Evaluation as evolution: a Darwinian proposal for health policy and systems research

Health Research Policy and Systems

Merrick Zwarenstein¹  Seye Abimbola³  Alexandra L Martiniuk² 

[1] Institute for Clinical Evaluative Sciences, Toronto M4N 3 M5, ON, Canada;Dalla Lana School of Public Health, University of Toronto, Toronto M5T 3 M7, ON, Canada;National Primary Health Care Development Agency, Abuja 900247, FCT, Nigeria

关键词: Health systems;    Health policy;    Evolution;    Evaluation;   

Others  :  1170920
DOI  :  10.1186/s12961-015-0007-x

 received in 2014-10-14, accepted in 2015-02-21,  发布年份 2015

【 摘 要 】

Background

Health systems are complex and health policies are political. While grand policies are set by politicians, the detailed implementation strategies which influence the shape and impact of these policies are delegated to technical personnel. This is an underappreciated opportunity for optimising health systems. We propose that selective ‘breeding’ through successive evaluations of and selection among implementation strategies is a metaphor that health system thinkers can use to improve health care.

Discussion

Similar to Darwinian evolution, the acceptance and accumulation of successful choices and the detection and discarding of unsuccessful ones would improve health systems in small and uncontroversial ways, over time. The effects of better implementation choices would be synergistic and cumulative, accumulating large impact (and lessons) from small changes. Just as with evolution of species, this means that even slight improvements over usual outcomes makes these numerous small choices as important a focus for system improvement as the overarching policy itself. Several alternative implementation approaches can be compared under real-world conditions in prospective head-to-head experimental and non-experimental explorations to understand whether and to what extent a strategy works and what works for whom, how, and under what circumstances in different locations. As in breeding or evolution, the best variants would spread to become the new, proven superior, implementation strategies for that policy in those settings.

Conclusions

Evolution does not produce a new species whole, in a single transaction. Instead it gathers new parts and powers over time as different combinations are tested through competition with one another, to survive and spread or become extinct. Without necessarily changing or challenging grand policies, extending this idea to health systems innovation can facilitate thinking around how local, small – but cumulative – improvements in implementation potentially contribute to a pattern of successive adaptation spreading within its viable niche and ultimately providing locally-derived, long-term improvements in health systems.

【 授权许可】

   
2015 Martiniuk et al.; licensee BioMed Central.

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