I’m just back from the second global symposium on health systems research in Beijing, still recovering from jet lag, obviously, but happy to have left the Chinese capital just before the arrival of the snow. ‘Inclusion and innovation towards Universal Health Coverage’ was the overall theme of the conference. Below I’ll reflect a bit on the symposium, from my point of view, mainly focusing on the messages and buzzwords in plenaries, which I mostly attended. In other words, this is not a comprehensive but instead a very subjective account of the Symposium. Other participants might have a totally different view, based on the parallel sessions they attended.
Let’s kick off with the organization by Peking university health science center, which was flawless, with the exception of the coffee provided though, the fuel on which all of us thrive. Contrary to the lousy coffee on offer during the breaks (which seemed to contain more and more water as the symposium proceeded), acoustics gradually improved over the four days. Luckily there was also a (pricey) coffee lounge with divine coffee; however, the place was slightly less efficient than one would have expected in this country. So was internet at the venue – “worse than in Nepal”, one of the Emerging Voices joked. But overall the hosts did a great job, including the magnificent symposium dinner, martial arts & Beijing opera performance show and party on Friday evening at the China national convention center. The human signal posts on the way to get to the venue were an excellent idea for example – although the ‘Chinese volunteers’ were lucky it wasn’t raining yet.
The symposium itself then. The opening plenary session on Wednesday, ‘the road to UHC: lessons learnt in BRICS countries’, was a sleepy affair, until we all woke up with the witty and black humoured presentation of a Russian professor, Kiril Danishevsky. He gave a very unambiguous account of the situation in his country over the last decades, chuckling throughout his powerpoint. The key message I will remember from his presentation was: once you introduce the market, old solutions don’t work anymore (this is a message the PBF community should probably keep in mind, one is tempted to say). In the afternoon, in the female ‘Emerging Voices’ satellite session, I had somewhat foolishly taken part in a fishbowl discussion on the many barriers female researchers face around the world, and not just in terms of the career/family trade off. Tricky discussion for the men among us, I have to say, although it’s obviously true that female researchers face huge barriers, from a ‘glass ceiling’ in the West to an almost ‘Chinese wall’ in many other countries.
Xu Jin, a Chinese emerging voice from Peking university, was the master of ceremony of the real opening plenary session on Thursday – he did a marvelous job, although one could have thought he introduced speakers at the 18th Party congress, scheduled to begin in a few days. The Chinese Minister of Health gave an encouraging account of the reforms underway in his country, but thoroughly messed up the time schedule for the rest of the day (at least he showed up on time, something decision makers around the world don’t usually do). Then, probably inspired by the setting in Beijing, Rockefeller Foundation President Judith Rodin turned on the propaganda button, showcasing all the wonderful things the Rockefeller Foundation did and does around the world. Not sure whether taking credit for the barefoot doctors in China was the most tactical move, though. She could probably learn a thing or two from Lincoln Chen, who always seems to find the right words, regardless of the setting. So did the Emerging Voices (Lungiswa Nkonki, Mabel Carabali and Beverly Ho), shortly before Chen, reminding the HSR community of the importance of the new generation of researchers residing in the Global South. The three Emerging Voices in the final plenary session on Saturday would make a similar case, stressing the importance of mentorship of young health systems researchers. They deservedly got a noisy “vuvuzela” response from the audience.
I missed the lunch break session on the new WHO strategy on Health Policy and systems research, where a case was made for more embedded research in decision making, as I was attending another lunch session at the same time, ‘health in the post-2015 development agenda- the global consultation process’. But just like journalists didn’t fancy ‘embedded journalism’ a while ago, one wonders whether health systems researchers will all endorse embedded research, for similar reasons, no matter how much the authors emphasize the importance of maintaining independence. I’ll come back on the post-MDG discussion, as there was also a plenary MDG+ session on the last day of the symposium.
I manned the ITM marketplace booth in the afternoon, so I only got to another session in the early evening, ‘Addressing critical questions in the UHC debate’, a session chaired by David de Ferranti, in a by then nearly deserted Convention hall 1. CGD fellow Victoria Fan talked about the third global health transition (towards UHC), after the demographic and epidemiological one.
On Friday, the morning plenary session on state of the art methods pleased most participants, including myself. Excellent presentations were given by a number of people, but the flashy story by Babak Pourbohloul on ‘viewing health systems through a complex network lens’ topped them all. At some point, when he showed how the informal leaders and followers of the Indignados movement in Spain could be tracked, Big Brother seemed upon us. Over dinner, though, he mentioned to some of us that by the time scientists get hold of this technology, the ones at the top already possess it for a long time. If there were any PSB people in the room, they probably would have nodded – at least if they understood some English. In the same session, Kabir Sheikh also made an eloquent case for more qualitative research.
