By Suzanne Kiwanuka (Makerere University School of Public Health, Department of Health Policy Planning and Management)


“The loftier the building, the deeper must the foundation be laid.”

Thomas Kempis


Innovation, sustainability, systems thinking, governance, Roman architecture, software and knowledge management were the key words at the Global Health Architecture Conference in Rotterdam earlier this week. And while I walked in (straight from the airport) with major concerns of not being able to stay awake for the sessions, my pathetic concerns were quickly and effectively dispelled. Within minutes I realized that there was no other place I would rather be than here, at the Lanteren theatre, Rotterdam, listening to the passionate provocative pitches of global health gurus. Wow! What a day!


It all kicked off with a refreshing musical prelude (an intriguing quartet with a blend of African drums and a Western flute). Just the recipe to kick the creative juices of the attendees into high gear (a note to conference organizers out there….this is innovation at its best…pick a leaf!).  Then the “conversation” started, with the speakers having been invited by their host Godelieve van Heteren to “be themselves”, to be “provocative” and of course to  “think outside the box”.


Dr Agyepong began the conversation passionately imploring us to reconsider the current efforts of sustainability in global health systems which she vividly painted as “fishing for the hungry as opposed to teaching the hungry to fish”. You couldn’t have missed her point even if you wanted to. She said “you may be able to estimate how many fish you can catch per minute and how many fish you are able to give per person per year or indeed document how many lives have been saved by the fish but in the end you are doing the fishing and the hungry are left hopelessly dependent and probably worse off than before thereby threatening the future” (Okay, maybe not her exact words, but you get the idea). Indeed empowered people are at the centre of health systems sustainability!


Prof. Stefan Peterson argued that introducing new health systems hardware (medical supplies, laboratories, policies) can only work with adequate software (values, ideas, power, accountability). We simply cannot keep adding new hardware solutions to solve software deficiencies. An example was given of the futility and potential danger of introducing new vaccines of a failing immunization system! How poignant!


Dr Breda highlighted the importance of maintaining a few evidence-based interventions in order to “ensure the biggest bang for our buck” particularly in the case of using physical activity and diet to control most of the life threatening non communicable diseases. He lauded the role that stakeholders can play in promoting good health practices but warned that this role should not be allowed to disintegrate into a situation where “foxes are put among the chickens” (food manufacturers allowed to play a key role in devising food policies?). The data he presented on the dismal status of exclusive breastfeeding in some European countries was particularly disturbing.


After a music and dancing interlude, Dr Soucat reminded us that although increased development assistance has not resulted in better health outcomes for recipient countries, the tide is changing. The last decade has seen rapid economic growth in many African countries and soon these countries will be taking greater responsibility for funding their health needs. She warned however that these economic resources should wisely be invested in improving infrastructure as well as human capital for optimum returns. Therefore a shift from quick fix, magic bullet health system solutions to well thought through long term solutions which offer value for money, social safety nets, accountability and contribute to economic transformation is a must.


Professor Meessen talked of “philanthrocapitalists” and “philanthrocracy”, two terms anyone interested in global health should acquaint themselves with. He said that the emerging trend of the economically driven “ultrarich” funding health could be a double-edged sword. While there is a risk that it might be more difficult in this landscape to make a case for health/poverty and inequality as a global responsibility, could there be a possibility that perhaps the entrepreneurship approach in the public health sector might indeed work better than the charity approach? (Provocation at its best!)


Dr Fritsche reiterated that systemic problems in health systems cannot be solved using “tip of the iceberg” simple solutions. There is a need for a paradigm shift involving making use of data with good governance and accountability for better health outcomes. The importance of empowering public sector health workers to think and act like entrepreneurs promoting a brand of quality services instead of providers of charity was again pitched.


Dr Loewenson posed the most provocative question of the day. Is sustainability a mere maintenance of status quo or do we sometimes need to disrupt to sustain? She reasoned: why not disrupt and rebuild innovatively? After all, the current architecture and efforts are not sustainable for the kind of change needed to achieve the benefits we seek for our diverse societies? She posited that we need to reclaim our transformative power in global health by employing a three-pronged approach: by reclaiming preventive public health, reclaiming public health authority and accountability and reclaiming society by improving collaborations between and across key players. It is a question of shifting our mindsets and awakening to the challenges and opportunities with creative innovation in global health.


In line with shifting mindsets Dr Kabir proposed some 3Q thinking to knowledge translation. Research can inform policy domains, stimulate discourse, reframe debates and promote reflection and learning among other things. Sharing knowledge is power.


The afternoon round table sessions offered their own pickings of stimulating debate. One of the discussions focused on how Africa is indeed on the brink of major economic growth if not already engulfed in it and what implications and opportunities this holds for African youth and how educating them prepares them to benefit from this economic growth.


From my own perspective as a researcher and public health specialist from Africa, I came away convinced more than ever before that the current health system is not in any way built to solve current problems and incremental solutions have proved to be mostly ineffective. Thinking outside the box? Perhaps it’s time to throw away this pesky box? The views of the people delivering services should be of interest since these people are central to the success of health interventions. The need to disrupt and rebuild a modern state in health systems requires forging smart alliances instead of isolated niches. It requires radical innovation as opposed to incremental innovation. It requires putting a “laser focus” on the health system dynamics emerging as a result of interventions. “Entrepreneurship” for the public health sector is not a four-letter word! Building the health system might not happen fast enough but there are signs that a major shift is certainly underway. With emerging southern leadership in public health, young vibrant researchers testing one system innovation, one step at a time!


Never doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has.”

Margaret Mead

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