Abstract

Background

The process of health policy decision-making is complex. There is international awareness about the need to bridge the gap between research, practice and policy [1], as the decision-making process varies between settings and is not viewed uniformly by different key players [2]. One factor influencing the decision-making process is health policy and systems research (HPSR). Incorporating HPSR into decision-making involves two groups, namely researchers, who produce knowledge, and health policy-makers, who use the created knowledge in their attempt to formulate effective and efficient health policies. Previous studies identified possible reasons why evidence is not being used to inform policy [1–6]. Some of those findings stem from the political and economic constraints over which health policy researchers and policy-makers have little influence. Yet, there are areas which have been identified as contributing to the evidence-to-policy gap over which researchers and policy-makers can effect change. Despite the efforts expended by researchers, if research from knowledge producers is not considered by policy-makers to be relevant, packaged in ways in which it can be applied to policy formulation, or readily accessible when decision-makers need it, then the likelihood of decision-makers utilising the research evidence is low [2, 7–10]. Policy-makers need to be receptive to evidence-informed policy-making. On a practical level, this means that they must be equipped with the knowledge and ability to access the information and apply the research evidence. If research uptake by policy-makers is not optimal because infrastructures for obtaining research findings in a timely manner are not effectively employed, then it is unlikely that policy will be informed by the best available evidence [2].

Bridging the gap between knowledge producers and knowledge users is an international challenge [11–16]. The process of knowledge transfer and exchange (KTE) is one approach that has been employed to bridge the ‘know-do’ gap [17]. KTE is defined as “a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of [citizens], provide more effective health services and products and strengthen the health care system” [18]. Simply providing evidence through publications or meetings is an insufficient means to get research evidence into policy decisions [19]. In a time where transdisciplinary research encourages collaboration and creative problem solving, approaches to support evidence-informed decision-making are becoming more adapted and utilised in the healthcare context, and different theories and frameworks are being presented to aid in the dissemination and implementation of research knowledge [20]. KTE is particularly vital in healthcare because knowledge can be fragmented, research proliferation is immense, and the cost of bad decision-making or slow knowledge implementation in healthcare can have dire consequences [21, 22].

Numerous frameworks have been developed, describing an array of potential initiatives related to evidence-informed policy- and decision-making [20, 23–30]. The framework developed by Lavis et al., and modified by others [14, 25, 31, 32], assists in assessing country level efforts related to KTE and provides insight as to which elements a health system should have in place. The first element focuses on the local climate and context in order to assess feasibility and possible implementation challenges. The second element, linkage and exchange, is the building block for the remaining efforts and focuses on creating strong links between knowledge producers and users to enhance the transfer of research into practice. Knowledge creation is the next element, which must be timely and applicable for knowledge users. ‘Push’ and ‘pull’ efforts are also important, and respectively push knowledge out to necessary groups or pull it into those groups from within. Facilitating pull efforts is the next element which focuses on making knowledge accessible for policy-makers and facilitating the identification and use of relevant research. The final element is evaluating the various aforementioned activities to inform future efforts. Understanding how these elements inform the functioning of health systems and those involved in the policy-making process can be the key to understanding what can be changed to make these systems more effective and efficient.

Understanding the main actors’ views about the process can assist in identifying the barriers and facilitators for KTE, minimising barriers and building upon the facilitators. Globally, there have been several qualitative studies comparing the perceptions of researchers and policy-makers, exploring their areas of agreement and disagreement. It is valuable to gain insights from different health systems as solutions are dynamic; certain factors may be applicable across contexts, while others may only have local application. Campbell et al. [3] interviewed researchers separately from policy-makers and reported perceptions from each group regarding getting research into policy. Respondents reported their perceptions of research being used to inform policy, if policy-makers found research accessible and useful, communication and exchange between researchers and policy, and their suggestions of how to increase the use of research in policy. Each group noted that, although research evidence was used in policy planning, more could be done to increase its use in policy. Petticrew et al. [33] and Whitehead et al. [34] conducted two studies looking at the evidence base for policies to reduce health inequalities and examined researcher and policy-maker views on the use of evidence in policy-making. They reported a significant congruence between researchers and policy-makers, suggesting that there may be a common understanding between them and that both groups acknowledged the need to promote an evaluative culture including training researchers to go beyond describing the research towards evaluating the outcomes of interventions. The studies underscored the benefits of the two parties working together, as indicated in other studies [35–37]. The use of health systems evidence by policy-makers in Eastern Mediterranean countries was studied by El Jardali et al. [38] and, although they described differences by region, they did not compare knowledge producer and knowledge user perceptions. Work has also been performed in lower and middle-income countries. For example, Tomson et al. [39] and Jonson et al. [40] examined research evidence usefulness in policy implementation from the perspectives of health services researchers and health policy decision-makers in Laos. Many of the health services researchers in their study were policy-makers who were taught research skills as part of the study. These policy-based researchers facilitated “getting research into policy and practice” [39]. Ultimately, regardless of the specific results in each study, all underscored the benefits of researchers and policy-makers working together.

