Knowledge Value Chain in Health

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Bulletin of the World Health OrganizationPrint version ISSN 0042-9686

Bull World Health Organ vol.84 no.8 Genebra Aug. 2006

doi: 10.1590/S0042-96862006000800009

POLICY AND PRACTICE

The knowledge-value chain: a conceptualframework for knowledge translation inhealth
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La chane de valeur des connaissances : un cadre conceptuelpour la mise en pratique des connaissances en sant

La cadena de revalorizacin de los

conocimientos: un marco conceptual para latraslacin de conocimientos en materia de salud

Rjean LandryI; Nabil AmaraI; Ariel Pablos-MendesII;Ramesh ShademaniII,1; Irving GoldIII

IDepartment of Management, Faculty of Business, Laval

University, Qubec City, Canada G1K 7P4IIDepartment of Knowledge Management and Sharing, WorldHealth Organization, 1211 Geneva 27, SwitzerlandIIICanadian Health Services Research Foundation, Ottawa,Ontario, Canada

ABSTRACT

This article briefly discusses knowledge translation and lists theproblems associated with it. Then it uses knowledge-managementliterature to develop and propose a knowledge-value chainframework in order to provide an integrated conceptual model ofknowledge management and application in public healthorganizations. The knowledge-value chain is a non-linear conceptand is based on the management of five dyadic capabilities:mapping and acquisition, creation and destruction, integrationand sharing/transfer, replication and protection, and performanceand innovation.

RSUM

L'article prsente brivement la mise en pratique desconnaissances et recense les difficults que rencontre cetteopration. Il utilise ensuite la littrature disponible sur la gestiondes connaissances pour dvelopper et proposer un cadre du typechane de valeur, visant fournir un modle conceptuel intgrde la gestion et de la mise en pratique des connaissances dans
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les organismes de sant publique. Ce modle est non linaire etrepose sur l'organisation de cinq couples d'activits : cartographieet acquisition, cration et destruction, intgration etpartage/transfert, reproduction et protection, et performances etinnovation.

RESUMEN

En este artculo se analiza brevemente la traslacin deconocimientos y se enumeran los problemas asociados. Acontinuacin se hace uso de las publicaciones existentes sobre lagestin de los conocimientos para desarrollar y proponer unsistema de cadena de revalorizacin de los conocimientos conmiras a ofrecer un modelo conceptual integrado de gestin yaplicacin de los conocimientos en las organizaciones de saludpblica. La cadena de revalorizacin de los conocimientos es unconcepto no lineal, basado en la gestin de cinco capacidades

binarias: mapeo y adquisicin, creacin y destruccin, integracine intercambio/transferencia, replicacin y proteccin, ydesempeo e innovacin.

Introduction

The golden era of modern research, which started after theSecond World War, was a period during which research findingsoutside strategic government projects were published1 andpassive diffusion followed. The 1970s saw the birth of evidence-based medicine, which used a "push strategy" of both activedissemination of practice guidelines and education for their localinterpretation and adaptation; technology assessment alsoemerged at a time when private industry took over most of theresearch and development of products. At the time, conceptualframeworks derived from the social theory of the diffusion ofinnovation included those of research transfer and researchutilization; the private sector developed value-chain models andmarketing strategies. The success of evidence-based medicine,


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however, plateaued in the 1990s and the new millennium dawnedbringing fresh thinking to this old frontier. In Canada, forexample, as the institutions were reorganized or created, theterm "knowledge translattion" was coined and it emphasizedmodels of linkage and exchange.2

