DEBATE DEBATE

The authors reply

Los autores responden

Celia Almeida; Ernesto Báscolo

We wish to begin by thanking all the discussants for their comments, which stimulate our rethinking in various ways, since they have provided excellent contributions that enrich the debate. Some of the discussants have quite perceptively grasped our main concerns, emphasizing and summarizing the points that to us seem crucial to advancing this discussion. Thus, Raquel Abrantes Pêgo highlights the importance we ascribe to the relationship between the "experts" (in this case, the researchers) and the state, emphasizing its very historicity, in a specific context where research that was intended to contribute to the dynamic of reform processes has helped bring "rational-instrumental" criteria to prominence in policy-making. She also grants our questions relating to the capacity of the available analytical models to situate the complex relationship between knowledge production/use and decision-making in social relations. These processes of interaction among actors, and the links they produce, are never neutral and are situated in specific contexts, encouraging us to think critically about the instrumental legitimacy of professionals in relation to the play of interests [read "power game"] generated around a decision on policy formulation or implementation.

From this same perspective, Mario Hernández contributes further elements to the discussion, emphasizing the importance of an analysis of the political side of the two processes – the formation of scientific communities and knowledge production on the one hand and policy formulation and implementation on the other – and questioning the pretense of exerting an aseptic (non-ideological) influence based on scientific evidence.

Meanwhile James A. Trostle raises new questions, signaling that in our eagerness to review the various contributions from the literature, we have missed opportunities to compare the different approaches critically. He also questions our version of "the historical growth of political science theorizing", which at its origins led to a certain confusion (in the mid-20th century) between scientific research and operational perspectives, and to the differentiation between the roles of researchers and consultants.

In answer to Trostle, and granting that we may not have been totally clear, we emphasize that our thinking on the historical constitution of the political science field is endorsed by various authors, as signaled in the paper, and that it refers more to the initial structuring of political science as an autonomous discipline in the sphere of the social sciences. This is also linked historically to the emergence of professionals with different profiles, specialized in different activities. On the other hand, this reference is not a criticism of the field of operational research (or action-research), since we reiterate that the field of health policy and systems and services research was created a priori with an operational and instrumental outlook. However, we emphasize that the fact that research is operational or that its results are instrumental does not exempt it from developing a solid and consistent theoretical and analytical framework; and that likewise, good consultants should have a solid scientific grounding and field experience allowing them to quickly evaluate problematic situations and formulate proposals for effective intervention. In short, the critique is aimed at the simplistic instrumentalization with which these issues have often been treated, and the persistently false trade-off between the "scientific" and the "pragmatic" in these debates.

Quite correctly, Trostle encourages us to compare the different approaches reviewed in the current paper, for example those of Kirkhart, Patton, Forss, and Walt & Gilson. Admitting that Trostle is right, and accepting the challenge in his suggestion, we add the following comments. It appears to us that these authors' approaches converge in a critique of the linear, unidirectional, and merely instrumental perspectives on the use of research results in policymaking. However, while Walt & Gilson focus their discussion on the specifics of and differences between the two processes – knowledge production and decision making – without moving very far in elaborating categories to explain their interrelations, Kirkhart, Patton, and Forss advance in this direction based on the critique of the traditional concept of "use". Kirkhart focuses the discussion on studies to evaluate results, examining what is evaluated, who evaluates it, and the mechanisms that actually drive change. She sees the analysis as focusing on the impact of the evaluation and not specifically on the immediate use of its outputs. She thus proposes the category of "influence", referring to the "power" to stimulate behavior changes. Thinking along the same lines, Patton emphasizes the concept of "use" as "process" rather than "product", identifying "typologies of use", and the categories she proposes, although with different names, are close to Kirkhart's approach. Finally, Forss et al. expand on the previous proposal, identifying five typologies of process-related use.

