Processes and challenges of the interaction betweeen research and policy from the perspective of researchers

Abstract

Evidence-informed policies can produce social and economic impacts and equity and health benefits. Interaction between researchers in politics depends on the interests of social stakeholders and favorable political environments. This paper seeks to understand the meanings and researchers’ perspectives of interaction processes between scientists and decision-makers that would influence the research impact on the health policy. This is a qualitative content analysis study conducted in 2014 to identify the core meanings and relationships between research and politics. The paper builds on the RAPID program approach of the Overseas Development Institute. Fourteen researchers who conducted maternal and neonatal morbidity and mortality studies sponsored by the Health Ministry were interviewed. Researchers focused on the production of knowledge, strengthening of research capacities and dissemination of results. On some occasions, researchers also participated in the definition of clinical care policies and performance of health services. They pointed to barriers to interact and produce an impact on politics due to tensions in the political, economic and social context, as well as to institutional and organizational changes in the health sector and to the academic evaluation system.

Key words
Health research policy; Health research; Research utilization

Resumo

As políticas informadas por evidências podem produzir impactos sociais e econômicos e benefícios na equidade e na saúde. A interação dos pesquisadores na política depende de interesses dos atores sociais e de ambientes políticos favoráveis. Este artigo busca compreender os significados e as perspectivas de pesquisadores sobre os processos de interação entre cientistas e tomadores de decisão que influenciam o impacto da pesquisa na política de saúde. Trata-se de estudo qualitativo, realizado em 2014, de análise de conteúdo para identificar os núcleos de sentido e as relações entre a pesquisa e a política. Baseou-se na abordagem do programa RAPID da Overseas Development Institute. Foram entrevistados 14 pesquisadores de projetos sobre morbimortalidade materna e neonatal financiados pelo Ministério da Saúde. Os pesquisadores orientaram-se para a produção de conhecimentos, o fortalecimento de capacidades de pesquisa e a divulgação dos resultados. Participaram, em algumas ocasiões, da definição de políticas de cuidado clínico e desempenho dos serviços de saúde. Apontaram barreiras para interatuar e produzir impactos na política devido às tensões do contexto político, econômico e social, às mudanças institucionais e organizacionais no setor saúde, e ao sistema de avaliação acadêmica.

Palavras-chave
Política de pesquisa em saúde; Pesquisa em saúde; Utilização da pesquisa

Introduction

In the last decades, there has been growing recognition that policies and health systems management are best implemented in terms of their effectiveness, efficacy and performance insofar as policymakers and decision-makers seize evidence and experience validated by research results. Some health and research systems actively develop strategies to draw academia and recipients of research nearer in order to influence the proper use of their results to legitimize legislative norms and care networks policies, improve or transform clinical care and promote cultural changes in decision-making in the organization of health services. However, effective interaction and communication among social stakeholders for the utilization of research in politics continues to be one of the main challenges of national health research systems^1–3.

Studies on transfer of knowledge and interfaces between research and policy tend to emphasize the need to overcome barriers and generate favorable conditions to make the relationship between researchers and health policy formula- tors effective. These conditions would promote the appropriate participation and interaction of stakeholders in the elaboration and implementation of the research policy; the improved identification of knowledge gaps by research users; quality assurance of research results; the training of health professionals for research; the experience of researchers’ involvement at political and decision-making levels in politics; the demand for research by health policymakers; the improvement of synthesis mechanisms, dissemination and disclosure of results, institutional capacity and mechanisms for critical use by formulators and different audiences at national and local levels^4–6.

This paper seeks to understand the meanings and perspectives of researchers on the impact of research on politics and how they evaluate the processes and dynamics of interaction between scientists, decision-makers and professionals that influence the use of research results in the Brazilian health policy. This paper also points to opportunities and challenges perceived by the researchers for the greater involvement of academia in the development of policies.

Approaches that explore the practical implications of researchers’ work reveal complex interaction dynamics that refer to new organizational and interorganizational research schemes in universities and research institutions, to the sociopolitical environment, as well as new patterns of relationships and non-liner interactive processes influenced by values, expectations and interests of social stakeholders that constitute the context of the applications of knowledge to inform health policies and, consequently, the production of research impacts^7–9.

