On the eve of the Replenishment, McGill University hosted a pre-conference to celebrate Canada’s renewed commitment towards global health and development. The event, in a packed hall, brought together a high level panel including Canada’s  Minister of Health, Jane Philpott; Mark Dybul (well-known to IHP readers, we reckon); Peter Singer, Chief Executive Officer, Grand Challenges Canada; Lucica Ditiu, Executive Director, Stop TB Partnership and eminent McGill faculty members.

Snapshots from the event:

With her opening remarks, Jane Philpott already set the scene when she said infections are not statistics and deaths aren’t dry data. She didn’t mince her words, “this is about human lives, people with eyes and faces and we have to treat them the way we should, as human beings”. She also described these deaths as outrageous, particularly as humanity today has the means to solve them.

Some solutions towards improving health outcomes were presented. Some key steps were highlighted, these included collaborating towards investing in research, working with vulnerable people to address equity, access and human rights, and last but not least, generating “political will”. The last one is probably the hardest, especially in the current international environment.

Everybody emphasized there is no magic bullet and real life processes are complex. It is essential to translate data and clinical trials into public health programmes.  It is also vital to promote local innovation to address local needs, collaborating with district officials, civil society and communities. Health systems strengthening is also key to improve supply chain delivery , and service quality, collection of data – all towards a more resilient and sustainable response to health challenges.

The panel also reiterated the Canadian government’s focus on ending tuberculosis, HIV and malaria by reaching out to the vulnerable, the poorest and ending discrimination, stigma and associated fear. To achieve this, the panel highlighted that countries will need to invest in technological innovation with social integration, invest in gender equality to empower women and young girls and most importantly, identify youth as change agents acting as “propellants” for future generations.

Social determinants and equity were at the heart of the event, and deservedly so. Mark Dybul put it nicely, “To end these diseases we must become better humans”. A tall order, yes, but there is no other way. Or in the words of South Africa’s Minister of Health, Aaron Motsoalendi, “Above all it’s about social justice and solidarity and providing universal access to care”.

As the Global Fund replenishment kicks off in this great city, various panels will focus on empowering girls, the most marginalized (including the LGBT community) and engaging with the youth towards the sustainable development goals and the GF disease targets in particular. The (now ongoing) events will be interesting to follow, and hopefully the money will follow too! I’m also very much looking forward to the Global Citizen concert tomorrow evening, an event that will certainly celebrate Canada’s renewed commitment to international aid and the Global Fund with a bang.

Yes, the Global Fund needs billions and with many others we are hopeful that the US$13 billion goal will be reached by Saturday, despite the challenges of the global environment. But as MSF’s Joanne Liu puts it, the global health community can show that the SDGs are not just empty promises. So we hope that Canada’s leadership will be followed by many other governments.

Still, the panelists reminded us that in the end it is not about the billions, but about human lives. The Global Fund can help these people to live lives with dignity and respect, like all of us. Which is why the Fund needs our support.

“We don’t want anything. We don’t need a single rupee or tea but only do something on water and give us drinking water”.

– Hiren(a pseudonym), male, village health, sanitation and nutrition committee members, rural northern India

While conducting an implementation research study in a marginalized area of northern India, on the implementation of guidelines to support village health, sanitation and nutrition committees (2013),  day after day, interview after interview, people explained to us how desperate they were for an adequate supply of clean drinking water. Yet, day after day, interview after interview, we kept exploring and focusing on other issues.

Yes, we took note of the urgent need for water. But as we had “a job to do” as researchers,  we moved on to other topics. Our study had to cover a lot of ground. As mentioned, we were there to learn about village health, sanitation, and nutrition committees, which were primarily set up to take collective local health action (such as organizing village health education or cleaning events) and monitor the services offered by government pre-schools and clinics.

We weren’t expecting to find such severe water shortages and terrible drinking water quality. Much of the water in this region of north India was either too salty or too high in fluoride content to be consumed. Women explained that it ruined the tea when mixed with milk. The shortage and change in water quality also affected crop cultivation and changed the pattern of production. People could only access potable water through a few deep bore wells, and the bore wells could only be used when the irregular electricity became available.

