Dear Colleagues,

 As you will notice, this week’s newsletter is shorter than usual. While the Chief Editor, Kristof Decoster, is tied up with attending the EV Governance Board Meeting, being held in Dubai this week, I have been given the responsibility of taking care of the newsletter. It is finally time to put the lessons I learned as an IHP resident in these past few months, into practice. While matching up to your supervisor’s level of work and efficiency is aspirational, it is also challenging. I have tried to put together the newsletter to the best of my ability.  

The key highlights of this week’s issue include coverage of World Health Day events, the WHO Partners Forum, 2^nd WHO Fair Pricing Forum, the World Bank’s new Director & the WB/IMF Spring Meetings, DRC seeing record setting Ebola cases for two consecutive days (the WHO DG decided to convene an emergency committee meeting to assess if Ebola should be declared a Public Health Emergency of International Concern (PHEIC)), State of Civil Society Report 2019 and catastrophic signs of Climate Change (as always) among other issues. Andrew Harmer in his blog suggests WHO should declare Climate Change (also) as a PHEIC, in order to channelize resources, actions and strong political will towards addressing it.

Enjoy your reading!

Deepika Saluja

(You find the pdf of the newsletter here: IHPn517 )

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!

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.

Based on my exchanges with different EV governance board members, who prepared the F2F programme together with the EV secretariat (IPH Bangalore), and several EV alumni who were involved in the 2018 venture as facilitators, I will first share some of the key ingredients and highlights of this venture’s F2F stage in this article. In a second part, I’ll reflect on some of the challenges for the network, moving forward.

Liverpool highlights

1. More systematic engagement with HSG Thematic Working Groups and “A theme for everyday”: this EV 2018 venture was aligned very well with the HSG structure of “Thematic Working Groups” (TWGs), by engaging with many other TWGs in the planning and implementation of the F2F training program for the dedicated themes for each day. Compared to previous ventures, collaboration with other TWGs was thus far more systematic and structural. As mentioned by various governance team members, following a structure of ‘themes of the day’ (6 in total) also helped them plan and prepare the sessions in a very systematic manner. The program featured a Community Health Systems day, a Private sector Engagement day, an SDG/UHC/GHG Day, a Human Resources for Health day, and a Fragile and Conflict Affected States day. Last but not least, the program also included a local health systems day that provided the Emerging Voices with a perspective on the functioning of local health systems in Liverpool.

2. Well-structured days: Each day typically comprised four specific kinds of sessions: a “Big Talk” (by an established scholar, usually), an EV led session, a TWG dedicated session and finally, a knowledge translation (KT) session. People from different parts of the world were invited for the Big Talks, not just experts from the UK. As was the case in Vancouver (EV2016), each day, a group of EVs were in charge of a session, where they engaged on the theme of the day through panel discussions, debates, fish bowls, even TV-shows! (“EV rocks”) The TWG sessions usually started with some brief info on the (work of) the specific TWG, and then linked – usually in an interactive way – the TWG’s work with the theme of the day, discussing both empirical evidence but also some of the theoretical underpinnings. In some cases, for the example on the ‘engaging with the private sector’ day, the link with the TWG was rather straightforward, sometimes it was a bit more of a stretch. In the afternoon, most knowledge translation sessions were scheduled. Focus in these sessions (overseen by Nasreen Jessani, EV alum 2014) was on training the Emerging Voices to articulate (and cater) their messages to different kinds of audiences ranging from the communities, to policy makers and practitioners, media, researchers of course, … using different modes like policy briefs, presentations & posters, blogs, media channels, social media etc. As was already the case in Vancouver, in the evening a “tune-up café” (with whizzkid Diljith from the EV Secretariat in a key role) was sometimes foreseen, to help EVs finetune their posters & presentations, or some other social activity. And food of course!

3. Track 2: the (other) “change agents” track: although the 2016 venture already included participation from a few policy makers (matched with EVs at the time), EV2018 had for the first time a separate Track 2 for “other change agents”, such as policymakers, practitioners, staff working in different government machineries implementing programmes in their respective countries, a few activists also. These Track 2 participants brought a diversity of perspectives from their “on the ground” & “hands on” experience into the discussions. Their input was very much appreciated by the cohort.

