Document(s) 11 of 21

From a research-to-action point of view, funding for research plays an important role in determining the extent of the linkage between the research and decision-making processes. Some research-funding agencies play crucial roles in mediating between these processes, especially influential external donors, such as international banks that also provide development loans.

Even when research funds derive from national sources and the demand for research leading to action is high, countries do not always make financial resources readily available for such studies. In some countries with national sources of funds for research, the emphasis has still been on technology development; this was illustrated in Brazil (see Box 5.3). Although research leading to workable technologies is highly desirable, especially when it results in large-scale manufacturing for either the domestic or the international market, it seems that most funding sources have given a much lower priority to research more directly aimed at guiding action.

In many countries, national research funds flow through agencies for S&T, where health research competes with research in other sectors, such as agriculture. Countries with a separate funding mechanism for health research may put an emphasis on technology development or use, paying little attention to policy decisions or program development. Developing countries need to strike a balance in health-research funding, based on their health priorities and their actual and potential research capabilities.

Although a great deal of attention goes to strengthening the various components mentioned above, the overall context or environment seems to play a crucial, if not deciding, role in the linkage between research and policy. One would be naive to assume that overall societal values and practices will be supportive of the search for, and the use of, evidence, even despite the logical expectation that good evidence makes for good decisions. It would also be naive, however, to assume that evidence has no place or will have difficulty finding its place in societies less supportive of evidence- or knowledge-based decision-making. This depends on the extent to which societies see researchers and research communities as sources of solid evidence and reliable information. In a country where a dictatorial regime has dominated for a long time, it may not matter much how much evidence is available for a given decision; a story from Uruguay illustrates this unfortunate lesson (see Box 5.4). The other extreme is the theoretically ideal situation in which decision-makers consult researchers and all available evidence before making a decision. In most countries, the reality is somewhere between these two extremes. The public expects decision-makers to make use of good information to guide their decisions, rather than relying solely on their personal opinions or experiences. Decision-makers will make use of the various available sources of information to the extent they feel the pressure to do so. It is encouraging to note that in many countries the research communities are striving to create evidence- or knowledge-based societies. The situation is changing quickly, and it will be important in this dynamic global environment to provide opportunities for intercountry dialogue to share experiences and ideas.

In countries where democracy or people-based politics is developing or gradually evolving, the place for evidence generation and dissemination is becoming more apparent. Researchers may find it easier to do their job. They may change their research strategies completely so that decision-makers properly know and use their results. It is in countries that still concentrate power in the hands of a few people or groups that researchers find it difficult to properly and effectively carry out their roles. They may even face problems in the initial stage of conceptualizing and planning a research study, not just after they have completed the research and are making efforts to disseminate their results.

International organizations play a very important role in influencing health research in most developing countries, where research funds are scarce. They include not only those working specifically to support health research, but also those dealing with health development or even socioeconomic development in general. Research is as an entry point for these organizations to exert their influence on the direction of national health development or health in the context of socioeconomic-development policies. This can have either a positive or a negative outcome, depending on how the process unfolds and the nature of the relationship between those involved in the process.

A common criticism is that international organizations only support the research that fits their own agendas. Sometimes those agendas are relevant and useful for countries; at other times, they are at odds with national health-research priorities. Some countries have tried to address national priorities, but with the use of external expertise and little involvement of their own national counterparts. Even when these undertakings involve nationals, these people tend to have the role of assistants, rather than of researchers. Lack of equal partnership and lack of concern for a country’s own context and needs still predominate. Those imposing “external” agendas may worsen the situation in a developing country by insisting on the use of external experts to carry out research studies rather than actively involving nationals in the undertaking. Use of external experts is often a condition on receiving loans from the major development banks for health- and social-sector reforms. Some international organizations even carry out studies without involving national researchers at all; they simply “inform” countries of their health-development situation and recommend strategies for addressing it. Walt et al. (1999a) and Buse (1999) have recently described and analyzed this unhealthy asymmetrical power relationship between donor agencies and recipient countries and made suggestions on ways to change the attitudes and behaviours of both recipients and donors.

