Document(s) 4 of 21

A key element in ensuring that health research indeed becomes an “essential link to equity in development” is creating a dynamic link between research and policy. In describing this challenge in 1990, the Commission on Health Research for Development outlined four pathways by which research can lead to health improvement: identifying and setting priorities, enhancing the efficiency and quality of health-care systems, developing new technologies and interventions, and advancing basic knowledge of human biology and behaviour.

This chapter analyzes some of the experiences of developing countries in strengthening this link over the past 10 years. It begins by identifying the key components of effective research–policy linkages. These include the dual processes of research and policy development, the context in which they both operate, the stakeholders involved, the products or outputs of both processes, and the critical role of mediators.

To begin, we must try to understand the attitudes of key stakeholders. Researchers typically feel they should remain “objective” in their work and are uncomfortable about close contacts with either decision-makers or the community. Decision-makers often regard researchers as too “academic,” impractical, and slow, as the decision-makers work in an environment in which they must try to balance the demands of various pressure groups. Members of the community, an often forgotten stakeholder in the research process, may feel intimidated by both researchers and decision-makers, even though, given the opportunity, community members can have much to say about issues to investigate and the exact application of new knowledge.

Much more attention should focus on the social, political, and economic context of knowledge production and use. This principle is particularly important if the goal is to conduct and apply research relevant to a country’s needs. At one level, science and technology (S&T) cannot thrive when a country is involved in armed conflict or has a dictatorial regime. Indeed, there are some sad examples in which the squelching of processes to nurture and apply science actually contributed to reversing gains in the health and welfare of people. At the more local level, people have sometimes refused to use the fruits of S&T because researchers failed to study and understand their deep-seated practices and traditions.

This chapter particularly emphasizes the importance of mediators in bridging the two parallel processes of research and policy development. It puts forward the proposal that various mediators can play distinctive and complementary roles in achieving successful linkages between research and action:

• Researchers themselves can develop some skills of communication and advocacy. In particular they must understand how decision-makers make resource-allocation decisions and how policymakers develop, implement, and monitor policies.

• This chapter makes a special plea for giving more attention to the critical role of national health-research managers, preferably within the context of an Essential National Health Research (ENHR) mechanism or system. These leaders can be the researchers themselves, research users, or funders. They require skills such as facilitating the process of multistakeholder priority-setting, building coalitions to work on specific problems, seizing opportunities (“entry points”) to identify relevant research questions or ensure the use of available research, and nurturing future leadership for national health research and development (R&D). In particular, these leaders must learn to function as “knowledge managers” within the rapidly changing context of the global knowledge economy.

• National governments also have an important role to play in improving both the technical and human infrastructure for social communication. Governments set the political climate by listening and responding to people’s concerns, conducting the affairs of government openly and transparently, and asking for evidence to support decision-making. Political leaders must also understand that investing in S&T, both for short- and longer term purposes, is an investment in enhancing the well-being of people.

• Finally, the international research community has a major responsibility to ensure stronger links between research and policy. International agencies should consider changing the ways in which they have traditionally operated, for example, by aligning agency agendas with those of recipient countries, providing funding support directly to a multistakeholder national research structure, rethinking the function of technical assistance as a condition for funding, making much more use of national consultants (who understand the local context), and using external experts only for carefully negotiated distinctive contributions.

A growing expectation of health research is that it contribute to enhancing human development. Ten years ago, the Commission proclaimed it an “essential link to equity in development” (CHRD 1990). The Commission purposely defined health research in broad terms as “the generation of new knowledge using the scientific method to identify and deal with health problems” (CHRD 1990, p. 13). Given such a definition, health research encompasses many disciplines and includes epidemiology, policy, social sciences, management research, biomedicine, and clinical research. This definition also takes account of the fact that health research may be an undertaking not only of trained scientists but also of governmental- and nongovernmental-agency staff, district health managers, and even communities themselves, as discussed in Chapter 4.

The Commission outlined four pathways for research to lead to action to improve health (see Figure 5.1), each entailing a range of research topics and disciplinary perspectives (COHRED 1994, p. 10):

• Identifying and setting priorities — The first pathway involves studies of the distribution of health and disease, as well as of health care. It demands a continuous process of gathering and analyzing data about communities, including people’s perceptions of health and disease. These data can enable researchers to assess the major determinants of health and disease in various segments of the population; identify the biological, behavioural, social, economic, and environmental risk factors and vulnerable groups; monitor changes; project trends; and recognize and combat epidemics.