4. LSTM provided strong institutional support: “LSTM rolled out the red carpet for us, literally”, in the words of Dorcus Kiwanuka, the Chair of EV4GH. The unwavering institutional support received from the Liverpool School of Tropical Medicine (LSTM) has been consistently reported by all governance board members as one of the key factors behind the success of the EV2018 venture. A special thanks goes to Laura Dean (EV2016 and EV Board liaison with LSTM) for taking care of pretty much the entire logistics, planning and execution of the F2F training program, and Sally Theobald and Tim Martineau for their support. The F2F task force committee (led by EV board member Faraz Khalid) was thus able to focus on the sessions and training content, without having to worry much about logistics or other practical issues.

5. Dedicated Alumni: EV4GH is a “one of a kind” and largely volunteer network, with many alumni showing a strong commitment and passion to contribute to the network (and the broader HSG society), and mentor young researchers like themselves. In the words of one governance member, in a way it’s about wanting to ‘give back to the next generation/cohort what they have received from the venture & network themselves’. Like in 2016, this 2018 venture was thus also driven by EV alumni and the governance team (which comprises EV alumni as well), and this in several task force committees. Alumni involvement has been consistent right from the stage of selection, to planning the training program under different task forces, and executing it (in distance & F2F stages). And let’s not forget that all these alumni who contributed to the success of the program already have full time professional jobs. They are thus dedicating their time, efforts and commitment to EV4GH in addition to their existing full time responsibilities. And although they’re still young, some have families too!  Some were even multitasking in Liverpool, having brought their toddlers along (true, they also brought a few mothers(-in-law)).

6. A fabulous EV secretariat: IPH Bangalore has been key in this venture, as was the case in Vancouver. Some of the EVs even used the term ‘angels’ for some Secretariat staff , perhaps inspired by the lyrical setting of Liverpool.

Challenges remain

While the 2018 venture has been a huge success, there is always room for improvement.

First and foremost, the disappointment due to visa denials of many selected EVs (and also other LMIC researchers) was enormous, and shared even in the symposium’s closing plenary; read some of their stories here and here, for example. As media have reported, other conferences in the UK have presented a similar picture lately. And so everybody hopes Dubai will turn out a more visa friendly country for the next symposium in 2020, and that indeed there will be no visa rejections there. Fingers crossed!

Secondly, although EV4GH is becoming more autonomous with every venture, securing funding remains challenging, as governance board members admit. Among the key funders for this year’s venture were USAID’s HRH2030, WHO’s Alliance for Health Policy and Systems Research and the Belgian Development Cooperation, together with of course, the overall support and assistance provided by HSG. As you can imagine, fundraising for Dubai has already kicked off. Funding limitations do not only constrain the participation of (more) emerging voices (i.e. scholarships) but also of facilitators and alumni who would like to contribute but can’t. This year too, quite a few alumni joined the training program as facilitators at their own expense. Yes, that shows the high level of commitment within the community but it also gets challenging at the same time. Certainly because one of the key aims is always to try to have a number of EV alumni from the previous cohort, as facilitators in the next venture.

Lastly, although the program was very intensive – participants were exposed to a diverse set of areas and discussions over a period of 10 days – it left them perhaps with too little time to reflect, and learn more from each other’s work. Perhaps, we need to extend the duration of the program (funders, do take note!) or else, put a bit less on the agenda in order to make the learnings and participant engagement richer, as there is always a trade-off between quality and quantity.

In sum, the EV4GH community has organically grown over time into a network where people have developed relationships, personally as well as professionally, which each of us deeply cherish, helping each other, mentoring, collaborating and attending each other’s festive ceremonies,  …  it’s like a second home for everyone. It has been an incredible journey for each of us, and I think I can say that on behalf of the entire EV4GH community. Well-rooted in its initial vision of empowering young researchers to raise their voices against the (unsustainable & often dysfunctional) status quo, inspired by a deep commitment to health equity, the EV4GH program continues to provide such a unique platform to just do that and create a wave of Emerging Voices around the globe. I look forward to getting engaged in many more EV ventures and growing with them!

