CHALLENGES OF RESEARCH IN PUBLIC HEALTH TODAY ... 
Graduate Institute of Public Health Dr. Arnoldo Gabaldon
Days Arnoldo Gabaldon
Scientific
"The challenges of public health research today," December 11 to 13
Maracay
Challenges for Public Health Research today
Rubén Darío Gómez Arias MD, MPH, Professor, School
DSP
Public Health National University of Antioquia (Medellin, Colombia) Colombian Red
Executive Secretary
Research in Health Policy and Systems
rdgomez@guajiros.udea.edu.co; rubengomez00@hotmail.com Good morning.
A greeting to the participants, on behalf of the Colombian Network of Research Area Policy and Health Systems, and my gratitude to the organizers for their kind invitation to share with you some thoughts that we have done in this regard within the network, and that at this time are still being work on by researchers and institutions that shape it.
In consideration of the agenda as requested by the organizers, I have divided my presentation into three sections tion: First, I will refer to the global state of public health research and I will support this in some reports of organ- international agencies. Then I invite you to review the situation in light of the trends that are being imposed on research from the economic model and since the meeting in Budapest. Fi-nally put to your consideration some challenges, in my opinion should we address the short and medium term if we use the knowledge to improve people's health.
STATUS OF PUBLIC HEALTH RESEARCH In 1998, the World Health Organization-Health Organization, the World Bank and the Rockefeller Foundation, concerned about the global health situation and the initial support six countries (Canada, Sweden, Norway, Switzerland, Ireland and Mexico) in Geneva created the Global Fund for Health Research as an independent foundation aimed to promote health research worldwide. The foundation, now run by an international council, believes that if you want to improve global health requires much more research, 1 and in this regard aims to generate changes in the prioritization criteria now apply to allocate resources in health, promote research resource allocation to health areas that are currently neglected and strengthen research on problems that contribute most to the burden of disease and disability.
The initiative to create the Global Forum was the result of tests carried out by international agencies at the end of the 90 who showed a poor outlook for research in health.1, 2
By 2000, funding for research policies and health systems were really cramped and represented less than 0.02% of spending on health.3 The problem is not reduced because of inadequate funding allocation of resources showed serious asymmetries reflecting the particular interest of the agencies that fund research. At this time, studies of the Global Forum showed that the USD 73 billion invested annually in the investigation in health worldwide, by public and private sectors, 90% was intended to solve problems countries developed and less than 10% to research health problems account for 90% of the global disease burden (measured in DALYs), mainly in developing countries. 1 The preparatory work of the Commission on Health Research for Development stressed that difference, and called "10/90 gap."
This gap implies high disease incidence in the world, responsi-ble for the greatest burden of disease and disability, such as respiratory infections, diarrheal disease, cardiovascular diseases, mental health, tuberculosis, diseases tropical perinatal conditions and HIV / AIDS, receive relatively little attention from the research. Four
diseases (leishmaniasis, malaria, trypanosomiasis and tuberculosis) that represent more than 5% of the total burden of disease in the world, paradoxical paradoxically receive less than 1% of the funds for
investigación.1
gap 10/90 is also accompanied by other imbalances. Studies in recent years promoted by WHO and the Global Forum showed that in-research priorities in health are traditionally formulated in terms of diseases and biomedical technology and not on the determinants of health. 1, 2 Over 70% of funding for research are derived studies in medicine and medical technology while the remaining 30% is intended to support basic research and health policy and evaluation. 1
In this latter field in recent years seen an increase in the quantity and quality of studies on the relationship between population health, inequalities in living conditions and level of development. 4 The increase in the number of investigations are also given in relation to health care systems, which rose from 0.27% of the publications indexed in Medline in 1991 to 0.71% in 2000. However, this proportion remains low extremadamen-te and concentrated in industrialized countries expressing inequality gap even greater than 10/90.3 A study conducted for the Network in 2003 found a sharp increase in publications related to health policies and systems, notorious since the beginning of the 90 and associated with the issue of reforms , which decreased again from 2000. The analy-sis of this trend showed further that interest magazines and Editorial-les are very heterogeneous and may be reflecting the political changes that affect them most. Also showed that the indexed production-related health policies spread mostly in biomedical type publications aimed at clinicians, and predominantly in language English. Under the conditions described, it can be argued that the information published by scientists hardly reaches the decision makers.
