Bridging the gap between the two ends of the spectrum.
Evidence Policy and Global Health
A social problem is not only defined by its objective conditions or attributes, but also through social and cultural meanings ascribed to the problem.
Understanding the causes that effects people health and well-being have been addressed throughout the years with a set of traditional methods. That no longer able to provide conclusive answers to the wicked multilayered health concerns. Approaches such as positivism, which is the notion of the ‘science of man’ assuming that reality is concrete and can be measured using randomizing and blinding. Developing theories from which testable hypotheses can be conceive(Buchanan, 1998).There is no doubt that positivism is valuable tool that produce unbiased scientific evidence, able to distinguish potentially erroneous beliefs from scientifically validated facts, evidence that is reliable and can be generalized. (Buchanan, 1998)
Despite the scientific value, positivism fall short in the understanding of the social facts, their linear view of the cause and the effect ”if X arise then Y will appear”. That assumes that human behavior, culture and intentions can be collected and interpreted objectively. Failing to answer questions such as, why people may refuse a certain interventions or why they might delay seeking for help, what are the intentions and the life experience of someone that might affect his decisions?
On the other end of the spectrum, relativist where much social science work, is a less objective approach. Where people life experience and cultural aspects are more complex, subjective and cannot be easily explained through blinding and randomizing procedures(Buchanan, 1998). Whereas positivism seeks to explain events through the knowledge of their causes, relativist seek to understand and grasp the underlying rationale beyond the prediction and explanation(Buchanan, 1998). Studying the purpose and the intention which led to the behavior. Gives a wider and deeper understanding of the events and the embedded cultural and historical aspects related to it, allowing the researcher to develop interpretations subjectively. Leading to the creation of new ideas and the birth of new unconventional methods to address complex health concerns (Buchanan, 1998).
Although constructivist paradigm provide a rich and deep understanding to the events and their outcome. It cannot be generalized as it view the interpretation as the primary subject of inquiry(Gilson et al., 2011). And in some cases radical researchers may even argue that pure physiological conditions such as cancer or diabetes are socially and culturally determined.
This essay will discuss the value and the importance of the social science in the field of health research, as an alternative yet complementary perspective. That can provide deeper understanding for complex health concerns. Explaining this by assessing Gilson’s claim, that health systems and policies are ”social and political constructions”. Presenting an example of a qualitative study on obesity, that illustrates the conflicting perspective on the same reality. Also the essay will address the Mexico City policy as a clear example of policy that lacked the vision, and failed to bring positive change. And finally this essay will emphasis the value of addressing health problems and policies from a relativist approach.
Conflicting perspective, the two end of the spectrum:
Before going deep into the topic of the essay, and to illustrate more on how the two different paradigm understand and approaches health research and policy. Taking the example of qualitative study conducted in the United Kingdom of the perception of overweight individuals(Greener, Douglas and van Teijlingen, 2010).
Looking at the issue of obesity from a linear (cause and effect) paradigm would suggest that the cause of obesity is biomedical and psychological reason. Framing that obesity is caused by lack of motivation and physical activity. Therefore health services should focus on health promotion, by provision of comprehensive, high quality advice. With the assumption that once the people have received enough information about their health problem, they are most probably to engage in healthy behaviors, despite the lack of evidence that support this claim(Greener, Douglas and van Teijlingen, 2010).
In contrast, relativist prospective viewed obesity as a socio-ecologically determined problem. Suggesting that social policy and environmental changes are most likely to create sustainable solution to current obesity trends. Hence interventions such as ‘urban planning, media regulation, food availability, and taxation, more likely to sustain widespread population behavior change”. Although previous studies showed that ” there is significantly less support for regulations which restrict advertising, tax unhealthy or ban unhealthy foods and There has been societal resistance towards policies which are perceived to jeopardize consumer and lifestyle choices”(Greener, Douglas and van Teijlingen, 2010).
From this example a person cannot help but to ask, what is the truth and is there one truth, many truths or no truth. And what type of knowledge needed to feed policies to be more adaptable and inclusive.