• Enhancing the efficiency and quality of health-care systems — This pathway includes research into the use of health services; efficiency and cost-effectiveness of health interventions; evaluation and selection of technologies; assessment of the effectiveness of various combinations of medical, social, and other nonmedical interventions; design and testing of alternative approaches to delivering health care and financing health services; and, in regard to equity, the search for new ways to improve services to vulnerable, poor, and disadvantaged people.

• Developing new technologies and interventions — The third research pathway for health improvement involves the search for new biomedical tools, such as drugs, vaccines, diagnostic tests, and environmental-control measures for biological, chemical, and physical hazards; discovery and development of tools for disease control that are safe, simple to use, acceptable to communities, and affordable; and development of social, educational, and other interventions relevant to improving health.

• Advancing basic knowledge of biology and human behaviour — The final pathway includes achieving a better understanding of biological processes in health and disease; the biology of infective agents and their vectors; the role of genetic factors in resistance and susceptibility to disease; and advances in the understanding of health-related human behaviour.

Figure 5.1. Pathways from research to health improvement.

A principal finding of the Commission, however, was that potential users of research (in particular, policymakers, health-care providers, and communities) tend to view research as peripheral to their interests and livelihoods. Moreover, much of the research being done, particularly in developing countries, is unrelated to local concerns and realities. The Task Force on Health Research for Development (TFHRD 1991) reported that a prevailing understanding within the research community is that policymakers often do not make use of research findings in decision-making. In addition, researchers feel that the managers of health-care programs are not always using research results or applying scientific methods in planning, monitoring, and evaluating the services they deliver. By the same token, policymakers, health-care managers, and the public have accused researchers of failing to address the health problems with top priority; moreover, the researchers often fail to make readily understandable and timely reports of their findings and recommendations to people outside the academic community. Some attribute this situation to a lack of effective interaction between researchers, policymakers, health-care providers, and communities and an absence of mediators to bridge the gap between research and action, specifically the gap between research and policy.

Strengthening the linkages between policy and research requires an understanding of the key components of their interface: the research and policy processes, stakeholders, mediators to help link the two processes, research products, and the larger context of decision-making and research. Walt (1994) and Trostle et al. (1999) described similar frameworks:

• The research and policy processes — It is important to pay attention to the research planning and execution and decision-making processes. We need to link many steps in both processes, not just the initial steps of defining research questions and policy priorities and later steps of disseminating results and implementing policies and programs. Linking the two processes may mean more than simply inviting policymakers to participate in research planning. It may be equally useful for researchers to participate in the policy- and program-development process, from which they can distil crucial research questions.

• The stakeholders — Decision-makers would be more likely to use research results if researchers identified the intended users (policymakers, donors, communities, or health-care providers) and involved them in formulating questions and problems.

• Mediators — Mediators are individuals or institutions with an active role in fostering linkages between the research and policy processes. They may be organizations supporting research work. They may be the researchers themselves. They may even be academic or civic groups supporting evidence-based decision-making. National research-coordinating bodies may also play a mediating role to better foster research-to-policy linkages. International agencies, too, have an important contribution to make as intermediaries in linking knowledge and action.

• The products and outputs — “Products” refers to the research studies themselves and how they link up to the decision-making process. In most cases, researchers are concerned about the quality of research as the criterion to determine whether to use it. The nature of the issues and the studies themselves, however, can also play a crucial role. Studies providing factual findings have a status and use different from those of studies with concrete recommendations and especially studies addressing a particular problem. In fact, it may be helpful to think of research products not as final reports at the end of research projects, but as a series of diverse outputs within an ongoing integrated program for both research and action. Sometimes researchers carry out several studies within a program and these lead to a single decision. In turn, experience with decisions and actions can lead to the next series of studies.

• The context — “Context” refers to the environment surrounding the research and decision-making processes. International organizations and existing funding structures have a significant impact on the linkage of research and policy, as do the socioeconomic and political situations of a country. Other important factors are the prevailing nature of the decision-making process and the influence of mass media.

With these components in mind, let us now look at developing-country experiences in linking research to policy, drawn from the Council on Health Research for Development’s (COHRED’s) Working Group on Research to Action and Policy (COHRED 2000f) and other available studies (Loewenson 1993; ADDR 1996). What lessons can we extract? What new ideas and actions might these sources suggest for addressing the research–policy gap?

