Time for innovative dialogue on health systems research.

Editorials 715 A forthcoming report by the World Health Organization (WHO) on evidence for policy is already fuelling passionate debate, especially among scientists. Opinions are divided: some scientists believe strongly in the systematic assessment of evidence on the effectiveness of health system interventions and reforms; 1 others are skeptical. 2,3 This is not just another academic debate. Health policy is a noisy field involving many stakeholders. Health reform approaches that seem promising in practice are assessed critically by institutional researchers, whose method-ological dictums are sceptically received by field practitioners. In a recent Bulletin editorial, for example, Fretheim et al. reported the results of their Cochrane review of performance-based financing studies, which yielded few studies meeting Cochrane criteria. When the authors concluded that little could be said about performance-based financing, 4,5 advocates of this approach responded with an avalanche of critical commentaries. 6 These debates are typical, necessary and energizing. They hail a new era in the worldwide scrutiny of health policy and its knowledge architecture. As legislators, researchers, knowledge managers and contributors to health reform, we welcome the deepening interest in the intricacies of health reform and acknowledge the global relevance of an ambitious new knowledge agenda. A balanced dialogue between different knowledge holders – researchers, practitioners and policy-makers – is, in our view, a conditio sine qua non for successful health policies. It concerns us all to consolidate the body of evidence surrounding promising approaches, including data on their possible pitfalls and side-effects. For such a dialogue to take off and become truly global, the following prerequisites should be fulfilled. All contributors should realize that the knowledge agenda for successful reforms extends beyond their own niches. 7 Serious knowledge programmes for improving health systems in low-and middle-income countries go well past merely scrutinizing evidence, and certainly outcome evidence. Our own experience has taught us that most schemes anywhere fail because of poor design, insufficient funding, weak gov-ernance and muddled implementation. These dimensions of the health system development process warrant proper attention from researchers. In addition to the hierarchy for the strength of the evidence, there should also be a hierarchy for practical relevance. We should revisit current evaluation methods or at least their interpretation. The broad transformative character of many health system reforms, such as performance-based financing, poses challenges for evaluation methodology. 8 Promising features of health reforms can stem from dimensions not amenable to randomization, such as professional …