Linking researchers and policy-makers : some challenges and approaches

In developing a proposal for the study of the effect of user fees on access to preventive care, a team, comprising researchers and policy-makers, initiated interaction with key policy implementers in the Jamaica’s Ministry of Health to ensure that their perspectives were considered at the prelim-inary stage. There were many pressing events occupying the minds and energies of the implementers, but the team was able to capitalize on existing good relationships to capture attention. In the interviews that followed, agreement was reached on the necessity for the study, its focus and methodology. The process of consultation achieved notable successes and can be regarded as a model for successful research and policy interaction. Medical Fees; Research Personnel; Consultation Introduction This paper describes the process involved in the development of a proposal to study the impact of user fees on the uptake of preventive services in Jamaica. It is part of an initiative that is organized in two phases. The first involved the planning and development of a research protocol to be followed by the execution of the research tasks. In this paper, the interaction between researchers and policy-makers at the stages of research issue identification and formulation is examined. An important objective was to ensure that the perspectives of policy-makers were considered at this preliminary stage 1. Relevance, usefulness, and compatibility were critical considerations. Key policy personnel were interviewed to ascertain which information gaps needed to be filled, which research information would be most useful in policy-making, and the context within which policy decisions are made. This paper describes the interaction between the researchers and policy-makers at this first stage of defining the research study. The theoretical framework for evaluating research’s influence on policy Two principal frameworks are often used in evaluating research’s influence on policy. The first is the linear model, which looks for direct Cad. Saúde Pública, Rio de Janeiro, 22 Sup:S69-S76, 2006 Gordon-Strachan G et al. S70 Cad. Saúde Pública, Rio de Janeiro, 22 Sup:S69-S76, 2006 links between research and policy, and in this model the relationship may be knowledge-driven or problem-solving 2. The other school of thought holds that the impact is more diffuse; research results add to the knowledge base of policy-makers, and the new information percolates through the policy environment. This is described by Weiss as “enlightenment”, in which overlapping policy networks feed into a dynamic process of information exchange 2. This study sought to draw on both models; it was knowledge-driven in the sense that it sought to provide relevant information to policy-makers, and it also entailed an element of enlightenment as the issue of user fees in preventive care was introduced into the discussion to percolate, thereby preparing the pathway for receptivity to the new information in terms of impacts and possible options on user fees. Factors which determine the relationship between research and policy Several factors that facilitate the role of research in policy formulation have been reported in the literature 3,4. These include: (i) timing; (ii) identity of the researcher; (iii) the involvement of researchers in policy-making positions; (iv) communication; (v) perceptions of usefulness; (vi) good relationship between researchers and policy-makers; (vii) political feasibility; and (viii) political legitimacy. Recent assessments from Jamaica have also shown that where the research is well funded, the researchers recognized; where there is continuous dialogue between researchers and policymakers and a clear, precise language in communicating, the successful integration of research is more likely. Of particular value is the involvement of policymakers in the actual conduct of research. Policy-makers need the answers to questions that may seem straightforward until research is added to the mix. They ought to be involved at every stage, posing the questions and championing the results 5. Collaboration supplies policy-makers with the research-based evidence they need and puts researchers in the position to appreciate the needs of decision-makers. There are many instances of extremely successful collaboration between the Ministry of Health and the academic community in Jamaica, and there are several examples of research recommendations that have been translated into policy. The Maternal and Child Health Protocol and Policy document was derived from collaborative research involving the Ministry of Health and the University of the West Indies on maternal and child health 6. The policy on the clinical management of acute gastroenteritis using oral rehydration therapy was also based on collaborative research 7. Paradoxically, the introduction of a user fees policy was influenced by research recommending their implementation 8. In a sense, it is not meaningful in the Jamaican context to draw a hard line between researcher and policy-maker, since a few policy-makers have formal links with academic institutions. However, despite the relationship shared by some researchers with policy-makers, much of it is ad hoc and there is a need for stronger linkages. This study sought to build on previous successes, identifying promoting factors and using these to guide strategies for forging linkages and gaining acceptance and legitimacy for the study proposal. Principal challenges Identifying the objectives of study A study was needed to evaluate the impact of user fees on utilization of preventive care services and to prepare policy options for consideration by decision-makers. Within the Ministry of Health there are conflicting approaches to the issue; the technocrats composed primarily of persons with medical training, hold the view that user fees are barriers to the uptake of preventive care. The administrators on the other hand, are more concerned about covering costs and balancing the budget. They feel that user fees should be charged. The technocrats are forced to implement a policy that they feel is inimical to the interest of the poor but need hard evidence to support or disprove this position. The study was designed to fill the knowledge gap, that is, to examine the impact of the fees and to explore other options to user fees in preventive care. This paper describes the interaction between the researchers and policy-makers in the first and planning phase of the intervention. Interviews were held with policy-makers in key positions in the Ministry of Health and these interviews were designed as for bi-directional communication, mechanisms by which insights gained in the performance of their duties could refine or redirect the research problem.


