting health through organized efforts of society”
(Acheson 1988, p. 1). This is often linked, either implicitly or explicitly,
to a concern for improving health equity (or reducing health inequali-
ties) – for instance within the World Health Organization’s calls to achieve
‘health for all’ (Detels and Tan 2015; Whitehead 1991). In recent decades,
efforts to improve population health and to reduce health inequalities
within countries and globally between states, have been linked with calls
for evidence based policy (EBP). Drawing on the idea of evidence based
J. Parkhurst (*)
London School of Economics and Political Science, London, UK
e-mail: j.parkhurst@lse.ac.uk
S. Ettelt • B. Hawkins
London School of Hygiene and Tropical Medicine, London, UK
e-mail: stefanie.ettelt@lshtm.ac.uk; ben.hawkins@lshtm.ac.uk
© The Author(s) 2018 1

J. Parkhurst et al. (eds.), Evidence Use in Health Policy Making,
International Series on Public Policy,
https://doi.org/10.1007/978-3-319-93467-9_1
2 J. PARKHURST ET AL.
medicine (EBM), health policy actors see engagement with policy-relevant

evidence to identify more effective, and by extension cost effective, inter-
ventions as the way to achieve their overarching policy objectives.
EBM as a concept is based on the idea that medicine should be prac-
ticed by making “conscientious, explicit, and judicious use of current best
evidence in making decisions about the care of individual patients” (Sackett
et al. 1996, p. 71). The origin of this idea is often attributed to Archie
Cochrane, who wrote in the early 1970s about the need to use evidence of
effectiveness to guide clinical practice (Cochrane 1972), although it was in
1993 that the formal establishment of the Cochrane Collaboration further
served to provide both a global repository of evidence for specific clinical
interventions, and an authority for best practices on how to review or
select evidence to inform medical practice (Starr et al. 2009).
The notion of ‘conscientious, explicit, and judicious’ evidence use is
relevant to consider in this context. From the earliest origins of the EBM
movement, there was recognition that it is not necessarily appropriate to
rely solely on research evidence when making decisions on diagnoses and
medical treatment. Professional experience and judgement on the part of
medical practitioners, in light of the evidence base and relevant inferences
from this, remain important (Sackett et al. 1996). However, over time, the
principles of EBM have gravitated towards specific types of evidence with
clear preferences for certain study designs – encapsulated in so-called
‘hierarchies of evidence’ (Petticrew and Roberts 2003) – reflecting con-
cerns about the internal validity of studies and the potential for biased
outcomes that, in medicine, “routinely lead to false positive conclusions
about efficacy” (Sackett et al. 1996, p. 72).
The EBM movement has, overall, been heralded as a triumph and is
credited with ensuring that medical treatments produce beneficial results,
particularly compared to the past, when many interventions were pro-
moted solely on the basis of hypotheses of potential cause and effect that
may, in fact, have been incorrect (Howick 2011). The Academy of Medical
Royal Colleges, for instance, has argued that EBM “is the key to the suc-
cess of modern Healthcare” (Sense About Science and Academy of Royal
Medical Colleges 2013, p. 1), co-authoring a report providing examples of
how EBM has improved health outcomes on a range of issues from HIV/
AIDS treatment to emergency allergy care and mental health treatment
(Sense About Science and Academy of Royal Medical Colleges 2013).
The success of EBM has been seen by many authors as the inspiration
for calls to expand the concept to other forms of decision making including
‘evidence based policymaking’ in health and other social policy areas
STUDYING EVIDENCE USE FOR HEALTH POLICYMAKING FROM A POLICY… 3
(Berridge and Stanton 1999; Wright et al. 2007; Lin and Gibson 2003;
Parkhurst 2017). This is despite recognition of the challenges in appropri-
ating ideas from clinical practice and applying them to shape policymaking
processes. For example, Black (2001) urged the medical community to
‘proceed with care’ with the idea of evidence based policy due to the quali-
tatively different nature of policymaking compared to medicine. A num-
ber of other authors have similarly argued that the political realities of
policy decisions mean policy cannot simply be ‘based’ on evidence in the
same way as clinical decisions and that the notion of a linear-rational rela-
tionship between evidence and policy is a fallacy (c.f. Lewis 2003;
Hammersley 2005; Greenhalgh and Russell 2009).
Russell et al. (2008), for example, have explained that:
…academic debate on health care policy-making continues to be couched in

the dominant discourse of evidence-based medicine, whose underlying
assumptions – that policies are driven by facts rather than values and these
can be clearly separated; that ‘evidence’ is context-free, can be objectively
weighed up and placed unproblematically in a ‘hierarchy’; and that policy-
making is essentially an exercise in decision science. (p. 40)
These messages appear to have had only limited impact on the concep-
tual vocabulary of health policy making and scholarship. Despite these
warnings, the language of ‘evidence based policymaking’ has become
firmly established in health policy discourses, particularly in the United
Kingdom (UK), Canada, and within many global health networks. As
such, recent publications have continued to critique examples of the over-
simplified or idealised embrace of evidence on which to ‘base’ policy (c.f.
Hammersley 2013; Cartwright and Hardie 2012; Parkhurst 2017). In
addition, recent systematic reviews have found limited engagement with
the political nature of policymaking to help explain evidence use. Oliver,
Innvaer, and Lorenc (2014a) concluded from one such review that while
studies of evidence use have spread from health to other sectors, few works
actually engage with aspects of the policy process or provide sufficient
details to draw firm conclusions. In a related paper, the authors argue that:
The agenda of ‘getting evidence into policy’ has side-lined the empirical
description and analysis of how research and policy actually interact in vivo.
Rather than asking how research evidence can be made more influential,
academics should aim to understand what influences and constitutes policy,
and produce more critically and theoretically informed studies of decision-
making. (Oliver et al. 2014b, p. 1)
Another review by Liverani et al. (2013) (undertaken as part of the

research programme making up this volume), similarly reviewed literature
on evidence use related to health policymaking and found few examples
that explicitly addressed politics to help explain the use of evidence to
inform health policymaking.
Given this state of affairs, this book aims to contribute to a greater
understanding of the political nature of policymaking and how it shapes
the potential for, and resultant outcomes of, evidence use in health policy-
making. In particular, we focus on scientific evidence arising from research
and related systematic processes of data collection (e.g. data collection for
monitoring the health system) as our principle subject. This is because,
while we recognise that the term ‘evidence’ can take many meanings –
including personal experience and legal argumentation – it is the formal
results of research activity and the application of the scientific method that
have been seen as essential to the aspirations of both the EBM and the
EBP movements.
We argue that while policy advocates have pursued their normative
goals of improving health outcomes through ‘better’ policymaking, asso-
ciated with reliance on research evidence, this has brought about a dis-
course that too narrowly focuses on certain conceptions of what counts as
policy-relevant evidence. In addition, it overstates the role which evidence
is able to play in the policy making process whilst paying insufficient atten-
tion to the politics of that process, including the competition of values,
ideologies, and policy objectives which cannot themselves be determined
by recourse to evidence.
There is thus a need to examine the complex interrelationship of evi-
dence use and politics to form a more nuanced conception of the health
policy process. This starts from an explicit recognition of the fundamen-
tally political nature of the policy process that recognises that, while evi-
dence can and should be an important factor informing policy debates, it
cannot provide the sole basis for policy decisions or is usually insufficiently
suited to resolve policy conflicts.
The Multiple Meanings of ‘Use’ of Research Evidence

The point of departure for developing our conceptualisation of how evi-
dence informs policy is to start by questioning what it means to ‘use’ evi-
dence in policymaking. Unlike clinical decision making, which often
involves a choice between clearly circumscribed interventions for a fairly
specific purpose (to improve patient outcomes), using evidence to inform

policy usually does not fit this model. More often than not, policy is not a
clearly delineated object, and there may be disagreement not just about
the preferred policy ‘solution’, but also about the nature and definition of
the problem to be addressed.
That evidence use in policymaking is not entirely compatible with
notions of instrumental rationality has been known for some time. Indeed,
Carol Weiss (1979) described a number of different meanings of research
utilisation in the late 1970s. She discusses social science research more
widely, but her models of research use are conducive to health policy
research as well. In particular, she identifies seven variants of research utili-
sation, including a ‘knowledge-driven’ model in which basic research
identifies new social problems; a ‘political’ model in which research is stra-
tegically used to achieve pre-existing goals; and an ‘enlightenment’ model
in which research influences broader thinking more generally.
The model that perhaps best aligns with the current dominant rhetoric
in the health sector, however, is Weiss’ so-called ‘problem solving’ model
of research utilisation, which sees direct application of a study’s findings
(for example findings from an evaluation of an intervention) to inform a
specific policy decision (for example, a decision about which intervention
to fund). Weiss, however, notes that it requires a tremendous, and incred-
ibly rare, alignment of circumstances to see research used in this way.
Indeed, this requires the identification, and agreement on the definition of
a problem that policy and research are expected to address. In practice, of
course, both problems and their solutions tend to be highly contested. For
example, to some, health inequalities run counter to accepted norms of
social justice and are thus identified as legitimate targets of government
intervention, while for others inequalities are seen as the outcome of per-
sonal choices and thus beyond the remit of the state. Similarly, for some,
governments are seen to have a responsibility to care for all, while for oth-
ers government intervention in health is seen as an unwelcome overreach
or intrusion on individual and market freedoms.
Contestation between groups who have different sets of values or
beliefs in many ways is at the heart of many theories of policy change
which perceive policymaking as a competitive process rather than a tech-
nocratic one (Sabatier 2007; John 1998). Yet it has been argued that the
level and nature of these competitive environments can incentivise the
manipulation of scientific or empirical evidence to achieve desired political
goals (Parkhurst 2016). As a result, strategic, rather than instrumental
uses of evidence appear commonplace in many policy arenas where politi-

cal interests exist – often decried as ‘policy-based evidence-making’ and
seen as a fundamental challenge to the ideal rational use of evidence that
many social sector stakeholders champion (Marmot 2004; Strassheim and
Kettunen 2014).
Nutley et al. (2007) have also provided a comprehensive mapping of
many potential meanings of evidence use/utilisation that includes, but
expands on Weiss’ original concepts. They identify that “the most com-
mon image of research use is of an instrumental process that involves the
direct application of research to policy and practice decisions” (p. 34).
However, the authors detail a number of other ways to conceptualise
research use beyond this simple view. This includes producing typologies
of evidence use (similar to Weiss’ (1979) model), as well as models which
see practices of evidence use as a continuum from more conceptual to
more instrumental uses, or instead considering evidence use as a process
or series of stages rather than as one or more types.
These works highlight the limitations of instrumental approaches to
evidence use, even if this continues to be held up as an ideal in many aca-
demic and professional circles. Yet mapping the different ways research
and evidence are used does not, on its own, explains neither why we see
different forms of evidence use arise at different times and in different
contexts, nor what constitutes a ‘good use of evidence’ in particular policy
areas. This is particularly important when reflecting on the specific goals of
health sector actors, and the common belief across that sector about how
robust use of evidence (and in particular of research evidence) will help to
achieve those goals. In this volume we thus attempt to move forward from
these initial mapping exercises to directly engage with the political nature
of policymaking to reflect on how evidence is used within the health sec-
tor. This approach allows explicit consideration of the systems in place that
work to provide evidence to policy decision makers, or seek to improve
evidence use in some way.
A Public Policy Perspective

