DEBATE DEBATE
Debate on the paper by Celia Almeida & Ernesto Báscolo
Debate sobre el artículo de Celia Almeida & Ernesto Báscolo
Ligia Giovanella
Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. Red de Investigación en Sistemas y Servicios de Salud en el Cono Sur, Rio de Janeiro, Brasil. redsalud@ensp.fiocruz.br
In their literature review on the relations between production of scientific knowledge (research results) and use in policy formulation and implementation processes, Almeida & Báscolo carefully selected (within the numerous available literature) the principal publications on the issue in the field of health systems and services research. Expanding on previous studies 1, the authors have summarized important information, providing readers with an excellent overview of the theme by approaching different dimensions in the complex debate on the possibilities for research results to inform decision-making in public health policies, and by identifying the principal gaps in the analyses found in the literature.
The article is very timely, in a context where research funding agencies are increasingly encouraging partnerships between researchers and managers, and where government agencies, pressured by conditionalites set by multilateral agencies, are issuing calls for projects for research teams to produce baseline studies for programs to be funded and/or to evaluate public policies already implemented. These requirements for more applied research, or research focused on responding to public health problems, raise new challenges for researchers and research institutes, and in this sense it is crucial to understand the issue's characteristics, as provided by the article.
The authors' focus on the field of health systems and services research is pertinent, since the use of research results by policy-makers is especially dear to this field. This multidisciplinary area combines applied research activities with the following characteristics: operational, action-linked, conducted with a view towards changes in health systems and services, and participatory, and should involve the actors related to a given research problem (policy-makers, service providers, users) 1,2,3. The health systems and services research area is developed with a view towards the production of knowledge that can provide the basis for decision-making processes. As such, the field developed in the context of this debate and gained important impetus in the 1980s and 90s with the market oriented health sector reforms aimed at cost containment, disseminated by multilateral agencies.
For health systems and services research, the issue of application of research results to policy implementation remains as an important challenge, with critical assessments that have failed to link research to policy 4. In this sense, I wish to highlight some important aspects approached by Almeida & Báscolo in order to understand this difficulty. The authors point appropriately to the lack of analytical and explanatory models for the relationship between knowledge production and public policies. They elucidate various intercepts and differences between these two distinct fields, and emphasize that in order to understand the influence (or lack thereof) of research in real-life cases it is necessary to analyze the differential dynamics of the complex processes of knowledge production and decision-making. It is necessary not only understand the limits of knowledge dissemination by the academic community but also the policy formulation and implementation processes. The authors thus highlight studies according to which it is indispensable to examine the political, social, and economic contexts, the research content, the actors and their interests and power resources, the decision-making arenas, and the policy negotiating processes. In addition, academics and researchers constitute one actor among others in policy-making, and traces of their activity can be found throughout the decision-making process, especially in the definition of alternatives, rather than setting the agenda itself 5.
Also important along this same line are the limits for possible use of research results in policies. Research results are important power resources, and their dissemination can help enhance the political debate by fostering a confrontation of ideas, proposals, and interests. The information can alter the terms of the debate and become an important power resource that changes the correlation of forces vying in the political arena (even though better debate does not necessarily result in more effective policies).
In my comments, besides highlighting crucial differences between research and policy-making processes and the fact that difficulties in the use of knowledge for policies are posed by the scientific production and decision-making processes themselves, I also wish to emphasize that science does not provide definitive or universally applicable answers, besides stressing the importance of discussing what constitutes evidence in public health policies. Although some authors emphasize the need to analyze power relations and shed light on the complexity of public policy decision-making processes, the intrinsic power relations and interests in knowledge production have received little attention. For example, multilateral agencies, the pharmaceutical industry, and other productive sectors in the health field both finance and encourage research output on given themes, and the results may or may not be disclosed, depending on the interests at stake. Although it may sound like a truism, it is important to recall that production of scientific knowledge is not neutral, and that faced with the same problem, different "evidence" can be produced, depending on the approach to the object, the research objectives, and the methods employed. Different concepts and values inform the generation of knowledge, while the process of transforming knowledge into evidence to inform decision-making is permeated by interpretations and value judgments 6. In the field of social public policies, the ideological disputes concerning the modalities of state intervention in the health sector, the concepts of citizenship, equity, and social justice determine choices, with crucial repercussions for guaranteeing the social right to health.
The theoretical reflection by Almeida & Báscolo is certain to shed light on this multifaceted debate and inform researchers and research institution leaders about key aspects in their interaction with financers who require that research projects include activities to increase the use of results in policies, as well as in building institutional strategies for knowledge transfer. Despite the gaps identified between the fields of knowledge production and decision-making and related obstacles, is it desirable for Brazil's research institutes in collective health to step up initiatives for knowledge transfer and more participatory research production, involving policymakers and managers. Such initiatives can influence the debate, expand the range of alternatives on the agenda, and contribute to the implementation of more effective public health policies, focused on the population's needs, helping reduce the deep inequalities in the use of services and in health conditions and ensuring the universal right to health in our country.
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