On the heels of the next major health systems event in a country that feels refreshingly “new” since yesterday, the Emerging Voices for Global Health team is also gearing up for a shift.

A few months back, EV alumni organised themselves to come up with a new globally representative governance structure comprised of EV alumni from all regions:

* Prashanth Nuggehalli Srinivas (Institute of Public Health, Bangalore) (South-East Asian region)- Chair;

* Dorcus Kiwanuka Henrikson (Karolinska Institutet) (East/South African region)- co-chair;

* Jin Xu (Peking University) (Western Pacific region) – treasurer;

* Arsene Kpangon (University of Parakou) (West/Central African region);

* Vladimir Gordeev (London School Of Economics) (European region);

* Asmat Malik (AMZ Consulting, Pakistan) (Eastern Mediterranean region) – co-chair;

* Elena Vargas (Independent Researcher) (Region of the Americas) – Secretary.

Two liaison (and not elected) members complete the Governance team:  Kopano Mabaso (liaison with HS Global); Kristof Decoster (liaison with ITM).

Together, the new EV4GH governance hopes to improve the scope, reach and impact of the EV event in future editions. After the new governance team was put together, the EV4GH group has been closely interacting with the WHO Alliance for Health Policy and Systems Research as well as with Health Systems Global, both entities being important partners and well-wishers for us. Indeed, over the coming months, EV4GH hopes to pursue a systematic collaboration with Health Systems Global and eventually integrate in some way with the society.

This month, with the help of ITM’s EV team, a new secretariat is being established for the EV4GH at the Institute of Public Health Bangalore (IPH). IPH has been an early partner of the EV4GH having been involved since the first edition that was held in association with the first global symposium on health systems research in Montreux. For the coming year, the team at IPH (including Prashanth N S, the Chair of the EV governance group and Sophia Thomas, the secretary for the EV governance) hopes to take forward this new phase in the EV4GH evolution.

IPH is of course not alone in this. With the support of various EV partner institutions including the Institute of Tropical Medicine, Antwerp (ITM), Belgium;  the Public Health Foundation of India (PHFI); University of Cape Town (UCT), South Africa; University of the Western Cape (UWC), Cape Town, South Africa; Peking University Health Science Center (PUHSC), Beijing, China, the new secretariat at IPH is all set to launch a call for fresh EVs to participate in the 4th global symposium at Vancouver. We foresee a new and vibrant bunch of researchers, implementers and other health system actors to be selected in this edition to participate and constructively engage and challenge the global health discussions at the symposium. This year, the new EV2016’s will gather a few weeks before the symposium in Vancouver for a face-to-face training and will again try to enliven the discussions at the symposium. We look forward to welcoming a fresh batch of Emerging Voices for Global Health!

Stay tuned for the call details on the website of the 4th Global Symposium for Health Systems Research and on the EV4GH website.

Commitment to the poor and disadvantaged by the government comes at an opportune time. In spite of apparently progressive pro-poor schemes of the previous Congress-led government targeting rural employment guarantee and a more communitised health system (see Rajani Ved’s blog on India’s ASHA programme and Arima Mishra’s blog on the mission mode for India’s programmes), corruption and mal-administration plague India’s public services, as noted by R S Rajan. Modi ran on an election platform that showcased how his governance would be exactly NOT like the previous regime. In health, the Modi election manifesto promised “health assurance to all Indians and to reduce the out-of-pocket spending on health care”.

However, in a federal state, which is still battling with worse-off governance at state levels than the relatively better-off systems at the centre, this national health assurance is slowly proving to be a difficult promise to deliver. As Neethi Rao reflects in her blog on federalism, Indian states often with their own local state-level politics are not always in line with such national commitments, more so on health services organisation and delivery which is on the so-called state list. A much more systematic support at state and district levels is possibly needed before such national commitments may be fulfilled. While this complex socio-political negotiation between a PM at the centre, who portrays clear convictions on how to chart India’s development story, and a general poverty of governance and vision at the state level (with respect to health and development) continues, there are not yet clear positive trends for India’s health on the horizon.

