It was a gathering of stakeholders from across the globe who converged to attend the 5^th AfHEA Biennial Scientific Conference on Primary Health Care (PHC) as a Foundation for Universal Health Coverage (UHC).

The event, held in Accra, Ghana, West Africa from where it was born, out of the International Health Economics Association (IHEA). It was a thrill for me as an aspiring Health Policy & Systems Research (HPSR) expert coming from the mainstream media.

Against the backdrop of the jollof rice ‘war’ between Ghana and Nigeria, I was very excited to moderate a session involving an all Ghanaian team with dons like Prof. Irene Agyepong, Dr. Isaac Morrison and Dr Charity Sarpong, among others who presented papers and were panellists. They spoke on a per capita payment system as a viable strategic purchasing option for assuring universal access to PHC in Ghana.

This edition which was also the 10^th anniversary of AfHEA was themed ‘Securing PHC for all: the foundation for making progress on UHC in Africa,’ with global actors and stakeholders in the industry presenting papers on their findings from their various researches, health ministries, organisations and governments. The goal was charting the way forward for Africa to achieve UHC by 2030.

Supported by Ghana’s Ministry of Health, The World Bank, World Health Organisation Africa Region, iDSI Health, Bill & Melinda Gates Foundation, the Korean Government and UNFPA among others, AfHEA 2019 spotlighted the challenges people in Africa face every day in accessing healthcare and what financial protection or its non-existence they are having to contend with.

It was also a forum which brainstormed on how innovations, new research and political will power could advance UHC and change the narratives to ensure health for all, even at the lowest level of healthcare provision.

Representatives from the various ministries of health, researchers and other stakeholders from across the continent spoke on their respective journeys towards achieving UHC reflecting on the challenges and successes in the various papers and discussions they presented and/or participated in.

In his speech at the opening ceremony of the conference, Ghana’s Vice-President, Dr. Mahamudu Bawumia said the government has approved the operationalization of Zipline’s drone technology to deliver drugs and blood to rural areas in the country. This is in a bid to ensure a cost-effective approach of providing quality healthcare.

He said, “Next month, Ghana will begin the introduction of drone technology in the delivery of medical supplies. We are taking a lead from Rwanda who pioneered this in Africa. Once we start our drone delivery service will be the largest in Africa. We are also innovating means of healthcare delivery to reduce cost and be as efficient as possible. We are trying to rely on technology to help us be more efficient and also be cost-effective.”

This initiative which is expected to start in April 2019, challenges other African leaders, especially the ‘giant’ of the continent, Nigeria, where communities would rather resort to traditional self-treatment methods than visit primary health centres where they are very often met with the lack of medicines.

The five-day event started with pre-conference workshops on grants writing, applied health economics in Africa, tracking progress towards UHC and promoting informed choices in young people as per sexual and reproductive health.

One of the takeaways at the opening plenary was from Dr. Asamoah Bah, former WHO Deputy Director General who made an analysis of global health in comparison to fashion where styles trend until they later go out of vogue. Bah took participants down memory lane where the snag was Primary Health for All by the year 2000 which was reflective of the different campaigns that have happened over the years with regards to UHC and PHC and why it is important for them to be sustainable rather than fade out of style.

Nigeria’s Dr. Emmanuel Meribole highlighted some of the country’s achievements in the last five years regarding UHC, the national health act and the basic healthcare provision fund among others. The plenary while raising questions on accountability and the need for it, also called for a critical view on policies and programmes beyond simply adopting them.

The conference also featured sessions on hospital management and financing, public health research issues, the influence of cultural practices on the spread of diseases and health systems strengthening among others.

This year, there was something new to AfHEA introduced by Leanne Brady, a Health Policy & Systems Researcher, for which she was also recognised at the conference gala night. This was a session on decolonising health policy and systems research to include and exclude a number of elements like allowing for more Low and Middle Income Countries to participate more actively and decolonising colonial residues which still determine actions in former colonies as well as the sensitivity of choosing locations for confabs that would benefit the global south.

As part of the celebrations, individuals along with the local organising committee were honoured for their efforts towards pursuing the ideals of AfHEA at the gala night which was held at the famous Labadi Beach Hotel. They included among others, the local organising committee for successfully organising this year’s outing and Leanne Brady for suggesting a new angle to the usual AfHEA format.

Prof Di McIntyre, the Executive Director of IHEA received the François Diop Award for lifetime contributions and achievements in health economics.

At the closing session there was a call for more youth engagement at the forum with emphasis on not ignoring them on the road to UHC as their health concerns should command their own context and shape the conversations surrounding it.

Some of the takeaways from the conference included the need for more synergised working structures among all stakeholders from policy makers to financiers, academia, health economists and the media.

According to Prof. John Ataguba a health economist at the University of Cape Town, South Africa, purchasing is often forgotten within health financing. “Purchasing is an aspect of health financing that Nigeria needs to begin to look at strategically. Strategic purchasing is basically ensuring that decisions made in terms of purchasing services have some underlying principles in ensuring that you cut down cost and also ensuring that you can get services as less expensive as possible but of adequate quality to the last person who uses the services.”

While there were over 450 registered attendees at the outing this year from about 40 countries with Nigeria having the largest number of members, it is hoped that lessons taken away will not gather dust only to be cleaned out and rehearsed in time for the next biennial.

First, a caveat. There is a reason this was the first time I attended the annual CUGH meeting.  I am, quite honestly, often skeptical about anything labelled as “global health”.  As someone who is interested in studying determinants of the health of the global population, I am often baffled with the lack of consensus on what the field of global health encompasses in practice.  This is in spite of the many efforts, examples include the work of Koplan et al, Abimbola, and  Taylor, to establish a clear definition in the literature. In practice, at least in my limited experience, the term ‘global health’ is often used to describe unidirectional initiatives (often from HICs to LMICs) dictated by power imbalances—geopolitical, monetary, or other forms of power—and constructed around the concept of the ‘haves’ giving to the ‘have nots’.  In short, not all that different from its predecessor, ‘international health’.  I think that without addressing these imbalances, those working in “global health” will not be able to address the emerging threats facing the global population in this century. My reflection should be taken with that understanding in mind.

Second, a disclaimer. I really enjoyed the conference.  In addition to the wide range of timely topics discussed, it was clear that the organizers went out of their way to embody values of equity and diversity.  The conference itself was global in terms of representation—with participants from over 50 countries and a diverse set of presenters and moderators (it was a bit heavy on presenters from the US but that is understandable given that the conference was held in Chicago).  

The Great Debate

Back to the content of the CUGH annual meeting.  This year, the proposition of the conference’s ‘Great Debate’ was “The field of global health should prioritize existential threats, including climate change and environmental degradation, over more proximate health concerns” with Stephen Luby arguing for the motion and Agnes Soucat arguing against it.  Many of the conference attendants—including the moderator and the two discussants—noted in their remarks that creating an either/or distinction between existential threats (examples used during the debate included climate change and nuclear threats) and proximate health concerns (this was not clearly defined in the debate but the context implied by the term meant, more or less, current areas of interest for the field of global health) would be artificial.  The debate ended with the two discussants making  a similar argument—although with different framing—that the two goals are not contradictory, can work in conjunction, and feed into each other (Although, for a while there, Soucat drove the discussion towards the direction of individual versus collective responsibility).  By the end of the debate, about half of the attendants voted for the motion and half voted against it but the general consensus was that the field did not need to make a distinction between priorities.

At first, I did agree with the apparent consensus. After some more reflection, however, I think that the question was actually well phrased and that it is perhaps the single most important question to ask in global health right now. Further, the split in votes does reflect the current state of global health as a field unsure of its future direction. While both goals reveal a concern about the health of the global population, embracing for one or the other can fundamentally determine how we frame global health as a discipline, what issues fall under the jurisdiction of global health “actors”, and, more importantly, who we consider to be global health actors to begin with.   

Choosing proximal health concerns (as framed in the debate) as a guiding vision for the field is a noble goal that fits the business-as-usual approach we currently, overwhelmingly, adopt in global health.  On the other hand, embracing existential threats as a key driver for global health priorities would require a bold shift in the field.  It would mean broadening the scope of the discipline, becoming more “political”, and engaging stakeholders who are not currently being considered as global health actors.  That is not to say that current proximal concerns (say UHC, NCDs, …) do not require a more “political” approach. But, embracing existential threats as a key target for global health requires making sweeping and most likely unpopular and uncomfortable decisions.  It means a deeper (and more radical) engagement on issues such as the structure of the global economy. For example, adopting such vision to global health would imply that adding a chief economic advisor to the structure of the WHO’s HQ is not a far-reaching question asked on twitter but rather one of the most logical steps to prepare for the future threats facing the health of the global population.  To his credit, Luby tried to make a similar argument multiple times during the debate.

One thing to keep in mind,  as the field continues to search for its purpose, is that while the debate was indeed a good intellectual exercise, we might not have the luxury of being able to continue debating the proximal vs existential for much longer.  Soon, even the proximal may become existential (e.g. biodiversity implosion and climate change) or is it the other way around?  In fact, the ability to define what constitutes a global priority might not be in the hands of “global health experts” much longer but rather in the hands of those who will suffer the most from what we call now existential—also often (still) implied as distal—threats (for an example, look no further than the global movement of youth climate change strikes).  Importantly, if we continue with our business-as-usual approach to global health, we might very well end up unprepared for the looming future global (health & other) threats.

CUGH 2019 Honorable mentions

China as a Global Health Actor

One of the sessions at the conference was dedicated to showcase the role of China’s partnerships with LMICs to improve health outcomes.  I was particularly intrigued to see how the session unfolded as China itself (still) has a long way to go when it comes to improving a number of health indicators and outcomes.  Acknowledging China as a global health actor means, in principle at least, more discussions about south-south collaborations.  However, the rising geopolitical power of China—in Africa, South-East Asia, … — (not the least via the Belt and Road Initiative) means, again, a power imbalance in these partnerships.  The presentations, however, were encouraging. Multiple presenters from academic institutions (e.g. Tsinghua University, Fudan University, and Wuhan University) in China made it clear that they, also, are still working on what it means to be a global health actor. Many highlighted the need to first define what global health means and what a successful partnership in global health would look like.

Mentorship in LMICs

I’m mentioning this session because it focused on a topic that is dear to my heart.  As you can see from a screenshot from a live-tweet below, I was ecstatic to see that the issue was systematically addressed at the conference and (hopefully also) beyond.

Medical Humanities in global health

This session gets an honorable mention because it aimed to conceptually address the current power imbalances in global health with a nod towards the emerging topic of decoloniality in health research and practice. I would argue that at least a basic training in humanities is essential, yet it’s foreign, to many of us who are working in clinical medicine/public health. 

Short-term placements in global health

Multiple sessions aimed to address the ethics of short-term placements; a popular practice by global health educational institutions in the west.  Such placements are often in located in LMICs. The global community is increasingly acknowledging the, often, unintended harmful consequences of such placements on local communities.  While none of the sessions directly addressed the inherent power imbalances driving these placements, they definitely highlighted the ethical issues that need to be considered as global health institutions in the west continue with the practice.   

Final thoughts

To be honest, a week after the CUGH meeting, I’m still puzzled by what we mean when we say global health.  I do not think anyone at the conference would disagree with Koplan et al’s definition of global health as “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population based prevention with individual-level clinical care.” At least I hope not.

But at this point in time, does global health, in its current shape and with the current political economy of global health actors, does what it aims to do?  How do we operationalize such definition?  Huge threats to the global community such as climate change will surely have an effect on the health of the global population, already now but certainly even more so for future generations.  So, is global health—in its current form—ready to face such threats? Currently, global health seems to focus on ‘mitigating’ the worst aspects of our world while not really taking on the challenges we face in the 21^st century in a more substantial and transformative way. Maybe Koplan’s definition doesn’t pay enough attention to the health of future generations?

Another important question to ask is what constitutes empirical evidence that could drive the field of global health? How do we identify and measure “global health priorities”? In other words, what type of work do we feature as global health research?

At this conference, the answer was overwhelmingly: research conducted in LMICs, regardless of the topic. Such focus is fine—but it does reinforce the narrative that, at least empirically, global health remains a fairly unidirectional discipline.  Such emphasis is also a bit weird in the—supposedly “universal”—SDG era.  Further, I wonder whether current global health curricula adequately prepare us to address, at least some of, these emerging transnational (and more existential) threats.

The emerging health challenges facing our global population require taking quick steps towards defining whether global health is truly concerned with the global population (including future generations) or whether it remains, deep down, an extension of international health.  No matter the direction, there is much work to be done to create a discipline that is courageously devoted to address drivers of health in the global population—now and in the future—conceptually, methodologically, and in practice (be it global health or something else).

NAIIS-2018 revealed a national HIV prevalence of 1.5% for people between 15-64 years and VLS of 44.5%. Women aged 15–49 years are more affected by HIV than men (1.9% versus 0.9%). The estimated population of people living with HIV (PLHIV) aged 0 – 64 years is 1.9 million, the estimated treatment gap comprises 800,000 PLHIV. VLS among PLHIV aged 15-49 years with access to treatment is 42.3%. Among adults aged 15-64 years, HIV prevalence varies by geopolitical zones, with the highest prevalence in the South South Zone (3.1%) and the lowest prevalence in the North West Zone (0.6%). Disaggregation of the HIV burden by age shows that an estimated 75% of PLHIV are 15-49 years old and 8% adolescents (10-19 years). Prior to the NAIIS, national HIV prevalence was estimated at 3.4% (NARHS, 2012), while the estimated population of PLHIV in Nigeria was 3.4 million.

