Contents
1.    The challenge of the healthcare systems in Latin America and the Caribbean
2.    Evidence-based public policies?
3.    Healthcare systems: social systems and political processes
4.    Knowledge and information needed for the development of the healthcare systems in Latin America and the Caribbean.

Premises
1.    The development and strengthening of the domestic healthcare systems is one of the most important tasks of the states and governments of Latin America and the Caribbean.
2.    Decision-making in Public Policies and Healthcare Systems requires scientific knowledge support.

The challenges of the healthcare systems
1.    To reduce inequalities and inequities and social exclusion in health.
2.    To protect the population from health damage and risks (epidemiological  accumulation)
3.    To contribute to social cohesion and to assure citizens the social right to health.
4.    To meet the commitments expressed in the Millennium Goals.

Social exclusion in Health: Latin America and the Caribbean, 2003.
1.    230 million inhabitants (46%) do not have health insurance.
2.    125 million inhabitants (25%) do not have permanent access to basic healthcare service.
3.    17% of births are not properly cared by skilled health staff.
4.    680,000 children do not complete their vaccination schedule – DPT3 every year.
5.    152 million persons do not have access to running water and basic sanitation.

PAHO/ WHO global and regional mandates
1.    Health for All, 1977
2.    Primary Health Care, 1978
3.    Sustainable healthcare systems that will assure equity, universal access and quality, 1994, WHO 2005.
4.    Extension of Social protection in health, 2001
5.    Systems based on the primary health care strategy, 2005

Public policies and scientific knowledge
It is required that scientific knowledge support the decision-making processes in public policy and health system building.

The issue of evidence-based public policies
The issue of the gap separating researchers from political decision makers.

EVIDENCE IS A RESULT OF SCIENTIFIC RESEARCH, it is a USE of KNOWLEDGE.
Evidence-based public policies?
Influence of Evidence-based Medicine paradigm (EBM)
Assumption: the policies fail because they are not based on evidence.

EBM
1.    Origins
2.    Forensic legal research
3.    Clinical epidemiology
4.    Successful and very useful in clinical practice.
5.    Influence of the model Controlled Randomized Studies.

Criticism on EBM paradigm applied to the public policy

EBM in Public Policy
It assumes that relation between research and policy is linear
A………….B
•    That political decision-making is an isolated event
•    That political systems and healthcare systems are simple and predictable machineries.
•    It does not take into account the importance of the setting.
•    The analysis unit is the individual; in public polity the unit is the population.

Why does the model work in public policies?

•    Political decision-makers have targets other than the clinical effectiveness (social, financial, strategic development of services, Human Resource management, elections, political pressure, etc, etc).
•    Evidence (derived from research) is considered irrelevant (corporative, inferred knowledge, not applicable to local reality)
•    No consensus on evidence (complexity of evidence, scientific controversy, many interpretations).
•    Competition of other types of evidence: personal experience, local information, experts´ opinions, etc.
•    Poorly favourable social environment to policy changes. EBM does not consider the political viability.

Who are the political actors?
•    Not only the high governmental officials, responsible for policy formulation.
Included are
•    Political parties
•    Organized citizens (civil society)
•    Corporations
•    Professional
•    Entrepreneurial and industrial
•    Tradeunion
•    Financing bodies and cooperation agencies (multilateral and bilateral cooperation)

Three types of health policy (Black 2001)
1.    Practical policies
2.    Use of resources by professionals
3.    Clinical effectiveness

•    Service policies
•    Allocation of resources
•    Service organization models
•    Service operation
•    Governance policies
•    Management
•    Financing
•    Structures

Evidence in public policies
1.    Descriptive information
2.    Economic data, cost of life, taxes, unemployment, coverage, etc
3.    Analytical information
4.    Research that identify factors associated to conditions (life, health, system behaviour)
5.    Evaluation
6.    Program and service effectiveness
7.    Political analysis.

Gap between researchers and public policy decisors
•    Mutual distrust, tensions and misunderstanding
•    The joining of research and political decision-making has a great impact on the quality of the process of policy making and its implementation…
•    Active search for bridges between both parties
•    Possibilities for encounter
•    Condition: Overcoming – denial of the linear and mechanical model by a social, interactive model

Types of uses of research
1.    Instrumental (practical and service policies)
2.    Conceptual (service and governance policies: change of understanding of a situation)
3.    Mobilization of support (governance policies: research as persuading tool – value of argument)
4.    Influence expansion (governance policies; beyond the health sector, change of political paradigms, citizen behaviour patterns).

Models of encounter between research and policy
Beyond dissemination of knowledge (linear process)
Two main models:

Knowledge brokering (networks)
Individual
Organizational………………….Knowledge and practice communities
Knowledge translation (Communication)

Who are following this working line in our Region?
•    Canadian Health Services Research Foundation: http://www.chsrf.ca/home e.php
•    Canadian Institute of Health Research (CIHR): http://www.cihr-irsc.ca/
•    OMS: http://who.int/kms/en (Evipnet)
•    Iniciativa OPS-IDRC: http://www.paho.org
•    The Cochrane Collaboration: http://www.cochrane.org/
•    Centre for Knowledge transfer: http://www.ckt-ctc.ca/
•    Canadian Coalition for Global Health Research:   http://www.ccghr.ca/