The ‘Development aid for health’ parallel session that followed was a great session, with excellent and sometimes very didactic presentations – Joseph Dieleman’s (IHME) was a case in point, but he wasn’t the only one. Having said that, one wonders whether ‘development aid for health’ is not something of the past, with the new geopolitical constellation, the recent discourse of the need to go ‘beyond aid’, and the huge amount of financing needed for climate change adaptation and mitigation, which might crowd out aid for health.
Taking care of my stomach, I missed the first part of the second ‘health in the post-2015 development agenda’ lunch session – a presentation on UHC goals, indicators and measuring, but I showed up in time for the discussion afterwards. In a reaction, Anders Nordström, ambassador for global health from the Swedish ministry of Foreign Affairs, who just wrote a blunt Lancet Comment, made a case for measuring ‘healthy lives’. He would also make a few valid points (pro and contra an overall UHC goal after 2015) in the Saturday plenary session on post-MDGs. The one argument against UHC as an overall goal I will remember from him, is the risk that it will be interpreted by many as a goal about the health sector only, whereas perhaps we need now, more than ever, ‘health in all policies’.
I decided to go for some “celebrity-watching” then and went to a session on ‘How can research hit the mark for health policy and systems decision making’ featuring the likes of Anne Mills, Richard Horton and Ariel Pablo-Mendez. Joseph Kasonde, Minister of Health of Zambia, one of the few decision makers present in Beijing, and hence heavily solicited, was also part of the panel. It was a remarkable session, for a number of reasons. Horton had to respond to a cheeky Anne Mills, when she mentioned David Roodman’s blog post on the (flawed?) peer review process by the Lancet of social sciences articles. Horton was phlegmatic in his answer, pointing out that the Lancet tries everything to bring two communities together, while stressing that development economists tend to write ‘virtually unreadable’ papers. Anne Mills also showcased the – what People’s Health Movement member David Legge called in an earlier session – rather ‘unsophisticated’ holistic understanding of the multiple and interlinked challenges the world faces among many global health scholars, when she said she couldn’t see much wrong with the measuring of scientific ‘impact’ in the UK, measured also in terms of ‘its contribution in terms of economic growth’.
Lancet editor Richard Horton was no less than impressive, when he made the case for a “remoralisation” of science. As compared to some centuries ago, at the time of the Enlightenment, science has lost its moral purpose, he maintained. He would make the same case the day after, equally forcefully, in one of the final plenary sessions. Instead of just worrying about getting their next paper published, scientists shouldn’t be shy of politics and activism. They instead need to hold politicians accountable, and engage in activism, as the world’s challenges are enormous, both in terms of scope and in terms of the multisectoral, cooperative and holistic answers needed. Coming from the Lancet editor in chief, this “manifesto” struck a chord. Horton admitted that health systems researchers perform better in this respect than many other scientists. Yet, reflecting on the four days, I’d add that in spite of all the talk of ‘power’ and need for more knowledge translation, the first reflex of many health systems researchers is still to produce the data, and then hand them over to civil society to do the dirty job of speaking truth to power and advocacy. The Beijing statement, read aloud by Tim Evans during the closing plenary, is in line with this scientific reflex. It’s a reflex not shared by everybody, though: in some sessions, the need for ‘transformative’ researchers was eloquently raised.
On the final day of the Symposium, the new ‘Health Systems Global’ society was launched, with the announcement of the newly elected board. The session was led by a hyperkinetic Lucy Gilson – poor Chinese volunteers had to run all over the place to get the microphone for questions from the public in place, fired on by an impatient Lucy. The new Board looks quite balanced (although there’s nobody from Latin America yet, and Martin McKee raised the question of the representativeness of the Western board members – they don’t study health systems in Europe/America but in LMICs, he argued). Obviously, the mission and activities of the Board will have to be finetuned in the coming months. Not too many members voted (over 300?), which raises some doubts about the future of health systems researchers as activists (if many of them can’t even be bothered to vote for their own society). An Indian lady raised a pertinent question about the name of the society – Health Systems Global – the name reminded her too much of a multinational corporation’s name. That’s not what we want to project, she said. She has a point.
The afternoon plenary session on Saturday was titled ‘Post-2015 development goals: framing the issues, prioritizing health and using evidence’, and chaired by Richard Horton. I found the session somewhat disappointing, in spite of the thundering opening quote by Horton, a quote from Vladimir Lenin on the state of capitalism, a century ago, but still ringing true now (and perhaps even more so). The highlight of the session was what I would call the ‘Horton Manifesto for the remoralisation of science’ (see above), but it was a highlight also because it so obviously contrasted with the rather disappointing panel discussion before, where being ‘diplomatic’ seemed the watchword. The panel member from the US especially excelled in this art, perhaps because there’s an election coming soon.