Introduction
This paper describes the process involved in the development of a proposal to study the impact of user fees on the uptake of preventive services in Jamaica.It is part of an initiative that is organized in two phases.The first involved the planning and development of a research protocol to be followed by the execution of the research tasks.In this paper, the interaction between researchers and policy-makers at the stages of research issue identification and formulation is examined.An important objective was to ensure that the perspectives of policy-makers were considered at this preliminary stage 1 .Relevance, usefulness, and compatibility were critical considerations.Key policy personnel were interviewed to ascertain which information gaps needed to be filled, which research information would be most useful in policy-making, and the context within which policy decisions are made.This paper describes the interaction between the researchers and policy-makers at this first stage of defining the research study.
The theoretical framework for evaluating research's influence on policy S70 links between research and policy, and in this model the relationship may be knowledge-driven or problem-solving 2 .The other school of thought holds that the impact is more diffuse; research results add to the knowledge base of policy-makers, and the new information percolates through the policy environment.This is described by Weiss as "enlightenment", in which overlapping policy networks feed into a dynamic process of information exchange 2 .This study sought to draw on both models; it was knowledge-driven in the sense that it sought to provide relevant information to policy-makers, and it also entailed an element of enlightenment as the issue of user fees in preventive care was introduced into the discussion to percolate, thereby preparing the pathway for receptivity to the new information in terms of impacts and possible options on user fees.

Factors which determine the relationship between research and policy
Several factors that facilitate the role of research in policy formulation have been reported in the literature 3,4 .These include: (i) timing; (ii) identity of the researcher; (iii) the involvement of researchers in policy-making positions; (iv) communication; (v) perceptions of usefulness; (vi) good relationship between researchers and policy-makers; (vii) political feasibility; and (viii) political legitimacy.
Recent assessments from Jamaica have also shown that where the research is well funded, the researchers recognized; where there is continuous dialogue between researchers and policymakers and a clear, precise language in communicating, the successful integration of research is more likely.Of particular value is the involvement of policymakers in the actual conduct of research.Policy-makers need the answers to questions that may seem straightforward until research is added to the mix.They ought to be involved at every stage, posing the questions and championing the results 5 .Collaboration supplies policy-makers with the research-based evidence they need and puts researchers in the position to appreciate the needs of decision-makers.
There are many instances of extremely successful collaboration between the Ministry of Health and the academic community in Jamaica, and there are several examples of research recommendations that have been translated into policy.The Maternal and Child Health Protocol and Policy document was derived from collaborative research involving the Ministry of Health and the University of the West Indies on maternal and child health 6 .The policy on the clinical management of acute gastroenteritis using oral rehydration therapy was also based on collaborative research 7 .Paradoxically, the introduction of a user fees policy was influenced by research recommending their implementation 8 .In a sense, it is not meaningful in the Jamaican context to draw a hard line between researcher and policy-maker, since a few policy-makers have formal links with academic institutions.However, despite the relationship shared by some researchers with policy-makers, much of it is ad hoc and there is a need for stronger linkages.This study sought to build on previous successes, identifying promoting factors and using these to guide strategies for forging linkages and gaining acceptance and legitimacy for the study proposal.