In short, these authors' thinking is overlapping and complementary to some extent, since they all work with evaluations from the perspective of change (in policies and behaviors), and they do not appear to be competitive or antagonistic theoretical formulations, as claimed by Trostle. To the contrary, we believe that inter linking these approaches may make it possible to build a more promising perspective in explanatory and analytical terms. In this regard, the "consensus" that we refer to relates to the existence of various "barriers", identified by various authors in prior and preliminary investigations, while in our view the authors above attempt to move forward in analytical and explanatory terms. Finally, and still replying to Trostle, our reference to the designation of a single term in Spanish and Portuguese-speaking countries "política", which incorporates the two meanings, "politics" and "policy" aims to call attention to the fact that in some cases in our countries language can lead to confusion between politics (both with a capital P and petty politicking) and public policies, thereby casting discredit on the latter. This is because in recent decades the "technical" aspect has been revalued to the detriment of the "political" (considered negative), as if the two could be separated. In addition, as summarized well by Pêgo and also emphasized by Hernández, linking the policy dimension, i.e., policy content, to politics, or the struggle for resource distribution, allows one to understand that the configuration of a technical and political sphere in the State to respond for social policy, including health policy, is not independent of the various ideologies orienting social life or of the way decisions are made to allocate resources. In other words, instrumental (technical-scientific) legitimacy is not neutral, and neither are power mechanisms aseptic, and both are based not only on the workings of the market but also on the multiple links established in social relations.

In short, although the single term for "politics" and "policy" does not make it especially problematical to draw on the theories developed in the Anglo-Saxon world in Latin American national and regional analyses, we feel it is important to highlight the multiple meanings of "política" (as well as the links between the different meanings) and the importance of revitalizing it in Latin America from a positive perspective.

Michael Thiede complements our thinking by reminding us of something important that we neglected to discuss in this review: the importance of communication – in terms of both organizational relationships as well as the functions of language – as a fundamental and promising element in the construction of more effective models of interaction between researchers and policymakers, since research to policy transfer can even be interpreted as communication in its most basic sense. His comments also reinforce our opinion that the standardization of "products" and "formats" and the commodification of internationally streamlined research do not necessarily lead to building a more favorable environment for effective communication between researchers and policymakers.

Gabriel Carrasquilla, to a certain extent agree- ing with Thiede, also refers to the lack of "understanding" between researchers and policymakers, which he feels is mistakenly identified as mutual intellectual disdain. He also points to an issue that was neglected in our review: how to measure the use of research results in policy formulation and implementation. We obviously do not propose to reply to this question here, but with a view to stimulating further thinking, we emphasize that the available literature on innovation and technical development shows the difficulty of identifying what is innovation in the services sector, including health services, in addition to emphasizing the lack of effective indicators to identify such technological developments. Thus, this is a theoretical question that merits further exploration.

Vic Neufeld calls attention to other points not dealt with in the review: the existence of global experiences focused on overcoming the "know-do gap challenge", and the need to step up efforts to define "necessary research agendas", particularly related to the Latin American context. The information he adds on these endeavors by national and international institutions and organizations is particularly relevant for our thinking.

We identify the same concern in the comments by both Ligia Giovanella and Julio Suárez, with the latter presenting a list of interrelated dimensions that merit attention, shaping perhaps a first approximation to what Neufeld calls for as a regional research agenda.

Finally, Elsie LeFranc states that our review has not succeeded in achieving its objective or proving its critiques. With all due respect and thanking her for the opportunity for dialogue, we take the liberty of disagreeing with her opinion. Our review did not propose to elaborate new theoretical or methodological paths to overcome what we identify as deficiencies in the analytical approaches that we reviewed. However, although we agree that perhaps the comparison between the approaches could have been more emphatic and conclusive, as we have admitted previously, we believe that this paper does indeed provide elements that help to think about sounder analytical alternatives, by pursuing a political and institutional perspective, revaluing and recognizing the links at the social and organizational interfaces which sustain the power relations that permeate the processes of academic production and health policy formulation and implementation.

To conclude, and to reply to the last request by Trostle, the space reserved for this paper did not allow us to make much progress in analyzing empirical experiences, which are certainly present in the literature, although to a lesser extent. However, the five case studies published in this Supplement and the subsequent analyses are certainly a contribution and provide interesting elements in this direction. We thus recommend reading the rest of this issue of the journal.

Again, our warmest thanks to all those who have collaborated in this debate!