At the "Closing the Loop" Conference
Speaking Notes
for
Alan Nymark
Associate Deputy Minister of Health
(Canadian Policy Research Networks Panel on "Evidence and the Social Policy Debate")
Toronto, Ontario
October 2, 1999
Check Against Delivery
Introduction
Let me begin by saying what a privilege it is to participate in such a distinguished conference.
This is truly an international event, and the range of perspectives - and the breadth of experience
- of its participants is certainly very exciting to take part in.
I am particularly pleased to share this panel with two colleagues who have truly distinguished themselves
in the field of public policy. One of the many advantages of participating in these panels, is that
you get a front row seat to the other speakers! And I am very much looking forward to hearing the
presentations of my fellow panellists.
This morning, I would like to discuss, very briefly, the relationship between what I would call
the "generation" of information and evidence and the "utilization" of that information by policy
makers and the public at large.
Federal Budget and Evidence-Based Decision-Making
Last February, the federal government presented what has been called the "health" budget because
of its strong emphasis on investing in the health care system.
Recognizing the need for a more evidence-based system, the budget made significant investments in
improving health information systems and in promoting health-related research and innovation.
This emphasis should not surprise us. As we approach the 21st century, the onrush of
new technologies, the pressures of an ageing population, the need to establish health priorities
and the need to commit scarce resources where they will produce the greatest return -- all of these
require decisions based on better information.
And so we are making new investments to enhance our research capacity through the  Canadian
Institutes of Health Research and the Canadian Population Health Initiative. And we are committing
resources to generating better information for this research through the Canadian
Institute for Health Information.
Now, let me say at the outset that we are under no illusions that better research or better information
alone will be the panaceas to all of our problems. Drowning problems in an ocean of information is
not the same as solving them.
To really be effective, we need to improve the linkages between the evidence and 'evidence-based
decision making' and I'll have more to say about that in a moment.
The Public's Need for Information
Nor is it only decision-makers who need evidence about our health care system. The population at
large does as well.
Here in Canada, public support for our health system is strong - but it is not unconditional. It
is given in exchange for a commitment that governments will ensure access to quality care.
The pressures on the system which became apparent during the 1990s, raised concerns among Canadians
that that access was in jeopardy - that the health care system would not be there for them when and
where they needed it.
As a result, they wanted health programs to be delivered more efficiently and with greater accountability.
They want to be assured that their tax dollars are being spent wisely.
Nor will it be enough simply to report on outcomes: Canadians want evidence that the health system
itself - defined broadly - has contributed favourably to those outcomes.
So the public needs more evidence than is now available.
Connecting Evidence to Decision-Making
I spoke a moment ago about the need to build linkages between researchers (the generators of information)
and the decision-makers (the users, if you will, of that information). Without such linkages, the
evidence won't get into 'evidence-based decision making'.
As former co-chair of the federal government's Policy Research Initiative- which was designed
to strengthen links between the research and policy communities within governments and across the
country - I've learned a number of things about connecting evidence to decision making. Let me share
just five ideas with you this morning.
First, is the need for an external, and policy relevant, capacity;
Second, is the need for a capacity within government departments both to generate our own research
and to receive and process research which comes from external sources.
Third, is the great need for integration across organizational structures, between external and
internal capacities, and across disciplines;
Fourth, is the constant need to balance short-run policy requirements against the long-term promises
of research.
And the fifth component necessary to connect evidence with decision-making, is the need to develop
the information systems, technology and data resources which develop the data needed to fuel research,
foster a more efficient health system, and help to disseminate the accumulated evidence.
Let me just expand a bit on each of these.
Building External Research Capacity
First, building an external and policy relevant capacity. This is fundamental. Without
the "raw material," policy makers will have little with which to make informed decisions.
That's why we have created the Canadian
Health Services Research Foundation, which sponsors and promotes applied health systems research,
strives to enhance its quality and relevance, and serves to facilitate its use in evidence-based
decision making by policy makers and health systems managers.
We have also created the Health
Transition Fund to help the provinces experiment with new approaches to home care, drug
coverage and other innovations that will enable them to "road- test" ways to improve our health
system.
We have also supported the creation of National
Centres of Excellence, to encourage collaboration among research partners from academic,
commercial, labour and government sectors and to foster the creation of a national network of
Canadian scientists from a variety of disciplines.
Among Canada's National Centres of Excellence is HEALnet,
which has a mandate to develop and refine both conceptual and analytical methodologies for evaluation.
HEALnet also works to provide a better understanding of the interaction between health care workers
and technology, including collaboration, decision making and the use of evidence.
And, as I mentioned a moment ago, the Canadian federal government is in the process of establishing
the Canadian Institutes of Health Research, which will create networks designed to draw
together investigators and institutions to provide a national focus to Canada's health research efforts
and to better integrate that research.
A key objective of CIHR will be to turn knowledge into useful clinical practices, applications and
policy-relevant evidence for the benefit of all Canadians.