I sincerely thank Dorcus Kiwanuka, Dena Javadi, Faraz Khalid, Kerry Scott, Kristof Decoster, Laura Dean, N Prashanth, Wim Van Damme and all others for sharing their thoughts and reflections on their journeys as part of the EV4GH community.

Acknowledgement: Kristof Decoster (ITM) assisted with finetuning of this blog. 

The conference was held in response to a few World Health Assembly Resolutions (68.8 in 2015 and 69.18 in 2016) to address the increasing morbidity and mortality resulting from air pollution. The 3-day meeting in Geneva included workshops, plenaries and parallel sessions on a wide range of issues related to air pollution including households’ access to clean energy, ambient air quality monitoring, air pollution and children’s health, air pollution and NCDs, air pollution and climate change, reducing health sector emissions, protecting workers from air pollution outdoors and indoors, and equipping national health workforces to deal with air pollution amongst many others. The conference brought together substantial evidence on each of these issues from across the world (with some creative and feasible solutions like targeting pregnant women rather than poor households for using clean fuels for cooking), highlighting the complex interlinkages and their potential implications on human health as well as ecological (i.e. planet) well-being. In addition to the intensive sessions, the conference also showcased some very interesting and innovative ways to create awareness about air pollution as a critical health, climate and environmental issue, like Pollution Pods: a sensory art exhibit created by UK artist Michael Pinsky in which the air quality from the 5 most polluted cities of the world was simulated. On 31 October, a Breathe Life Concert also took place – the cultural event of the conference that featured “United Nations Humanitarian Artist” Ricky Kej along with several other Grammy award winners, nominees and artists from across the world advocating their (likeminded) messages through music and art.

Given the scale of impact from air pollution (ambient and indoor combined) killing around 7 million people every year and significantly affecting the health and development of 1.8 billion children, everybody in the room agreed it’s more than time to speed up the global response to prevent these deaths and sufferings. Billions of people are breathing toxic air (referred to as the ‘new tobacco’ by Dr. Tedros) every day, not only risking their own lives but also jeopardizing the health of future generations and the environment in which they will grow up. In his opening plenary speech, Dr. Tedros highlighted that ‘if the cost of action appears so high, then imagine how enormous would be the cost of our inaction’. The urgency of taking real action, using a more systemic approach  (rather than a siloed one) was being reiterated multiple times during the conference and special emphasis was laid on multi-sectoral collaboration, bringing the health sector at the forefront in addressing these emerging challenges. Although the harmful effects of air pollution are widespread and nobody from mother’s womb to the grave is spared, air pollution disproportionately impacts women and children and other vulnerable population groups in terms of income, age levels, zip codes etc. resulting more often than not in huge inequities. Therefore, we need to make these people the focal point of our actions and include their voices in the decision making.

As is customary, the conference ended with a ‘High-Level action day” where key messages from the previous days of the conference were taken stock of, in order to identify future steps. An aspirational goal of reducing the number of deaths from air pollution by two-thirds by 2030 was announced in the closing plenary along with around 70 voluntary commitments from different countries and international organisations. Commitments ranged from making cities plastic free and converting public transport to electric buses, over manufacturing zero-emission vehicles and achieving WHO prescribed air quality standards, to bringing air pollution and clean energy access to the political agendas and capitalizing on children as young advocates for change, to committing more investment and research in data collection, surveillance and air quality monitoring and many more.

Only if we are as unified in our vision to produce results on these commitments, as we were in (vigorously) announcing them, we will be able to prevent a great proportion of deaths due to air pollution and substantially reduce the suffering. Every human being is entitled to breathe clean air and (only the clean air of) the sky should be the limit!

