Maryam Bigdeli  (Alliance for Health Policy and Systems Research)    Maryam Bigdeli

(…but views expressed here are my own!)

Many readers of this now popular and much expected blog participated to the gigantic Second Global HSR Symposium in Beijing -including the noisy and refreshing yet very serious and professional Emerging Voices- so you know that we spent a lot of time there talking about UHC. Many of us are already preparing for the upcoming Third Symposium in Cape Town, where we will talk about the “Science and practice of people-centered health systems”. In preparing your abstracts for the organized sessions and the individual submissions, I am sure many of you, just like me, have to constantly be reminded that this upcoming conference is NOT about UHC AGAIN. And you, just like me, go back to your 300-words text and wonder how you can manage to insert as much “people” or “centered” (or preferably both) as you can in there without altering the word count.

Well, I have good news for you. Since I have been in Singapore last week, I feel much more empowered to do so. Indeed, the 2013 version of the Health Systems in Asia conference took place last week at Lee Kuan Yew School of Public Policy, National University of Singapore (NUS). The conference was about “Equity, governance and social impact”: exactly those ingredients that are absolutely necessary to spice-up a (so far rather) technocratic debate around UHC and transform it into a people-centered one!  The title and content, as well as speakers and participants in this Health Systems Research Symposium 2.5 built an essential and much needed bridge over continents, to connect Beijing and Cape Town.

To start with, Tan Chorh Chuan, President of NUS, did what all excellent opening speakers should do: he set the tone by reminding us of the complexity of health systems, the “entangled web of health” that Srinath Reddy later illustrated with a striking example, a “simplified” view of the obesity system map, as below (I let you imagine the reaction of the audience to this hairy slide…and some people tell me I am overusing arrows!)


picture arrows

Ichiro Kawachi provided us with a brilliant yet smooth and simple introduction to social determinants of health: telling the story of the ER physician who is diving in the river every day to save people crying for help, and who has no time to figure out “who the hell is upstream pushing them all in”.

After Reddy and Kawachi had finished with us, those who thought they had registered for a random regional conference already knew they were mistaken. Given the pouring rain, we all decided to stick around and we were baffled, as the rest of the program delivered to the highest standards. Sub-plenary and parallel sessions did not shy away from difficult governance issues: pluralistic health systems and the role of informal providers in Asia, the importance of health literacy, accountability to consumers and citizens, the multiple faces of social exclusion including but not limited to ageing, and even medicines!

Yes, not unlike some other people in global health, I had a hidden agenda when I boarded that plane to Singapore. My (not so hidden) agenda is that sooner or later, I will talk about medicines, and nobody can stop me. On Twitter, I am by now the ‘access to medicines’ equivalent of Rob ‘UHC’ Yates, or so I was told.

Medicines account for up to 60% of out-of-pocket expenditures in LMICs, the majority of initial health seeking in lower income countries is towards drug shops and pharmacies. Prof. Reddy said that NCDs were “the climate change of public health”. Well if this is the case, we are not prepared for it any better than we were prepared for Taiphoon Haiyan. Because many countries do not consider NCD medicines in the benefit packages covered by health financing schemes: the meeting in Singapore demonstrated many examples from Indonesia, Cambodia and elsewhere. In  the subplenary on “Access to medicines in Asia: developing equitable and sustainable systems for better health care”, we were able to touch upon a few pharmaceutical policy issues in Cambodia and China and we also started a discussion on broadening the concept of UHC to include equity, thanks to Calvin Ho. But if you refer to the collection of tweets from the conference that specifically mention medicines issues here, here and here, you will promptly see that medicines were present everywhere, in many presentations and discussions. That is because medicines are everywhere in the health system, public or private, formal or informal, they are the heart of service delivery, whether we decide to acknowledge or ignore it. And we better acknowledge it as some people have already predicted that if we ignore it, we may ruin all our hopes in UHC (see Jonathan Quick’s pertinent question, Medicines and UHC: Golden Ring or Trojan Horse?)

But the cherry on the cake was the closing plenary. In most conferences, everybody is tired when the time comes to say goodbye. So many presentations, so many people to meet, catch-up with, reconnect, all conversations revolving around concepts, theories, methods, results and future collaborations. Many delegates just expect closing plenaries to be a succession of acknowledgements and thank you’ s and some conventional take home messages. But again, this HSR symposium 2.5 managed to surprise us. Tim Evans had prepared a festive, energetic and unconventional closing session: Pecha Kucha presentations not lasting more than 6’40’’, followed by comments from the panel limited to 5’ sharp, to finally open for almost one hour to questions and comments from the floor and from live tweets up on the screen. Wow! That felt almost like fireworks on New Year’s Eve! Santa Claus sent us back home with some ideas to distil in our abstracts for Cape Town. Increased coverage in UHC schemes has not always led to decreased out-of-pocket and catastrophic expenditures. We know already that coverage is not enough, but we need to seriously think of what else needs to be there to make it really work for people: benefit package, provider payment mechanisms, readiness of health services, coverage of NCDs – or even better, a new paradigm of service delivery for NCDs!, consideration of the inherent pluralism of health services and the health workforce in LMICs, and of course… M.E.D.I.C.I.N.E.S!

As Dina Balabanova summarized in her final tweet under #healthsysasia: “Health systems researchers need to contribute to real life solutions -our take away challenge!”

I am looking forward to HSR symposium 3.5 or better say Health Systems in Asia 2015! In the meantime, more tweets from Health Systems in Asia 2013 here and a nice blogpost by Jeff Knezovich @Furure Health Systems.

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One Response to Health Systems Research from Beijing to Cape Town via Singapore

  1. jakdown says:

    and might be the best preconditions for a rising lower- or middle-income country to achieve universal health care in the future.

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