The concept of knowledge translation (KT) is developing at a timewhen unprecedented global investments in health research havegenerated a vast pool of knowledge that is underused and nottranslated rapidly enough into new or improved health policies,products, services and outcomes. KT comes at a time when thegap between what is known and what gets done (the knowdogap) is highlighted by shortfalls in equity (for example, asunderscored by the Millennium Development Goals)3 and quality(resulting in the developmment of the patient safety movement)in health services. However, there is a limited interpretation of KTas a linear transaction between research "producers" and "users"who trade knowledge as a commodity. Knowledge can be createdwithout science and KT is not research: it moves from respondingto curiosity to focusing on purpose and problem solving. It isdefined as "the synthesis, exchange and application of knowledgeby relevant stakeholders to accelerate the benefits of global andlocal innovation in strengthening health systems and improvingpeople's health".4 More concretely, KT is about creating,transferring and transforming knowledge from one social ororganizational unit to another in a value-creating chain: it is acomplex interactive process that depends on human beings andtheir context. The transfer of knowledge from one community ororganizational unit to another usually faces five problems:knowledge access, knowledge incompleteness, knowledgeasymmetry, knowledge valuation and knowledge incompatibility

(Box 1).58
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The knowledge-value chain

Knowledge management studies tend to adopt the organizationas their focus of attention, thus looking at how organizationalcharacteristics affect the translation and implementation ofknowledge in the solving of public health problems. Themanagement literature considers knowledge to be the resourcewith the highest strategic value for organizations. For publichealth organizations, such as WHO, the capability to acquire,create, share and apply knowledge represents their mostsignificant capability in terms of solving public health problems.Two characteristics arise from such a perspective on knowledge


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and organizations. The first characteristic is related to the processof knowledge application. The second characteristic is related tothe aim of knowledge application, which is to create value fororganizations. These two characteristics suggest that knowledgeshould be managed and used as a resource that adds value to theactivities undertaken in the production and delivery processes of

public health organizations. In management literatture, this ideaof value creation is often approached through the concept of aknowledge-value chain. The arguments that follow describe theframework presented in Fig. 1 (the arrows linking thecomponents of the chain indicate the non-linear nature of theknowledge-value chain).

In this paper, the concept of a knowledge-value chain isdeveloped in three stages. First, we look at what the word"knowledge" could mean for public health organizations. Second,we consider the value characteristics of knowledge. Third, wereview the five dyadic capabilities supporting the concept of aknowledge-value chain in public health organizations.
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What does knowledge mean for public healthorganizations?

Knowledge constitutes an intangible resource that takesmultivariate forms. Blumentritt & Johnston have reviewed themost frequently cited typologies of knowledge.9 Their reviewshows that there is an overlap between typologies. Clearly, thereis no consensus about the level of analysis at which knowledge isa valid concept. For the sake of this papper it is useful tocategorize knowledge according to its articulability and itsholders. Articulability refers to the differentiation between explicit(or codified) knowledge and tacit knowledge. Explicit knowledgeis knowledge that can be consciously understood and articulated,for example, in the form of scientific articles, books, guidelinesand electronic records. It includes explanatory knowledge andexplicit propositions. Tacit knowledge is knowledge that the

knowledge holder is not aware of. For instance, the knowleedgeholder may know how to ride a bicycle but could articulate thisknow-how only with great effort.

When addressing issues related to knowledge application,technical experts have the inclination to depend almostexclusively on explicit knowledge. The realm of biotechnologyresearch and evidence-based medicine is dominated by theintensive use of explicit knowledge. By comparison, practitionersin the health professions, policy-makers and managers of publichealth organizations rely on the use of complementary types ofknowledge in a context where explicit research knowledge doesnot usually dominate. The lesson that can be derived fromexamining the different types of knowledge used is that sounddecisions and professional practices must be based on multipletypes and pieces of knowledge that bring complementarycontributions to problem solving.10 Explicit and tacit knowledgeare especially important with respect to knowing how to performa particular task, solve problems and manage change in unique,complex or uncertain circumstances. Additionally, organizationsare necessary to provide the infrastructure in which individualscan coordinate the integration of their specialized knowledge inorder to solve problems.

What are the value characteristics of knowledge?

Knowledge is information whose certainty is context-dependentand that gives individuals and organizations the capacity to act.Knowledge is the result of a series of three successivetransformations.


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1. From reality to data: This transformation allows individualsand organizations to develop instruments to represent, collect,record, and store discrete facts about reality.