This study uses the integrative approach of the Research and Policy in Development program of the Overseas Development Institute (ODI-RAP- ID)^10–12, which proposes to understand the relationship between research, policy and health practice from the analysis of three aspects: a) The political and institutional contexts that influence the process of decision-making in diverse, broad and dynamic situations. In this aspect, it becomes fundamental to know the formal political and institutional structures, the relative power of institutions, the informal political culture, the interests of decision-makers and researchers, the structures and ideologies delimited by political changes, organizational and bureaucratic pressures and the implementation of the policy in the context of practice and decision-makers; b) The credibility and communication of evidence emphasizes elements such as research methodological matters, those responsible for conducting the research, the perception of reliable evidence, as well as the relevance of appropriate and adequate communication for decision-makers; c) The relationship between influence and legitimacy of researchers and decision-makers allows the identification of key players, the role of researchers and decision-makers in certain types of networks and the linkages of legitimacy that they develop in several policy areas as central elements to the influence of research on politics.

This approach is based on the assumption that research can contribute to informed decision-making insofar as it recognizes the political and institutional limits and the pressures on decision-makers and those exerted in their performance or the possibility of exerting the necessary pressure to challenge these limits in the interface between politics and research; the identification of shared networks between researchers and decision-makers and the development of networks of legitimacy in certain policy areas and the production of results from local involvement and reliable evidence, communicated in a more appropriate, timely manner and in a variety of formats, styles and channels.

Methods

This study is part of the research entitled “Impact of Research on Maternal and Neonatal Morbidity and Mortality funded by the Ministry of Health and institutional partners between 2002 and 2010 in Brazil”. The Research Ethics Committee of the Faculty of Health Sciences of the University of Brasilia approved the study on December 12, 2013.

This paper used a qualitative content analysis and thematic approach to identify the core meanings and relationships between research and policy assigned by research participants, according to the ODI-RAPID's aspects. We interviewed 14 of research coordinators who received funding on specific call for studies on maternal mortality and neonatal morbimortality in 2004¹³. All were invited by e-mail, up to three times, in August 2014. Twenty-five of them responded to the invitation, four of whom did not agree to participate and seven interviews did not take place due to operational reasons.

Respondents received the Informed Consent Form electronically. Interviews were conducted via Skype (http://www.skype.com) between September and October 2014, recorded with Pamela software for Skype 4.9 (http://www.pamela.biz) and transcribed for analysis. The mean interview time was 50 minutes. Topics covered were: 1) opinion on the impact of health research; 2) processes that favor or not the production of research impact on policy and informed decision-making; 3) strategies to promote the use of research results by policymakers and health programs; 4) role of researchers and university in the impact of research on health policy, 5) role of the Ministry of Health in the management of health research. Interviews’ excerpts were quoted, preserving the anonymity of respondents using the term “pesq” followed by the list number in the alphabetical order of respondents’ names. The preliminary results of this paper were published in minutes of an international event¹⁴.

Results

The perspective of researchers on the relationship between research, politics and health practice

Health research impact

Respondents’ statements revealed two central ideas about the impact of health research. The first one concerns the recognition of the social relevance of research impact evaluation. Thus, the “strategic importance of health in a country's development and economy” and the ways in which research influences “change in health indicators” and “social and economic well-being” were highlighted. The second points to the need to use research in “identifying clear evidence to guide public policy”, “improving health policy planning”, and “providing inputs for decision-making”. The following lines evidence this recognition:

The research begins to have a relative impact, maybe not so great, but a relative impact on the issue of changing health services. (pesq 2).

However, respondents mentioned hardships and frustrations in the “direct implementation of the research” and questioned the real possibilities of drawing academia and practice nearer, as is demonstrated in this statement:

It is frustrating […] since the purpose of research is social transformation through the implementation of these results. However, let me phrase this question: where have health and social welfare improved? (pesq 14).

Researchers’ experiences on research impacts on health policy and practice

In general, researchers revealed that their main activities are oriented to the production of knowledge, training postgraduate programs’ in research and dissemination of results, mainly scientific papers. These activities, in the opinion of researchers, require significant time of their work, which has contributed to the consolidation of their research groups. The professional master's degree, a modality oriented to the professionals of health secretariats, was recognized as a privileged space for the training of technical staff of national management and development of responses to the demands and interests of subnational health secretariats:

We have the professional master's that are requested by health institutions, state and municipal secretariats, and in these courses, students have the obligation to make their dissertation addressing a problem that is of interest to their institutions. (pesq 11).

Some of the researchers mentioned their participation in events for the communication of research results as an interaction experience. They see decision-makers and health professionals increasingly attending academic events. At the same time, they quoted the interest of health decision-makers at different management levels in organizing seminars and forums that generate opportunities for appropriation and exchange of research results on interventions for service improvement, as one of the respondents pointed out:

These results dissemination initiatives, in addition to publications, which is most commonly used by researchers […] holding seminars, calling in managers. (pesq 13).

