Can medical journals contribute
to the national health?
Medical journals are no longer the preserve of the academic community. Their function is no longer just to share information among the scientific community and meet promotion requirements. Readership is widening and demands of readers are changing. Analysis of Pakistan’s medical journals as listed in the Index Medicus for the Eastern Mediterranean Region indicates a domination of general medical journals with little obvious scope for linking up with health system needs. Editors of medical journals are uniquely placed to help bridge the gap between research and policy- making. Medical journals have immense potential to contribute to health in Pakistan and its time to develop their potential in this regard.
Most medical editors in the region see their journals as a vehicle for publishing research so that the authors can advance their careers, in line with the requirements and pressures of the academic community in which they function. But there are other considerations: improving patient care, for example, or sharing knowledge, influencing health outcomes, informing policy-making. Globally, most of the burden of premature death and illness among the poor, in particular, is due to problems for which solutions are known and prevention is possible. Many of the solutions to health problems of the poor are known but are not applied.1 This know-do gap is seen as a key obstacle to progress in improving health and health equity, and to attainment of national health goals and the UN millennium development goals (MDGs).
There is of course a wide body of knowledge also available, globally and nationally, to provide solutions to health problems affecting the wider population, not only the poor. Nevertheless, despite its availability, evidence is often not shared with or disseminated to or otherwise does not reach the policy-makers, decision makers, practitioners or the communities who need to know. Nor does it always translate into improved clinical protocols, improved health systems practices, norms, standards and guidelines. Furthermore, the quality and relevance of that research to either good clinical practice or policy-making is rarely evaluated.
Access to health information is itself inequitable for reasons of affordability, infrastructure, capacity to find and manage information, or simply because the information is not available in appropriate formats, languages or cultural contexts. At the same time, paradoxically, for many there is information overload which makes it difficult to assess and extract the most useful.2 The creation of knowledge and the formulation of policy are two different processes. Often, it is the academic community, rather than the policy-making community, that decides what research is conducted and this results in research which does not answer the questions the latter wants answers to.3,4 Policy-makers may see a problem but not know how to frame the question or find the answer. In countries such as Pakistan, where resources available for research are limited it makes sense to bring the two sides together to address the issues that really matter. Making the most effective use of the limited resources means making strategic decisions about what type of research is conducted.
Health systems research in particular seeks to find solutions to very real problems affecting the health of the population, health care and health equity, and health research policy is increasingly targeted at support for research that meets those objectives.5 Medical journals offer a crucial link between the academic community, policy makers, decision makers in the health system and health practitioners. Increasingly they also provide a link with the community, as literacy levels improve and as access to health information through the internet increases. Medical journals are in the business of sharing knowledge and they are increasingly adept at managing the production of knowledge in both print and electronic format so that it is easily and freely accessible. WHO defines the term ‘knowledge management’ as “a set of principles, tools and practices that enable people to create knowledge and to share, translate and apply what they know to create value and improve effectiveness”. Medical journals are an important element in the knowledge management structure, providing just such a tool for knowledge creators to share and translate what they know so that it can be applied to create value and improve effectiveness in health. They thus have a clear role to play in national health strategy but are they fulfilling this role?
Medical journals are no longer the preserve of the academic community. Their function is no longer just to share information among the scientific community and meet promotion requirements. Their readership is widening, and if they are publishing research in which the community has participated and that the nation has supported, then surely they have a duty to ensure that information reaches those who need it and can use it. To fulfil this role they need good quality research material. This means research that addresses questions that are important to the community and the nation, that is relevant and timely. This means, first, that the journal must have a peer review system to be able to evaluate the articles submitted to it. Second the journal itself needs to meet some quality criteria. In addition to peer review, regularity in publication is important. Third people need to know the journal exists. This means being indexed, at least at national level and regional level, and if possible at international level. Fourth, the journal needs to be interesting to the readership, highlighting the messages contained in the journal so that they become relevant, through summaries, editorials, education sections, policy to practice sections and community medicine sections.