2. From data to information (also called "know-what"):This transformation allows individuals and organizations to

process and organize data in order to create a message, such asby producing reports.

3. From information to knowledge (also called "know-how"): This transformation allows individuals and organizationsto interpret information in order to derive an action.

Knowledge carries characteristics that increase or decrease itsvalue. In the field of public health, one can associate four value-increasing characteristics with knowledge: (1) the deployment ofknowledge is possible at the same time in multiple sites aroundthe world; (2) knowledge increases in value when used by

multiple knowledge holders; (3) knowledge brings increasingreturns (instead of diminishing returns as tangible assets may) the more we use it, the better we use it and the better are theoutputs and outcomes; and (4) knowledge creates futureopportunities using knowledge improves learning which, inturn, creates opportunities for future action and interventions.

Conversely, knowledge also carries value-decreasingcharacteristics that public health officials need to consider: (1)knowledge assets are more difficult to manage than tangibleassets such as medical equipment; (2) investments in knowledgeassets aimed at developing or improving public healthprogrammes and interventions are risky due to their role in theearly stages of innovation; (3) knowledge assets are difficult tomeasure; and (4) valuing knowledge assets is difficult. These lasttwo characteristics mean that collecting solid evidence onknowledge investment and returns from investments in publichealth programmes and interventions is usually not easy.

From knowledge to the knowledge-value chain

By defining knowledge as the capacity to act, we postulate thatthe combined use of knowledge and other resources givesorganizations their capabilities for action. There is no consensuswith respect to the critical capabilities required to manageknowledge productively.11 In public health, five dyadic capabilitiesappear to be of critical importance: (1) the capabilities ofmapping and acquisition complement each other; (2) creation ispartly associated with destruction; (3) integration is dependenton sharing and transfer; (4) replication is related to protection;and (5) performance assessment is linked with innovation.Knowledge creation is the capability that has received the most


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attention from the research community. The other capabilities areless well documented but the management literature hassomething to say about all of them.

From an organizational perspective, the interdependence of suchdyadic capabilities generates a knowledge-value chain that moves

from knowledge mapping and acquisition up to the productionand delivery of new or improved public health programmes andinterventions delivering added value for people.1214 The mission,vision, goals and strategies of a public health organization orsocial enterprise drive the knowledge-value chain. The higher theknowledge performance related to dyadic capabilities, the higherthe value generated (Fig. 1).

Knowledge mapping and acquisition

The internal knowledge mapping in a public health organizationallows it to learn what it knows. It refers to the understanding

and self-awareness that an organization has with respect to itsknowledge resources and their limitations.15 Internal knowledge isespecially important because it is unique, specific to theorganization, tacit and therefore difficult to reproduce byknowledge holders located outside the organization. On the otherhand, external knowledge acquisition refers to a capability forexternal awareness, more specifically to the capacity foridentifying and acquiring knowledge from external sources andmaking it suitable for subsequent use by the organization.Knowledge mapping and acquisition involve many specificcapacities for example, locating, accessing, valuing andfiltering pertinent knowledge; extracting, collecting, distilling,refining, interpreting, packaging and transforming the captured

knowledge into usable knowledge; and transferring the usableknowledge within the organization for subsequent use in problemsolving.11 External knowledge may provide new ideas andcontexts for benchmarking internal knowledge; this type ofknowledge is more explicit and more costly to acquire but it iseasily available from other similar public health organizations.