If financing of healthcare is any indicator of government’s commitments to health of its people, the signals are not (yet) so positive. The precious little coming to the healthcare sector has to be partitioned between pet national institutes of excellence, even as a hugely under-funded and under-performing primary and secondary care system watches, as Shreelata Rao Seshadri notes in her blog. In spite of being a prominent supplier of inexpensive medicines to several countries in the global South, access to medicines in India’s own primary health centres is not yet optimal (see Maya Annie Elias’s blog on this topic). Early pronouncements of health insurance for all later morphed into health assurance for all with no clarity on how such assurance or insurance would supplement or rather undermine India’s large public sector. Budget cuts in the social sector programmes and schemes of the central government followed; again cutting of central government spending in the social sector was accompanied by higher revenue share to states, arguably favour of co-operative federalism. However, there are doubts that such trade-offs will work, at least they may not work in all states. Many of the worse-off states where targeted central assistance was in fact unconditionally focusing on the social sector, the shift of greater revenue to states might in fact be weaned away from supporting long-term social sector spending and may succumb to low politics at the state and be used for short-term vote-gain programmes.

While the debate on whether India ought to go for a privately provided market-based insurance route for UHC or veer towards publicly provided (or purchased) care is a debate that has strident advocates on either side, Modi government’s slogan of “minimum government, maximum governance” fails India on two counts. There is the actual need of quite some “government”, at least with respect to sectors like health, education and environment, where we know from several global experiences that reducing government’s stake to mere stewards while handing over organisation, management and delivery of these systems to non-governmental entities is a dangerous trend. The need for building a strong partnership with states and investing in multi-level governance system and effective regulation of private sector in health, especially the provision of healthcare by private entities is a crucial need for Indian public health.

In fact, if the current weakening of environmental norms in favour of quick-wins is any indication of times to come, then India’s short-term gains in infrastructure, investment and global image may come at a long-term health and environmental cost. As Shankar Raman reminds us, environmental effects on health are not marginal concerns any more. In its eagerness to make sure we all feel the development, the Modi government may be over-enthusiastically cosying up to big business. India’s environment ministry has been delivering clearances for clearing forest land for industry faster than ever before, and the rural development ministry has been steering land acquisition for industry directly, while the health ministry, after bold declarations against big tobacco delivered in much fanfare by Modi government’s own previous health minister, backtracked on implementing large-size health warnings on tobacco products. Corporate and industry interests are high priority and not without reason, but their influence on health, development and environmental policy is indeed worrisome. More so, when India’s biggest business interest groups that are involved in public policymaking bodies and several Indian parliamentarians in important committees related to health and development have very close ties to big tobacco. Indeed India’s finance minister, a close aide of Modi minces no words when he characterises his government as being “pro-poor and pro-industry“. How this marriage between unusual partners – pro-poor and pro-industry- works, time only will tell, as Ramaswami Balasubramaniam notes in his 1^st year report card for the Modi government.

Commitment to co-operative federalism and decentralisation may be a mantra on one hand, but the government’s attitude towards publicly expressed dissent has not always been well received. Many NGOs are on the Modi government’s radar, including environment campaigner Greenpeace, which has faced the ire of the government. Several NGOs being cracked down upon were dubious and were deservedly at the wrong end of the stick, but slowly and steadily an atmosphere intolerant of criticism and dissent seems to be cropping up; not a healthy trend warns Adithya Pradyumna in the blog ‘health of NGOs in India’.

Image consciousness is of course not always a bad thing. Modi’s leadership is clearly visible in his administration embracing social media and being accessible on the several government-run online platforms that are mushrooming. Many leading government officials are today on social media and sharing decisions and developments in their offices. Online platforms such as mygov widens reach of the somewhat common (wo)man (access to the Internet and more so, being vocal on that platform is still not so commonplace here). The trend of ministers making frequent public statements and not hesitating for open media debates is also healthy. However, it is still unclear as to how such social media and online platform engagement by citizens is used or feeds the policy process.

Amidst public debate on apparently farmer-unfriendly policies, the government faces stiff pressure to show a more human face to the large farmer base in the country. As Shridhar Kadam notes in his blog, India’s villages are unsure whether to enjoy the fruits of globalisation or miss the comfort of their erstwhile sustainable living. This is of course not only an Indian story but a global one, playing out differently in many of the emerging economies.

