Yvo NuyensI; Mary Ann D LansangII,1
IUniversity of Leuven, Leuven, Belgium
IICollege of Medicine, University of the Philippines, Room 6, Dr Paz Mendoza Building, 547 P. Gil Street, Ermita, Manila 1000, Philippines
In their article in this issue, Lavis et al.1 propose a framework for assessing country-level efforts to link research to policy and action, with the goal of informing dialogue about various options, strategies and approaches. They do not aim to give a systematic review of past efforts, and therefore their article does not reflect the long-standing history of this important issue. It should be noted, however, that the question of dissemination, translation, utilization and implementation of knowledge in general and of research findings in particular has been placed high on both national and international agendas for more than two decades, notably by the Commission on Health Research for Development in 19902 and by international bodies including WHO, UNESCO, UNDP, the World Bank, the International Health Policy Program, the International Clinical Epidemiology Network, the Alliance for Health Policy and Systems Research and the Agency for Healthcare Research and Quality.
The International Conference on Health Research for Development held in 20003 concluded that, for health research to contribute effectively to equitable development, a national health research system with clearly defined goals and based on shared values is needed. Knowledge management, which includes knowledge production and utilization, was defined as one of the four major functions of such a system. Linking research to action and using knowledge for better health was also in the spotlight at the Ministerial Summit on Health Research held in Mexico City in 2004.4 This issue of the Bulletin situates itself within the same stream of debate, but has enlarged the scope from research utilization to the broader concept of knowledge translation.
We draw the following lessons from knowledge translation initiatives.
The systems context is paramount. Linking research to action (knowledge translation) is an essential component of the research process (or knowledge management system), and the construction, management and maintenance of this process are the raison d'etre of the national health research system. Any attempt to landscape knowledge translation at country level should therefore be defined, framed and developed within the context of the functions of an evolving national health research system.
Continuity is important. Past, current and future initiatives related to research and knowledge utilization have been trying to advise countries how to make better use of research in policy, practice and action. They have not always respected the limited critical mass and absorptive capacity in many low- and middle-income countries to undertake multiple and competing initiatives; more importantly, they have failed to build on existing efforts and to establish continuity and synergy among them.
Complexity should be considered. Knowledge translation and linking research to action should not be viewed as a homogeneous and static set of strategies and activities. To be effective, they have to be defined and adapted according to the specific layer of the health system (e.g. policy, service, clinical practice, community and individual), the expected aims or outcomes (e.g. raising awareness, formulating policies or practices, evaluating programmes and policies) and the envisaged strategy (e.g. evidence base, consensus/advocacy or conflict/confrontation).
All stakeholders should be involved. Based on positive experience in high-income countries, several commentators have proposed that knowledge translation can be successfully facilitated by a designated group of "knowledge brokers". While such a group may have a role to play, particularly in well-established institutions with sophisticated infrastructure and adequate resources, it is important not to lose sight of the fact that knowledge translation is an essential role for all stakeholders in the research process, and strategies should be developed to facilitate this.
Capacities are the weakest link. Most activities linking research to action or knowledge translation have focused mainly on advocacy and promotional aspects, and less on the specific competencies, skills and techniques required to carry them out. Existing capacity strengthening has generally been developed in support of either producer-push efforts or user-pull efforts. There is an urgent need for a more comprehensive approach to capacity strengthening, which takes account of the specific needs, skills and responsibilities of various stakeholders involved in knowledge translation efforts.
With the above lessons kept in mind, the article by Lavis et al. provides a starting point for assessing country-level efforts, based on a review of "what works", mainly from systematic reviews conducted in developed-country settings. It is a warning not to take elements piecemeal but to build up an incremental system of knowledge translation development. However, the framework needs actual testing, application and rigorous evaluation in low- and middle-income countries in the context of specific functions of the health and health research systems.
Web version only, available at: http://www.who.int/bulletin