A public policy perspective on evidence use accepts that political dimen-
sions of health policymaking will affect the relevance and use of evi-
dence within those policy processes. Yet the policy sciences are a broad
field, consisting of a wide range of theories and concepts that can each
be used to provide insights into policy processes and outcomes. Thus
calling for more public policy insights requires consideration of how

precisely to apply this field of work to study evidence use in a compara-
tive perspective.
Previous authors have engaged with theories of policy change to help
explain when or how evidence might be used within policy processes. Yet
what is apparent from these works is that there is a tremendous range of
theories that could provide insights in one or another way to this question.
Cairney (2016) highlights the relevance of a number of theories, frame-
works, and approaches including: multiple streams theory, punctuated
equilibrium theory, social constructionism, narrative frameworks, the
advocacy coalitions framework, studies of policy transfer or diffusion, and
complexity theory (see Cairney 2016, chapter 2). Cairney, however,
embraces the usefulness of the concept of bounded rationality in particu-
lar, due to his work having a central focus on policy makers’ perspectives
and a need to overcome the comprehensive rationality underlying the
evidence-based policymaking thinking. Smith (2013a) reviews many of
the same theories as Cairney, including theories of policy change, but
focuses on the ‘power of ideas’ to shape what is considered relevant evi-
dence, and to affect the roles and actions of policy actors for two contrast-
ing health policy issues: health inequalities and tobacco control.
The variety of policy studies theories thus provides a range of explana-
tory perspectives to consider different questions about policymaking and
policy change. For example, if one was concerned with how evidence fits
within ongoing processes of policy change, Kingdon’s multiple streams
approach or the Advocacy Coalitions Framework could be the most appro-
priate approaches to adopt. We are sympathetic to this wide variety of
approaches and the insights they can provide into particular questions of
evidence use.
However, in this volume we focus on two particular approaches derived
from the policy sciences. First, we engage with the contested nature of
policy decisions between multiple stakeholders who may be pursuing dif-
ferent interests, and conceptualising policy problems in different ways.
Second we consider the influence of the political institutions that work to
shape when and how particular forms of evidence influence policy deci-
sions in different settings. Our decision to focus on these factors arose
primarily from a desire to explore how the political nature of the policy
process affects evidence use in different settings; as well as a desire to
understand which forms of evidence use arise in different institutional
contexts.
Politics as Power and Contestation

One of the most widespread criticisms of calls for ‘evidence based policy-
making’ comes from authors who point to the inherently contested nature
of policy decisions. Unlike in clinical decision situations, policy is, as
Lasswell (1990 [1936]) classically observed, about ‘who gets what, when
and how’, emphasising the possibility of conflict over the distributive
effects of policy. Ultimately, policy-making is about power and influence,
and the ability of policy actors to generate or withhold support and influ-
ence an outcome. It is therefore not possible to separate policymaking
from politics. Scholars have historically noted that policymaking repre-
sents decisions, made on behalf of society, to decide on what collective
goals that society should pursue (Brecht 1959). As such it can be argued
that these processes require some form of democratic legitimation that
would typically be derived from ensuring that multiple interests are articu-
lated or considered in the decision making process (even if some are
excluded in the final choice of outcome) (Young 2000). In such a process,
however, competing stakeholders participating in this process will seek to
frame the terms of policy debates in way amenable to the objectives in
order to shape decisions (Russell et al. 2008), with the recourse to ‘evi-
dence’ serving as one mechanism through which policy discourses can be
shaped in favour of (or against) a particular outcome.
In many instances there are wide asymmetries of power between differ-
ent actors with obvious consequences for their ability to influence the defi-
nition of the policy problem, for example through issue framing, and the
type of intervention put in place to address them (Lukes 2005). Trans-
national corporations, for example the global tobacco and alcohol indus-
tries, have enjoyed high degrees of success in shaping policy and the wider
debates which surround policy decisions, not simply through direct lobby-
ing, but through their use of media consultants, public relations and cor-
porate social responsibility campaigns (Hawkins and Holden 2013).
The importance of issue framing in policy debates is thus critical to
understand, both in relation to the construction of policy-relevant concep-
tualisations of evidence and in relation to what can be achieved by appeals
to evidence in the context of highly contested policy debates. The framing
of an issue can shape the way in which a policy problem is seen; the very
essence of what it ‘is’ for the observer. This affects what the correct and
legitimate policy response to this is considered to be, and thus what is
identified as the most relevant body of evidence in assessing the policy
problem under consideration and the proposed responses (c.f. Bacchi

2009; Fischer 2003). If we accept multiple, often mutually exclusive, fram-
ings of policy problems are possible, each claiming support from different
(sometime overlapping) bodies of evidence, then the impossibility of set-
tling policy dilemmas through recourse to the evidence becomes acutely
apparent. This is why Russell et al. (2008) noted that it is ‘naively rational’
to assume that evidence can simply direct policy making in a linear way,
with Hammersley (2013) going so far as to claim that ‘evidence-based
policy’ is nothing more than a slogan used to discredit opponents.
Recognising the contested nature of decision making means that the
specific form of issue contestation, the strength of relevant interests, the
power of stakeholders and their networks, and their ability to frame prob-
lems and solutions, can be expected to play important roles in shaping
how evidence is used within health policymaking processes. From this per-
spective, the actors involved in policymaking take centre stage analytically,
with regard to the interest they may represent, the strategies they pursue
and the behaviours they display to achieve their desired outcome. Focusing
on contestation therefore allows for a deeper analysis of the role of actors,
their interests, and agency. It also allows an alternative conceptualization
of evidence use in policy processes. As Weiss (1979, 1991) already
observed, actors can use evidence strategically or tactically to support a
decision and to delegitimise other positions that are not supported by
evidence (or by evidence of the same methodological robustness).
Likewise, it is conceivable that evidence is used to build support and gen-
erate ‘buy-in’ and consensus, especially from audiences that are likely to
support the notion that evidence should be a key ingredient of policy-
making. In practice such efforts can fail as well as succeed. It will therefore
be difficult to clearly separate different uses of evidence, which may be
simultaneously instrumental and strategic.
Lines of contestation can be studied through a variety of case study
types, including analysis of a single health issue in a single context; of
multiple health issues in a single context; or for the same health issue in
different contexts. We have examples of all of these within this volume.
However, policy contestation is merely a starting point to apply the policy
sciences to the study of evidence use, even with the depth of conceptual
insights this initial step allows. Our driving interest was not only to look at
single decision events or policy choices, but to consider longer term and
systemic uses of evidence within the health sector. This means recognition
that evidence use in decision making is not just a single occurrence or
event, but rather it is an ongoing process integral to the policy process.

Thus the second main component to our conceptual approach is to engage
with concepts of institutionalism in order to explore how institutions
shape and direct the ongoing use of evidence affecting health decisions
across multiple decision points and over longer time frames.
An Institutional Perspective to Analyse

Evidence Use in Policy Processes
Lowndes and Roberts (2013) posit that “[i]nstitutions are central to the
subject matter of political analysis (p. 1),” and, indeed, institutional anal-
ysis is well established in the fields of political analysis and international
public policy comparisons, including comparisons of health systems and
reforms (Immergut 1992; Tuohy 1999). Given its history with EBM,
many look to the health sector in particular as leading other social sectors
in its engagement with evidence use (Parkhurst 2017); but even in this
field, only a small number of studies to date have directly analysed institu-
tions in relation to evidence use for policy. Some of these have focussed
on organisational arrangements that facilitate or hinder the uptake of
pieces of evidence; for example in relation to drug policy in England and
Scotland (Nutley et al. 2002), in health inequality policy in England
(Smith 2013b), or, in relation to clinical practice, in routine nursing prac-
tice in US hospitals (Stetler et al. 2009). The interest in organisational
arrangements is also reflected in some current work on organisational
‘embeddedness’ of evidence use as well within health policymaking bod-
ies (c.f. Gonzales-Block 2013; Koon et al. 2013). Other work has looked
at institutionalised processes of evidence use to inform fairly circum-
scribed sub-fields of health policy, such as coverage decisions relating to
publicly funded health services and pharmaceuticals, with the use of
health technology assessment (HTA) a prominent example (Garrido
2008; Turchetti et al. 2010).
However, our own systematic review of studies on evidence use, could
find only a limited engagement with the concept of institutions, especially
political institutions relevant to policymaking, to help explain the use of
evidence in policymaking in the health-related literature (Liverani et al.
2013). This echoes an earlier finding by Nutley et al. (2002), who looked
at public policy more broadly and concluded that “insufficient attention
has been paid to the institutional arrangements for connecting research
(and other evidence) to policy (p. 77).”
Therefore, we find that a significant gap in the literature still exists to

consider institutions more directly in relation to their role in shaping evi-
dence use for health policy making. In this volume, we draw on the
broader concepts typical of new institutionalism, as explored by authors
such as Peters (2005, 2008) and Lowndes and Roberts (2013), who see
new institutionalism as a way to move beyond historical work that focussed
solely on formal arrangements of political systems, to additionally consider
how institutional rules, practices, and narratives work to shape policy actor
behaviour.
From this perspective, and based on the analyses in the chapters that fol-
low, we stipulate that institutional structures, norms, practices, and narratives
will influence evidence use in policymaking in two ways. First, institutional
arrangements will shape the processes of policymaking and thus determine
which actors have access to policy and whose positions are considered rele-
vant or legitimate. This can be formal, for example through stipulations as
to who will be involved any given policy decision, or informal, with actors
having an implicit understanding, or a shared perception, of the appropri-
ateness of who should be involved in and who excluded from the decision
process. This focus on the roles of key policy actors helps to capture the
institutionalised features of policy contestation in different settings, akin to
what Peters (2005) describes as a rational choice branch of new institutional-
ism which maintains a focus on policy actors pursuing their interests within
institutional arrangements. We have used this perspective in a number of
different countries to analyse how different institutional arrangements
influence which stakeholders bring evidence of different kinds to policy
processes, often in the pursuit of particular interests.
Second, efforts to improve the use of evidence in policymaking can
themselves lead to the creation of new structures, rules, practices, and nar-
ratives that inform future policy decisions, i.e. evidence utilisation of one
form or another can become institutionalised, described elsewhere as
‘governing’ how evidence is used (c.f. Hawkins and Parkhurst 2015;
Parkhurst 2017). For example, governmental or non-governmental bod-
ies have been set up in countries with the explicit aim of generating, assess-
ing or synthesising evidence to develop a more consistent (and often a
more instrumental) approach to evidence use in policy. In order to exer-
cise their mandate, these bodies have, over time, created a set of rules and
practices that guide how they execute their mandates and go about their
tasks. These rules and practices are typically accompanied by ideas about
the ‘right’ types of evidence (e.g. the ‘hierarchy of evidence’), methods of
appraisal and synthesis, and ways of using them in decision-making (c.f.