Based on the results of the knowledge mapping and acquisitiondiagnostic, one could attempt to look into the knowledge gap thatmay exist between what a public health organization has to knowto implement its mandate and what it currently knows. Thisassessment may lead to one of three conclusions: (1) the

organization faces a situation where there is an internalknowledge gap if it does not know enough to implement its publichealth mandate; (2) the organization has an external knowledgegap if it knows less than what other public health organizationsknow in order to implement similar mandates; (3) theorganization has no knowledge gap if it knows enough toimplement its mandate or if it knows more than other publichealth organizations know in order to implement similarmandates.
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Knowledge mapping and acquisition may rely on one of fourorganizational modes: undirected viewing, conditioned viewing,informal search and formal search.16 In undirected viewing, apublic health professional is exposed to information when he orshe has no specific public health informational needs in mind.Undirected viewing is an informal strategy that can be useful for

the early detection of emerging problems. In conditioned viewing,a public health professional directs his or her viewing oninformation regarding selected public health topics or issues.During the informal search process, a public health professionallooks for information that will improve his or her understanding ofa specific public health issue. Finally, in a formal search a publichealth professional engages in a systematic search for ideas,information and knowledge about a specific public health issue.This last mode includes conducting systematic reviews andexternal surveys as well as training and hiring employees (inorder to bring knowledge into the organization). The othermapping and acquisition modes are more likely to rely onidentifying and acquiring ideas, information and knowledge

through informal networks.

Knowledge creation and destruction

The size of internal and external knowledge gaps influencesknowledge-creation efforts. The knowledge-creation capabilityrefers to the capacity to combine knowledge (tacit, explicit,individual and collective, internal and external) in order todevelop new knowledge.17,18 Knowledge creation is usuallyassociated with research and development activities. However, itshould also be understood to include activities such as solving apublic health problem, devising a public health promotion

strategy, discovering a pattern, developing a public healthprogramme or intervention, or conducting monitoring andevaluation activities. Only individuals can create knowledge.Organizations support and amplify the knowledge created byindividuals.13

We know little about the knowledge-destruction capability, whichis the capacity to eliminate pieces of knowledge or disentanglethe interconnectedness of pieces of knowledge.19 Two examplesof knowledge that are frequently targeted for destruction includeprofessional behaviour based on experience and organizationalroutines.20 Knowledge destruction frequently paves the way for

knowledge creation and innovation. However, the adoption ofbudgets for or spending on restructuring and re-engineeringshows how difficult it is to abandon old knowledge. The literatureon evidence-based medicine also shows to what extent it isdifficult to destroy old knowledge and replace it with theimplementation of new knowledge (for example, replacing oldclinical guidelines with new).

Knowledge integration and sharing/transfer


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Knowledge integration is the capacity to transform a public healthorganization's knowledge resources (tacit, explicit, individual,organizational, internal, external) into actionable knowledge bytaking into account the organization's strengths, weaknesses andopportunities as well as threats to the organization.13 Over time,public health organizations develop more or less explicit

processes to synthesize the internal knowledge accumulated andto integrate it with knowledge acquired from other organizationsor other external sources (such as scientific publications orclinical guidelines). Organizations integrate the knowledgeaccumulated over time, developing and delivering programmes,interventions and services using knowledge from externalsources.

Integrating disjointed pieces of raw knowledge into actionableknowledge is necessary but not sufficient to solve public healthproblems; knowledge must also be shared and transferred.Knowledge sharing refers to the capacity to make availablepertinent knowledge to others within an organization, aprogramme, a project or an intervention.21 Knowledge sharing ismore demanding than knowledge reporting.22 Reporting involvesdisseminating information through codified formats (such as an ITsystem) to target groups within a public health organization. Bycontrast, sharing implies person-to-person interactions duringwhich one individual converts his or her (individual and oftentacit) knowledge into a form that can be understood by othermembers in the organization.23 Knowledge sharing provides themechanism to transform individual knowledge into organizationalknowledge that can be redeployed to create value and solveproblems at the organizational level. Knowledge sharing is asocial process that may lead to the emergence of communities of

practice.24

In public health, such communities exist at the local,regional, national and international levels.

