The symposium was well attended, with around 200 people present. Somewhat unexpected, perhaps, but heart-warming and encouraging. A diverse audience, with people from North and South (to the extent that these terms still have meaning in our times); Masters and postgraduate students (making up about 2/3 of the audience) and experienced professionals; academics and practitioners. In short: a diverse public but also – unfortunately – still a bit a biased one given the dominance of people with a medical background in the room.

Let me first share the main lessons I draw from the ITM symposium. Firstly, PHC – a value and rights-based framework – is still considered as relevant, both in ‘technical’ as well as in ‘political’ terms, despite the unsatisfactory global track record when it comes to implementation and notwithstanding the dramatic changes that have taken place in our world since 1978. Secondly, there’s a consensus on the need for a pragmatic, inclusive and systemic vision on the concrete implementation of PHC. No room for rigid and dogmatic one-size-fits-all blueprints, but rather context-specific combinations of models ranging from genuine community involvement, over specific and complementary contributions by first-line professional multidisciplinary teams, to specialists at referral hospitals, and cadres from specific disease-control interventions.

With some hindsight, however, there are also three issues that would have deserved more attention, in my opinion (even if a one-day symposium of course only lasts… for one day!).

First of all, there is  a clear need for more insight into – and thus research on – how to achieve effective and sustained multi-sectoral collaboration. How to move beyond the slogan? Which approaches work and which don’t? And why? And should we per se start from the health sector? We somehow seem to take that for granted, but is that justified? For instance, in my experience with Belgian local governments, which play a growing role in the local stewardship of PHC, the social welfare sector is a more important driver for multisectoral collaboration…

Secondly, it’s important to caution for a too naïve – i.e. overly smooth – view on participation. Indeed, participation tends to go hand in hand with a tension between people and professionals, sometimes a very frank one. Social movements channeling people’s needs and expectations, via (social) media and through demonstrations or other public activities,  may indeed pressure politicians and policymakers to act. That’s when and how ‘political will’ gets created in the first place, in many settings. The case of the recent Belgian municipal elections is telling in this respect: people’s call for radically different mobility and environmental policies in our inner cities and for more clean air became, a bit unexpectedly, a central theme in the debates preceding the elections.

And thirdly, there is the elephant in the room… What about the clear and loud call in 1978 for a New International Economic Order (NIEO)? What about a NGEO (we would probably call it a New Global Economic Order nowadays) in 2018? There are doubtlessly many explanations for the relative silence on this front… I wish to share a hypothesis. A new social, economic, political and ecological order encompasses so many interlinked & intermingled issues (complexity!) that debating such an order is anything but easy. How to engage into a wider public debate on something that virtually influences all dimensions in our societies and lives? What language to use? I have no definitive answer. But I believe it would be useful to consider a ‘pedagogical’ approach – a narrative – that enables a dialogue with the general public. A suggestion? Well,  the recent book by Oxford economy professor Kate Raworth – “Doughnut Economics” – made a deep impression on me. The clarity and coherence of her analysis, and, above all, the power of the images she uses, stood out for me. In her book, the inner ring of the “doughnut” represents the “social foundation”, the situation in which everyone on the planet has sufficient food and social security. The outer ring represents the “ecological ceiling”, beyond which excess consumption degrades the environment beyond repair. The aim is to get humanity into the area between the rings, where everyone has enough but not too much – or, as Raworth calls it, “the doughnut’s safe and just space”. Perhaps the doughnut is a good starting point for a new narrative on the NGEO anno 2018?

Over to the meeting in Astana, then.

I am truly happy (and proud) that I could attend this historical conference, hosted by WHO (with a prominent role for WHO Europe), UNICEF and the government of Kazakhstan – as part of the official Belgian (federal) delegation. This landmark meeting was only possible because of the commitment of so many national governments, international and multilateral organizations. The conference was attended by 2156 delegates coming from 96 countries. The relevance of the core values and principles of the Alma-Ata declaration were explicitly reconfirmed and the vital role of PHC in Universal Health Coverage (UHC) emphasized. The Director-General of WHO, Tedros Ghebreyesus, was crystal clear: there’s no UHC without PHC. He further referred to the forthcoming United Nations General Assembly (UNGA) High-Level meeting on UHC in September 2019 “as a powerful opportunity for PHC”.