The Israeli healthcare system is held in high regard across the world, providing high quality health services with good outcomes while maintaining manageable levels of expenditures [41]. Like many countries, Israel faces challenges such as scarce resources and the need to make rapid policy decisions. However, while Israel has just as many national policy issues as much larger countries, it has fewer researchers to study them. Although all countries supplement their own research with external sources for formulating policy (e.g. conducting systematic reviews), Israel’s more limited capacity to devote time, effort and money to research may make prioritising what research should be done in-house and when to rely more on outside research much more significant. This can impact the interaction between researchers and policy-makers. On the other hand, the smaller size means that, in many cases, researchers and policy-makers know each other on a personal level, which can influence the nature and tone of their relationship.

The Israeli health system is comprised of the Ministry of Health (MOH), which has overall responsibility for the health of the population and functioning of the health system, four health insurance funds and other non-profit organisations. Many of the decisions, including policy-making, are made at the national level (e.g. coverage under the National Health Insurance Law, nationwide public health initiatives, emergency preparedness, allocation of hospital beds and special devices), but each of the health insurance funds can also make their own internal policy decisions.

In Israel, the high-level policy-makers (e.g. the Minister of Health) are replaced frequently and may possess limited knowledge or experience with certain health policy and system issues. KTE initiatives and incorporating HPSR with policy are more likely to involve those who provide support to high level policy-makers involved in the policy development process, as they remain in their post for longer periods of time, have the organisational memory and are typically more experienced with HPSR. This means that any processes put into place should take into account policy-makers, those that support policy-makers, and senior executives involved in the policy development process in Israel. More infrastructures and processes to support KTE in Israel need to be put into place, taking into consideration the viewpoints of the stakeholders involved [4, 5].

In two separate studies, Ellen et al. [4, 5] explored the views of both health systems and policy researchers and health policy-makers in Israel regarding the role of HPSR in health policy-making. Researchers conducting HPSR in Israel may be based in research institutes, academic institutions, government agencies, the four health insurance funds, hospital settings, or have appointments at a combination of these. The National Institute for Health Policy Research is an independent association charged by the Israeli Health Council, a body appointed by law to advise and assist the MOH in certain matters. It is the primary organisation involved in directing and funding HPSR at the national level. The money for the grants it provides comes from a budget set aside for such research by the MOH. The Myers-JDC-Brookdale Institute is a partnership between the Israeli government, the American Jewish Joint Distribution Committee and the Myers Foundation, and is also a major player, conducting studies especially related to societal issues. Some of the health maintenance organizations also have research institutes which conduct HPSR. Many researchers that have appointments within these institutes also have academic appointments as well.

Ellen et al.’s [4, 42] work revealed that fewer than half of these researchers were involved in KTE activities, which includes interacting with policy-makers, and fewer than half were engaging in bridging activities to facilitate the use of their research by their target audience. Policy-makers are the other side of the equation as knowledge users. Previous research in this area demonstrated that data usage increased over time, there were instances where key data was missing and, moreover, policy-makers rarely explored how to use data to contribute to their decision-making in a systematic way. Political motives have also been implicated as a strong driver that informs policy-making.

To our knowledge, our work was the first in Israel to examine the views on the use of HPSR by health system policy-makers and researchers in a quantitative manner. The purpose of this study was to compare the perceptions of Israeli health systems and policy researchers and health services policy-makers regarding the role of HPSR, factors influencing its uses and potential facilitators and barriers to HPSR, and implementation of KTE activities.