When asked about their involvement and direct interaction in health policy, some researchers reported on their research experience in health services. The methodology of this type of investigation facilitated the use of results by state managers or directors of the health services where these studies were carried out. For example, one researcher reported the use of her study on childbirth care models with participation in obstetric nursing to support changes in clinical practice, investigation of fetal death and definition of public beds for normal delivery in municipal maternities.

University's influencing ways in politics and health practice

The perspective of approximation between academia and politics to generate impacts in politics and practice coexists with the critical view of most researchers on the effective role of university and researchers in the interaction and direct involvement with other social stakeholders, as the following lines showed:

I have been a teacher at this university for 27 years and try as I might this integration is not there. Academia and services remain distant. (pesq 14).

In every study, we argue that it is important to have information to subsidize the elaboration of public policies, but what happens concretely, at least for me, is that it is not so simple. (pesq 8).

According to some of the respondents, institutional incentives and evaluation criteria of researchers in universities - progression in the teaching career, granting of research funding, productivity grants, support for participation in events, among others - defined by university councils and governmental postgraduate and research agencies strongly influence the definition of their priorities and activities, which are geared towards academic recognition rather than engaging in political processes of research impacts. This speech illustrates the influence of agencies in defining their priorities from the perspective of researchers:

We want to enrich the curriculum to have career progression; the very CNPq [National Council for Scientific and Technological Development] wants this, and so does Capes [Coordination for the Improvement of Higher Education Personnel] for the progress of postgraduate courses; we want to publish the results of our studies in international journals […]. (pesq 11).

Aspects to understand the relationship between research, politics and practice

Political and institutional contexts that influence the impacts of research on decision-making

From the standpoint of researchers interviewed, the political decision-making processes are complex, slow and with rationales that are often perceived as hard to understand. Thus, they consider that involvement in settings of negotiation “mediation between knowledge and politics” requires the advice of expert technicians to facilitate dialogues and recommendations. As one of the researchers pointed out:

There has to be someone who can bridge this gap between academic knowledge and health policy … I believe they are two parallel traveling worlds. (pesq 8).

Thus, the experience of health management researchers and research formulators was pointed out by some of the respondents as a favorable element for the mutual interaction between academia and politics, as shown by the following lines:

I think some researchers have had experience in health care and, regarding formulators, managers as well. (pesq 9).

However, some of the researchers say that the will and the political interest of formulators and decision-makers, as well as the willingness to “share managerial power” become relevant elements for the promotion of spaces of cooperation between researchers and the institutional representation to generate policy impact. The statement of one of the respondents reveals this realm of power:

This policy formulation requires the manager to accept sharing his power, and I think that the Brazilian political situation does not favor this type of work… When talking about the researcher participating in the formulation of programs and policies, there is no space here, the politician does not want to share his own power. He wants to rule, he wants to exercise this prerogative he believes he has acquired in the election process, so he can read the work and one of his advisors may say: “I believe you should do this” However, the final decision is his: I don't see this kind of openness in the local context. In the national context, this is very rare, you know… This is not a space, politics on one side and science on the other, so there is really a divorce and there are no prospects, I don't see any good prospects at all. (pesq 2).

Another aspect mentioned by researchers was the organizational instability resulting from abrupt political and institutional changes at the various levels of management. They believe that this instability causes significant repercussions in the changing positions of local institutions’ management, which sets hurdles to the negotiation, the implementation of strategies and the continuity of actions for the improvement of programs. One of the respondents said:

We were in this process… and municipal secretariat and university managers were all favorable: we shall provide all the support […]; however, this did not happen […]. One of the great difficulties was that the municipal secretariat has an elevated staff turnover. (pesq 3).

According to researchers, monitoring these institutional dynamics to facilitate the use of the results would require efforts that due to their scarce availability of time, the increased participation in administrative activities, the lack of skills and experiences with the political process and the lack of interest of educational institutions end up limiting their engagement with politics. However, they pointed out the importance of promoting the institutional culture of informed decision-making for health in the academia and management.

Research credibility and communicating evidence

Researchers reported on the delay and resistance of formulators and managers and even labeled some directors of health services and professionals as “refractory” vis-à-vis the incorporation of evidence on efficient and effective practices in the management of the health system and new protocols, procedures and technologies that would result in improved clinical practice:

I believe that some research results managers take a while to absorb even if you demonstrate scientifically, especially in the evaluation of services, but results are not always applied in practice as desired […] they often take some time to reflect on their own practice for a behavioral change. (pesq 1).