Even if the world may have become a healthier place compared to 1978 (see the increased life expectancy and the improvements in child and maternal mortality, for example), there is no room for complacency. The conference acknowledged that progress in PHC implementation is lagging behind and that for many the promise of PHC remains unfulfilled. Achievements are uneven and unfair. Social determinants of health are insufficiently addressed. And people should be at the center, not diseases. Henrietta Fore, UNICEF’s executive director, was firm: “at the current pace, we will not reach SDG 3.8”. In short, it is now time to deliver.

The two-day event was built up around six plenary sessions and some 25 parallel more specific sessions. Youth got a prominent place in Astana (120 youth delegates attended the conference!). A number of new focal areas were addressed in light of the dramatically changed (and ever faster changing) world. These ‘updates’ covered a wide range of issues and concerns: the digital revolution, connectivity, development of new technologies, disruptive innovations, quality of care, research on PHC, family medicine, social accountability, mental health (cyber bullying!), health for indigenous people, metrics for monitoring PHC implementation, the interface of health with ministries of finance, healthy cities (even healthy islands!) and the positioning on PHC by European mayors, human resources for health as an investment and not a cost, and much more…

The issue of a NGEO was also addressed in a specific session organized by the network organization Medicus Mundi International (see video), but with limited participation, unfortunately. Again that same elephant in the room…? One of the speakers in that session, a well-known academic and activist from South Africa, put it bluntly:  “people do not seem to have a clue what we are talking about”. So, still (much) work to be done, it seems.

My main take-home message? The glass is definitely half full (which, arguably, tends to be my ‘natural’ sort of perspective on things : ) )  The renewed commitment from the international community towards PHC presents a powerful opportunity and PHC does remain a pertinent and rock-solid societal program. Still, the glass is also half empty: if during the last 40 years we were not as successful as we would have liked to be, why then would we succeed now? Quoting Primo Levi’s epic book is appropriate here: “If not now, when?”

Let me conclude on a positive note.  I was pleasantly struck by the intervention of the Nuncio of Vatican City at the opening of the conference in which he explicitly blamed the “current systemic tendency in our world towards inequalities and inequities in health and health care”. And then there was the hopeful and rallying pro-PHC speech by Dr Caryssa Etienne, current PAHO Director, at the closing session of the conference. She was rewarded with a standing ovation from the audience.

Primary Health Care, here we come!

PS: on a side note, Alma-Ata means ‘father of apples’ in Kazakh. Alma-Ata claims the honor of being the birthplace of this fruit. The Kazakh Minister of Health Elzhan Birtanov in his final closing speech mentioned that… 17.000 apples were eaten during the conference!

The contrast with the spirit of Christmas  could not be greater. Indeed, Christmas –  notwithstanding the excessive and irritating commercialization which envelop its celebration in many parts of the world – is also a time which reminds people of the ethical imperative to care (more) for each other, something that seems very much needed in our current times. From this religious and philosophical inspiration, we take the liberty to extrapolate and reflect on an issue that is (or at least should be) central to public health policies and programmes:   the place of caring in the interface between people and health systems.

We believe that (the concept and practice of) patient-centered care (PCC) – or if you prefer, person-centered care – tries to capture this caring dimension. Essentially, PCC focuses on the quality of the interaction between a patient and a health worker. PCC embraces a holistic approach towards the provision of healthcare to an individual – health care that does not just take  into account biopsychosocial elements, but also a patient’s preferences, ideas, concerns and expectations. PCC aims for an alliance between the health worker and the patient which implies the sharing of power and responsibilities. Central in PCC are mutual respect and empathy.