The federal government is also launching Canadian Population Health Initiative, designed
to bring together researchers and analysts from across the country, build on existing databases and
create a statistical infrastructure that will form the foundation of population health research.
It will aggregate and analyse data, develop data standards and common definitions, report to the
public on national health status and health system performance as well as act as a resource for the
development and evaluation of public policy.
We are also helping to fund other networks of researchers, such as the Canadian
Policy Research Networks (CPRN), and I will have more to say on the CPRN initiative
in just a moment.
So, as you can see, we are taking the challenge to build external sources of research very seriously
and we are confident that this is an investment which will pay huge dividends down the road.
Building Internal Research Capacity
The second area we need to focus on is the need for internal departmental research and
the capacity to receive and process information received from outside sources.
Good research and research networks alone cannot do the job of bringing evidence to 'evidence-based
decision making'. For that to happen, we need to make sure that we have a strong analytical capacity
within the department.
Too often, I think we see the 'research transfer' function as one of flowing the current stream
of new research to the decision makers as it is generated. Sounds good in theory, but on
a practical level, it just doesn't work that way.
The fact is that senior decision makers are overwhelmed by information and too often preoccupied
with la "crisis" du jour. As a result, it is extremely difficult to attract their attention
and keep it for any length of time, unless one's timing is perfect.
Indeed, it is sometimes just "dumb luck" if the current flow of research is what they need at
that time.
That's why the analytic capacity is so important: the department needs to have a firm grasp of the whole
stock of available research (not just the current flow) and be able to funnel the relevant
research to the senior managers when they need it - whether that is this year,
this month, or this afternoon.
The Canadian Health Services Research Foundation recognized this and brought together,
this spring, over 100 distinguished researchers, sponsors and policy makers to discuss these linkages.
Their recommendations were very interesting. They suggested that policy-making bodies should do
a better job of communicating their priorities to researchers, and develop a "receptor capacity" to
better understand how to receive and use the findings from the research received.
That in-house capacity should have several characteristics. First, it should be of a sufficient
scale to achieve 'critical mass'. In other words, we shouldn't scatter a few researchers hither and
yon throughout their structures. We need to concentrate the expertise.
Second, policy-making bodies should be sufficiently expert that they can be effective'receptors'
for the research done elsewhere. This means that it must be able not only to generate its own research,
but have the capacity to truly understand the research process and the reliability of conclusions
drawn from research done by others. This capacity will make them wise 'buyers' when using external
consultants and other resources.
Third, this in-house capacity should be managed by people who understand the work and are senior
enough to be advocates for the evidence in the decision-making process. This means making it an integral
part of the department's decision-making process, so that it can help to develop and amass the needed
evidence and employ that evidence at a point when it can exercise a 'challenge' function.
Fourth, there should be the capacity to communicate effectively, including communicating with non-expert
audiences. It should be sufficiently responsive, so that it can deliver answers- and even short research
or synthesis reports- very quickly in response to pressing needs.
Fifth, it can't consider itself the source of all wisdom, but rather, needs to be 'plugged in' to
the broader research community. This means knowing what is going on "in the outside world" so that
it can allocate its own research activities to fill any gaps.
Being plugged in also means that it can communicate to the external research community the research
needs of senior decision-makers - perhaps even before they are aware of those needs.
Sixth, it should be able to act as an 'entry point' into a department, whereby intelligent, well-educated
young people can join government, develop their analytical, strategic thinking and communications
skills, and then advance to new responsibilities, taking with them an enhanced appreciation of the
role of evidence.
Finally, the internal capacity must be situated in such a way within the department that it is out
of the day-to-day fray - because that could quickly absorb all of its resources - while at the same
time, remaining closely attuned to the goings on of the department so that it can feed the short-term
needs - such as Power Point presentations! -- of senior managers.
This last point is particularly important because senior managers will almost invariably become
less enamored of long-term research and want to see "concrete results" from "those folks down in
research."
Speaking for Health Canada, I can say that we once had such a capacity, one that led to the forward
thinking of the Lalonde report. But over time, that capacity atrophied and we have only recently
begun to rebuild it, with the creation of the Information,
Analysis and Connectivity Branch. Within
that Branch, a new directorate - the Applied
Research and Analysis Directorate - will provide this
internal research and receptor capacity for Health Canada.
So if we are to truly connect evidence to decision-making, we need to develop a strong external
research capacity as well as an internal ability to both generate research and analyze the work of
others.
Need for Integration
But we also know that we will waste both time and resources- not to mention efficiencies - if the
right hand does not know what the left is doing. And so the third component is the need to integrate
research across disciplines and organizational structures.
The federal government is working hard on bringing the various research environments together through
the Policy Research Initiative which acts as a kind of information broker and research coordinator
across federal departments.
Of course, Departments also need to do that within their own domain, by building their own integrative
research and knowledge dissemination structures. Again, this will be a key role for our new Information,
Analysis and Connectivity Branch.