PS: I’m rooting for the next global WHO conference on air pollution and health to take place in Delhi : )

Coming to the WHS straight from Liverpool after attending the global Health Systems Research (HSR) Symposium there, we could see some stark differences in the agendas of both events, the way they were organised and the kind of participation they displayed. At the HSR Symposium, young researchers from the Global South were involved in engaging and diverse plenary discussions, and also in most of the other sessions, diversity & inclusion were certainly not empty words, even if there’s always room for improvement. Inclusiveness has been a key objective of the symposium since its beginning (including of the Emerging Voices venture), and it was good to see that goal being achieved in Liverpool.

In contrast, we found the World Health Summit (still) largely dominated by people from the Global North and global elites. In spite of the organisers’ efforts, still too many of the panels were #manels (i.e. male panels) or male-dominated. Panels (certainly in the main plenaries) were, moreover, often comprised of leaders and key decision makers of big funding organisations like the Bill & Melinda Gates Foundation, GAVI and The Global Fund; and CEOs from pharma companies like Pfizer and Merck. There was very little representation from (more radical) civil society and young voices of the global south. The absence of these key actors – civil society organisations and communities for whom the policies are actually being issued and implemented (for example in the session on global health security) was consistently pointed out by the audience during panel discussions as well as on Twitter. Apparently, some civil society actors are considering engaging more in the future which would be great for the Summit. True, there were lots of young global health & medical students from Germany, Holland, and other European countries, but with only 10 New Voices in Global Health, 20 young physician leaders and 10 entrepreneurs from the start-up track being officially included in the Summit programme to showcase their work, in an audience of over 2000 delegates, there is still a huge gap to bridge between the ‘high-level’ (and occasionally stratospheric or even outer space) policy level discussions and on-the ground realities.

Although the theme of the summit was Science, Innovation & Policies and how they can (and should) be synergized to address the global health issues across the world – the phrase “together we are strong”  was reiterated multiple times throughout the summit, including by Dr. “Partnership” Tedros –   there was more emphasis on science, innovation, development of new vaccines, AMR and global health security, with a focus on multi-stakeholder partnerships and “getting the incentives right” for big pharma companies and donor agencies to get them engaged and invested for the long term; rather than on what it actually takes to implement these partnerships and policies on the ground and address inequities. Yes, partnerships are very important in our complex times in which we face many wicked challenges, and for sure “together we are strong(er)” but somehow the people selected to discuss all this on stage were surprisingly kind to each other. Big Pharma CEOs didn’t get many questions on their tax optimisation ‘best practices’, for example.

In line with some of the major global health challenges of our times, core topics at this WHS were Pandemic Preparedness, the SDGs, Health in All Policies, Access to Essential Medicines, Health Systems Strengthening, AMR, and The Digital Healthcare Revolution. At the start of the Summit, the M8 Alliance, the academic think tank and backbone of the WHS, issued its Berlin Declaration 2018 stressing the central role of health as a driving force for the United Nations’ SDGs. “We strongly advocate a holistic and science driven approach to solving the global health challenges. Public and global health funding needs to increase”, Detlev Ganten, the WHS’s “eminence grise”, said.

With the launch of the SDG3 Global Action plan and participation from some of the most influential leaders and politicians in the field of global health, including Bill Gates, Dr. Tedros, state leaders and ministers from Norway, Ghana & Germany, and WHO’s Afro lead, Matshidiso Moeti, this year’s WHS and coinciding Grand Challenges meeting were used as a platform for positioning Germany as a key emerging Global Health hub for the coming years. In this respect, the week was certainly successful, and the love for multilateralism was all around. Few asked the question though, why multilateralism and global solidarity are in such trouble nowadays.

Hopefully, with more regional meetings planned in the coming years, among others in Makerere in 2020, the WHS will also start bringing more evidence “from the ground” to the global policy level, ideally basing it more on public health needs than on (geo?-)political, economic, and still somewhat Northern dominated interests.

One last remark: for now, the World Health Summit still remains firmly in the ‘global health’ mode, it appears. With a few exceptions (Anders Nordström for example), the Planetary Health paradigm hasn’t really sunk in yet. So here’s a plea to invite Naomi Klein and other Jason Hickels in the coming years to change that. It’ll make the WHS even better!

