Putting the power and politics into health systems research

Heath Systems Global have opened a call for suggestions on the theme of the next Symposium, which will be held in Liverpool, UK in 2018. This is a great opportunity to help shape dialogue and debate on global health over the coming years and to capitalise on the learning that has been shared at the conference since its inception in 2010.

As RinGs is a project that works primarily on gender and ethics, we were delighted that the 2016 Health Systems Global symposia included a stream on these issues. This meant that gender and ethics were more prominent in 2016 than in previous years. We were also excited by the focus on intersectionality and believe that this is an area that should not be discarded as we move forwards.

We at RinGs believe that a framing that focuses on power, politics, equity, and rights enables key issues to come to the fore and highlights the social, commercial and political systems and norms which prevent good health for all. This is particularly pertinent at the Health Systems Global Symposium in 2018, which is also the 40th anniversary of the Alma Ata Declaration, and a moment in global health where the erosion of rights and evidence-based decision making is gaining normalcy. Unlike in the Alma Ata Declaration, we expect to see gender and other intersecting forms of inequity highlighted throughout the agenda.

In our estimation, there are several areas where critical reflection is necessary and where we need to begin to try to address persistent and challenging questions. The areas are: Rights and justice; Inequity, gender and intersectionality; Participation and voice; Evidence and information; Money and control; and Solidarity and resistance.  In the discussion below, we identify the most challenging questions which we hope will be addressed in the Health Systems Global Symposium in 2018, as the answers will help promote good health for all.

Rights and justice

The right to health is the foundation of health systems strengthening and is firmly recognized within the Alma Ata Declaration. Key issues and questions include:

• How has the right to health been actualised in policy, practice, and legal challenge?
• How does the right to health interact with other rights (e.g. those of women and children)?
• How have social justice movements shaped health system development?
• How has the denial of rights been enacted through the health system (e.g. HIV criminalisation, trans-exclusionary services, use of frontline health staff for border control purposes)?
• How is the current social and political climate, both globally and nationally, affecting the right to health? For example, how do policies such as the Global Gag Rule affect the right to health of marginalized groups?

Inequity, gender, and intersectionality

Intersecting forms of inequity shape the way that health systems are conceptualised, which issues rise to prominence, and the importance and investment afforded to different challenges. How social stratifiers, such as gender, race, age, class, (dis)ability and/or sexuality etc., intersect creates different experiences of privilege and disadvantage, leading to vastly different health needs, experiences, and outcomes. Key issues and questions include:

• Social determinants of health continue to drive inequities in health and well-being. How are health systems responding to these up-stream issues?
• Risk factors driving both communicable and non-communicable diseases are disproportionately experienced by the poorest. How can approaches to prevention respond to intersectionality without stigmatisation?
• How do inequities play out in community and household power dynamics and how does this influence care seeking, service access, priority setting etc.?
• How can intersectionality be conceptualized within health systems research, both quantitatively and qualitatively?
• How far does the data used to inform health resource decisions capture the needs of the poorest and shed light on inequities?
• Universal health coverage cannot be attained without considering who gets access to what services and why. What services are available within essential care packages, what is covered by insurance schemes and other financing mechanisms, and whose issues are left out?
• How can we ensure that health systems ‘leave no one behind’, or even better, ‘put the last first’?
• How can we ensure that health systems are reaching the most vulnerable in times of conflict and crisis?
• Who benefits from new technologies and commodities and how can the health systems encourage – and ensure – equitable and ethical delivery of these public goods?
• What are the ways in which we can interrogate our own institutions and systems to address racism, sexism, xenophobia, ableism, ageism, etc.?
• How can we decolonise heath systems research and health systems strengthening?

Participation and voice

Participation is a key component of people-centered health systems. If we are going to achieve people-centered health systems, a range of diverse people need a voice and active role in health systems and health systems strengthening. Key issues and questions include:

• How can community inclusion, involvement, and leadership shape health system strengthening?
• What methodologies have broadened our understandings of people-centred health systems?
• Do authoritarian regimes and political elites, at all levels, silence voice and/or prevent critique?  How do they do this and what mechanisms can be used to successfully challenge these kinds of actors?
• Who is bridging the interface between diverse communities and health system decision makers and practitioners?
• Who speaks for whom and what are the politics of knowledge?
• Amplification or appropriation – how can we communicate health systems research in an ethical manner?
• How can we better support our colleagues at the frontlines of health systems – for example the workers and their unions?

Evidence and information

Knowledge is power, and information and evidence are not politically neutral building blocks of the health system. Key issues and questions include:

• In an era where censorship, post-truths, and alternative facts increasingly pose a threat to science, how have health systems’ researchers responded?
• How can we recognise and respond to the elitism within our systems of knowledge generation (in methods, communication styles and outputs etc.)?
• What is the cutting edge evidence base on health systems emerging from communities and their representatives, such as community health workers?
• What works and where are we going wrong in our international partnerships and collaborations for evidence generation?
• Why is there so little support for qualitative research in the world of global health and what can we do about this?
• How can we better ensure that knowledge is communicated beyond the ‘ivory tower’ to the communities, practitioners, and policy makers who need it for decision making?

Money and control

Those who hold the purse strings can determine how money is spent and who benefits from investments. Key issues and questions include:

• What are the potential avenues and political roadblocks to ensure financing for Universal Health Coverage?
• What role if there for public-private partnerships in ensuring that patients are protected and practice is ethical?
• How do donor practices shape the field of health systems research and the decisions that are made in practice?

Solidarity and resistance

Key issues and questions include:

• Can an approach to health systems strengthening build on ‘planetary health’ thinking to prompt new ways of tackling old problems?
• Many settings are experiencing conflict, economic and environmental instability, and migrant crises leading to the mass movements of people. How can we can ensure that health systems work across borders?
• How can work on health systems resist and challenge fascism and authoritarianism?
• Cross sectoral support for health is vital. How can we smash siloes to support health system development?
• The long term nature of health system strengthening requires that those working in this area sustain energy and support hope – what strategies are there to connect health system workers, researchers, activists, developers, community representatives and campaigners  over the longer term?

The goal of health systems research is to improve the performance of health systems – a focus on power, politics, equity, and rights asks “who for”? Issues of power and politics crosscut all components of the health system affecting who has access to the health system, experiences within the health system, as well as the institutions and processes that make up health systems research. The Fifth Global Symposium on Health Systems Research provides an opportunity for health systems researchers to come together and critically examine the ways in which power and politics shapes  research and research institutions, and explore how we as a community can ensure that good health is attainable for everyone.