The Rise of "Evidence Based Bureaucracies" Economic Knowledge in Health Policy in the UK and France

While “Evidence based policies” are now identified objects in policy analysis (Boaz and al. 2008), we would like to focus on organizations dedicated to the making of evidence for public policies. Far from being restricted to academic actors, the making of evidence rests on dedicated administrative organizations paying attention to their own credibility (Carpenter, 2010; Jennings, Hall, 2012). These administrative bodies, often labeled “agencies”, are herein characterized as  “evidence based bureaucracies” in order to insist on two main analytical traits: (1) the use of evidence is highly structured by standards and protocols, which gives them a bureaucratic flavor (Yesilkagit, 2004 ; Benamouzig, Besançon, 2005); (2) a high level of openness to non-state actors, like experts, citizens or interest groups, gives them meanwhile an inclusive and deliberative aspect (Moffit, 2010).

To explore empirically these agencies, we compare two similar bodies working in the field of Health Technology Assessment (HTA) in the UK and France. HTA is a worldwide process of evaluation of medical treatments implemented owing to specific methods based on clinical research, epidemiology, ethics and economics. The use of economic knowledge in the forging of evidence in this field is all the more important to understand that it raises political issues like equal access to health care.

England is often considered as one matrix of HTA. We focus on the case of the National Institute for Clinical Excellence (NICE) set up in 1999. From its inception, NICE developed a protocolization of its own work, by formalizing the contributions of a variety of experts and stakeholders. This organization is articulated with sequential methods and formal lines of reasoning developed in relation with expert communities. A threefold alignment — institutional, organizational and cognitive — articulates heterogeneous principles (scientific, epidemiologic, ethic, economic, social…) and reinforces the coherence of a deliberative but however quite formal bureaucracy.

In France, a specific and autonomous agency (Haute Autorité de Santé, HAS) has been created in 2004 to deliver public advice on the level of efficiency of public health programs, health devices and innovative drugs. So far, the use of health economics appears however slight and not so open. Economic knowledge is enduring resistance and pressures both from within the agency and other public and private actors. While the institutional framework influenced the way experts are working and debating, economic evaluation developed through a rather intensive proceduralization of economic knowledge combined with a slight openness of deliberative processes.

In both cases, the use of economics in health policy is performed by independent administrative bodies, which are responsible for gathering various kinds of actors and sources of evidence. They incorporate economics medical knowledge, epidemiological, social science and ethics owing to procedural ways of working and deliberating, which formalize the organization in a bureaucratic way. These organizational traits, which differ according to the national context, participate to the public reputation of agencies and increase or question their regulatory power.