By Michael Loevinsohn, STEPS Centre member
You know you’re a discipline or a significant sub-discipline when you can organize and find funding for a global symposium. Twelve hundred participants from umpteen countries also testify to the self-awareness that marks a field. And the Symposium’s theme is fittingly ambitious: Science to Accelerate Universal Health Coverage.
Charlie Chaplin is in town but can’t make it to the Symposium. He’s buried just down the road. But I wonder what his Little Tramp, bowler-hatted and down-at-heels, would make of it. Would he be considered part of the System? Am I? My interest is in the determinants of disease in the turbulent social, economic and natural environment, and what that understanding can contribute, especially to prevention.
A huge variety of material is presented in 110 plenary and concurrent sessions related to the mobilization of knowledge, capacity and financing and the translation of research into policy and action. Access to care and immunization is the focus of most of the discussion. Not much is said about the determinants of disease – which lie outside the health system “proper” – and how they’re understood and responded to. I don’t hear much reference to how other sectors approach complexity and rampant change.
But there are some welcome resonances. A session on neglected tropical diseases – lymphatic filariasis, onchocerciasis and others, which often occur together – describes how vertical control programs for each visit the same village, sometimes with the same village health worker who distributes drugs, sometimes the same one, to households – but at different times. Integration would make a lot of sense. It becomes clear, however, that the obstacles are not at the local level but mostly at the program level: integration means one program director and four former directors.
Control of one of the neglected diseases, blinding trachoma, includes educating people to wash their face. The message is repeated in Sahelian villages where people have to walk 3 km for a bucket of water – and washing their face is not the first thing they’re going to do with it. There are echoes of condom promotion for HIV – even in places where everyone knows power relations prevent many women from using them.
Irene Agyepong talks as a participant observer on the evolution of health insurance in Ghana. A number of small scale experiments were run by different institutions trying various approaches. A larger scale experiment was also implemented but ran into serious problems. Yet when the political winds build and a broader program can no longer be avoided, it is the failed experiment that most influences its design. Close to hand and ready to go, its proponents say, “we can correct mistakes later”. Irene points to rent-seeking behaviour but also says there are no easily-labelled saints or demons. It’s the reality of evolution.
René Loewenson from Zimbabwe talks about national health systems as knowledge systems. She points to the vastly under-exploited sources of evidence that exist within countries. Researchers’ attentions shift away from them, swayed by external priorities and funding. The consistency of focus that is essential to build trust with national audiences is lost. It’s not just a problem for health systems.