The politics of evidence-based policy-making: the case of Denmark.

Author:Hansen, Hanne Foss

1 Introduction

In Denmark welfare policies and public sector reforms are high politics these years. Demographic changes threaten on the horizon. Projections show that in the future there will be fewer people in the labor market, large numbers of public employees will retire and the demand for welfare services will increase. In this context the evidence movement has established itself in Denmark in recent years. In several policy fields organizations specialized in producing evidence through summarizing and synthesizing already existing evaluative knowledge in so-called reviews have been formed. By producing but also disseminating evidence produced internationally the organizations aim at ensuring that policy-making and policy delivery are evidence-based. The paper analyses and discusses this development.

The concept of "evidence" has a very broad and diffuse meaning in the debate on the "evidence-based policy and practice". The recent debate has shown heated disagreements about what counts as evidence (Donaldson, Christie and Mark 2009: 5-6). This discussion is part of a much wider discussion and also a field of study especially within evaluation. This wider field is about the use and influence of evaluation and research in policy and professional practice, on which there has been written extensively. One recent book with a good overview of the field is Nutley et al. (2007). However, in this chapter "evidence" understood as systematic research reviews is in focus, and not the general issue on utilization of research and evaluation.

The focus is on the Danish branch of the evidence movement and on the political aspects related to this. Three questions are addressed. 1) Why and how has the evidence movement become institutionalized? 2) How is it organized and how does it practice? 3) Which are the political dimensions and conflicts related to this development?

The paper is divided in two parts. The first part is empirical. It holds an analysis of how the idea of evidence-based policy and practice has travelled into Denmark, how the idea has been institutionalized in organizations specialized in producing evidence-based knowledge and how these organizations practice.

The theoretical, analytical approach in this part is institutional and methodological. The institutional approach puts focus on how the idea of evidence-based policy and practice has travelled into Denmark and how it has become institutionalized in organizations specialized in producing evidence. Institutionalization may be driven by different pressures. Using DiMaggio and Powell (1991: 67) a distinction can be made by coercive, mimetic and normative pressures. Coercive pressure results from formal or informal pressures and authority exerted on organizations by other organizations upon which they are dependent as well as by cultural expectations in society. Mimetic pressures results from uncertainty. When organizational technologies are poorly understood, when goals are ambiguous, or when the environment creates symbolic uncertainty, organizations may model themselves on other organizations. Normative pressures finally stem from professionalization defined as collective struggle of members of an occupation to define conditions and methods for their work and to establish a cognitive base for and thereby legitimate their occupational autonomy. The analysis of how the evidence idea travels and becomes institutionalized will clarify whether the institutionalization of the evidence movement in Denmark is driven by coercive, mimetic and/or normative pressures.

A central notion in DiMaggio and Powell (1991) is that the travel and institutionalization of ideas result in isomorphism defined as homogenization across organizations and organizational fields. The analysis of how the evidence-producing organizations organize and practice will clarify whether isomorphism occurs or whether the idea of the evidence movement is translated into local contexts and shaped by national and local political traditions and stakeholders, as suggested by among others Czarniawska and Joerges (1996), Sahlin-Anderson (1996), Radaelli (2005) and Rovik (2007).

The analysis of the practice of the evidence-producing organizations also draws on a methodological approach. Methodologically the historical point of departure of the evidence movement has been to produce systematic reviews using meta-analysis, defined as treatment-control comparison based on statistical calculations, to synthesize results from primary studies designed as randomized controlled trials (RCTs, also called "the gold standard"). Across time other kinds of reviews as well as other types of syntheses have been developed. A recent methodological overview on reviews and review practices thus distinguishes between systematic reviews, narrative reviews, conceptual reviews, rapid reviews, realist reviews, scoping reviews, "traditional" reviews, critical reviews, expert reviews and "state of the art" reviews as well as between meta-analysis, narrative synthesis, cross-study synthesis, best practice synthesis, vote counting, cross-design synthesis, best available evidence and realist synthesis (Petticrew and Roberts 2006). Wherever relevant these distinctions will be used and further defined for analyzing the practice of the evidence-producing organizations.

The second part of the paper is reflective. It holds a discussion of the political dimensions in and the political context of the development of the evidence movement including a discussion on the conceptual dispute, the methodological conflicts and the roles of different actors engaged in the arena of evidence politics. The approach in this part is political in a broad sense of the term. According to Warren (1999) the concept of politics should not be defined solely as behavior, as a game, as allocation, as institutional authority, as power, as conflict or as collective action. Instead the concept of politics should be defined more holistic as "the subsets of social relations characterized by conflict over goods in the face of pressure to associate for collective action, where at least one party to the conflict seeks collectively binding decisions and seeks to sanction decisions by means of power". Using this definition evidence politics is about conflicts related to what constitutes knowledge potential usable in collectively binding decisions.

The analysis is based mainly on publicly accessible documentary data, including websites for organizations producing systematic reviews, guidelines and handbooks from these organizations and reports from conferences on the topic and interviews with four key persons, including three Danes and one from Norway. In addition, the authors of this paper have participated in seminars and conferences on evidence topics in Denmark and abroad. Four international conferences and three Danish conferences have been attended. Our work on the evidence movement is research-based and has been supported by the Danish Social Science Research Council. More details on our sources are available in the two original reports from the project (Bhatti, Hansen and Rieper 2006: 18; Rieper and Hansen 2007: 16). However, we are not only analytical outside observers of the institutionalization of the evidence movement. On several occasions we have been involved in discussions on methodological questions. We have stressed the need for not only focusing on the "what works question" but also focusing on the "what works for whom in which context question" as well as the "why question". We advocate for a contingency-based approach to evidence and are so to speak players on the center ground not preaching in any of the often sectarian churches (Rieper and Hansen 2007).

2 The historical institutional development

In Denmark the evidence movement has gained ground and become institutionalized in especially three fields: the health sector, the field of social work and the educational field (Bhatti, Hansen and Rieper 2006). Each of these fields will be analyzed beneath.

Evidence-based medicine

The concept of evidence travelled into Denmark in the late 1980s and the beginning of the 1990s where researchers in the field of medicine arranged several conferences inviting among others the Canadian David Sackett, who some years earlier had coined the idea of evidence-based medicine, to hold keynotes (Kristensen and Sigmund 1997: 10). At that time it was stressed that practicing evidence-based medicine requires the best available clinical evidence on which to answer clinical questions and that the clinical question determines the evidence one seeks (Sackett 1997: 19).

In the beginning of the 1990s Danish researchers also participated in the British initiatives to establish the international Cochrane Collaboration. In 1993 a branch of this, the Nordic Cochrane Centre, was established in Copenhagen. The center is the "host" for four of the Cochrane Collaborations among 50 internationally composed review groups. The center facilitates the four groups, arranges courses in review methodology and disseminates Cochrane produced evidence. The center is financed from a number of sources including the Danish Government, but no commercial companies.

Over the years more evidence-producing organizations have been established and have started to produce reviews. Copenhagen Trial Unit (CTU), which is involved in both preparation of reviews and ordinary clinical experimental activity, was established in 1995. CTU is closely related to Cochrane. Institute for Rational Pharmacotherapy, which produces reviews on new medical products, was established in 1999 under the Danish Medicines Agency and Pharmakon (a conference and training center in the pharmaceutical sector), which is involved in preparation of reviews in pharmacy (e.g. good pharmacy practice, patient safety and medication errors), was established in 2000. (1)

The Cochrane Collaboration is without doubt the most...

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