Principal challenges
Identifying the objectives of study A study was needed to evaluate the impact of user fees on utilization of preventive care services and to prepare policy options for consideration by decision-makers.Within the Ministry of Health there are conflicting approaches to the issue; the technocrats composed primarily of persons with medical training, hold the view that user fees are barriers to the uptake of preventive care.The administrators on the other hand, are more concerned about covering costs and balancing the budget.They feel that user fees should be charged.The technocrats are forced to implement a policy that they feel is inimical to the interest of the poor but need hard evidence to support or disprove this position.The study was designed to fill the knowledge gap, that is, to examine the impact of the fees and to explore other options to user fees in preventive care.
This paper describes the interaction between the researchers and policy-makers in the first and planning phase of the intervention.Interviews were held with policy-makers in key positions in the Ministry of Health and these interviews were designed as for bi-directional communication, mechanisms by which insights gained in the performance of their duties could refine or redirect the research problem.

Timing of the issue
A number of factors in the current political environment meant that it was a propitious moment to raise the issue and seek to have it pri-Cad.Saúde Pública, Rio de Janeiro, 22 Sup:S69-S76, 2006 oritized on the policy agenda.There was an ongoing debate on the sustainability of health services and a fees committee had been established within the Ministry of Health with the mandate to examine the current fee structures and make recommendations.The issue of user fees was already on the agenda and there was a measure of readiness that was viewed as a strong promoting factor 9 .However, there were also some competing items that had to be taken into consideration.

• Macroeconomic and fiscal environment
Because of the unfavorable macroeconomic climate, the Government of Jamaica had to make concerted effort to generate higher revenue flows.At the end of March 2003, the total public sector debt was J$601.2 billion or 151.8 percent of GDP, representing an increase of 21% over the corresponding period for 2002 10 .The government was challenged to finance the budget.The 2003-2004 budget included a number of tax increases such as a 5% increase in the General Consumption Tax on telephone bills, and the imposition of a tax on all imports.The import tax was expected to generate the largest proportion of government revenue.All Ministries were made aware of the increasingly difficult economic situation that the government was facing and were encouraged to generate more income.

a) Pressure on Health Regions to charge and collect fees
Given the difficult economic environment, the Ministry of Health had to compete with the other economic demands of the Government and pressure was put on the Administrators of the four Regional Health Authorities in the island to improve collection.User fees account for 18-20% of the Health Regions' budget, while approximately 3% comes from primary care and preventive care services.While the percentage contributed by preventive services was small, persuading the Health Regions to agree that it might be in the interest of a vulnerable sector to give it up was seen as a formidable challenge.

b) Safety net reform
There were many in the society who did not benefit from social insurance coverage.In order to improve the lot of this group, improvement in the safety net measures were being considered.Safety net reform necessitated a narrow targeting of beneficiaries and the tai-

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loring of programs to specific risks.The Program for Advancement Through Health and Education (PATH) was first implemented in education, and its implementation in health and social services was being debated 11 .Improved targeting was to be achieved through a proxy means testing system, and those qualifying for exemption would not be required to pay user fees.The possibility was that this could have been used as an argument against the need for the removal of user fees for preventive care despite the difficulties of targeting, subjective assessment, and selection of beneficiaries.

c) Children's home report
There were items on the agenda that were also of great interest to the public.Shortly before the start of the interviews with key informants, a damning report on the status of state-run children's homes in Jamaica was published.Since these homes were the responsibility of the Ministry of Health, the capacity and efficiency of the Ministry were immediately called into question.In and out of the country's Parliament there were calls for the resignation of the Minister of Health and for a while a major portion of the Ministry's energy was directed towards damage control.

Strategy for getting the attention of policy-makers
There were thus a number of competing events, but the team was still able to hold interviews with key policy personnel.The main reason for this success was the ability to build on the existing good relationship between academic researchers and the Ministry of Health.There was no need to break out of the traditional mold of research and policy as two distinct entities with separate philosophical and ideological functions.A mixed research team was established comprising recognized university researchers and technical persons from the Ministry of Health who were also involved in research and who had easy access to policy-makers.The quality of the team ensured that the attention of the policy-makers was captured.