The “drop” in key HIV indicators in the country is a confirmation, first of all, that previous national HIV estimates were wrong. As mentioned above, the NAIIS used a better methodology to assess HIV-related indicators compared to previous surveys in Nigeria. In addition, the huge investment from stakeholders (Government of Nigeria, U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosis and Malaria, and other development partners) was worth it, and no doubt explains part of the decrease.

The drop in HIV prevalence has implications for HIV programming in Nigeria, however. The big question is, to what extent will the outcome of this survey influence HIV programs in Nigeria? Will the country sustain funding for the current strategies to HIV prevention, care and treatment or redirect funds? What happens to donor-funded HIV programs? Will donors invest less or shift focus to other diseases of public health importance or redirect funding to countries with higher HIV prevalence in sub-Saharan Africa?

It is clear from NAIIS results that the picture of the HIV epidemic in Nigeria is mixed and is probably fueled by socio-cultural practices, stigma and discrimination, poverty, key populations and poor commitment from both national and state governments. Other contributing factors include inappropriate technology, inadequate human resources for health and stock outs of essential drugs.

Key populations (KP) comprising of female sex workers, men who have sex with men and persons who inject drugs, accounted for 32% of new infections in 2014. Therefore, this population must be prioritized if we want to win the war against HIV/AIDS in Nigeria. All stakeholders in the health sector should advocate for government policies that support an enabling environment for KP to access HIV services in the country. Funders and implementing partners should also ensure a gender and KP sensitive approach to program implementation. Also, there is a need to scale up community-based Anti-Retroviral Therapy (ART) services for KP by setting up specialized clinics where KP can access HIV treatment without fear of stigma or discrimination.

Currently in Nigeria, Pre-Exposure Prophylaxis (PrEP) is not readily accessible. The Federal Ministry of Health and the National Agency for the Control of AIDS should shoulder this responsibility in order to increase access of eligible patients who are at substantial risk of HIV, to PrEP. As a priority, Nigeria should scale up PrEP beyond the ongoing demonstration studies and PrEP interventions in select clinics for key populations and sero-discordant couples..

To further improve on HIV indicators in the country, community involvement and involvement of PLHIV in programming is crucial. This can be promoted through community based programs and individualized care. Evidence from studies on Differentiated Service Delivery (DSD) models revealed that a significant percentage of PLHIV receiving treatment through this/these model(s) achieved optimal virological suppression and retention to care.

Nigerian researchers and implementers should invest more in HIV research and conduct studies to bridge gaps in HIV implementation with a focus on HIV testing services, linkage to treatment, ART uptake, virological suppression and retention in care.

Sustainability is key and it is high time Nigerians invested more in the health sector. The NAIIS survey was conducted by the Government of Nigeria with support from international donors but in the future, the Government should conduct its own survey. This gesture will showcase sustainability and real ownership of the HIV/AIDS response in Nigeria. The time has come for more commitment from the political class and all stakeholders in the health sector to take ownership in order to sustain whatever gains we have achieved since the emergence of the HIV infection in Nigeria.

Introduction:

Thank you honourable chair.

Disclaimer: I am representing myself in the talk, not the institutions I am affiliated with.

I was in Yemen last year. I had to travel back from the UK, the place where I conduct my academic research, to take care of my dad who was admitted to a hospital in Yemen.

The health services were of inferior quality, doctors struggled to diagnose and follow up my father’s condition the way it should have been, and the treatment course ended up in too many medical complications. Because there is no formal health insurance for the Yemeni people, I had to spend more than half of my annual income and savings for hospital admission and treatment. My dad passed away after two months of suffering.

I was fortunate that I was able to hospitalise my dad and cover the enormous costs of treatment using my savings, although I lost my father eventually. I remembered those families who are living below the poverty line and can’t afford to pay for medical consultation when they need it. These people aren’t few, ladies and gentlemen, there are millions of them.  The people of Yemen have to pay for treatment or die, it’s as simple as that.

This experience, along with the sense of vulnerability and helplessness my family and I felt, was an eye-opener for me, from which I realised how crucial it is to have adequate and affordable health services that can be accessed by the people in Yemen during these difficult times.

The impact of Yemen’s conflict is huge as you all know. The overall deterioration in the country’s social and economic conditions has a serious impact on all public sectors, making Yemen currently the largest humanitarian crisis in the world. Yemen’s gross domestic product  contracted by 50%, and the inflation rate went up by 40% just last year. The oil and gas pipelines have been damaged, and in combination with the blockade of international ports and a reduction in production and export of natural resources, the government’s budget – in deficit since 2015 – was slashed by trillions of Yemeni Riyals.

For 2019 the UN humanitarian response plan has requested almost 3 billion US $ funding. You may think this is a huge number, but in reality it isn’t. The United Nations Office for the Coordination of Humanitarian Affairs states that Yemen has lost almost 50 billion US$ of its GDP since the emergence of the conflict in 2015. Imagine: a 50 billion US$ loss against 3 billion of US$ aid funds.

The health sector situation, in particular, was severely affected. In the limited areas where they operate, international and local NGOs are almost the de facto providers of health services. These providers are struggling with coordination with two ministries of health.  The fragmentation in our health system is delaying the processing of paperwork needed to grant access to aid organisations as each actor has to go through two parallel channels in both sides of the country, this hinders the delivery of a timely health response to the people in need.

Moreover, the international health agencies are confused by this situation (with two ministries): while they do develop a country work plan for Yemen as a whole, what applies to the South does not apply to the North. This confusion is evident among new international staff who find designing and managing country-wise unified programmes very challenging.

The health workers in many Yemeni areas are yet to get their salaries, many of them received none for the third year in a row, which is made worse by fragmentation in the MoH’s payroll. Access to services is restricted by the active conflict in hot zones. I heard tragic stories from families and friends, who had to sell all that they got, to access inpatient care or to undergo a lifesaving surgery. The lucky ones were able to travel to neighbouring countries to seek treatment after selling all they got or borrowing a fortune. The people in Yemen are poor and are further getting impoverished.

One of my observations amid this miserable situation is the growth of the private health sector, which is a natural consequence of the weakness of government-run health facilities. Nevertheless, many people suffer from catastrophic health costs to receive the treatment they need in the private sector, even though the quality it provides is substandard.

Recent nutritional surveys have confirmed over 1.7 million children under five and 1.1 million pregnant and lactating women as acutely malnourished. 400,000 children are at risk of immediate death because of the severe form of acute malnutrition. One-third of the 30 million Yemenis are having various degrees of malnutrition.

Moreover, ladies and gentlemen, as you may have heard, the cholera outbreak in Yemen has reached unprecedented levels in recent history. WHO reports almost one and a half million suspected cases to date. Meanwhile, two new outbreaks are emerging and taking lives of children and people: diphtheria, a disease which can be prevented by vaccination, and dengue fever, a disease that needs a correct diagnosis and supportive treatment. There is a glimpse of hope though: the low number of deaths among cholera patients who reached the health facilities for treatment. For me, this means that even though the health system is collapsing, our health workers did, and continue to do, great work saving the lives of millions. Many of these health workers, however, are in constant struggle to deliver services in this fragmented and collapsing system. I salute my fellow brave health workers, physicians, nurses, midwives, lab assistants, pharmacists, nutrition workers and community health volunteers. These are the people who are protecting our health system from total collapse and saving our lives.

Ladies and gentlemen, I will conclude with the following recommendations:

Number 1: Peace is the umbrella under which the functions of our health system can be fully restored. We need peace now.

Number 2: The health stakeholders should strengthen their coordination with the governorate [i.e. province, the second administrative level in Yemen] and district health offices and build the latter’s capacities in leadership and financial management using a mini-version of a health system approach; this will ensure smooth health operations until a political solution is reached to address the fragmentation at the government level.

Number 3: Salaries of health workers have to be paid. It is worth mentioning that the current salary scale of health professionals in Yemen is outdated and doesn’t reflect the high inflation rate within the country. The salary scale should be reviewed and improved to ensure a dignified standard of living for our health workers. It is not acceptable at all for a health professional, who saves lives, to live on less than 100 $USD per month.

Number 4: The humanitarian response in Yemen provided by national and international health stakeholders should ensure participation and engagement of the private health sector in the humanitarian response and the health cluster to expand the coverage of health and nutrition services.

Number 5: the current health interventions in Yemen’s target tertiary healthcare with specific focus on war-wounded people (care for them is hospital based). While I do acknowledge the vital importance of having emergency and tertiary health services, the people in Yemen also need  primary health care of high quality. It would be more effective and sustainable if the NGOs and UN agencies channel part of their funding to directly support MoH facilities in providing operational costs, investing in health infrastructure, rebuilding the damaged health facilities and strengthening the local health capacities.

Number 6: I recommend to the UN-led humanitarian coordination mechanisms in Yemen, specifically the Cluster Approach and UN OCHA, to consider merging the health and nutrition clusters. Lessons learnt from Ukraine or Uganda should be taken into consideration. This will ensure better planning, a more holistic approach to health and less duplication of interventions.

Insisting on separating the treatment of malnutrition from health fuels the health services fragmentation and puts more emphasis on portraying malnutrition as a food or emergency problem. This attitude is very prevalent among international donors and aid agencies. It is worth mentioning that malnutrition was already endemic in Yemen before the conflict, the war just made it worse. Therefore, there should be a sustained integration of prevention and treatment services for acute malnutrition at all levels of health care.

Number 7: The 2004 Yemeni constitution states that health is a right for all Yemenis and that the state shall guarantee access to free health care. In the medium term, the vulnerable people of Yemen have to be financially protected against the cost of healthcare. To serve this purpose, the ministry of public health should resume the discussions for establishing a national health insurance which was on the table before the conflict. I urge Dr. Tedros, the DG of WHO, to put Yemen’s universal health coverage on WHO’s list of priorities. Conflict is not a justification for withholding UHC or not protecting people from financial hardship associated with health costs. Affordable and quality health services can be an important route to long term peace and stability.

And finally: I urge the minister of health to consider involving the Yemeni health experts around the world in the medium to long term health plans. The world is changing, and these young experts will ensure that fresh and modern ideas in governance and health economics are brought into our health system.

These are the messages I would like you to take home, please spread the word on all relevant platforms. Thank you for your attention and listening.

Yours sincerely,

Sameh

I was in London on an official visit which began with attending a session on decolonizing the curriculum at the London School of Economics, where the panel discussed their experiences and understanding of how skewed the academic system is towards the white elites, in a number of ways, ranging from the curriculum to jobs, scholarships, publications, forms of knowledge production, to even the everyday experiences of racism in public spaces. The panel was chaired by Prof. Alcinda Honwana (Centennial Professor at LSE), who said that universities should not be static or ‘ideological zombies’, rather they need to be the sites of subversion and rebellion, they must critique and debate, challenge the existing power relationships and re-center the knowledge production process. A master’s student from the audience raised an interesting question on the role students like her, who come to London for a relatively short term (1-2 years), could play in decolonizing the curriculum. Dr. Lyn Ossome from the panel responded beautifully: “Be yourself and the contradictions will emerge in the classrooms and the streets and your daily interactions with people around you. You deal with it, and that’s how you can begin your contribution. You need to acknowledge the reality first. Decolonizing has a lot to do with acknowledging the reality rather than talking in a vacuum.”

Thanks to Gorik Ooms, whom many of you IHP readers will have heard of, I also got the opportunity to attend a few sessions at the London School of Hygiene & Tropical Medicine, from its Masters Course on Globalization and Health. The discussions ranged from the inclusion of the right to health in the Universal declaration of human rights, to the huge global economic cost (~USD 16 trillion) of mental disorders, to how Ebola is framed more as a security threat and a political crisis than as a global health problem. I also attended a fascinating seminar – Ideology over theory: World Bank policy on user charges for health care, 1978–1993.  All in all, I got a small flavor of London as a global health hub in these few days across the Channel. 

However, the key highlight of my visit to the UK capital was International Women’s Day 2019 (IWD 2019), with this year’s theme, #BalanceforBetter – the better the balance, the better the world: calling for a more gender balanced world, as you might have guessed. While gender equality/equity is increasingly discussed and addressed, there is one day when this issue gets more attention than the other 364 days of the year, i.e. 8^th March- IWD. On this day, several gender related conversations are ignited again and some interesting and eye opening stats are released. Just one example: “If gender parity were theoretically reached, $28 trillion would be added to the global economy by 2025”, according to a study by McKinsey.

Multiple sessions and events took place throughout the week on IWD 2019 (and its overall theme) in different areas and streams. I managed to attend a few of them and below I will share what I learnt by taking part in those sessions. Most sessions included panels where women from different fields, age groups and ethnicities reflected on their respective journeys and struggles to deal with the currently skewed and gender-imbalanced world. It was interesting, though perhaps also a bit sad, to see that (just) one of the panels I attended included a male panelist. Gender equity isn’t just about female emancipation – it is about fair and equal chances amongst all the sexes. Neither gender equality, nor equity can be achieved without the engagement of all.