Insufficient water and poor water quality were the single most pressing issues for all the villages we visited. Yet the health committee intervention was not designed to engage in the large-scale infrastructure projects required to address this problem. Buying reverse osmosis filters, digging new bore wells, installing new motors, building new tanks, and setting up piped water systems were all (often) beyond the capacity of the health committee. Many village committees tried to address their water issues by writing request letters to the authorities. However without access to sufficient funding, and without the ability to apply political pressure, few committees made headway—at least during our one-and-a-half year research period.

What do you – researchers – do when the community’s expressed priority does not perfectly align with your public health program? In many cases, including ours, a public health intervention seeks to address important local challenges but often has little to contribute towards solving the most pressing ones, such as water shortages or unemployment.

Ideally, community-oriented public health will support communities in identifying and solving local problems. But reality is rarely like this. Many projects have a pre-determined focus. Many funders want to use evidence-based public health approaches to generate a measurable reduction in mortality and morbidity, within a fixed timeframe and fixed budget. A hand washing promotion intervention is a feasible way to achieve this goal. Conversely, an expensive, intensive and multi-sectorial attempt to bring potable water to a drought ridden fluoride belt is usually not what they have in mind.

The reason that so many public health interventions focus on valuable but secondary issues in people’s lives is that we lack the political clout or consensus to solve the bigger social problems: rampant financial inequality and unfair distribution of scarce resources. These huge, seemingly intractable, issues are the primary social determinants of health. We need to emphasize cross-sector collaboration and long-term funding for initiatives that create health-enabling environments—rather than short-term disease-specific or behaviour change oriented interventions.

The United Nation’s Sustainable Development Goals (SDGs) may help create such a push. These goals present an opportunity to renew our vision for development. Countries must set agendas, allocate finances, partner across ministries and implement development projects that are oriented around the “causes of the causes” of ill health. Just this week, for example, it was reported that  at least two-thirds of the global population, over 4 billion people, live with severe water scarcity for at least one month every year.

It’s uncomfortable to learn that a remote village is desperate for water, and then try to convince community members to get excited about joining a health committee that is not equipped to solve their water problems. Perhaps this discomfort should be a reminder to refocus on the big stuff. There will always be a tension between specific, short-term interventions (encouraging hand washing behaviour, improving health worker training and support) and broad, long term interventions (water infrastructure development, labour rights advocacy, increasing the money available for public services). Ideally we can integrate these approaches, for example through helping village health committees in India gain the power to better advocate for their water needs.

Let’s remember that our greatest work lies in addressing the broad social determinants of health. Short and medium term interventions matter too—but we need to ensure that public health remains oriented around the true priorities, even though they are the most difficult.

They are so for a reason.

The course evolution and curriculum development followed a gradual, systematic and consultative path through a series of workshops and smaller meetings. Two committees have been developed out of the members of the core group and advisory group: a course promotion committee and a curriculum committee.

The course comprises an intensive two-week programme (23 Feb-5 March), with additional pre- and post-engagement through the open source learning platform Moodle. KEYSTONE aims to develop individual capacities and channel latent capacities of participants, for investigating and addressing real-world problems of health systems and policy, through rigorous immersion in current HPSR approaches, cross disciplinary approaches and frameworks. The course will emphasize the relevance of training and research for people involved in health system change. The ultimate goal of KEYSTONE is to activate a community of Indian HPSR researchers capable of addressing the critical needs of health system and policy development. Participants in the KEYSTONE course are predominantly mid-career level researchers, many of whom are in PhD programs; some participants are also working in health systems or civil society organizations. Participants are expected to have some research experience.

KEYSTONE learning outcomes include the capacity to frame HPSR questions, select appropriate research strategies for answering these questions, and think through strategies to support the use of research knowledge in health system decision-making.

The inaugural course has generated quite a stir and enthusiasm among the Indian HPSR community. Organizers received 77 applications from across disciplines (public health, medicine, geography, anthropology), sectors (academic, NGO, government health service) and geographies (eastern, western, northern and southern regions of India).The applications were reviewed by a group of 21 national and international HPSR experts who scored the applications on motivation of the participant to participate in the course, relevance of identified health system problem, level of HPSR related experience, language competency, and overall expectation of the candidate’s contribution to the course and to the wider group. The final selection was made by a core committee that also considered regions, constituencies, gender and how likely the candidate was to make use of the course.