Selection and composition of the research team
As this was a scientific research project there was a need to ensure that the members of the study team did not have, or were not perceived to have, their own agenda.Researchers viewed as advocates with an agenda could impede the S72 research/policy links.Results had to be accepted as objectively produced scientific evidence.The study team was selected based on the criteria listed below.
• Criterion 1. Team should be lead by an independent researcher not affiliated with the Ministry of Health To encourage the acceptance and legitimacy, a Professor from the University's scientific academic community with an established and acknowledged research record was chosen as team leader.
• Criterion 2. The team should include personnel from the Ministry of Health whose work is used in informing the policy process.
To maintain balance and give information on the mechanics of the policy process, representatives from the Ministry of Health were selected to join the study team.The representatives were chosen primarily on their ability to provide technical input (Epidemiologist and Health Policy Analyst).In this case the Director of Health Research was included in the research team.The skill mix required for this research needed to reflect its cultural, geographic, social, economic, and medical components.Experts with these attributes were invited to be a part of the study.Researchers from the Ministry of Health were also required to possess technical and organizational assets.From the Ministry of Health, technical officers with requisite skills, who shared a good relationship with key policy-makers, and did not seem to be pushing an agenda were invited to join the study.The desire to use someone who would not be perceived as having a fixed agenda nevertheless had to be balanced against the need for Ministry project personnel with the ability to link the research to policy and move the process forward.Such a person therefore had to be either directly involved in policy formulation or have the ability to keep the item on the policy agenda.
In the end the study team comprised persons from the Ministry of Health, the Department of Geography and Geology, and the Sir Arthur Lewis Institute of Social and Economic Studies of the University of the West Indies.The team's competencies are as follows: Medical Geographer, Health Sociologist, Epidemiologist, Health Policy Analyst, and Health Economist.

Setting the frame of reference between researchers and policy-makers
During the first month the team met to determine the roles and responsibilities of each member, clarify administrative issues, and determine the framework for the development of the research as well as the activities to be conducted.The team decided that policy-makers should be made aware of the proposed research and have sufficient information about it to remove the possibility of misunderstandings.Moreover, they had to be given the opportunity at this early stage to discuss, contest, and where necessary, make suggestions for reframing the team's approach to the issue.These key individuals were seen as very important to the process, since it was felt that success was more likely if they were supportive and if they occupied positions that allowed them to harness the support of other significant parties 12 .Their perspective was sought on three main areas -whether a study of that nature was necessary and if it were, the area that should form the focus and the methodology believed to be most appropriate.
In addition, the team saw this as an opportunity to determine the likely members of an Advisory Committee for Phase II or the implementation phase of the project.

Activities
The team decided to interview at least 10 policy-makers and five implementers and that the following policymakers should be included: (i) the Minister of Health; (ii) the Permanent Secretary; (iii) the Chief Financial Officer; (iv) the Chief Medical Officer; (v) the Director of Family Health -for her views on immunization, family planning, and other maternal and child health services; (vi) the Director of Health Promotion and Protection -for her views on chronic diseases; and (vii) other members of the policy fraternity from the Regional Health Authorities such as Regional Directors and Regional Technical Directors.
The implementers should include: (i) at least one assessment officer; (ii) at least one cashier; (iii) a nurse working in a Type V clinic; and (iv) a doctor from a Type V Clinic.

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Gaining acceptance: initiation of contact -issues and challenges • Description of the process: the approach After the preparation of the questionnaire, the team decided that communication would be by both formal and informal mechanisms.Firstly, informal discussions were held with some key policy-makers to introduce the research initiative.A week after the informal discussions were held, formal letters were sent to the Permanent Secretary.
In arranging the interviews, team members attempted to speak directly with the interviewee, since this approach was seen to be more effective.Failing this, arrangements were made by telephone.A great deal of thought went into the protocol that ought to be adopted in approaching policy-makers, and the strategy finally adopted was to be as informal as possible.Interviewers approached each policy-maker/ implementer and explained that the team was preparing a proposal for funding and hoped to examine the impact of user fees on preventive services.During this initial contact, three clear messages were conveyed.The team was trying to satisfy the need for empirical evidence based on which to formulate policies.The outcome of the research depended on the quality of the protocol that was being developed, and they had the opportunity to inject what they saw as being relevant to a user fee policy.Their input was needed, valued, and important.