The panels discussed a wide range of barriers women face at the workplace, not the least of which is the age-old challenge of the household and family, largely being a woman’s responsibility. Many discussions revolved around sharing and understanding the internal inhibitions women deal with (like how to deal with hatred and criticism, the biggest barriers to become a leader, how to answer questions/comments on body shaming etc.), but they also highlighted their sources of strength and support that help them realize their goals and dreams, the skills and characteristics required to succeed, their limiting beliefs and how to overcome them. An issue pointed out by virtually all panels was the high prevalence of the ‘imposter syndrome’ amongst women as compared to men. For example, two panelists from different panels referred to their feelings of self-doubt for being called to speak on the panel: “I am being invited to speak on the panel, has someone cancelled? I must be a back-up plan for them”. It was highlighted that women experience negative self-perception and under-confidence all the time, ‘I am not good enough’, ‘have I done it right’ etc.  There are also often people around us who try to pull us down, who deliberately make us doubt ourselves. Just a personal example perhaps:  when I got admitted for a PhD program at India’s most prestigious school, IIM Ahmedabad, my colleagues said, oh you must have been lucky; one person literally came to me and said he had dreamed of my selection process, “seeing” in his dream that the jury showed mercy to me and so I got admitted. Gosh!  We, women, need to get rid of such toxic people from our lives and we need to strengthen our beliefs in our own selves and capabilities, this is what will prove such bullies wrong. Too many of us women continue to seek validation from others and often forget what we really deserve. We need to stop doing that.

A very interesting exercise was conducted during the IWD 2019 Future Leaders Forum (organized by The Sister-Sister Network that aims to provide leadership training to women from different fields in the UK) on how to deal with the feelings of self-doubt. Every person has two selves to deal with a situation, a “negative and disparaging self” which will always display negative feelings towards everything (and certainly oneself), as in ‘I am feeling ugly today’, ‘I shouldn’t have volunteered for that’, ‘I am feeling anxious, I shouldn’t go for that session’, always radiating negative energy all around. And then you have a “wise self”, which tries to find something positive in every situation. ‘I look good today’, ‘Good that I went for that session, I got to know about women’s leadership’, ‘it’s okay, everything will be alright’, ‘what’s the worst that could happen, I will get an experience’. In this exercise, they asked a volunteer to reflect on a situation and understand what her negative and wise selves would say to her, and how easy and sensible it is to choose the wise self. So the lesson is: whenever you get overpowered by your negative self, always go check what your wise self has to say in that situation, and you will be surprised to see that your nerves calm down and you feel the positive vibes around. Whenever in confusion, always listen to your wise self! (not sure it works for men too! J)

Another very interesting exercise at the Future Leaders Forum was carried out by Mark Francis, the Director of a Leadership Training program, @Uspire. He made us meditate for a few minutes to help us imagine and visualize our future, under the assumption that it is impossible to fail. The impossibility of failure was the key. All too often, we limit our imagination to the possibilities of success that we can foresee (or not). I felt that organisations and institutes should often conduct such sessions reminding people of their potential and the sheer power of imagination, pushing their boundaries, because often we get so engrossed in our work and family life, that we forget what we really are capable of.

Last but not least, like the 10-year challenge that recently went viral on social media, it is important to reflect on the journey for gender equality along similar lines. Where were we 10 years ago, advocating for gender equality? Yes, we are advocating for it right now and, we will still be doing so in 10 years from now, as the progress is often incremental and slow. Make no mistake, we are fighting against deeply ingrained beliefs and patriarchal ways of governing the world. Achieving a gender-balanced world will require a massive paradigm shift and participation from each and every one of us in our own little ways like breaking the stereotypes when raising our girls and boys, teaching them about equality and respect towards women, instilling the confidence in our daughters to focus on their inner beauty rather than their outer appearances, becoming role models for our children and most importantly supporting other men and women who stand up for these causes. I did my good IWD deed of the long weekend by briefly (ahum, 10 minutes) taking part in the Women’s Strike in London on the eve of International Women’s day, organized in solidarity for women’s rights and equality across the world.

I will leave you with this rather interesting panel question: which one will be achieved first, the end of global warming or gender equality? While we have only 12 years to avoid climate change catastrophe (and some say even less), it will take us around 108 years to close the global gender gap, according to the Global Gender Gap Index 2018 (by the World Economic Forum) – and many think even that won’t suffice. 

Let’s prove them wrong!

The ethos of feminism espoused by the current government was demonstrated at the outset—Prime Minister Justin Trudeau started out with the first gender-balanced cabinet in Canada, a national inquiry into the gender-based violence of indigenous women, and finally, a feminist ODA policy. The gender wage gap in Canada has shrunk, and the federal child care benefit scheme is believed to have led to a reduction in child poverty. All of this has been welcomed by Canadians, women and men, from all backgrounds.

BUT.

On this IWD, I have a visceral reaction to the political drama surrounding the conduct of the Prime Minister’s Office and its efforts to prevent the prosecution of a private sector firm. A parliamentary inquiry is in progress at the time of writing, with several key people resigning from their posts as a result of this affair.

Two highly respected Canadian cabinet ministers, both women, have resigned in the last couple of weeks, citing concern about the integrity of the justice system and their own ethical responsibilities. During a sensitive time in women’s leadership internationally, where women’s rights and empowerment are often seen as a direct attack on power structures, all this begs the question whether the current political upheaval has a gendered nuance to an issue of values and ethics. Is it possible that women are pushing back at the way politics, with its backdoor deals, is played out?

Why is citizen engagement important for health policies?
Citizen engagement is important to make health policies more inclusive and equitable. By engaging citizens, we ensure that their knowledge feeds into the policy-making process. What citizens know (e.g. what a teacher knows about the implementation issues linked to offering healthy food in schools) can be extremely valuable in identifying feasible policy options, understanding context and implementing policies. Citizens’ knowledge goes beyond what is written in the literature.

Besides, the benefit of citizen engagement extends beyond the improvement of policies; being engaged in policy-making processes can build capacity and empower citizens to speak up for their needs, and to hold policy-makers accountable.

What did you learn about citizen engagement from the literature? 
Firstly, most studies on citizen engagement that we identified had been conducted in high-income countries, and the methods used are thus not necessarily applicable in low- and middle-income settings. Contextualizing the modes of engagement is a must.

The political support, culture of engagement and established citizen engagement processes that exist in some countries are inspiring. Yet, in contexts where these factors are not a given (let alone in conflict-affected areas), introducing the concept of engagement might be the main challenge in itself.

Finally, although the published processes of engaging citizens do not necessarily apply in the Lebanese context, they helped us identify which components we should be looking at, e.g. in terms of levels of engagement and methods of recruitment.

How did you develop a context-specific approach for citizen engagement in Lebanon? 
We have gone through a learning process that included “trial and error” on citizen consultations, a qualitative study and close collaboration with a steering committee.

The study is entitled “Developing a contextual model for citizen engagement in health policy and decision-making in Lebanon”, and will be published later this year. It consists of 1) interviews with policy-makers, researchers and civil society on methods of citizen engagement, 2) focus group discussions with citizens on how they would like to be engaged, and 3) piloting these methods. We expect that the lessons we are able to draw will be useful for Lebanon and the Arab world.   

What are the barriers and facilitators for citizen engagement in Lebanon? 
Many factors influence citizen engagement – from the human and financial resources available to support such processes, to the citizens who are involved and able to contribute, to policy-makers; ideally, the latter are ready to listen to citizens, and act upon what citizens have to share.

While recruiting citizens for a consultation, some individuals were hesitant to get involved due to their lack of trust in both policy-makers and researchers. Even during consultations, we were repeatedly asked: “How will you use what we tell you?”

We increased citizens’ trust by being clear and transparent about the engagement process, and building on the perception of K2P as a neutral player. We keep individuals in the loop on a regular basis, e.g. by sharing updates via WhatsApp. Citizen engagement is a (learning) process, not a single event.  

How did K2P put citizen engagement into practice?
Citizen engagement is part of K2P’s strategy to empower citizens through the use of evidence, and for them to become an active pressure group for change. Dealing with the political and interest-charged issue of childhood obesity in Lebanon, we realized the potential of engaging citizens in policy-making. Citizen engagement would add depth to discussions that we would otherwise not be able to reach through a policy dialogue alone.

We organized four citizen consultations on the topic. The following steps have worked well for us so far: 1) recruiting citizens via municipalities, primary care centers and community health committees, 2) introducing the topic through advocacy and using infographics and videos, 3) starting discussions in homogenous groups (e.g. teachers among teachers) to harness feedback on the topic, policy options and implementation considerations, 4) continuing the discussion with all invited citizens, 5) summarizing citizens’ feedback and sharing it with them, and 6) including the feedback in the related policy brief.

The policy brief will be discussed during a policy dialogue in March. Knowing that the policy brief will include citizens’ views has already made policy-makers curious.

What are your lessons learned related to citizen engagement?
We know that we still have a lot to learn on how to engage citizens in Lebanon, while using innovative methods and being flexible. What we are sure of is that citizens’ views are necessary to develop inclusive and equitable health policies, and enhance accountability for policy implementation.  

The K2P Center is a World Health Organization Collaborating Center on evidence-informed policy and practice. It is a leader in the field of knowledge translation, working closely with the Ministry of Public Health and other key stakeholders in Lebanon, the Eastern Mediterranean Region and internationally.  The K2P Center is also co-hosting the Sixth Global Symposium on Health Systems Research in Dubai, United Arab Emirates, in 2020.

During a visit at the K2P Center, Olivia Biermann developed the idea for this blog, together with Rana Saleh. Fadi El-Jardali and Rima Nakkash provided input to the content of the blog. All authors approved the final version of the blog. 

Gender relations have had some significant attention lately with, among others, the recent Lancet issue focusing on gender inequality endemic in research and academia. Progress in women’s rights experienced today builds on the activism of our foremothers: a recent story from India describes how women fought their way into the legal profession way back in the early twentieth century. Change takes time, however, and change is still urgently needed. A new wave of feminism (which is the movement to define, establish, and achieve political, economic, personal, and social equality for all genders)  is evident even this week, with a new system of penalties for those who force women into ‘menstruating huts’  just established in Nepal.  Further publicity around menstruation (and the need to end stigma around it) was prominent in this week’s Oscar award that was won by Period. End of the sentence, an Indian documentary describing eco-sanitary pad manufacture in a village near Delhi.

The central role of gender relations in resilience, wellbeing, participation and access to care is evident every day. Young men in informal urban settlements describe their deep sense of failure and shame when they can’t find a job or generate income, while they are expected by family members to be the breadwinner. Women as caregivers for family members with severe mental health problems are disadvantaged more than male caregivers as they are more likely to lose social contact with friends and neighbours in the tangle of stress and social exclusion. A brother and sister both have epilepsy, yet only the daughter is kept back from attending school. Gender norms limit freedom of movement for women and obstruct those with mental distress from seeking care. The list goes on.

In my day job, our main focus is to promote mental health and social inclusion among people living in disadvantaged communities in Uttarakhand, a mountainous state in North India. As a team we try to understand the community analysis of gender relations. Sitting and talking with groups of women in a remote village some weeks back, I was surprised that their preliminary verdict was “young women and men have equal opportunity nowadays”. One group of women, sitting outside a temple above the Yamuna river, described how their daughters are at least as educationally qualified as their sons, and in fact several young women from the village had completed a Bachelor’s level degree in a nearby college. A mother with four teenagers described how things are hugely different to how they were in her childhood, and thanks to advocacy by a maternal aunt, one of her daughters is actually living and studying in Dehradun, the state capital six hours drive away. Although most of these women had not completed high school, their children were getting much bigger opportunities.

We talked more, and I asked about the differences in opportunity for women and men in terms of freedom of movement. Would their daughters have travelled to Delhi or the Taj Mahal? Would their daughters inherit land and property equally to their sons? Who cooks the dinner and sweeps the floor?  They laughed then and ceded that actually, the range of opportunities and expected roles for young men is (still) very different to that of young women. In a rural setting in Uttarakhand, young women may be free to go with peers to cut firewood or cut grass for a whole day but rarely would buy household groceries. In an urban setting, young women may be more likely to go to the houses of the middle-class to cook and clean but rarely walk places without a male family member as escort. Women in both cities and villages have underlined that every family needs to ensure they have a son to care for aging parents, perform funeral rites and just, because.

Structures that support gender inequality and son preference are widespread and systemic in South Asia but women are bringing slow but inexorable change. We have had enthusiastic participation in a psycho-social support group we facilitate in one informal urban community. Women describe ‘mera mun halka ho jate hai’ (my heart feels lighter) after group meetings. A group of nine young women with mental distress decided to study correspondence school together and all of them passed their 10^th class exams. Another group of young women in Dehradun city got together, made placards and marched in a vociferous rally through their community to promote high schooling for girls. A group of women impacted by psycho-social disability has coproduced a tool for social recovery in an Indian context.

Women are pushing back, innovating, trying new ways of doing family, working, studying and changing structures. Next Friday, on March 8^th, we celebrate International Women’s day. It is an opportunity to notice the ways that women show innovation, show leadership and bring change. The theme from UN Women is “Think equal, build smart, innovate for change”. I’m cheering for women participating in all spheres of life. Whether we are riding scooters or marching on foot – the focus must be emancipation. In Uttarakhand and beyond.

As a result, it has forced the institution to explore other ways to raise funds, including by forging partnerships. The bulk of its funding is tightly circumscribed by what donors want, leaving it little room to spend resources as per its priorities. However, reaching out to other kinds of donors, and engaging other stakeholders in global health, inevitably comes with strings attached.

Director General Dr Tedros Adhanom Ghebreyesus said he wants to broaden the donor base and use  innovative financing mechanisms to shore up funds, at the recently concluded Executive Board meeting of the organization. WHO plans to organize a partner’s forum later this year to ostensibly find new contributors offering flexible financing.

Practical as this approach may sound, it is likely to run counter to the very intentions the organization’s Framework of Engagement with Non-State Actors (FENSA) has set out to do. Civil society members have cautioned against this conspicuous shift from risk aversion to risk management on these sensitive matters. Since the majority of its funding is voluntary, it leaves WHO vulnerable to undue influences, they say.