As mentioned, the course starts on Monday 23 February,  so the final countdown towards KEYSTONE has really begun now, and the inaugural video for the course has already been launched. After weeks of preparation, staff and facilitators involved in the course will now move to the delivery of the course itself. The number of planning meetings and emails among core members seems to be increasing exponentially and the drive to create an Indian HPSR community is keeping the organizers awake throughout the night. Luckily, nights and skies in Delhi are pleasant now.

The Keystone faculty and facilitators are excited to facilitate the course for this diverse group of participants, which brings together government health services representatives from the national and district levels, activists from prominent NGOs, PhD students, committed academicians and practicing senior medical doctors. We will soon find out whether these discussions will most resemble a battlefield, chaos theory in practice, or the evolution of complexity with emergent patterns that the facilitators can bind together (our preferred scenario). Another question on many faculty and facilitators’ minds is that many course participants are mid-career – so one would have somewhat already framed their lenses to look at the health system. As this course introduces different lenses to look at health system problems, such as economic, policy analysis, ethnography, theory driven inquiry, and participatory action research, participants will be (gently) asked to move out of their comfort zones. This exposure to a range of research perspectives might result in lively discussion and critique of each lens (preferable) or instead, adherence to one lens that the participant finds more appealing or feels more comfortable with. Anyhow, faculty will have to devise mechanisms throughout the course to emphasize that the lenses are not incongruous but rather different ways to look at similar problems. (Here Keystone goes a touch Buddhist, we have to admit.)

Meanwhile, the administrative team is busy trying all permutations and combinations to make the course logistics comfortable and smooth. The course is set to be paperless and wi-fi enabled. With considerable challenges of selection of food menus (participants from northern, eastern, western and southern regions have very different food affinities and choices – in that respect there exists only one “truth” for most participants, a researcher’s stomach is less flexible than his/her mind) to selecting room partners, they are also juggling participant queries regarding travel and stay.

The stage is set for a theatrical performance with some greenroom preparation still going on. A vivid plan to subject KEYSTONE to a documentary film is being pursued. The actors (faculty and facilitators) are set to perform, and instead of applause at the end of their show they are hoping for curious questions and exciting debates throughout. So it’s a house full of positive radiant energy and enthusiasm to take the first step in developing and expanding the Indian HPSR community to shape and strengthen the future of Indian health systems.

We will keep the IHP readers updated on course progression, so stay tuned for other upcoming KEYSTONE blogs.

As part of the EV face-to-face program, we had an opportunity to learn about the South African health system and local environmental health issues of Khayelitsha, an informal (and notorious) township in Western Cape, South Africa. Dr. Lena Stofie gave a brief but thought provoking presentation on the numerous challenges in these informal settlements, which was followed by a short visit to Khayelitsha. Our tour guide on the bus, a settlement ‘experience expert’, “entertained” us with lively stories about his past in a local gang and on what life really feels like in a tough place like Khayelitsha, for example for kids trying to go to school.  Very insightful. Many of us learnt a great deal, in a way dry statistics and figures can never do (our tour guide was less successful in converting us, though).

While sitting through Dr. Sofie’s presentation and listening to our rather entertaining tour guide, I wondered how similar the landscape felt to another informal settlement, thousands of miles away and in the very different culture and society of India, my home country – more in particular in Dharavi, Mumbai. I spent two years in Mumbai studying for my master’s course and did one of my internships in Dharavi, trying to understand the public health challenges there. Mumbai is well known for the luxurious lifestyle of the many Bollywood stars living there and for the newly constructed (and super-posh) Ambani home, ‘Antilia’. Yet, it is also home to some of the worst slums on the continent, as anybody can testify coming from the airport.

Both Cape Town and Mumbai are aspiring world class cities filled with beautiful skyscrapers and good amenities but they also share the burden of rapid and often problematic urbanisation. Despite a very different history and course of evolution, current challenges look quite similar in these poor areas, whether you call them settlements, townships or slums. In South Africa, these settlements represent a legacy of apartheid planning – till today, this path dependency causes enormous difficulty, including in terms of urban planning. Dharavi on the other hand was once a fishermen’s village, which gradually turned into a hub for poor people from different states to migrate to. Today, it stands as a marker of gross inequity in our society.

