critical issues in knowledge utilization and health policy-making robert f. rich, ph.d. university...

Critical Issues in Knowledge Utilization and

Health Policy-Making

Robert F. Rich, Ph.D.

University of Illinois at Urbana-Champaign

Donald Schon: Beyond the Stable State

A social system learns whenever it acquires new capacity for behavior… but government as a learning system carries with it the idea of public learning; a special way of acquiring new capacity for behavior, in which government learns for society as a whole. In public learning, government undertakes a continuing, directed inquiry into the nature, causes and resolution of our problems.

…continued

Donald Schon: Beyond the Stable State (continuation)

If government is to solve new public problems, it must also learn to create the systems for doing so and to discard the structure and mechanisms grown up around old problems.

Because many sorts of social systems have governments, the requirements of public learning may not be limited to traditional political units… the concept of public learning applies as well to institutions such as the church, labor unions, schools, welfare agencies, and business firms.

Donald Schon: Beyond the Stable State

Because many sorts of social systems have governments, the requirements of public learning may not be limited to traditional political units… the concept of public learning applies as well to institutions such as the church, labor unions, schools, welfare agencies, and business firms.

John W. Gardner

A society that is capable of continuous renewal will have effective internal communication among its diverse elements. We do not have that today. We are drowning in a torrent of talk, but most of it serves only to raise the noise level. Communication in a healthy society must be more than a flow of messages; it must be a means of conflict resolution, a means of cutting through the rigidities that divide and paralyze a community.

Knowledge utilization, the social contract, and the role of public learning (1)

• What is the social contract? (This is a legal, political, economic, and social concept.)

• The social contract (as it relates to the relationship between science and government) “evokes the voluntary but mutual responsibilities between government and science, the production of the public good of basic research, and the investment in the future prosperity that is research.” (Guston, 2000)

• There has traditionally been an uneasy partnership between science—especially basic research—and government.


• Scientists believe that it is in society’s best interest to incorporate scientific knowledge into decision-making.

• Policy-makers have posed a critical set of questions:• What is the return on our investment?• What is the utility of the research that is being

financed out of public funds?• How are these publicly financed research

studies going to be used?


• Is it science serving the needs of society or society serving the needs of science?

• The adaptation of scientific knowledge to meet with needs of society is recurring in Western thought.

• How does the social contract apply to knowledge inquiry systems in a “knowledge society”?

• How has this changed over time? What is the relationship to “public learning”?

Examples of Public Learning

• Public learning is a process by which citizens become engaged in the search for valid responses to a problematic issue or situation.

• Such learning is a social phenomena—interacting with government agencies and other stakeholders—to frame the problem and then to become engaged in the process of formulating what to do about it.

• Public learning involves changing attitudes and beliefs, which may lead to action – indeed to behavior changes in society.

Focus of Knowledge Utilization

• The “knowledge inquiry system”—What is the basic model?

• The acquisition, distribution, utilization, and impact of knowledge on decision-making / policy-making

• Decision-making can be made by individuals, organizations, (in the public and private sector) governments, and society.

• The role of information / knowledge in the formulation of beliefs and attitudes and in motivating or driving actions.

Basic Assumptions

• Information is collected for a variety of reasons and not necessarily for purposes of use; information may be collected simply for building inventory or building capacity.

• There may be negative, unintended consequences of using information.

• It may be fully rational to ignore available information or to actively reject it.

• Intended non-utilization is different from mis-utilization of information.

Different Types of Knowledge

• Practical knowledge• Intellectual knowledge• Small talk or past-time knowledge• Spiritual knowledge• Unwanted knowledge• All of these types have implications for the

operations of a knowledge inquiry system• The distinction between data, information, and

knowledge

Common Myths

• Acquiring information will automatically lead to its distribution and use.

• Using basic research is a “rational act.”• The “problem” with policy-making or decision-

making is that there isn’t enough scientific information being used.

• If we can bridge the gap between the two cultures, we will have solved the primary problem of translating research into action.

• Use is use is use !• Use for decision-making is the same as

organizational learning or public learning.

Special Issues in Health Care (1)

• The growing complexity of technology and medicine

• This technology has an ever growing influence on every-day life

• Evidence-based medicine and health care decision-making is of growing importance

• The general model of decision-making in health care is fundamentally different from decision-making in politics


• Health policy more than many other areas relies on science and is, in many ways, guided by science:• Telemedicine• Biotechnology• Molecular biology• Genetic screening and the development of

diagnostic procedures• The human genome project• Therapeutic technology• Health economics


• Is there some reason to believe that decisions that involve a heavy scientific or technical dimension should be handled differently than those that do not?• Legally the answer is no• Is there a difference—the answer is yes• Why is this the case?• What are the consequences?

Key Findings from Research (1)

• Learning involves introspection and self-reflection, and the demands of the public sector usually do not encourage this type of behavior.

• Public and private organizations tend to reward people for knowing and winning, and not for admitting they don’t know. (Implications of this)

• Knowledge is power to the bureaucrat; does this conflict with the system of scientific publication?

• The use of knowledge produces effects and not in a single effect.


• The realities of the political policy-making process reinforce feelings of distrust and suspicion between the “two communities.”

• To a great extent, bureaucrat’s credibility, prestige, and legitimacy are related to the reliance of their superiors on the information they provide. This has implications for the system used to produce and collect information.

• Who provides the information (the source) is at least as important as the content of the information provided.


• In health care, voting records on traditionally controversial issues like needle exchange programs directly oppose research demonstrating their public health value.

• Government sponsored studies have concluded that needle exchange programs decrease HIV transmission and drug use; yet, lawmakers have continued to ban federal funding for such programs. What is the basis for this seeming contradiction?

• Use is not the same as dissemination or impact.

Key Questions (1)

• What types of information are preferred over others?

• To what extent do decision-makers take research into account?

• To what extent does research influence or change a position the decision-maker is already predisposed to? (This has particular implications for health policy-making)

• What are the characteristics of basic science that make it useful for decision-making?

• How do lawmakers define their needs? Where does scientific knowledge fit in with these needs?

Theoretical and Empirical Issues

• Developing an appropriate theoretical or conceptual framework

• The theoretical frameworks which have been used are ALL problematic • Rational Actor• Two Communities• Communications Model• Bureaucratic Actor model

Measurement issues

• There are also a key set of measurement issues:• The input-output model

• Linear models• Specifying the dependent variable• Defining what is meant by use• The problem with causality• The use of interviews• The use of citation analysis

Promising Areas for Research and Practice (1)

• Organizational learning—organizations can also be thought of as having learning disabilities

• Public learning• The role of e-government and d-government• The knowledge inquiry system and the use of

technology ( i.e., e-mail, the internet, decision-support systems, artificial intelligence)

Promising Areas for Research and Practice (2)

• Management of information• Processing errors and biases• The use and abuse of information by

individuals and by organizations• Symmetries and asymmetries of information

(this may be particularly relevant in the area of health care)

Conclusions and Implications (1)

• In health care, understanding the use of scientific and technical knowledge continues to be a real challenge;

• Researchers and practitioners will not be able to advance much further if they continue to rely on the Two-Cultures metaphor or the rational actor model.

Conclusions and Implications (2)

• Advances in technology have underscored the importance of• Channels for transmitting information• Increasing the speed and efficiency with which

information can reach our desk• Resisting the temptation to allow the availability of

technology to define the decision to be made

• The utilization process is directly and measurably affected by the type of information that is available for purposes of potential utilization AND the area in which the information is being applied.