DEBATE DEBATE

Debate on the paper by Celia Almeida & Ernesto Báscolo

Debate sobre el artículo de Celia Almeida & Ernesto Báscolo

Julio Suárez

Organização Pan-Americana da Saúde/Organização Mundial da Saúde, Brasilia, Brasil. suarezj@bra.ops-oms.org

This is an excellent theoretical review article on a relevant theme for those who work, study, and generally accompany the relations between health policies and research.

The article approaches health policies from a historical perspective in the field of social sciences. The analysis of health policies with theoretical and methodological frameworks from the social and political sciences allows a better approach to the relations between research/knowledge and policies/decisions in health.

The initial hypothesis poses a truly crucial issue. More than a search for straight paths and instruments to link research and policies, we need references to organize, facilitate, and enhance the analysis and explanations of relations between the two.

The authors structure the discussion around four related topics: analytical models on use of research in policies, the use of results in health policies, interaction between researchers and decision-makers, and health policies based on information, knowledge, and evidence. Based on a critical review of the specialized literature, they highlight that the fields of knowledge production and policy formulation and implementation are very different. Macro themes like public policies and health systems and services management and their relations with knowledge and research and their methodological and analytical models are discussed as a function of enriching the debate and encourage the two "strategic partners" (researchers and health managers) to enhance and upgrade their relations. They confirm their initial premise concerning the simplification and excessive formalism and pragmatism with which the theme has been treated, while noting some advances.

I will now present some comments based on my reading of the paper, thanking the authors and editors for the opportunity to share some ideas on the subject.

The scientific approach breaks down and simplifies reality in order to understand it better and "technically grasp" the object of study. This simplification always entails a tension with the full nature of reality, in a kind of "tradeoff" in which one gains specificity while losing comprehensiveness. The dialogues between production of scientific knowledge and public health policy formulation and implementation is a living process in which both parties constantly interact and exchange/change dialectically within a movement that includes other decisive variables for the outcome of this dialogue.

The health decision-making process is characterized, among other things, by its complex sectoral and inter-sectoral nature. Health research is called on to accompany this complexity, with an emphasis on improving health systems and policies. The political process is not linear or mechanical. As shown in this article, "political logic" and "research logic" are not the same. There are parabolic and crooked paths between "evidence" and "decisions". More than a cause-and-effect relationship, one observes a complex and dynamic web of factors associated with a society's or community's values, power dynamics, historical experience, political and institutional culture, greater or lesser social participation, and even the policymakers' intuition, a game in which so-called "scientific evidence" is merely a part (and not always the most important one) in the outcome of the social policy formulation and implementation process.

Ideally there would be cross-fertilization between fields of knowledge to enhance explanations and solutions for problems and challenges in a highly complex reality that we break down scientifically to understand better and propose changes in order to reach new objectives.

From the perspective of defending the right to health and building citizenship in health, the most important guidelines in our health work, I take the liberty of proposing some priority issues and challenges.

With progress in democratic processes and decentralization (for example, in Brazil), the number of decision-makers and participants in decision-making processes has multiplied exponentially. Public policies in health are formulated in local, regional, and national spaces. In addition to the "formal" policy-makers and managers, citizens are exercising social control and participating increasingly in policy formulation and implementation. Furthermore, the community, families, and individuals make greater or lesser health-related decisions every day. The number of health research users thus grows and diversifies, with different and changing realities, with varied and legitimate needs that should be contemplated in the debate on the relationship between research/knowledge and policies/decisions in health.

With the objective of calling the attention of researchers and managers, I propose to focus efforts on four interdependent and interacting dimensions, recognizing that other approaches are possible:

1) Values and principles: equity, universality, comprehensiveness, participation;

2) Health system organization: decentralization, regionalization, segmentation/ fragmentation, conduction, and management;

3) Strategic actions: essential public health functions (EPHF) ¹ as proposed by PAHO, a health care model based on primary health care ², prioritized programs;

4) Strategic components: financing, human resources, drugs, and health technologies.

A cross-approach among these dimensions by the research, from the perspective of the social and health sciences, should provide new and better arguments for achieving objectives in terms of values and strategies, in concrete realities, and with viable solutions.

To conclude my comments, I return to the authors' central thesis. The important factor for improving public policy formulation and implementation in health is the development of explanatory frameworks fed by evidence and research results, accumulated information and knowledge, ideas and interests of various authors, political and economic experiences, and general cultural inputs from each context. To feed and enrich this framework, research is called on to play a central role: research to generate new knowledge on the relations between the proposed dimensions, thereby enriching the framework for policy analysis, and research to promote the incorporation of the analytical framework into the culture of decentralized health management.

1. Organización Panamericana de la Salud. Salud pública en las Américas. Washington DC: Organización Panamericana de la Salud; 2002.

2. Pan-American Health Organization. Renewing primary health care in the Americas. A position paper of the Pan-American Health Organization/WHO. Washington DC: Pan-American Health Organization; 2005.