Bridging The “Know–Do” Gap Meeting On Knowledge .
WHO/EIP/KMS/2006.2Bridging the “Know–Do” GapMeeting on Knowledge Translation in Global Health10–12 October 2005World Health OrganizationGeneva, SwitzerlandOrganized by the Departments of:Knowledge Management and Sharing (KMS)Research Policy and Cooperation (RPC)World Health OrganizationWith support from:The Canadian Coalition for Global Health ResearchCanadian International Development AgencyGerman Agency for Technical Cooperation (GTZ)WHO Special Programme on Research & Training in Tropical Diseases
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Main Messages Bridging the know–do gap is one of the most imppportant challenges for public health in this century.It also poses the greatest opportunity for strengtheniping health systems and ultimately achieving equity inglobal health. Knowledge translation (KT) is emerging as a paradpdigm to learn and act towards closing the gap. Whileknowledge is more than research evidence, knowledgetranslation strategies can harness the power of scientificevidence and leadership to inform and transform policyand practice. There are pioneering efforts as well as exciting newinitiatives in various developed and developing countptries with respect to knowledge translation. Countries(policy-makers, health workers, researchers and thecommunity) can work together and share experiencesand lessons in bridging the gap. Although there are ongoing innovations and learningby doing, there is still no comprehensive framework orcommon platform for better understanding the know–do gap and systems to address it. WHO has a major role to play in bridging the know–do gap and supporting countries through better knowlepedge management. Given the breadth and scope of thisgreat challenge, WHO should focus on the following:strategic advocacy for KT; platforms for knowledge excpchange and sharing among countries and within WHO;resource mobilization; support country initiatives onKT strategies for health systems strengthening. For countries and the global community alike, someinitial recommendations for action are: capacity developopment for KT, focusing on knowledge exchange anddemand-side awareness-building; joint learning platfpforms for KT; research on improved methodologies forknowledge synthesis and exchange, and best practiceson KT; KT-sensitive peer review and funding systems.“There is a gap between today’s scientific advances andtheir application: between what we know and what isactually being done.”“Health work teaches us with great rigour that actionwithout knowledge is wasted effort, just as knowledgewithout action is a wasted resource.”LEE Jong-wookWHO Director-General1Background and MeetingObjectivesIn setting the tone for the meeting, Tim Evans, WHO’sAssistant Director-General, Evidence and Informationfor Policy, described the very complex health developmpment landscape and the “grand challenges” of improviping health systems in terms of scale, distribution andequity, protection and safety, and systems capabilities.He underscored the importance of harnessing knowlepedge to overcome health system constraints and to scaleup effective interventions, echoing the call to action embpbodied in the Mexico Statement on Health Research.1Ariel Pablos, director of the WHO Department ofKnowledge Management and Sharing, discussed thechallenge of the “know–do” gap and the opportunitiesto address it. Two aspppects of the know–do“ despite 30 years ofgap were outlined:research in this area, we stillthe gap from researchlack a robust, generalisable eviito policy, and the gapidence base to inform decisionfrom knowledge to actpabout strategies to promote thetion. Early efforts tointroduction of guidelines orbridge the know–doother evidence-based measuresgap in public healthinto practice.”were largely passive,Grimshaw et al. 2004focused on diffusionthrough journals. These evolved over the next two decpcades to “push” strategies in the form of knowledge disspsemination and guidelines. Currently, partner and “pull”efforts have emerged, such as linkage and exchange procpcesses. WHO has developed a knowledge managementstrategy that explicitly considers translating knowledgeinto policy and action.Declaration made during the Ministerial Summit on Health Research, held in Mexico, 16–20 November 2004.Bridging the “Know–Do” Gap