Sutherland 2001; Petrisor and Bhandari 2007; Evans 2003; Borgerson
2009). Bodies such as these also operate with a legal framework set by
government or legislatures, which can lead to instances where their deci-
sions may be challenged or overridden by other political institutional
structures (c.f. Chap. 5 in this volume and Ettelt forthcoming).
Critically exploring these concepts can utilise what Peters (2005)
describes as normative institutionalism, which applies ideas such as March
and Olsen’s (1989, 2006) ‘logics of appropriateness’. This concept is in
many ways the antithesis of rational choice perspectives that see individuals
as pursuing their own interests, and instead explores how, within institu-
tional arrangements, individuals work towards outcomes guided by collec-
tive normative principles of what is seen to be the correct thing to do, or
what is the right outcome to achieve. This can therefore be used to explore
how practices play out within key administrative bodies in relation to domi-
nant ideas about evidence use (or about evidence-based policymaking)
within the health sector; and further allows consideration of how alterna-
tive logics play out when health related policymaking takes place across
institutions and policy sectors with their own distinct normative goals.
Institutions can be formal and informal, as well as explicit and implicit,
which means that at times they can be difficult to pin down analytically or
observe empirically. Yet all permutations may play out in important ways to
shape evidence use in different political contexts. Rules such as legislation
would be at the formal, explicit end of the spectrum, while narratives and
discourses about which behaviours of policy actors are appropriate are
more likely to be informal (and potentially implicit). In combination, insti-
tutional elements form structures and logics that shape how actors behave,
how they relate to each other, and how they relate to policy processes, both
individually and collectively. Ultimately these factors can play important
roles in shaping which of the many forms of evidence use arise in different
health policy processes – be it instrumental uses in line with idealised views
of the health community, strategic uses by policy actors to pursue their
interests, or some other form or combination of the types of evidence use.
Outline of the Book

The remainder of this book presents a set of chapters consisting of country
case studies and comparative analyses that arose from a five-year research
project supported by the European Research Council entitled ‘Getting
Research into Policy in Health’ (the GRIP-Health project). The project

aimed to improve the understanding and practices of evidence use by
examining health policy processes in six countries cutting across low, mid-
dle, and high income settings, as well as varying in their geographic loca-
tion and administrative arrangements. Specifically cases come from
Cambodia, Colombia, Ethiopia, Germany, Ghana, and the United
Kingdom (analysed as the UK in Chap. 7, but more narrowly focussing on
England in other comparative chapters).
The first set of chapters presents findings from individual country-
focussed investigations. These examined one or more health policy topics,
as well as processes of decision making, with explicit consideration of the
contestation of the issues and/or the institutional arrangements in place
that end up affecting the use of evidence.
Chapter 2 presents the first of our country examples with a case study
from Cambodia that specifically looks at the differences in evidence use for
three contrasting health policy issues – HIV/AIDS, tobacco control, and
performance based financing of midwifery services. The chapter illustrates
that despite the broad rhetorical embrace of the concept of evidence based
policymaking within the health sector, the extent to which evidence is
used in instrumental ways can vary substantially depending on the political
realities of specific policy topics, including competing governmental inter-
ests in issues or the conceptual framing about what evidence is meant to
achieve in different cases. The chapter considers the differing logics of
actors in each policy process and how these shape evidence use for differ-
ent health issues.
Chapter 3 follows with an analysis from Ethiopia that looks specifically
at the challenges to multisectoral planning for nutrition in that country. It
continues the concern over logics of appropriateness in relation to e vidence
use by reflecting on how different sectors (health, agriculture, finance,
etc.) may see their goals and thus their perceptions of policy relevant evi-
dence in different ways. The chapter also reflects on the constructed nature
of the framing of nutrition policy in the country, which could reflect com-
peting goals between differing policy sectors. Overall it considers how
these features make multisectoral planning, and the use of evidence within
such planning, a challenge.
Chapter 4 presents a case from Ghana that, rather than looking at a
specific policy topic, focusses on a key part of the evidence advisory system
of the country. Specifically, the Chapter investigates the institutional sys-
tem in place which dictates how routine local data is used to inform annual
health sector planning and policy reviews. The chapter considers how the
data and evidence review process has been institutionalised in ways that
not only shape which data and pieces of evidence inform certain planning
activities, but which also may have governance implications in terms of the
systems of accountability in the country, and the role or influence of inter-
national funding agencies.
In Chap. 5, a case study in Colombia further expands the institutional
lens to look more broadly at the role of the legislature within ongoing
health systems reform debates. The chapter also engages directly with the
importance of policy contestation in shaping when evidence will, or will
not, have a role in influencing legislative outcomes. The analysis illustrates
that even though scientific evidence was found to be available to decision
makers, it was unable to provide common ground or positions of compro-
mise within the highly contested and fragmented health policy field.
Chapter 6 presents a case study from Germany that particularly explores
the instrumental and strategic uses of evidence to inform debates about
minimum service volumes in hospitals (i.e. whether facilities should have
to provide a minimum number of procedures to be allowed to offer the
service). The analysis illustrates how the interests of key actors can lead to
strategic uses of evidence, but further highlights the dynamic relationship
between evidence use and the political and institutional context, exploring
how the legislative nature of policy-making, corporatism, and the role of
the judiciary in Germany influence these uses of evidence in this case.
The final country case study in this section comes in Chap. 7 presenting
the case of electronic cigarette policy in the UK. This case study focuses on
the contested nature of policy debates, but further considers the importance
of how alternative constructions or framings of the policy issue itself by com-
peting groups may help to explain how evidence is used. The chapter then
discusses why appeals to particular forms of evidence do not have the impact
that many health actors might expect. It concludes by reiterating a core
theme of this volume that the political nature of policy debates must be
engaged with explicitly to understand evidence use for health policymaking.
Following these country specific chapters, we present a set of three
comparative analyses that draw lessons from across multiple country cases
to address key themes arising from the project. Chapter 8 begins with a
direct consideration of the institutional systems in place that work to pro-
vide evidence to inform decision making by Ministries of Health. It begins
by considering the roles that Ministries of Health have as stewards of
national health care, considering how this can also extend to having a
mandate to shape the evidence advisory systems which will inform health
policy decisions. It then looks across all six of our country cases to con-
sider whether such systems provide relevant information in a timely man-
ner to key decision points. The chapter illustrates how key structural and
practical differences exist between countries, and also notes that, at times,
key health decisions lie outside the authority of Ministries of Health, pro-
viding further challenges to the roles that formalised evidence advisory
systems might play to inform those decisions.
This recognition of non-ministerial authority over health decisions
leads directly to Chap. 9, which discusses insights about the roles of
legislatures and the judiciary in shaping evidence use for health deci-
sions. The chapter draws out lessons from multiple country case studies
to illustrate the different ways that these bodies may use evidence to
classic ideas of instrumental or problem-solving use embraced by many
health sector actors. Ultimately the chapter draws out just how different
evidence use can look within national policy processes based on existing
institutional systems embedded in the legal or constitutional frame-
works of countries.
Chapter 10 presents the final comparative chapter, drawing lessons on
evidence use in relation to the role and potential influence of international
aid donors in our lower-income, aid-dependent case study countries
(Ethiopia, Cambodia, and Ghana). The chapter draws out the importance
of factors such as: the levels of local technical capacity, differing stake-
holder framings of issues, and the influence of external actors on underly-
ing systems of decision making. The chapter discusses how these were seen
to affect which evidence was used and for what purposes – illustrating how
the broader political economy of aid and development can play out in
multiple ways in terms of evidence use in health policymaking.
Finally, Chap. 11 provides a discussion chapter that allows us to reflect
on the issues raised in this introduction. We revisit what our cases show in
terms of the many meanings of research utilisation, and consider what has
been learned in terms of how political and institutional factors shape the
form of evidence use arising in health policy processes. The chapter syn-
thesises insights about how political contestation, issue construction, and
institutional arrangements all work (and at times work together) to shape
and direct evidence use. The chapter, however, concludes by recognising
that the insights from this volume only present a starting point to under-
standing the politics of evidence use from a public policy perspective,
merely scratching the surface of the many areas of research that can further
be done in this field.
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CHAPTER 2
The Many Meanings of Evidence:

A Comparative Analysis of the Forms
and Roles of Evidence Within Three Health
Policy Processes in Cambodia
Helen Walls, Marco Liverani, Kannarath Chheng,

and Justin Parkhurst
This chapter presents an edited version of a paper first published as:

Walls, H., M. Liverani, K. Chheng, and J. Parkhurst. 2017. The many meanings
of evidence: A comparative analysis of the forms and roles of evidence within three
health policy processes in Cambodia. Health research policy and systems 15 (1): 95.
H. Walls (*) • M. Liverani

London School of Hygiene and Tropical Medicine, London, UK
e-mail: helen.walls@lshtm.ac.uk; marco.liverani@lshtm.ac.uk
K. Chheng
National Institute of Public Health, Cambodia, UK
e-mail: ckannarath@niph.org.kh
J. Parkhurst
London School of Economics and Political Science, London, UK
e-mail: j.parkhurst@lse.ac.uk
© The Author(s) 2018 21

J. Parkhurst et al. (eds.), Evidence Use in Health Policy Making,
International Series on Public Policy,
https://doi.org/10.1007/978-3-319-93467-9_2
22 H. WALLS ET AL.
Introduction
In this chapter, we investigate the evidence perceived to be relevant to
policy decisions for three contrasting health policy examples in Cambodia –
tobacco control, HIV/AIDS and performance-based salary incentives.
These cases allow us to examine the ways that policy relevant evidence may
differ given the framing of the issue and the broader institutional context
in which evidence is considered.
It is widely agreed, including within the global health community, that
data and evidence are essential to inform policy formulation and implemen-
tation (Lavis et al. 2004; Katikireddi et al. 2011; Macdonald and Atkinson
2011; Franklin and Budenholzer 2009). However the rhetoric of evidence-
based policy – one based on the assumption that research is objective or
unbiased, and its uptake is a priori positive, with particular emphasis given to
pieces of evidence classified at the top of so-called ‘hierarchies of evidence’ –
has long been critiqued by social science scholars (c.f. Oliver et al. 2014a, b;
Cairney 2015; Cairney et al. 2016; Wesselink et al. 2014; Guyatt et al. 2008;
Tunis et al. 2003; Liverani et al. 2013; Smith 2013a; Smith and Joyce 2012;
Smith 2014; Hawkins and Parkhurst 2016). For example, Weiss (1990) has
argued that research alone ‘is almost never convincing or comprehensive
enough to be the sole source of political advice’, and ‘there are always issues
that research doesn’t cover’. Increasingly policy-studies scholars have
explored aspects of the political system that may shape when, how and the
types of evidence used within policymaking (Cairney 2015). These can
include both how political institutions (such as formal structures, and less
formal rules and norms) (Lowndes and Roberts 2013) and how key ideas
(including the way that issues are framed and understood) influence which
types of evidence appear to be relevant for, and are used within, different
policy processes (Smith 2013a; Shiffman and Smith 2007; Parkhurst 2012).
However, as described by Oliver et al. (2014a), little empirical analysis
has been undertaken of the processes or impact of evidence use in policy
and the way that research and policy processes interact. This paper seeks
to help address this gap, through a comparative examination of the role
that institutional and ideational factors play in shaping evidence use for
three contrasting health policy decisions within a single country context.
Specifically this paper presents findings from research conducted in
Cambodia, where the Ministry of Health (MOH), like many government
departments in countries elsewhere (Cabinet Office 1999; Government
Office for Science 2012; DEFRA 2011), has explicitly embraced the
overarching language of using ‘evidence-based’ approaches to health
THE MANY MEANINGS OF EVIDENCE: A COMPARATIVE ANALYSIS… 23
policymaking. One example of this endorsement is in the country’s sec-

