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Ready for a paradigm shift in global health?

By Remco van de Pas
on October 7, 2016

Last week, I participated in three consecutively-held global health seminars which focused on the changing nature of health cooperation and the increasing prominence of global health in international politics. Coincidentally, all meetings referred to (the need for) a paradigm shift in global health and the transformative change required to attain the health related goals of the sustainable development (SDG) agenda. In this blog, I would like to clarify this “paradigm shift” framing and discuss some of the implications. Besides, in this era of transparency and accountability, taxpayers have the right to know how I spend my time funded by public financing!

The three-day event marathon began in Berlin with “Leaving no one behind in global health – What should Germany’s  contribution be?” followed by a workshop of the Medicus Mundi Network the next day on “Health cooperation beyond aid” (also in Berlin). The third event of the week was a seminar on “complex systems thinking in international aid and health development” in Antwerp.

The meetings signal a certain trend. First, it is clear that global health is becoming an issue of significance for both foreign and domestic policy development of countries, hence the need to take an integrated, inter-sectoral approach involving multiple actors, including the government. Secondly, the SDGs call for a universal, transformative approach to health, moving beyond working in silos and vertical programs, and the (now artificial) divide between ‘developed’ and ‘developing’ countries. Buse and Hawkes have eloquently described the implications of this in their paper Health in the sustainable development goals: ready for a paradigm shift?  They identify five challenges in the way to address global health.

The (much-abused) term ‘paradigm shift’ was introduced by Thomas Kuhn in his essay,  ‘The Structure of Scientific Revolutions’ (1962). Kuhn defines a scientific paradigm as “universally recognized scientific achievements that, for a time, provide model problems and solutions for a community of practitioners”. Kuhn explains how scientific progress is not linear, nor cumulative, but rather occurs in phases – ‘normal science’, periods of crisis and revolutionary changes in world view, respectively. In the last phase, the crisis is resolved by a revolutionary change in world-view in which the now-deficient paradigm is replaced by a newer one.   Moreover, he argued that competing paradigms are “incommensurable,” that is to say there is no objective way to assess their relative merits. Or, in more general words, contrasting paradigms and their merits cannot be compared with each other on the basis of scientific validation, as they are bound by the specific communities, moment in time, and societal conditions that structure them.

The question then is whether something similar is now going on in international health cooperation and the sustainable development agenda. This merits a longer discussion, but perhaps the answer is ‘yes’, as the current major focus on evidenced-based interventions in health development programs is increasingly being questioned.  Let me use this “paradigm shift” angle to reflect on these three global health meetings.

The VENRO Global health seminar in Berlin focused on the (increased) prominence of global health on the German foreign policy agenda and Germany’s global health leadership within the G7 and G20. Germany chaired the G7 in 2015 and will be chairing the G20 in 2017; global health expectations are high after the positive track record of the Merkel government in 2015. The German government has developed a roadmap of their policy approach called “Healthy Systems – Healthy Lives”.  The seminar explored how actors such as NGOs could work in synergy with the German government to attain global health objectives. With global health having become more prominent at the UN (see the last UNGA71 meeting for example), and in the G7 and G20, the paradigm shift could be explained then as a next phase of the global health revolution, a concept elaborated by scholar David Fidler, “global health has been lifted from political neglect into more prominence among States, intergovernmental organizations (IGOs), and non-State actors.”

The MMI workshop (disclaimer: I was one of the organizers) focused on the changing role of NGOs, but also on health cooperation in general. A discussion paper critically analyzes the relevance, legitimacy and effectiveness of health cooperation and its actors in a fast changing environment.  A central point in the paper – also discussed in the workshop – is that currently much attention goes to ‘output’ legitimacy in the work of NGOs and health development (i.e. accountability, transparency and effectiveness) while ‘input’ legitimacy of NGOS – deliberation and representativeness –gets far less attention. What are health NGOs and who do they really represent in global health advocacy and policy shaping? How do they discuss and convene to come to their policy decisions and what are their values and own socio- political or even financial interests? The needed paradigm shift here consists of creating more (self) reflection and awareness in the agency of NGOs and health cooperation agencies as to strengthen their relevance in global health programs and UHC more specifically.

At the complexity & aid meeting in Antwerp, an initiative by ITM and the Belgian Development Cooperation, the recent publication Development cooperation as learning in progress was discussed. The meeting focused on the need to approach health development and programming from a non-linear perspective, allowing complex adaptive system (CAS) thinking, reflection and learning to inspire health cooperation programs – so yet another paradigm shift is required, it turns out. Two nice quotes that were presented during this meeting, perhaps: “Power corrupts, absolute power corrupts absolutely. Charity also corrupts, absolute charity corrupts absolutely!”, a quote originally from Halfdan Mahler (former WHO DG), and “International development agents often have a myopic view. TWP takes the naivety out of institutional relationships by understanding that change happens as a result of decisions that invariably have a political dimension.” (Geert Laporte, ECPDM, on Thinking and Working Politically, TWP).

Reflecting back, can we really speak of a ‘paradigm shift’ in global health policies and international cooperation?  If we include the framework by Buse and Hawkes, we now have four different approaches of what a paradigm shift should entail for global health in the SDGs era. The differences between these four concepts might indicate that there is “discontent with the status quo”, that we have entered a period of crisis and “debate over fundamentals” of what is the appropriate conceptual framework to advance global health.

My personal take on this is the following.

First, I hesitate whether a philosophy of science concept like ‘paradigm shift’ can (easily) be translated to the politics of global cooperation for development goals. Second, I am in doubt (call it a personal scientific crisis) about the ‘phase’ we are in, currently. The SDGs, in spite of their undeniable transformative language and universal potential, are still structured on the Western development model initiated after WWII. This follows the principles of economic growth (increase of production and consumption) based on capitalism, free trade, democratization, good governance and the rule of law via cooperation between sovereign nation states. However, there are analyses that health related human rights are undermined in the sustainable development agenda.  Moreover, we are facing a deep financial, ecological and social crisis. Issues like widening global income inequalities, thinking on a post-capitalist society,  the notion of planetary  boundaries and limits to growth,   global demographic projections and their implications for mass migration, reflections on cosmopolitan realism and the erosion of national sovereignty,  but also high-level political attention to health security threats like Antimicrobial Resistance all challenge  traditional development thinking and the status quo. There is fierce debate on the fundamentals going on and because of these structural global drivers and challenges world views on global health concepts might actually enter a revolutionary new phase.  For example, the recent ratification of the Paris Agreement on climate change by the EU, China, India and the US might trigger an energy revolution that will have a deep impact on global health outcomes in the years and decades to come. Hence, ecologically oriented frameworks such as the manifesto on planetary health  would guide us, eventually, towards a new paradigmatic worldview.