Knowledge Translation is defined as the “The synthesis,exchange and application of knowledge by relevant stakeholdeiers to accelerate the benefits of global and local innovation instrengthening health systems and improving people’s health”(derived from the Canadian Institutes for Health Respsearch, 2001). Despite these developments towardsactive engagement of stakeholders in KT, many challplenges remain. But the time is ripe to seize the opportunpnities for knowledge translation and make a real differepence in solving global health problems and achievingbetter health. Hence the meeting on “KnowledgeTranslation for Global Health” was convened with thefollowing objectives:1) To learn from country experiences in bridging theknow-do gap and to develop a typology of knowledgetranslation approaches in countries;2) To clarify knowledge translation concepts and framewpworks, and to identify effective and feasible practicesand approaches; and3) To identify priorities and mechanisms for knowledgetranslation research and action in global health.Evidence and Knowledge: TheirRoles in Guiding Policy and PracticeA full day was devoted to clarifying KT concepts andframeworks and identifying good approaches and practptices. This started out with Jonathan Lomas provocativepresentation on “What is Evidence.” Lomas distingpguished two concepts of evidence for guidance for thehealth system: (1) “Colloquial” evidence, which represpsents relevant information at a more personal and contptextual level, e.g. experiential knowledge, societal valupues, political judgment, resources, habits and tradition;and (2) scientific evidence, which is derived from systemapatic, replicable and verifiable methods of collecting infpformation and facts. Scientific evidence, he said, couldbe further categorized into context-free or context-sensitiveevidence. The former ascribes to science “a sense of abspsolute truth” and is largely generalisable. Context-sensitptive evidence, on the other hand, adopts a practical andoperational orientation and considers the context in theguidance and the decision-making process. In additionto the different types of evidence that are considered inhealth system guidance, there is a need for transparentdeliberative processes that explicitly integrate technicalanalysis of the evidence with stakeholder and lay publplic deliberation to make the final guidance feasible andimplementable. “Deliberative processes are not neutralin their design,” said Lomas. “Some will favour oneform of scientific evidence over another, others willfavour colloquial evidence over scientific evidence orvice-versa.”In contrast to Lomas, Andy Oxman contended that “allevidence is context sensitive” since all observations are made in a specific context. On the other hand, judgmpments about the applicability of evidence go beyond theoriginal context and should be made systematically andexplicitly using good evidence, especially (but not excpclusively) research evidence. He delineated the roles ofglobal evidence and local evidence, stressing that whileglobal evidence is useful for making judgments abouteffects and likely modifying factors, local evidence isnecessary to make context-specific judgments, includiping the presence of modifying factors, the extent of theproblem, availability of resources and prevailing values.Thus he proposed that WHO should focus on supportiping countries to make context-specific policies by provpviding global evidence, frameworks for decisions andpractical advice for incorporating local evidence.Mary Ann Lansang referred back to the WHO/EIPgoal of global health equity in considering the role ofevidence in policy and practice. Given this goal, thetremendous challenges and needs of developing countptries, and the problem-based and value-driven nature ofpolicy-making, she supported the view that evidence iscontext-sensitive. However, for developing countries,the essential qualities of useful evidence for policy-makiping are often absent, i.e. available research evidence andother information may not be credible (invalid or unreliapable), accessible or affordable, and it may be irrelevantto the needs of a specific country and hence not apppplicable. At the same time, there are unique challengeson the policy-making side, such as lack of demand forevidence, corruption, rapid turnover of policy-makers,traditional and top-down governance processes, and donpnor dependence.In the discussion that ensued, most meeting participantsagreed that evidence is context sensitive, in varying degpgrees, and that policies and decisions should be informedby good evidence that is contextualized. This impliesthat evidence is plural and that the implementabilityof good “global” evidence must be triangulated withlocal knowledge. Hence a key action point for WHOand countries is to ensure that the evidence base fromcountries is strengthened and built up, and that transppparent and evidence-informed policy-making processesare promoted.Country Knowledge at WorkRecognizing that the experiences and efforts of countptries to bridge the know–do gap are valuable in developoping improved approaches for knowledge translation,a variety of initiatives and programmes at work or inprogress in different countries were presented and discpcussed. The experiences from developed countries(EURO Health Evidence Network and Canada) anddeveloping countries (multi-country studies on evidence– policy linkages, experiences and new initiatives in eastAfrica, Brazil, Bangladesh and Afghanistan, China andBridging the “Know–Do” Gap
