Health systems: more evidence, more debate.

The design and performance of health systems are now at the centre of the international health agenda. This month’s special section of the Bulletin and The World Health Report 2000 are both devoted to health systems. The next decade will witness a lively debate on these issues, increasingly fuelled by multicountry evidence and analysis. Historically, the World Health Organization has not been heavily engaged in policy work on health systems or health economics and finance. Throughout the 1990s, the World Bank was the strongest influence in these areas. Since the election of its new Director-General in 1998, WHO has signalled its intention to strengthen its competence and influence in nonmedical areas such as economics and finance. This intention was marked dramatically in January 2000 by the launch of the highprofile Commission on Macroeconomics and Health. This month, with its two major publications on health systems, WHO takes a further step towards a leadership role in global thinking on health policy. Health systems policy issues are intrinsically complex. The evidence is weak, no country has discovered an ideal model, and appropriate policies differ widely in different country settings. Publications in this field, especially if they are bold in their conclusions and prescriptions, are likely to prove controversial and attract criticism. This is to be welcomed. What the world needs is more evidence, more intercountry sharing of experience, and more debate. The global and idealistic prescriptions of the 1970s must be jettisoned in favour of policy formulation and evaluation grounded in the disparate realities of where countries really are today— not where they might wish to be. As we look forward to the research and policy agenda in health systems for the next decade, two issues stand out as being especially important and difficult. These are the public–private interface and the trade-offs between spending more and spending better.