Of course this is a two way relationship. Policy makers, health systems decision makers and practitioners also need to start demanding that journals deliver the information they need in a way they can make use of. Policy-makers who want to solve their country’s health problems need to read the journals, and engage with researchers and editors, not only to identify the problems and find the solutions but to promote translation of knowledge into policy and practice.6 Finally, we need to ensure that the research being conducted and the journals available for publishing are appropriate.
Looking at the dominant health issues in Pakistan, i.e. those that affect the majority of the population, the profile is of a country where social and health indicators have yet to catch up with improvements in economic growth.7 The latest surveys for which data are available indicate that around a quarter of the population lives below the poverty line and this is reflected in the health indicators. The effects of malnutrition, diarrhoeal disease, acute respiratory illness and other communicable and vaccine-preventable disease, and inequitable access to quality health care are still very much in evidence. Pakistan is in an epidemiological transition with communicable disease on the one hand, and non-communicable disease and injuries on the other accounting for almost equal proportions of mortality. Vaccine-preventable diseases, diarrhoeal diseases, hepatitis B and C, TB, malaria and acute respiratory infections all contribute significantly to the burden of disease. Meanwhile, changing lifestyles mean that diabetes, hypertension, cardiovascular diseases and cancer are increasing. The number of injuries due to road traffic accidents is already high despite relatively low density of traffic compared with other countries. The relative rate of noncommunicable diseases is rising in relation to communicable diseases as the population and life expectancy grow.
Of the 60 or so journals in Pakistan, how many are targeted at the issues the country needs to address? How many are devoted to tackling: health systems, health policy, health education, health behaviour and lifestyles. How many editors are asking the research community to address the issues that matter? How many editors are engaging with the research community they serve and with their readers, and with the wider constituency: the policy-makers and the community at large? How many more small hospital-based studies does the country need? It is a responsibility of editors to anticipate the needs of readers, of the community and of the country. Editors need to start raising these issues. If they don’t, readers will eventually start demanding the journals address the real issues. And they will start reading those journals that do meet their needs.
Brief raw analysis of Pakistan’s medical journals as listed in the Index Medicus for the Eastern Mediterranean Region indicates a domination of general medical journals, some representation for public health and mental health but little obvious scope for linking up with health system needs (Table-1). Editors of medical journals are uniquely placed to help bridge the gap between research and policy-making. A number of steps could be taken to help this process. At least two countries in the WHO Eastern Mediterranean Region have established national committees on medical journals to set minimum quality criteria for journals to be accepted as vehicles for promotion. Revitalization of the process of national indexing, with criteria for acceptance, would help journals prepare for indexing at regional and international level. Dialogue and engagement with key stakeholders at national level to support quality in research and research publishing is also a key step. Medical journals have immense potential to contribute to health in Pakistan and its time to develop their potential in this regard. The question then, finally, is not: Can medical journals contribute to the national health, but, are they contributing to the national health?
1. World report on knowledge for better health: strengthening health systems. Geneva, WHO. 2004.
2. WHO global knowledge management strategy. Geneva, WHO, 2005.
3. van Kammen J, de Savigny D, Sewankambo N. Using knowledge brokering to promote evidence-based policy-making: the need for support structures. Bulletin of the World Health Organization, 2006, 84:608-612.
4. Pang T. Evidence to action in the developing world: what evidence is needed? Bulletin of the World Health Organization, 2007, 85: 247.
5. WHO. The Mexico statement on health research. Knowledge for better health: strengthening health systems. From the Ministerial Summit on Health Research, Mexico City, 16-20 November 2004. Available from http://www.who.int/rpc/summit/agenda/Mexico_Statement-English.pdf (accessed 10 September 2007).
6. Hamid M et al. EVIPNet: translating the spirit of Mexico. Lancet, 2005, 366:1758-1760.
7. WHO. Pakistan country profile. Available from http://www.whopak.org/pakprofile.htm (accessed 10 September 2007).
WHO Regional Office for the Eastern Mediterranean,
Cairo - Egypt.