A few very important questions were raised after the panel discussion, though, for example on climate change – which was virtually absent as an issue throughout the symposium – by a lady from the London School, and the need to address ‘the causes of the causes’, a pertinent question eloquently phrased by David Sanders – linking the question back to Lenin (not John Lennon, he insisted, although he too imagined a different world). Rapacious and globalized financial capitalism is the problem, and Big Food one of the key enemies in the drive towards a healthy world society. But both got a very disappointing (and deflecting) answer, respectively from the guy from the US administration (who mumbled something about the need for climate adaptation), and Thomas Palu (a Bruce Willis-lookalike from the World Bank), who pretended to answer Sanders’ question but did anything but.
In spite of all the talk of ‘complex adaptive systems’ and the need for more ‘systems thinking’ by the health systems research community at the symposium, you can’t escape the conclusion that in the key discussion on the future of our world, the People’s Health Movement seems to start from a more accurate analysis of the current global state of affairs than the health systems research establishment. Which is worrying, to say the least, as the movement is far less influential and has less opportunity to frequent the powers that be. The solutions they tend to offer are perhaps less convincing, but if you don’t get the analysis right, how good can your solution be?
Health Systems researchers and the public health community do have an impact on power and politicians in their countries, at national level and below, as many encouraging stories on UHC can testify, but in the global conversation about a more just and healthy society, we are nowhere. As yet, we have very little influence on the direction of the world in the coming decades, in spite of all the talk of the need to have health included in the post-MDG framework. Probably that’s part of the reason why global health governance was hardly an issue here, at least in the plenaries. Health will no doubt be in the post-MDG framework, if such a global agreement ever materializes, but the worldwide trend towards hyper-individualism, hedonism, consumerism, and other capitalist excesses seems unstoppable. We talk about the enormous NCD challenge facing the world, and the need to do something about it urgently, but when you go to Chinese department stores and shopping malls, the ‘BMW lifestyle’, Gucci & Vuitton shops and Kentucky Fried Chicken branches, although catering to different audiences, shout their message in our faces and point to the ugly reality. In addition to a global fund for infectious diseases, or even a global fund for health, the world probably also needs a well-resourced Global Fund for promoting a more holistic way of living and thinking, which would emphasize different values and a more sustainable lifestyle, at all levels of society. I didn’t hear the Rockefeller Foundation about this, and neither did Tim Evans mention it in the Beijing statement. It’s perhaps no coincidence that countries that seem to go backwards instead of making progress towards UHC (like some countries in Europe), with the exception of some post-Soviet Union countries, were virtually absent from the conversation. The same was true for the dirty UHC struggle in the US, where progress is anything but guaranteed.
Obviously, given the theme of the conference, UHC and state of the art methods were the key focus of the second HSR symposium. The event was first and foremost about boosting the self-confidence of the HSR community as a rigorous scientific discipline. UHC was all over the place, and rightly so. Yet, you wonder why UHC has to be framed so much as a story of optimism, rather than realism. Countries don’t just make progress towards UHC (although many do). Many countries backslide, not just because of decisions taken nationally or national economic constraints, but also because of regional and global influences and decisions. A third symposium (to be held in Vancouver or Cape Town, apparently) should pay more attention to these. A good way to start, would be by bringing in more journalists, civil society representatives and decision makers.
Last but not least, I would encourage all of us to keep in mind another important sentence of Richard Horton: far too often the global health community bases its policy recommendations on the current political situation, unable to think of what the political environment could be in ten, fifteen years from now. China is an obvious example, and the one he was perhaps referring to, but the same is true elsewhere. That’s why I expect more from the coming ‘Rage of the precariat’ (Guy Standing) around the world, prompted by the series of worsening crises of globalized financial capitalism, and the policy response (sometimes in anticipation of rising social instability) from decision makers, to arrive at a world characterized by more sustainable development and global justice, than from post-MDG & SDG discussions and frameworks, or from better knowledge translation & research embedded in decision making, for that matter… At the very least, the scientific community should be ready to offer their policy recommendations, when rage is boiling and a window of opportunity opens. But Horton would argue that’s not enough.
Having said that, the taxi driver who took us back to the airport was very positive about the Chinese communist leadership, in spite of the huge catastrophic expenditure he had himself faced when he had to cough up money for his own illness (cancer), 200.000 Renminbi. The communist party has done a great job, he said, in the past few decades. When he grew up in the country side, there was little to eat. Now his belly was full, just like the bellies of many other Chinese people.
He liked doctors, he said – but the Chinese ones like money a bit too much, he laughed, making some gestures which nobody could misunderstand. My taxi partner, David Hercot – a medical doctor, unlike me – grinned in response…