ond Health Strategic Plan (2008–2015), which defines priorities and
goals for the entire health sector, highlighting the need “to strengthen
and invest in health information system and health research for evidence-
based policymaking, planning, monitoring performance and evaluation”
(Ministry of Health 2008). In this context, our study aimed to examine
and compare the ways evidence was discussed or used in three contrasting
health policy areas – tobacco control, HIV/AIDS and performance-
based financing (PBF) – in particular for PBF we focus on a widely-
praised government midwifery incentive scheme (GMIS) that was
introduced to increase deliveries at public health facilities.
Tobacco control represents a policy decision for which there is a long
history of acknowledged corporate and governmental financial interests
that have often attempted to influence how health-related evidence is used
in regulatory policy-making (Bero 2003, 2005; Ong and Glantz 2000;
Tong and Glantz 2007). HIV/AIDS, on the other hand, is an issue with
strong donor and global interest, and which has seen policy ideas particu-
larly shaped by global civil society movements and consensus (Parkhurst
2012; Schneider 2002; Buse et al. 2008; Doyle and Patel 2008). Finally,
PBF tends to have much less external contestation or debate, but is largely
seen as a more technical matter related to health economics, health service
provision or health systems functioning (Mills 2014; Meessen et al. 2011).
As such, these three examples provide useful ways to reflect on how the
different institutional settings in which policymaking takes place may
influence evidence use, including how interests and ideas of key actors
within the differing institutional arrangements play out in relation to evi-
dence utilisation.
Methods
The paper draws on findings from in-depth semi-structured interviews
conducted in Cambodia in 2015 and 2016 with stakeholders from key
health sector organisations, as well as a related documentary analysis. The
interviews were undertaken as part of a wider research project examining
political aspects of evidence use for health policymaking in multiple coun-
tries. In case-study countries, key informants were first asked questions
about the systems and processes through which evidence was used to
inform health policy broadly, followed by asking for multiple examples of
recent health policy decisions that could be illustrative of different aspects
24 H. WALLS ET AL.
of evidence use. In all countries we subsequently investigated evidence use

within tobacco control policy – given the importance of tobacco use for
health in virtually every country context, as well as the existence of both a
well-established evidence base and a global policy framework (i.e. the
World Health Organization’s global framework convention on tobacco
control). After consultation with local stakeholders, we then selected addi-
tional country-specific health policy decisions of interest or importance to
enable comparative analysis. As noted earlier, this approach led to the
selection of three examples in Cambodia: tobacco control, HIV/AIDS
and performance-based financing.
Key participants were identified though purposive and snowball sam-
pling strategies. In line with our approach, we first approached high-level
policy makers likely to be knowledgeable about major policy develop-
ments across the entire health sector, and thus could provide a general
overview of systems and structures in place to use evidence and advice on
the selection of case studies. Subsequently, a scoping review of relevant
documents (i.e. published studies and grey literature in the public domain
such as policy documents and reports) was conducted to collect back-
ground information on each policy issue. This was followed by identifica-
tion of individuals who could comment further on the use of evidence to
inform the selected policy decision. We endeavoured to conduct inter-
views with people who represented a diverse range of perspectives for the
health decisions investigated. In total, 26 participants were interviewed,
including both government representatives as well as individuals repre-
senting influential stakeholders in the policy process, particularly from aid
providers, non-governmental organisations, multi-lateral organisations,
and local research institutes.
Interview guidelines focused on the following broad topics, which were
tailored to the different roles of informants and the specific expertise or
insights they would bring: (1) perceptions about the policy process,
including the role of different actors and contextual factors; (2) the nature
and source of evidence that was used to inform the policy decision; (3) the
way in which evidence was presented and evaluated; (4) general views on
institutional structures and practices of evidence use within the Cambodian
health sector. Interviews were conducted face-to-face by the authors,
recorded (if permission was given), and subsequently transcribed and
coded into themes in an iterative process (Bourque 2004). Citations from
interviews and documents are included in the presentation of results to
illustrate key points and emerging themes.
Consent was obtained at the initiation of each interview, with respon-

dents given options on levels of anonymity desired. Ethical approval to
undertake the study was provided by the London School of Hygiene and
Tropical Medicine; and research permission obtained from the Cambodia
National Ethical Committee for Health Research (n. 0120; 06/05/2014).
Policy Studies Perspectives

It is now reasonably well-established that national policy contexts can vary
considerably with important implications for evidence use. Yet even within
a single country, the characteristics of evidence use for different health
issues may also vary considerably. Previous work has made it clear that the
political nature of policymaking means that there can be multiple compet-
ing interests and concerns at stake for any given policy decision – even
within the health sector (Parkhurst 2017; Russell et al. 2008; Cairney
2015). This indicates that multiple pieces of evidence may be relevant or
considered in the policy process, depending on the differing concerns at
stake, rather than any single piece or body of evidence. Thus an important
step in moving beyond an over-simplistic treatment of evidence use is to
understand the differing interests of stakeholders holding varying power
and influence over a given policy decision. Indeed, Cairney notes that
there can be such contestation at each step of the policy process – from
defining the problem, to deciding which evidence to generate (or presum-
ably which evidence to consider), to choosing solutions (Cairney 2015).
Scholars have thus begun to apply a range of theories and concepts from
the policy sciences to help deepen our understanding of evidence use given
these realities. Pearce (2014), for instance, describes a ‘mistaken consensus’
that local climate policy can be based on emissions data, instead drawing
out how ideas and arguments are also used, and needed to construct local
policy responses. This view is similar to that of Wellstead et al. (2017), who
argue that climate change adaptation science advocates are too narrowly
functionalist in assuming that policies will change in response to feedback
about climate change. Instead they argue that understanding policy changes
in this area requires looking not just at the specific problems climate science
identifies, “but also at the political and institutional factors that transform
situations into problems and attempt to address them (p. 13)”.
This shift away from thinking about policy problems as fixed, but instead
to consider how issues become ‘problematised’ directly draws on the field
of interpretive (or critical) policy studies, which considers the roles of rhet-
26 H. WALLS ET AL.
oric or discursive framing in shaping policy outcomes (c.f. Fischer 2003;

Bacchi 2009; Stone 2002). It is not just climate science, however, which
has seen such developments in analysis. In looking at health policy, Smith
(2013a), for example, argues that it is the roles and interplay of ideas (and
ideas about evidence) that can be critical to understand evidence use within
differing health-related concerns (Wesselink et al. 2014).
The policy sciences have thus been increasingly applied to questions of
evidence use in health policymaking and beyond. These perspectives allow
consideration of the multiple interests and multiple bodies of evidence
that are important to a policy decision, while further recognising the ways
that institutional and ideational factors can lead to differing constructions
of what evidence is seen to be appropriate to address any given interest in
the first place – with institutional forms and ideas closely linked to the rela-
tive influence of different stakeholders in policy processes.
In this paper, we embrace this approach, applying ideas from new insti-
tutionalism to explore the competing or contrasting constructions of evi-
dence use for a set of three differing health policy concerns in the setting of
Cambodia. On the one hand, new institutionalism highlights the not just
the structures in place that shape decision making processes and outcomes,
but also the importance of rules and norms within organisations that guide
actor behaviours or decisions (Lowndes and Roberts 2013; Peters 2005).
The approach also expands the focus of analysis beyond classic comparisons
of state bureaucracies or legislative forms to consider the nature of institu-
tionalised forces directing policy-relevant action across a much wider set of
organisational forms, including non-state bodies, collections of stakehold-
ers, or contrasting elements within a government system.
Applying such an approach to the question of evidence use for health
thus allows us to focus on multiple issues. First we can consider the power
or influence different stakeholders have over policy processes based on
their structural positions for a given policy issue – reflecting on how differ-
ent bodies of evidence may be more or less relevant to given stakeholders
with influence. This approach also, however, allows exploration of the
institutional logics which those stakeholders possess (c.f. March and Olsen
1989, 2006) that further shapes uses and understandings of policy-relevant
evidence. In order to achieve these goals we first provide an overview of
the three policy areas addressed, followed by a description of the types of
evidence seen to be applied or important in each case. This is then fol-
lowed by our analytical section that applies this institutional and ideational
lens to explore such questions.
One Country, Three Health Policy Issues
Tobacco Control
Tobacco smoking became increasingly prevalent in Cambodia in the
1990s when the country was recovering from its civil war. At this time,
there emerged the presence of many transnational tobacco companies in
the country, the most prominent of which was British American Tobacco
(BAT). The need for foreign investment and lack of regulation of advertis-
ing at this time, was explicitly recognised by British American Tobacco
(BAT) who described Cambodia as “an attractive and strategically impor-
tant target” (Mackenzie et al. 2004). A 1993 BAT industry plan, for
example, acknowledged that awareness of the relationship between smok-
ing and morbidity/mortality would increase in Cambodia through the
activities of the World Health Organization (WHO), but estimated that
“the significant revenues generated by tobacco advertising [for the gov-
ernment] will, in the short term, delay anti-smoking initiatives until alter-
native forms of revenue are guaranteed” (Mackenzie et al. 2004). BAT’s
preferred option was reportedly to become a majority shareholder in a
joint venture alongside local interests. Such an arrangement would pre-
sumably allow industry control of the composition of company board of
directors and significant influence over corporation activities, whilst also
encouraging a local stake in the corporation’s success. BAT achieved this
in 1995 (Mackenzie et al. 2004).
According to Mackenzie et al. (2004) there was also at this time, owing
to the lack of regulation, huge scope for tobacco-control advertising and
promotional activities (Mackenzie et al. 2004). Indeed, a 1994 survey of
twelve main streets in the country’s capital Phnom Penh recorded 49% of
the advertising signs (8495 in total) were advertising tobacco products
(Smith 1996).
HIV/AIDS
HIV/AIDS in Cambodia has a very different history to tobacco smoking.
In the mid-1990s, Cambodia had one of the fastest growing HIV preva-
lence rates in Southeast Asia, with injecting drug use and commercial sex
driving HIV transmission (Weiss and de Cock 2001). Adult prevalence
peaked at approximately 2.0% in 1998 (Pean et al. 2005). Since then, a
number of prevention and treatment programmes have been introduced,
28 H. WALLS ET AL.
however, and the country’s prevalence has reduced, to an estimated 0.7%

in 2013 (UNAIDS 2015; Vun et al. 2014).
The response has been divided into three phases: in phase I (1991–2000),
a nationwide HIV prevention programme targeted brothel-based sex
work, introduction of voluntary confidential counselling and testing and
home-based care, and peer support groups of people living with HIV
emerged; phase II (2001–2011) was characterized by expanding antiret-
roviral treatment (covering more than 80% of the population) and conti-
nuity of care, linking with other health services, accelerated prevention
among key populations at higher risk (entertainment establishment-based
sex workers, men who have sex with men (MSM), transgender persons,
and people who inject drugs), engagement of health workers to deliver
quality services, and strengthening health service delivery systems; and
phase 3 (2012–2020) aims to attain zero new infections by 2020 through
sharpening responses to high-risk population groups, maximizing access
to community and facility-based testing and retention in prevention and
care, and accelerating the transition from vertical approaches to linked/
integrated approaches (Vun et al. 2014). In recognition of the country’s
success in halting and reversing the spread of HIV (relating to the United
Nations Millennium Development Goal or MDG 6), Cambodia was in
2010 presented with an MDG Award (UNAIDS 2010).
Performance-Based Financing, and the Case of the Government