Clearly, the first year of Modi government has been different from the previous regime on most counts albeit the difference does not (yet) augur too well for health and environment. In any case, assessing a nation’s health based on one year of a new PM is a flawed enterprise. Nonetheless, broad public policy trends in favour of public health are not (yet) evident. If at all, close association with big business could indeed mean higher private sector role in healthcare delivery. What form this will take, how much of collaboration and how much of regulation is still to be seen (see for instance Vijayashree Yellappa’s reflection on this). Whether invited or not to the healthcare party, the private sector is here to stay. If indeed public health has to prevail, an effective regulatory system that reins in India’s unbridled private sector is a very large unfinished agenda in India. And irrespective of how private, or how public India’s healthcare future is, the Modi government needs to put more government (not less as they are hoping) in healthcare regulation (see Sunil Nandraj’s post on reining in India’s private sector). One only hopes that the crushing of bureaucratic barriers for big business will not be the downfall of public health and public institutions in India. Time only will tell. But, on one thing there is no doubt; health, education and environment in India require quite some government (not less) and certainly better regulation. In this respect the proposal in the draft national health policy 2015 to make access to healthcare a constitutional right in India is a bold and a very welcome move, only if Modi’s government in the remaining four years of its term make it into reality.

An ecologist friend of mine sent me a paper from the mid-80s titled What is conservation biology by Michale E Soulé that sought to build (rather define) the (then) emerging discipline of conservation biology. Soulé framed conservation biology as a crisis discipline, with strong foundations in biology (and ecology), but not entirely so, drawing analogies between going to war and political science. He says:

“A conservation biologist may have to make decisions or recommendations about design and management before he or she is completely comfortable with the theoretical and empirical bases of the analysis (May 1984, Soult and Wilcox 1980, chap. 1). Tolerating uncertainty is often necessary…..Although crisis oriented, conservation biology is concerned with the long-term viability of whole systems.”

The paper got me thinking on the whole enterprise of health systems and the recent spate of interest around health (policy and) systems research (HSR/HPSR). Ours too is arguably a crisis discipline. Health too draws from and depends heavily on medicine and the underlying biological sciences (at least for doctors), but not entirely so. The increasing realisation that the social determinants of health and the inter-connections between individuals, societies and their environments (the physical environment in terms of air and water, but also the larger social and political environment too!) and the complex web in which health and well-being of people are woven into, indeed require a much larger pool of knowledge to draw from than merely bio-medical sciences.

Building on the richness of methods rooted in the various social sciences, HPSR seeks to embrace inter-disciplinary research and allow questions to drive choice of methods than succumb to a hierarchy of methods usually organised by disciplinary assertions of rigour. One such platform that brought together rich discussions within and between various approaches within the umbrella of HPSR was the KEYSTONE course that recently concluded.  Keystone was coordinated by the Public Health Foundation of India, but brought together several institutions across the country to offer a smörgåsbord of approaches to look at health systems problems. Being a question-driven field, HPSR draws heavily from the social sciences. With a pre-course and post-course online learning component, the 10-day classroom teaching was supposed to be a primer to the course participants, many of them at various stages of research, management or technical support. Methodological approaches ranging from economic approaches and policy analysis to implementation research, ethnography, realist evaluation approaches and participatory action research were discussed among a few others.

My own lens on offer at the course was realist evaluation, drawing from the realist philosophy, “which considers that an intervention (or a policy) works (or not) because actors make particular decisions in response to the intervention (or not). The reasoning of the actors in response to the resources or opportunities provided by the intervention is what causes the outcomes.” With content inputs from Bruno Marchal (of ITM, Antwerp), the one-day realist menu included a brief history of realist evaluation, its underpinnings in critical realism and its origins within the larger body of theory-driven approaches. Participants were introduced the realist way of thinking, why programmes and policies work for some and not for others, an elegant and somewhat simple question that underlies most of the important reasons for any evaluation of public policies (much beyond health). In this regard, realist evaluation approach is very much suited for the HPSR mission, in that it is not driven by particular methods or tools, but by this fundamental question that allows for the evaluator to begin the quest of unearthing the underlying (latent) mechanisms within people (and societies) that interact with particular elements in their context to contribute to outcomes (for some and not for others). In addition to the day-long lectures, discussions and group-work on the various approaches within the HPSR umbrella, the course allowed for rich discussions between the practitioners of these various approaches.

