DEBATE DEBATE
Debate on the paper by Celia Almeida & Ernesto Báscolo
Debate sobre el artículo de Celia Almeida & Ernesto Báscolo
Gabriel Carrasquilla
Centro de Estudios e Investigación en Salud, Fundación Santa Fe de Bogotá, Bogotá, Colombia. gcarrasq@fsfb.org.co
In a study carried out in eight Latin-American and three European countries, the NEVALAT Project group showed that the decision-making process for different issues in the health system (reimbursement for new drugs, resource allocation, provision of public health interventions, inclusion of services in health insurance packages, adoption of new technologies) is based not on research, but primarily on political criteria, historical records, geographical areas, and specific groups of patients and diseases 1. The authors emphasize the need for a clear understanding of the research-to-policy process. The paper by Almeida & Báscolo provides a critical update of the literature on this process, and the authors highlight the complexity and non-linearity of research use for decision-making and policy formulation processes in the health sector.
The authors have tackled numerous relevant issues that deserve academic and theoretical analysis, but I will limit my comments to just a few. As the paper states, there are several barriers preventing research results from influencing decision-making and policy formulation. One is the chasm between scientists and policy-makers, due both to "mutual intellectual disdain" (science is sometimes viewed as authoritarian and triumphalist 2) and a lack of reciprocal knowledge and understanding. Policy-makers have rarely related to science: according to Carl Sagan, less than 1% of Members of the U.S. Congress have any scientific background 3. Meanwhile, researchers are unfamiliar with the political world, where research is merely "another view" according to politicians, who must also take social, economic, and political factors into account during policy-making, an attitude that is not always understood or accepted by scientists. In addition, as the authors state, the timing of the two processes (research and decision-making) may not coincide, and research results are not immediately available on request by policy-makers. Scientists should also be aware that results can take time to reach the paths for translating evidence into policy: regulatory mechanisms (occupational health, environmental quality), public health recommendations (immunization, smoking), the legal system (causation of injury), and health care delivery (guidelines, outcome assessment) 4.
One point missing from the paper relates to methods for measuring the success of using research results for policy-making. Information for policy or decision-making processes comes from many sources, including research results. In some cases the association between results and decisions can be straightforward (as in the case of the rational approach mentioned in the paper), but in other cases measuring the contribution of results can be cumbersome.
Another issue approached by the authors is the interaction between policy-makers and research- ers. They emphasize "moments of opportunity" and draw on the literature to identify facilitating and constraining factors for such interaction. In a recent experience in five Latin American countries in a project funded by IDRC/PAHO, we identified some requisites that facilitate interaction between the two groups for development of the proposal and consolidation of research teams in order to influence the decision-making process before, during, and after the research.
In two projects, the decision-maker was in charge of implementing the health sector reform, and there was thus a clear interest and priority for the proposal at the highest level of government, and hence the need for results to support decisions. Another facilitating factor was prior and long-lasting relations between research centers and government agencies, but also prior personal relations. Both contributed to establishing research teams for developing proposals.
To be successful, participation should accompany the project from the beginning, when questions are raised and priorities are set and research questions must coincide with clear political interest by government 5. In such cases, we found that interaction between researchers and policymakers facilitated the program's objectives.
I wish to congratulate the authors for their effort in synthesizing a highly relevant issue for the health sector and promoting discussion on how research should be used not only for academic purposes but also for improving healthcare and ultimately the population's health conditions.
1. Iglesias CP, Drummond MF, Rovira J; Nevalat Project Group. Health-care decision-making processes in Latin America: problems and prospects for the use of economic evaluation. Int J Technol Assess Health Care 2005; 21:1-14.
2. Cronin H. Getting human nature right. In: Brockman J, editor. The new humanists. Science at the edge. New York: Barnes & Noble; 2003. p. 54-65.
3. Sagan C. El mundo y sus demonios. La ciencia como una luz en la oscuridad. Barcelona: Editorial Planeta; 1995.
4. Samet JM. Epidemiology and policy: the pump handle meets the new millennium. Epidemiol Rev 2000; 22:145-54.
5. Carrasquilla G, Almeida C, Bazzani R. Incorporating social protection in health into health sector reforms: defining and developing useful research evidence for successful policy implementation. In: 5th International Conference on the Scientific Basis of Health Services. Washington DC: Agency for Healthcare Research and Quality; 2003.