TOMORROW'S HEALTH SYSTEMS: IN PHASE WITH REALITY?

by KATE HAWKINS, STEPS Centre Member

Members of the Future Health Systems Research Programme Consortium are actively engaging in discussions at the Geneva Health Forum. The conference began in dramatic fashion with an assessment of the changing landscape within which health systems are being forged. The opening plenary session featured a range of speakers who aimed to situate health in a dynamic world. Changes in epidemiology, shifts in political and economic organisation, a strong and growing for profit and not for profit sector and a burgeoning role for information technology all featured.

Andy Haines of London School of Hygiene and Tropical Medicine highlighted changes in epidemiology and demographics which are likely to shape future investment and interventions. As the percentage of people over 65 years old grows in developing countries their health needs will take a growing proportion of health financing. Alongside this chronic disease and diseases of affluence will demand a larger slice of the pie.

Richard Samans from the World Economic Forum talked to the economic drivers of health and their political implications – what he called a ‘cocktail of stimulants’. Emerging economies such as India and China will alter global health governance – demanding leveller playing fields for decision making. States will struggle with how they relate to a private sector and civil society actors who are organising across borders on health issues of interest. Increasing deregulation of health care is, in some settings, reducing the role of the state and reducing trade barriers between countries. He also felt that increased access to information technology would shape the role of health care providers and those who access services.

Information technology was an issue taken up by Kendall Ho (University of British Columbia). He presented on ‘eHealth’ – urging health care workers to respond to the ways in which the Internet, cell phones and other digital technologies have changed the way that we do business. In particular he felt that these technologies could help to improve patient/doctor relationships, increase decision co-creation, streamline inter disciplinary collaboration and speed up judgements on evidence based health interventions.

With this in mind we will continue to use the STEPS blog to report on emerging debates at the conference.

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CHALLENGES FOR THE FUTURE OF PRIMARY HEALTH CARE

by GERRY BLOOM & HILARY STANDING, STEPS Centre members

It is thirty years since the Alma Ata Declaration outlined an international consensus on the need to provide universal access to primary health care (PHC). During the ensuing years some countries established well-organised government health services in which PHC played an important role. Many others were less successful. The lead up to our session at the Geneva Health Forum on future health systems provides a moment to reflect on some of the new challenges for PHC.

National governments and the international community are renewing their efforts to expand access to PHC and they have committed a lot of money for this purpose. But there have been many major changes in these last three decades that pose big challenges for the future of PHC. The drafters of the Alma Ata Declaration drew largely on the experiences of those post-revolutionary and post-colonial regimes, which were rapidly overcoming a lack of health facilities, health workers and drugs.

Whilst some remote areas still lack health services many settings have both trained and untrained people, providing health care and selling drugs. The boundary between public and private sectors is blurred and government health workers frequently ask for informal payments or see patients privately. Many of these activities occur outside an organised, regulated framework of health care provision. Potential users are much more likely to live near a health facility or some kind of provider than 30 years ago, but now they face major challenges in paying for care and finding competent providers and effective and appropriate drugs.

PHC was designed to deal with prevention/health promotion and with infectious diseases associated with poverty, poor sanitation and certain insect vectors. Although these illnesses persist, there is growing pressure on health systems to address other problems. One dramatic change has been the transformation of HIV infection into a chronic and progressive disease for which people can claim entitlement to treatment. People are also affected by other chronic conditions, associated with ageing and “lifestyle” changes. This raises difficult questions about which treatments are appropriate, who should pay for them and how health systems should be organised to help people manage long-term conditions.

Concern is growing about the potential threat of epidemics of new diseases or organisms resistant to the available drugs. Recent examples are SARS, multi-drug resistant tuberculosis and a possible influenza pandemic. Government responses rely heavily on convincing people to report suspicious outbreaks and cooperate with public health measures they may perceive to be against their short-term interest. This requires high levels of trust between the population and their health system.

More actors are involved in health systems than thirty years ago, including a variety of private providers of health-related goods and services, national and international NGOs, citizen advocacy groups and political parties (where competitive electoral politics have been introduced). Governments are seeking new ways to influence health systems with their powers to allocate money, enact and enforce laws and publish information. This sometimes involves new types of partnership for service delivery and regulation.

Finally, there have been dramatic developments of new technologies for diagnosis and treatment of disease, which influence the design of health systems. In addition, the rapid changes in information and communication technologies are having a big impact. Providers and users of health services increasingly have access to the mass media, mobile telephones and the internet. They carry health information produced by governments, professions, citizen advocacy groups and private companies. In contrast to 30 years ago, when health professionals were the major source of expert knowledge, people have a variety of sources from which to find information.