The most common approach to linking research to policy has been to produce good research and disseminate the results to the intended users. This relies on the assumption that decision-makers will always be receptive to relevant and useful information and make ready use of it once it is available. One cannot always make this assumption, as illustrated in some experiences from Burkina Faso (see Box 5.1). The success of such a supply-driven, linear approach hinges on ensuring that the intended users properly understand the research results. Consequently, a great deal of effort has gone into making the presentation of the research interesting and understandable. In fact, training courses and materials have been available to help researchers communicate more effectively (Porter 1995; SARA 1997). However, too often the emphasis has been on forging links with users once researchers have obtained the results, and not earlier in the process.

Over the last 10 years, more than 50 developing countries have adopted the ENHR strategy to support action promoting equity in health. Although various countries have adopted a variety of mechanisms to implement the ENHR strategy (COHRED 1999), all these mechanisms include an element of linkage between research and policymaking. Listed below are examples of the ways some countries have integrated ENHR into their social-development plans:

• In the Philippines, an autonomous ENHR Foundation works closely with the ENHR unit in the Ministry of Health to integrate the strategy into the National Health Plan. A detailed 5-year research plan coincides with the research needs of this plan.

• In Kenya, the National Development Plan of 1994 incorporated a Master Plan of ENHR activities (1992–98). Kenya’s priorities relate to maternal and child health, water and sanitation, health-care delivery systems, AIDS, and sexually transmitted diseases.

• In Ethiopia, a clearly articulated policy on science and development serves as a springboard for detailed policies and action plans for various economic and service sectors, and ENHR has a recognized role as an appropriate integrated strategy for organizing and managing research for health development.

• In Thailand, national development plans have formed the backbone of transformation and development for the past 36 years. Its 7th National Development Plan (1991–96) formally incorporates the ENHR strategy.

• In Jamaica, an ENHR Task Force has been active since 1995. Formally recognized by the Ministry of Health, it brings together representatives from the ministry, university-based units, and the Planning Institute of Jamaica in promoting and advocating ENHR.

• In Benin, a number of institutions have taken leadership in promoting ENHR. These include the Faculty of Health Sciences, the Regional Centre for Health and Population Development, and the Ministry of Public Health. ENHR also has a decentralized role within the Ministry and other organizations to allow for greater community participation. The strength of this arrangement has been the high level of participation from diverse interest groups. Its weaknesses have been its ill-defined interaction and lack of coordination with the Ministry of Public Health.

The experiences of these and others countries demonstrate that ENHR is making progress at the national level in linking research to action and policy. However, progress has been slow and uneven for a variety of reasons, including entrenched attitudes, ineffective communication strategies, and weak national funding arrangements. At another level, the sociopolitical realities of some countries or parts of countries prevent their establishing effective links between research and policy. In addition, international organizations involved in health research have a significant influence on what happens within a recipient country. Some aspects of these various challenges are explored below.

Although many potential users of research results each have a role and contribution to make in linking research to action, most people have seen researchers and decision-makers alone as vital to increasing the probability of success and have largely ignored or overlooked the role of the community, the third stakeholder in ENHR. The values and attitudes of each of the three stakeholders bear further examination, as they can remove or create barriers in linking research to action.

For the most part, researchers adhere to the idea that they should be unbiased and neutral with respect to the issues they study. With this attitude, they may resist “interference” from both decision-makers and the community. As a result, they may be reluctant to communicate with decision-makers during the research process and may be critical of information and suggestions from decision-makers or their staff. They may also have negative attitudes toward community involvement in the research process, viewing community members primarily as beneficiaries of the research. The researchers may believe that community members have too little information to make sound judgments about health priorities and problems and that sensationalistic and alarmist reports in the media sway their opinions. Some researchers may want to involve the community but are unsure of how to include them in the research process.

Despite a demonstrable demand for research to guide action, academicians often show a lack of capacity and interest in action-based research. This is partly due to the belief that research aimed at new discoveries or a better understanding of the natural world or human nature are of greater academic merit than that designed to guide decision-making. The latter type of research also tends to have short funding time frames. It may acquire the label “case-study research” because it deals with specific country situations, and for this reason international journals refuse to publish it. Such research is perceived to contribute little new knowledge to the global knowledge base. Such beliefs and practices discourage academicians from doing research for action. Without respect and acceptance from the academic community, studies to guide decision-making may fail to influence people in decision-making circles. Although the values described above are not universal and they are changing in some countries and institutions, many people undeniably still hold them, even in developing countries.