Providing care that is oriented towards a patient or person may sound obvious, but it was only acknowledged on a global scale towards the turn of the century. For instance, in 2001 the Institute of Medicine in the USA explicitly highlighted patient-centeredness as a key dimension of quality of care. Despite this formal recognition, PCC continues to be a neglected aspect in the delivery of care irrespective of the setting, whether high or low income (although perhaps not to the same extent).  Focusing on low-income countries, we explored this gap in a recent article on PCC in sub-Saharan Africa, in the International journal of Person Centered Medicine. We arrived at the conclusion that the concept and practice of PCC in public first line health facilities are still underdeveloped in that part of the world. The title of the paper summed it up neatly: “Patient-Centered Care and People-Centered Health Systems in Sub-Saharan Africa: Why So Little of Something So Badly Needed?”

From the perspective of health workers, we found – quite obviously perhaps –   that health worker attitudes are influenced by a broad variety of factors related to the socio-cultural environment, the  personality of the health worker but also his/her working conditions, the patient’s characteristics, the structure and organization of the health system, etc.  In an attempt to structure this variety of factors which have an impact on the delivery of PCC, we proposed a simple, three-layered model  to conceptualize  the individual interaction between a patient seeking care and a health worker (a medical doctor, clinical officer,  nurse-practitioner, …).

In the context of high-income countries, even if there’s still room for further improvement (see for instance the care for the elderly in our own country, with shamefully long waiting lists…), substantial progress has been made towards PCC, for example through the increased recognition in academic and health policy circles of the value of Primary Health Care implemented via the practice of Family Medicine delivered by small multidisciplinary teams.  As formulated by the late Barbara Starfield, Primary Care relates to the social integration of health workers in the local community they serve, a biopsychosocial approach to people’s problems, a long term relationship between health workers and people, a sound balance between technicity and human relationships, and an offer of truly integrated care…

In many sub-Saharan African countries, on the other hand, this sort of care is still rare, unfortunately. The reasons for this are many, but the fact that health workers and patients, when they interact in the context of modern health systems ( be it within the frame of educational programmes or when seeking health care) only rarely encounter ‘living models’ of care delivery that match the above-mentioned features, is certainly an important factor.

Against this backdrop, we strongly advocate for more patient-centeredness in health care, and for more research on the impact of socio-cultural, structural and organizational conditions on the development and system-wide recognition of PCC in different contexts. Instruments to measure PCC (or the lack of it) need to be developed and validated in a set of culturally distinct environments. And, perhaps most importantly, possible solutions need to be tested using a participatory action-research framework.

Following in the footsteps of Mahler, Mercenier and Van Balen…

When engaging in end-of-the-year musings on PCC in SSA, it would be inappropriate, almost indecent, not to refer to the recent  loss of Dr. Halfdan Mahler who served as the Director-General of the World Health Organisation between 1973-1988. Dr. Mahler will go down in history as the visionary co-founder of the Primary Health Care (PHC) movement that culminated in the Alma Ata declaration in 1978. Dr Mahler passed away on December 14^th. We honor his tremendous legacy.

At the same time, as faculty of the Public Health Department of the Institute of Tropical Medicine in Antwerp, we also seize the opportunity to pay tribute to the important work done in the domain of PHC and PCC by the late Professors Pierre Mercenier and Harry Van Balen, founders of the Antwerp school of thought. Their emphasis in teaching, practice and research on the famous triad of global, continuous and integrated care (or in French: “des soins globaux, continus et intégrés”) as key characteristics of quality health care, familiar to the many hundreds of students that have attended their classes, has not lost an inch of its relevance.

On that note, we wish all of you some restful and peaceful days ahead, and time with your beloved ones. Our warmest season’s greetings!

Dear Ladies and gentlemen, dear colleagues, dear MPH graduates,

This ceremony for the 50^th anniversary of our Master of Public Health (MPH) course is a time to celebrate, to acknowledge the achievements of the course, to thank a great many people, but also to reflect on the way forward …

It is with humility that I stand here. My role in and contribution to the MPH is relatively recent and therefore limited. But it is an honor for me to be addressing you on this occasion, and I like to see myself as a spokesman of the many people who have contributed to this Masters…

I would first like to briefly take you through the highlights of the history of the MPH  from 1964 till today; discuss some of the most important recent changes; but also reflect on the future…

The Antwerp MPH has a long and passionate story. Describe it as an opportunity to pay our respect to the late Harrie Van Balen and the late Pierre Mercenier, the founding fathers of the course.

