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Some random thoughts on the Cape Town symposium

By Kristof Decoster
on October 7, 2014

Two and a half weeks Cape Town aren’t yet out of my (I’m afraid not so complex) system, but I thought I’d try to put together some thoughts on the third HSR Symposium anyway. Not very systematically, but rather in a random way, the way  Donald Sutherland (not the ‘Hunger games’ actor) started his pitch on Vancouver, the venue for the 4th HSR symposium, at the closing plenary, mentioning he didn’t know much about health systems until a month ago. That was great to hear, and it got even better. Right after that, we saw a merry ad on Vancouver as a convention Mecca, including golf courts and Gucci. It’s fair to say we all got in the mood for yet another people-centred health systems research event. But apparently the ad hadn’t been scrutinized before, so no big deal as far as I am concerned.

My not very coherent view will be mainly based on the plenaries and a couple of sessions I attended. It’s thus as fragmentary and idiosyncratic as anybody else’s take on the symposium  – especially so as I had to juggle all this with so called ‘strategic use of social media’ (for example, via the EV twitter account, which I managed together with Ildiko Bokros, our ITM social media steward). As we encourage Emerging Voices to use social media, I feel kind of a moral duty to blog about the symposium myself, hence this blog with some of my impressions.  For a more in-depth overview of the content of some of the plenaries, as well as the Cape Town statement, see the symposium website.

We all agreed the organization of this symposium was flawless. For example, there was – unlike in Beijing – rather ok coffee available. More than necessary after 10 days of the EV programme – I was surviving on double espressos by the time the symposium started.

Sara Bennett summarized the symposium in an apt way at the closing plenary, saying among other things that this symposium had been more political (than anticipated by me, for example, but also compared with the Beijing symposium (for less than mysterious reasons)), had focused more on health service delivery than Beijing (which spent quite some time on health financing, I remember), and had shown an increasing and encouraging openness to methodological diversity.

A key question was raised by EV 2010 Seye Abimbola at our EV “wrap-up” (or roll-on) day: whether we should continue to have a Health Systems Research symposium, or instead a Health Systems Symposium – the latter one would make it easier to draw in activists, the private sector, stock traders, business people, decision makers, Fox News journalists (as moderators), … you name it. Not unlike HIV conferences.

At a micro-level, the same goes for the Emerging Voices. Given their focus on research (more than previous EV batches, perhaps), it seems obvious HS Global now takes the lead to train the future generations of health systems researchers. But at the same time, we’d also want some more hardened activists among them (perhaps using different selection criteria?) or at least confront them with some seasoned activists during the EV Face to Face Program. In the country of Mark Heywood, we somehow overlooked this opportunity. (Next time the event is organized in Beijing, we’ll surely ask a few youngsters from Hongkong.)

In general, it’s great to see activists take on researchers and vice versa, as happened for example in the Health Inc session on social exclusion I attended. They can learn from each other (researchers for example in terms of the strategies used by activists), and unlike health systems researchers, activists don’t do “fluffy”. But as my colleague Gorik Ooms likes to say, first we’ll have to identify health systems activists… Second, once we have found them, of course, activists shouldn’t face financial hurdles to attend events like these. Rob Yates, the most famous UHC activist on earth, wasn’t there (at least, I think so, but in his case we suspect no financial barriers). On the bright side, even Bill Gates and Bill Clinton like to talk about health systems nowadays, so health systems activists might be found in rather unlikely quarters.

What about decision makers, then? An Indian EV told me his state’s health minister is actually very interested in complexity, but can’t do much with this lens in his daily job.

As for journalists, it is rather sad that in the midst of a horrific crisis like the Ebola crisis (which was on everybody’s minds in Cape Town), at a time when even random US columnists discuss weak health systems in West-Africa, I hardly came across any mainstream newspaper article (outside SA) on this symposium, dedicated to health systems research. That can only imply we have our work cut out to reach out to the world.

