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Series Use of research to inform public policymaking
John N Lavis, Francisco Becerra Posada, Andy Haines, Eric Osei Lancet 2004; 364: 1615–21 To improve health and reduce health inequalities, public policymakers need to find the best solutions to the most
burdensome health problems, the best ways to fit these solutions into complex and often overstretched and
underresourced health systems, and the best ways to bring about the desired changes in health systems. Systematic
reviews can inform public policymaking by providing research-based answers to these questions. Public
policymakers can encourage more informed policymaking by asking to see systematic reviews on priority issues,
commissioning reviews when none exists, and placing more value on such work in their deliberations and in their
interactions with stakeholders. Donors and international agencies can encourage more informed public
policymaking by supporting national and regional efforts to undertake reviews and assess their local applicability,
and by supporting regional or worldwide efforts to coordinate review and assessment processes.
Health ministers in low-income and middle-income
countries who take their responsibility to improve health
and reduce health inequalities seriously face both many
challenges and little support. Quite legitimately in many
cases, ministers can criticise the health-research
community (especially funders), their political staff and
civil servants, and others who seek to advise or influence
them for not giving them what they need to be
successful. Like clinicians, health ministers can benefit
from high quality, locally applicable systematic reviews
of research. Unlike clinicians, health ministers can turn
to very few systematic reviews of the reports most
relevant to them (ie, health systems research) and they
cannot rely on advice about how to critically assess the
local applicability of reviews.
In this report we describe the challenges that public
policymakers (ie, health ministers, their political staff,
and senior civil servants) face in answering three types
of questions relevant to improving health and reducing
health inequalities in their countries; outline an
approach that public policymakers can use to critically
assess the local applicability of systematic reviews of
health systems research; and propose several steps that
public policymakers, donors, and international agencies
can take to ensure that in future public policymakers will
stand a better chance of finding high quality, locally
applicable reviews to inform their decisions. Although
our observations are applicable across a range of
potential health goals, we use the three millennium
development goals most directly related to health
systems—reducing child mortality, improving maternal
health, and combating HIV/AIDS, malaria, and other
diseases such as tuberculosis—to illustrate both the
associated challenges and the opportunities on the
horizon.1,2 Challenges faced by public policymakers
Improving health and reducing health inequalities,
whether in general or in the specific domains implicated
by the millennium development goals, constitutes a
daunting task for public policymakers.3,4 Three questions
need to be answered: (1) what are the best solutions to
www.thelancet.com Vol 364 October 30, 2004 the most burdensome health problems; (2) what are the
best ways to fit these solutions into complex and often
overstretched and underresourced health systems; and
(3) what are the best ways to bring about the desired
changes in health systems? We call these first-order,
second-order, and third-order questions, respectively,
because the complexity of both the issues and the
investigations needed to address them become
progressively more complicated from one level to the
next. The iterative and time-pressured nature of the
public policymaking process and the interrelations
among the potential answers mean that the questions
are often considered simultaneously.
Public policymakers are well served by researchers
who help them find the best solution in terms of
effectiveness and cost-effectiveness. Health ministers
turn to their political staff and senior civil servants for
input about other elements of what constitutes the best
option. Feasibility is one such element, in view of the
jurisdictional authority, administrative capacities, and
financial discretion that government structures, public
policies, and the financial situation have created for