BMJ  2004;329:1120 (13 November), doi:10.1136/bmj.329.7475.1120

Editorial

Knowledge for better health

WHO's plan to strengthen health systems requires greater clarity

This month's world report on knowledge for better health makes common cause with medical journals.¹ Its focus on research has encouraged this week's theme issue,² a series of articles in the Lancet,³ and a theme issue in the Bulletin of the World Health Organization.⁴ What is more, all these publications kick off a ministerial summit and this year's global forum for health research in Mexico, both of which will address the issue of failing research in failing health systems. Indeed, after a lengthy consultation process, "strengthening health systems" is the subtext of all this activity.

"There is a gap between today's scientific advances and their application: between what we know and what is actually being done," says Dr Lee Jong-wook, the World Health Organization's director general. This is a familiar riff, particularly to readers of our recent theme issue on whether evidence based medicine makes a difference to patients.⁵ Some experts now believe that evidence based medicine might be better recast as evidence informed practice.⁶ Similarly, WHO should now argue for evidence informed public health practice—and explore ways of making it a reality. "More health equity can only be achieved," argues Dr Lee, "through better management of health research and increased investment in health systems research." But the extent of what we don't know is even greater in public health in poor countries than in biomedicine in rich countries.

The conclusions of the report are threefold: more investment is needed for innovative research on health systems; health research must be managed more effectively; and a stronger emphasis should be placed on translating knowledge into action, bridging the "know-do" gap, the cliché of the moment. Encouragingly, the report places research at the heart of health systems reform, promoting local capacity building through national health research systems that dance to the tune of local priorities instead of imposed rhythms. WHO has quickly shifted under Lee to an organisation that sees itself strengthening health systems in member states and supporting national agendas instead of a centrally driven organisation, although Dr Gro Harlem Brundtland, Lee's predecessor, would surely argue that decentralisation only works if the centre is working effectively.

Another theme of the report is how current research methods, publication processes, and information dissemination channels must be revolutionised to meet the needs of low and middle income countries. Action research is proposed as an alternative method to randomised controlled trials to evaluate the complexities of health systems. Inequalities in the "publish or perish" culture are highlighted exhaustively—a failure of journals to respond to the needs of low and middle income countries. An ambitious call for health information for all by 2015 sums up a report that is replete with admirable intentions but short on concrete ways of achieving them. This gulf is neatly depicted by a simple calculation that one million additional health workers are required for sub-Saharan Africa to achieve the millennium development goals. In a scenario where health systems in poor countries are worsening, this goal is unachievable. Targets and goals are useful for focusing attention and driving initiatives, but once they are impossible they become irrelevant.

WHO has moved from the statistical complexity of the evidence produced under its previous regime to the equally inscrutable jargon of knowledge management. "All key stakeholders must join forces to construct a robust platform through which quality information can flow in a more sustainable manner," says the report. "Explicit" knowledge has to be combined with "tacit" knowledge. Strategic research must maximise "the impact of explicit and tacit knowledge within health systems and can gain much from a `knowledge management' framework in public health." We then dance the conga, party until we drop, and wake up in a world of health for all. Clearly, aggregating information in its various forms to produce knowledge that can then be applied by clinicians and public health workers is essential. And the agenda of the knowledge wonks at WHO is commendable, but people outside WHO—and perhaps within—need greater clarity on what knowledge management means and how it will be implemented, and some reassurance that producing high quality information has not been jettisoned.⁷ In the world of "know-do" you can only do once you know, and doing what you don't know probably isn't a good thing.

Yet this is an important report, as WHO draws attention to failures in health systems and health systems research, and trumpets them as a priority. These are, however, difficult challenges, their very familiarity testament to our inability to overcome them. WHO is turning the research agenda over to its members, focusing on its role as an enabler and adviser. A brave vision although a politically fraught mission. Knowledge management on a global scale is an unenviable task that will take years to make an impression in a climate where spending on research is still skewed towards wealthy nations.⁸ This report is a valuable start that documents the problems, conveys urgency for change, but falls short in the clarity and the persuasiveness of its solutions.

(kabbasi{at}bmj.com)

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Competing interests: KA is a former editor of and current editorial adviser to the Bulletin of the World Health Organization

References

1. World Health Organization. World report on knowledge for better health. Geneva: WHO, 2004.
2. Richards T, Tumwine J. Poor countries make the best teachers: discuss. BMJ 2004;329: 1113-4.[Free Full Text]
3. The Lancet. Mexico, 2004: Global health needs a new research agenda. Lancet 2004;364: 1555-6.[Medline]
4. Pang T, Pablos-Mendez A, Ijsellmuiden C. From Bangkok to Mexico: towards a framework for turning knowledge into action to improve health systems. Bull World Health Organ 2004;82: 720-2.[Medline]
5. Strauss S, Jones G. What has evidence based medicine done for us? BMJ 2004;329: 987-8.[Free Full Text]
6. Glasziou P. Evidence-informed practice and not Meme-BM [electronic response to Gabbay J, le May A. Evidence based guidelines or collectively constructed "mindlines?" Ethnographic study of knowledge management in primary care]. BMJ 2004. http://bmj.bmjjournals.com/cgi/eletters/329/7473/1013?ck=nck#83785 (accessed 8 Nov 2004).
7. Murray C, Lopez A, Wibulpolprasert S. Monitoring global health: time for new solutions. BMJ 2004;329: 1096-100.[Free Full Text]
8. White C. Global spending on health research still skewed towards wealthy nations. BMJ 2004;329: 1064-5.[Free Full Text]

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