I thoroughly enjoyed the first two plenaries, not only because moderator Sisonke Msimang did a marvelous job, getting under the skin of her ‘male only’ panel, and the audience enjoyed some of her more feminist remarks, but also because Thandika Mkandawire, professor of African Development (London school of Economics) although perhaps not a gifted public speaker, didn’t quite mince words. Karl Polanyi (and the need for a Fourth Transformation, whereby our social policies would again go beyond just ‘correcting market failure’), our “choiceless democracies”, pro-poor policies which turn out what you expect them to be, the influence of Washington and to a lesser extent Brussels on budgets in LICs, … the professor knocked me out. And I wasn’t the only one. Thandika would probably also favour the proposal by a symposium participant to call the ‘market place’ something else, a ‘solidarity bazaar’ or so, in the future.

Martin McKee did the same in the plenary the day after, and was as arrogant, witty and to the point as you would expect him to be, talking about hospitals increasingly being seen as mere ‘investment vehicles’, or that we should learn from the financial sector (“They never waste a crisis, (for example) to dismantle the European welfare system”). Martin is a social movement of his own, has the imposing body required for the task, and understands the power of satire. Unfortunately, there aren’t many like him – health systems researchers can be a nice (or is it sweet?) bunch, perhaps too sweet for this ugly world… ( In case you wonder, I’m very much part of this too  sweet species, even if I don’t qualify as a health systems researcher  – just ask my pharmacist).

But all in all, there was definitely enough politics for me at this symposium (both in the first two plenaries, and in the final one – excellently moderated by Tim Evans (the man doesn’t just excel in dancing). Even Sara Bennet’s slip of the tongue at the closing plenary – “methodologies not well respected (euh, reflected) in journals” – can be considered as politics, if you want – and the way she corrected herself was comforting for many among us. Overall, we think Sara will be a great chair of the new Board (just like former chair Irene Agyepong, a warm lady very much “embodying” people-centred health systems research ).

In other sessions, we also came across politics, like in the session on the political economy of people-centred health systems (with  a great presentation by Jesse Bump, a historian (!), among others). And of course, Anne Muendi, our eloquent EV representative at the closing plenary, didn’t shy away from politics. She discussed the need for a health systems social movement, for example.

The theme of people-centred care worked quite well, even if some sessions had to push a bit to make their research fit into the theme – I even heard a colleague of mine saying that ‘impact’ is people centred, in a way. Not that he’s (it’s a “he”, of course) necessarily wrong, but you get the point.

Like many others, I feel that health systems research has carved out a niche for itself now, unlike at Montreux, when thousand flowers were still in the air. The downside is perhaps, that all these health systems research methodologies & paradigms have delved deeper and deeper by now. There is a danger of health systems ‘silos’ now, and it’s not clear what the answer should be. Definitely not one of the lowest common denominator, in order to find some common ground between them. But as health systems strengthening is still rising on the global agenda (with 2015 as a key year), there’s a risk of a ‘divided we stand’ HSR  field.

It was great to see “Twitter faces” and email contacts finally getting a real face  (be it Robert Marten, Mandip Aujla, Mariam Bhacker, Thomas Schwarz or many others). I also have to applaud HS Global for the work they’ve done, it’s nice to see the HS Global Thematic groups are really taking off now (as well as reaching out to the EVs). Many important special issues, flagship and other reports were launched during rather well attended breakfast sessions (even on Friday morning, after the ball on Thursday evening – we are a disciplined community!). It was a great pity some people weren’t able to attend, with Richard Horton being the most prominent one (but also some CGD people, and of course, Margaret Chan – we only saw a short video message of her at the formal opening, due to the Ebola emergency).