Midwifery Incentive Scheme
The final health issue we explored in relation to the use of evidence was
that of performance-based financing (PBF), with specific discussion in
interviews about the role of evidence in supporting the government mid-
wifery incentive scheme (GMIS). In many low and middle-income coun-
tries, PBF is increasingly being used to redress particular aspects of health
system underperformance, particularly the productivity and quality of
healthcare providers. It involves offering incentives intended to redress
underperformance, particularly high worker absenteeism, which is fre-
quently observed in poorly funded public health systems with poor
accountability (van de Poel et al. 2016). Support for PBF has spread rap-
idly in many countries in recent years (van de Poel et al. 2016). But whilst
there is considerable enthusiasm for PBF policies, according to a Cochrane
Collaboration review (2012) of pay-for-performance to improve the deliv-
ery of health interventions in low- and middle-income countries, the
current evidence base is too weak to draw any general conclusions regard-
ing effectiveness, with more robust and comprehensive study needed
(Witter et al. 2012; van de Poel et al. 2016).
According to van de Poel et al. (2016), Cambodia was the first docu-
mented case of a low-income country to experiment with PBF of public
health care. Since 1999, a variety of health programme funding of districts
and facilities in Cambodia have been contingent on performance targets
or have directly linked revenues to services delivered. The main PBF pro-
grammes implemented have specified performance targets relating to child
vaccination, antenatal care, delivery in a public facility, and birth-spacing
use. These funding arrangements have been intended to increase aspects
of healthcare provision, and there has been considerable variation in the
strength and conditions of the incentives offered (van de Poel et al. 2016).
The interviewees specifically identified the GMIS as a notable PBF pol-
icy, and described how the policy contributed to reducing Cambodia’s
high maternal mortality ratio (MMR) over recent years. The GMIS
became operational nationwide in late 2007, following a joint prakas
(directive) from the MOH and MEF to allocate government budget to
the incentive payments (Ir and Chheng 2012). The UNFPA was consid-
ered to be behind the policy change, for example through supporting a
High-Level Midwifery Forum in late 2005 that bought together represen-
tatives from several government departments. However it was the prime
minister who reportedly ‘gave the green light’ for the policy to go ahead.
Other stakeholders were not thought to have had much direct influence
over this decision, and the Cambodian Midwives Council, for example,
was established after the implementation of the GMIS.
The GMIS aimed to boost facility deliveries by motivating skilled birth
attendants (or trained health personnel) to promote deliveries in public
health facilities. It did this by providing midwives (and other trained per-
sonnel) cash incentives based on the number of live births they attended
in public health facilities – USD15 for a live birth in a health centre and
USD10 for a live birth in a referral hospital. The reason for the higher
payment in a health centre than a hospital was to provide a stronger incen-
tive for deliveries at health centres – the recommended facility for normal
deliveries to be managed (Ir et al. 2015). According to the MOH’s guid-
ance, besides midwives, physicians and other trained health personnel can
also receive these incentives when attending deliveries in public health
facilities. Up to 30% of the incentives will be shared with other health per-
sonnel in the facility and eventually with other people such as traditional
30 H. WALLS ET AL.
birth attendants (TBAs) who refer women to the facility for delivery (Ir
and Chheng 2012). The number of deliveries is reported monthly by
health facilities through the routine health information system. Based on
the number of reported deliveries, incentives are disbursed quarterly to
the facilities through public financial disbursement channels (Ir and
Chheng 2012).
The Nature of Evidence Used

In this section we begin to describe and examine the reported differences
in evidence use between the three policy areas. The evidence relating to
each issue can be categorised in various ways, including by evidence topic
(e.g., health, economic) or type (e.g. epidemiological, pilot study), which
relate to the issue framing by key stakeholders, and the sources relied upon
(e.g. global literature, national statistics, government survey). What is
clear, however, is that no single uniform construction of policy relevant
evidence was seen across cases.
Tobacco Control
Global evidence on tobacco harms were at this time considered well estab-
lished, but local data on smoking rates were fairly limited. In the late
1990s, Cambodia had some small regional surveys of smoking prevalence,
but it wasn’t until 2005 that accurate nationwide prevalence data on
tobacco use were available (Singh et al. 2009). In spite of a lack of local
data on smoking, in May 2004 Cambodia signed the Framework
Convention on Tobacco Control (FCTC), a global policy agreement that
calls for a number of restrictions on tobacco advertising and promotion –
restrictions which many global health authors present as ‘evidence based’
(Myers 2013; Rosen et al. 2013; Glantz and Gonzalez 2012). Many stake-
holders interviewed noted the importance of the FCTC locally, as it
dictated that the government could not engage with industry on develop-
ing tobacco control policy. However implementation of the elements of
the convention were described as only occurring slowly or in limited ways,
which interviewees suggested was due to industry influence.
For example, one independent health sector consultant explained:
The tobacco industry and lobby is massively powerful here. (IDI1-01, June 2014)
1
IDI, In-depth interview
Another respondent, a senior civil servant in the MOH, explained:
We don’t know exactly why the law is very slow to be approved. Probably this is
also due to lobbying of tobacco corporations, but we don’t have evidence to prove
it. (IDI-10, August 2014)
This individual also noted that tobacco control did not appear to be a
priority in the national health sector strategic plan.
The context of a deeply entrenched and powerful tobacco interest was
also manifested in how respondents conceptualised the evidence that was
relevant for moving tobacco control policies forward. A number of civil
servants interviewed, for example, stressed the need to counter other evi-
dence the tobacco industry uses to frame tobacco control in a way that
suits industry interests. For example:
They [tobacco corporations] always complain that if we increase taxes, farmers

will lose their job. So, you have to explain to the government that, if you increase
taxes, the margin will not affect the industry. Also, we have to explain that
farmers do not rely on one crop only, so reduced tobacco production will not
significantly affect them. (IDI-06, June 2014)
Tobacco industry is powerful and has money. Some people are lobbied by tobacco
corporations. They [tobacco corporations] have a lot of experience. They can
approach friends or members of the family and get confidential information
about policy making. Then, people that are lobbied create opposition at the
inter-ministerial meetings. They often say that tobacco control will impact on
the economy and farmers. (IDI-08, August 2014)
Respondents also emphasised the importance of making different

evidence-based arguments to different actors. In particular, it was noted
that the Ministry of Economy and Finance (MEF) needed different evi-
dence regarding tobacco control to the MOH to try to convince it to
support policy action. As one civil servant explained:
You have to find a way to convince people… also because policy is multisectoral.
It’s not that one minister decides. If you want to increase tax, this is not an issue
of the Ministry of Health. We don’t have the power to do this. We can do a
smoke-free policy, but tax is under the Ministry of Finance. So you have to work
closely with the Ministry of Finance. In Cambodia, when you talk to the
Ministry of Finance, first you have you prove to them they can make more
money… The industry can say ‘oh if you increase taxes, you will lose revenue’.
And you have to present evidence that increasing taxes is not a loss of revenue.
(IDI-06, June 2014)
32 H. WALLS ET AL.
We explain to the government that an increase in tax does not change the over-
all volume of cigarettes that are sold in the market. The case of Thailand shows
this. Why? Because smoking prevalence decreases, but population increases.
Cambodia is the same. Smoking prevalence has gone from 49.6% to 42.6%, how-
ever the absolute number of smoking is always 2 million because population
increased… and you have to tell the government these facts. So you have to do a
lot of work with the government to prove this. And of course, the tobacco indus-
try makes a lot of money. We cannot stop them. (IDI-06, June 2014)
This civil servant also explained how evidence from neighbouring

countries was considered influential, as was the normative element of the
FCTC.
Usually in Cambodia we present evidence or examples from ASEAN2 coun-

tries. How is Vietnam doing? Thailand? Indonesia? Then, we also do interna-
tional. But ASEAN is very important, also because we are approaching the
ASEAN [Economic] Community in 2015, and member countries do not want
to be left behind. (IDI-06, June 2014)
Overall, whilst many of the respondents spoke of the slow progress of

tobacco control policy in Cambodia, the government has made substantial
progress in tobacco control by banning the advertisement of tobacco
products in 2011 as well as smoking in workplaces and public spaces in
2016 using sub-decrees. However it wasn’t until April 2015 that the
Cambodian National Assembly passed the country’s first-ever law on
tobacco control, which was ratified later the same month. The new law
tackles tobacco from a variety of angles, including through import and
sales restrictions, and bans on sales to minors and pregnant women (FCTC
Implementation Database 2014).
HIV/AIDS
HIV/AIDS policy-making illustrates a radically different political context
in which the utilisation of health policy-relevant evidence can be explored.
The United Nations AIDS programme (UNAIDS) has stated that
Cambodia has “used high-quality strategic information to inform a [suc-
cessful] evidence-based response” (UNAIDS 2012); and interviews stood
in dramatic contrast to those with stakeholders advocating for greater
2
Association of South East Asian Nations.
tobacco control who expressed the need to develop or discuss evidence of

financial impact (e.g. on farmers or the treasury) to justify policy action.
Instead, in discussions of HIV/AIDS, whilst a variety of evidence types
were clearly brought to bear, NGO and donor-organisation respondents
discussed how it has often been epidemiological modelling and cost-
effectiveness analyses (IDI-21, 19, May 2016) – forms of evidence more
typically advocated by public health actors for priority setting – that were
seen as important evidence to guide policy. One of the respondents spoke
about how this approach should be replicated in other areas of health
policy-making:
I would say for HIV/AIDS it’s that way [evidence use more technical than in
other areas of policy] every time. I feel like that’s brilliant and the model of
HIV/AIDS [should] be replicated to other disease, for example we still have a
very high number of death among pregnant women, the baby, the infant. So
why don’t they learn from the HIV/AIDS program. (IDI-21, May 2016)
When interviewees were asked about the use of evidence within par-
ticular policy developments, a range of evidence types were described, in
addition to epidemiological modelling and cost-effectiveness studies men-
tioned above. Other relevant evidence was said to include pilot studies,
used for example to inform the development of a community-based test-
ing approach implemented in 2013, where the HIV testing is performed
by lay counsellors – volunteers from population groups at higher risk of
HIV infection. National prevalence estimates and international evidence
were also evidence types that were frequently mentioned, particularly with
international evidence from other Southeast Asian countries, and particu-
larly Thailand. The importance of international evidence may also reflect
the strong role of donors in HIV/AIDS policy-making in Cambodia.
Yes they [policymakers] welcome [overseas evidence] in the HIV area. I don’t
know about the other area. They welcome to learn the best practice from the
region. This week one [NGO] staff member. He joined the field in Bangkok.
(IDI-20, May 2016)
Epidemiological modelling of future prevalence scenarios has been

