Beverly Ho, Raoul Bermejo & Isidore Sieleunou (EVs 2010, 2012)
In this blog post, Emerging Voices report on the UHC & Research session at the GIZ Forum on UHC in Bonn (26-27 August), in which they played a prominent role. The session contained an introductory keynote and a lively fishbowl session.
Earlier this week, at the GIZ forum in Bonn, Germany on UHC, ‘Universal Health Coverage: From Promise to Practice ‘ (hashtag: #uhcforum ) (26-27 August), we took part in a session on UHC and research. The session kicked off the second day of the conference. As Emerging Voices from the Philippines & Cameroon, we had been invited by professor Wim Van Damme (ITM), who gave an introductory keynote speech, to offer country and regional illustrations (as well as challenges) of some of his key messages. Former EV Walaiporn Patcharanarumol from Thailand did much the same, and some of our Heidelberg colleagues (also former EVs, Mohammed Shafiu and Gilbert Abiiro) participated as initiators of the following fishbowl session and rapporteurs. Manuela de Allegri (University of Heidelberg) facilitated the fishbowl.
It was lovely to get together again, 9 months after the Beijing Health Systems Research symposium, and attend a wonderful workshop on UHC in the process. Wim’s keynote was organized around three themes (see below). The fishbowl turned out to be a lively affair: at some points 8 chairs (instead of the usual 5) were filled, so participants were more than eager to get their voices heard. They generally reacted well to the country examples provided by us in the keynote. For the ones who couldn’t make it to the session in Bonn, we summarize some key messages from the keynote and fishbowl below.
Wim first dwelled on UHC in context, zooming in on global framing of UHC (as described in different publications and by different institutions), as well as national adaptation and implementation. His overall message, that UHC is both a technical and political process, resonated with the audience, and was also heard in other sessions, for example in a keynote by a former Ugandan Vice President, Dr. Speciosa Wandira-Kazibe.
Why does UHC appear on the national agenda in many LMICs? In a number of countries, we can see that UHC easily fits into a populist rhetoric or good governance platform – as is the case in the Philippines (see the Aquino Health Agenda on UHC). In Thailand, the Universal Coverage scheme was continued even with (plenty of) changes in leadership (a total of 6 prime ministers, 10 health ministers, 6 permanent secretaries for the MOPH, in just 10 years).
UHC also seems to be a good way to respond to increasing demands for better social services, as can be observed in the Arab Spring, and the recent unrest in Brazil. China is another case in point – people who attended the Beijing Health Systems Research Symposium last year will remember how the Chinese Minister of Health explicitly linked UHC to social stability. In particular, UHC also seems to be about balancing the health care situation of the rural with the urban one in China. In India, expanding care to the poor is the main objective.
All agreed that context is indeed important … but what about the context is so important then? Is it the income level of countries, or fiscal and decision space? Burden of disease? Culture? Last but not least, context is no doubt also about issues of power and politics, how decisions are made, and about the numerous actors who play a role as stakeholders in this political and technocratic ‘game’.
Also, if context is so important, is everything contextual then? In other words, is there still room for lessons learning and is it still possible to transfer lessons to other settings? Joe Kutzin, for one, thinks so. He emphasized in a recent WHO Bulletin viewpoint that NOT anything goes on the road towards UHC. We happen to agree.
In a second part of the keynote, the focus was on the diversity of actors in UHC and the importance of brokering. ‘Brokers’ act as bridges between researchers (producers of knowledge) and policy makers (consumers), although of course the picture is more complicated than that. Brokering is about identifying and synthesizing what type of evidence to use, when, and for whom. Good brokers can be individuals (many of us know some examples of effective brokers…), institutions (for example the Finance Ministry played this role in the recent Sin Tax Reform in the Philippines), Communities of Practice (increasingly effective knowledge broker platforms in Sub-Saharan Africa, as elaborated by one of us), social movements and civil society (as is the case for UHC in Thailand), international organizations, and we no doubt forget some. In many countries though, different actors wear different hats and researchers may be brokers themselves.
An important stakeholder (if not the most important one) often left out from the high-level policy dialogue is the general population; even more overlooked are marginalized populations in most countries. Can researchers play a role in making sure that their needs and (crucial) voices are heard and that their perception of UHC gets incorporated into the UHC definition & dialogue ? The answer will follow post-2015.
The third part of the keynote tried to offer some suggestions to make research more relevant and timely for efforts to achieve UHC. This again triggered a very lively debate, perhaps because the latest World Health report also has the same aim.
Among other suggestions, Wim emphasized the importance of a comprehensive, systems view if health research is to have added value. All participants agreed on the need for evidence-informed policy but also recognized that research time frames are very different from policy time frames. Often, the picture is one of ‘policy-based evidence’ rather than ‘evidence-informed policy’, as policy makers need to make decisions ASAP in many cases, for example when they see a narrow window of opportunity. This reality was really emphasized throughout the fishbowl. Sadly, evidence is also often used to defend a policy once the decision has already been taken.
Researchers, if they are given the opportunity to work in ministries of Health, shouldn’t be afraid to become ‘co-opted’ by the system, it was also pointed out. This can help them become better researchers over time, as they will understand how the decision making system functions. As with accompanying/embedded research, though, it is vital to remain critical. Easier said than done, perhaps.
A key challenge for researchers seems to be finding the right balance between ‘fast science’ (relevant, reactive to the needs of policy makers, but with the obvious risk that the scientific community might have some doubts about this ‘research’) and ‘slow science’ (more rigorous, complying with the demands of the academic environment, but perhaps less responsive and relevant in the short term). So researchers need to learn to work in two different ways – a fast, reactive way, and a slower, more rigorous way. Whether the same people can be used for the two purposes, is another question, though.
As for the role of development partners, they should streamline their efforts and support countries instead of fragmenting them. For some reason, participants still have to emphasize this at this sort of Forum, unfortunately, many years after the Paris Declaration. Participants also stressed that a key role for development partners is to build capacities, and supporting institutions is perhaps even more important than supporting individuals (as even talented individuals need an enabling place to let them flourish, and more importantly stay as civil servants or work for the benefit of their country).
Researchers should also take into account that UHC is a long term goal, and that dialogue between the many stakeholders is crucial to move things forward in all countries. In this respect, a key question is, for example, how to use research in order to balance social cohesion and solidarity with the pluralistic health system reality in many countries.
A final remark struck a chord too, especially among the researchers in the room: a participant pointed out that researchers sometimes shy away from more important/relevant research questions, as they seem harder to research – read: they are potentially more controversial. Why is that nobody is studying the impact of ‘disappearing diamonds in Africa’ on development efforts, for example? Why does hardly anybody study taxation of sugar drinks, junk food and fast food chains? Is it because these are more powerful industries and many researchers don’t really want to offend these influential forces?
Overall, we had the feeling the session and its structure were well appreciated – with lots of room for discussion around themes and issues covered in an introductory keynote. Most other sessions at the conference were so packed with presentations that there was very little opportunity for discussion. Good we did our share in ‘brokering’ knowledge! Having said that, the overall feeling we had in Bonn was one of very interesting sessions. We’re happy to take all this new knowledge back home, where we will try to put it to good use.