While listening to Dr. Sofie’s and other presentations on South Africa, I realized that South Africa and India share quite some other characteristics, both historic and 21^st century ones. Both countries were once under colonial rule for a substantial time, and they are known as the land of Mandela and Gandhi, respectively, who devoted their lives to end discrimination and strive for social justice. The two countries have now emerged as growing world economies and are proud BRICS nations. As an Emerging Voice, it was nice to get to know another one of these “Emerging Countries” a bit better, even if my visit to Cape Town was only brief.

Moving on to the wicked problem of slums, and drawing from examples and experiences from working in Dharavi in Mumbai, let’s look through a range of complex issues that a slum dweller faces in a daily life. I will focus on Dharavi in the remainder of this piece, as I know this slum far better than Khayelitsha. As mentioned, though, I got a sense they have a lot in common.

A day in Dharavi

Dharavi is a small city within a city with its own socio-economic structure. A day in Dharavi starts with queuing for common toilets with your small water pot or small children sitting beside the open drain of houses. Long queues at common water taps, and filling up the blue coloured plastic storage drum. Cooking food in one small room which has no windows making one cough and choke. Waste thrown in drains or dumped in common open grounds for disposal. These (often choked or overflowing) drains are common sites to spot a rodent, food waste or faeces and they serve as a breeding place for mosquitoes, too.

Employment is mostly informal in a slum like Dharavi, as people do small-scale work from home which varies from making leather and textile goods, pottery, recycling of plastic and metal scrap to hand embroidery; some are working in small factories. Job insecurity is huge. Another constant worry for residents is their health status, with cases of Tuberculosis, recurrent diarrhea, skin ailments, unintentional injuries and fever all very common. Although city municipalities have tried to resolve the multiple problems in the slum and also to redevelop Dharavi, they have largely failed. They couldn’t sustain efforts towards a more conclusive solution and as a result, slum dwellers have now become very reluctant to leave their homes and resettle to a new location.

A multi-ethnic, multi-religious and multi-state population lives in these settlements – with squatters from all corners of India and social and economic backgrounds but sharing a common dream of a better, more “human” life. They act as societal mirrors reflecting our unexplainable tolerance for huge structural differences and inequities. For some reason, these horrendous disparities do not cause large-scale indignity and social disruption in our societies.

Looking at slums through a complexity lens

The application of a complexity lens to these slums is more than just a theoretical exercise; it is very much necessary as such a lens forces us to ask hard and often uncomfortable questions about the real (obviously, complex and transdisciplinary) world. It allows us to think more holistically and seems crucial in identifying and conceptualizing both the problem and pinpointing possible solutions. The challenge of urban slums represents an interconnected web of problems, which can’t be reduced to smaller parts or even sectoral responses and requires more knowledge of formal and informal networks and linkages between various actors. Instead of the linear and top-down approaches tried (without much success) by municipal and other governments, room should be made for solutions that take into account nonlinearity, multiple causes, emergent properties and iterative adaption, tipping points, real world messiness and the like. As you might expect, that is as difficult as it sounds.

The problem of slums in a metropolitan city like Mumbai also has different (interconnected) layers – global, national, state and local ones – and a complex multilevel hybrid governance framework. Global, national and municipal policies will have to be put in place to try to solve the problem, all the while acknowledging that there is a lot of uncertainty in complex societal nested and/or co-evolving systems. Hope you’re still with me.

For instance, at the global level, neoliberal globalization has led to a booming trade, deregulated capital markets, imbalanced growth and very inequitable societies. In India, the consequences are felt in the rural areas. Many poor farmers have migrated to these slums, as they couldn’t survive anymore on their farms (sometimes literally, sadly). The Lancet/University of Oslo  Commission on global governance for health is one of the many high-level reports calling for global political solutions and new governance mechanisms to address the huge (market and other) failures of our current global economic system. At the local level, accountability of social and public policy is more often than not lacking, due to the chosen path of non-inclusive development. Taking into account all this, urban planners face a huge challenge to make their cities more resilient and a better place to live for all its citizens.