However, one of the respondents considers that, from the perspective of managers, evidence has a relative, yet not absolute or independent role in the formulation and implementation of the policy, as observed in the following lines:

Health policy is done differently, not so much trusting in evidence and knowledge. So I think there is always some other information, because the manager is not only guided by evidence, since other things influence this decision-making process. However, definitely, looking at knowledge is fundamental […] both to decide based on this and even for us to justify a certain decision. (pesq 9).

The importance of researchers knowing daily life settings of health services was pointed out by some of the respondents as one of the strategies to get around these resistances. They believe that, as they approach the needs and demands of managers and users, appropriate research questions are developed and timely responses provided to problem solving:

We as researchers who are not part of that service, for example, it is difficult to study from the outside and to show a result and be incorporated; it does not depend, exactly, on our will. However, it is a good strategy for you to promote your research. (pesq 12).

The statements of some of the respondents mentioned a “significant gap” in the academia regarding the use of tools and development of appropriate skills for the dissemination and communication of research results and translation of knowledge to different audiences and objectives. Thus, they emphasized the need to encourage appropriate attitudes and strategies for the translation of knowledge geared to different publics, suggesting the promotion of scientific journalism as a responsibility of universities and that organization of events be incumbent on formulators, clinical directors and health professionals. Thus, they recognize the critical role of the media in ensuring broad coverage of results among health users and the public. One of the respondents pointed out:

I think that, first, there is lack of specialized journalism in health, in Brazil we still do not have it very well developed, and the second thing is the great difficulty of researchers in translating their results into a simpler language for society […]. (pesq 2).

The influence and legitimacy of researchers and decision-makers

Some researchers have recorded experiences of participation in national maternal health care policies decision-making settings. They argued that this participation stemmed from the academic legitimacy recognized by health authorities and at the same time revealed the influence of researchers in the power and political making relationships:

I am participating in a consultancy for the maternity quality assessment program linked to the release of additional funding for the institutions […] there is a great tension between researchers and the power of the Ministry of Health […] when you try to interfere a little more with technical arguments … for example, we proposed something to put in the evaluation and the National Council of Municipal Health Secretaries vetoed … that would require tinkering… with maternity directors. (pesq 2).

Strategic opportunities for the involvement of researchers in politics

Most of the respondents considered that continued political orientation and the role of the Ministry of Health in the management of the research system, initiated in 2004, with the definition of science, technology and innovation policy in health were fundamental. They highlighted the following strategies:

• The long-term continuity of the definition of research priorities at the national and state level, and optimization of processes of interaction with the health system and institutions in the perspective of the social and economic relevance of health science and technology policy. As one of the respondents pointed out:

  Why do we have to have an agenda? Why do we have to work with priorities? Because the volume of resources that we have is finite. Challenges are huge. In a country like Brazil, what is going to happen if we do not focus and start funding each one to do what he pleases? (pesq 6).

• Strengthening the PPSUS, a Research Program for the Unified Health System (SUS) - decentralized management, in order to improve access and adequate distribution of financial investments to respond to the needs and interests of health formulators, researchers and other social stakeholders in the states, as illustrated by two respondents:

  I think that the PPSUS was a great advance for people to be able to induce research that is applied in the states. (pesq 13).

  The PPSUS program is fantastic, because it really had the idea of bringing the services research closer together, and another very interesting thing was state decentralized financing, because in the old days … it was very hard for states with lesser research tradition to compete with national funding […] services agenda's priorities […] will be set from the manager's request […] and the scientific community responds. (pesq 2).

• The construction and strengthening of research networks and decision-makers for the implementation of strategic research and innovation programs; financing research in health systems and services; strengthening university research capacity and partnerships with industry, and the legitimacy of results and influence on state and local health policy.

• The wide participation of several social stakeholders in the process of managing research, monitoring and evaluation of the results of the call for proposals and research impact. The experience of the São Paulo State Committee of Science and Technology was quoted:

  There is a stage of formulating the public tender and monitoring the development of studies. I believe that if managers can follow up, they can sometimes adjust the research issues […] and when the final result of the project is at hand […] I believe that for managers it is necessary to think ways of disclosing [with] more accessible language, which do not overly emphasize methodological issues, but rather the application of results… in fact, the manager's confidence is boosted by believing in that result. (pesq 13).

• The communication of results according to specific contexts and priorities of the researchers and health decision-makers.

• Strengthening formal and informal spaces for dialogue and exchange between decision-makers and researchers to identify needs and solutions in the health system's governance and organization, conducting their own research, collaboration and interaction to produce policy impact.