Bridging the gap, what is the truth:
Having two different paradigm of knowledge with a different prospective of understanding and explaining social issues, feeding policy makers. Undoubtedly will only result in solutions and policies that insufficient, not comprehensive or inclusive enough, to what lies beyond the obvious problem.
Lucy Gilson, argues in her paper ” Building the field of health policy and research; social science matters”, that for policies to be more Effective and adaptable to the complexity and multilayered social determinant of health. Policies need to move beyond the parameters of the positivist paradigm, toward humanistic perspectives. Since, manners, religious observances and other human practices need to be learned and addressed, in order to generate effective policies (Gilson et al., 2011).
Introducing her claim that ‘ Health policies and systems are complex social and political phenomena, constructed by human action rather than naturally occurring’. In her argument, she acknowledges that although the positivism and relativism find it difficult to understand each other, as they speak a different language. However, they share a common concern and goal, which is enhancing and strengthen the health care system(Gilson et al., 2011).
Therefore, a third perspective must be introduced, ”critical realism, can be seen as placed HPSR embraces complex causality. This perspective lay somewhere between the other two perspectives”. It is similar to the positivism as it’s acknowledge that there is cause and effect, but they are not linked together with linear and predictable path. There is a set of complex and unpredictable causes that lead to the effect, therefore such complexity can only be seen as result of the influence of the different actors and their interpretation to reality(Gilson, 2012).
In other words, she insists that, researches need to have a wider scope to understand the social factors that formed the understanding of reality which led to the causes. Since this is the only way to tackle the wicked problems in the health system, by incorporating all the players and their different interpretation to the same issue. Keeping in mind that different actors have different understanding to same reality and influence this reality in a different ways. Which emphasis the claim that health systems and policy is socially and politically constructed. This approach does not aim to provide conclusions that can be generalized, instead it motivate the creation of wider theoretical insight, producing far reaching and expanded policies that is inclusive to all actors and underrepresented groups(Gilson et al., 2011).
Using this approach on the above example of the qualitative study on obesity. The researchers in this study understood the value of having a wider scope when looking at the issue of obesity. And the different languages used by each paradigm, and In order to have a more inclusive and effective policy, they needed employ Different qualitative methods. They conducted 63 interviews across the UK. Allowing all actors to be represented such as, policy makers, health professionals and individuals who had first hand experiences and insights about the barriers to weight loss. Bringing broadly representative sample from diverse ethnic and socio-economic backgrounds using Purposive sampling. Creating three focus groups that were interviewed face-to-face in a variety of settings, the interviews lasted between 15 and 60 min. The analysis focused on identifying how different groups understood the causes, effects and interventions that would address obesity. At the end the study produced a broad spectrum understanding for the issue of obesity from different perspectives. Which resulted in wide range of interventions that takes in considerations all aspects and actors involve in the issue. For instance the overweight group saw obesity as relating to their individual lives, focused on immediate barriers such as work, family life. Suggesting that, Biomedical orientated services, weight management classes or support from dieticians and personal trainers might help them in their weight reduction journey(Greener, Douglas and van Teijlingen, 2010).
On the other hand the Health professional group, almost equally highlight biological and socio-ecological determinants, and their idea of intervention focused on biomedical interventions and health service reform(Greener, Douglas and van Teijlingen, 2010).
Finally, Policy maker group, Took a socio-ecological approach to obesity focusing on environmental factors, and they suggested that large scale environmental policy changes. Such as town planning and food industry regulation, will result in reducing the obesity trend(Greener, Douglas and van Teijlingen, 2010).
Such approach using methodologies like individual interviews, focus groups and action research that allow different actors and stakeholder, to be involve in the conversation. Bringing wide range of interventions will only result in comprehensive and inclusive policies. Which brings back the question what is value of interpretivist approaches to the study of health policy and systems? When we address large scale policies that cross borders. Taking the example of the Mexico City Policy (Global Gag Rule) and how the lack of comprehensive understanding led to and continue leading to catastrophic consequences.