a) Challenges and strategies of this approach
The greatest challenge in this phase of initiating contact was in achieving access to the policy-maker.As stated earlier, direct contact was the method of choice.A strategy utilized was to capitalize on the presence of staff members from the Ministry of Health and assign them the responsibility for organizing the interviews.This met with a high level of success.Chance meetings (for example, in corridors and elevators) with high level persons (such as the Minister of Health) facilitated the arrangement of early appointments.The employment of interpersonal influence through social network is invaluable in moving the process along both at the initial stage as well as during the diffusion process 13,14 .Without this use of the more informal organizational culture there could be (and frequently were) several layers of interference that had to be overcome.For example, secretaries were often unable to arrange appoint-ments without first consulting the policymakers, and despite follow-up telephone calls, the process resulted in fruitless delays.Another challenge in initiating negotiations lay in finding the method for communicating the request for information from the policymakers that would ensure their ascription of relevance and legitimacy to the subject matter and the way it was being formulated.The problem was addressed by making the message explicit and phrasing it in language and concerns normally used and expressed by policy-makers.
• Description of the process: the interviews Each interviewer was briefed on the current fee structure, and the questionnaire included prompts to elucidate other relevant issues.A copy of published fees was also taken to each interview along with the study objectives.
For the most part, policy-makers and implementers interviewed were accommodating and made special efforts to schedule early interviews in view of our time constraints.One policy-maker did not want to be interviewed and said that he was weary of interviews, had already decided on the answer to the questions, and did not see the need to conduct a study.The interviews addressed the following questions: a) Was a study necessary?
All but two persons interviewed thought a study was necessary.The exceptions expressed the view that studies had already been done and that it was time to start implementing the results.

b) What should be the focus of the study?
The responses to this question varied, and they included: (i) user fees as a deterrent to seeking health care; (ii) new areas for revenue generation using user fees; (iii) how to improve assessment; and (iv) the short and long term impact of user fees on preventive care services in family planning, maternal and child health, immunization, and tuberculosis.

c) What methodology should the team use?
The most favored methodology was community-based surveys, followed by focus group discussions.Cohort and mystery clients were the third most selected methodology.A cross-sectional survey was not a popular choice.One policy-maker suggested that cohort studies were too long and too costly and that case-control was a better methodology.Another suggested that observational studies would be a useful way of determining deterrence.

d) Other issues to consider
Policy-makers introduced a number of other issues, either as areas that could profit from similar attention or as areas that could have a confounding effect on the outcome.They felt, for example, that some curative services such as elective surgery may be better able to demonstrate the impact of user fees on the exacerbation of untreated illnesses; that the burden on secondary care to generate income was too great and that perhaps the research effort should be broadened to include all service delivery points.Some also cautioned that care should be taken to separate the effects of user fees from the multiplicity of factors that influence access to preventive care.
The results were compiled, and the committee identified the main issues raised.Each issue was discussed to determine the extent to which it met the objectives.The committee's unanimous decision was that all suggestions by the policy-makers and implementers were covered in the objectives; that the issue of user fees as a deterrent to seeking health care was covered in the examination of impact; that new areas for revenue generation and methods to improve assessment would be analyzed when the team considers policy options and alternatives to the collection of user fees for preventive care services; and finally that the short and long term impact of user fees would be analyzed using economic models.
Feedback from the interviewees on the method that should be used was useful in devising a multiple method approach.The team realized that one method would not be sufficient to provide the range of answers sought.The decision was made to include communitybased surveys, focus group discussions, mystery clients, and a cohort study.In addition, expert informant interviews would also be conducted.
Though a cohort study was not the most commonly chosen methodology and one policymaker thought cohort studies were too long and too costly; the team decided that it would be used.The main reason lay in the strength of the methodology.It allows observation and measurement of health-seeking and coping skills as incidents occurred and decisions were made; events could therefore be captured in real time.It was also felt that the cohort could be followed beyond the lifetime of the project, and could continue to provide important information on coping strategies.