WHO’s objectives & the limitations of earmarked funding

WHO has numerous responsibilities, from quelling epidemics to prequalifying medicines, from setting norms to negotiating prices for drugs and diagnostics; from thinking up new ways of protecting health from climate change to coming up with international standards for the oversight of human genome editing. These are complex and diverse tasks attracting a variety of players for different reasons. The organization has estimated that it will need $10.1 billion over the next five years to deliver on its Triple Billion target. This ask includes $ 2.5 billion for humanitarian and emergencies, $1.6 billion for polio eradication and $ 10.0 billion for the WHO base budget. (It needs $14.1 billion, but WHO says, current projected income against the $14.1 billion is $ 4 billion, which includes income from annual dues and long-term pledges.)

In a document that explains the overall financing status in the biennium 2018–2019, WHO said the approved program budget for 2018-2019 is $4.4 billion.  The budget segment for base programmes is financed by US$ 956.9 million of assessed contributions and US$ 2443.4 million of voluntary contributions.

The Proposed Programme Budget for 2020-2021 stands at $3.9 billion. Any increase over the previous year is expected to be met through voluntary contributions. And hence there is no demand to increase assessed contributions, WHO says. Dr Tedros has refrained from asking more from countries, even as he has not shied away from pushing for unearmarked funding. (Norway has signalled some contributions as unearmarked funding during the board meeting last month.)

The organization admits that “Financing with flexible funds continues to be available for only about one third of the Programme budget.” It notes that communicable diseases is the best funded among technical categories, followed by health systems. “However, funds under these categories are usually highly earmarked and designated for specific work, often not allowing resources to be shared with related programme areas within the same categories and between categories,” it said in a document to the board. As before, noncommunicable diseases continues to be the least funded category. Even though most activities in this category are considered to be of high priority, “donor interest does not match the prioritization made by Member States,” WHO said.

So how will this tension on financing realities and organization objectives be resolved? Some believe that assessed contributions are safer than voluntary funding. A “donor chokehold” is how civil society classifies this seemingly intractable problem.

How WHO proposes to raise funds

WHO seeks to “broaden the donor base and increase flexibility in funding. This, it believes, will enable more efficient use of funds and ensure more balanced resource allocation for all its priorities.” It is also hoping to deploy innovative financing to help address this – but details on such mechanisms have not yet been forthcoming.

For now, WHO is working to transform its interaction with donors. It has asked for unearmarked and soft-earmarked funds, so that resources are more closely aligned with strategic priorities. 

In addition, a new resource mobilization framework is in the works. It hopes to implement the resource mobilization strategic framework to fully finance the proposed programme budget 2020–2021. “The framework consists of three segments, with a focus on three groups: Member State contributors, both existing and new private donors (in line with WHO’s Framework of Engagement with Non-State Actors), including foundations and Funds; and international development banks, and multilateral organizations,” according to WHO. The framework will also illustrate how innovative financing can generate revenue, increase flexibility among other goals.

Dr Tedros has been clear and consistent about working with the private sector on Sustainable Development Goals. This is in line with the wider partnership with the private sector on the SDGs.

Speaking on the institution’s Framework of engagement with non-state actors, he has now (famously) said that FENSA is not a fence and that WHO must be engaged. He has called for a need for “appropriate engagement” and has assured to take into account and manage any conflict of interest.    

WHO plans to convene a partner’s forum – in some ways taking forward WHO’s erstwhile Financing Dialogue – to work on “new mechanisms to allow a wider group of contributors to provide flexible funding, as well as newer themes, such as innovative financing by and partnership with the private sector,” among other objectives.

The link between financing & FENSA

For a lay observer, like this author, the link between financing of the institution and its engagement with non-state actors is not so obvious at first.

In its status update on FENSA to the board, WHO reiterated that “transforming partnerships, communication and financing is one of the operational shifts” of the Thirteenth General Programme of Work, 2019–2023. The “triple billion” goal (that has energized most member states), cannot be met without stronger and more systematic engagement with non-State actors, it has said. To that extent, even its external relations strategy will also be governed by the framework, according to WHO.

The framework serves as an instrument for identifying risks and balancing them against the expected benefits, while protecting and preserving WHO’s integrity, reputation and public health mandate, it says.

But WHO admits associated implementation challenges. “..For example, with respect to the requirement that non-State actors confirm that they have no engagement with the tobacco industry and that their activities do not further that industry’s interests, it has proven difficult to come up with a consistent definition of how broadly “furthering the interests” should be interpreted. Similarly, WHO wants to promote its objectives by cosponsoring major global health events. Often, however, such events are also cosponsored by private sector entities with a potential commercial interest in the event’s outcomes,” it informed the board. The Secretariat is reviewing its cosponsorship practices in order to increase engagement in a manner that is in line with the Framework, it added.

“The extent to which non-State actors can contribute to the Organization’s normative work has also been hard to define, bearing in mind the importance of obtaining certain data and information, while at the same time balancing the risk that such actors will have an undue and unacceptable influence on the work of WHO,” it cautions. And adds that financial and human resources will be required to ensure compliance with the framework.

To be sure, the framework is fairly comprehensive in that it not only categorizes various kinds of non-state actors, but also the range of possible engagements and the potential impact on WHO’s work. The framework spells out due diligence on verifying non-state actors to have a clear understanding of their profiles. It also suggests assessing the risk of specific proposed engagements with non-state actors. On risk management, the framework describes it as a process leading to a management decision whereby the Secretariat decides explicitly and justifiably on entry into engagement, continuation of engagement, engagement with measures to mitigate risks, non-engagement or disengagement from an existing or planned engagement with non-state actors.

Reviewing FENSA in light of these implementation challenges is telling. The framework says, “All institutions have multiple interests, which means that in engaging with non-State actors WHO is often faced with a combination of converging and conflicting interests.” Further, an institutional conflict of interest is described as a situation where WHO’s primary interest as reflected in its Constitution may be unduly influenced by the conflicting interest of a non-State actor in a way that affects, or may reasonably be perceived to affect, the independence and objectivity of WHO’s work.

On conflict of interest, the framework says, “The existence of conflict of interest in all its forms does not as such mean that improper action has occurred, but rather the risk of such improper action occurring. Conflicts of interest are not only financial, but can take other forms as well.” (Italics mine)

“For WHO, the potential risk of institutional conflicts of interest could be the highest in situations where the interests of non-State actors, in particular economic, commercial or financial, are in conflict with WHO’s public health policies, constitutional mandate and interests, in particular the Organization’s independence and impartiality in setting policies, norms and standards,” the Framework explains.

WHO would do well to carefully analyse its future partners irrespective of the level of engagement.

In the past, civil society organizations have cautioned that the “reliance on financial support from the private sector risks leading to the corporate capture of WHO.”   In a letter in 2016, for example, organizations advised against using FENSA as a fund-raising strategy. 

Does WHO really have a choice?

So does WHO have a choice in its strategy to diversify its financing needs? Depending on who you talk to, it appears WHO can avoid potential fault lines as it were.

Steadfast believers in the partnership model, point towards the near impossibility of getting diverse countries with varied interests and motives to agree on how to spend on priorities (global health security, emergencies or norms-setting?) The asymmetry of powers that has long plagued multilateral discussions in both health and trade spheres continues, albeit in somewhat different configurations. Hence, this alternative approach of working with interested partners. In other words, stakeholders who also stand to benefit from such partnerships.

This pressure to forge partnerships is not only obvious at WHO, and clearly it transcends even the wider UN system. Think, corporate social responsibility goals meet international public sector needs.

It may be hard to argue against partnerships and associated benefits per se – but surely erring on the side of caution by taking a clinical and calibrated approach is advisable. In its January meeting, a number of member states rightly asked WHO about how it proposes to broaden its donor base.

Finally, WHO must fight the narrative of inefficiency. Curtailing wasteful expenditure is valid, but it must also continue to focus on the big, strategic areas – as it has done in the past. As one passionate advocate pointed out, the proposed target of US$ 99 million for savings through reallocation and efficiencies (that will offset a part of the suggested budget increase for 2020–2021) is a fraction of the potential savings WHO can generate for member states – for example – by merely ensuring lower drug procurement costs for countries. This it can do by helping ensure availability and accessibility of cheaper drugs.

The Indian health system recognises seven traditional systems: Ayurveda, Siddha, Unani, Yoga, Naturopathy, Homoeopathy and more recently Sowa-Rigpa (Tibetan system of medicine). Of these, Ayurveda is probably one of the best known. It has even spread to neighboring countries like Sri Lanka and Nepal and has influenced other traditional systems in South Asian countries like Thailand and Tibet. In recent years, Ayurveda has gained popularity and recognition as a complementary or alternative approach to modern medicine in western countries. 

As a practitioner of Ayurveda myself I am well-acquainted with its benefits, and yet acknowledge the controversies surrounding this system of health. In this piece I put across my arguments for why I believe Ayurveda can play a role in health and wellbeing of people in the 21^st century.

I’d like to begin my argument with our lifestyle. Our modern-day pace of life is increasingly having a negative impact on our physical, mental, social and spiritual health which is manifesting itself in symptoms such as burn-out, anxiety, loneliness, etc.  Ayurveda can help to guide us to addressing some of these issues. But first, what is Ayurveda?

The term Ayurveda consists of two words, ayu (life) and veda (knowledge) and deals with health and well-being. Although the word ayu is loosely translated as ‘life’, Dr. Ram Manohar (Ayurveda scholar) gives better insight into its meaning. Ayu is derived from the (Sanskrit) root ‘iṇ gatau’ or Gati, which means movement, the movement of going away as well as the movement of change. The word Gati also indicates the dynamic and adaptive nature of life. The key to health and longevity is flexibility and constant adaptation, and as long as this ability to adapt remains, life continues. The goal of Ayurveda is to preserve life, and restore health and well-being. Ayurveda’s understanding of health is considered to be comprehensive and dynamic in nature and explains health in its entirety as a “many-sided equilibrium” (samya), which results, in turn, from balanced interaction and interrelations with living beings and their environment. Although the absence of disease (Arogya) is considered as good health, it’s not a key defining element of health or the definitive state of health. The term Swasthya brings a clearer understanding of how Ayurveda understands health. This Sanskrit word defines health as ‘being rooted within one’s own inner self’. The interpretation of this term is that the “self”can be realised through a harmonious balance between body, mind and spirit. This means even when there is some dis-ease, a well-balanced ‘self’ has the ability to cope with the stress of dis-ease and achieve health and wellness.

The potential impact of Ayurveda, also in this day and age, I’m convinced, rests on its basic principles and a rather unique concept of health, that include the understanding of five elements (panchamahabhuta- ether or space, air, fire, water and earth), constitutional types (Prakriti – Vata, Pitta and Kapha) , as well as in its personalised approach to diagnostics and treatment. The study of Prakriti evaluation has indicated that Ayurveda can easily classify humans into phenotypes irrespective of ethnicity, geography and race. This way of understanding the human constitution leads to a better understanding of health and well-being. In order to achieve health, Ayurveda not only deals with the physical and the mental aspects, but also incorporates spiritual, social and environmental aspects. While dealing with issues of health it considers several related (non-drug) approaches like lifestyle modification, personal hygiene, dietary adjustments, exercise and social and environmental relationships. There is a great focus on a person’s daily and seasonal regimen (Dinacharya and Ritucharya), and Ayurveda practitioners thus provide strict guidelines on food and nutrition, lifestyle and even deal with psychosocial health. 

While dealing with the mental, social and environmental aspects of health, Ayurveda proposes concepts like svasthavratta (code of conduct) and achar Rasayana (social behaviour), dharanneyavega (urges needing control eg. anger, greed), pragnaparadha (an offense against wisdom), and Yoga (Yama, niyama, asana, etc). This overall Ayurveda strategy helps to achieve personal transformation and regulate behavioural (social) conduct, which in turn helps ensure the development of the community and ability to adapt in a changing environment, leading, ideally, to a ‘healthy society’. This is achieved through promoting lifestyle with ethical conduct and by cultivating virtues like truthfulness, modesty, courage, forgiveness and kinship to all forms of life. Ayurveda perceives human beings as the microcosm of the macrocosm, and highlights our interconnection and interdependence with nature. In achieving health it always stresses this connection and uses strategies which link us (back) to nature. Ayurveda assists individuals to take control of their own health and increase self-reliance and re-establishes our connection to the environment. Ayurveda is not limited to medicine or therapy; instead it implies a holistic approach to life and living in harmony with nature.

Sadly, current strategies used to “modernise” Ayurveda are based on human-centric biomedical approaches leading to the medicalisation of Ayurveda. These modern strategies have neglected the ancient multidisciplinary and holistic approach which not only considered health and well-being of humans but also of plants, animals and environment. Ayurveda branches like Vrukshayurveda (Ayurveda for plants), Pashuayurveda (Ayurveda for farm animals), Hastiayurveda (Ayurveda for elephants), have lost their place in this approach. It is clear that this medicalisation has narrowed the holistic perspective and potential of Ayurveda. Processes like standardisation and unification of Ayurveda education have neglected the local and regional variation and pharmaceuticalisation has reduced diversity and availability of medicine to less than 10%. We need to bring back this lost perspective not only to Ayurveda but also to use this holistic way of thinking to fill gaps in our current biomedical model of health care delivery. The ancient knowledge of Ayurveda is as relevant today as when it was recommended for the first time.