The International Course in Health Development (or ICHD) – the initial name of the MPH – was organized for the first time in 1964 resulting from a joint initiative of Dutch and Belgian authorities, more specifically the Tropical  Institutes in Amsterdam and Leyden/Rotterdam in the Netherlands, and the Institute of Tropical Medicine here in Antwerp. The course was launched at a very important and radically new time, i.e. the period immediately following the gulf of decolonization and independencies in most of the developing world.

From the start on, the course was organized around two basic assumptions (both still very relevant today): first, to consider health and health care as part of a more comprehensive human and societal development and wellbeing; and second, the need to take into account cultural, social and economic factors in the endeavor to bridge policies and implementation.

Initially the ICHD started as a 5-month course, one in English (ICHD) and one in French (CIPS), which took place simultaneously, one year in Amsterdam and the other in Antwerp, and targeting medical personnel from developing countries with a number of years of experience. In 1967, the 5-month programme was complemented with a second semester and a thesis was added at the end of the course.

In 1969 Harrie Van Balen joined  ITM as course coordinator – the function that Marjan Pirard and Marlon Garcia occupy today. Pierre Mercenier joined the institute in 1971 and teamed up with Van Balen. Both had been active overseas, but were also very much involved in a think tank reflecting on health policies in Belgium… A great deal of their inspiration came from their work in the Groupe d’Etudes pour une Réforme de la Médecine  (GERM) – they had the genius to bridge the thinking on public health and health services organization in developing countries with the one in high-income countries. Ivan Beghin, professor in nutrition, joined the tandem a couple of years later.

Already from these early times, the option was to go for an international student audience with maximum 2-3 people from the same country and not more than 3-4 Europeans. It was seen as appropriate to organize the course in Europe, because a critical analysis of one’s own health system would be less threatening and benefit from the exposure to the experience of people coming from different contexts.

The launch of the Kasongo research project in eastern Zaire in the early 70s contributed to the enrichment of the concepts on Health Services Organisation. The commendable academic triad of research, teaching and service delivery was operating at its full potential by then – with tremendous synergies.

It is also in the seventies that the concept of a ‘critical mass’ appeared in the discourse of the public health department. The hypothesis was that a number of motivated ICHD graduates in a given country could make a difference. The cases of Thailand and Mali are noteworthy: in the former, the Rural Doctors Association led by former ICHD students contributed to shaping national PHC policies; and a number of ICHD alumni contributed in Mali to steer the health sector reform process.

At the end of the 80s, another Masters course was created: the Master of Science in  Tropical Biomedical Sciences that focused on the control of tropical diseases – this course later evolved into the current masters in Disease Control. One of the privileged areas of collaboration between the ICHD and this new course focused on the vertical analysis, well known to many of you, that was developed by Mercenier a couple of years earlier.

In the 80s, the ICHD course coordinators also started with organizing study visits to health systems in high-income countries: a first visit was to Italy, later visits were organized to Scotland, France, the Netherlands, Canada, and the Maisons Médicales in Belgium. The aim of these visits, which we still have today in our MPH, was to apply the acquired knowledge to a real-life situation, but also to illustrate that the frameworks and concepts discussed during the course are relevant to study health systems in high-income countries as well.

The early nineties were an important transition period with the departure of Pierre Mercenier and Harry Van Balen. Their legacy was a successful course, with a great international reputation, that since then of course has evolved a great deal, but where the core views and values of its founding fathers still play a key role.

After their retirement, Jean Pierre Unger, Patrick Van der Stuyft and Wim Van Lerberghe took over the ICHD course; they were later joined by Guy Kegels. Steps were taken to adapt the teaching curriculum to a changing international context. Important in that respect was the fact that more room was given in the course to the study of health policies at national and international level – beyond the operational district level. Another major change in the MPH landscape was the launch – at the end of the 90s – of the MDC focusing on training disease control programme managers – and with special attention for HIV/AIDS, tuberculosis and malaria, but also reproductive health.