The Ayushman Bharat (AB) Programme (which means “blessed India” in literal terms or “healthy India” in the context of health) rests on the twin pillars of  the National Health Protection Mission (NHPM – the secondary & tertiary care social health insurance programme) and the establishment of 150,000 additional Health and Wellness Centres (HWCs- an updated version of primary health centres that will include a focus on wellness as well). In his Independence Day speech, Modi called the health protection scheme “Pradhan Mantri Jan Aarogya Abhiyaan” (PMJAA – meaning the Prime Minister People’s Health Mission). The programme has had quite a multi-monicker journey since its first announcement in Feb, 2018. Its name has been changed several times, all in the quest to find a Hindi name that would be acceptable to its target beneficiaries: from Modicare to National Health Protection Mission (NHPM) to Pradhan Mantri Rashtriya Swasthya Suraksha Mission (PMRSSM, meaning Prime Minister National Health Protection Mission), and now Pradhan Mantri Jan Aarogya Abhiyaan (PMJAA). PMRSSM was interestingly dropped for the presence of the letters “RSS” (Rashtriya Swayasevak Sangh- meaning National Volunteer Organization) in the name, RSS being the Indian right-wing, Hindu-nationalist voluntary organization. For the time being, though, Modicare and NHPM are the names used most frequently.

“Successor” of RSBY & some lessons from my PhD

Maybe good to know for you: I studied the implementation of Rashtriya Swasthya Bima Yojana (RSBY) in one of the western states of India for my PhD thesis. Using a theory-based evaluation, I identified the accountability mechanisms available in the programme design of enrolment and tried to understand how they functioned on the ground. Based on my 8-9 months of extensive field experience interacting with multiple stakeholders from all levels (public as well as private; national, state, district as well as local), I found that most of these mechanisms largely played a symbolic role. Hence, I have some serious concerns about the design and implementation of this newly announced AB-NHPM, as in many ways, it’s the successor of RSBY. Let me explain a bit more in detail below, after elaborating how NHPM differs from RSBY.

The National Health Protection Mission (NHPM) aims to provide free access to secondary and tertiary care to over 100 million households for a coverage of up to INR 5 lakhs (~7000 USD) annually, without any limit in terms of family size and age of the household members. RSBY, NHPM’s predecessor introduced in 2008, provided a financial coverage of INR 30000 (~500 USD) for a family of up to 5, to ~36.33 million households (against the target of 60 mn households). While the target population for RSBY was primarily the Below Poverty Line (BPL) population (based on the 2001 Census in a majority of the implementing states) along with a handful of unorganized sector categories, NHPM has improved upon this, by considering the Socio-Economic Caste Census, 2011 to identify its target beneficiaries. Still, a lag of 7 years will result in the exclusion of some eligible beneficiaries.

Enrolment (mandatory in RSBY) has been eliminated and replaced by the beneficiary identification process for AB-NHPM at the point of contact for healthcare i.e. healthcare facilities. Elimination of the first point of contact with the beneficiaries via enrolment in NHPM, makes the role of Information, Education and Communication (IEC) activities even more critical, as the beneficiaries need to know about their eligibility for the programme, programme features and benefits and ways to access it. Do not assume that the current mass media coverage on Modicare will inform the beneficiaries of all these details.

Similar to RSBY, NHPM aims to provide cashless, paperless transactions to its target beneficiaries with portability features, i.e. beneficiaries can get the treatment through any empaneled public or private hospital across the country. Evidence from RSBY implementation pointed to difficulties in settling inter-insurance claim settlements (in terms of delays and rejections). Also, like in RSBY, the new scheme will cover all pre-existing illnesses, pre-hospitalization, post-hospitalization, and transportation expenses, though the literature on RSBY reports beneficiaries who received treatment under RSBY incurred OOP expenditures particularly on medicines and diagnostics. The National Health Agency (NHA) and State Health Agencies (SHAs) – the agencies established at central and state levels respectively to manage and monitor the implementation of the programme, will have to ensure that the implementation of NHPM improves upon the mistakes identified in the implementation of RSBY, and make evidence-informed decisions.

