How can knowledge brokers help health systems learn from one another?
Every country in the world experiences challenges with its health system. No matter the strategy, the implementation seems expensive and imperfect. But at the same time, high quality healthcare is an extremely valued and often a core component of society — literally providing lifelines. The general push is to offer more services to a larger proportion of a population, paid for in such a way that getting sick does not push you into poverty. These are the core principles behind universal health coverage (UHC). All UN member states have agreed to pursue this. Exactly how to achieve it, however, is much less clear. Along the way, could countries could learn from each other?
Global trends have created unprecedented opportunities for this. The internet has made a wealth of information about experiences in other countries available. Theoretically there is no need to completely reinvent wheels or repeat mistakes. And yet, imagine you are a director of planning or a minister of health. How exactly would you go about doing this? With all their differences (one health system’s and another’s) and your busy schedule, how would you (a) find out which countries have relevant experience from which to learn, (b) learn it, and (c) work out how to act on it? Once you start to think about it, learning from another country is much more complicated than it initially seems.
For the past 18 months, I have been managing a project to understand how information about health systems experiences (both successes and failures) spreads between countries, with a focus on sub-Saharan Africa. We asked policy stakeholders (such as politicians, ministers, civil servants), academics (those researching health systems), and people working for international organisations (such as the World Bank, WHO, and bilateral donors) about their views and relevant experience on this topic. Conscious that we didn’t just want to hear a series of opinions, we complemented this with eight country case studies. We looked at actual long-term reforms, such as the Health Extension Programme in Ethiopia.
Overall, one of the stand out points has been that this is the perfect arena for knowledge brokerage.
What is knowledge brokerage, and why is it needed?
Knowledge brokerage is the process linking the producers and users of knowledge in a way that enables useful communication between the two – for example a scientist and a politician. The knowledge broker brings them together. Their job is to understand both the technical details of the knowledge being produced and the practical details of the questions being asked. They make the laboratory results relevant in the local context and ask the researcher to adjust their experiments to better match the questions.
This is not a new phenomenon, but it may be a service that is undersupplied. One study of seven African schools of public health found generally low self-reported capacity to communicate health systems research findings to diverse audiences (such as the media and general public), but higher confidence with regards to links with policy leaders. Only one out of the seven had a formal knowledge brokerage strategy. Another more recent study brought together two sides of the process. Separate surveys were sent to research institutions and ministries of health. The research institutions identified the lack of core funding, definitional clarity, and academic incentive structures as significant constraints. On the other side, the ministries of health identified a lack of locally relevant evidence, poor presentation of research findings, and low institutional prioritisation of evidence use as significant constraints to evidence uptake.
Knowledge brokerage can help bring these two worlds together. It is all the more important in the ‘learning from other countries’ process because here the producers and the users are one step further removed from each other.
Five knowledge brokerage activities to consider
- Rapid response: this is a near immediate response by a broker to a policy stakeholder’s question. We found that this is highly valued by the ‘decision maker’ category of policy stakeholder (i.e. politicians and ministers). Their interests may focus on very specific questions, and they are likely to be subject to strict time constraints for making a decision or providing a public statement. It is generally informed by the knowledge of the broker themselves – only requiring minor evidence review between question and answer.
- Evidence synthesis: if there is a bit more time, a few weeks can be spent compiling an answer. This variety of synthesis appears most appreciated by civil servants, who are looking to present recommendations to decision makers. It generally provides an account of the global evidence base and its relevance to a current policy concern. The Alliance for Health Policy and Systems Research have worked with various institutes around the world to help them develop this skill, and have published their general guidelines.
- Facilitation of policy dialogues: these are a means of gathering punctual, discreet advice from a trusted, respected source in a safe environment. Current or former stakeholders from other countries can share their personal experiences and lessons learned regarding policy success and failure, navigating the political arena, etc. Dialogues can also be coordinated between policy stakeholders within one country, to create space for internal co-digestion of information or knowledge sharing.
- Facilitating the use of existing platforms: knowledge brokers can act as a guide through the complexities of the available platforms that already exist to help countries learn from each other (global networks, databases etc.). We have counted at least 170 such platforms. Together they have the potential to be a great global resource, but understanding where to go for what has become a skill in itself, putting many busy policy stakeholders off.
- Health in Transition reports (HiTs): also known as Health System Reviews, HiTs are country-based reports providing a detailed description (with some analysis) of the health system and recent reforms. They are produced by academic and policy stakeholder country experts, based on a standardised template and can be a useful input for others to learn from your system. But they are also a baseline from which to compare your own system to theirs. Over the last 20 years a body of comparable information about health systems in Europe, Asia, and the Pacific has grown. Why aren’t they being done in sub-Saharan Africa?
Managing the link between evidence, policy, and implementation is a skill itself. For the researchers, decision makers, funders, and beneficiaries who want to see this done successfully, it is not just important for research to be of good quality. It must also ask the right questions and be presented to the right people, at the right time, in the right format, by the right people. The specific attention of knowledge brokers, through simple activities and services such as those described above, can help. This applies to all kinds of evidence to policy processes, but is especially true when one country embarks on the daunting task of trying to learn from another.
Alex Jones is a health economist and was project manager of Learning for Action Across Health Systems. The project was commissioned by the Bill & Melinda Gates Foundation and implemented by Oxford Policy Management. Its objective was to investigate how external funding agencies can help countries learn from one another as they build and strengthen their health systems.