Views of health system policymakers on the role of research in health policymaking in Israel

There is international awareness about the need to bridge the gap between research, practice and policy [1–6]. For close to a decade calls have been made to implement initiatives that link research to action. Knowledge transfer and exchange (KTE) has emerged as a paradigm to start bridging the “know-do” gap [7]. 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” [8]. While there are some excellent examples of effective links between research and decision making [9–11], there are still many challenges in using health systems and policy research to inform policy.

One of the main challenges that countries face in KTE is developing and using effective strategies to promote the use of research in policymaking [12, 13]. The two predominant actors in the KTE process are knowledge producers i.e. researchers and academics, and knowledge users i.e., managers and policymakers. Both knowledge producers and knowledge users have initiatives that they can undertake to support the use of research in policymaking. Knowledge producers produce the research, and if the research is not relevant, packaged in ways that highlight decision relevant information or readily accessible when decision makers need it, then the likelihood of decision makers utilizing the research evidence is poor [14–17]. Other barriers also exist to the use of research evidence in policymaking, for example academic research is frequently written in academic jargon and traditional scientific formats, and is not packaged or disseminated in a user-friendly manner [18, 19]. Numerous initiatives that researchers can undertake to support KTE have been proposed and studied, such as having researchers ‘push’ the research out through different channels, facilitating the use of research by ensuring that research is more readily available when it is needed and in a form that is easy to use, and utilizing knowledge brokers and other mechanisms to support linkage and exchange [20–22].

Knowledge users, such as policymakers, also have a role to play in the use of research. While research evidence may only be one of many factors within the decision and policy making process, there is an increasing awareness of its value [23]. Health system policymakers are required to make important and costly health system decisions related to the governance, financial, and delivery arrangements that determine whether the right programs, services and drugs get to those who need them [24]. Policymakers need to be open and receptive to evidence informed policymaking and they are integral to setting the climate for research use. Furthermore, if knowledge users do not know how to acquire, assess or apply the research evidence, and if they do not implement infrastructures that support the use of evidence, then the likelihood of using research evidence to inform policymaking will be poor. Lavis et al, and further reiterations of his framework [4, 20, 25], highlight some actions that policymakers can undertake in order to facilitate evidence informed policy making, such as training and implementing decision making processes that support the use of research evidence.

The success of any KTE strategy is dependent on tailoring the approach and initiatives that are implemented to the local context and the barriers and facilitators operating in these contexts [4, 25–27]. Understanding the local context and the views of the main actors in the process can assist in identifying the barriers and facilitators for KTE. Governments and international agencies provide recommendations and implement policies which they claim to be based on the best available evidence at the time. However, studies have shown that in many cases, these recommendations are not based on the best available evidence and there are gaps between the evidence that was available at the time a recommendation was made and the recommended action [28, 29].

While research in the area of KTE and understanding the views of key actors in the process and actual use of research in policymaking has been conducted in Canada, some Arabic countries, and elsewhere, [3, 13, 23, 30, 31], minimal work has been done in this area in Israel. The use of research evidence in health policymaking is an international challenge. Health systems, including that of Israel, are usually characterized by scarce resources and the necessity to make rapid policy decisions. The Israeli health system is based on the national health insurance (NHI) law, instituted in 1995, that provides every Israeli resident with a basic package of health care, i.e. universal health coverage. The main components of the Israeli health system are the Ministry of Health (MOH), four health insurance funds and other non-profit organizations. The MOH has overall responsibility for the health of the population and the effective functioning of the health care system. The system is financed through taxation linked to income and accounts for approximately 8 % of the GDP [32, 33]. In Israel, the high level policy makers (e.g., the Minister of Health) change frequently and may be limited in their knowledge or experience with certain health policy and system issues. However, those that support policymakers and senior executives involved in the policy development process in Israel, have the organizational memory, remain in their post for longer periods of time, and can support KTE initiatives and incorporate HSPR to inform policy. Due to the fact that policymakers are changing often, the culture and processes need to be implemented to support KTE and the approach to KTE and HSPR needs to be suitable to both policymakers, those that support policymakers, and senior executives involved in the policy development process in Israel.

Additionally, Israel is a small country with a lot of internal diversity. This means that there may be difficulty in conducting research on policy-type interventions since there can be a problem with the small “sample size” and generalizability. In addition, Israel faces diseconomies of scale; it has just as many national policy issues as much larger countries, but far fewer researchers to study these issues. Thus, it is even more important for researchers and policy makers to be more coordinated, and also be able to use research from other countries as a basis, that can then be assessed, adapted and applied to the Israeli context.