Just as researchers may be sceptical of decision-makers and communities, decision-makers can have the same attitude toward researchers. Many decision-makers feel that researchers are too academic and theoretical. They see their recommendations as overly ideal or impractical. Researchers, they argue, fail to understand the reality of the health problems because they are, in many cases, distant from them. As a result of this attitude, decision-makers show a lack of interest in what researchers have to say about issues.

Politicians deal with demands from pressure groups and tend to respond more to the ideas and suggestions from these groups than to those of researchers. They may ignore evidence that fails to support these demands or accord it lesser priority. Consequently, such evidence may carry little weight unless it is acceptable to other societal groups with influence on decision-makers, whether they are politicians or administrators. We may have difficulty amending this attitude, and researchers need to understand it better if they want decision-makers to give proper attention to research findings. Researchers, in fact, may want to strengthen their own alliances with communities and those nongovernmental organizations (NGOs), forums, and groups acting in their interest. To better understand the realities confronting policymakers, researchers may find it helpful to invite thoughtful individuals to present their views about the linkage challenge (see Box 5.2).

The community, or the public in general, is an important stakeholder but is largely ignored in both decision-making and research. Researchers most commonly involve the community through participatory research, in which community members help to identify and seek solutions to local health problems. The community, however, can also be a crucial partner in determining the use of research for decisions and actions taken outside the community; researchers who wish to influence decision-makers through research should try to involve the community as much as possible, even if the political situation in a country does not yet allow it to get involved in the policy process. (A more detailed analysis of the role of the community as a participant in research can be found in Chapter 4.)

One of the difficulties of involving the community in research for action is that its participation is necessarily partial, particularly at the national and district levels. Researchers tend therefore to work with NGOs or civil-society groups representing the interests of communities. They may also work with officially appointed leaders of communities, sometimes overlooking the unofficial leaders. In urban settings, where people congregate more within their work environment than within their neighbourhoods, researchers may have difficulty identifying groups representative of community interests. Commonly, community members are “consulted” about their health needs and problems. They are seldom allowed to play an active role in decision-making processes.

An important aspect of linking research to policy is effective communication. This requires an effective communicator and means of communication. Various communication channels are already available. Researchers have created some specifically to convey messages about their health research to intended users. Others include the press, radio, television, and even the Internet. Communication channels may be both part of the process of conveying a message and the “context” that determines the ways policymakers link research to policy. A common communication channel is the technical workshop, where researchers present their findings. Experience has shown, however, that the decision-makers themselves seldom attend such workshops, as they are too busy; instead, they send their representatives, who may fail, however, to bring the message back to the decision-makers. And in many instances, the only people who attend the workshops are other academics interested in some technical aspect of the research.

Many institutions doing research to guide action invest a lot of their financial and human resources in effectively communicating their results to decision-makers. In addition to using the sorts of workshops or meetings already described, they often create various types of succinct, easy-to-read publications, with no technical jargon or complex figures and data. The International Health Policy Program (IHPP) is well known for advocating effective communication between researchers and decision-makers. It makes resources available not only for doing research but also for communicating its findings, primarily through dissemination workshops. Another example comes from the experience of the Health Systems Trust (HST) in South Africa, which evaluated the effectiveness of various communication strategies in getting messages across to decision-makers and influencing their decisions.

Often researchers and research communities create channels for communicating with decision-makers that allow the researchers to retain a neutral stance and not appear to be advocates of a particular issue or solution. However, the overall system and culture of communication within a country can directly or indirectly affect these channels of communication; researchers attempting to communicate evidence for decision-making may fare badly in countries where no one welcomes such an endeavour or no one takes it seriously. Even if the researchers would like to go beyond the accustomed dissemination workshop, they may find themselves without good supporting partners or infrastructure to increase their chances of making the research known. Publishers who can produce attractive print materials might be scarce. People who can make technical research easy to understand for various audiences might also be in short supply. A country’s rules and regulations may constrain the mass media, or an invisible power may even threaten the media to make it stay away from such functions. Taken for granted in some societies, communication between people of diverse levels of power is not the norm in others. Again, in many countries, people still perceive it as too costly to purchase the infrastructure to support communication and dissemination of information. Added to this is a lack of appropriately skilled human resources in social communication, as opposed to commercial communication, which may be less difficult to find nowadays.

Document(s) 4 of 21