Having to rely on external sources of funding and follow externally imposed research agendas are common problems facing most developing countries. Such factors need not always lead to difficulties in creating relevant research and effectively linking it to action. This depends on the ways international organizations work with a country’s decision-makers and researchers. In some cases, external sources of funding for research have played a crucial role, not only in allowing countries to set their own priorities and conduct relevant research, but also in strengthening national expertise and capability. In addition to supporting specific research studies, IHPP has provided funding for research dissemination and capacity-building consistent with national priorities. The Rockefeller Foundation initiated National Epidemiology Boards in Cameroon, Mexico, and Thailand to assist these countries in health-situation analysis; this in turn contributed to their identifying national health-research priorities. The Kaiser Family Foundation supported HST in South Africa in more or less the same manner.

Most international health-research agencies, however, still adhere to the conventional style of work. They believe that by setting a global or regional research agenda they will help to better guide a developing country’s health R&D. They also hold that good national researchers are scarce and that international experts are the best people to carry out the research crucial to policy development. They prefer to develop specific research programs and let countries compete for funds within those programs, rather than providing funds directly to countries to support research with high national priority. International organizations need to reconsider capacity-strengthening strategies to ensure that training grants match national health priorities. Capacity-strengthening support should go beyond individuals and institutions and include national networks and annual meetings. With such a broadened support, national groups doing research may contribute to action on a more sustainable basis, as opposed to contributing to it in an ad hoc manner reflecting the demands of external donors.

Although good-quality research on policy-relevant issues, with well-packaged and well-targeted products, may succeed in informing decision-making processes, there is a pressing need to build sustainable linkages between research and policy to achieve development goals. To understand the factors contributing to a sustainable arrangement, researchers may find it useful to conduct detailed descriptive studies of the research-to-policy process (see Box 5.5).

Figure 5.2 presents a framework for addressing the research–policy gap. The framework incorporates the key components outlined earlier in this chapter; the research and policy processes are discrete but parallel, and dialogue among the various stakeholders links these processes at multiple stages. Stakeholders include many groups with diverse possible contributions to the various stages of the two processes, and these processes must properly involve them all. Many are potential mediators, including the researchers themselves, national health-research managers, governments, and the international research community. Each group can make a distinctive contribution to bridging the gap by fostering new ways of thinking, improving infrastructure, and introducing new practices. All the actions of mediators require sensitivity to the broader sociopolitical context. Lastly, the research products themselves need not be a single final output at the end of the research process but may be a series of outputs of a variety of types that occur throughout the research process and inform the next steps in the decision-making process. The remainder of this section focuses on the various mediators and their ability to act as catalysts in creating and sustaining effective linkages between research and policy.

Figure 5.2. Strengthening research-to-policy linkages.

For researchers to have a place in the decision-making process, it is important that they not isolate themselves from it or allow decision-makers to deter them from participating in it. If research is to become an integral part of the decision-making process, then so too must researchers. This means that researchers must be involved in policy development or decision-making and not limit themselves solely to executing research. They may start their work by identifying research questions, based on a literature review or some theoretical conceptualization of interest to the academic community. But to make their research relevant to a decision-making process, they must become aware of the decision-making mechanisms and priority issues and concerns.

Researchers need to understand these issues from the perspective of the various stakeholders and take these points of view into account in formulating their research questions. However, they should not carry their solicitude for stakeholders and decision-makers so far that they compromise their objectivity or feel they need to obtain consent or endorsement from decision-makers.

Being involved in the decision-making process goes beyond the initial steps of identifying and formulating research questions. It also means that researchers have to be concerned about two parallel processes: one is the research process, in which the researchers are fully accountable for carrying out the best work possible; and the other is the decision-making process, which decision-makers may determine in response to their policy environment. Researchers will have to keep in mind the dynamics and progression of both processes and try to link them as they unfold. Researchers will, for example, need to consult periodically with the various stakeholders to ensure the relevance of the content, as well as the proper tempo, of the research work. This requires researchers to be fully aware of the context of the decision-making process and to interact with stakeholders and users of the research as much as possible, rather than carrying out their research in isolation and assuming that in the end good-quality research products will sell themselves.