considered key to informing policy as to the prioritization and targeting of
interventions, preparation of operational plans, budgets and resource
mobilization efforts (11) (12), and cost-effectiveness analyses such as
modelling has highlighted areas where technical efficiency might be
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round in his saddle, pointed to the rear. Far in the distance, a dark
object was seen, which was quickly recognized as a horseman
coming with his animal on a dead run. He was not in a direct line
behind the train, but a little to the south. If he kept to his course he
would pass a couple of hundred yards to the south.
On he came with his half-breed pony running as if a hundred lives
were at stake. He made swift, tremendous leaps, his thin neck
outstretched, his flowing tail streaming straight behind, with his nose
extended, as he strained every muscle to reach his destination
without the loss of a minute. His rider was a small man, weighing not
more than a hundred and twenty pounds, and his riding revealed a
master of the art. He leaned slightly forward in the saddle, the front
of his hat standing straight up as if plastered against his forehead,
the ends of the handkerchief looped about his neck fluttering in the
gale caused by his own swiftness, while he occasionally pricked the
ribs of his horse with his spurs, though such urgency was hardly
needed.
As he flashed opposite, the rhythmic thump of the pony’s hoofs on
the sod was heard by the emigrants, all of whom were gazing at man
and animal. The former’s garments fitted so snugly that only the
fringes over and back of the shoulders, and those on the thighs
quivered. The trousers were thrust into the tops of his boots, whose
heels were high and pointed, and after the fashion among cowmen
and plainsmen.
The watchers identified his character at once, and needed not the
sight of the broad flat flaps fastened across the saddle, one in front
and the other behind him. He glanced toward the train, and
observing all eyes upon him, raised a hand in salutation, but did not
speak or make any further acknowledgment of the cheers. In a
twinkling the emigrants were gazing upon his back, the ends of the
fluttering handkerchief, fringes of clothing, streaming tail and flying
hoofs of the pony, which flung chunks of earth into the air as he
skimmed away on the wings of the wind.
“A Pony Express Rider!” said Alden; “how he goes!”
“How long hab he been doing it?” asked Jethro.
“From the station five miles back, and he’ll keep it up till he
reaches the next station farther on.”
“What den?”
“He’ll shift his saddle and mail bags to a pony that is waiting, and
then gallop at the same headlong speed for ten or twelve miles
more, and change again unless that is the end of his run. This isn’t
the first time, Jeth, we have seen those men riding like mad, and we
are likely to see many more before we get sight of the Pacific.”
“I didn’t obsarve dat he carried a rifle.”
“He had none, but a few of the riders carry them; this one doesn’t
think he is likely to need any, and so he lightens the load of his horse
that much. Shagbark managed to say a few words to me last night,
and one thing he told me was that the Pony Express riders
sometimes miss it in not taking a rifle with them. They are so anxious
to make schedule time that they run into danger. It often happens
that when they most need a gun they haven’t it. I hope that fellow
won’t be caught in such a fix.”
“Gorrynation! don’t he trabbel? Why can’t we do de same ting, Al?”
“If we could change horses every ten or twelve miles, we might
keep it up for a day at a time, but we should have to have two or
three hundred horses waiting for us at the different stations,”
observed Alden, thinking to close the argument.
“How would it do fur us to ride ahead and fix it dat way? Den we
could come back and skim ober de kentry like a couple ob
muskeeters.”
“After we had placed our ponies at the last station this side of
Sacramento, what should we gain by coming here and going over
the ground a second time?”
Jethro lifted his well worn hat and scratched his head.
“Dat’s so; I didn’t tink ob dat; blamed queer how it slipped my mind
—what’s de matter wid Shagbark?”
Before the flying horseman vanished in the distance, the emigrant
train resumed its slow progress. The massive guide, on the back of
his gaunt steed, kept his place well in advance. Often he went for
hours without looking back to note in what order the company were
following him, but now he had turned like Alden did a few minutes
before, and, without checking his steed or shifting his course, was
gazing fixedly to the rear. His brierwood was between his lips, and
from the thicket of whisker and mustache the blue vapor issued as if
from the funnel of a small steamcraft.
At the moment the two youths looked at him, he raised one of his
huge hands and beckoned.
“His eyes are on us,” said Alden.
“He’s looking at me,” added Jethro; “he feels bad at de way he
snubbed me jest arter we started, and means to apolergize; he don’t
want you; notice now. Gee up, Jilk!”
The negro twitched the rein, and his pony struck a moderate trot.
He had not crossed a fourth of the intervening distance, when the
guide thundered:
“NO! I don’t want ye, ye black imp! Stay whar ye are! Young Payne
is the chap I meant; why don’t ye come when I tell ye to come?”
The laughing youth spoke to his mare, and hurried forward.
“Wal, if he ain’t the mos’ umbrageous rapscallion dat eber trod on
two legs,” growled Jethro as his friend passed him, hurrying to
answer Shagbark’s call.
Acquainted by this time with the moods of the old trapper, Alden
did not speak as he drew up beside him, but waited to learn what he
had in mind.
“I want ye to keep with me a while,” remarked Shagbark, who had
checked his animal and now resumed his progress on a walk; “I’ve
something to say to ye.”
“I’m listening.”
“Have ye obsarved anything ’tickler?”
Uncertain what was meant, the youth replied:
“I can’t say that I have: what do you mean?”
“Ye carry a telescope by a cord round your neck; ’spose ye use it.”
Still in doubt, Alden brought the binocular round in front, and held
it suspended with one hand.
“In what direction shall I look?”
“Anywhar ye choose, but thar’s no need of wastin’ time; p’int it
ahead and a little to the left away from the river.”
The lad raised the instrument and scanned a fourth of the horizon
to the right and left. At first he saw only the broad, level sweep of
plain, and was about to say so, when something caught his eye.
What seemed to be a half dozen or more specks flickered on the
horizon, but even with the aid of the glass he could not make them
out clearly and at first was in doubt.
Shagbark kept his keen eyes on the youth. He knew from the
expression on Alden’s face that he had discovered that which the
other meant him to see.
“Wal, what is it?” asked the guide.
“I am not sure, but I think a party of horsemen are hovering along
the bank of the river, a little way out on the prairie.”
“Zactly; are they white or red?”
“It is impossible to tell at so great a distance.”
“Onpossible fur ye; what good is that gimcrack of yers, anyway?”
“It shows me what I could not otherwise see.”
“I never use them things, but my eyes tell me a blamed sight more
than that can tell ye; them horsemen ye obsarved are Injins.”
“You have wonderful eyesight, Shagbark,” remarked Alden
admiringly, again lifting the glass to his eyes and peering through
them.
“I can make out the horsemen quite plainly, but that is all.”
“I seed ’em two hours ago and have been watching ’em ever
since.”
“That Express Rider that went by will run into them.”
“No, he won’t; he ain’t such a fool; he’ll make a big sneak to the
left and get past ’em; if it was among the mountains, he wouldn’t
have half the chance, but he knows what to do and he’ll do it, as
sure as ye are knee high to a grasshopper.”
“Why do they keep so far from us?” asked Alden.
“They don’t want us to see ’em, and they hain’t any idee that we
do, but,” chuckled the guide, “they don’t know old Shagbark has
charge of these folks.”
The old man seemed vastly pleased, and his massive shoulders
bobbed up and down for a minute, while he puffed hard at his pipe.
“Do you think they intend to bother us?” asked Alden.
“No; I don’t think; I know it; we ain’t through with ’em; if they don’t
pay us a visit to-night, we shall hear of ’em to-morrer night as sure
as a gun.”
“Why don’t they make an open attack, as I have been told the
Indians often do?”
“A red varmint never takes chances when he has a show of getting
what he wants without it; there ain’t ’nough of ’em to ride up and
open fire; don’t ye see that if they hold off till darkness, believing as
how we haven’t an idee they’re within a thousand miles, and we ain’t
keeping a lookout, they believe they can play thunder with us?”
There was no questioning the truth of this theory. Alden slipped
the cord which held the glasses over his head and handed them to
the guide.
“Try them; good as are your eyes, these will help you.” But the old
fellow shook his head.
“I don’t need any of your new-fangled notions; when my eyes go
back on me, I’ll resign and hike over the divide.”
Alden Payne was deeply interested in what he had been told. A
crisis threatened in which under heaven all depended upon the
sagacity of this veteran of the plains. The youth waited for him to
explain his intentions.
“Ye see now the sense of my making some of the men stand
guard every time we went into camp; they’ve been trained so they
know how to do it; ye’ve had to take yer turn with the rest of ’em.”
“And glad was I to do so; I hope you will use me to-night.”
“Which is ’zactly what I’m going to do; that’s all I’ve got to say now;
ride back to that thick-headed darky.”
“Shall I tell him what you have just said to me?”
“I hain’t any ’bjections; it’ll probably scare him half white, but ye
needn’t say anything to anybody else, ’cepting Fleming; tell him to
come up hyar for a little talk on bus’ness with me.”
Alden turned his mare about and galloped to where the leader of
the company was riding beside another man, and told him Shagbark
wished a few words with him. Fleming instantly moved forward, and
was soon engaged in earnest conversation with the guide.
“Wal, Al, did Shagbark ’spress sorrer fur the way he treated me?”
asked Jethro, as his friend joined him.
“Nothing of the kind; you may have noticed that I pointed my
glasses toward the prairie ahead?”
“Yas; I had my eye on you.”
“Well, some miles off is a large party of Indians on horseback; they
are keeping us in sight, but don’t think we know anything of them.”
“Gorrynation!” gasped Jethro; “you don’t say so; what am dey
gwine to do?”
“Quite likely they will attack our camp to-night.”
Jethro gasped again and nearly fell out of the saddle.
“W-w-what we gwine to do?” he stammered.
“Make the best fight we can; you can shoot pretty well, Jeth, and
you may have a chance to prove your marksmanship. Bear in mind,
however, that when a painted warrior raises his gun to shoot you,
you must fire before he does.”
Swallowing the lump in his throat, the colored lad faltered:
“You’s joking, Al; you don’t mean it suah.”
“Very well, if you prefer to look upon it as a joke, do so, but it is
likely to prove a serious one to you and all of us.”
“Why don’t Shagbark turn de teams round and hurry back to St.
Joe as fast as he kin, or to Fort Kearny or some place whar we has
friends dat will took care ob us?”
“We should make a fine show with our oxen dragging the heavy
wagons; all the Indians are well mounted and can come up with us
whenever they choose to do so.”
“Let de oxen and wagons stay where dey am.”
“We haven’t enough horses to carry half the women and children.”
“Can’t dey run?”
Alden was silent a moment as if considering the suggestion of the
sable youth. Finally he shook his head.
“It won’t do, Jeth; they wouldn’t have half a show; the Indians
would overtake the women and little ones before they could go more
than a few hundred yards. No; we must stand our ground like men,
keep cool and put up the best fight we can.”
“’Spose de Injins lick us?” asked Jethro in a trembling voice.
Alden shrugged his shoulders.
“That will be the end; they won’t spare a man, woman or child; you
are the only colored member of the party and you know an Indian
hates a black man like poison.”
“Am you suah ob dat?”
“I have been told so by those who know.”
“Why do dey feel dat way?” asked the scared youth.
“I can’t explain it; they seem to have a deep prejudice against all
American citizens of African descent. I have met some white men
who feel the same way.”
“Can’t you manage to explanify to de red gemman dat dar ain’t no
reason for dar dislike ob us colored folks?”
“I am afraid that no explanation will help, Jeth; make up your mind,
as I said, to put up the best fight you can and if you have to go down,
do so with colors flying.”
CHAPTER V
ON GUARD
S hagbark kept continually scanning the horizon in all directions. It