Mali) demonstrated that there are exciting innovationsin push, pull and exchange systems to address gaps inresearch-policy-practice in a variety of settings. At thesame time, lessons learned from these concrete countryand community experiences underscore the importanceof continuous monitoring and evaluation of proposedapproaches to bridging the know–do gap (see Table 1).“What factors explain whether and how the producepers and users of research support the use of and/or usehealth research as inputs to decision-making?” asked Tikkkki Pang. He then presented the ongoing WHO collaboratptive work with 10 developing countries, which attemptto help answer this question.2 This research has identifpfied several “push” factors (such as a tailored approachto target audiences, credible messengers/brokers), “pull”factors (notably access to searchable databases), and excpchange/linkage activities (e.g. long-term partnerships).There has also been interest in the launch this yearof the Evidence-informed Policy Networks initiative(EVIPNet), which aims to support health decision-makiping and health policy formulation through better accessto evidence, the promotion of linkages among producepers and users of research and capacity building. The initptiative has started with proposals developed in Asia butthe networks will be extended to Africa in 2006. In closiping, Dr Pang suggested that EVIPNet could become thevehicle for an integrated approach by WHO (throughRPC, KMS and the Health Metrics Network) in its supppport to countries that are trying to address the know–dogap through improved health policy and action.Don de Savigny talked about the development of the Regpgional East African Community Health Policy Initiative(REACH Policy), an innovative mechanism to institutptionalize knowledge brokerage in order to access, syntpthesise, package and communicate evidence for policyand practice in East Africa. A joint prospectus fromhealth policy-makers and researchers in Kenya, Ugandaand the United Republic of Tanzania was developedthrough a series of national and regional consultations,workshops and case studies dating back to 2001 andendorsed by the East African Sectoral Council of Minipisters of Health in July 2005. The prospectus is beingfinalized for a donor’s meeting in January 2006 and thelegal framework is under development.The experiences of BRAC (Bangladesh Rural Advancempment Committee) were presented by Mushtaque Chowdhkhury specifically the successful adaptation of the BRACmodel from Bangladesh to Afghanistan. Grounded onvillage organization as the building block, programmesin health, education, microfinance, agriculture, nationalsolidarity and capacity development were initiated inAfghanistan in 2002 and have already been scaled up tocover 18 of 34 provinces in the country. The BRAC expp23perience demonstrated that experiential knowledge onpoverty alleviation programmes, coupled with good systptems management and built-in research and evaluation,can be shared, translated and successfully scaled up.Ramesh Shademani presented the work of the HealthEvidence Network (HEN)3. HEN is a network of 35China, Ghana, India, Iran, Kazakhstan, Lao PDR, Mexico, Pakistan, Senegal.HEN website: www.euro.who.int/henBridging the “Know–Do” Gap
Table 1 – Examples of Country and Regional Experiences and Plans for Knowledge TranslationCountry/RegionWHO/RPC-sponsored initiatives:(1) 10-country study on research –policy linkages;(2) EVIPNet (Asia)KT ObjectivesKT Lessons(1) To determine the factors influencingwhether and how health research is usedfor decision-making;(2) To support health policy formulationthrough improved access to evidence,policy–researcher linkages and trainingIndigenous research evidence is morelikely to influence practice. Increasedaccess to evidence and increasedinvestment in capacity developmentfor KT are needed.REACH Policy Initiative,East AfricaTo access, synthesise, package &communicate evidence for policy &practice and for policy-relevant researchagendaA proposed institutional mechanismfor KT through knowledgebrokerage was developed throughcountry-wide and regionalconsultations and workshops.BRAC, BangladeshTo translate the development knowledgefrom the Bangladesh experience toprogrammes and action in AfghanistanDevelopment knowledge can besuccessfully shared, adapted andscaled up, using village organizationas the nucleus of the intervention.Health Evidence Network,To answer questions from policy-makersEuropeand to provide easy access to evidenceDemand-driven evidence seems towork. It takes time, money and awide collaboration of partners to gettimely answers to policy makerquestions.Rural Internship