Included among the various stakeholders and users of research are what one may broadly refer to as “the affected population,” decision-makers, and intermediaries such as policy advisers, the media, and academics. Researchers need to recognize that actions resulting from their research affect many people. Such actions, therefore, often require the direct or indirect consent and cooperation of many other groups beyond the decision-makers. Working with those who can help to translate the messages into languages appropriate to the various groups of stakeholders therefore provides another entry point into the decision-making process. In this respect, researchers need to realize that they will have to work with many other groups beyond their academic peers. Some researchers are realizing that they can be both scientists and advocates, without compromising their scientific integrity (Brown 2000).

Researchers need to learn how to interact with these various groups of people. They must be prepared to listen to diverse viewpoints and perspectives. But more importantly, they must be able to incorporate them into their research, without sacrificing objectivity or neutrality. However, they must also be ready to communicate their ideas at various stages in the research process, as the decision-making process demands. They cannot just be passive observers or participants in the decision-making process, afraid of losing their impartiality once they speak out. Being actively and properly engaged in the dialogue helps researchers understand how to incorporate various concerns and viewpoints into their research and identify the people who might be receptive to the research products.

Researchers strive to produce work of the highest scientific quality, and many feel that the products of their research will speak for themselves. An important way of letting research products do so is to publish them in academic journals, where researchers working in related fields will search eagerly for relevant new findings. Yet, researchers cannot afford to limit communication of their results to other members of the research community. Communicating with the larger public and policymakers is an essential part of being a good scientist, just as a surgeon’s ability to communicate with patients is a crucial, but sometimes neglected, part of being a good surgeon.

The intended users of research constitute a broad group, and the ways and means of reaching them are quite different from those already familiar to researchers. Consequently, they need to learn new skills and adopt new attitudes to carry out their duties as social marketers. Social marketing involves getting the crucial messages across to the target population. It demands an ability to understand the target population in terms of its preferences and its style of learning new information so as to present the intended messages effectively.

Using marketing principles to disseminate research products means giving careful attention to packaging these products to make them attractive to various audiences. Timing is also important. Researchers need to be alert to opportune moments to present their results. Research marketing involves teamwork and requires the help of nonresearch professionals to formulate difficult technical messages for lay people and identify effective media channels or publishers with a commitment to reaching certain groups of people.

Successful linkages of research to policy are not a matter of merely changing the attitudes or modifying the skill sets of the researchers themselves. Other mediators are needed. Distinctive contributions may come from people responsible for providing leadership in health research, such as directors of research institutions (including academic institutions), coordinators of national research networks and forums, and executives of funding agencies. Such research managers may come from various backgrounds: research per se, academic life, public-service and private-sector management, or leadership of NGOs.

Given the movement toward a “knowledge economy,” it is particularly important for research managers to understand how the production and use of knowledge can contribute to economic and social development. For example, people increasingly recognize that an understanding of local conditions is critical to making programs successful. Combining local and global knowledge is an important mediation skill. Local knowledge includes an understanding of epidemiological trends, cultural patterns, and social structures (for example, who the opinion leaders are in a given community). One must adapt knowledge of “evidence-based interventions” imported from the world’s scientific databases to effectively apply them to local realities. Knowledge management for change also includes identifying crucial information needs for national health development and translating these needs into research opportunities to enhance local knowledge and facilitate research to develop new technologies. The latter may involve talking to private investors so that certain technology prototypes get into the manufacturing process.

Countries need to make a systematic effort to develop the leadership skills of their national health-research managers. The ENHR mechanism can play a crucial role in producing research managers who understand the process of innovation dissemination and system change. Such research managers would ensure not only that studies generate good-quality research products but also that these studies examine questions relevant to national health priorities and take into account the perceptions and concerns of the various stakeholders. Moreover, these research managers would look for opportunities and possible entry points or linkages to the decision-making process and keep information flowing between the two processes. They would help researchers obtain the viewpoints of various groups for data analysis and for relevant, useful recommendations. They would also play a crucial role in marketing the research products and working to mobilize other groups to assist the process.

The ENHR mechanism can work with research-funding agencies to increase their awareness of the need for such managers, arguing on the basis of the value added in terms of the research funds already provided. This may convince funding agencies to organize training sessions to increase the number of such research managers. The research manager can be a member of the research team or someone the funding agency selects. Whatever the arrangement, it would clearly require additional resources to enable managers to properly carry out their roles. (Some further suggestions for strengthening the leadership skills of national health-research managers can be found in Chapter 6.)