The increase in the studies concerned with policy and health systems has not been uniform. Studies of the 70's were particularly interested in the problem of coverage. Since 1978, under the influence of the Declaration of Alma Ata and the importance of this conference attached to the research, there was a resurgence of publications das interested in health care systems and financing. Since 1987, under the influence of the World Bank, the value of research focused on reforms the organization and its services is striking financiación.3 low interest publications equity issues, determinants of health and social rights in this field.
The gap in the social management of knowledge also expands the availability of resources for research.
industrialized countries have almost three times more researchers than poor countries, make more investment in research, are six times more computers per institution, are better connected to the Web 1 and generate a greater number of publications per year concerning with health systems, and although poor countries have increased their output gap remains very wide. 3
Global Forum shows that there is inequity in the knowledge that is published, when more than 90% of health research publications from research workers in core countries (first world) .3
SERVE " OF SOME RESEARCH? The 10/90 gap and all the inequities that surround it, are for them-but a serious concern that our government should move to other ways of conducting research.
However the problem is not just the political arena and a question to ask from the academy in connection with the investigation, is how far can we trust the research and knowledge we generate in any way affect the political decisions that affect health. In other words, we work from the academy should ask ourselves seriously ... anything to go by our research?
political analysts cautiously welcome the ability of research to influence public policy, arguing that the latter are the result of complex processes of political interaction, where the academic logic and scientific evidence succumb to the force of interest prevailing in the organization social ,5-7 and its formulation and implementation are due more to processes of conflict and negotiation between groups with different interests, that technical criteria or científico.8, 9
addition, policy makers themselves may be without being aware of it, or feel obliged to take into account research when making their decisiones.10, 11 analysts who rely on the influence of the investigation on the political process, consider the value of the studies could related to its capacity to facilitate and streamline decision making and generate socially beneficial changes, 12, 13 and draw attention to the need to strengthen research into the process of managing
políticas.14 Bronfman10's works have shown that between research and decision making there is another gap, complex and difficult to overcome, and identifies several issues that play a key role as critical success factors:
For Bronfman, the focus of research has a significant impact on their potential use and interest of researchers bring their research questions to the priority needs and political agenda vechamiento contribute to appropriate studies. This observation suggests that researchers can contribute to improving value and importance of their studies to the extent they are more interested in the priority problems for the people and adopted as the object of his analysis.
Another critical success factor research refers to methods used by researchers to conduct and present their studies. Often the language and techniques used by scholars to account for their findings are extremely complex for people and often unintelligible to politicians and decision makers. The researchers investigated more to publish in foreign journals for people affected by the issues studied. In this regard and has been reported to favor the methodological rigor, and insist on separating research from the political process, are practices that can block more than contribute to the development of policy research públicas.15 This does not mean to neglect the rigor of methods, also because this is also a critical factor success in studies, especially when controversial contexts conflicting interests to discredit studies will, in this case the ar-guments technician should be even stronger, because not only will face the counterargument of scientists but also politicians and the media.
A final critical factor that I submit for consideration relates to the mutual stereotypes that exist between researchers and politicians, a case that has been well studied by Bronfman and his grupo.10 Researchers often see politicians as being essentially corrupt, unable to understand the arguments science and therefore being second, the policy, for its part is assumed to be a murky business in which a serious scientist should not be involved. From its own border, politicians often perceive as the Project by scientists who are extremely rigid, unable to adjust to the real world, that give answers to questions nobody has asked and provide results when the problem is resolved. Science, meanwhile, is perceived as an incomprehensible language increasingly distant from the real problems of society. In this context of alienation and mutual distrust is very difficult for researchers and decision makers from making arrangements socially productive.
analyzed factors help to understand why we have an attitude re-enlist in front of the case. Research can help to improve policies, but do not be easy.
GLOBAL TRENDS IN MANAGEMENT OF RESEARCH Before examining the challenges and ways to meet them, I invite you to review some trends that are dominating the field of research.