Methods

This study builds on previous work examining the perceptions of health systems and policy researchers and of health policy-makers, and a full description of the methods appear elsewhere [4, 5].

Results

A total of 107 health policy and systems researchers were invited to participate in the survey, of whom 37 responded (response rate of 35%). Among the 37 respondents, 16 were males and 17 females. The average age of the respondents was 51.9 (SD 10.9) years with a range of 30 to 68 years; 16 respondents (44.4%) were affiliated with an academic university, 12 (33.3%) with a research institute not within a university, 7 (19.4%) work in a teaching hospital setting, and one was affiliated with a government department or agency. Overall, 73 potential policy-maker respondents were contacted; three of them did not meet the criteria for participation in the study (e.g. career change or current area of work does not focus on health systems and policy).

A total of 32 policy-makers were interviewed for a response rate of 46%. Among the 32 respondents, 23 were males and 9 females. The average age of the respondents was 54.7 (SD 11.3) years with a range of 34 to 83 years; 18 (56%) participants were from the Ministry of Health, 4 (12.5%) each from health service organisations and national councils, and the remainder from other organisations such as the national insurance institute, the Ministry of Finance and members of the Knesset; 5 (16%) of the respondents were either Ministers, current or past director generals of the MOH or CEOs, 9 (28%) were deputy director-generals or vice-presidents, and 18 (56%) were in other positions, i.e. department heads or chairpersons of national committees.

There were a few differences in the perceptions of the groups regarding the role of HPSR and the factors that influence its use (Table 1). While only a little more than two-thirds of the researchers felt that use of evidence from HPSR in policy was hindered by practical constraints to implementation (such as financial implications), 91% of the policy-makers perceived that those constraints hindered the use of HPSR evidence in policy. Further, 59% of the researchers felt that the use of evidence from HPSR in policy-making was hindered by a lack of coordination between knowledge producers and knowledge users, while less than one-third of the policy group (32%) felt this to be true.

A higher percentage of policy-makers, as compared to researchers, reported that facilitators in the KTE process are in place (Table 2). Specifically, 68% of the policy-makers felt they have access to technical support for acquiring, assessing and applying HPSR research while only 42% of the research group felt that the policy-makers had such access. Additionally, 68% indicated that structures and processes exist to link them with researchers to facilitate the use of HPSR in policy while only 38% of researchers agreed. Policy-makers were more convinced that national funding sources encourage KTE activities, as 70% of them reported this as a facilitator while only 38% of the researchers were in agreement. Similarly, 45% of the policy-makers saw themselves as creating opportunities to develop joint HPSR research initiatives, while only 22% of researchers viewed this to be true.

Table 2

Potential facilitators and barriers to the use and implementation of knowledge transfer and exchange (KTE) activities

Factors	Researchers	Policy-makers	χ2 test for independence
	Percentage agree or strongly agree		χ2(1)
Facilitators
National funders formulate their priorities and calls for proposals in response to national and regional needs	59	78	2.376
Personal and organisational contacts among policy-makers were quite stable over time	43	61	1.946
Funding sources (e.g. granting agencies) consider KTE activities an allowable expense	43	65	3.001
Policy-makers have access to technical support for acquiring, assessing and applying health policy and systems research (HPSR)	42	68	4.555*
Structures and processes exist to link you with policy-makers	38	68	6.039*
National funding sources encourage KTE activities	38	70	6.869**
Policy-makers invest financial and/or human resources in KTE activities	22	42	3.261
Policy-makers create opportunities to develop joint HPSR research initiatives with them	22	45	4.271*
Barriers
Policy-makers lack the expertise for acquiring, assessing and applying HPSR research	59	31	5.274*
Priorities in the health system draw attention away from HPSR research	59	43	1.727
Policy-makers do not make decisions on the basis of HPSR research	51	24	5.043*
Policy-makers do not have technical access (i.e. journal subscriptions, links to research) to the appropriate databases to search for HPSR research	32	10	4.798*

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^*p<0.05; ^**p<0.01

A higher percentage of the researchers perceived barriers within the KTE environment as compared to the policy group (Table 2), wherein 59% viewed policy-makers’ lack of expertise for acquiring, assessing and applying HPSR research as a barrier to the use and implementation of KTE while only 31% of policy-makers saw this as a barrier. Further, 51% of the research group felt that policy-makers do not make decisions based on HPSR as compared to 24% of policy-makers who shared this view. Close to one-third of the researchers identified policy-makers’ lack of access to appropriate databases to search for HPSR as a barrier while only 10% of the policy-makers agreed.