Successes
The process of consultation achieved a number of notable successes.By and large there was support for the research program.Moreover, the team had a promise of material support from the policy-makers if the study obtained approval.Policy-makers indicated that they were willing to commit funds as "in-kind" contributions.
There was evidence at this stage that in spite of the distractions, the team had, in fact, captured the attention of the top policy-makers.The Minister of Health asked the Principal Financial Officer to evaluate the cost of collection of user fees in primary care where the majority of preventive care services are delivered.The team saw a "push" of this kind at an early stage as an indication of the receptivity of an official at the highest level of decision-making.It was felt that this increased the chances of the eventual success of the intervention.
The factors that seemed to work in favor of bridging the policy/research linkages in this first phase are captioned below: • Research team selection: selecting key technical officers to be members of research and having members of the policy environment on the team.These people were not seen as pushing an agenda, as they are not directly responsible for policy formulation; • Setting the frame of reference before the research is agreed on: interviews with key policymakers and implementers to help determine what information would be useful served both to get support from the policymakers as well as to set the frame of reference for the research; • Communication strategies: informal discussion with policy-makers emphasizing the value of the policy-makers input.The fact that the team needed their input seemed to be appreciated by the policy-makers.One commented that this approach was valuable, as often research was conducted without consultation.Formal channels where appropriate were utilized.Direct contact was the preferred choice of communication; • Timing of issue: the team capitalized on the readiness of the social environment, as there was a current debate on the user fees policy.The issue was already on the agenda and promoted the process of linking the research/policy bridge; • Setting mutual trust and commitment: the team incorporated the comments of policymakers and implementers in the research protocol.The finalized protocol will be presented to the policy-makers for feedback.This should help to establish mutual trust and demonstrate the commitment of the research team to providing research data that bear relevance to policy.

Changes
In the second phase of the project the team was faced with a critical change in government policy.Because of the continuing resource problem, a new fee schedule was published just before the start of the project 15 .As a result, fees at public sector health facilities were increased as of January 2005.For example, the registration fee for adults in health centers, a fee that has to be paid at each visit, was doubled, and the fees attached to all services and materials increased.
There were also changes in the composition of the research team.The Health Economist resigned from his position in the Ministry of Health to take up a position in another Caribbean island.He thoroughly briefed his replacement before his departure.There were problems in coordinating the activities of researchers and policy-makers for which creative solutions had to be found and which raised questions as to the level in the organizational structure from which participants in the process should be drawn.

What constitutes useful research?
To address the usefulness of the research issue, the researchers went to the policy-makers to have them define what research would be useful to them.They were asked to identify gaps in information needed for policy formulation as well as to inform the researchers of what would be useful to them.This was done to ensure high political feasibility and acceptability for the issue.The team operated on the assumption that if the research is defined by the pol-icy-makers, then it should be politically feasible.However, there was recognition that political feasibility for an issue such as user fees is highly dependent on the economic context.At the time of dissemination of the research findings these contextual factors may change.
Usefulness on the part of the policy-makers was the provision of options.The researchers will use economic modeling to make projections in the long and short term of the policy options available.Policymakers were particularly impressed by this component of policy options analysis.

Machinery for moving research into policy: sustainability of the linkages
Despite the relationship shared by some researchers with policy-makers, there is still need for stronger linkages.An Essential National Health Research (ENHR) Survey found that fewer than 50% of research institutions thought the Government of Jamaica policy of importance in determining their research priorities 16 .The ENHR is a strategy to ensure that health priorities are defined in a participatory manner and that research findings inform policy formulation.The Commission on Health Research (COHRED) has described the elements for implementing ENHR strategies as: promotion and advocacy, creating an ENHR mechanism, priority setting, capacity building and strengthening, networking financing, and evaluation (Council on Health Research for Development) 17 .Rudimentary machinery via the adoption of the policies and strategies of the ENHR exists.However, this needs strengthening.
The project has the potential for remarkable success, since from its inception the policy-makers and researchers were involved.If it works, it will help strengthen the linkages between research and policy and could be regarded as a model for research and policy interaction.

• Criterion 3 .
Skill mix should be relevant to the research question.Researchers from the Ministry of Health should possess ability to facilitate the movement of research findings into policy