Mexico City Policy (the evidence free policy):
The Mexico City Policy is a US Executive Order, which prohibit US government funding to any international organization that promote or provide abortion services. In other words requiring nongovernmental organizations to accept as a condition of receiving Federal funds that they would neither perform nor actively promote abortion as a method of family planning in other nations (Lo and Barry, 2017). This order was first enacted by Ronald Reagan in 1984, the main purpose of the policy is to reduce the use of abortion in developing countries. A policy that been cooked in the US domestic politics and that been rescind and enacted depending on the political party in power. An ideology that turned into a foreign policy denying women their freedom of choice, eroding ethics and democracy.
Despite the intended purpose of the Policy, however, this policy achieved the opposite. All the evidence suggest that the abortion rate has increased, subsequently increasing the maternal death, and place the children’s health at risk (Lo and Barry, 2017). As the cutting of the fund to the international organizations, puts the organizations in a critical situation between accepting the fund and discontinue their work in providing and promoting abortion services. Or refusing the fund which many organizations did, and jeopardizing all the other services provided by them to the population, especially that most of these organizations depend on the US fund to perform their duties.
This policy, is a typical example of a evidence free policy that lacks the scientific and the humanistic perspectives. Clear example of policy makers ignoring the vital questions that need to be asked before producing and implementing such policies. This policy has number of catastrophic consequences related to it. Starting with the restriction of modern contraception, which means increase in the unintended pregnancies that lead to deaths from pregnancy-related complications. Increased reliance on unsafe abortions, and higher rates of unsafe sex increasing the HIV rate (Lo and Barry, 2017). Looking at the impact of the policy in Ghana ” policy-induced budget shortfalls reportedly forced NGOs to cut rural outreach services, reducing the availability of contraceptives in rural areas. The lack of contraceptives likely caused the observed 12 percent increase in rural pregnancies, ultimately resulting in about 200,000 additional abortions and between 500,000 and 750,000 additional unintended births. These additional unwanted children have significantly reduced height and weight for age’’ (Jones, 2011).
Secondly, the impact of the policy on the family planning programmes in developing countries. As the cutback of the fund led to reduce the outreach and services which is vital to the rural communities. For example, ”the Planned Parenthood Association of Zambia (PPAZ), the primary private family planning provider for Zambians, refused to sign the global gag rule. When it lost US funding as a result, PPAZ dismissed nearly 40 percent of its staff, scaled back reproductive health services, and ended community-based distribution of contraceptives. Similarly, the Planned Parenthood Association of Ghana (PPAG), the country’s largest and oldest family planning organization, lost $200,000 when it refused to sign the global gag rule. As a result, PPAG discontinued a rural outreach program, ending support to 1,700 community-based agents who provided family planning in rural areas” (Bingenheimer and Skuster, 2017).
Other impacts include the child health which is affected by the unintended pregnancies that reduces the child spacing and consequently, child development and mother health. Furthermore, the effect on the economy whether at a micro level when the family has fewer children that mean the household income can be greater, as both parents can participate in the paid labor force, shifting the mother job from child care. Or at a macro level, studies have showed that countries with fallen fertility tend to have better economy, faster growth in the GDP, and decline in poverty (Bingenheimer and Skuster, 2017).
And definitely such policy is a clear violation to women’s rights and the freedom of choice. And a violation for the freedom of speech rights for organizations that works in reproductive health (Bingenheimer and Skuster, 2017).
Let along the violation of the medical ethics, as the legal obligations and professional codes of ethics govern health care professionals to act in the best interest of the patient and her welfare. Which means ” the right to receive adequate, accurate and unbiased information that enables them to understand their options. Provide informed consent to care and receive referrals, so they are not effectively abandoned by the health care system’’ (SA, 2015).
And finally, the Global Gag Rule will eventually, slow the progress of the governments toward the Sustainable development goals 2030. As one of the aims of the SDG by 2030, is to reduce the global maternal mortality ratio, Unsafe abortion is a major contributor to maternal mortality. Unsafe abortion persists where abortion is criminalized and reproductive health services are unavailable. In addition, the SDGs commit governments “by 2030, to ensure universal access to sexual and reproductive health-care services, including family planning(Bingenheimer and Skuster, 2017).