Findings of my Ph.D. thesis also highlighted other critical issues in the design and implementation of the RSBY, more in particular the involvement of private actors at multiple levels (Insurance companies, Third Party Administrators, Smart Card Service Providers, and hospitals); their varying power relations with different levels of the government machinery, lack of clarity on specific roles and responsibilities of each of these implementing actors, often leading to poor communication and weak co-ordination amongst them while working on the ground, and all this coupled with weak accountability mechanisms. It is clear that many of these concerns will need to be addressed if implementation of NHPM is to be effective on the ground.

Apprehensions on the involvement of the private sector, and regulatory and monitoring elements in the design of NHPM make the findings of my thesis even more pertinent. In the absence of adequate accountability mechanisms, challenges like overutilization of health care services through over-prescription of diagnostics and treatment, converting outpatient into inpatient care, selectively choosing profitable cases or hospitals charging for cashless procedures are quite foreseeable, having been highlighted several times in the implementation literature of RSBY.

Nevertheless, ‘Modicare’ is seen as a significant step towards achieving the twin targets of SDG 3.8 of reducing the financial burden and increasing population coverage. India’s Health Minister, JP Nadda claims that ‘NHPM is going to be one of the world’s largest social health insurance programmes due to its sheer numbers and this scheme shall be a game changer for the Indian Healthcare’. Along with its preventive arm of establishing 150,000 HWCs aiming to provide comprehensive primary health care, AB can also be seen as improving on the third element (the other two being financial coverage and population coverage) of the “UHC cube”, i.e. improving access to a wider range of healthcare services. As NHPM gets the bulk of the attention, it is feared, however, that the HWCs might not receive their due resources.

Quality concerns

In addition, while the focus is largely on increasing service coverage to ~40% of the country’s population, another potential challenge the scheme will face is the quality of services delivered. A Lancet  article published coinciding with the launch of The Lancet Global Health Commission on High Quality Health Systems in the SDG era reported  that 2.4 mn people in India yearly die due to treatable conditions, out of which 1.6 mn (~66%) die due to poor quality of health care, and the rest due to non-utilization of health care. While ‘Modicare’ would potentially increase the utilization of health care services in India, it should also at the same time focus on ensuring (and improving) the quality of health care services delivered through its empaneled hospitals and HWCs.

Around 6000 private hospitals are expected to join NHPM, but not all would be accredited by the National Accreditation Board for Hospitals and Healthcare providers (NABH), an accreditation board established by the Quality Council of India (QCI) to ensure quality standards in the delivery of healthcare. Only 540 hospitals across the country have NABH accreditation currently and not all of them may join NHPM. Given the incentive of 15% higher rates for approved treatments to NABH accredited hospitals and 10% higher rates to entry-level NABH hospitals, a rise can be expected (not sufficient, though) in the accreditation of hospitals as NHPM implementation takes off. With respect to the HWCs, other than the inauguration news of these centres in different parts of the country, there’s not much information on the availability and utilization of resources in terms of staff, medicines, medical equipments etc. and more importantly on how the quality of services delivery in these centres will be monitored. By the way, focusing on quality would also need integration with other social determinants of health like clean drinking water, hygienic toilets, nutritious food etc. as well as appropriate handling of bio-medical waste, especially in the hospitals, to prevent any hospital-acquired infections (but also in their homes).

Current picture & hope for a good start of Modicare

With the soft launch of NHPM by Modi on Independence Day, we now have 30 states and union territories on board (with Tamil Nadu being the latest to join). 21 out of the 30 states who agreed to be a part of NHPM are opting for the “trust model” (where the state establishes a trust and handles the entire implementation of the programme) as opposed to the “Insurance model” (where the state contracts out the insurance services to the insurance companies). With changes in the implementation design model, it won’t be easy to avoid state capacity deficits and other issues of alignment of central and state level schemes with respect to population coverage, financial coverage as well as service coverage, that much is clear. It would also be important for the states to have clearly defined roles and responsibilities for each of the implementing actors to avoid any ambiguities at the time of roll out.