Previous research has been published that examines the experiences related to KTE in Israel of researchers who have conducted health systems and policy research in Israel. Most researchers that conduct health systems research in Israel are based either in research institutes, academic institutions, government agencies, the four health insurance funds, or hospital settings, and many researchers have cross appointments in a number of the aforementioned institutions. This previous research has demonstrated that less than half of the respondents were involved in various KTE activities such as interacting with knowledge users throughout the research process and developing reports and summaries that used language appropriate for their target audiences [34]. More than a third of the researchers in Israel reported that they were frequently or always involved in interactions with target audience through the research process (i.e. during developing a research question or executing the research) or through formal or informal meetings during conferences, workshops or conversations. However, less than half of the researchers stated that they were engaged in bridging activities aimed to facilitate target audiences to use research [34]. While there is engagement from the researchers in Israel, it is important to note that health system researchers are only one part of the equation when it comes to ensuring the use of research in health policymaking. Policymakers in the health system also play an important role in the use of research evidence to inform their decisions. Previous research in Israel has documented the reforms made to the health system as well as the potential role of data to inform policymaking. While the research did demonstrate that data use increased over time and decision makers did rely on data, at times key data were missing and furthermore, the policymakers rarely explored in a systematic way how data could contribute to the decisions they face. In addition, one study found that even where the intention may be to use data to inform policymaking, political motives are also a strong force [35, 36]. The purpose of this research was to explore the views of health system policymakers and senior executives involved in the policy development process in Israel regarding the role of health systems and policy research (HSPR) in health policymaking, the barriers and facilitators to the use of evidence in the policymaking process, and suggestions for improving the use of HSPR in the policymaking process.

A survey and an interview were verbally administered in a single face-to-face meeting with health system policymakers and senior executives involved in the policy development process in Israel policymakers in Israel.

In this study, we investigated the views of health system policymakers’ and senior executives involved in the policy development process in Israel on the use of HSPR to inform decision making. Both the quantitative and the qualitative components of the study demonstrated that while there are many barriers in place, there are numerous facilitators that are already in place and support evidence informed policymaking and they can also be capitalized on for future initiatives. The barriers primarily focused on the currently available research and the lack of some of its relevance and timeliness to support decision making, the usually ineffective dissemination of research, and interests of different stakeholder groups. The main facilitator that was identified both in the quantitative and the qualitative research was the strong foundation of relationships and collaborations between researchers and policymakers or decision makers. Participants provided a wealth of suggestions regarding how to improve the use of HSPR to support health policymaking and decision making.

The diversity of respondents can be viewed as both a strength and a limitation of the study- it provides us with a wider context of many of the actors in the policy making process, but, on the other hand, their divergent perspectives and personal experiences can lead to different opinions on the use of HSPR and its role in the policymaking process, thus obfuscating the results. While we may note the differences in response rates for each category of respondents, two issues must be taken into consideration. Firstly, the number of potential respondents in each category is relatively small, especially if we integrate the different categories together (i.e. director level- government, other-non-government, etc.) as well as other subdivisions within each category, so that it is likely that potential systematic biases may be overshadowed by the individuality of each respondent’s unique position. Secondly, the categorizations was based on the respondents current position, or the one that they held within the previous 5 years- many of the respondents have a long history of different positions within the healthcare system or the policy-making process, therefore their response may reflect experiences and perspectives that place them into more than one category.

The biggest strength of this study is that, to our knowledge, this is the first study examining the views on the use of HSPR by health system policymakers and and senior executives involved in the policy development process in Israel. Further strengths include that the close-ended questions were built on a pre-existing and validated instrument and that the survey was administered face-to-face as opposed to online, thus promoting a somewhat higher response rate. However, our survey is not without limitations. The two main limitations are: a) despite the fact that the researchers went to great lengths and repeated attempts to recruit participants, the response rate is lower than hoped and b) the survey is based on self-reports and therefore, social desirability bias cannot be excluded. These limitations may influence both internal validity and the generalizability of the findings to the broader population.

Another limitation of the study is that it asked respondents to relate to the research-policy interface overall. It is quite likely that the effectiveness of the interface varies across institutions, policy area, type of research, etc. There may also have been some differences in among various types of respondents in their perceptions; however given the relatively small sample size it is not possible to differentiate the effects of those differences from just individual variability. There are important opportunities for further research to explore what accounts for the variation in the effectiveness interface in Israel; both quantitative studies and in-depth case studies can play an important role.

Some of the findings of this study are in alignment to the findings of other international studies. Similar to other studies, this study identified the need for the timeliness and relevance of the research as well as the local applicability of the research as factors that can influence the uptake of research evidence [15, 39–41]. Furthermore, numerous papers and studies have been written about the importance of relationships and collaboration between researchers and decision makers which can facilitate the increase of evidence informed policymaking. Barriers such as lack of personal contact and opportunities to discuss challenges and research opportunities between researchers and knowledge users impede the use of research in policymaking [15, 17, 39, 41–44]. The issues uncovered in this research, while not new in the field of KTE, are new to the Israeli context. These findings provide insight as to the challenges experienced in Israel and provide researchers and decision makers with the necessary evidence to build interventions to support the use of HSPR in policymaking and decision making.