onCollective Health,Estado de Minas Gerais, BrazilTo integrate scientific evidence, local tacitknowledge and the capacity to implementpolicies through social participation inlocal health systems.Dissemination and sharing ofuser-friendly information andknowledge promotes socialparticipation in local health systemsplanning and management.Efforts to link researchto action in CanadaTo link research to action, with a focuson healthcare management andpolicy-makingA framework to assess countryefforts on KT emerged (see boxeditem) and will continue to evolvewith further dialogue. Several push,pull and exchange strategies are inuse in Canada, but large-scale KTplatforms are lacking.Use of knowledge inTo use knowledge for refining approachessupport of healthand solving problems related to healthsector reform, Malisector reformPolitical commitment and managers”experiential knowledge were keyfactors in the formulation andimplementation of the health sectorreform policy in Mali. Researchevidence has contributed to therefinement, further planning andsystematic documentation andexchange of experiences and alsoserved to “contain donorimpatience”.Knowledge managementin ChinaStill at the planning stage. Capacitybuilding of all stakeholders onknowledge management and sharingis recognized as a major challenge.To establish an efficient system for thecapture and use of pro-poor evidence forhealth policy-making in China Bridging the “Know–Do” Gap
European government agencies and other public institutptions as well as health-related UN agencies that collaborprate to answer questions from European policy-makersand to provide easy access to the best available evidencefor improving public health. This is achieved throughthe following avenues: 10-page synthesis reports and 1page summaries in response to questions raised, a rapidresponse HEN e-mail box, and selected policy-relevantdocuments and databases on the HEN website. Therehas been increasing demand from policy-makers overtime, with one new synthesis produced per month, onenew summary from HEN partners per month, and aboutthree responses from the HEN e-mail box each week.The HEN experience shows that evidence tailored tosuit policy-maker’s specific concerns and timing is aneffective KT strategy.Francisco Panadés Rubió and Ulysses Panisset presentedthe experiences and lessons learned in managing andutilizing local knowledge through social participation,as demonstrated in the Rural Internship on Collectptive Health programme in the state of Minas Gerais,Brazil. It was noted that local decision-makers had noexperience in working with evidence and technicalinformation. However, a two-way interactive processfor learning was developed involving decision-makers,health practitioners, the communities as well as federapal, local and state funders. Information technology respsources, in addition to human resources, were deemedto be essential tools for social production, sharing anduse of knowledge.John Lavis provided a useful framework for assessiping country-level efforts to link research to action (seeBox 1), applying it specifically to Canada. He cited theCHSRF and the Canadian Institutes of Health (CIHR)as examples of institutions established in recent yearswith explicit mandates to support knowledge translationas well as excellence in research. Regarding models forlinking research to action, several push efforts in Canadasupportive of knowledge translation were: identificationof actionable messages tailored to user groups, crediblemessengers, media releases for systematic reviews. Exapamples of pull efforts were: use of the Cochrane Libraryby provincial governments, maintenance of a one-stopshopping for evidence at the Canadian Cochrane Netwpwork and Centre, a policy-maker-targeted response unitfor health technology assessment, and continuing educpcation programmes for health programme managers. Interms of exchange efforts, partnerships have been developoped in response to requirements by funding agencieslike CHSRF and CIHR for linking research to action.Despite Canada’s many efforts on KT, it was observedthat there are still gaps, notably the lack of large-scaleKT platforms to facilitate exchange efforts.Fatoumata Nafo-Traoré discussed a policy maker’sview of the role of research evidence in the health sectptor reform movement in Mali. Although in the initialstages, policy formulation for health reform was mainlybased on experientialknowledge of the factp“Policy-makers often regardtors contributing to“research” as the opposite ofthe crisis in Mali, Dr“action” rather than the oppiNafo said that thereposite of “ignorance””.was increasing use ofMartin Surrresearch evidence duriping the scale up of health programmes, particularly onhealth service delivery models, simulation models forsustainability, systematic documentation of process andBox 1 – General Framework