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Health Systems Research Symposium 2018 (HSR2018):
A brief summary of the latest global health systems debates as prioritized by the academic/research community
Background information
Health Systems Global (HSG) is the only existing network worldwide that brings together researchers, decision-makers and implementers to address issues related to health systems through research and knowledge translation. Before the organization was legally founded, in October 2012, a first symposium of the network was gathered in Montreux (Switzerland), in November 2010. That event, attended by over a thousand participants from all over the world (including the author of this report, partially) elaborated a set of initial recommendations for the network’s global agenda, and kick started the biennial symposium cycle (Health system research – HSR – symposium), hosted by Beijing in 2012, Cape Town in 2014, Vancouver in 2016 and Liverpool in 2018. The 2020 edition of this global event will be taking place in Dubai and resulting from the collaborative efforts of various Middle-East partners. The main theme for the 2020 symposium will be decided through a poll system followed by a board decision throughout 2019.
Each symposium addressed one main underlying concern of health systems; the 2018’s edition was dedicated to inclusive health systems and the SDG era, with a strong focus on engagement with the private sector.
Since 2010, HSG has remained committed to pursuing the following goals/engaging in the following broad areas of work:
Foster the creation of new knowledge
Support knowledge translation focusing on bridging knowledge creation with practical application
Foster research on the application of new knowledge in real world settings.
Nevertheless, overtime the group grew and as new research/knowledge needs arose by the growing complexity of the contexts, where interventions on health systems are most needed, semi-independent sub-working groups of the HSG were created, and in-depth thematic agendas pursued. Currently HSG counts with the following 9 sub-working groups (thematic working groups – TWG), and the list is growing (as new interest groups emerge):
1) Ethics of Health Systems Research
2) Health Systems in Fragile and Conflict Affected States (the biggest group. Born after 2012 symposium in Beijing)
3) Medicines in Health Systems
4) Social science approaches for research and engagement in health policy & systems
5) Supporting and Strengthening the Role of Community Health Workers in Health System Development
6) Teaching and Learning Health Policy and Systems Research
7) The Private Sector in Health (the smallest and newest group. Born is 2014 after Cape Town symposium)
8) Translating Evidence Into Action
9) Quality in Universal Health and Health Care
Highlights from HSR2018 and ways forward: a shift toward increasingly pluralistic and inclusive health systems
The 2018 edition of the HSR symposium welcomed to Liverpool (UK) 2368 delegates from 146 countries. The full coverage of the event is available online, as well as the official statement resulting from the plenary discussions: (http://healthsystemsresearch.org/hsr2018/symposium-coverage/). HSR2018 focused on four subthemes addressing inclusive health systems in the SDG era, that is: i) multiple determinants of health and their interaction, ii) community health systems, iii) systemic approach to health and engagement with the private sector, iv) inclusion of marginalized voices. The main conclusions across subthemes converged in insisting on the importance to increase multi-sectoral research and practical work on health. Besides, a shift in perspective from health as a public good belonging to the exclusive prerogative of State actors (with the Ministry of Health as often sole entry point and responsible body) to one of health as a public good that needs to be responsibly managed by a constellation of actors according to pluralistic/complex systems mechanisms was promoted.
Practical experiences as well as results from action research across the world highlighted currently existing flaws in the way health for all is globally addressed, which are contributing to hindering the chances of reaching health for all and meeting SDG3 by 2030 in a number of contexts. Among the main challenges yet to overcome, the following were stressed:
Sustainability concept needs to be applied to systems, not programs, in order for investments to translate into meaningful impact on health outcomes. Numerous existing funding mechanisms for health (mainly external, but at times also national) are currently designed to fund programs instead of focusing on reaching clients/patients. Accountability for results should transition out of programs and address coverage at large.
In numerous contexts (particularly fragile ones) formal authorities tend to not represent the vulnerable population and, therefore, might represent a suboptimal target, if singlehandedly involved in partnerships for the improvement of health systems and outcomes.
Decision-making power that shapes the health sector may (or increasingly does) belong to non-health actors, who are often not included in global and national prioritization or otherwise debates
Urban poor (slums) are more vulnerable, that rural communities. Urbanization needs to be understood as a shock for health systems and addressed as such
Health systems worldwide don't take into account human mobility in their resilience strategies. In general, social issues including health and healthcare are rarely treated through cross-border collaborations and regional dynamics.
In post conflict contexts external influence is still largely overshadowing good policy dialogue among national/local stakeholders. External financial arrangements are more often than not distorting internal (context-based) dynamics.
Disproportionate out-of-pocket costs largely generated by doctors dividends (corruption starts in medical schools) and shareholding.
Critically ill patients are often referred to the public sector. There is an increasing risk of the latter becoming the “dumping site” of health systems bearing all the risks at a time, when public finances and structures are no longer able to cope alone with healthcare.
HSS never thinks of strengthening networks of health services in the periphery to absorb flow coming from the center, when the latter is weakened or disabled by large shocks.
Research seems to be contributing a lot to the current statu quo on who leads what agenda, since it seems to fail to generate discussions about the really issues at stake
Research community assumes too often that lessons learned and scientific evidence should be naturally used by policy-makers, because it makes sense… Politicians talking together are the missing link between research and its uptake in practice.
Numerous traditional stakeholders still believe that engaging with the private sector is “anti-equity” and, thereby, hinder the progress on public-private partnerships
Some concrete practical recommendations for more effectively addressing health for all were presented and debated:
The international/global community should aim at minimizing the burden imposed on countries for the use of tools for assessment and guidance (only responding to the needs of donors and implementing agencies)
Mobilization of funds from large informal economy. The latter includes prominent but rather invisible (in terms of statistics) health care providers across Africa. Rarely considered by governments in health systems resilience strategies, although they contribute to the resilience of the health sector, since they tend to flourish whenever and wherever the public system is weak
Drug sellers are usually the first point of contact for people seeking health care services in a growing number of contexts (not only in recognized fragile settings with distressed formal health systems). Self-medication is the preferred health-seeking strategy for populations unable to afford healthcare. These actors need to be involved in UHC policies
Regulatory measures need to be balanced against costs and needs. In some setting harm-reduction strategies are more efficient than interventionist measures
Capitalize on inbuilt stabilizers; there is no single health system in the world completely resilient to any type of shocks (instead of creating resilience one should look at what makes a broken system resilient despite the circumstances and capitalize on those strengths).Shifting the response upstream (from only looking at poverty and resource constraints to seeing in developing countries contexts of opportunities and mobilization)
Intersectionality approach in research (looks at roles within health systems, at what powers and dynamics govern health) and exploration of counter-intuitive solutions (VS seeking validation through "evidence" of donors sought interests)
Theory of complexity applied to fragile contexts states that predictability of results of actions and replicability of those actions (across contexts is impossible. It is important to move away from the replicability, upscaling, modeling approaches
Low density of nurses/midwives and corruptions are the variable of health systems that needs to be looked into to reduce the effect of war on maternal mortality
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