The anniversary of the Alma Ata Declaration provides a good opportunity to reaffirm national and international commitments to expand access to PHC. But, it is important to understand the changed context when formulating strategies for achieving this. Many innovations have emerged that involve quite different roles for governments, markets, civil society and individuals than the drafters of the Alma Ata Declaration envisaged. We need to find ways to involve all actors in an intensive process of innovation and learning if the latest statements of good intentions are to be translated into major improvements for poor people.


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ONGOING DISCUSSIONS AT COP-MOP 4

by ADRIAN ELY, STEPS Centre member

I am in Bonn this week for meetings around the Cartagena Protocol on Biosafety, the United Nations’ agreement to regulate the trans-boundary movement of living (genetically) modified organisms. From sensitive political discussions over liability and redress to questions over how to incorporate socio-economic considerations into decision-making, the working procedures of the protocol are still very much “under construction” 8 years after its text was first agreed.


The fourth Conference of the Parties, serving as the Meeting of the Parties (COP-MOP 4) to the Cartagena Protocol on Biosafety is running until 16th May. On Tuesday 14th I took part in a side event at the Conference at the invitation of Dr Sachin Chaturvedi of RIS (Research and Information Systems for Developing Countries, based in New Delhi) looking specifically at Article 26 of the protocol. Initially introduced following efforts from the Africa group, the first part of this article allows countries to take into account socio-economic considerations in their decisions over allowing imports of living modified organisms. Although there are a growing number of (primarily economic) analyses demonstrating the benefits and costs to farmers of various transgenic crops, several countries are unclear about how best to employ them in decision-making, and there is no official mechanism for the sharing of such information (as mandated in Article 26.2).

Dr Chaturvedi introduced an RIS report that outlined the Indian experience in this regard and highlighted the need for developing countries to take the initiative in proposing systems for research and information exchange. This presentation was put into an international context by my own talk, in which I gave an overview of US, EU and Chinese regulatory frameworks, and a presentation by Moustapha Kamal of ICTSD, who introduced work that his colleagues had conducted on key trade and sustainability issues around biotechnology. International trade issues were also noted by the session chair, John Komen of the Programme for Biosafety Systems at IFPRI, who highlighted the need for countries to take into account other international obligations (e.g. under the WTO) but stressed that, with only one relevant dispute to draw upon in terms of case law, the situation here was still evolving.

Meanwhile, delegates have been involved in discussions around Article 27, attempting to define “rules and procedures in the field of liability and redress for damage resulting from transboundary movements of living modified organisms”. The process, initially scheduled to last for four years, still seems far from resolution. When I left the discussions in the Liszt Room yesterday, parties were split over a proposal for a legally binding instrument that had been put forward by the large negotiating block known as the "like-minded group". This conflict potentially jeopardises one of the most potent components of the protocol, and has become one of those most discussed in the corridors.
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COMPLEXITY, SIMPLIFICATION AND RESILIENCE

By ADRIAN SMITH, STEPS Centre member

Complexity pervaded debate at the Resilience Alliance conference last month. In one way or another, participants tried to get to grips with the sheer complexities of the socio-ecological systems that concerned them, and puzzled over the kinds of adaptive governance that might ensure these systems provided resilient livelihoods to the various human and non-human members dependent upon those systems. At best, these complexities were bewildering, requiring new kinds of resilience thinking. At worst, an appreciation of the complex connections and interdependencies in the world induced paralysis. Where to start; what to do?

It was only at the very end of the conference that I realised that, in actual fact, the last three days had not been about complexity. Rather, we had been grappling with simplification. We were all trying to simplify in ways that were sensitive to the uncertainties and surprises associated with complex realities.

Apart from discussion of ‘stylised models’, this process of simplification was largely implicit. But perhaps we might advance further if we considered resilience to be about temporary simplifications, sensitive to experience, and open to revision when the inadequacy of those simplifications is subsequently revealed? The critical question is how do we simplify wisely? Whose perspectives are considered in those simplifications; which ones bracketed out; and which ones simply forgotten? Which simplifications subsequently work, and for whom, and for how long before complex reality undermines them?

Buzz Holling’s adaptive cycle is one such simplification. It was the emblem for the conference. A lop-sided figure of eight, used to organise complexity into processes of growth, maturity, decay, and rejuvenation (and out of which is generated a new figure of eight development). And it is a persuasive simplification. Many participants applied it to the natural world, to social development, and to combinations of the two. To many participants, it promises a better simplification than the equilibrial approaches that dominated the governance of complex socio-techno-environmental systems in the last century. But it is still a simplification for all that; as were the agent-based models inspired by Buzz’s adaptation of the infinity symbol, and the equally inspired, contextualised case studies. My own presentations were simplifications of complex processes of social and technological change.