for Assessing Efforts to Link Research to ActionJohn N. Lavis – McMaster University, CanadaAssess elements, programmes, processes or activities that are supportive or unsupportive(gaps) of efforts to link research to action in terms of: The general climate for linking research to action: What elements or actions support efforts to link research to action?What is not being done? What more can be done? Production of research: What elements or actions support efforts toundertake systematic reviews that are responsive to needs of policy-makers and other stakeholders? What are the gaps?What more can be done? Mix of models to link research to action: What approaches have been used to link research to action in a given settingand for different user groups? Is there an optimal mix of models? What more can be done?- Producer/purveyor-push efforts- User-pull efforts- Exchange efforts Approach to evaluation: Are there rigorous evaluations of efforts to link research to action?Bridging the “Know–Do” Gap
Box 2 – Enabling and Constraining Factors in Translating Knowledge to Policy and PracticeBreak-out Group OutputsEnabling FactorsBarriersPush factors (supply side)Push factors (supply side) Production of relevant and good evidence Timely and understandable repackagingand synthesis of the evidence; evidence-basedactionable messages (EBAMs) Credible knowledge mediators/brokers/messengers, opinion leaders Availability of and access to knowledge Knowledge mapping Donor/funding agencies” support for KT Lack of a common framework for knowledge translation Limited integration of quantitative and qualitativemethods for synthesis of evidence Costly and slow process of knowledge production andsynthesis Lack of and poor access to relevant evidence Competing sources of knowledge that may be distortedand biased Donor-driven research agendaPull factors (demand side)Pull factors (demand side) Political commitment and local knowledge champions Political mapping and understanding of thesocio-political environment Problem-based evidence and user-initiatedpolicy questions Integration of social actors in localdecision-making bodies (social participation) User-friendly access to knowledge andsearchable databases Low demand for scientific evidence by policy-makers Different paradigms for evidence and policy amongdecision-makers, practitioners and researchers Political and/or financial reasons for not acting on goodevidenceExchangeExchange Education of and dialogues with users andmedia on high-impact stories on the use of knowledge Innovative ways of knowledge sharing,esp. tacit knowledge Lack of interactive communication between producersand users of scientific evidence Lack of knowledge sharing, especially with policy-makersand the communityoutputs and systematic exchange of experiences. Sheconcluded that scientific evidence played a role in mobpbilising donors and political support, but that the drivingforce for change consisted of the managers, their experiepence and political commitment. She added that it wasdifficult to find financial support to fill the knowledgeand intervention gaps.Gao Jun described the plan for knowledge managementto improve health policy-making in China. Althoughmuch has been done in China with respect to healthmanagement information systems and informationtechnology, the Ministry of Health has articulated theneed for an efficient capture and synthesis of pro-poorevidence that could be used for policy in a timely mannpner. Strategies proposed for the new knowledge manapagement for health policy and strategic planning projectin China are: improving access to health information;sharing and applying experiential knowledge; creatingan enabling environment for knowledge management;and using knowledge translation strategies. In the break-out groups, the meeting participants discpcussed the different country experiences presented aswell as their own experiences in order to identify keyfactors for success and constraints/barriers in knowlepedge translation. They agreed that the factors identified(see Box 2) were common knowledge and applied tomost countries, even though the context and degree towhich these factors operate may vary.The major conclusions and recommendations fromthe plenary discussion on Day 1 were:1. There is no satisfactory and common terminologyand framework for KT. Many, but not all of the participants, believed that a concpceptual framework is needed before a coherent programmeof action for WHO and its partners can be developed. Most of the participants agreed that a broader definitption of “knowledge” should be adopted, going beyond aBridging the “Know–Do” Gap
