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Situating U.S. health services research in a global context – reflections from the Annual Research Meeting of AcademyHealth

By Veena Sriram
on July 6, 2018

Last week, a few thousand researchers, policymakers and practitioners gathered in Seattle for the Annual Research Meeting of AcademyHealth, the leading organization for health services research in the U.S.  Health services research (or HSR as it is called in the U.S., which is confusing as it is also an acronym for health systems research) and the more LMICs focused health policy and systems research (or HPSR) have much in common – a focus on health services and systems, engagement with multiple disciplines, and arguably, an underlying emphasis on equity. Much of my experience has been in the context of HPSR, and having now taken some steps into the HSR world – including participation in two AcademyHealth meetings – I wanted to reflect on similarities and differences between these two fields:

1) The (lack of) emphasis on the ‘P’ – HSR seems to be predominantly focused on services, with a clear focus on policy implementation and evaluation, but less so on the development process underlying new policy, particularly issues of agenda setting and formulation, and the reasons for the entrenchment of existing policy. In the U.S. context, the latter types of studies – delving into issues of politics, interests and power – seem to be far more common in research from disciplines such as political science. I sense less of an incorporation of that kind of policy research in the HSR space, which is contrast to HPSR, where such studies have been actively encouraged (although still quite neglected). At AcademyHealth meetings, this inevitably results in many ‘elephants in the room’ – for example, the outsize role of lobbyists in shaping health care.

In my view, this is one of the fundamental differences between HSR and HPSR – the longer term vision in HPSR to delve deeper and understand how and why certain policies gain traction, in an effort to try to fundamentally reorient systems to become more equitable, rather than just retooling what exists. The U.S. health care system is notoriously complicated, and much of the AcademyHealth meeting felt as though we were focusing on band-aids to the problem, rather than trying to get at the heart of these issues. Those are understandably difficult conversations – even more so due to the intense politicization of health care in the U.S. – but is essential to a holistic understanding of health.

2) Shared struggles of HSR and HPSR researchers – HSR and HPSR researchers seem to wrestle with similar issues – the desire to highlight community (but tellingly referred to as patients in the U.S. context) perspectives, underlying tensions between qualitative and quantitative methodologies, and challenges in integrating social science approaches. One common theme between last year and this year at AcademyHealth was the difficulties in developing constructive relationships between researchers and policymakers, something that has become more fraught with the Trump Administration. I had assumed that HSR researchers have an easier time accessing policymakers and disseminating findings given the dominance of government in funding HSR, but that assumption was proved wrong. Many of the issues brought up – need to use innovative methods for dissemination, challenges in engaging with the media, generating actionable messages, developing long-term engagement with policymakers and journalists, etc. – are themes that have come up repeatedly in the context of HPSR. I wonder if more can be done to share lessons across contexts, for example at the annual Dissemination and Implementation Symposium sponsored by AcademyHealth.

3) How ‘global health’ is perceived by the HSR field  – AcademyHealth has a small, but growing, focus on global health, and one can find posters, presentations and discussions on health services research outside the U.S. scattered throughout the conference. However, what’s more striking is how difficult it can be for stakeholders in the U.S. to draw lessons from other countries (even though international exchange has shaped the development of medicine in the U.S. for over two centuries). Few panels seemed to bring in lessons from other regions of the world, including other high-income countries with market-based systems. One reason for this might be that as the U.S. health care system becomes more byzantine, researchers, policymakers and practitioners gravitate to lessons from within the country – for example, at the state- and local-level – rather than countries where the political and socio-economic scenario is perceived to be too different to allow for meaningful learning and exchange. I would argue that such learning is in fact essential for benchmarking (not in the ranking sense of the word), and for introducing and testing new ideas and approaches.

I was also intrigued by how global health is perceived amongst HSR stakeholders. In one panel, someone noted that ‘We need to bring a global health mindset to U.S. domestic care  – lower cost, higher quality’. This comment says several things to me. One, due to the dominant role of technologically motivated global health organizations (including those based in Seattle), health in LMICs is increasingly being seen as a space for innovation – for trying out interventions that are in theory low cost and perceived to be more effective. However, there continues to be sharp criticism of these types of approaches. Two, introducing such a ‘mindset’ into the U.S. is a step in the right direction – but one wonders if this is a continuation of the band-aid approach discussed earlier. Finally, the panelist seemed to acknowledge that despite the major role of U.S. stakeholders in global health, HSR as a collective is still a bit isolated from international engagement and learning. As progressives (à la Bernie Sanders) embrace ‘Medicare for All’, it feels as though the U.S. will eventually reengage with Universal Health Coverage, and that could possibly an avenue for further exchange (we will however likely have to wait for the next Democratic administration for this to happen).

Definitions and understandings of the term ‘global health’ are evolving, and there is now a recognition that we need to see high-, medium- and low-income countries in relation to one another, and to also incorporate a focus on inequities within high-income countries, rather than the traditional dichotomy between high-income countries and low- and middle-income countries. It will be interesting to see how the Annual Research Meeting at AcademyHealth begins to reflect these changes in the coming years, and to see how the HSR community situates itself in relation to HPSR and other health stakeholders around the world.

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