In 1993, upon the initiative of Wim Van Damme, the MPH alumni network was created, implementing the wish of the Institute to maintain privileged relationships with former students. By now more than 1300 MPH students have been trained at ITM… The alumni network responded to the demand of our alumni to keep in touch with the Institute, with new scientific developments and to share their professional experiences with other alumni. A number of regional meetings have been organized with alumni – these have been powerful opportunities to get feedback on the relevance of the course. The list of meetings held is impressive: a first one took place in Ayutayyah (Thailand) in 1999 with a selection of participants from South-East Asia; this meeting was followed by other regional meetings in Cuba,  Morocco, Uganda and together with the MDC in the DRC and India. Today the alumni network funds the participation of former students in international conferences with side-events where alumni and staff can interact more informally.

In the last 10 years we have again implemented a number of important changes in our Masters architecture. I want to highlight two of them.

A first was the launch of two options in the ICHD and in the MDC. The ICHD was relabeled HSMP (Health Systems Management and Policy) and its participants were offered the option in the third trimester to attend the short course strategic management of health systems or the short course health policy. The establishment of these short courses was accompanied by more flexibility in the intake of students. External participants, other than the ones who started with the MPH in September, can now also attend these short courses. This “flexibilisation” fits well in current developments at European level where the Troped program overlooks the organization of modular MPH courses. The creation at ITM of the MPH in International Health is an exponent of this dynamic.

A second development has been the “rapprochement” between the HSMP and the MDC courses. In 2010-2011 the decision was taken to go for one single MPH with two study orientations – HSMP and MDC respectively, each one with its specific identity. The rationale for this was straightforward: ITM over the years built clear conceptual views on how to structure the often tense interface between “horizontal” systems and “vertical” programs, going for integration whenever there is an added value to do so, but also recognizing the potential contribution of control programmes in improving service delivery to people. In real-life situations, systems managers and disease control specialists need to interact and collaborate… In this context, it makes a lot of sense to foster such a dialogue during the training of our MPH participants. In the same vein, in the academic year 2011-12, a common core was created for HSMP and MDC participants – covering more than a third of the total number of credits of the MPH. This experience so far has been extremely positive.

It is time now, I believe, to say a word on the future. What developments can we expect for our MPH in the years to come? There is as of yet of course no blueprint lying on the table but a number of important contextual elements must be taken into account nevertheless…

There is the steady increase in MPH courses in the global South, not in the least organized by some of ITM’s partner academic institutions in Africa, Asia and Latin America – however, most of these MPHs only reach a national audience of health professionals. There is also uncertainty whether donors will still be willing (or even able) to fund fellowships for people from the South wishing to attend the ITM Masters for much longer. Our alumni however continue to appreciate the field knowledge of our teaching staff – or to put it in their words “you people know what you are talking about”…

The case of Thailand, a middle-income country, where a number of national MPH programs have been set up, is illustrative in that respect. The Thai government has recently expressed the demand to go on sending selected Thai health professionals to Antwerp for their Masters, despite the fact that their people can’t  get Belgian cooperation fellowships. Thailand has accepted to fund the participation of their people to our course itself. That is a major recognition from a middle-income country that has made great advances in its own health system over the last decades… This may very well become a scenario that spreads to other MICs.

The alleged end of development cooperation in the coming years, be it in Belgium or in other HIC, is a possible scenario, but not necessarily the only one. Low income countries, some of them fragile states, will not soon be in a position to go without international solidarity – also when it comes to training their national health professionals. We therefore need to safeguard equitable and needs-based access to our MPH.

Having said all this, is there a reason to be complacent and to go on with business as usual? Of course not. The future of our MPH lies in innovation, as well in terms of content as in terms of teaching methodologies, without therefore throwing overboard the good things – even if they are “old”. Flexibility is definitely welcome and needs to be further encouraged, although we should refrain from turning it into a fetish – flexibility should be carefully balanced with coherence. I am also convinced of the need to find a sound balance between specialisation and a comprehensive generalist view on systems to make sure that the oversight is not lost. And we should also go on making explicit the values that guide and drive us (solidarity, participation, equity) without ignoring the realities from the field and without hampering the freedom of our students to make their own choices.

