POLICY AND PRACTICE
COMMENTARY
Bridging the implementation gap in health systems research
Miguel Angel Gonzalez Block
Manager, Alliance for Health Policy and Systems Research, World Health Organization, 1211 Geneva 27, Switzerland (email: blockm@who.int)
Haines, Kuruvilla and Borchert review the interface between science and medicine in the research-to-practice cycle. There is a need to ask a similar set of questions about the interface between health systems research and the development of health systems. Furthermore, it is important to bring in the political dimension to ensure that bridging mechanisms are appropriate. Indeed, if politics has played a critical role in the development of scientific medicine, its role will be more pronounced in evidence-based health systems. Semmelweis's discovery of the origins of puerperal fever in the unwashed hands of physicians was blocked for decades partly as a result of hospitals' conservative politics and inappropriate advocacy (1). Today the progress of stem cell research is similarly enmeshed in the vagaries of political debate (2). What are the challenges of the political context in health systems research and development?
Out of the ivory tower
Health systems research relies on "soft" social science disciplines and has to contend with complex health systems. Furthermore, health systems research relies on data, concepts and methods originating in health systems, thus placing science, policy and practice in a close and often uncomfortable relationship. Research results will almost always challenge political and economic interests.
Health systems in developing and transitional countries are undergoing rapid change along with changes to political and economic values. Among the most important reasons for this are the rapidly growing private sector and the introduction of health sector reforms that tend to lean towards decentralization and hospital autonomy. HIV/AIDS, tuberculosis and malaria are posing enormous challenges, and international donors are making increasing resources available but they are also increasing their demands on health authorities.
Opportunities in the policy context
Because a country is undergoing rapid change and is engaged in political debate it does not necessarily imply that research should be sidelined. On the contrary, these phenomena provide opportunities to test alternative interventions, but only if their design and implementation are well coordinated with research. Strategies to reduce poverty have been tested using quasi-experimental designs made possible by visionary policy-makers taking advantage of a necessarily gradual implementation process (3, 4). Other policies, such as decentralization, have been tested using quasi-experimental designs that were made possible by gradual policy implementation (5).
The role of mediating mechanisms
Government and civil society agencies can play a vital role in building bridges between research and implementation in rapidly changing and politicized contexts. Thailand's Health Systems Research Institute was charged by the government with developing a wide consensus on health sector reforms, something the institute was able to do in part because its work was trusted by a wide range of actors (6). Research in Thailand also played a major part in informing an innovative form of health insurance for the poor (7). Other examples of nongovernmental agencies having similar roles exist in Mexico (8), India (9) and South Africa (10). Indeed, these agencies are often established by former policy-makers and researchers who have access to varied networks of stakeholders. Such agencies can also manage research funds efficiently and play a unique role in actively disseminating information to a range of audiences.
Health systems research has unique characteristics and faces unique challenges; these must be analysed to ensure that research evidence contributes fully to strengthening health systems and enabling them to meet their new challenges (11). 
References
1. Nuland SB. The doctors' plague: germs, childbed fever, and the strange story of Ignac Semmelweis. New York: W.W. Norton; 2003.
2. Parson A. Stem cell research awaits shifting tide. Boston Globe, 2 August 2004 (http://www.boston.com/news/globe/editorial_opinion/oped/articles/2004/08/02/
stem_cell_research_awaits_shifting_tide/).
3. International Food Policy Research Institute. Honduras family allowances program: monitoring and evaluation system. Washington, DC: International Food Policy Research Institute; 2000.
4. Gertler P. Final report: the impact of PROGRESA on health. Washington, DC: International Food Policy Research Institute; 2000.
5. González Block MA, Leyva R, Zapata O, Loewe R, Alagón J. Health service decentralization in Mexico: formulation, implementation, and results of policy. Health Policy and Planning 1989;4:301-15.
6. Phoolcharoen W. Health systems reform in Thailand: the role of the Health Systems Research Institute. Geneva: Alliance for Health Policy and Systems Research; 2002 (Working paper No. 16).
7. Tangcharoensathien V, Teerawattananon Y, Prakongsai P. Universal health care coverage: how the 1,202 Baht capitation rate arises? Journal of Health Science 2001;3.
8. Soberón G, Valdés-Olmedo JC, Martínez-Narváez G, Knaul F, Izazola-Licea JA, Nigenda G. Research on health policies and systems: FUNSALUD's interest in the matter. Geneva: Alliance for Health Policy and Systems Research; 2001 (Working paper No. 12).
9. Yesudian CAK. Policy research in India: the case of regulating private health providers. Geneva: Alliance for Health Policy and Systems Research, 2001.
10. Buthelezi G, Wadee H, Makhanya N. Confronting the role of research in policy development and implementation: a case study of community service for doctors in South Africa. Geneva: Alliance for Health Policy and Systems Research; 2002 (Working paper No. 15).
11. Alliance for Health Policy and Systems Research. Strengthening health systems: the promise of health policy and systems research. Geneva: Alliance for Health Policy and Systems Research; 2004.
(Submitted: 9 August 2004 Accepted: 10 August 2004)