Unlike ITM at the river Scheldt where the Congo boats moored, Harvard is situated on the banks of Charles River, Boston. And while Boston never had a formal colony, it is the capital of a New England settler state, and its United Fruit Company plantation hospitals were field stations for Harvard students till deep into the 20^th century. Which made the opening remarks of Elizabeth Solomon – one of 80 survivors of the Massachusett Ponkapoag tribe – rather fitting: “Here is where we interacted with the visitors. Here is where those who survived remained (…) But colonization is not limited to centuries ago. The systems of colonization continue, in this place and others (…) Each and every one in this room is a colonist. So please be mindful, introspect, and respect”.

Solomon’s plea did not fall on stony ground. Among others, Anne-Emmanuelle Birn made it clear to everyone in the conference hall that a straight line goes from erstwhile ‘tropical medicine’ – “actually reinforcing the political and social stratification between colonizer and colonized” – to present-day ‘global health’ dominated by “Tata kills, Tata funds” and Davos-style philanthrocapitalism. Yesterday’s colonialism and today’s coloniality have one thing in common – the reinforcement of inequity – and the current mainstream global health is essentially colonial, hence needs to be decolonized. One possible and much needed way of doing so is to decolonize global (and international, and tropical) health syllabi. Which is one of the more immediate aims of the student committee that came up with the great idea to organize this conference. But it is not enough: Harvard scholar Melissa Barber outlined a chain of academic mechanisms maintaining the global health community as it is, and which all need to be redressed – “(1) Gatekeeping for people entering; (2) Selecting of global health frameworks; and (3) Legitimizing mainstream global health initiatives”. Much remains to be done before we arrive at “a vision of global health that is equitable, reflexive, and anti-colonial in both delivery and discourse”.

In the closing plenary, distinguished health and equity champion Mary Travis Bassett pointed out the essence of the way forward for genuine decolonization: “replace the happy handholding of global health partnerships with solidarity, meaning equal value and rights of all humans”. She concluded by asking all of us to “apply the principles of solidarity on the whole globe, not only far away, but also in your own environment”. Which brings me back home, in my own academic environment, at ITM. There is little doubt that our own house needs decolonization too. Are we willing to take on the task?

Nevertheless, while global health’s mission has already expanded from protecting colonizers from disease to improving health equity worldwide, it can be argued that there are still some signs of colonialism lingering in the field. Old colonial powers still very much control the restricted space of global health policy and decision-making – though the rise of China’s Silk and Belt Road and the backlash against globalization as shown by Brexit and Trumpism may also be initial signs of (global health) crumbling empires. Recent decades have seen the birth of neocolonizers – from non-state actors without legitimacy to emerging economies demanding a seat at the table – that rather than offer a new narrative, end up helping perpetuate the status quo. Meanwhile, dissidents and emerging voices from the Global South still largely assume token positions in global health discussions instead of playing meaningful roles in global health operations – though I would be remiss to ignore programs such as the Emerging Voices for Global Health from which I greatly benefited and that are attempting to, borrowing this blog’s tagline, switch the poles in international health policy.

The past months have seen a surge of interest in the idea to decolonize global health. Late last year, I started a hashtag #DecolonizeGlobalHealth on Twitter which generated some initial feedback and suggestions, especially from fellow young Global South voices. Some even reiterated that the growing movement towards advancing women leadership in global health is deeply intertwined with progress in global health decolonization. Last week, my fellow students at Harvard organized a conference on the decolonization of global health, whose slots were not just immediately filled but which was also widely anticipated in livestream worldwide. (I missed the conference because I’m currently based in the Philippines finishing my doctoral thesis. As part of my decolonization project, it was my intentional choice to focus on a community-based action project in my home country rather than write a global health policy paper for an international organization.) In the past weeks, I was approached by some colleagues asking what can be done to move this conversation from Twitter to the real world.

But what do we really mean by #DecolonizeGlobalHealth? In order to prevent this new concept to end up becoming a buzzword that will later fade away, it is vital that the global health community of scholars and practitioners unpack, examine, and reflect upon this idea. From my view, there are at least three areas of inquiry where researchers and policy-makers can ask questions, debate ideas, and find answers.

1) The analysis of global health. All global health action emanates from a certain understanding of the world. There are values, assumptions and premises on which decisions and relational arrangements are based, and frameworks for analysis define the boundaries and dictate who is included and who is not. Just a few years ago, developing countries were still generally seen as mere recipients of charity and generosity, bereft of good ideas and innovation, and possessing limited potential for leadership. Along the same lines, ‘capacity-building’ of poor countries was (is?) a ‘white man’s burden’ of the ‘developed world’. Today, arguably, new narratives are evolving, moving away from the traditional donor-recipient relationship towards country ownership and partnership – though some may feel that this is more rhetoric than practice.

Territorial colonialism may be long over, but the colonization of the mind, of culture, of domestic politics and of the economy continues and reparations are yet to be realized. Meanwhile, colonial powers did not just dominate over foreign lands – the Western mindset of progress and capitalist ‘development’ (copied pretty much everywhere in the world now) also exerted enormous pressures on the very Earth that sustains our health and wellbeing, leading to the climate crisis that puts our future health at great risk in return. The new frame of planetary health offers the best form of hope – but it will require a deep expression of humility from planetary colonizers of all forms – countries and corporations alike.

2) The institutions of global health. Who are the agents of modern-day colonialism in global health? This question requires scrutiny of a wide range of actors – from formal institutions such as the WHO and World Bank, to non-state players such as the Gates Foundation and the pharmaceutical industry, to influential personalities that control what Richard Horton once called (on Twitter) the ‘old boys’ club’ of global health – whether they are in Lancet Commissions, Twitter feeds, or conference organizing committees. One time, I saw an academic tweeting a photo of an all-white global health meeting – I thought ‘global’ was more colorful than that!

Promoting diversity and inclusion in boards and staff of global health organizations is a good first step. For instance, apart from UN agencies and philanthropic foundations, I have always wondered about the composition of global health departments in elite schools of public health. A quick count of faculty members in my alma mater, Harvard Chan School, shows that out of 35 primary faculty at the Department of Global Health and Population, only 13 have non-Western-sounding names and 14 are non-white or white Latin Americans. Only 1 professor worked in a developing country immediately prior to joining the faculty, which may indicate that almost everyone from the Global South stayed in the US or Europe either prior or shortly after graduate school. One piece of good news is that a Brazilian professor just got appointed as department chair, replacing a Sudanese who served for seven years.

But decolonizing global health actors is more than having additional Global South seats in still-colonial organizations. Colorful composition does not automatically mean transformed structures and changed values. To decolonize institutions, there is a need to retell the story, rewrite the rules, and even redesign the system.

3) The processes of global health. Finally, apart from critiquing the starting framework and the cast of characters, it is also important to investigate the processes that animate the global health space. The management of organizations, shaping of rules, making of decisions, generation of knowledge, and allocation of resources are just some examples.

Let me describe two processes that receive little attention. Part of the decolonization of processes is to level the playing field so that emerging scholars and practitioners from the Global South can have a chance. The first are the procedures and requirements governing journal publications. I once had my Global South-perspective commentary about a novel emerging issue rejected not because of it being not well-written but because of ‘oversubscription’ and ‘lack of space.’ Meanwhile, a colleague from the Global North who has clearly penetrated the ‘old boys’ club’ published six commentaries within a six-month period in that same journal – or at a rate of one article per month!

Another area that needs to be examined is the recruitment of global health professionals and how their work is recognized. To illustrate, a year-long stint done in a developing country by a colleague from a rich country will be counted as ‘global health experience.’ Meanwhile, coming from a developing country in the process of health reform, my decade-long contributions at home will be considered only ‘domestic work.’ This means there is a high chance that the development bank, which counts the number of countries an applicant has worked in, will hire the other and not me.

Some initial steps: write, mobilize, reflect

To start global health’s decolonization and rewrite its narrative, more Global South scholars and practitioners must begin writing and talking about global health – its analysis, institutions, and processes – as they see it. There is nothing to fear about sounding politically incorrect – after all, there is nothing politically correct about colonialism. But there is always room for a respectful conversation.

As an indication of the need for alternative global health stories, only seven of the global health books included in a list recently generated from a Twitter survey are written by a Global South author (plus Global Health Watch by the People’s Health Movement, and not counting Harvard-based Amartya Sen). Meanwhile, Paul Farmer – the white Harvard doctor who would cure the world – has six books out of 100 – five written by him, and one about him. (Don’t get me wrong – I admire him and his work.)

Another essential step is to ensure that the decolonization discourse does not only occur in Twitter-verse and global health reunions. Decolonization begins at home, and so movement-building at the country level is crucial. A Global South expert sitting comfortably at a desk in Geneva is not decolonization. #DecolonizeGlobalHealth must inspire a new generation of global health leaders to question the status quo and take bold action at home and elsewhere.

Finally, for us who were educated in schools of public health that are based in former colonizers or were agents of colonialism themselves, we need to be constantly reflexive about our position of privilege. We might not be noticing it, but in our pursuit to decolonize global health, we could very well end up becoming neocolonizers ourselves.

Less than two years on, one can be fairly convinced that this administration is serious in leading from the front and some might even say, successfully walking the tightrope – for now. 

“Innovation without access does not mean anything,” Director General Dr Tedros Adhanom Ghebreyesus, told member states during a discussion on access to medicines last month at WHO’s 144^th Executive Board meeting.

The event saw member states consider two agenda items on access to medicines.

THE WHO ROADMAP ON ACCESS TO MEDICINES

First, the WHO roadmap on access to medicines and vaccines was taken up at the Board meeting.

The roadmap is a product of consultations and discussions with member states during 2018 on ways to work on access to medicines, vaccines and other health products, between 2019–2023. In May 2018, the 71^st World Health Assembly had considered a report on addressing the global shortage of, and access to, medicines and vaccines. The report had prescribed a list of priority options for actions. 

The roadmap reflects existing WHO mandates in key Health Assembly resolutions of the last 10 years related to access to safe, effective and quality medicines, vaccines and health products, and also the Thirteenth Global Programme of Work, 2019–2023, the secretariat has said.

In their statements on the roadmap, countries stated their wide-ranging suggestions and concerns on the roadmap. While some countries pushed for regulatory harmonization such as Germany, others including Brazil cautioned against it. India asked for greater clarity on the resources to implement the roadmap. 

Some stakeholders are not comfortable with the concepts of “fair pricing” and “equitable access” – as discussed in the roadmap. In the roadmap, WHO has referred to a fair price as one that is affordable for health systems and patients and at the same time provides sufficient market incentive for industry to invest in innovation and the production of medicines.

It is not clear when and how fair pricing as a term became an acceptable phrase in a WHO document, one observer remarked. During the discussion, the delegate representing Iran said, that there is no shared understanding on what “fair pricing” means and that WHO must stick to “affordable” medicines instead. In its statement, Romania on behalf of the EU, suggested that talking about market failure alone will not help.

Some believe that the fair pricing debate can be useful to arrive at more meaningful discussions on access issues. One developing country delegate believes that “fair pricing” can be a lever to open the wider discussion on access to medicines. “At least, the fair pricing discussion will serve the purpose of getting some of the European countries at the table to talk about high prices of medicines,” he said in an off-the-record conversation. (The previous fair pricing forum was in The Netherlands in 2017.)

To be sure, European countries have already been drawing attention to rising drug prices.

MEDICINES, VACCINES AND HEALTH PRODUCTS – CANCER MEDICINES

During the EB proceedings, The Netherlands among others drew attention to its efforts to get more transparency on drug prices, in the context of the discussion on WHO’s cancer report.  Italy in fact called for a resolution at the next World Health Assembly on transparent pricing of medicines. In a statement, Italy suggested that WHO must enhance and broaden the discussion on prices and transparency of medicines to improve competition, affordability and availability of drugs.

High prices of drugs continued to dominate discussions at the Board. Member states came together to note  the crucial report on cancer medicines.

The WHO issued this comprehensive 171 page report in December 2018 following a resolution on cancer prevention and control in the context of an integrated approach at the 2017 World Health Assembly. The report untangles the complicated and connected issues of price of drugs, costs to make drugs, the incentives to invest in R&D; and whether these mechanisms should be transparent for the sake of public interest and good governance. The industry, represented by IFPMA has said that the report is flawed.

Some WHO insiders say that the report is very “un-UN” like in its tone, because it speaks directly. Apart from saying that companies set prices according to their commercial goals and focus on extracting the maximum amount that a buyer is willing to pay, it essentially said that an over-incentivized industry may be distorting investment and stifling innovation.

The report, supported with more than 400 references, was crafted through several stages of consultations and meetings. There were consultations with member states on the report. Sources say, no objections were raised by any country on the scope of the report. The secretariat reported that there were several meetings with the Essential Medicine List Cancer Medicines Working Group and an informal advisory group on availability and affordability of cancer medicines, whose experts provided advice on the technical approach to assessing benefits of cancer medicines, the scope of the report, analytical feasibility and case studies, and suggested options that might improve the affordability and accessibility of cancer medicines.

As I reported recently, countries have called the report a milestone, a tour de force among others. It is now seen to be an important reference for the future and is shaping international cooperation and dialogue on addressing rising prices of cancer drugs in the wider context of access to medicines.

Not all stakeholders were happy with the report. Notably, the US and IFPMA asked WHO why the private sector was not consulted for the cancer report.

Dr Mariângela Batista Galvão Simão, assistant director-general for drug access, vaccines and pharmaceuticals, gave a clear debrief on how the cancer report was shaped, and admitted to the constraints in involving the private sector for the cancer report.