External research, too, needs to pay more attention to the issue of horizontal integration. The
Canadian Institutes of Health Research will work to promote this integration in a number of ways
including:
- forging an integrated health research agenda across disciplines, sectors and regions that reflects
the emerging health needs of Canadians and the evolution of the health system;
- creating a robust research environment in Canada, based on excellence, to ensure that the best
and brightest have opportunities to contribute to improved health in Canada;
- promoting the creation and translation of new knowledge into improved health for Canadians as
well as a more effective and efficient health system;.
- and by promoting economic development through the commercialization of Canadian research.
Balancing Short-Term Policy Requirements with Long-Term Research
The fourth key to connecting evidence to decision-making -- and it is one I have alluded to earlier-
is the need to balance short-run policy requirements and the longer-term promises of research.
It is only natural that senior decision-makers will demand research that is relevant to policy.
Unfortunately, in such a situation, the urgent will often crowd out the important and the really
ground-breaking research - research that will significantly advance our understanding - will often
be deferred in favour of providing information that is immediately relevant to the thrust and parry
of policy-making in government.
To avoid this situation, we need to encourage research in a variety of fora - everything from internal
policy departments and external research networks, to pure researchers doing the true "blue sky" thinking
that will lead to new insights.
Infostructure
The fifth and final component of bringing evidence to decision-making is developing the information
systems, technology and data bases which both underpin research and support the dissemination of
health-related information.
We call all this health 'infostructure' and it is essential for the implementation of an evidence-based
vision and culture.
By making better use of information systems, we can help make our health system more open and accountable
to Canadians. We can provide Canadians with the facts they need to make informed decisions about
their health. And we can facilitate the collection of comparable and compatible data across Canada,
so that governments and health care providers can share best practices and assess the effectiveness
of different approaches.
Quite simply, we need to manage knowledge better. And this has several components: it involves better
use of knowledge, through evidence-based decision making; it necessitates generating better information
and it means doing a better job of disseminating knowledge, through more effective use of information
technology.
This is why we are supporting the Roadmap
Initiative, at the Canadian Institute for Health Information which will improve the
quality and availability of health information to Canadians, researchers and policy makers.
We are also establishing the National Health Surveillance System and the First Nations
Health Information System to enable national and international surveillance of diseases and
other potential health risks, a byproduct of which will be rich information bases.
Finally, if consumers are to make healthy choices, they need access to a reliable pool of information.
We will provide this information through the Canada
Health Network which will act as a gateway to health information.
Canadian Policy Research Networks
Just before I close, let me return for a moment to the Canadian Policy Research Networks (CPRN)
initiative. This is a virtual network, which ties together CPRN and universities, think tanks, governments
and other organisations. It is an excellent example of an integrated, external research capacity
that is policy oriented. And it is 'plugged in' to the needs of policy makers.
One project under this Network is particularly timely: the "New Perspectives on Health Policy Project."
As you know, limited fiscal resources in health care have forced us to look at the potential for
'upstream' solutions that can generate better health outcomes and even alleviate 'downstream' (e.g.
acute care) costs down the road.
Population Health Approach
The population health approach is extremely useful in this regard, because it focuses on achieving
health and not just treating the sick. And because it focuses on health outcomes it leads
to a mind-set that encourages us to think in terms of the underlying determinants of those outcomes.
This last point is crucial, because it is only by looking at the underlying determinants of outcomes
that we can find the appropriate 'policy levers' for achieving those results.
To date, population health research is "suggestive" of the interactions between individuals' biology,
lifestyles, socioeconomic situation and the level of health they will enjoy. The Second
Report on the Health of Canadians is an example of this. But what is missing is the solid evidence
about the interventions that actually work and lead to those 'downstream' savings.
And without such evidence, it is difficult to know precisely which policy levers to change- or to
pull.
The CPRN project, and others like it, must try to help in this regard by doing the rigorous analysis
that takes one to the policy lever level, and by recommending and assessing the best mechanisms for
achieving outcomes.
This will not be easy, because it means establishing causality, and separating out the policy levers
from the numerous other factors contributing to a particular health outcome.
Still, progress is possible and will be greatly aided by the contribution of new, advanced analytical
techniques applied to the much richer data sources now coming "on stream." For example, Statistics
Canada can now link the National Population Health Survey with Revenue Canada's administrative data
on earnings and their sources to look much more closely at the socioeconomic gradient and health
outcomes.
Conclusion
In closing, our goal must be to integrate our approach to health policy with the other social and
economic aims of Canadians. And to do that, we need both better information and better systems to
connect that evidence to decision-makers.
As I have suggested, that goal can be furthered by developing a dynamic external research capacity;
by developing a strong internal capacity, with sufficient expertise to understand and adapt the research
of others.
It can be advanced by integrating across different disciplines and structures so that we obtain
the greatest efficiencies and balance the immediate demands of the short term with the necessary
investments in longer-term research.
And we will need to develop the information systems that will tie the whole system together and
help us to communicate our findings more effectively.
Thank you.
|