linear view of translation of research evidence to policyand practice to the inclusion and consideration of othervalid information that contributes to decision-makingand problem solving.2. Innovations to improve knowledge translation stratepegies should be encouraged, especially those aimedto improve the know–do gap in developing countries.Monitoring and evaluation of future KT projects andprogrammes should be developed up front. Learning bydoing, coupled with knowledge sharing, is a key stratepegy of learning organizations and initiatives.3. Capacity building and knowledge exchange are imppportant for all stakeholders (policy-makers, health workepers, the community and civil society, and researchers)involved in knowledge-based enterprises.Expanding the KnowledgeTranslation ToolkitOn Day 2, an overview of different practices used inknowledge translation were discussed, with the end inview of enhancing the competencies of those committpted to integrating KT in their work. Knowledge topicsthat were presented were: Knowledge mapping Knowledge value chains Diffusion of innovation in clinical practice Health service management and organizational learning Strategic advocacy Community mobilization and social entrepreneurship Knowledge brokering Quality improvementKnowledge mappingSteeve Ebener provided a conceptual framework whichintegrates knowledge mapping to identify potential opppportunities and gaps within the knowledge translationprocess by providing a picture of the knowledge assets,their locations and flows in the system. It is a tool tohelp decision-makers quickly understand and managecomplex systems and networks and therefore supportsknowledge translation. WHO/KMS plans to collaborprate with interested developing countries in conductingknowledge mapping and audits, develop guidelines andprotocols and to map existing expertise in WHO’s Collplaborating Centres and other networks to foster globalknowledge networks in WHO priority areas.As an example, Maylene Beltran described the ongoingknowledge mapping in the Philippine Department ofHealth (DOH), which is being conducted as part of aKnowledge Audit project supported by GTZ. The audpBridging the “Know–Do” GapA commitment to a knowledge managementstrategy:“We envision a system that enables DOH workers toquickly access the right information they need to makeprompt and effective decisions and to provide quality servivices for our internal and external clients. Along this visision, we intend to develop a world-class DOH Portal thatwill serve all DOH units and attached agencies, as well asexternal stakeholders and partners of the Department.”Department Memorandum2005.07, Dept. of Health,Philippines, 3 June 2005dit is one of several knowledge management initiativesof the DOH to support its health sector reform agenda.Using questionnaires, interviews and workshops, theknowledge resources and assets as well as gaps andweaknesses in policy-making have been mapped in thecontext of the DOH vision, mission, culture and thedifferent core process of policy-making. Findings fromthe knowledge mapping exercise suggest that knowledgeutilisation in the DOH is not systematic and not yet anintegral part of the health system, particularly withregard to the devolved local government units. It wasobserved that knowledge mapping is resource-intensive,requiring dedicated full-time staff. As such, it should beintegrated within an overall plan for knowledge manapagement that addresses, resource requirements, capacipity building, incentives for workgroup collaboration andperformance commitment.Knowledge value chainsRéjean Landry defined a knowledge value chain (KVC)as “the set of knowledge-creating activities to move fromconcept up to the production of new or improved produpucts and services, delivering added value for clients”. Hecriticized the oft-held assumption in knowledge transferstrategies that knowledge stocks of managers and healthprofessionals are very low, leading to a heavy emphasison knowledge inflows without considering knowledgestocks and knowledge outflows. The KVC adds valueby focusing on the processes of knowledge acquisition,creation, sharing/dissemination, utilisation/applicationand performance assessments within the context of thestrategic goals of the health system.Robert Ridley discussed the lessons learned in applyingKVCs in pharmaceutical R&D, and how these might apppply to public health. He stressed that the “chain” is nota linear process but involves many feedback cycles fromconcept to product to policy and implementation. Unlplike the pharmaceutical development chain where thereis a clear dollar value to its products, the added valuein public health knowl
and lessons in bridging the gap. Although there are ongoing innovations and learning by doing, there is still no comprehensive framework or common platform for better understanding the know– do gap and systems to address it. WHO has a major role to play in bridging the know– do gap and supporting countries through better knowlp
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