Bridging the policy gap: How innovative partnerships are taking the guesswork out of improving population health

It sounds simple: identify a problem that affects the health of certain groups or of entire populations, and then come up with policies to fix it. But even if the goal is clear, the path toward it is often complicated.

"People say that if we have the right policies, then we can achieve better population health," says Dr. Arijit Nandi, Interim Director of the Institute for Health and Social Policy and an epidemiologist at McGill University. "But what are the 'right' policies? It's a complicated question, and certainly a challenging one to answer, because population health is difficult to measure and can be affected by many factors."

Dr. Nandi is tackling this challenge by leading PROSPEREDFootnote 1, a network of partners from seven countries on five continents that studies the impacts of public policies on the health of populations. As a research team, they systematically identify and analyze policies from around the world related to socio-economic status, health services, public health, and the environment. Using the health-related targets in the United Nations Sustainable Development Goals (SDGs) as their guide, the team helps determine whether specific polices are helping to move things in the right direction.    

"Not all policies that we think are good, or that were designed with good intentions, are working in the way they were meant to," says Dr. Nandi. "Our role as researchers is to examine not just if these policies are effective, but also how and why they are effective. Through this process, we're aiming to find the best and most equitable ways to bring about the positive changes we all want to see."

Moving beyond biology to understand health and policy

Determining the best policies, however, is complex and means considering a variety of different factors and approaches.

"There's a common understanding now that the health of individuals and of entire populations is affected by a number of factors. Our biology is important, but we can't ignore the ways in which these other pieces come into play," explains Dr. Nandi. "These include the political, economic, and environmental factors that affect our day-to-day living conditions and health over the course of our life."

For example, encouraging people to eat healthier foods may seem like a straightforward way to improve overall health and wellbeing, but an individual's ability to access those foods can be affected by other forces, such as their household income (ability to pay for such foods) and even the environmental and geopolitical factors influencing global food supply. These broader factors also influence access to affordable housing, quality health services, employment opportunities, education, and other social determinants of health. And the impacts of these factors may also vary from person to person based on their nationality, race or ethnicity, gender, and other aspects of their social position and broader identity.

"These intersecting characteristics have important implications for population health equity," Dr. Nandi continues, "which is part of what makes the work so complex. It can be hard to anticipate and measure the full impact of specific policy reforms, and even harder to understand how policy affects different groups of people."

It’s also important to remember that some policies might not have been designed with a population health goal in mind. For example, economic policies tend to focus on influencing economic conditions in distinct communities, regions, and countries – but this can also be inextricably linked to the health of the people in those places. Plus, these policies may not affect everyone in the same way: a policy could technically improve the average levels of an outcome (such as household access to healthy foods) but might also exacerbate social inequalities and make things worse for certain groups.

"With these multi-faceted issues, it's unlikely that we'll ever look at a single policy or program and find that it fixed everything," Dr. Nandi says, adding that it can also take a long time for a policy to have a measurable impact in the first place. "We need to encourage an iterative cycle of evaluating, adapting policy design, re-evaluating, and repeating, all with an emphasis on learning along the way. This, of course, requires significant coordination between researchers and implementers, in addition to the time and resources."

Building partnerships for bigger impacts

As part of this iterative approach to program and policy design, PROSPERED is increasingly engaging stakeholders much earlier in the research process.

The team initially followed a traditional approach to sharing its findings, such as publishing studies in peer-reviewed journals and then looking for ways to communicate recommendations to different non-academic groups, including non-governmental organizations (NGOs) and policy makers. This led to some notable successes. One of their studies on 20 LMICs, for example, showed that paid maternity leave was associated with a reduced infant mortality rate. Drawing in part on this study, the Philippines passed legislation in 2020 to extend paid maternity leave from 60 days to 105 days.

However, the traditional approach to influencing policy is hit-and-miss. "The questions we're trying to answer through our research may not be priorities for some stakeholders, or may not provide the answers they're looking for," Dr. Nandi says. "We also learned that it's important to take advantage of 'policy windows' and share findings in formats that make them easier to use."

Adopting a more collaborative research approach has already shown great promise for the team's partnership with Alive & Thrive (A&T), a global initiative that works to improve maternal, infant, and child nutrition. "Our relationship with A&T has evolved over time," Dr. Nandi continues. "We started by asking our partners at A&T for input on questions developed by our research team – but now A&T identifies a research gap or policy need, and our team tries to design epidemiological studies to provide them with credible answers and information."

In Vietnam, for example, they collaborated to examine the impact of a program designed to encourage and facilitate breastfeeding. Rates of early initiation of breastfeeding (EIBF), defined as providing milk to infants within 90 minutes of birth, and of continued exclusive breastfeeding (EBF) are low in many parts of the world despite evidence of the benefits to infant health and development. Marketing of breastmilk substitutes in LMICs has played a role in this trend, as have increased rates of birth by caesarean section (which can make EIBF difficult). The maternal and infant care practices used by the hospital shortly after birth can also have an impact – and that's where A&T wanted to make a difference.

A&T worked with Vietnam's Ministry of Health (MOH) to develop a model for breastfeeding best practices in maternity hospitals, which was then piloted in 28 hospitals across the country in 2019-2020Footnote 2. Thanks to their existing relationship, Dr. Nandi's team was able to design a study that used pre- and post-implementation survey data from patients to evaluate whether the model was having the intended effect. The results showed that the model was positively associated with rates of EIBF and EBF across the 28 hospitals, which supported the decision by the MOH to take the next steps in scaling up the program.

"It's a gratifying way to work, especially with a partner like A&T that can help us interpret research results and even communicate them directly to policy makers," says Dr. Nandi.

And as for finding the "right policies" to improve population health? "I think we need to start with the right questions, and we can do that better together," he says.

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