Applying the GRADE Evidence-to-Decision framework to inform a Public Health Policy: an experience from Chile

Background: The GRADE Evidence-to-Decision (EtD) framework was developed to support systematic, transparent, and structured processes for translating research evidence into healthcare recommendations. While widely used in clinical guideline development, its application in public health policymaking remains less documented. Population-level decisions require consideration of broader contextual factors, including implementation feasibility, equity, and health system constraints. This study documents the application of the GRADE EtD framework within Chile’s Ministry of Health to inform a policy decision on milk fat content in a national child nutrition programme. Methods: The study used the GRADE EtD framework adapted for health system and public health decisions. A structured research question was formulated using a PICO approach, and evidence was synthesized to inform EtD criteria covering benefits and risks, certainty of evidence, values and preferences, resource implications, equity, acceptability, and feasibility. Evidence reports on effectiveness, cost-effectiveness, and population values were prepared through systematic searches of major bibliographic databases. Additional contextual reports addressed programme costs and implementation considerations. A multidisciplinary expert panel reviewed the evidence and completed the EtD assessment during two deliberative meetings, leading to a final recommendation. Results: The EtD process examined whether children aged 24–71 months should receive whole or reduced-fat milk in the national programme. Evidence synthesis identified limited observational studies with very low certainty across critical outcomes, showing no clear benefits of whole milk and possible small risks for susceptible children. Values and preferences were variable, and no cost-effectiveness studies were identified. Although whole milk was slightly cheaper, equity and public health considerations favoured reduced-fat milk. The expert panel issued a conditional recommendation for reduced-fat milk, accompanied by implementation, monitoring, and periodic evidence review plans. Conclusions: This experience demonstrates the feasibility of applying the GRADE EtD framework to inform complex public health policy decisions where evidence is limited and contextual factors are critical. By structuring deliberation and documenting value judgments, the approach supported transparent and accountable decision-making. The experience suggests that evidence-to-decision frameworks can support health systems to integrate research evidence with programmatic and equity considerations when designing population-level health interventions.