By Werner Soors (ITM)
Let me start with three truisms: “Universal health coverage cannot be achieved without evidence from research”, “research into health services and systems gets relatively little support and tends to be narrowly focused”, and “there is a particular need to close the gap between existing knowledge and action”. No health policy or health systems researcher would disagree with any of these quotes from the World Health Report 2013: Research for Universal Health Coverage. But what kind of evidence is most needed, how can a systems perspective be brought to the fore, and how will the research advocated for really improve health for all? In my opinion, the present World Health Report falls short in answering these questions, in the first place because it is narrowly focused itself.
The core of the report (pages 31-89 of 146) consists of the feel-good message that “research for health is on the rise worldwide”, followed by 12 examples “of studies that show how research can address some of the major questions about achieving universal health coverage”. The promise is made that these examples “rang(e) from the prevention and control of specific diseases to the functioning of health systems”. At first sight, the promise is held: six case studies are directly related to disease control and six are more related to health systems. But the report articulates none of these from within a systemic perspective that is beyond ‘programmatic advantages’ and takes into account the interactions of actors and interventions, which is a little surprising to say the least.
Wasn’t it WHO that four years ago published Systems thinking for health systems strengthening, rightly recognizing health systems as complex adaptive systems and promoting systems thinking as “an essential approach for strengthening health systems”? Or just about a year ago, Health policy and systems research – a methodological reader, 474 pages of advice to improve the evidence base for health policy making and health systems strengthening? And is systems thinking not “key for policy and decision makers dealing with universal health coverage”, as – among others – MMI argues?
A second missed opportunity is the very fragmentary coverage of social determinants as part and parcel of research for universal health coverage. Social determinants are mentioned sporadically, yet not explicitly in the examples, and equity is treated only superficially. Yes, “indicators should be disaggregated”, but when will we start unpacking processes that reproduce inequity? Will categorical data be enough to “measure and understand the problem (of health inequities) and assess the impact of action”, as argued by WHO and for Developing an evidence base for political action? Will this be sufficient for an equity-focused research agenda in support of truly universal health coverage?
Equally under-addressed is research on Health-in-All policies, in spite of being a promising way forward to tackle health inequities and to arrive at fair or at least proportionate universalism. The World Health Report 2013 recognizes the need “to develop research that can enhance understanding of how intersectoral policies can improve health”, but only as “an additional and complementary challenge” and by adding that “because many more questions can be asked than answered, it is vital to set priorities”.
These three missed opportunities are interrelated. What unites them is a lack of people centeredness. At best, uptake of the report might lead to more of the same. There is however a risk that worse will happen. Research for Universal Health Coverage makes a strong call for “finding local answers to local questions”. Admittedly, coverage gaps and health inequities have local manifestations, worthy of research. But doesn’t the combination of a more-disease-than-people-centred approach and local priority setting encompass a peril: chances are that universal health coverage then gets stuck in selective health coverage, just like comprehensive primary healthcare watered down to selective primary healthcare three decades ago? We all know what that meant. The world deserves better, and we should feel obliged to research deeper and broader.