key: cord-0689530-7zbb9uiv
authors: Bennett, Sara; Jardali, Fadi El
title: Reimagining health systems: reflections from the 6th Global Symposium on Health Systems research
date: 2021-11-12
journal: Health Policy Plan
DOI: 10.1093/heapol/czab102
sha: d14eafd81e7efd8daf7f1595b0833d89100f7e55
doc_id: 689530
cord_uid: 7zbb9uiv

nan

In a year like no other in living memory, Health Systems Global (HSG) held an unprecedented and entirely virtual biennial symposium. It was fitting therefore that our theme was 'Reimagining Health Systems for better health and social justice'. At the time of writing the original call for abstracts, we focused on the challenges to achieving Universal Health Coverage (UHC) and the broader health-related Sustainable Development Goals (SDGs) and, in particular, the tectonic shifts currently taking place in our globally connected world-from climate change to massive population migration and refugee crises and political polarizationthat we saw as potentially undermining the political will to achieve UHC as well as the feasibility of doing so. In crafting the call for abstracts, we argued that 'Health systems, as they stand today, are not equipped to address increasingly complex and interconnected health and development challenges of the twenty-first century'. Of course, since drafting this, the COVID-19 pandemic has further underscored the point: radical change is required in our health systems to protect people across the world from current and new health threats and, in particular, the poor and most vulnerable who have suffered most during the pandemic.

In unpacking this broad and ambitious theme, we identified three sub-themes that guided the agenda for the Symposium, namely:

• Engaging political forces that impact health systems-this theme cast a light on how power, politics and corruption work within health systems and sought to identify strategies that might strengthen accountability and promote stronger stewardship. • Engaging social, economic and environmental forceshere, we sought contributions that analysed the broader social, economic and environmental forces that shape both access to health services and the way health systems across the world operate. In particular, we welcomed submissions that explored the connections between health systems and the major demographic and environmental shifts of our time, namely urbanization, migration and climate change.

while it is easy to retreat to doom-mongering given current challenges, there are also remarkable innovations unfolding in health systems across the world. Much of this innovation is driven by new technologies spurred by artificial intelligence, big data or digital innovations, which, in turn, raises critical questions about the potential and risks of these interventions.

In line with HSG's efforts to continue to build the field of Health Policy and Systems Research (HPSR), a stream within the Symposium addressed methodological issues in health systems research to support the essential transformations in health systems.

The 2020 Global Symposium on Health Systems Research brought together 2350 actors involved in health policy and systems research and practice from more than 125 countries. The call for abstracts attracted a total of 2721 submissions for individual sessions and 216 for organized sessions. Abstracts were reviewed and scored by scientific committee members and diverse high-scoring abstracts selected to build the scientific program for the Symposium.

This supplement to Health Policy and Planning emerged from a call for papers from the Symposium. Four out of the six papers are lead authored by colleagues based in lowand middle-income countries (LMIC), and all have strong LMIC participation reflecting the collective commitment of the society, Health Systems Global; the funder, the International Development Research Center (IDRC); and the journal, Health Policy and Planning to support promising authors from the Global South. The six papers in this supplement span the Symposium's three sub-themes, albeit with a notably lighter touch for the second theme where indeed, for the Symposium as a whole, we struggled to find significant contributions.

The papers by Novignon et al. (2021) , and Mgoli et al. (2021) both contribute to the sub-theme on engaging political forces. Novignon et al. address the questions of (a) what were the political paths towards the establishment of the National Health Insurance Scheme in Ghana and (b) how was political interest in the scheme sustained over time. Applying a recently proposed approach to understanding the political economy of health financing reform (Sparkes et al., 2019) and drawing on document review, including the examination of political manifestos, as well as key informant interviews, the authors demonstrate the broad swathe of stakeholders who were key to the success of the Ghana reforms and also demonstrate the sustained political interest in reform across both of the main political parties. By contrast, Mgoli et al. approach the question of political engagement from a more microlens. They explore the sustainability of a community scorecard initiative in Malawi, assessing the legacy of an initiative supported by the international NGO CARE, two and a half years after all formal support to the scheme ended. Mgoli et al.'s paper describes how community-level stakeholders, and notably youth, recognized that the community scorecard scheme provided a safe space for dialogue on health issues and civic engagement and how they sought to adapt the original initiative in order to make it more sustainable. The scorecard presents an approach through which transparency and accountability can be created-a critical component of subtheme 1.