But conversations across disciplines separated by philosophical firewalls are not easy. There are bound to be classical interpretations within disciplines that are likely to conflict with HPSR’ised application of these approaches. As jt emerged in a discussion with Rakhal Gaitonde (fellow EV who introduced participatory action research at KEYSTONE) and a few others, how does an ethnographer digest the HPSR’ised ethnography-inspired approach applied by a biomedically trained researcher/practitioner? How does HPSR then reconcile with the varieties of disagreements and arguments on rigour within many of the approaches, often not reconciled within these, let alone across disciplines. These are all early (and somewhat abstract) reflections within HPSR, but what is clear is that the disciplinary firewalls can only tunnel our vision vis-a-vis strengthening health systems and field-building exercises within HPSR could help find a bring together health systems related dialogue happening within disciplinary silos.

That said, even the apparently comprehensive HPSR conversation too is happening within a slightly larger silo. Across decades, every mature discipline is possibly questioning the boundaries. Soulé’s paper on conservation biology seeks to situate it within conversations that ought to happen across genetics, biology and natural sciences as well as various social sciences. If indeed, questions of health, development or conservation ought to be so pluralistic in seeking knowledge inputs from all of these disciplines, one wonders why most of the practice of health, development or conservation within societies is still shorn of the width and depth of these various disciplines. Could this be the hard landing for the aircraft of science on the tarmac of society? Enough said, I am already feeling quite (key)stoned…

In India these are opportune times for HPSR. A large nation-wide programme for strengthening health systems, the National Rural Health Mission has completed its first phase and is in transition to a second phase of engaging with the neglected problem of urban health. The new government is keen to launch a programme for Health Assurance, hoping that this will be India’s answer to universal health coverage (UHC). Also encouragingly for HPSR advocates, a recent review of HPSR outputs from India by Rao and colleages reveals a healthy upward trend of HPSR studies with first authors from India increasing from a mere 92 in 2006 to over 300 in 2013.

However, publications in international journals are not the best indicator for integration of HPSR knowledge into practice. At district and sub-district levels, there is a huge need to improve the demand for and application of locally generated HPSR knowledge into practice. And building the capacity of decision-makers and practitioners at these levels is crucial in generating knowledge and its subsequent use. In many low- and middle-income countries including India, research allocations for understanding public health programmes and systematic evaluation of such programmes are lacking. Rao’s review especially highlights gaps in research on governance of health systems in India and a comparative neglect of research on human resources for health and health financing. They also find that the current output of HPSR is limited to some states (provinces), few institutes and researchers.

The Keystone initiative is a response to these gaps in India’s HPSR capacity. It is one of the main national level HPSR capacity building initiatives in HPSR and conceived as a specialised programme for early and mid-career health professionals as well as health policy and systems researchers. The ultimate goal of KEYSTONE is to activate a nationwide community of HPSR researchers towards addressing critical needs of health systems and policy development in various parts of the country. The kick-off of the initiative entails a short course on HPSR which will draw from dialogues with researchers and HPSR practitioners from various institutions in India, South Africa, UK, Australia and USA.

One of the key challenges that the course seeks to address involves the need to ask and answer how and why questions and to understand and address the role of particular contexts in shaping health system performance. The course seeks to tap into latent capacities in social sciences that have not effectively been used to understand health policies and systems. The course also aspires to nurture a community of HPSR practitioners – between institutions and researchers – across the country, while at the same time making linkages to global experience in organising HPSR courses and capacity building of young researchers. The experiences of CHEPSAA and emerging voices for global health have both been influential in the shaping of the KEYSTONE initiative. The initiative has also benefited from the multiple linkages facilitated through Health Systems Global, the fast expanding global community of health system researchers.

The inaugural edition of the KEYSTONE course starts in the last week of February in New Delhi. Under the leadership of the Public Health Foundation of India in its role as Nodal Institute of the Alliance for Health Policy and System Research, a group of senior researchers from leading public health institutions from across the country are coming together for designing the curriculum and delivering the course. Hopefully, the KEYSTONE initiative will be able to trigger nation-wide interest and pursue locally relevant and methodologically sound knowledge to shape the design and implementation of health systems strengthening and policies in the country.