National governments and the private sector can also play an important role in creating and sustaining effective linkages between research and policy. Cooperative or independent efforts can be useful in improving, for example, infrastructure for social communication. This includes both hardware and human resources. Conventionally, the emphasis has been on hardware, such as telephones, newspapers, television, radio, Internet connections, and computers. Yet, groups of people with common goals and objectives can work together in a type of coalition that helps foster communication in the broader population. Both types of infrastructure require investment and active efforts to create and sustain them.

The information industry (commonly referred to as the media) is an example of a private-sector stakeholder with an important role in linking research and action. By informing the public of research gaps, the media can help to create a demand for research. It can also play a critical role in communicating useful information about new knowledge to the public. In turn, the public can influence political leaders in their support for certain health issues, including research on priority problems.

Of greatest importance are an open society that allows debate on social issues and a government that allocates some financial resources to building proper infrastructure for better social communication. In many countries, however, although investment for physical infrastructure is available, the political culture would have to change to allow open social communication. Some countries have a supportive political culture but limited resources for physical infrastructure. In the latter case, funding agencies may be more readily able to step in to provide financial support for the needed infrastructure and improve the communication of research results to users. It is important, however, to invest in the wider infrastructure, rather than simply targeting a portion of investment to the research community; in other words, it is not enough to provide better access to communication for researchers while the rest of the country still has problems with communication infrastructure.

The international research community can also provide crucial support, both directly and indirectly, for effectively linking research to policy. Connecting researchers from countries with comparable health concerns or those with experience in dealing with similar issues is one form of support. This can result in both information exchange and new contacts with decision-makers. The recently launched Alliance for Health Policy and Systems Research may be able to serve in this role.

Another type of support involves creating opportunities for a broader network of researchers to share experiences and learn from one another. An example of this is the annual Global Forum for Health Research. An example at the regional level is the Tropical Medicine and Public Health Center of the Southeast Asian Ministers of Education Organization. Organizations such as these create a sense of belonging to a larger international research community, and they increase the prestige of research for action in countries where people perceive it as less academic and less valuable to the global knowledge base. However, such an increase in prestige is unlikely to occur without a shift in thinking in the international research community, which needs to better appreciate and contribute to local research.

International agencies supporting health research can reshape their supportive roles to better link research to policy. First, they should put greater effort into reconciling their research agendas with national priorities. This requires an ability to listen to various stakeholder groups and understand their positions, rather than using the agency’s considerable financial resources to push its agenda.

A fresh approach is needed to support health research for action. Instead of funding research projects or programs, international donor agencies might fund a national mechanism to promote research to meet national priorities and effectively link the results of research to decision-making and action. Both the mechanism and the research projects would require funds. Furthermore, nationals should be in charge of decision-making concerning the use of research funds. For example, in Tanzania the Swiss government provided an endowment of 200 000 USD to establish a Health Research Users’ Trust (NIMR 1999). A consortium of national groups manages this fund. It facilitates communication, disseminates information, and implements research projects in line with Tanzania’s recently revised health-research priorities. International funding agencies can further support the learning process of national research mechanisms by facilitating their contacts with other mechanisms sharing similar concerns and goals.

Another approach would be to fund only the operating costs of the national mechanisms themselves, which would then mobilize further technical, financial, and political support for research projects. Neither approach has wide acceptance, however, owing to the concern that once such external funding sources start to support developing countries they will always be required. When donors support a management mechanism, they also tend to raise a concern about national responsibility, but they rarely raise the issue in regard to research projects.

As long as countries do not see the need for health research or do not have the capacity to support it from national budgets, they will require funding from external sources. A failure to convince nationals of the worth of investments in health research is often the reason for a country’s dependence on external funding. Donors, however, also need to understand that they can achieve a better research linkage to action through better research management, not merely through making research grants available to do research. Investment in a research management mechanism is a cost-effective approach to helping countries create and make use of research for action.