lacked an hour of sunset when the flickering forms to the
northwest passed over the rim of vision. But the guide was not
misled by the fact. He thought it likely that some of the red men,
whose tribe he did not know, had galloped farther away, fearing they
had been observed by the emigrants. Even in those days, the dusky
rangers of the plains knew of the artificial eyes used by the whites,
which enabled them to see far beyond the unaided vision.
The trapper rode some distance out on the plain, and made
complete circuit of the camp. He studied every point of the compass
and with his permission, Alden Payne was his companion on the
brief ride. The company halted earlier than usual, and every
preparation was made against attack.
Alden with his glass was no more successful than the glum old
fellow, who used only the power that nature gave him.
“I can’t catch a glimpse of them,” remarked the lad when the circuit
was completed, and he lowered his instrument.
“Hooh! ye needn’t tell me that; if the varmints was to be seed I’d
seed ’em.”
The six lumbering wagons were drawn up in a circle, the space
inside being about a hundred feet across. In the center of this a fire
was kindled from the driftwood brought from the bank of the Platte,
where all the animals were allowed to drink, after which a number of
vessels were filled and brought to camp. While the water was roiled
and not specially attractive in appearance, no one felt any objection
to it. As one of the men remarked, it “beat a raging thirst all hollow.”
Over the fire several of the women busied themselves boiling
coffee and cooking venison from the game that was shot that
morning. As has been intimated, the company carried a reserve of
food, in the form of bread and jerked beef, but it was not thought
prudent to draw upon it until no choice was left. There was an
abundance of sugar, salt and various spices, and enough tea and
coffee to last the entire journey, provided it was not lengthened
beyond expectation.
When the fire had served its purpose it was allowed to sink. The
night was so mild that the blaze was not needed for warmth. Every
one had comfortable clothing, for they knew they would need it
before reaching the coast. Soon after the meal was finished the
children were bundled to bed. Three of the wagons were set apart
for them and their mothers, the others being given over to the male
members of the party. The parents were warned not only to keep the
heads of the little ones below the upper edge of the wagon bodies,
but to make sure that they did so themselves. So long as this caution
was observed, they had little to fear, for the thick wood was arrow
and bullet proof.
It was comparatively early in the evening when Shagbark placed
the guards. His plan was that six should act as sentinels until
midnight, when, if nothing occurred, they would give place to the
same number, and retire to their quarters for the remainder of the
night. As for Shagbark, he said he would be on duty until daylight. If
when morning came, he found himself in need of sleep, he would lie
down for a short time in one of the wagons, but he didn’t expect to
feel any drowsiness unless he was robbed of slumber for two or
three nights in succession.
Each of the six wagons was put under the charge of a single man,
who was warned to be vigilant through every minute while on duty.
They did not need to be told that their foes were the most cunning
fighters in the world who were sure to try every possible trick upon
them.
“If ye see anything moving outside, shoot!” was Shagbark’s
instruction to each: “no matter if it is only a bunch of grass waving,
bang away at it and ye’ll find it’s the head of a redskin. If ye fall
asleep when you wake up ye’ll put your hand on top of your head
and discover yer skulp’s gone.”
Since the sentinels could not pace to and fro, as is the usual
custom, they were at much disadvantage in that respect, for we all
know how insidious sleep is and how in many circumstances it is
impossible to fight it off. Shagbark met this statement of the situation
by Fleming thus:
“Ye ain’t likely to begin snoring so long as ye keep on your feet. No
matter how much ye may feel like setting down or leaning up agin a
wheel or side of a wagon, don’t do it for so much as a minute. Ye can
steal back and forth on the inside of the circle of wagons, fur that will
help keep yer peepers peeled, but ba’rs and beavers! no man’s wuth
shucks if he can’t stay awake till midnight, and them as comes on
duty then will have had ’nough sleep to last ’em till daylight.”
This sounded so reasonable that there was a general expression
of confidence that none would find any difficulty in keeping full
command of his senses.
Alden Payne felt complimented by the trust which the veteran
showed in him. He led the youth to one of the wagons in which some
of the mothers and their children had lain down. While approaching
it, they heard the murmured prayers of the parents and the little
ones. A tiny girl, known for her remarkable sweetness of voice, sang
softly a hymn that she had learned at her mother’s knee. The words
could not be distinguished, but when the soft tones, like those of an
angel hovering near reached the couple, the trapper abruptly
stopped and listened. The voice ceased the next minute and he
sighed. Neither he nor Alden spoke, but the soulful strains must have
awakened some childhood’s remembrance in the breast of the old
hunter. Alden even fancied when he raised his hand, that it was to
brush away a tear from the eyes that were unused to weep. If so,
Shagbark did not know his companion had noticed his action.
“Hyar’s where ye’ll stand,” said the guide, lowering his voice, so as
not to disturb anyone within the wagon; “I don’t have to tell ye that
the favorite spot for them varmints to strike is where there’s only
women and children; a good deal depends upon ye, younker.”
“I shall do my duty,” quietly replied Alden.
“You needn’t tell me that; a feller’s got only to look at ye to see the
sort of stuff ye’re made of; I like ye, younker.”
Never had Shagbark uttered so pointed praise, and it sent a
grateful thrill through the youth, who could not doubt the sincerity of
the words.
“Now ’bout that darky,” added the guide; “it won’t do to put any
dependence on him.”
“He means well, but I shouldn’t advise you to trust him too far.”
“No fear of that, but he such a big, hulking chap and eats so much
that he oughter be made to do something; I’m going to put him on
tother side of this wagon and make him b’leve it’s the most important
post of all, and that if he drops asleep, the whole shebang will be
wiped out by the redskins. Mebbe he’ll be able to stay awake but I
don’t b’leve it.”
Shagbark walked as silently as a shadow to the middle of the
circle, where the fire had sunk to smouldering embers. He had seen
Jethro there some minutes before and as he expected found him
sitting on the ground, upon which he had spread his blanket. The
spot attracted the dusky youth, for it was farthest removed from the
wagons, and was the safest place except the interior of the vehicles.
He would have cuddled down there among the sleepers, had not
Shagbark notified him that he had work for him to do.
Jethro did not hear the soft footfall, but hastily climbed to his feet
when the guide gruffly spoke to him:
“Wal, younker, be ye ready?”
“Ise allers readdy to do my dooty; what is it you want, Mr.
Shagbark?”
“Ye know how ticklish things is to-night; we must all take turns in
watching fur the redskins that will be sure to try to steal in among the
wagons and skulp us all; ye are to stand guard till the middle of
night, when some one else will take yer place,—that is if ye live to
give ’em a chance.”
Jethro’s teeth rattled at these awful words.
“Do you think, Mr. Shagbark, dey’s gwine to pitch into us?”
“That’s what Injins seem built for; ye can feel powerful sartin that if
we give ’em the chance they’ll grab it.”
“Yas, sir,” replied the youth, as he gingerly followed the guide to
the wagon where he had placed Alden Payne a short time before; “I
wish I felt better.”
Shagbark stopped abruptly and turned upon him.
“What’s the matter with ye?”
“De fac’ is, Mr. Shagbark, I doan’ feel very well dis ebening: I hain’t
felt well all day,—sorter ob a big pain in my innards.”
He leaned over, pressing his hand against his side and groaning.
“I observed that ye eat as much as me and young Payne together;
don’t seem to affect yer appetite any.”
“Dat’s de way it allers takes me; sometimes I kin stop de pain—
Oh! oh!—by swallering all de food I kin git hold of.”
“Ye won’t think anything about yer pain, when ye see a big Ingin
stealing up out of the grass and making ready to skulp ye; come on.”
Jethro dared not refuse to obey the terrible fellow, and kept at his
heels until they reached the wagon, where Alden grinningly awaited
them.
“Younker,” said the hunter in his rumbling voice; “being this the
most dangerous p’int, I’m going to put two of ye here.”
“A good plan, Shagbark; I never knew a fellow with better eyesight
and ears than Jeth; between him and me, the red man will find it
hard to steal upon us unawares.”
“Whar—whar am I to stand?” faltered the negro.
“Ye will stay right whar I place ye,—alongside of the left hand
wheel of the wagon; the younker will hold his position clus to the
right wheel; ye two will then have only the breadth of the wagon
between ye; neither of ye must stir from the spot till I come round to
bring some one else to take yer place. Do ye understand?” he
demanded of the terrified Jethro.
“Yas, sir; I’ll do de best I kin; nobody can’t do no better dan dat.”
“And nobody asks you to do any better; wal, I reckon I’ve said
’nough.”
And the guide moved away with his noiseless tread melting from
sight in the gloom.
It must be said of Jethro that although scared almost out of his
senses, he was resolved to do his duty so far as it lay within him to
do it. Even in his panic, he saw an advantage over the other
sentinels. A wagon guarded by two persons must be twice as well
protected as one under the care of a single person. Alden was so
watchful that he could be counted on to detect any approach of
danger. Jethro was in the position of a man who had a reliable
support in an enterprise involving great peril.
The two stood so near each other that it was easy to converse in
under tones. Within the Conestoga, all was still. The mothers and
their children were sleeping, feeling secure in the protection of
heaven and the strong and brave hearts around them.
“Say, Al, am you dar?” asked Jethro in a husky, half-whisper, as he
peeped round the rim of the wheel at the figure dimly visible in the
shadow, and almost within arm’s reach.
“I couldn’t well be anywhere else,” replied his master.
“What do you think ob things?”
“I think you and I have got to keep our eyes and ears open to-
night, Jeth.”
“Dat’s what I’m doing; do you think de Injins will come?”
“You heard what Shagbark said; he knows a hundred times more
about such matters than we do; he and I certainly saw a party of
them a few miles away on the prairie, and I haven’t any doubt that
they are a good deal nearer to us now and coming nearer every
minute.”
“Gorrynation! Al, why didn’t you and me stay home?”
“Because we came with Mr. Fleming and his company; you were
as eager as I to cross the plains, and you were told all about the
Indians.”
“Blame it all. I didn’t b’lebe dat stuff.”
“I guess you believe it now, but, Jeth, I don’t think Shagbark
wishes us to talk while we are on post.”
“Nobody can’t hear us.”
“It distracts our attention from our work; better give your whole
mind to the business we have in hand; if you see anything that
doesn’t look right, let me know.”
“Berry well.”
Now, you do not need to be told that one of the hardest things to
do, is to stand still for an hour or two at a stretch. Even though you
shift the weight from one foot to the other, the strain soon becomes
unbearable, whereas a rugged man can find pleasure in pacing
regularly to and fro after the manner of sentinels.
“A feller mought as well be comfor’ble,” mused Jethro, leaning his
rifle against the side of the wagon body, where he could snatch it up
the instant needed. He next placed his elbow on the highest point of
the broad tire of the large hind wheel, and rested his head upon his
hand. His pose was made still easier by swinging one foot in front of
the other ankle, and supporting it on the toe of his shoe.
This posture was so agreeable that he was sure he could hold it
for several hours without fatigue; but it is such poses that irks one
the soonest. He changed the position of the feet, but found that
rather awkward, so long as his elbow remained on the tire. By
turning his body round so that his back was toward the open plain,
he could use his other elbow and the relief was pleasant.
“Big idee,” he muttered to himself; “bime by when I git tired, I’ll
swing round agin.”
It certainly was a strange pose for a sentinel, deliberately to turn
his back away from the field from which danger threatened. Yet that
is precisely what Jethro Mix did and his self explanation was not
without some force:
“If any ob de Injins try to sneak up, Al will be sure to see ’em; he’ll
let me know in time to whirl ’bout and lambast ’em or—git out ob de
way myself.”
The neglectful guard found some comfort in another fact: he was
gifted with an unusually keen sense of hearing, and believed his ears
would tell him as much as his eyes. In the circumstances, however,
when it is remembered that absolute silence is one of the features of
Indian subtlety, this was the gravest of mistakes.
By and by, Jethro swung back and resumed his first position,
shifting his feet again as before. He stood so well toward the front
that he could not see his friend, except by leaning forward and
peering round the tail of the wagon. He took care to keep a position
that shut him from Alden’s sight.
“It’ll be jes’ like him to kick when he sees me standing with my
back toward de Injins, and dere ain’t any use ob habing any quarrels
at a time like dis.”
When Jethro pivoted to the front for the third time, he held the
position longer than usual. The situation was one which impressed
even his dull nature. The moon near its full, had risen and shone
upon the silent earth below. Ragged, white clouds swept slowly
across the sky, like moving mountain peaks of snow. The orb was
forever groping among these feathery masses, some of which were
attenuated while others had enough body to eclipse the orb for a few
minutes. This dodging into view and out again made the light
uncertain. The shadows ran swiftly over the ground and whisked out
of sight, then came a brief space of gloom, and then the illumination
revealed objects with diminishing distinctness, for a hundred yards
out on the plain.
It was a night favorable for Indian cunning to do its work. The
spring grass was tall enough to allow a warrior to steal through it
while lying flat on his face, with little fear of detection, until he came
close to the foe whom he was seeking to slay. If ever a sentinel
needed all his wits it was on that night when more than half a dozen
of them were guarding the emigrant train plodding its way to the
distant Pacific coast.
CHAPTER VI
ABORIGINAL CUNNING
S uddenly through the tomblike stillness brooding over camp and

