The following questions can be used to guide the preparation and use of policy briefs to support evidence-informed policymaking:
1. Does the policy brief address a high-priority issue and describe the relevant context of the issue being addressed?
2. Does the policy brief describe the problem, costs and consequences of options to address the problem, and the key implementation considerations?
3. Does the policy brief employ systematic and transparent methods to identify, select, and assess synthesised research evidence?
4. Does the policy brief take quality, local applicability, and equity considerations into account when discussing the research evidence?
5. Does the policy brief employ a graded-entry format?
6. Was the policy brief reviewed for both scientific quality and system relevance?
1. Does the policy brief address a high-priority issue and describe the relevant context of the issue being addressed?
Policy briefs are distinguished most clearly from other packaged evidence summaries by the fact that they begin with the explicit identification of a high-priority issue. In instances where an issue has been on the agenda of key stakeholders for some time, policy briefs may act as a way to spur progress. This is highlighted in the example shown in Table of low coverage rates for artemisinin-based combination therapies (ACT) to treat uncomplicated falciparum malaria in sub-Saharan African countries. Alternatively, if the issue is relatively new, the policy brief may play an agenda-setting role. Either way, it is critical that the issue is deemed a priority by at least some key stakeholders. Ideally the prioritisation process should also be systematic and transparent and Article 3 in this series outlines an approach for achieving this [
12].
| Table 1Outline of a policy brief about supporting the widespread use of a new, highly effective treatment for malaria in an African country |
A second key feature of policy briefs is that they are typically
context-specific. Describing the key features of a context in the policy brief is important as a way of creating a level playing field among policy brief readers. Table highlights issues related to limited or inequitable access to sustainable, high-quality community-based primary healthcare in Canada. There, as the policy brief explained, the issue could only be understood in the context of the particular features of Canadian primary healthcare and the existence of 'private delivery/public payment' arrangements with physicians. These are of particular importance in this context for they have meant historically that most primary healthcare in Canada is delivered by physicians working in private practice with first-dollar, public (typically fee-for-service) payment [
13]. Improving access in creative ways, including the use of collaborative practice models, requires an understanding that: 1. Physicians tend to be wary of potential infringements on their professional and commercial autonomy, 2. No other healthcare providers at this time can secure the public payment required to function independently as primary healthcare providers on a viable scale, and 3. Many forms of care (including prescription drugs and home care services) would still not be covered [
14].
| Table 2Outline of a policy brief about improving access to high quality primary healthcare in Canada |
2. Does the policy brief describe the problem, costs and consequences of options to address the problem, and the key implementation considerations?
A policy brief would ideally describe different features of a problem, what is known (and not known) about the costs and consequences of options for addressing the problem, and key implementation considerations. As outlined in Article 4, a problem can be understood in one or more of the following terms [
15]:
1. The nature and burden of the actual common diseases and injuries that the healthcare system must prevent or treat
2. The cost-effective programmes, services and drugs that are needed for prevention and treatment, and
3. The broader health system arrangements that determine access to, and the use of, cost-effective programmes, services and drugs, including how they affect particular groups.
A policy brief would help to clarify the problem by diagnosing it in one or more of these terms.
Ideally, the number of options described in a brief that is to be presented to senior policymakers would conform to local document conventions. Three-option models, for instance, are familiar to many policymakers. But regardless of the number selected, each option in the policy brief can be characterised in terms of:
• The benefits of each option
• The harms of each option
• The costs of each option or their relative cost-effectiveness (if possible)
• The degree of uncertainty related to these costs and consequences (so that monitoring and evaluation can focus on particular areas of uncertainty if any given option is pursued)
• Key elements of the policy option if it has been tried elsewhere and adaptation is being considered, and
• Stakeholder views about and experiences with each option
A policy brief would help to make clear the trade-offs involved in selecting one option over others. If the options are not designed to be mutually exclusive, a policy brief would also help to make clear the benefits of combining particular elements of the different options and which combination of options might bring about positive synergies. Alternatively, the elements from one or more individual options could be presented first, followed by 'bundles' of options combining different elements in various ways.