But perhaps the main challenge and opportunity ahead lies in the close collaboration of our MPH with the teaching programs of our overseas framework agreement partners. The Framework Agreement between DGD and ITM is a powerful opportunity, and the Switching the Poles philosophy a great mobilizing idea. We are grateful that it is there, it may very well be a game-changer for our MPH… I am thinking more in particular of the programme Alliance of Schools of Public Health.

In order to illustrate this, let me briefly share with you the findings of a recent mission by Marjan Pirard, our departmental academic coordinator, and myself, to the Institute of Public Health (IPH) in Bangalore in South India. The demand from IPH was to reflect on how we could collaborate in terms of teaching.

The current MPH landscape in India is very fragmented, with a booming offer of MPHs in a mostly market-driven logic, and operating in the virtual absence of regulation and accreditation policies – with all the negative consequences one can expect in terms of financial accessibility of the course and quality of the teaching. Moreover, there is hardly a focus in these MPHs on the organizational and managerial dimensions of health care delivery systems;  they are often built around ex cathedra teaching and hardly rooted in the day-to-day realities at the grassroots level. IPH is currently developing a number of stand-alone short courses or modules of a couple of weeks each that could then be nested in some of the most promising of these existing MPH courses. IPH would be interested to obtain accreditation and visibility for these short courses – perhaps TropEd can play a role in this? –  but is also keen on joining the teaching in our own MPH: as trainees, in order to learn how to teach and to organize training programmes, but also as lecturers in order to contribute to the enrichment of our own teaching portfolio (and where we can learn from them!). Since a couple of years, IPH Bangalore offers internships to young health professionals from the Netherlands and the USA who wish to get acquainted with the realities of an under-resourced health system… Perhaps this could also be an avenue for our own postgraduate students or something to fit within the MPH-IH… ?

Our MPH has strongly evolved over the last decades in an environment that has dramatically changed – with important social, political, technological, epidemiological transitions. In addition, keeping up with the (increasing) pace of changes is a challenge. The quasi monolithic public health care delivery systems of the 60s and 70s have been replaced by complex pluralistic systems operating in a globalized world.

If we go back 20 or 30 years,  we recall the MPH as a rather peaceful and traditional course, operating in a relatively stable environment, focusing very much on the operational levels of the health system, with a student population that almost exclusively comprised medical doctors, most of them men, coming from LICs and receiving mostly traditional teaching in a class room environment, with a significant dose of well-intentioned hand holding…

In 10 years from now we can imagine a course that might and will probably have a more diverse student population in terms of professional background and gender, originating from Low-Income, Middle Income but also High Income Countries, using a greater variety of teaching methods, with a more international, colored and multidisciplinary teaching staff,  with modules organized (in Antwerp or overseas) by experienced staff from partner institutions in the South, with a greater focus on getting research into policy and practice, on making optimal use of social media and global knowledge management platforms,  and with enhanced student abilities to take decisions in rapidly changing environments characterized by a great deal of uncertainty.

At the same time we see a course where values will still matter very much and where past achievements are not thrown overboard just because they are from the past, but are optimally integrated in new course formats.

Our course is flexible enough to adapt to changing circumstances, I hope that my brief historical account has illustrated that. This ability will be challenged for sure. At the same time past changes have always been the result of thorough and careful thinking, never blindly following the market or the fad of the day… That is definitely a culture to nurture… Reflexivity and flexibility will remain key in a context of growing uncertainty about what the future will bring. We hope that our most faithful donor, the Belgian cooperation, will further accompany us on that journey.

Let me conclude with the following:  ITM’s Master is first of all about training health workers, yet, it is also a project that can contribute to “linking” staff within the public health department, that constitutes a forum to discuss rapidly evolving views on public health, and that contributes to shaping a common professional identity. It therefore deserves to be handled with due care.

I thank you for your attention.