It was more difficult to find contributions that addressed the second sub-theme on social, economic and environmental forces, and, in some regards, the paper by Rwafa-Ponela et al. (2021) does not exemplify the type of paper that we were initially searching for, but it is fascinating nonetheless, particularly as it aligns with growing global interest in public health, accelerated by the COVID-19 pandemic. Social determinants play a critical role in shaping people's health over their lifetimes. Health systems that can deliver strong health promotion functions that assess risk, reach vulnerable communities and empower them to achieve healthy behaviors can improve population health, especially among disadvantaged communities. Rwafa-Ponela et al. employ structuration theory to investigate the role of health promotion staff within the South African Department of Health and the barriers to more effective health promotion activities. They describe how a health system that is predominantly curative focused, with limited funding for health promotion and a lack of appreciation for the role of health promotion, has undermined the agency of many health promotion staff and led to the demotivation of staff and depletion of activities. This situation is familiar in many contexts, and so readers may find the concrete proposals for how to address these challenges particularly interesting.

This supplement includes two papers linked to the third sub-theme on innovation. Avan et al. (2021) report on an initiative to implement community-based newborn care in Ethiopia. While community health workers in Ethiopia have for many years had responsibilities linked to the care of newborns, the initiative described sought to engage them in the administration of antibiotics for newborn sepsis, through training, improved availability of relevant drugs and supplies, referral system strengthening and improved supervision. The paper reports an evaluation of this innovation, which found significant improvements in some of the structural aspects of care (such as availability of required drugs) but ongoing challenges with community health worker knowledge and skills that undermined overall effectiveness of the initiative. The authors conclude that a less intensive, more systems-oriented approach to the intervention may have been more successful. Thein et al. (2021) report on an innovative initiative in Myanmar to contract private general practitioner clinics to provide primary care services. They find that this initiative led to lower out-of-pocket payments by households.

Finally, the paper by Hailu et al. (2021) does not fit cleanly into any of our three sub-themes but reflects one of the Symposium's core concerns, namely equity. The paper reports the results of a benefit incidence analysis of health financing in Ethiopia, finding that funding for primary care is on balance pro-poor, whereas funding for hospital and inpatient services tends to benefit higher socio-economic groups more. In light of this, the authors argue for expanding service infrastructure in the rural areas of Ethiopia and conducting regular assessments of equity in health financing systems.

While these six papers make significant contributions to the literature, particularly with regard to strategies for achieving UHC in the Sub-Saharan African region, it is perhaps inevitable that they do not cover the breadth of topics in the initial call for proposals or do justice to the rich debates and discussions that took place during the Symposium. Based upon the papers in this volume, but also the submissions received for the Symposium, it is clear that the health systems community needs to do much more to understand how broad social and environmental trends are affecting health systems and what can be done to mitigate them. For example, on the topic of climate change, how will essential packages of services need to change with rising heat and increasing extreme weather events? How might climate change and rising sea levels affect referral networks? What can be done to mitigate the effects of climate change on health facility structures? Similarly, on the topic of population mobility, more research is needed to explore how UHC can be made migrant and refugee inclusive and how UHC can be achieved beyond the basis of borders and citizenship. We also note that while there were some strong contributions to the Symposium on the topic of corruption and corporate interference, none of the papers on this important theme made it through to this supplement. Moreover, the 2020 Global Symposium was to have taken place in Dubai and cast a particular spotlight on health systems research in the Eastern Mediterranean Region. It is particularly notable therefore that not one of the papers included in this volume originates from this region.

The 2020 Global Symposium marked the 10th anniversary of this series of conferences. While there is much to celebrate in the contributions made in this volume, as well as the enormously diverse contributions during the Symposium itself, there is clearly much work that remains to be done both to institutionalize health systems research across the world and to ensure that health systems researchers are addressing pressing policy questions to help achieve UHC and the broader health-related SDGs. Moving beyond HSR2020, we hope that the Symposium has at least sown the seeds for the longer-term transformation of health policy and systems research into a field that is less focused on equity, addressing the social determinants of health and understanding the implications and possibilities that major global changes offer. Individuals interested in understanding the rich body of knowledge generated by the 2020 Global Symposium can freely access recordings from all HSR2020 Symposium sessions (https://healthsystemsglobal.org/globalsymposia/previous-symposia/hsr2020/). We look forward to carrying the conversations, aspirations and lessons into the next Symposium in 2022.

This paper was published as part of a supplement financially supported by International Development Research Centre.

Conflict of interest statement. The authors declare that they have no conflict of interest.

Embedding communitybased newborn care in the Ethiopian health system: lessons from a four-year programme evaluation

Equity in public health spending in Ethiopia: benefit incidence analysis. Health Policy and Planning

From effectiveness to sustainability: understanding the continued implementation and impact of CARE's community score card social accountability approach in

Political economy and the pursuit of universal health coverage in Ghana: a case of the National Health Insurance Scheme. Health Policy and Planning

Organizational structure and human agency within the South African health system: a qualitative case study of health promotion

Political economy analysis for health financing reform

Effects of a new health financing scheme on out-of-pocket health expenditure: 1 Findings from a longitudinal household study in Yangon, Myanmar. Health Policy and Planning