Bridging the Know-Do Gap

by Alex Whitcomb and Michelle Roberts

“Action without knowledge and knowledge without action means wasted resources and missed opportunities” –Dr. J. W. Lee, WHO Director General

The know-do gap is the chasm between what is known and what is done in practice.  Dr. Paul Farmer frames the know-do gap in terms of infectious disease in saying,

“Simultaneously, rising life expectancy and rapid social change have led to an increasing burden of chronic diseases for which we have effective therapies but inadequate innovation for delivering them efficiently to the neediest people–the so-called know-do, or delivery gap”  (Farmer, 2013). 

This is a fundamental challenge in global health and reducing the global burden of disease.  Though this is a fundamental challenge, it also provides the greatest opportunity for strengthening of health systems.

The gap exists from research and policy to practice as well as the gap between knowledge and awareness to action and behavior change.  Eliminating this gap would mean eliminating preventable deaths.  It is estimated that two-thirds of child deaths worldwide could be prevented by available, effective and cheap interventions.  The World Health Organization estimates that 85.34% of the global disease burden is addressable by already available and cost effective interventions. This is huge.  If this is the case, why isn’t this being done?  Why is this still such an enormous problem?

The challenge remains to synthesis existing knowledge and disseminate this knowledge appropriately.   There is a wealth of information that exists on the Internet, but policy makers, health managers, and service providers are not receiving succinct and synthesized information.  Grimshaw et al. (2004) stated in a review that assessed guideline dissemination and implementation strategies that “despite 30 years of research in this area, we still lack a robust, generalisable evidence base to inform decisions about strategies to promote the instruction of guidelines or other evidence-based measures into practice” (Grimshaw et al., 2004).

Furthermore, care delivery is messy. It isn’t easily studied with a randomized-controlled trial – there are too many variables, too many potential confounders. This is especially true in impoverished settings with endemic inequality. Developing effective care delivery strategies requires observational and qualitative methods and establishing cultural understandings. Despite all of these obstacles, it remains fundamentally true that all our research is for naught if we don’t actually help anyone with it. Isn’t that why we all want to be in global health in the first place anyway?

Policy memos are a tool for bridging the knowledge gap between research and policy.  When done correctly, policy memos provide a concise and comprehensive account a specific problem with an impactful, feasible, cost effective solution.  

Yet, policy memos are only one example of the implementation of public health research. For a new intervention, vaccine, or service to alleviate disease to be effective it must be addressed systematically through policy and programs and services to implement the latest scientific data into patient care.

One of the most poignant examples of the power of care delivery has been the President’s Emergency Plan for AIDS Relief (PEPFAR). PEPFAR was able to do what many thought couldn’t be done - treat a chronic infection with a multidrug regimen poor settings. PEPFAR has made huge strides to diagnose HIV disease, enroll patients, and thus bridge the know–do gap and have a real effect on patients’ lives. Worries about patients in low-income settings ability to follow complex multidrug regimens have been proven surmountable. Dr. Farmer estimated that “in Haiti and Rwanda, so too in South Africa, Kenya, Tanzania, Uganda, Mozambique, and across the continent: more than 7.1 million Africans — nearly half of those who would most benefit from it — are now receiving ART; an estimated 700,000 deaths and more than 200,000 perinatal infections were averted in 2010 alone” (Farmer, 2013). The success in the global effort to combat HIV/AIDS shows what can be done when the know-do gap is addressed effectively and systematically.

The solution lies in figuring out a path to action for each unique situation and replicating a model to scale up.  In order to reduce the know-gap, we must focus on knowledge translation.  We must bring together information from entrepreneurs, basic research and innovation and operations research, and synthesize results to scale up and allow for continuous improvement.  Knowledge translation strategies can harness the power of scientific evidence and leadership to inform and transform policy and practice.

If you’re interested in learning more about the know-do gap, why it is so problematic, and what has been done to address it, read Dr. Farmer’s article in the New England Journal of Medicine, “Chronic Infectious Disease and the Future of Health Care Delivery.”

The effectiveness of PEPFAR and the Global Fund’s efforts to fight HIV/AIDS was accomplished because of advocacy efforts to overcome the delivery gap. Now, we must engage in advocacy efforts for other disease burdens to develop care delivery systems and meet real need. Doing science isn’t enough. If our work is to have any real impact, we must figure out how to apply it to the lives of those suffering from disease around the world.

  

Farmer, P. E. (2013). Chronic Infectious Disease and the Future of Health Care Delivery. New England Journal of Medicine, 369(25), 2424–2436. http://doi.org/10.1056/NEJMsa1310472

Grimshaw, J., Thomas, R., MacLennan, G., Fraser, C., & Ramsay, C. (2004). Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment, 8(6), 84. http://doi.org/10.3310/hta8060