Discussion and conclusions

Our findings show that researchers interviewed recognize the social relevance of the impact of research on politics with likely social and economic benefits in society. Priority activities of these researchers are oriented to the production of knowledge, to the strengthening of institutional research capacities and skills and the dissemination of the results through traditional channels (scientific papers and academic events). However, they value and participate in the spaces of knowledge translation for formulators and decision-makers of health and science and technology policy at national and state level, and contribute to the definition of policies and strategies oriented to clinical care, health system organization and performance, including at municipal and local management levels.

Our results are consistent with other studies on the translation of knowledge and the role of development agencies, producers and users of knowledge, research impact evaluation and the processes of direct interaction between researchers in politics. Authors demonstrate that, from the viewpoint of respondents, communication of results to managers, health professionals and public opinion; the incorporation of research into health policies; the contribution of research to solve health problems, improve conditions and strengthen management of the health system and services were less recognized issues vis-à-vis sustained funding, the capacity to produce valid results and publication of papers^15–17.

Research impact evaluation studies show empirical evidence, mainly in advancing knowledge (production of scientific papers, thesis, dissertations, abstracts published in annals of scientific events and showing results in various academic and decision-making forums) and building research capacity (master's and doctoral training, teacher career improvement); modest impact on management and clinical practice, and health interventions (elaboration of clinical protocols, educational materials, program development)^18–20.

In this study, motivations and interests expressed by respondents to participate in processes of direct interaction and mediation between academia and other social stakeholders in the use of research in politics coexist with the perspective of addressing and overcoming realities permeated by tensions mainly related to four issues.

The first one is about the national political, economic and social context, often perceived as unfavorable and unstable, influencing the engagement of researchers in the implementation of efficient and effective interventions in the public sector. Studies show that political settings may or may not favorably affect the use of research results in politics. Thus, other elements should be considered in order to balance political issues, such as credibility of academic leaderships, the establishment of research groups, health professionals associations, the role of networks of researchers and decision-makers at national, regional and even international levels, the emergence of health problems and the relationship with the international health agenda^8,21.

The second issue is related to time, efforts and resources demand to understand the dynamics and the national and subnational political processes involved in health policy. In the analysis of the implementation of a federal health policy, Vianna et al.²² concluded that policy institutionality requires decision-makers to understand the “difficulties in conducting the policy and support their internal and external legitimacy, institutional strengthening and continuity”. The participation of researchers will depend on the institutional commitment in decision-making processes, the intense articulation of the institution with key political players and bridging the gaps with social stakeholders for institutional cooperation.

The third question relates to the nature of institutional and organizational changes in health programs and services. Several authors point out that interaction with managers and health professionals can be effective insofar as researchers build strategic partnerships to promote access to adequate and quality research results; to recognize that results can inform them at different levels of intervention and offer elements to confirm, improve or transform their practice^23–25. However, managers and health professionals are not “passive” users of the research^9,23. Lemay & Sá⁹ point out that the use of results can be broader and more diverse than “reading scientific papers, using policies and discussing results among co-workers.” Thus, according to Figueiró et al.²³, the role of researchers increases insofar as they participate in the organizational procedures of implementing the policy to “operate as learning facilitators.”

The fourth issue reveals the implications of faculty assessment system and career development that may inhibit researcher activities in the utilization of research. Other studies record similar findings in developed and mature research systems, in which researchers realize that their efforts to produce policy impact are undervalued by universities or development agencies^2,25. Appropriate incentives for researchers including environments of reasonable approval of epistemological approaches and research methods, at least in the research process, and criteria for evaluating results consistent with the purposes of call for proposals can have lasting effects². Poliakoff & Webb²⁶ found that the prior experience of scientists in participating in public activities was the strongest predictor of their intention to remain engaged in politics. The perception of approval or disapproval of a particular group about political engagement, proper perception of the utilization of research, career recognition, and time and money constraints were not significantly predictive of researchers’ intentions to participate.

One of the limitations of this study is that the relationship between the research working area, academic production and interaction experience in the policy by the responding researchers has not been sufficiently studied. Authors demonstrate that researchers with higher academic production interact more with decision-makers by creating strategic opportunities for the utilization of research results^5,26. Another limitation was the exclusive interviews of researchers covered by this specific call for proposals. The perspectives and views of health and science and technology decision-makers responsible for fostering this call would have contributed to a better understanding of policy processes in the use of evidence in the implementation of health policy.

Acknowledgements

The authors are grateful for the contributions of the anonymous reviewers and the Foundation for Research Support of the Federal District, Brazil (Fundação de Apoio à Pesquisa do Distrito Federal, Brasil - support for participation in scientific events), which facilitated the dissemination of the results.

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Publication Dates

• Publication in this collection
  Jan 2018

History

• Received
  30 Jan 2017
• Reviewed
  25 July 2017
• Accepted
  15 Aug 2017