Barriers to implementation (outlined in further detail in Article 6 in this series) are located at different levels, ranging from the consumer (citizen or healthcare recipient) level through to healthcare providers, organisations, and broader systems [
16]. Policy briefs would help to identify these barriers and describe what can reasonably be expected (again, in terms of benefits, harms, and costs) as a result of pursuing alternative implementation strategies to address these barriers. A policy brief could also identify considerations related to the preparation of a monitoring and evaluation plan. Table provides a possible outline for a policy brief.
| Table 3Possible outline of a policy brief |
3. Does the policy brief employ systematic and transparent methods to identify, select, and assess synthesised research evidence?
Policymakers and a wide range of stakeholders who will be involved in or affected by a decision, are the main audience of a policy brief. Research language should therefore be kept to a minimum as most people will be unfamiliar with it. A policy brief, nevertheless, should still ideally describe how synthesised research evidence was identified, selected and assessed in ways that are easily understood. This objective can be achieved by using techniques such as explanatory 'boxes' within the brief to clarify or highlight particular concepts, or through the inclusion of additional appendices. The methods, too, should be systematic in nature and reported in a transparent yet understandable way. For example, users could be provided with a description of how systematic reviews addressing the benefits and harms of particular health system arrangements were identified through a search of continuously updated databases containing reviews in particular domains. This could provide significant reassurance to readers that most, if not all, key reviews had been found and that few, if any, key reviews had been missed.
4. Does the policy brief take quality, local applicability, and equity considerations into account when discussing the research evidence?
Systematic reviews may be of high or low quality, their findings may be highly applicable to a given policymaker's setting or of very limited applicability, and they may or may not give consideration to the impacts an option is likely to have on disadvantaged groups, and on equity in a specific setting. Ideally, a policy brief would flag such variations for policymakers and other readers. As outlined in Article 8, explicit criteria are available to assist with quality assessments [
17]. Importantly, some databases of systematic reviews, such as Rx for Change
http://www.rxforchange.ca, provide quality ratings for all reviews contained in the database. If possible, a policy brief would provide a quality review for all systematic reviews from which key messages have been extracted. Explicit criteria are also available to assist with local applicability assessments and these are outlined in further detail in Article 9 [
18]. Given that policy briefs are typically context-specific, a policy brief would also ideally comment on the local applicability of the findings of any systematic reviews that are critical to an understanding of the impacts of any options being considered. Equity considerations can also be addressed using explicit criteria (see Article 10) [
19]. A policy brief should also note in its introduction whether any groups have been given particular attention in the brief. Group-specific key messages could be added to the overall key messages in each section.
5. Does the policy brief employ a graded-entry format?
A policy brief would ideally allow busy policymakers and other readers to scan the key messages quickly in order to determine whether these corresponded sufficiently closely to their key issue of concern and context to warrant reading the entire document. A graded-entry format could take a number of forms. These could be achieved, for example, through a 1:3:25 format - i.e.
one page of take-home messages, a
three-page executive summary, and a
25page report [
9]. Or a brief may take the form of a 1:12 format, with one page of take-home messages followed by a 12-page report. Whatever form is chosen, the minimum that a policy brief should contain is a list of key messages, a report, and a reference list for those who wish to read more. The key messages would range from the identification of the problem through what is known about the options, and the key considerations for implementation.
A number of other features of a policy brief could engage potential readers and facilitate assessments of who was involved in preparing, informing and funding it. The title of a policy brief could be worded in a way that would engage policymakers and other stakeholders. This could be achieved, for example, by using a compelling question as a title. The cover and/or the acknowledgements section of a policy brief could provide a list of authors and their affiliations. It could also include a list of those involved in establishing the terms of reference of the policy brief, a list of the key informants contacted for additional perspectives on the issue and to identify relevant data and research evidence, and their affiliations. A list of funders for both the organisation producing the policy brief and the policy brief itself, and a statement about any conflicts of interest among authors could also form part of the policy brief document.
6. Was the policy brief reviewed for both scientific quality and system relevance?
Policy briefs need to meet two standards: scientific quality and system relevance. To ensure this, the review process could involve at least one policymaker, at least one other stakeholder, and at least one researcher. This so-called merit review process differs from a typical peer review process that would typically only involve researchers in the review process, and hence focus primarily on scientific quality. Involving policymakers and other stakeholders can help to ensure the brief's relevance to the health system.
1 Govin Permanand,2 Andrew D Oxman,3 Simon Lewin,4 and Atle Fretheim5
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