On a more positive note, pilots have now started in more than half of the agreed states and the first claim under NHPM has already been raised from a public hospital in Haryana for a newborn baby girl.

If Modicare is implemented effectively, the landscape of Indian Healthcare will indeed substantially be transformed in the coming years. With the official launch date of 25^th September quite near, the NHA and SHAs will have to gear up their preparation for the implementation of NHPM.  As hiccups can be expected and are only normal if such a huge scheme is to be rolled out, hopefully, these agencies will turn out to be ‘learning systems’, being quick and responsive in addressing these initial hiccups.

Last but not least, I also hope that Modicare doesn’t get caught in a similar destructive polarization process as is the case in the US for Obamacare. Indians need UHC, more than ever.

A second notice of “World Scientists’ Warning to Humanity” signed by more than 15000 scientists from 184 nations was released last week, stating that ‘we have unleashed a mass extinction event, the sixth in roughly 540 million years’. The notice revealed that since the first warning to humanity issued in 1992, there has been a dramatic increase in human population, annual surface temperature, carbon emissions, ocean dead zones, and a significant decline in fresh water availability on the planet. Due to a decline in ozone-depleting substances, the ozone hole reduction is the only positive change noticed, pointing towards the hope and possibility of controlling the ecological damage rate. This catastrophic warning is a strong reminder for us to take a step back and reflect on our behaviors and actions.

The two conferences I attended this fall, APHA2017 (in Atlanta) and CCGH2017 (in Ottawa) addressed the now increasingly relevant issues of climate change and its impact on health. APHA’s 2017 Annual Meeting was themed ‘Climate Changes Health’.  APHA declared 2017 as the Year of Climate Change and Health, and emphasized the need to bring together more evidence on how climate change is affecting human health. More than a hundred papers on this theme were presented at the annual meeting along with several roundtable discussions, social hours and documentaries screened at the Global Public Health Film Festival. APHA also took steps to ‘green’ its annual meeting by choosing a 27% more energy-efficient conference venue, promoting walking by contributing to the 2018 APHA 1Billion Steps Challenge, reducing the program booklet by three-quarters, creating reusable signage and building material and finally, and perhaps most importantly, removing the major fossil fuel and oil companies from its investment portfolio.

CCGH 2017 with the theme of ‘leaving no one behind’, also had a bunch of sessions and roundtables on experiences and lessons from conducting health research in crisis settings. Incidentally, the Lancet Commission on Pollution and Health also released the findings of its multi-year collaborative study on the economic and health impacts of pollution during CCGH 2017. The Commission reported environmental pollution to be the single largest cause of morbidity and mortality in low-and-middle-income countries, contributing to around 9 mn deaths worldwide in 2015, ~16% of the global death burden. In 2015, the highest number of pollution-related deaths occurred in India (2.5 mn deaths) followed by China (1.8 mn deaths). With many more chemicals yet to be detected and studied, the authors claimed these figures to be an underestimate of the actual health impact of pollution.

Climate change is fueling more frequent, intense and longer-lasting changes in the atmosphere (through rising temperatures and increasing concentration of pollutants in air, water and land). This is not only causing inconvenience to the people but is already killing them in large numbers. The population groups most vulnerable to these changes are, unsurprisingly, the economically disadvantaged households. Amongst these, people with disabilities/special needs, and the women and children are most at risk financially, socially, mentally as well as physically. Studies presented at both the conferences reaffirmed the increased rates of sexual assault and traumatic brain injuries post the disaster that are making these high-risk groups even more vulnerable. Thus, climate change deeply intertwined with poverty, poor health and social injustice potentially violates their basic human rights.