Of course, simplification is dangerous territory. Acknowledging the necessity for simplification risks blunting the critical edge that rightly problematises certain forms of simplifying that currently enjoy institutional privileges, such as narrow and static forms of engineering cost benefit analysis. Contexts and perspectives essential to Sustainability may continue to be deleted out of the equation on pragmatic grounds. How do we avoid simplification legitimising unSustainable expediencies?

Hopefully, the advantage with complexity thinking is that it forces some humility and prevents us from being simplistic. Complex realities force reflexivity into the necessary simplifications we undertake in order to consciously and deliberately act in the world. Institutions simplify, as do policy narratives, as do scientific reports. So as we continue to explore pathways to Sustainability through complex systems, the challenge is to be aware of the simplifications we have to make, and to make them wisely. In my view, this is the basis for resilience. Read more

SALZBURG: WHAT NEXT?

By JULIA DAY, STEPS Centre member

The conference defined some critical points of leverage, where delegates and their organisations can achieve a sustainable impact on priorities.The essential ingredients of a Green Revolution in Africa, definition of priorities, desirable outcomes and the points at which value-added initiatives can have an impact have taken shape here in Salzburg. Importantly, some of the competing priorities and unresolved issues and knowledge gaps have been identified.

Strategic alliances among many stakeholders and initiatives have been strengthened and the desire to work together, in partnership, to add value to the future of agriculture in Africa, was repeated time and again.

The momentum continues tomorrow (Saturday 3 May) at the follow-on seminar - ‘A Green Revolution in Africa: What Framework for Success?’ where delegates will revise and refine the work set in motion over the past three days. Then a series of sub-regional meetings in Africa will ground the debate firmly on the continent’s soil.

For news updates on the conference, seminar, sub-regional meetings and all the work around this theme going forward see: http://www.future-agricultures.org/
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SALZBURG DAY 3: FARMERS IN THE DRIVING SEAT FOR AFRICA'S GREEN REVOLUTION

By JULIA DAY, STEPS Centre member

Farmers and their needs must be placed at epicentre of a uniquely African Green Revolution, conference delegates from across the board agreed on the final day in Salzburg.Photo: Louis Michel, European Commissioner for Development and Humanitarian Aid addresses the conference / Julia Day

Much of the discussion today, running across thematic groups, focused on building alliances of farmers and their organisations at national, regional and continental levels. This was seen as absolutely key for insuring that priorities are set and funds are spent in a way that meets the needs of farmers. The direction of initiatives must all move toward that goal.

However there is an urgent requirement for substantial investment in building capacity. Delegates believe the skills that need developing go beyond the technical to ‘soft’ skills. An equitable Green Revolution requires an increased ability to facilitate inclusive approaches, organisational skills, business management skills, policy, advocacy and impact monitoring skills, delegates said. These seem to be lacking at the moment and are a potential focus for follow up efforts.

One particular proposal for directing research innovation and technology development towards farmers needs was the establishment of an African-wide, farmer-owned and farmer-driven fund. Delegates went as far as to propose a name: the African Agriculture Technology and Innovation Fund (AATIF). This would be an endowment fund supported by government, private sector, philanthropists and farmers to ensure demand-driven research with farmers in the driving seat.

Another key suggestion was that any funds or funding mechanisms to support the Green Revolution need to have independent accountability systems, operating with farmers at the centre. These would hold the delivery of key development actors to account, as well as offering a monitoring, evaluation and impact assessment function. Read more

SALZBURG DAY 3: A REPRESENTATIVE REVOLUTION

By JULIA DAY, STEPS Centre member

To ensure an African Green Revolution is equitable there is a pressing need to ensure that wide representation is assured, delegates said.It is paramount that inclusive processes going forward are attendant to gender and ethnicity issues. It should also be ensured, in particular, that smallholders and those farmers who are consumers, and not just producers, of food have a voice in farmer organisations. Photo: Kofi Annan takes part in the press conference / Julia Day

At present, the interests of smallholders, women and other more marginalised groups, including pastoralists and livestock groups are not well represented by farmer groups or service providers – private or public.

In addition to assessing the achievement sof this Green Revolution in quantative terms, delegates recommended that qualitative targets are also set to define targets in relation to empowerment, voice and inclusion, taking into account a rights-based approach. Read more