There wasn’t much on climate change at this event, and its link with a sustainable lifestyle and a sound work-life balance. It’s somewhat odd to see “300 mails a day” researchers address the threat of burn outs among health providers, failing to acknowledge that in their own lives, commitments can be overwhelming too. In this respect, the health systems research community is still a bit schizophrenic, we don’t seem to understand or at least acknowledge that not all of us have the batteries of Lucy Gilson or David Peters. Having said that, the interest for mental health at this symposium was underwhelming, almost as underwhelming as Deborah Birx’s speech on the opening day. It felt a lot like the speech she gave last year at Icasa. Speaking of schizophrenia, we stayed ourselves at Hotel Verde, a very ‘green capitalist’ hotel indeed. Four stars, – you could even earn “Verdinos” (a green currency), at the hotel, via jogging or other energy-generating activities. Quite a change from last year’s EV stay at the UWC campus, I have to say…

The symposium was perhaps not “universal” enough – we all face universal challenges, these days, it’s no longer a North-South or even South-North-South conversation. Martin McKee, talking about the impact of austerity in Europe, was one of the exceptions – I would have liked much more talk about for example the battle of fastfood workers in the US or other 99 vs 1  (or 0.01 %) debates. Piketty might be everywhere these  days, but he was still not present enough at this symposium, at least not when it comes to the rising inequities in the North.

Emerging Voices were struck by the enormous inequality and inequity in South-Africa – according to Prashanth NS, Cape Town’s situation is even worse than Mumbai. And I won’t forget David Saunders’ message to us, ‘the barbed wire is coming towards you in the North, as well, if we fail to reverse the current trend towards more inequity.’ I made a walk by myself from the Waterfront to the Southern Sun Cape Hotel, passing by barbed wire and Oscar Pistorius-style neighbourhoods, and it didn’t feel good. I wouldn’t be able to live in this country – although I understand that people who were born here want to stay on and make it a better place. There’s just too big a gap and too much resentment and aggression. Having lived in China for about 4 years, I’d surely prefer an authoritarian country like China – even if has many drawbacks as well.

Which brings me to another thing that struck me in these two weeks: quite some EVs seem to favour an authoritarian (but “stable”) government, at least at a certain phase in the development of their countries (rather than the so called democracies many have ). Not all of them think this way, true, but still a considerable amount.  That is something to reflect on, as we like to talk about human rights-based approaches, post-2015.

As is well known, the HSR community also loves to talk about knowledge translation, knowledge brokerage, …  (or K*, as Valéry Ridde calls it). We are definitely stars in this Olympic discipline!

Some of us, including many EVs, want to start a health systems social movement. Sort of a global version of the civil society movement in the famous Thai “triangle that moves the mountain” metaphor. However, if you can’t tweet during plenaries, it’s rather difficult to get a social movement going. But apparently, the bottleneck there was at the city infrastructure level. In Vancouver we won’t have this excuse.

I enjoyed the ‘can do’ mentality of many people at the symposium, a welcome antidote to the sometimes depressing headlines I go through on a daily basis while scanning for the IHP newsletter. And the delicate dance moves of Tim Evans and many others at the ball were just stunning (this batch of Emerging Voices were not just blossoming researchers, they were also Emerging Dancers!). Conversely, I didn’t quite enjoy the Ebola nightmares I had during one of the nights in hotel Verde.

We hope the Emerging Voices, and many others, will now take the fight for health systems to their countries (as well as to the global level). We also hope they’ll start questioning the corporate media structure, which very much influences our ideas on ‘what is politically feasible’, and that some will even become global health “hacktivists” & Wikileaks-collaborators. Some of the stories we heard about some global health stakeholders in the North that appear as corrupt as some actors in the South, were disheartening. So maybe HS Global should also start a global health Wikileaks.

We should be proud of our HSR jargon, whether it’s “UHC” or “social determinants” – some of these words might feel too sanitized, but hell, macro-economists get away with their jargon all the time in newspapers, and nobody seems to care. Alternatively, we could start talking about Ebola as the global version of the ‘Great Stink” (as Gorik & Raoul Bermejo did).

Let’s end with a couple of pertinent remarks by Gita Sen, “we don’t want People Centred care (PC) to become Political Correctness” and Martin McKee – “let’s learn from the financial sector: they never waste a crisis”.

And oh yeah, let’s make sure next time ‘The People’ are there.

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