plain, came the dull sounds of rifle firing. Two shots were in
quick succession, a third followed, then two more, after which all was
as silent as before.
The reports were apparently a half-mile to the northwest. Every
one of the sentinels listened closely, but nothing further reached
them.
Jethro Mix snatched up his gun with a gasp and held his breath.
Then he moved on tiptoe around the rear of the wagon to where
Alden Payne stood tense and motionless as a statue.
“Did you hear dat?” asked the negro in a husky whisper.
“Of course.”
“What do it mean?”
“I can’t tell; we shall soon learn.”
“Listen, Al!”
The two did so for a few seconds, and then Alden said in an
undertone:
“I didn’t hear anything more; did you?”
“Yas.”
“What did it sound like?”
“A hoss’s hoofs; wait a minute.”
Jethro dropped on his knees and pressed an ear to the ground. He
had done the same thing in different circumstances, and knew what
help it was to the hearing.
The next instant he sprang up.
“De Injins am coming! I hear dar hosses!”
Alden imitated the action of his companion and then quickly rose.
“It is a single horse, and he is coming this way on a run; I don’t
think the Indians are near or we should hear more hoofs; I wish
Shagbark would show up.”
But the guide did not appear for some minutes. Still standing the
two noted the sounds made by the hoofs of a pony traveling at the
highest speed. The sounds rapidly grew more distinct, and the two
were quickly able to locate the horseman. It was toward the point
whence came the rifle reports, and the fugitive must have had
something to do with them.
“Dar he is!” whispered Jethro trembling with excitement; “shall I
shoot him?”
“No; wait till we find what it all means.”
Just then the drifting clouds swept from before the face of the
moon, whose rays streamed down upon the prairie. From out this
misty obscurity shot a horse and rider, the animal with outstretched
neck, tail streaming and straining every nerve to carry the man who
was leaning well forward, beyond the zone of danger. The same
rhythmic beat that had fallen on their ears that afternoon greeted
them again. The pony was running for all that was in him.
Just as the rider flashed opposite the group of silent canvas
covered wagons, he seemed to catch sight of them. Without drawing
rein or checking the desperate speed of his horse he shouted:
“Look out for Injins! they’re close onto you!”
And then man and animal plunged into the night and disappeared,
though the fast diminishing thumping of hoofs was heard for some
seconds later.
“He’s a Pony Express rider,” said Alden; “and is making for the
next station as fast as his horse can carry him.”
“Ye’re right, younker,” remarked Shagbark, who appeared at the
side of the two with no more noise than that of the flitting shadows
on the plain.
“Did he fire any of those shots?” asked Alden.
“He couldn’t; he don’t carry a rifle.”
“He has his revolver.”
“It’s easy to tell the difference atween the barking of a revolver and
a big gun; there warn’t any pistol used. He run right into the hornet’s
nest afore he seed it, and the varmints opened on him; he must have
throwed himself forrard on his hoss and the animal scratched gravel
as them ponies know how to do. Every shot missed ’em both; I
reckon that rider will carry his gun after this, even if it adds to the
weight of his load.”
“It seems to me,” said Alden, “that if those Indians intended to
attack us they wouldn’t have fired at the express rider.”
“Why not?”
“Because it warns us of our danger.”
“Thar’s a heap of sense in what ye say, younker; that would have
been the way of it, if the rider hadn’t dashed into ’em afore he
knowed it, and afore they could slip out of his way; so they tried to
shoot him from his saddle; beats all natur’ what poor shooters most
of the varmints are.”
Shagbark glanced at the two.
“I’m powerful glad to see you both awake; I’m going to sneak out a
little way on the perarie where I kin see furder than from hyar. So
don’t shoot off yer guns ontil ye’re sartin it ain’t me but a redskin.”
Having given these instructions to each of the sentinels, Shagbark
set about the task he had in mind. It certainly was risky, for, while he
might count upon avoiding any collision with the red men, it was
quite likely that some of the sentinels in their nervousness would fire
upon the first glimpse of him. Be that as it may, the thought gave him
little concern.

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Evidence Use in Health Policy Making An International Public Policy Perspective 1St Ed Edition Justin Parkhurst Full Chapter PDF

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Evidence Use in Health Policy Making:

An International Public Policy

Public Policy in ALS/MND Care: An International

Public Policy in ALS/MND Care: An International

(eTextbook PDF) for Health Policy Issues An Economic

Social Value in Public Policy 1st ed. Edition Bill

An Introduction to the Policy Process: Theories,

International Impacts On Social Policy: Short Histories

Health Policy Analysis: An Interdisciplinary Approach

Narrative Politics in Public Policy: Legalizing

International Series on Public Policy

More information about this series at

International Series on Public Policy

Library of Congress Control Number: 2018950835

play a crucial role in informing decisions of international organisations

correct policy path to follow (a path presumably indicated by the evidence),

It is in the nature of these types of research endeavours to start with a

Cartwright, N., and J. Hardie. 2012. Evidence-based policy: Doing it better. A

1 Studying Evidence Use for Health Policymaking

2 The Many Meanings of Evidence: A Comparative Analysis

3 The Role of Evidence in Nutrition Policymaking

4 The Use of Evidence in Health Policy in Ghana:

5 Using Evidence in a Highly Fragmented Legislature:

6 The Politics of Evidence Use in Health Policy Making

7 Electronic Cigarettes Regulation in the UK: A Case Study

8 Ministries of Health and the Stewardship of Health

9 Evidence Use and the Institutions of the State: The Role

10 Evidence and Policy in Aid-Dependent Settings 201

11 Conclusion: Reflecting on Studying Evidence Use

Studying Evidence Use for Health

Justin Parkhurst, Stefanie Ettelt, and Benjamin Hawkins

© The Author(s) 2018 1

medicine (EBM), health policy actors see engagement with policy-relevant

…academic debate on health care policy-making continues to be couched in

Another review by Liverani et al. (2013) (undertaken as part of the

The Multiple Meanings of ‘Use’ of Research Evidence

specific purpose (to improve patient outcomes), using evidence to inform

uses of evidence appear commonplace in many policy arenas where politi-

A Public Policy Perspective

calling for more public policy insights requires consideration of how

Politics as Power and Contestation

problem under consideration and the proposed responses (c.f. Bacchi

event, but rather it is an ongoing process integral to the policy process.

An Institutional Perspective to Analyse

Therefore, we find that a significant gap in the literature still exists to

appraisal and synthesis, and ways of using them in decision-making (c.f.

Outline of the Book

Research into Policy in Health’ (the GRIP-Health project). The project

The Many Meanings of Evidence:

Helen Walls, Marco Liverani, Kannarath Chheng,

This chapter presents an edited version of a paper first published as:

H. Walls (*) • M. Liverani

© The Author(s) 2018 21

policymaking. One example of this endorsement is in the country’s sec-

of evidence use. In all countries we subsequently investigated evidence use

Consent was obtained at the initiation of each interview, with respon-

Policy Studies Perspectives

oric or discursive framing in shaping policy outcomes (c.f. Fischer 2003;

One Country, Three Health Policy Issues

however, and the country’s prevalence has reduced, to an estimated 0.7%

Performance-Based Financing, and the Case of the Government

The Nature of Evidence Used

Another respondent, a senior civil servant in the MOH, explained:

1 Studying Evidence Use for Health Policymaking

2 The Many Meanings of Evidence: A Comparative Analysis

3 The Role of Evidence in Nutrition Policymaking

4 The Use of Evidence in Health Policy in Ghana:

5 Using Evidence in a Highly Fragmented Legislature:

6 The Politics of Evidence Use in Health Policy Making

7 Electronic Cigarettes Regulation in the UK: A Case Study

8 Ministries of Health and the Stewardship of Health

9 Evidence Use and the Institutions of the State: The Role

10 Evidence and Policy in Aid-Dependent Settings 201

11 Conclusion: Reflecting on Studying Evidence Use