A somewhat sensitive point needs to be made in regard to the mediating role of the international research community, particularly donor agencies. They commonly demand that a country use international consultants or experts as a condition for loans and grants when they involve large amounts of research funding or are intended to support policy changes. The practice is based mainly on the assumption that having external consultants guide country research will benefit developing countries more and ensure better-quality and more timely results. Certainly this practice is neither illogical nor without its benefits, as pointed out in previous analyses of this issue (Berg 1993). However, international agencies should do this with great caution and weigh the benefits of using external consultants from various angles. Such requirements or conditions on loans can lead countries to reject the work of their own nationals. When faced with a trade-off between a level of quality in research and increased involvement of national researchers, it may be preferable if an international agency chooses the latter, provided that national researchers produce adequate research. Such trade-offs are fewer than people imagine. The final decision will depend on a mix between any existing sense of resentment, the ability of the external experts, the dynamics of the research process, and the nature of the research issues. Although there is no ready-made solution, the crucial message is that international funding agencies need to reexamine their policies and practices related to the use of external experts in country-based research for action.

International donors also need to rethink how they view national researchers. In many cases, they treat national researchers as informants and liaison persons, rather than as researchers with a status equal to that of external consultants. Although such roles are important to the research-for-action process, they do not make full use of the capabilities of national researchers, who often have too little involvement in planning for research. If we believe that the effective linkage of research to action depends on the interaction of the various stakeholders and their involvement, then the ways national researchers enter into each study will impact on the final outcome. In most cases, external experts have only an inadequate understanding of the national context, by far the most crucial component determining both the research process and its outcome. Studies aimed at involving stakeholders, linking research to decision processes, and marketing research products would benefit most from the involvement of national researchers who have a thorough understanding of the local context and the orientations of the various stakeholders. Although not all national researchers can claim to possess such ability and insight, there will always be those who can.

A chapter of the World Development Report 1998/99: Knowledge for Development (World Bank 1999) examines the role of international institutions in the production and use of knowledge, including those functioning as “intermediaries”:

Most knowledge that is beneficial for developing countries is not the product of internationally sponsored research, vital though such research can be. It is rather the consequence of actions taken in developing countries themselves. Local knowledge creation — and its transfer from one country to another — thus has the potential to unleash powerful development forces. Learning from others, assimilating that knowledge, and adapting it to local circumstances offer the opportunity to make rapid advances without repeating others’ mistakes.

— World Bank (1999, p. 133)

In several examples, international health-research agencies have played an important intermediary role in sharing knowledge and experience. COHRED’s monograph series is an example of such a contribution, one of compiling and analyzing the experience of developing countries on specific activities (see Chapter 8, Box 8.4). As well, the Kaiser Family Foundation and other agencies provide support to HST in South Africa. Among its publications is the annual South Africa Health Review, which provides a record of the struggles, achievements, and challenges of one country as it has tried to implement policies to provide effective and equitable health care to its citizens (HST 1999). Another example is the 1998 Population Reference Bureau review, describing how operations research has contributed to improved reproductive-health services in various parts of the world (see Box 5.6). The recently created cluster on Evidence and Information for Policy at the World Health Organization provides useful information to guide policy development at both global and national levels. Most of the work to date has concentrated on producing interesting information on developing countries’ health situations, but with relatively little involvement of national researchers.

In many countries, the focus of research for action has been on strengthening researchers’ communication skills, but such initiatives rely on the overly simplistic assumption that proper packaging ensures the best use of research. To increase the likelihood of research leading to action, we need to include many other factors in the equation. One is that the research-planning process requires broader participation and a diversity of dynamics. Another is that researchers need to concern themselves with the decision-making process and become involved in it, rather than paying attention solely to their research. They also need to improve their communication of research results, adopting more of a social-marketing approach.

To enable such a holistic participatory approach to yield the best results, researchers and research users need to strengthen their capabilities. A national mechanism with a dynamic, interactive, and inclusive process would be crucial to improving the chances of research linking successfully to action. The research community, decision-makers, and research-funding agencies need leaders, or managers, who understand the concepts and practices of knowledge management for change. Government also has a critical role to play, especially in providing both physical and social infrastructure to facilitate or demand research for action. The international research community and funding agencies need to change many of their conventional attitudes and practices and look at research for action more from a country viewpoint and from that of longer term development goals.

Document(s) 11 of 21