The first of these is well represented by authors such as Gibbons and Schwartzman 16, 17 who argue that in most regions of the world's scientific activity has shaped and strengthened the traditional model, which they call Model I research. Broadly speaking, this model is assumed as an eminently intellectual and individual activity conducted by scientists operating from their disciplinary fields, firmly convinced that research is itself valid. Scientists Model I consider themselves neutral and demand of society to recognize that neutrality. Also assume ethical responsibility is limited to the requirements of the method and its responsibility to society ends with the publication of certain findings, what happens beyond that is a political process that is not his concern.
examining the global trend Schwartzman Gibbons and I conclude that the research model is untenable under the present conditions and the need tending by a Research Model II, which is already apparent in some companies in industrialized countries, where scientists joints do not work from their home disciplines but from "problem areas", whose complex nature transdisciplinary action lawsuit. Scientists Model II reorganized their work in around the interests of the com-pany and society, and assume new tasks ranging from the theoretical to the business. The paradigm shift also implies a shift in values. Model II investigators attach great importance to its ethical commitments and are no longer considered responsible for in-form only technical but also of their implementation, and social and economic consequences of their scientific work.
Gibbons's proposal and Schwartzman has a number of important matches with a second current management models developed from modern enterprise that aims to transcend the traditional notion of research by the Management Knowledge (Knowledege management), 18 defined as the set of practices used by companies to identify, produce, represent and di-merge knowledge with the purpose of reuse and to ensure organizational learning. The programs of knowledge management developed from this line are typically tied to business objectives and are thought to con-duce to achieving specific results such as shared intelligence, improved functioning, competitive advantage, or higher levels innovation. In the background of these discourses, knowledge management is closely linked to economic profit and the company's ability to compete markets.
A third trend is observed at the World Conference on Science for the XXI Century, convened by the United Nations Educational, Scientific and Cultural Organization (UNESCO) and the International Council for Science (ICSU) and held in Budapest in June 1999. The Budapest Declaration on Science and use of knowledge científico19 widely recognized the importance of scientific activity and its applications for economic growth and sustainable human development model in the framework of a human future depends more than ever in production, equitable distribution and use of knowledge. The Declaration also made a special emphasis on the need to generate knowledge management to reduce poverty, and recognized the growing need for scientific knowledge to support decision-making, whether in public or private sector, bearing in mind the influence that science has to exercise in policy formulation and regulatory normative.
CHALLENGES AND OPTIONS Recognizing that the challenges of research in the field of public health are complex, I will draw your attention to three issues that I think are of special importance is "short and medium term.
The academic paradigm The first and perhaps closer to our daily activity relates to the paradigms that govern our academic life in universities and schools. The traditional models are academics and researchers, very solid scientific methods but little engaged with society and its problems are no longer sustainable approaches from any point of view. Neither market models and political models concerned with social rights will be willing to continue to support scientific research for publication only. It is possible that private universities and scientific acceptance of the Model II, and will do as you see in this an opportunity to increase profits. But this option will not solve global problems of po-poverty and inequality, and is even more difficult to do in the field of public health where many of the risks are closely linked to the dynamics of the economic model. The researchers contact with social reality is revealed as one of the main challenges for the institutions that promote social management of knowledge in public health.
To keep up with the requirements of public health, our research should recognize the complexity of health determinants, especially the social determinants. This means that we make a greater effort in developing approaches epistemológicos, teóricos y metodológicos capaces de dar cuenta de las dimensiones cuantitativas y cualitativas del proceso salud enfermedad y de las dife-rentes condiciones que determinan su curso. Nuestra decisión deberá cruzar también por las diferentes opciones que hoy orientan la comprensión e intervención de la salud pública, varias de ellas contradictorias, y nos exigirá tomar posición frente al debate. Debo insistir, si me lo permiten, en este punto. La solidez del conocimiento no depende solo del método. Implica ante todo una buena fundamentación epistemológica y conceptual que permita a los académicos y gestores del conocimiento dar sentido al dato y trascender las apariencias.