She informed the executive board during the discussions, “We believe that it would have been a case of perceived conflict of interest by consulting industry on this report. We would have been open to receiving information about net prices of individual cancer medicines their specific R&D costs, for example. But we believe this information would have been difficult to obtain from industry stakeholders.” She added that information from pharmaceutical companies can be included in an addendum to the report. The information furnished in the report is based on publicly available data.

This was not the only occasion when WHO top brass spoke in clear terms.

In a related discussion on the roadmap on access to medicines, the US continued to reiterate, as before, that IP related issues (“trade deliverables”) fall outside the expertise and mandate of WHO. In its statement, Canada also urged for more collaboration with WIPO and WTO on these matters.

Soon, Director General Tedros defended WHO’s turf on the IP territory, while acknowledging the continued need to work along with WTO and WIPO on these matters. He said that it has indeed been very much a part of the mandate of WHO to address matters of intellectual property in relation to public health.

Ultimately how far WHO will go on these issues, will be a function of how it handles the sustained pressure from many quarters – some overt and others subtle. This space will get more interesting – the rope will get tighter. 

We will likely hear more. “Transparency is good for governance and it is good for health,” Dr Simão declared during one of her interventions at the meeting.

While PMAC has been running since 2007, this is only my fourth time to attend this event. (See my blog about PMAC 2015 here.) Every year, this by-invitation-only conference revolves around a specific theme – and for 2019, it was the political economy of noncommunicable diseases (NCDs). This year’s opening speaker, Harvard professor Michael Reich, lauded PMAC for being the first global health conference to include “political economy” in its title. Inspired by Harold Laswell’s definition of “politics” – “who gets what, when, and how” – Prof. Reich offered a simple definition of “political economy” for PMAC’s audience – “how the allocation of political resources and economic resources affects who gets what, when, and how.”

While the focus of the conference was NCDs, one can’t help but use the same lens to understand PMAC itself as it unfolded. Recently, there has been so much buzz about global health conferences – from declined visa applications among Global South delegates to lack of representation in panels based on gender, nationality, and intersectionality. While a full-blown political economy analysis of “who gets what, when, and how” merits a longer academic paper (though Chatham House’s Rachel Thompson did a good job in a recent blog, drawing from her insider perspective), let’s do a quick-and-dirty description of “who gets invited, who doesn’t, and so what” – PMAC style. Here’s my part-ethnography, part-Twitter analysis:

Voices old and new

One of the biggest annual reunions of global health’s ‘Who’s Who,’ PMAC 2019 was more than a venue for political economy discourse; it was a sneak preview of global health’s political economy in action. As expected, the World Bank’s Tim Evans was there not just for one but two plenaries. Meanwhile, I’m not sure if anyone noticed the absence of Svetlana Axelrod, WHO’s assistant director-general for NCDs, though there was a sprinkling of WHO staff working on NCDs from Geneva and regional offices.

Of course, this is the time to shine for Thailand, as its hardworking public health specialists showcased the country’s impressive achievements from its Universal Health Coverage program to Health Promotion Fund. Various UN agencies, financial institutions, foundations, and nongovernmental organizations, especially those devoted to NCDs (such as the new Bloomberg-funded initiative Resolve to Save Lives led by former US CDC head Tom Frieden), were present as well. Due to Thailand’s location, PMAC also invites seasoned and emerging public health specialists from Southeast Asia – myself included.

While Richard Horton was sorely missed, the Lancet’s imprint was very much felt through the newly-launched Syndemic Commission linking obesity, undernutrition, and climate change. (These Lancet commissions are another agent of global health policy worthy of political economy analysis.) Meanwhile, as one of Global South’s most passionate planetary health advocates, I was elated that PMAC also had a few of us ‘voices in the wilderness’ talking about the more upstream environmental (non-behavioral) drivers of NCDs. (Dear Thai friends, here’s my suggestion for PMAC 2021 theme – “Planetary Health: A New Paradigm for Global Health.” Let’s do it before it’s too late!)

In the spirit of much-invoked and eternally-fuzzy ‘multisectoral collaboration,’ PMAC also invited a few representatives from the ‘industry’ as well. One notable guest came from the International Food and Beverage Alliance, who during the opening panel urged the audience to stop viewing the food industry as a ‘monolith’ and instead begin classifying individual companies into allies and enemies. What the speaker failed to say is under which category does IFBA – which includes Coca-Cola, PepsiCo, Nestle, and McDonald’s – belong. That would have been helpful in guiding how we in public health must engage with them – if at all.

Nonetheless, the presence of Big Food, Big Soda, and Big Alcohol (I suspect Big Tobacco was absent, or perhaps at least present discreetly) allowed NCD prevention advocates to tackle the ‘commercial determinants of health’ – global health academia’s newest buzzword – head on. From the audience, NCDFREE’s Rhea Saksena likened the ongoing interactions with industry to a ‘very tense couple’s counseling session,’ challenging companies to behave in a trustworthy manner if they want to be a ‘partner.’ Meanwhile, Paula Johns from Brazil remarked that “the best public-private partnership is taxation.” During the conference, there was general support for ‘sin taxes’ (which I suggest should be renamed ‘corporate sin tax’ to be precise), which Tim Evans described as a ‘triple win’; it does not only reduce consumption of unhealthy products and raise revenues for health – it also has an equity-enhancing effect.

Global health’s Desaparecidos

Like in any party, attending guests can’t help but look around and identify who were not invited. During the gala dinner, Suwit Wibulpolprasert, one of Thailand’s foremost public health leaders, started doing a roll call of Thai’s Fathers – the Father of Thai Universal Health Coverage, Father of Tobacco Control, etc. My seatmate whispered to me: “So many fathers – but where are the mothers?”

Meanwhile, my friend and colleague Mariam Parwaiz from New Zealand expressed her appreciation in the Twitter-verse: “Over 800 participants from 80 counties at #PMAC2019. One of the things that I really like about PMAC is that it’s a major #GlobalHealth conference that’s in the Global South. The future is Asia!” – to which I rapidly replied: “None of the keynote speakers though is from the #GlobalSouth #PMAC2019 #DecolonizeGlobalHealth.” Of course, I was not counting the Princess of Thailand who welcomed us all to the Kingdom.

Surely, concerns about lack of diversity and inclusion along the lines of gender, race, and nationality are not new but certainly need to be re-echoed. Johanna Ralston of the World Obesity Federation replied on Twitter that there was also an “absence of affected people as speakers other than a couple of side events #plwncd.” And while difficult questions were asked during sessions, another group hugely absent were the dissidents. A colleague told me that Thailand’s activist groups are generally not invited to PMAC each year. Thankfully, we have the People’s Health Movement – which another colleague described as PMAC’s ‘token opposition’ – boldly yet expectedly raising the difficult issues no one else will dare say in sanitized and well-scripted global health discussions. (Full disclosure: I’m a PHM supporter!)

Finally, there’s the big portion of our not-so-big global health family who generally did not see an invitation in their email inbox. My fellow Filipino colleague Gianna Gayle Amul, an emerging scholar from the National University of Singapore who is examining alcohol industry interference in Asia, tweeted her disappointment: “I thought I can just register and still come but apparently you can only do that if you actually have an official invitation… a little bit more exclusive #PMAC2019.” (By the way, Singapore is only two hours away from Bangkok! It should not have been difficult for her to come.)

The return of Margaret Chan

PMAC 2019 also appeared to be a homecoming party for Margaret Chan, former WHO Director-General – or as Suwit repetitively emphasized, DG Emeritus. After 2 years of being out of the limelight, Dr. Chan – herself a 1998 PMAC laureate – introduced herself as the global health czar of the China-led Boao Forum for Asia, which some already call the ‘Davos of Asia.’ Dr. Chan invited the PMAC crowd to fly to Qingdao in June 2019, where she is organizing the first Boao global health forum. (Another topic for a political economy PhD – the emergence of annual global health conferences hosted by countries especially in Asia – where the center of world gravity is shifting towards. Other examples include Taiwan’s Global Health Forum and Singapore’s Raffles Dialogue.)

During the gala dinner, Dr. Chan and Suwit unleashed their hidden talent by pulling off a stand-up comedy stunt, where they jested about whether she is still earning a salary from WHO or not (she said no), being ‘raised’ by her husband post-WHO, and how some physical distance is beneficial to marital relationships. She publicly admitted that her only failure as DG – or perhaps the only failure that she can admit in public – is not having been able to convince member states to pass a resolution on LGBT health. But when Suwit, PMAC’s mastermind, asked her on what the major driving force in global health in the next decade will be, Dr. Chan flatteringly remarked: “PMAC, PMAC, PMAC!” Then the two waltzed to the tune of Carpenters’ “Close to You.”

While she received deferential applause accorded to a former DG, her statements about engagement with industry drew mixed reviews. During the opening panel, Dr. Chan repeatedly emphasized that her stand on NCDs is clear – however, it felt more confusing than clear as she urged tackling the corporate drivers of NCDs on one hand and helping make the industry “good guys” while keeping their profit on the other. She also said she did not want to comment on Tedros’ plan to engage with the alcohol industry since “he is in-charge now.” Harvard professor Jesse Bump then reacted on Twitter: “Shameful performance: Margaret Chan sings and dances to avoid a question about whether @WHO should accept money from the alcohol industry at #PMAC2019, focused on #NCDs.”

Leadership beyond imagination

Given this year’s theme, PMAC was pressured to “walk the talk” by adding “Baby Shark” and other dance exercises at the start of sessions and installing food labels in buffet tables (though with lots of food wasted). This just shows that technical fixes in global health are quick and easy decorations. However, the real battle is how to get things done in a world where economic forces sell junk and the politics of change is controlled by a powerful few. This is what political economy is all about.

So what do we need to tackle the messy political economy of NCDs, of platforms such as PMAC, and of global health at large? I propose that it is strong, visionary, uncompromising leadership. Fellow Filipino Susan Mercado, former NCD head of WHO in the Western Pacific, eloquently articulated this during the plenary: “Leaders don’t work in the space that is easy. They work in the space that is beyond imagination.” I could say there were a few of them at PMAC 2019, but their tribe must increase.

May PMAC evolve into a space for courageous leadership and endless imagination. Kudos to the hardworking PMAC organizers – please don’t forget my invite next year!

Tanko Al-Makura is governor of Nasarawa State, in northern Nigeria and lives each day with a scar inflicted on his “life and psyche” by Lassa fever. This is what he knows of the disease that has constantly killed Nigerians every year since 1969.

A male child among seven sisters, Al-Makura took to hawking cassava flour as a vocation because “that’s what I saw my sisters doing,” he recalls, standing in front of an audience of Lassa fever researchers and experts at the Abuja event held on January 16 and 17, 2019. “It inculcated in me a feminine and domestic instinct of care and nurture.”

It is the contact that puts many families in danger of contracting Lassa Fever every year.

Al-Makura was a 37-year-old father when his sons were diagnosed with a fever. One son was clenching. That “feminine instinct as a father” took hold and Al-Makura wanted to ensure his son didn’t cut his tongue between clenched teeth. “I got bitten on one finger. It was a small cut, no blood,” he says. “I didn’t know that was the beginning.”

The son died, the other one survived but developed profound deafness. Five days later, Al-Makura developed classic symptoms—fever, headache, stomach pain, tight chest, erratic breathing. The treatment by trial and error went on for two weeks. “There was no improvement, despite the fact that I was in a teaching hospital,” he says. “Linking my symptoms to Lassa Fever was my saving grace.”

Oyewole Tomori, a virologist who’s worked on Lassa Fever since it was first identified in 1969, made the diagnosis and insisted Al-Makura be sent off to a facility equipped to deal with a haemorrhagic fever like Lassa. The only hospital suitable in 1990 was in Lagos. A blood sample was sent to the US Centre for Disease Control in Atlanta, 9728 km away.

Fifty years on, the infrastructure for dealing with a yearly epidemic has changed; there is more knowledge about Lassa Fever; hundreds of articles on knowledge, attitudes and perceptions of Lassa fever have been published; the science is better understood. Yet the disease’s outbreaks continue to strike annually, claiming lives.

From 1969 to 1978, the outbreak was confined to four states in Nigeria. Nearly every state in the country has seen an outbreak in the last 50 years, and with it, a rising number of deaths. Between 2009 and 2018, only Zamfara has not reported a case.

The Nigeria Centre for Disease Control (NCDC) has already declared an outbreak this year after 60 people across eight states were confirmed infected with the Lassa Fever virus in the first two weeks of January alone.

Despite the tons of knowledge-attitude-and-perception articles [nearly 160 papers were presented at the conference] published on Lassa Fever, the basic route of infection continues to make the country vulnerable. Environmental hygiene, personal hygiene, handling food materials, handling sick loved ones, handling patients—it is all in the mix.

In the lead up to declaring an outbreak, NCDC warned: “Lassa fever is an acute viral haemorrhagic illness, transmitted to humans through contact with food or household items contaminated by infected rodents. Person-to-person transmission can also occur, particularly in a hospital environment in the absence of adequate infection control measures. Health care workers in health facilities are particularly at risk of contracting the disease, especially where infection prevention and control procedures are not strictly adhered to.”  It advised the Nigerian public to “focus on prevention by practicing good personal hygiene and proper environmental sanitation. “Effective measures include storing grain and other foodstuffs in rodent-proof containers, disposing of garbage far from the home, maintaining clean households, and other measures to discourage rodents from entering homes. Hand washing should be practiced frequently. The public is also advised to avoid bush burning,” it added.

Al-Makura didn’t know any other way to handle his ailing son years ago. He and his doctors were at risk.