Although there were differences in the group responses regarding additional facilitators and barriers at the level of organisational support for KTE activities, these differences were found to be less pronounced (Table 3).

Results of the surveys indicated that researchers and policy-makers mostly shared similar views with regards to the research available to knowledge users (Table 4). One obvious difference was with respect to 14% of researchers reporting that available research lacked credibility among target audiences, while none of the policy-makers agreed.

Survey results showed large differences in the perceptions of the two groups regarding one aspect of policy formulation, wherein 62% of the researchers felt that policy formulation is usually based on internal MOH discussions and ad hoc processes while only 34% of the policy-makers agreed (Table 5).

Survey results indicated differing views regarding the organisations they perceived as exerting a strong influence on health policy-making, wherein 89% of the researchers viewed physician associations as exerting a strong influence, as compared to 59% of the policy-makers who agreed with this view. While 88% of the researchers viewed limited health funding as a strong influence on the health policy-making process, all (100%) of the policy-makers viewed it as such. Further, 22% of researchers reported that donor organisations exert a strong influence on the policy-making process as compared to only 3% of policy-makers who agreed (Table 6).

Similar to the χ² results, a larger percentage of respondents from the policy group perceived KTE activities were in place as compared to the researcher group (Table 7); 65% of the policy-makers reported receiving copies of articles and/or systematic reviews about HPSR and 55% reported receiving mailings or e-mails tailored to their needs from researchers, while only a quarter of the researchers reported providing these items. While over three-quarters of the policy-makers indicated receipt of or access to a searchable database of articles/systematic HPSR reviews, only 9% of the researchers indicated providing access to such information. A higher percentage of policy-makers reported receiving training from researchers on developing their capacity to use HPSR than researchers reported providing. A higher proportion of policy-makers also indicated maintaining long-term contact with researchers as compared with the researchers’ perception regarding maintaining contact with policy-makers.

Discussion

Conclusion

To our knowledge, this study is the first to compare, in a quantitative manner, the views of health system policy-makers and researchers on the use of HPSR in Israel. This research demonstrated that there are differences in the perceptions of knowledge producers and knowledge users on factors hindering the implementation of HPSR, the accessibility of evidence to policy-makers, evidence credibility, and groups/factors influencing health policy-making in Israel. The policy-making group responses indicate that they perceive the challenges to be less severe than as perceived by the researchers. Differences in perceptions exist among the many players in translating research into policy. While each country and healthcare system has its unique attributes, some of the points captured here may well be applicable to people involved in KTE in other countries. Campbell et al. [3] noted that different stakeholders “adopt diverse and often conflicting views” of evidence because their understanding of the concept seemed to reflect their personal experiences. Further work is needed on creating a shared understanding and expose the groups to new KTE activities, where they can share their perceptions and gain an understanding of each other and the values they each possess. Once the differences in their perceptions are understood, it will provide a foundation upon which to draw conclusions regarding how the two groups can better attempt to improve the KTE process.

Box 1. Quantitative sections

Additional file

Acknowledgements

Abbreviations

Authors’ contributions

MEE conceived, designed, coordinated and conducted the study, and led the drafting of the manuscript. JNL contributed to the conception and design of the study, oversaw the scientific direction, and assisted in drafting the manuscript. EH coordinated the study, assisted in the analyses and contributing in the drafting of the manuscript. RB assisted in the analysis and the drafting of the manuscript. All authors read and approved the final manuscript.

Notes

Footnotes

Contributor Information

Moriah E. Ellen, Phone: 416-256-4450, Email: moc.liamg@nelle.hairom.

John N. Lavis, Email: ac.retsamcm@jsival.

Einav Horowitz, Email: li.vog.htlaeh.rentreg@hvanie.

Robin Berglas, Email: moc.oohay@salgrebr.

References