There are some differences as well between this study and the international literature. One main difference is with respect to the groups or factors that exert a strong influence on the health policymaking process. In our study, the three biggest influencing factors were limited health funding, the health insurance funds and the media; however, in other studies, other factors were found to have a strong influence such as physician associations, donor organizations or the values of governing parties [13, 31]. Furthermore, in two other studies, about half to two-thirds of the respondents agreed or strongly agreed that research about problems related to healthcare or health systems exerted a strong influence on the policymaking process (46 % in the Eastern Mediterranean Region and 66 % in Canada; the Canadian study focused specifically on research related to healthcare providers), while in our study only 19 % agreed or strongly agreed with that statement [13, 31].

Also, based on the quantitative and the qualitative findings, it is apparent that there are strong relationships between researchers and policymakers in Israel. This is in contrast to the situation in many other countries where these relationships appear to be less well developed. For example, in one study from the Eastern Mediterranean region it was found that only 43 % of respondents agreed that there are contact and collaborative relationships between researchers and policymakers and/or decision makers [13]. The relatively strong relationships in Israel should be capitalized upon, as is elaborated below.

Based on this research, policymakers in Israel perceive that the linkage and exchange efforts exist in Israel and there is a strong foundation on which to build upon. Strong links between policymakers, stakeholders, and researchers can enhance the transfer of research into practice [51]. Linkage and exchange efforts fundamentally occur when there are positive relationships between research producers and knowledge users, which seems to be the case in Israel [52].

However, policymakers identified the biggest challenges to be within the research production and push efforts. With respect to research production, the quality of the research, its topical relevance, its operational usefulness, the solutions or recommendations associated with the research, and the credibility of the source are all important characteristics that can enhance the use of research in policymaking [48, 53, 54]. Health systems need to ensure that they have the capacity to conduct research and fund the creation of new knowledge [55]. Furthermore, changes are needed so that local stakeholders such as policymakers and decision makers can have influence in determining the nature, quality and applicability of the research being conducted [55]. Ownership of research and research ideas by stakeholders are also important [53]. If the Israeli health system wishes to support the creation of new knowledge that is applicable, future initiatives should focus on establishing regular priority setting processes with researchers, stakeholders, and policy makers, funding new research in the form of partnerships between researchers and knowledge users or health services agencies, and ensuring the overall capacity to conduct or commission research [20, 25, 56].

With respect to push efforts, ensuring the effective dissemination of research findings is essential. The push efforts that researchers or intermediary groups undertake can bring research evidence about an issue to the forefront and to the attention of policymakers and inform the policy development and implementation processes [12]. The messengers and the packaging of the research are important characteristics to consider [41, 53], and were identified by participants as interventions to consider in improving the dissemination of study findings. Traditionally, researchers disseminate their findings via publications and conferences; these are important initiatives but primarily contain the research findings within academic circles. ‘Pushing’ the knowledge out to users requires re-packaging of information and highlighting actionable, jargon-free messages [41]. To have an impact, research findings must be translated and adapted to specific contexts and situations [53]. Developing applied products and tools that help knowledge users see the relevance and usefulness of the research is a factor that can affect the successful transfer of research into practice [22, 41, 57]. Examples of push efforts are identifying actionable messages arising from research, fine-tuning the messages for different user groups, working with credible messengers for each group to disseminate the messages, supporting decision making and actions associated with the messages, and developing media releases for the actionable messages, and training researchers to develop their capacity to create, disseminate and execute evidence informed push efforts [25].

What is interesting to note is that most of the areas where policymakers identified a need for improvement fall within the responsibilities of the researchers. Most researchers that focus on health systems and policy research in Israel have acknowledged that they are minimally involved in KTE activities [34]. However, while increasing initiatives both within research production and push efforts to improve the use of HSPR in decision making is important, there are initiatives that can be undertaken by policymakers and decision makers as well.

This research demonstrated that health systems policymakers in Israel perceive to have strong relationships with researchers; however there is room to improve on these collaborations e.g., partnering in research projects to ensure their relevance. Furthermore, health system policymakers seem to be interested in receiving relevant research in an effective format and are open to using research in decision making. However, providing access to relevant material and assisting target audiences to acquire and use research is rarely done. KTE is a fairly new area in Israel and therefore the level of KTE activities is not very high. Health system and policy researchers in Israel need to be given a deeper understanding of the benefits and potential advantages of KTE in an organized and systematic way and interventions need to be implemented and evaluated to determine the effectiveness in the Israeli context.

KTE, Knowledge Transfer and Exchange; HSPR, Health Systems and Policy Research