“I was later informed that my infection was the result of the bite from my son,” he recalls. The outcome of Al-Makura’s bout with Lassa Fever is profound deafness. He’s been using cochlear implants since 2000 to process sound, “although with some distortion,” he says.  “Every day, I have to wear a hearing aid for 18 hours.”

Every year, this message goes out: “Health care workers are again reminded that Lassa fever presents initially like any other disease-causing febrile illness such as malaria; and are advised to practice standard precautions at all times, and to maintain a high index of suspicion. Rapid Diagnostic Tests (RDT) must be applied to all suspected cases of malaria. When the RDT is negative, other causes of febrile illness including Lassa Fever should be considered. Accurate diagnosis and prompt treatment increase the chances of survival.”

A lot needs to shift in manner toward Lassa fever.

“You are killing your loved ones, your doctor is killing you and the doctor is committing suicide from utter disregard for infection prevention and control,” says Tomori.

“My country is a country waiting for the lion to finish yawning before deciding to run,” he said. “Once it is down yawning, its ready to pounce on you.”

Infograph Credit: National Centre for Disease Control (Nigeria).

Last week the elite of Global Health gathered in Bangkok for the Prince Mahidol Award Conference. This annual invite-only event attracts Global Health leaders from around the world, as well as practitioners and researchers from South East Asia. While previous years have covered infectious disease, UHC, equity (i.e. the usual), what was special about this year was the original theme, The Political Economy of NCDs, making it the first Global Health conference to address explicitly political economy – an exciting prospect.

Yet as the conference drew to a close I was overwhelmed with the same familiar feelings of frustration and hypocrisy that I have got used to at Global Health events. I know these sentiments are echoed by many friends and colleagues. My hope is that by publicly articulating my feelings (in more than 140 characters), we can begin to help transform our disappointment, frustration and anger even, into something more useful.

DISCLAIMER: I am hugely grateful to the ever-impressive PMAC Secretariat, and all those who worked so hard to make this conference a reality. This is not meant as a critique of anyone in Thailand involved. However, by design, PMAC delegates power to the Organizing Committee, made up of the co-hosts (see below), described by Margaret Chan during the conference as a “who’s who” in Global Health. This blog is not aimed at anyone in the PMAC Secretariat, but it is aimed at everyone in Global Health – and especially those associated with these organizations.

PMAC co-hosts: the “who’s who” of global health

The political economy of PMAC

Leading up to the event, over the last nine months I had the opportunity to participate in the organization of PMAC at various planning meetings. I soon realized that what I was observing in these meetings was a microcosm of Global Health. Around the table, representatives from all the big players; speaking freely, but also defending their institutional perspectives, and protecting their own Global Health ‘territory’.

As conversations digressed from the minor matters of the conference sessions, to the mega matters of how PHC and UHC are related, I saw that this opportunity was in fact a unique window into the political economy of Global Health: how the unbalanced distribution of power and resources play out, to amplify some perspectives over others, ultimately to shape the agenda and control outcomes.

Although in this case the outcomes were fairly benign – the structure and content of a conference – the discussions were fascinating and, while being under Chatham House rule, I cannot share details of who said what, I can share my critical reflections on what I saw and heard. Combined with my experience (and participant observation) at other Global Health fora, below I outline what I have learned about the political economy of NCDs, and of Global Health.

Civil society is being systematically disempowered

In political economy terms, the funding organizations civil society organizations (CSOs) rely on use their resources and material power to control what activities are and are not funded. To paraphrase the proverb, it is hard to bite the hand that feeds; especially when that hand has paid for your airline ticket and is feeding you a three course dinner at a five star hotel. While it is important to have a seat at the table, that table is not an even one and power asymmetries perpetuate. Voices are heard and respect is given, but it is a bitter sweet respect that leaves a sour taste in my mouth.

In the world of NCDs beyond PMAC, civil society are being steered towards certain actions over others. CSOs are being offered funding and partnerships that focus on treatment and access to services. For all organizations, funding to work on the prevention of NCDs is limited. Funding to work on the drivers of NCDs (including the commercial determinants) is even harder to come by. All these issues reflect broader challenges around partnerships that the SDG era presents in its opening of the floodgates to the private sector. 

The conflation of treatment and prevention may be problematic in tackling NCDs

Within Global Health, the issues around NCDs are being framed in terms of treatment solutions. Solutions that, for example, often involve public private partnerships to accelerate access to pharmaceutical products. This issue was evident in the UN General Assembly high level week (leading up to the 2018 High Level Meeting on NCDs), where only four out of over 50 Global Health side events mentioned prevention. Although in contrast, prevention was very clearly on the agenda at PMAC, the discussions soon returned to circular debates over engaging with “health harming” industries such as food and alcohol. This clip illustrates the situation at PMAC, where civil society (the People’s Health Movement and NCDFree) felt they had to interrupt the plenary to have their voice heard, to help support the brilliant panelist Kwanele Asante’s points. My analysis: if, as to quote Rhea Saksena, civil society are in “an abusive relationship with industry”, Global Health is an uncomfortable third wheel in this long-term relationship between Public Health and trans-national corporations.

The commercial determinants of health are at the top of everyone’s intellectual agenda – but action is not being funded

The most energized and well attended session at PMAC was the excellent People’s Health Movement-led session on the commercial determinants. Although the atmosphere was one of activism the audience contained a range of delegates, including from all those on the “who’s who” list.  Engagement with industry was THE issue of the conference. However, as illustrated in the plenary video clip, the discussions did not progress and likely only served to re-enforce pre-existing assumptions on both sides. While the importance of tackling the commercial determinants is widely agreed, as mentioned above this is not reflected in funding flows (articulated on Twitter by Professor Kelly Lee ). This highlights the challenges for Global Health actors to implement research and projects that may displease their donors; donors who are beholden to private capital flows that may well be invested in the products that public health evidence now shows to be so harmful. In other words, the political economy of Global Health in action.

This brings me to a tautology that I think is worth repeating:

Public Health and Global Health are not the same

Public Health being “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988; WHO). Global Health, here, being the self-identifying group of institutions, actors and individuals who work on issues that affect global public health (my own working definition). In NCDs, arguably more than for infectious disease, this distinction needs to be maintained. While in reality it may be hard to separate the two endeavors, conflating them conceptually is an issue. Both are political, however, Global Health – as a product of a certain time and place – cannot be taken out of the global political (and economic system) that created it. Public Health is here to stay, Global Health may not have the same longevity. 

Global Health is part of the neoliberal global political economy

The global political economy is one dominated by the ideology of Neoliberalism, which places the individual and free-market at the centre. As I suggest above, Global Health is a product of the Neoliberal era (Public Health is not). While changing the rules of the economy is clearly beyond the remit of both Global and Public Health, failing to situate our endeavors within this bigger context is a problem. Once we understand Global Health as inseparable from Neoliberalism, we can begin to get to the root causes of why so much of the world are being “left behind” from global goals. To ignore its influence is to deceive ourselves and the people we are trying to serve.

Once we understand Global Health as part of a system that has increased global inequalities and inequities, it seems strange to expect it to do the opposite – to “reduce inequities” e.g. as part of Agenda 2030’s leave no one behind pledge. This is the paradox at the heart of my frustrations with Global Health.

The appropriation of ‘political economy’ by Global Health actors could distract from understanding the political economy (and underlying issues of power) within Global Health

Finally, there is a danger that by holding a conference on political economy, by self-congratulating ourselves on seeking to address the issues of power and inequality in NCDs, a box is ticked and we move on. There is also a danger that the appropriation of the term by powerful players is a dangerous move. We need more political economy analysis of Global Health and its institutions. But who will fund it? Who will publish it?

The aim of PMAC was to: “identify major bottlenecks, root causes and propose solutions at national and global level to accelerate implementation of NCD prevention and control”.  While it certainly fulfilled the former objectives, unsurprisingly, solutions to root causes were not forthcoming. This raises the question: should an elite UN dominated Global Health conference be dabbling in political economy? I am not so sure.

Moving forward…

To conclude, I offer a few tentative suggestions for those who are also frustrated with the current status quo in Global Health.

1) Let’s leave Global Health to do its business: to protect us from pandemics, to fight infectious disease, to find the cure for cancer, to work towards Universal Health Coverage, to give us all the data it can generate.

2) Let’s leave the UN system to its work with member states, in safe-guarding norms, and aspiring to global goals.

3) In the meantime, let’s use the data Global Health generates more smartly – to show what is not happening as well as what is. And to use more political economy analysis to help show why.

4) Let’s dumb down the messages around NCDs, so that members of the public all over the world can understand the issues and causes of injustice. Let’s tell the stories behind numbers in ways that people can understand, communicated in forms they utilize (clue: not case studies!).

5) Finally, and most importantly, let’s be inspired by people like Thailand’s Dr Suwit, to be champions, to not give up on what we believe in (for me, gender equality, equity and social justice).

But let’s also be realistic: Global Health is great for measuring things and improving health security; it is not necessarily the right place for people who want to tackle injustice, and change the world in the many ways it so urgently needs changing.

Moving on to the EB meeting then, my preparations for it started with the preparatory civil society meeting on the 23^rd of January, organized and hosted by the Geneva Global Health Hub (G2H2). Before hopping on the plane, I had already “done my homework”, going through the PHM Commentary on the EB’s agenda items, and WHO background material & reports in the areas of my interest. The preparatory workshop began with the paying of tribute to Dr. Amit Sengupta, one of the founders of the People’s Health Movement, who sadly passed away late last year. The workshop included open discussions on selected items on the EB Agenda [Item 5.5, 5.6 and 5.7, or Universal Health Coverage; Health, Environment and Climate Change; and Access to medicines, vaccines and other health products, respectively] and a closed civil society brainstorming session on changing WHO Governance (although you have to wonder, when is WHO governance actually not changing?). A few days earlier, Dr. Thomas Schwartz (MMI) had explored in a (well-noted) blog post whether the proposed recommendations on civil society engagement with WHO amounted to progress “Towards a new era of partnership” or whether civil society instead needed to “defend a shrinking space”.   As Jenny Lei Ravelo noted in a Devex analysis before the EB meeting,  WHO’s proposals on its engagement with non-state actors was one of the key contentious issues raised ahead of the EB meeting, others being the WHO’s draft roadmap on access to medicines, vaccines and other health products and – mentioned elsewhere –  reports of alleged misconduct within the organization. The PHM watchers also participated in the preparatory workshop and prepared their policy briefs and statements for specific agenda items.

As the 144^th EB meeting commenced on the 24^th, with an opening speech by WHO DG, Dr. Tedros, I was in the room. He shared experiences and observations from his various country visits ranging from UHC reforms in Kenya and India, to the Ebola outbreak in the DRC and polio eradication in Pakistan, all the time narrating inspiring stories of frontline workers working in the most difficult situations. As has been noted by other observers, Dr. Tedros has a knack for ‘humanizing global health’, and he certainly touched many hearts in the room (including mine), as he applauded the dedication of these frontline workers, who inspire him to work even harder. In his speech, Dr. Tedros also emphasized zero tolerance for any misconduct within the organization (in response to the AP report), and confirmed that thorough investigations would soon be concluded. In order to create an open culture within the organization and prevent such issues from materializing (again?), he proudly shared his open door policy for the staff, every Thursday for an hour, when he is in Geneva.  Given his rather huge carbon footprint (see above), I’m not sure that will happen often, but it is, nonetheless, a nice initiative.

Over the next few days, I got a chance to observe some of the interesting (and occasionally, entertaining) discussions and responses of several Board member and non-member states, and civil society organizations on the DG’s report on a few key agenda items including the Proposed Programme Budget 2020-21, the Implementation of the 2030 Agenda for Sustainable Development, and UHC. The states representatives generally welcomed Dr. Tedros’ commitment to transforming (the functioning of) WHO and achieving his – by now well known – “Triple Billion Goal” through WHO’s 13^th General Programme of Work. They shared their country experiences on each of the specific items and expressed their support for WHO’s initiative of moving from a disease specific siloed approach to a more health systems-oriented approach, and the strengthening of country offices. However, many also raised concerns about the relatively slow speed of progress, some great achievements notwithstanding, and emphasized that not only do we need to redouble our efforts towards achieving the SDG agenda, we must also work towards preventing the health gains of the past decade from sliding back  (a danger Gates also warned for last week in Davos). Tedros himself  acknowledged this, admitting that “Progress is slow, we’re not on schedule”, but he has good hopes that a WHO-led Global Action Plan for healthy lives and well-being for all can help get things back on track. Participating countries demanded information and clarity on the timelines, the operational framework, equitable allocation of resources, measuring outputs, accountability to the member states etc. before the next World Health Assembly in May, 2019. The WHO secretariat took note of the suggestions and feedback provided by the participating countries and shared a potential way forward on those elements.

On a lighter note, the WHO physical exercise breaks were really fun to watch and participate in. They happened almost every other hour, putting into practice what WHO preaches on NCDs (i.e. #WalktheTalk) and led to a wave of physical activity and laughter in EB room. Dr. Tedros – all smiles during these breaks – seems to be quite a fan too.

As you can imagine, many informal meetings ran in parallel to these main EB meeting sessions, where resolutions for different agenda items were discussed and negotiated. I managed to sneak into one such informal meeting to discuss the draft resolution under item 5.5 – preparation for the UN High Level Meeting on UHC, and so got the chance to closely observe how each and every word of the resolution was negotiated and (if all goes well) finally agreed by the member states. I could observe first-hand, during these negotiations, how different country contexts can shape the understanding of ostensibly similar concepts so differently (for instance on UHC, see here), thereby making it a challenge to reach a consensus. I was not only inspired by the commitment and patience of the member states delegates in such a time-intensive process but also became more appreciative towards such documents when they are at last released (and look, for outsiders, more often than not, more like “the lowest common denominator”).