Not only is the impact of climate change spreading across different population groups, but what happens in some regions also leads to changes elsewhere, due to the interconnectedness. ‘Changes in your lands and water are changing my lands and water, a new building or a road in your community and the energy underpinning its new development comes from digging more oil and gas wells in my community’, said Rosemary Ahtuangaruak, an Inupiaq activist and environmental justice advisor from the Alaskan Wilderness League at the APHA 2017 closing session. This in a way also reflects the need to adopt a ‘systems approach’ in achieving the Sustainable Development Goals rather than working in siloes. However, it is still not clear (to most governments and scientists) how they need to deal with complex issues of the SDG era in a coherent and inter-connected way.

The disasters the world is currently facing and the increasing amount of conferences focusing on climate change underline the fact that key voices are uniting in their understanding of the impact of climate change on health, advocating to the countries and its people to take immediate action to mitigate the situation.

Each one of us needs to get engaged in this, as it is our collective responsibility to protect and hand over a safer planet to the future generations!

Source: Pinterest ©2015 Alex Garland

Photo Source: http://www.povertyinsights.org/wp-content/uploads/2015/10/3667770124_781f5874a9_z.jpg

Following which, I went on a trail of thoughts imagining how it would feel to be in a situation like this, taking me back to the state of homeless people in my own country, India. Something seemed different. I was wondering what was driving them into such a situation. U.S., Canada being developed countries with per capita GDP and per capita welfare spending among the top 20 across the world and better social security mechanisms, I could not rationalize the extent of homelessness there (even if, in Vancouver for example, I got some explanations from public health experts on why the city struggles with a serious homelessness problem).

My own country is still a developing nation grappling with extreme poverty issues, hence, it is common to find homeless people even in the urban areas. The primary reason for homelessness in India is extreme poverty, while in the west, several other individual and relational factors like family break-up, domestic violence, mental illness, addiction challenges etc. are found to contribute to homelessness –  coupled with migration recently.

However, I noticed a difference in the way these homeless people approach others for help. In India, a poor homeless person is likely to be an illiterate and cannot read or write even in his/her own local language. Generally dressed in unkempt clothes, these people find it difficult to convey their message and have to largely rely on nonverbal gestures. Unlike them, at least some homeless people in the west appear better dressed, and are able to communicate their circumstances well through written messages. The latter manner of seeking help is less intrusive, provides clarity on their situation and reason for seeking help. One can even find people explicitly asking money for drugs or alcohol. Recently, a prankster carried out a social experiment in New York to find out who would receive more help: a homeless drug addict or a homeless father, and to everyone’s surprise, the former was able to get a good sum of money in an hour with messages like ‘stay high man’ & ‘get a big bottle for yourself’.

This cultural aspect reflected by their behavior and mode of communication is just one bit of the entire story. If we try to understand this at a macro level, then there are several structural and systemic factors reacting with their individual circumstances making them land in situations like these. Failure in the state’s social security system to address the needs of this section of population – too many holes in it, certainly in the US? –  coupled with several structural factors like poverty, increasing unemployment, lack of affordable housing and access to other welfare services makes the situation even worse. As reasons are rooted across several political and social welfare dimensions, tackling homelessness actually needs a multi-pronged approach.

My observations from the streets in Northern America made me think of how such conferences are successful in bringing out the voices of the neglected homeless people living on the streets endlessly. APHA has a specific caucus dedicated to homelessness (for every annual meeting) with sub-themes such as: housing as a human right, impact evaluation of interventions targeted to homeless people, severity of multiple health conditions experienced by them etc. Also, these conferences (especially HSR2016) emphasize the role of civil society organizations and community engagement as an important mechanism to promote active citizenship among the community members. A key question for HPSR researchers is perhaps this one: how are communities to be engaged if many citizens are (too often) desensitized to issues of power and privilege in their own local settings? Somehow, our social justice antennas seem to be triggered more in faraway lands…

The United Nations Commission on Human rights estimated a 100 million homeless people worldwide in 2005; and over one billion for people living in any sort of insecure, temporary or illegal housing. A recent global poll conducted by GlobeScan in 24 countries found a significant increase in perceived seriousness of poverty and homelessness as national concerns. Hence it becomes essential to see how the learnings and ideas generated through such conference discussions get translated into reality. At least if we’re serious about ‘leaving no one behind’…