Knowledge transfer complements knowledge sharing. Like Ipe,21

we associate sharing with an exchange of knowledge betweenindividuals and we associate transfer with the exchange ofknowledge between organizations or departments or divisionswithin organizations. The literature has identified many factorsthat contribute to the successful sharing and transfer ofknowledge: the type of knowledge, the formal and informalmechanisms linking the sources and recipients of knowledge thatprovide opportunities to share and exchange, and organizationalfactors, which include the culture of the work environment.21,2527

Knowledge replication and protection

The knowledge that has been shared or transferred provides atemplate or a guideline for decisions and actions. Knowledgereplication is the capacity to identify the attributes of theknowledge that are replicable, how these attributes can berecreated, and the characteristics of the contexts in which they


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can be replicated successfully.28 Replicating templates andguidelines is never easy. There are always significant differencesbetween the attributes of the knowledge and the context of theaction and decisions described in the templates and guidelines,and a real public health context. Moreover, the knowledge that isshared and transferred is never provided with "how-to" manuals

appropriate to fit all local conditions. The many idiosyncraticfeatures of the local context in which public health organizationsoperate make the precise replication of templates and guidelinesdifficult, if not impossible. Knowledge replication must be guidedby the attributes of the local context of actions and decisions,especially with respect to public health.

The capacity to replicate knowledge improves the efficacy andefficiency of public health programmes and interventions.However, knowledge replication is limited by many legalmechanisms of knowledge protection, such as patents,copyrights, trademarks and confidentiality agreements. Publichealth organizations aim to facilitate knowledge replication in acontext in which the biomedical industry frequently places theemphasis on knowledge protection (patent protection).

Knowledge performance and innovation

The assessment of knowledge performance is the capacity toassess to what extent the replication of knowledge delivers thedesired outputs and outcomes. Assessments are usuallyundertaken for one or a combination of perspectives that aim tobalance the financial and non-financial outputs and outcomes.2931

These perspectives assess:

1. value for money the public health benefits arising frominvestments in the creation, sharing and application ofknowledge;

2. knowledge users the extent to which public health policydecisions, community enterprises and professional practices arebased on sound evidence and the extent to which evidence-basedpolicy decisions and evidence-based professional practicescontribute to the development of new products and services orimprove them;

3. final beneficiaries of knowledge translation the extent

to which evidence-based policy decisions and evidence-basedprofessional practices are translated into new or improvedproducts and services and superior public health outcomes;

4. internal organizational process to provide an account ofthe activities and processes that public health organizations mustdevelop and excel at to achieve a milieu of superior knowledgecreation, sharing, transfer and replication for evidence-basedpolicy decisions and evidence-based professional practices and to


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achieve superior outcomes for the final beneficiaries of knowledgeapplication.

The performance-assessment capability is oriented towards theshort term. It should always be complemented by an innovationcapability that is more future-oriented. The innovation capability

is the capacity to develop a better understanding of theknowledge application process to enhance the future use ofresearch evidence and other sources of knowledge in thedevelopment and improvement of products and services and toachieve superior outcomes for the final beneficiaries of knowledgetranslation.

Conclusions

Any knowledge-management strategy should address these five

perspectives and formulate objectives and success factors foreach perspective. However, each public health organization orcommunity will arrrive at its own particular trade-offs betweenthe five perspectives in order to achieve its strategic knowledge-translation goals.29 The learning and innovation perspective islikely to be the primary driver in achieving superior outcomes forthe final beneficiaries of knowledge application. Such aperspective is supported by improved policy and managerialprocesses which, in turn, contribute to enhancing evidence-baseddecision-making and evidence-based professional practice. As aresult, the enhanced use of evidence contributes to achievingsuperior outcomes for the final beneficiaries of knowledgetranslation, which in return, generate value for money invested inknowledge and, through a feedback process, enhance learningand product and service innovation and development.

Funding: Rjean Landry and Nabil Amara acknowledge thefinancial support of the Canadian Health Services ResearchFoundation and Canadian Institutes of Health Research for thepreparation of this paper.

Competing interests: none declared.

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(Submitted: 7 April 2006 Final revised version received: 2 June2006 Accepted: 5 June 2006)

1 Correspondence to Ramesh Shademani (email:[email protected]).

2010 World Health Organization

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SwitzerlandFax.: +41 22 791 4894

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