All in all, my second visit to the “world’s health capital” was yet another milestone on my own “transformative” journey as a public health researcher.  Dr. Tedros will no doubt hope for the same, when it comes to the future of the organization he leads. Like in the rest of the world, transformation is certainly in the air of Geneva. But the mission of WHO remains the same:  to promote health, keep the world safe, and serve the vulnerable.

Acknowledgement: I thank Kristof Decoster for his review comments and feedback.

The current global momentum around UHC didn’t start with Dr. Tedros, as you know. UHC, at its best, can be a fundamental approach to the right to health but increasingly it’s also seen as a core factor in achieving economic progress and strengthening social and political stability. This is especially crucial in low and middle-income countries like Kenya whereby children, adolescents, and young people will be the key recipients of health gains.

Achieving this will not be a “bed of roses”, however. Significant health system challenges remain, which need to be comprehensively addressed if health for all Kenyans is to be realized by 2022. Some of these you find below.

Challenges to achieving UHC

1. An underperforming health system

Kenya is one of the countries listed by the WHO as having a critical shortage of health care workers, with only one doctor for every 10,000 people.  Growing disgruntlement by health workers about their workplace environment has led to frequent strikes, the longest being 100 days in 2016/17. Frequent stock outs due to weak supply chain management and inadequately equipped health facilities are more common than they should be. Funding levels for health have decreased from 6.4% of GDP in 2010 to 5.22% in 2015 while there has been a rise in out-of-pocket payments from 28.84% of current health expenditure in 2010 to 33.36% in 2015.  Poor quality of health service delivery is being showcased by an inability to perform basic infection prevention practices such as hand-washing (shown to be performed in only 2% of cases when it is indicated). In addition, issues of medical errors and hospital-acquired infections have led to increased hospital expenditure and public mistrust of public health facilities – not exactly what you want on the journey towards UHC.

These health system limitations further demonstrate the gaps that UHC reforms would need to fill, to ensure that the expansion of service coverage and financial risk protection is not undermined by shortcomings in the delivery and quality of care.

2. Weak prioritization of Primary Health Care

It’s fair to say that Kenya, like (too) many other countries, hasn’t focused enough on Primary Health Care (PHC) in the past.  Over the years, investment in specialized services and construction of new facilities got priority, leaving basic primary health care on the sidelines. This has only made it harder to reach the most marginalized, in most need of healthcare. Despite the efforts made, such as free maternity care and the abolition of user fees in primary health care facilities, challenges in governance, sustainable financing, and weak regulations have all impeded PHC (till now).

Seizing the current momentum

While acknowledging these challenges, a number of opportunities exist to turn this around, and the time is ripe to do exactly that. Recognizing the urgency to improve the health and well-being of millions of Kenyans, there is a need to take advantage of the:

1. Strong political will

Recognizing that UHC reforms are an inherently political process, the directive to achieve UHC by 2022, by the President of Kenya is an opportune window for all relevant stakeholders to rally behind. After the launch of UHC in 4 pilot counties in December 2018, this year will be crucial to strengthen community participation and accountability and generate evidence to drive a stronger and more resilient health system, in preparation of the country roll-out phase scheduled for next year (2020).

2. Renewed commitment to achieving PHC

The Astana Declaration saw renewed commitment towards achieving Primary Health Care. The recognition of primary health care as the most efficient and cost-effective way to achieve UHC, as advocated by WHO, provides a driving force towards increasing efforts in this area during Kenya’s journey to UHC.  This has seen Kenya sign a deal with Cuban doctors in the hope of narrowing the human resources gap and strengthening PHC, the latter an area in which Cuba excels. Of course, this has led to a fair amount of contention (but let’s keep this perhaps for another blog).

Furthermore, the increased attention towards formalization of community health workers (CHWs) as crucial members of the health workforce, is an opportunity to boost coverage and effectiveness of PHC. CHW programs have been shown to contribute to improved outcomes in child nutrition, maternal health, HIV and TB care. Strengthening the CHW system will thus be an important step on the journey towards UHC.

3. Innovation and Technology

Health innovation adds value in the form of improved effectiveness, efficiency, affordability, quality, sustainability and accountability in health systems. Kenya, a growing technology hub, has a platform to develop and strengthen technology needed to monitor and predict disease outbreaks, accelerate disease diagnosis and extend access to specialized medical knowledge among others.

Kenya’s UHC journey has started and both the national and global community have high expectations. The private sector will also be involved in UHC implementation, among others promoting innovative products, processes and funding mechanisms, increasing access to services and improving equity and quality of services. Clear regulation of the different partnership models will therefore be necessary to avoid any conflicts of interest and ensure the interest is focused on improving the health and well-being of all Kenyans.  Last but not least, it will be key to ensure implementation takes a multi-sectoral and participatory governance for health approach, capitalizing on partnerships and addressing the broader determinants of health as these are all equally important to achieve UHC by 2022. Our long distance runners are well known all over the world.

Likewise, let’s hope Kenya will indeed become a regional trailblazer, causing a UHC ‘ripple effect’ in the region in the years to come.    

ReBUILD travaille depuis 2011 sur les systèmes de santé dans les Etats fragiles et touchés par des conflits et tente de réunir différents groupes concernés pour réfléchir et agir sur les problèmes clés soulevés (par la fragilité et les conflits). En plus d’avoir mené de nouvelles recherches, nous avons synthétisé les connaissances acquises sur certaines questions clés, en suivant les sujets mis en évidence par un exercice de consultation. Que savons-nous de la résilience des systèmes de santé dans ces contextes, par exemple, ou de la marche à suivre pour parvenir à la couverture sanitaire universelle?

Lors d’une réunion à l’IMT en octobre 2018, nous avons appris que de nombreux pays francophones – par exemple au Sahel – sont confrontés à des défis similaires, notamment en raison de changements climatiques, de conflits et de pressions démographiques et économiques, mais que le débat sur ce que la fragilité ou une crise peut signifier pour les systèmes de santé y est moins développé. Cela nous semble être une opportunité manquée importante. En travaillant avec Collectivity, nous souhaitons aider à réunir les différentes communautés afin d’évaluer la meilleure façon de relever ces défis.

Aussi, pour atteindre et impliquer un public plus large, nous avons traduit en français la série de documents de synthèse sur certaines questions clés – vous pouvez trouver l’ensemble complet ici. N’hésitez pas à lire, partager et réagir.

Nous devons établir des liens et travailler ensemble plus efficacement dans ce monde souvent fragile. Rejoignez-nous! Quels sont les principaux problèmes et sujets qui vous intéressent dans ce domaine?

Tous les documents de synthèse de ReBuild peuvent être trouvés via les liens ci-dessous:

1. Résilience des systèmes de santé pendant et après les crises  
2. Systèmes de santé inclusifs en situations de crise
3. La couverture sanitaire universelle en situation de crise
4. Types de prestataires pendant et après les crises
5. L’économie politique des pays en situation de crise
6. Le renforcement de l’État pendant et après les crises
7. La durabilité des systèmes de santé dans les situations de crise
8. Les capacités de recherche des systèmes de santé dans les situations de crise
9. Répondre aux crises humanitaires de façon à renforcer les systèmes de santé
10. Financement basé sur la performance dans les environnements fragiles et en situation de conflit

Fragile and conflict-affected health systems – bringing together the language divide

The world is a divided place, as we know, and one of the barriers we face is language. Knowledge silos often build up, with people only reading certain bodies of work, depending on where they read and in what language. Academia is also strongly affected by these issues.

ReBUILD has been working since 2011 on health systems in fragile and conflict affected states and trying to bring together different groups concerned to think and act on the key issues raised. In addition to new research, we have tried to synthesise learning on some of the key questions, following topics raised in an agenda-setting consultative exercise. What do we know about resilience in health systems in these contexts, for example, or on how to move towards universal health coverage?

Following a meeting at ITM in October 2019, we became aware that many francophone countries – for example, in the Sahel – are facing similar challenges, including due to changes in climate, conflict, and demographic and economic pressures, but that the debate about what fragility or crisis may mean for health systems has been less developed there. This seems like an important missed opportunity. Working with Collectivity, we aim to help bring the different communities together to assess how best to respond to these challenges.

In support of this initiative, we have translated our set of briefs on some of the key issues into French – you can find the complete set here – to reach and involve a wider audience. Do please read, share and react.

We need to connect the dots and work together more effectively in this often fragile world. Join us! What are the main issues and topics of interest to you in this area?

All the ReBUILD issue briefs can be found through the links below (here in English – see above for French versions):

1. Resilience of health systems during & after crisis
2. Inclusive health systems in crisis-affected settings
3. Universal health coverage in crisis-affected settings
4. Types of health system provider during & after crisis
5. Political economy of crisis-affected health systems
6. State-building & health systems during & after crisis
7. Sustainability of health systems during & after crisis
8. Health systems research capacity in crisis-affected settings
9. Responding to humanitarian crises in ways that contribute to stronger health systems
10.  Performance based financing in fragile and conflict affected settings

Why? Well, applying Carol Bacchi’s Foucault-inspired poststructural approach to analyse how policy proposals contain within them implicit representations of problems (I know, I’ve lost some of you already!) isn’t exactly easy to explain in everyday language. I’ll try anyway!

After a lengthy – and sometimes challenging – data collection with 57 consultants, employees of international organisations, academics, and national policymakers, I was looking for an analytical framework that could help me link the representation systems (i.e., the overarching roadmaps, paradigms, and ideologies that shape policy actors’ understanding of the world) of PBF proponents and non-proponents (among them of course, some PBF opponents, but also many wait-and-see folks) and their shaping of the discourse of PBF at the global level. Bacchi’s “What’s the problem represented to be?” approach, which highlights how policies represent the problems they intend to address and how governing takes place through this “problematisation”, came in handy: we could highlight the specific representation systems of PBF proponents and non-proponents by demonstrating how their cultural and training background features were shaping their underlying problem representations. Using the first six questions of Bacchi’s approach, we could critically link these problem representations to their understanding and framing of PBF as the most (or the least) opportune policy solution to these deep-seated problem representations (yes, I know, my grandma is now rolling her eyes). We specifically looked at how the use of economic sciences/management sciences/clinical sciences/social sciences language categories reflected their background. The results pointed to quite different understandings of the world, and highlighted several limitations (including eluding issues left “unproblematic”) of both proponents’ and non-proponents’ problem representations – thus calling for much nuancing. For instance, for a long time, equity issues were largely ignored in PBF proponents’ discourse, while PBF opponents omitted to address the dire financial and working conditions faced by most health professionals in LMICs. Importantly, interview data also led me to realise that despite similar training (usually in economics), not all PBF proponents shared the exact same deep-seated presuppositions. This entailed numerous debates including among the most enthusiastic PBF proponents – those we called PBF “diffusion entrepreneurs”.

In several instances, we showed that the proponent/opponent debate which transpired in interviews led these diffusion entrepreneurs (DEs) to reframe PBF so as to increase its political momentum. Several “non-DE” respondents expressed concerns that PBF represented a policy innovation that failed to address structural issues of health systems in LMICs (“icing on the cake with no cake”), and/or a “piecemeal reform”. This criticism prompted DEs to gradually shift their discourse in 2011-2012. They emphasised the fact that PBF could close the can do-will do gap, not only by providing financial incentives, but also by increasing resource generation to enable better performance – notably through work environment improvements and closer performance feedback cycles. A lot of the proponents gradually also acknowledged that PBF indeed needed to be supplemented by other health system reforms. Some DEs strategically framed PBF as a systemic reform with the potential to leverage all health systems reforms, be it as an “entry point” for strategic purchasing, improving health workers’ motivation, or yielding the so-called health systems “data revolution”.

Shifting the attention to strong PBF proponents, Bacchi’s third question, i.e. How has this representation of the problem come about?, enabled to examine DEs’ motivations to deal with the problem, their resources (i.e., knowledge, material, social, political and temporal resources), and their expert/scientific/financial/moral authority at the global level. Using interview data, we showed that DEs were driven by a complex set of motivations: a genuine interest to improve health systems in LMICs, political interests (e.g., gaining visibility on the global arena), and financial interests (e.g., matching PBF with donors’ output-based aid “trend”). We also shed light on how DEs pooled their resources and sources of authority to make an impact and spread the policy proposal that matched their problem representations, i.e. PBF.

Empowered by such resources and authorities, DEs still had to seek relevant modes of operation to boost their discourse globally. Here we used Bacchi’s sixth question, i.e., How and where has this representation of the ‘problem’ been produced, disseminated and defended?, to illustrate the strategies used by DEs to propel the solution to their problem representations. These strategies entailed controlling the learning agenda, shaping the rules of PBF policy experimentation, and spurring policy emulation by using powerful PBF success stories to inspire LMIC policymakers. One of the key activities catalysing these three endeavours was the organisation of multiple study tours across sub-Saharan African countries. DEs’ strategies also had a snowball effect – creating “second wave DEs” spreading PBF on the African continent. Stay tuned for my next PhD paper to get more information on this!

So yes, one year after Paul et al.’s notorious paper in BMJ Global Health, we’re still talking about PBF because in my personal opinion, there’s still much to say about this policy while trying to avoid the strongly politicised debates that developed last year. With less passion, more nuance, and more listening to LMICs’ own problem representations (provided that these too are not shaped by global DEs) and their contextualised adaptation of PBF maybe?

I’m guessing my grandma lies on the floor by now, out of this world. Fortunately, when she wakes up, she can read the full story in Globalization and Health!