A complexity lens tries to look for solutions in urban slums using a multi-pronged approach. At a local level, it calls for buy-in, support and interventions from various social departments, which are often not very much into each other’s work, to put it mildly. The struggle to have proper shelter, employment, potable water, adequate disposal of waste and sanitation measures, and provision of health services cannot be seen as standalone determinants. They are basic needs but very much interdependent in the impact they can make: working on one component of water, sanitation and hygiene (WASH) without connecting it to the others leads to failure. Necessities have a profound effect on one another and to look at them with a linear and reductionist approach, without acknowledging the relationship between them, and possible feedback loops, is something we can’t afford anymore in this century. Or perhaps we never could.

Resettling of slum residents by urban planners has been largely inadequate due to a number of reasons: planners focused only on formal networks, and other factors like paucity of finances, lack of land, corruption and mismanagement by real estate agents and infrastructure companies all played a role in ‘resettlement going wrong badly’. The complexity approach stresses identifying also the informal networks which often have a far more profound impact – for instance through involving informal local leaders and capitalizing on them as conveners to mobilise and assist in organizing resettlement (or finding another solution).

In Dharavi, the delay and often lukewarm efforts in providing of housing and employment by formal social welfare departments have reached a tipping point long ago – unfortunately in the wrong direction. People have waited long enough for formal government work schemes to materialize and have finally settled for alternate mechanisms to provide for themselves. They have also taken loans and assistance from informal money lenders and local leaders to set up their own small-scale and often unauthorized, illegal work units and housing through their own initiative. Informal mechanisms and self-organization thus replaced more formal and top-down attempts to resettle populations. Depending on your perspective (local communities or urban planners), you can consider these as positive or negative feedback loops, or virtuous and vicious cycles. Anyhow, it is clear that urban planners’ initiatives have proved to be futile in the past for a number of reasons which can  (at least partially) be explained by complexity thinking. By now, slum inhabitants have strong doubts about “progressive” schemes for redevelopment and have lots of unanswered questions on the resettlement schemes, relocation areas, future of small and medium sized industries in the slum and employment guarantees.

So it seems obvious that the framing of the problems, planning and solutions for these slums require more intuitive, iterative and adaptive thinking, where people and communities are seen as part of the solution, from a sustainable development perspective. Good management of slum problems calls for being aware of uncertainties, doing pilot projects to induce learning by doing. It calls for inclusion of local leaders and organizations, allowing for meaningful bottom-up involvement.  Having said that, that doesn’t mean that urban planners have to meet with the local gang leaders to agree on the ‘way forward’!

Reframing the challenge of urbanisation

In line with this, there is an urgent requirement to reframe the global challenge of urbanisation. Unidirectional, top-down planning implemented by siloed departments won’t cut it, not in India, not anywhere. Creating healthy sustainable and equitable mega-cities, one of the key challenges in this century, will require complexity thinking, both in appropriately assessing the many dimensions, interdependencies and nonlinearity of a huge global societal challenge like this, and possible solutions. Not involving communities is a non-starter. Integration and collaboration of social departments, in an often multilevel governance constellation, including also civil society and private sector stakeholders, will be needed as well, but the city “stewards” will need to be prepared to adapt as they proceed, learning by doing. Imported solutions could inspire, sometimes, but it is likely that they will have to be adjusted to local contexts, partnerships and intricacies, or sometimes be ignored altogether.

All this is not very controversial, at least in the broader development community, as this is exactly what the new set of Sustainable Development Goals, currently under negotiation, aim to do –  at least in principle. They have been developed through a more consultative process (than the more top-down MDG process) and try to look at economic, social and environmental development in a more integrated and holistic manner. They also articulate flexible, tailored targets developed through participatory processes for regional, national and sub-national levels and leaving behind one-size-fits-all solutions. How this more holistic framework will work out in practice, is of course an entirely different question.

But as a young Emerging Voice, I prefer to look at the future from the bright side. So rather than looking at old failures and unsuccessful models of development, I see hope and opportunity for EVs to act upon. Together, we can act as drivers for change by engaging with development goals at our national, regional and local level. The brave ones among us could even take on the global powers that be. Through participation and engagement with real-world problems with our zeal, motivation and research skills and premised on building equity, trust, empowerment and promoting sustainability in local contexts, we can help rebuild solutions.

Even better, who knows, perhaps someday some EVs will become Mandela’s and Gandhi’s in their own setting, with a heart for social justice and a mind for scientific rigour? Then, perhaps, our world will look slightly less complex and more human…

Kristof Decoster (ITM & EV facilitator) provided some inputs for this article.