From the above it’s clear that the policy makers, who produced this policy, did not take inconsideration the effect of their policy on different actors. Narrowing the scope of understanding that is required to produce policies that can bring about change. Ignoring to ask the right questions when planning and drawing this policy. Such as, who are the stockholders and actors and how they will be affected by this policy?
What is the economic Subsequent of this policy on the developing already struggling countries?
How this policy will affect other aspects of health care service and outreach?
Is this policy serving the mission of U.S. foreign policy to help ensure economic and geopolitical security?
What is the indirect impact of this policy on other health programs such as The President Emergency Plan for Aids relief (PEPFAR)?
And finally how this policy will influence women’s life, their growth and prosperity?
Understanding and appreciating the claim of Gilson, that health systems and policy are made and interpreted by the human actions and not naturally occurred. Is the core in the process of solving and uncovering complexity that revolves health problems. Acknowledging the role of social science as researchers attempt to answer questions that can not be answered objectively, stepping out of the imposing of particular knowledge frame. Moving toward a more humanistic approach that involve all actors and allow the representation of all groups. The qualitative study on the obesity mentioned above is a significant example on how interpretivist approach can advance the field of health policy and research; give deeper theoretical insights that can produce wide range of interventions.
On the contrary, the Mexico City Policy, a policy with no evidence or consideration to other actors or even the level of consequences of this policy in communities in need. Creating a preventable epidemic, and slowing the progress of the governments toward achieving the Sustainable development goals, limiting the possibilities of creating comprehensive universal health access. And let’s not ignore the role that this policy play in jeopardizing the progress of other health initiatives such as The President Emergency Plan for Aids relief.
Lastly, the writer believes, that in order for the field of health research and policy to be more adaptable to the current waves of health complexity. Health policy and research need to move toward social science, using mix methods to answer critical and multilayered questions. Allowing interpretation and unconventional approaches.
Bingenheimer, J. B. and Skuster, P. (2017) ‘The Foreseeable Harms of Trump’s Global Gag Rule’, Studies in Family Planning, pp. 279–290. doi: 10.1111/sifp.12030.
Buchanan, D. R. (1998) ‘Beyond positivism: Humanistic perspectives on theory and research in health education’, Health Education Research, 13(3), pp. 439–450. doi: 10.1093/her/13.3.439.
Gilson, L. et al. (2011) ‘Building the Field of Health Policy and Systems Research: Social Science Matters’, PLoS Med, 8(8), p. e1001079. doi: 10.1371/journal.pmed.1001079.
Gilson, L. (2012) ‘Health Policy and Systems Research’, Health Policy, 104(3), pp. 18–40. doi: 10.1016/j.healthpol.2012.02.006.
Greener, J., Douglas, F. and van Teijlingen, E. (2010) ‘More of the same? Conflicting perspectives of obesity causation and intervention amongst overweight people, health professionals and policy makers’, Social Science and Medicine, 70(7), pp. 1042–1049. doi: 10.1016/j.socscimed.2009.11.017.
Jones, K. M. (2011) ‘Evaluating the Mexico City policy: how US foreign policy affects fertility outcomes and child health in Ghana.’, IFPRI – Discussion Papers, (1147), p. vi-pp. Available at: http://www.ifpri.org/sites/default/files/publications/ifpridp01147.pdf.
Lo, N. C. and Barry, M. (2017) ‘The Perils of Trumping Science in Global Health — The Mexico City Policy and Beyond’, New England Journal of Medicine, 376(15), pp. 1399–1401. doi: 10.1056/NEJMp1701294.
SA, B. S. C. (2015) ‘The Global Gag Rule and fights over funding UNFPA: The issues that won’t go away. TT -’, Guttmacher Policy Review, 18(2), pp. 27–33. Available at: http://www.guttmacher.org/pubs/gpr/18/2/gpr1802715.pdf.
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