Knowledge management as a political process The challenge in poor countries is more complex. The 10/90 gap is not only the expression of inequality but also the mechanisms that perpetuate it. In the globalized world of knowledge management is a political mechanism to serve the core economies. For this reason, and however painful, we must recognize that knowledge management requires our society is not confined to the improvement of the technical process of adaptation to the production model, and we are very far from being solved only if we face it as an adjustment problem or learning curriculum research methodologies.
To resolve the problems related to inequities in health will have to develop short-term knowledge management can turn the best in-formation available in the hands of the neediest communities and promote their implementation. Beyond knowledge management, we require a "social knowledge management" put the knowledge to serve the people and make the reasoning and research an essential component of policy decisions.
For those who work in the academic environment, promote social knowledge management involves working hard at three levels
technical reforms. Type I Transforming research into models of knowledge management more socially productive reforms requires technical, such as changes in our curricula, in order to strengthen the capacity of our teachers and students to generate, process, implement and disseminate the highest quality at the best level of international standards. The techniques involve reforms to increasingly intense efforts to ensure that all students have access to telecommunications and the Internet from its early years. Also involve integrating teaching, research and exten-sion to the academic activities of teachers and students occupy-RRAN within and for communities. Technical reforms include the promotion of teamwork guided by principles of solidarity, cooperation and transdisciplinarity rather than competition, gentrification and the sector. The change in the model also requires us to adjust the profile of researchers. Given the challenges of public health and its determinants can hardly sustain the figure of the research specialist who works alone in his office or laboratory. The new researchers will have to respond to increased demands. Must expand their repertoire of quantitative and qualitative methods be capable of working in transdisciplinary teams. They should also develop their managerial capacity to manage knowledge as a company of interest. Finally, meet our health needs will require us to develop agendas that define priorities and guide both the allocation of resources and the distribution of responsibilities.
Clearly, these settings can be a major effort to the academy ... But perhaps the greatest challenge of our education lies not in the technical aspects but in the task of concluding the ethical principles of a new culture of knowledge and commitments of academics against the power and ne-cesidades communities.
Reforms in the science-policy relationship A second challenge concerns break down barriers between academia and political power. A more difficult and thorny issue that we must provide dead ends. One option, in my opinion wrong, it can be to promote the academic uncritical political systems. Researchers politically correct form-ing is no progress. In fact it has been a widespread practice in the world and the form of neutral scientists is one of its manifestations. Freedom of thought and the ability to interpret and criticize the social reality are properties the academy that we should defend at all costs.
Breaking the gap between researchers and decision makers involves speaking a common language where studies acquire a social meaning for INVO-volved. Rather than insist that decision makers meet our methodological rituals as if it were a scientific process of colonization society, could promote the creation of spaces for interaction where re-searchers, communities and decision makers can share information two-way and where the academy can help clarify the dynamics of the problems and propose the best alternatives for action.
Knowledge as a factor in empowering communities The last point relates to the appropriation of knowledge by the communities and especially for those who are most affected by inequality. The novelty of the social management of knowledge lies not in the methods for obtaining and processing the data but in its ability to be incorporated into the daily life of people as a resource that people can control and use it consciously for their own benefit. This level of work involves creating and maintaining spaces of interaction between academia, researchers and community organizations where people have adequate access to information and improve competence to assess and apply knowledge. In this respect emerge from new forms of social interaction as the most appropriate space to bridge the gaps: options and research networks, observatories and the formation of interest groups are profiled in turn as particularly valuable strategies that have shown useful on several fronts. CONCLUSION
In a world where globalization has deepened poverty, inequalities and exclusions, but where globalization itself is an unprecedented opportunity to share efforts and solidarity, knowledge management is seen as an essential factor human development. But any management model, but a social management of knowledge that contributes to improve the degree of power of human groups to understand themselves and to direct their destiny with independence and responsibility. At bottom, the problem of knowledge is the problem of power ... It is then a matter to be resolved only from the technical or exclusively to feed the current production model. It is a matter that touches the ethical and political commitments of different stakeholders and especially of academics and the investigators to whom society has entrusted the delicate task of protecting this resource. Thank
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