There have been a number of attempts at establishing global level goals for health in recent decades. The Alma Ata declaration of 1978 which envisioned Health for All by 2000, the ICPD and the Millennium Development Goals are some examples, that preceded the present discussion on Universal Health Coverage at the international stage as part of the discussions on the post-2015 scenario. The success of these initiatives at the country level has been varied at best. It has also been well accepted that while the policy makers at national and international levels seem to have got the words and concepts right, it is increasingly being realized that in addition to the vision one needs to have an appropriately designed delivery system. Also, more and more people understand that the form and functioning of any given health system is dependent on the balance of socio-economic-political – cultural forces in a given society (1).
There is a growing understanding that emergent properties in a complex adaptive system are unpredictable. Studies of system level change and transition however have begun to delineate various stages in the life cycle of a system (2), as well as various levels (3,4) at which change processes can be studied. Similarly the study of social movements and their impacts on society level features have been studied in various fields including political sociology and political science (5). If one can begin conceptualizing the health of a given society as one such emergent property which depends among other things on the way the health system is configured, then there is scope for a much bolder imagination for health and indeed other social services than is presently being displayed.
My concern for the post-2015 scenario is that unless we learn from the Health For All, the ICPD and the MDG processes (for example) we are bound to let history repeat itself in terms of falling well short of the stated goals in any given declaration.
Using a systems approach as well as a dialectical approach the following seem to be the components that will be crucial to the evolution of such a system.
- Arriving at a consensus on value systems that will keep the poor and marginalized center stage. Not merely symbolically but as active partners / co-creators of the system.
- Globally, nationally and sub-nationally debate pathways, transition strategies and theories of change that go beyond the present constraints of present frameworks that are heavily influenced by market fundamentalism and neoliberal globalization.
- Aiming for at least a working consensus on establishing iterative processes of learning from such debates and initiatives and feeding this back into the governance of such evolving systems.
- Conceptualizing and setting up systems of accountability, which include shared goals and milestones and multi-stakeholder engagement.
The key issues for the future that need to be urgently addressed in my opinion are:
- Imagination and vision to conceive of a more just and comprehensive health system.
- Questioning the constraints being imposed on our thinking (eg. ‘resource constraints’), keeping the health of all as the paramount goal and starting point.
- Setting up systems to debate these goals and pathways at all levels and not only at the international levels.
- Setting up systems to learn from ongoing experiments from across the world.
- Collective leadership and vision to steer through an unpredictable future and a messy transition process.
My vision of the health system lies in its potential for being a key hub of change that will serve as the nucleus to crystallize and catalyze various diverse efforts of building such a just and equitable universal system. The way problems are represented or the way beneficiaries are thought about defines the way policies and systems are developed and in turn influences the behavior of the communities that interact with the system, thus in a way perpetuating the assumptions of those in power (6). This insight is key to the potential of the health system to become a key area where communities and those marginalized sections can be empowered.
(1) Freedman, L.P., 2005. Achieving the MDGs: Health Systems as core social institutions. Development, 48(1), 19–24.
(2) Holling, C. S., 2001. Understanding the complexity of Economic, Ecological and Social Systems. Ecosystem, 4(5) 390-405.
(3) Bunders, J.F.G., & Broerse, J.E.W. (2010). The urgency for change. In J.E.W. Broerse & J.F.G. Bunders (Eds.), Transitions in Health Systems: Dealing with Persistent Problems. Amsterdam: VU University Press.
(4) Ostrom E. 2007 Institutional Rational Choice: An Assessment of the Institutional Analysis and Development Framework. In: Sabatier PA, editor. Theor. Policy Process. Colarado: Westview Press; p. 21–64.
(5) Jenkins, C.J., & Form, W. 2005. Social Movements and Social Change. In T. Janoski, R. Alford, A . Hicks & M.A. Schwartz (Eds.), The Handbook of Political Sociology. 331-349. New York USA: Cambridge University Press.
(6) Ingram, H., Schneider, A.L. & DeLeon, P., 2007. Social Construction and Policy Design. In P. A. Sabatier, ed. Theories of the Policy Process. Colarado: Westview Press, pp. 93–128.