Dr Julio Frenk is Dean of the Faculty at the Harvard School of Public Health and a professor of Public Health and International Development, a joint appointment with the Harvard Kennedy School of Government. He served as the Minister of Health of Mexico from 2000 to 2006.
In an effort to respond to this question, I found a commentary I wrote for a newsletter in 1995, in which I stated the following:
“It would be naive to assume that decision-makers always base their decisions on objective evidence about the best means to achieve the desired ends. Often, such evidence is not available. Even when it is, the decision-maker, particularly in the public sector, must balance off the weight of evidence against the economic and political feasibility of following the desired course of action. While it is clear that decisions are made on the basis of many other forces apart from scientific information, it is also true that good evidence can steer those who have the power to decide into a better course of action. In other words, the power of ideas can help to shape the ideas of power.”
We now know that most of the health gains achieved since the 20th century can be attributed to the advancement of knowledge, which improves health through three main mechanisms. First, knowledge gets translated into technologies, such as vaccines, drugs, and diagnostic methods. Increasingly, new technologies in the telecommunications field, such as mobile phones, are also having major impacts on the health of populations.
Second, knowledge is internalized by individuals, who use it to structure their everyday behaviour in key domains like personal hygiene, feeding habits, sexuality, and child-rearing practices.
Finally, knowledge becomes translated into evidence that provides a scientific foundation both for health care and for policy formulation, implementation and evaluation, the third and less known use of knowledge for health improvement.
The value of knowledge to guide decision-making is emphasized by the policy innovations that are being implemented worldwide in search for universal health coverage (UHC). Together with economic, political, and ideological reasons, this search has been fuelled by the need to find answers to a complex epidemiological transition that is imposing a triple burden of ill health on developing countries: the unfinished agenda of common infections, undernutrition and reproductive health problems; the emerging challenges represented by non-communicable diseases, mental disorders, and injuries; and finally, the health risks associated with globalization, including the threat of pandemics like AIDS and influenza and the health consequences of climate change.
The process of policy innovation needs to be illuminated by research. There are so many unanswered questions about health system performance that a research agenda must be embedded in every reform initiative. Actual implementation of reform is a fairly rare occurrence, so failing to learn from these experiences condemns us to rediscover at a great cost what is already known or to repeat past mistakes. I like to say that to reform it is necessary to inform, or else one is likely to deform.
The opportunities for research to play a key role in health system reform have been enhanced by the development of new policy tools to gather and analyze information and generate evidence, such as the burden of disease methodology, cost-effectiveness analysis, national health accounts, political mapping, and performance evaluation of health care institutions, among others. These tools give firmer bases for problem definition and for the design, adoption, implementation, and evaluation of policy options.
This type of effort requires a global approach. In fact, the development of improved policy tools is only one of the various challenges we must face in order to link global research to health system reform. We also need to build mechanisms to exchange information, evidence, and lessons. While every policy experience will have features related to its local context, they usually generate lessons for other countries. National health policy initiatives will have a higher likelihood of success if they can also build on the positive experiences made available through global mechanisms for shared learning.
Such mechanisms would help to overcome the false dilemma between national and global research. Defining a common agenda, designing and improving tools for analysis, building a common repository of documentation, and comparing experiences, are all essential to both the national and the global research efforts.
The path is clear: research and policy should walk together. Scientifically derived evidence must be the guiding light for programmes and policies in national governments, bilateral aid agencies, multilateral institutions and civil society organizations. When we can achieve this convergence, we will have at last integrated ideas and power.