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Good evening. Um, thank you for coming either online or in person.

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And then I think we've got some stragglers who are going to be joining us.

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Um, it is my great delight to introduce professor A shaped from now from UCL.

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As you can see, he's professor of global health systems and policy.

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He's previously led the what was it, the health.

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What was the one that involves the alliance?

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I met him at the Alliance for Health Policy and Systems Research at the W.H.O. and and Systems Global Health Systems Global.

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He's done just about everything in relation to health systems, uh, internationally.

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Um, so, Kabeer, you're going to tell us about the changing dynamics of mixed health systems in low and middle income countries.

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Um, and you've been speak for about 40 minutes and take some questions.

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So, um, welcome everyone and thank you, Twitch, for the kind words for calling me here.

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Uh, it's a bit of a long winded answer. Yeah. My, uh, my sock.

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Um, and this is our system of the week, I believe, for all of you.

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So I think I'm okay. You guys are all at Oxford University.

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You're all super smart, so, uh, I will, uh, this is a version of my inaugural professor show that I did last year.

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And, uh, you know, I get I'll get it is funny because it's your sort of opportunity to talk about yourself and your own journey,

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and I think it's quite awkward doing that. It's kind of not the thing we're used to doing when used to talking about our work.

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But hopefully I'll talk about my walk through my my own journey.

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I also signal a little bit about what I have learned and what that what I think that means for the future of this field.

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So health systems research and policy and systems research.

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It's quite a long talk. So I'm a little bit worried that I might end up talking a lot and not have enough time for dialogue,

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as I really like to talk with you guys and not just talk at you. Uh, so let me see if I can cut some bits out or just prioritise some bits.

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Um, okay, let's crack on. So this is my journey.

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Uh, I'm from India. I'm Indian, and I grew up in western India.

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I have medicine in New Delhi.

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Uh, and so my first initial part of my career was very much shaped and formed by, uh, being a doctor in a busy government hospital in New Delhi.

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Uh, and that really got me thinking about systems,

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because it was kind of I'm getting all these really complex issues coming to me, uh, and complex cases coming to me.

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And I find that I can only really scrape the surface of what's going on over there.

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And there's so much more happening in people's lives.

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Uh, the, uh, the reality of working in a big hospital gave me a sort of exposure to all that happens behind the scenes when we really doctors,

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we really focus on the clinical case. But there's a whole lot happening behind the scenes that that I actually found as interesting,

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if not more interesting than the actual patient encounter.

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Uh, and that kind of drew me into thinking about systems. Uh, and then I went and worked with a research NGO.

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I did my doctorate at the London School of Hygiene.

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Uh, then I worked at the Public Health Foundation of India, which is a, uh, what they call an arm's length organisation.

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It's a technical agency serving the government. So we functioned pretty much like a university.

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We had students, we design courses, but we also did research.

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And a lot of the research was specifically focussed on answering questions that people in health systems and government health systems had,

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and really trying to be responsive to their, their problems.

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Uh, so it's a not a conventional university that our really our job was to support

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learning and change within health systems rather than to produce knowledge per se.

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And that kind of philosophy. And that approach has really informed a lot of my research and my academic career as well.

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Uh, and then so after that few years in, uh, the Public Health Foundation of India, I joined W.H.O., and I was there for six years,

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a colour coded all of these because they all represent different types of, uh, uh, like sort of spheres of work, different nasal work.

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And I think that's, that's been really important for me as well in my career,

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that sort of overlap between teaching research but also policy and practice and

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really having all of those mixed up together and having them inform each other.

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And then finally, I've now joined, you'll see.

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Uh, well, what finally, I hope, I think, I hope that I'm not going to sort of pass away after, uh, after UCT, but have continued to do something.

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Uh, so, uh, in all of that and then there's sort of all these other links that I've had and this is not to kind of,

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you know, again, I feel very kind of, uh, a little bit show off talking about this.

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But that's not the idea. The idea is to just demonstrate that it's very important.

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It's been very important for me to have all these different strands feeding into each other.

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Uh, so I've been visiting, uh, various universities, and that experience has been very formative.

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In fact, one of my first experiences teaching an international group of master students was at Brac University in Bangladesh.

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And I actually think that was like one of the most exciting and dynamic, uh, group of students I've ever had, ever worked with.

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And that was very formative for me as well. I learnt a huge amount from them.

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So Brac has this really interesting format where they actually have the whole masters in a rural setting in Bangladesh,

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uh, where they are running a lot of that program. So Brac is one of the Bangladesh's biggest NGOs.

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You know, there's a Nobel Prize associated with them. They've been really influential in shaping the Bangladesh story.

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Uh, and, uh, so what happens when you're in a setting like that is you can't really escape the realities of, you know,

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impoverishment of health systems in challenging situations because they are literally outside your doorstep.

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And you kind of you just step outside the campus and you see those, uh, every day.

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Uh, and so that's, that's really important, I think,

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to sort of give people that exposure to what happens in the real world so that we're not just, like removed from our settings.

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Uh, other some other associations as well. And then I've always been involved with policy groups as well,

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because trying to sort of feed that practical experience back into thinking about how we can actually bring about change.

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So through my work with W.H.O. and then the other bit that I've been quite involved with is,

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uh, getting this community of health systems researchers together.

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Uh, so we've as health systems research is not a fully evolved field, right?

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It really started only about 25 years ago. Uh, W.H.O. set up a department on health systems research.

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Um, there have been some publications, but there's no real canon.

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There's no, like, sort of fundamental understanding that this is a feed that you can take in a masters or you can, you know, specialise in.

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So a lot of people arrive on it through a very twisted path.

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I mean, we are the doctors, all the social scientists, all the people working in management.

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And we we arrive at this, these health systems problems.

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And, and that's actually that interdisciplinary building of the field has really helped to shape it.

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So I got together with a few people and I mean a lot of people,

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and we we started a membership society called Health Systems Global, which has now become quite active.

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And they had on a bi annual global. Belgium. The next one is in Nagasaki in November, so if you get a chance, I think this to, uh, looking at perhaps.

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No, I think the abstracts are close now, but you can see that I just don't go with you if you're interested or maybe follow it online.

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Uh, and. Yeah, so it's a few different sort of. Influences in my pathway and.

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Whereas whereas I wrote bridges, I think what that's helped me to do is to think about a few different kinds of,

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uh, boundaries that I've spanned and I think are important for any professional and health systems to span.

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So I think a lot of my work has been focussed in India a little bit in Asia, other countries in Asia.

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Uh, and I think that depth, uh, of work in India,

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so like ten years of working in India has helped me to look at the world through a particular set of experiences,

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which is not unique to that, that setting. But it's given me a window at home, and it doesn't make me an expert on other settings,

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but it gives me a way of looking at other settings that that's been quite, uh, interesting.

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And I reflect on some of that as well. So we sort of bridge between India and Asia and the rest of the world is an interesting, uh, sort of,

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uh, boundary for me that I've tried to span, uh, the idea of doing research and making research.

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I think that's really key. I mean, I think far too much research ends up on virtual shelves or actual shelves and doesn't get used.

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And there are specific reasons for that.

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It's all about the incentive structures, a lot of the ways that universities function, and I'm in a big university now,

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I think is deeply flawed because we don't actually necessarily have to support learning in context where learning needs to happen.

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We we have to focussed on generating information. We're not focussed enough on creating learning.

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You know, I see the distinction and I'll talk a little bit about that as well. And then this what I already mentioned,

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this idea of looking at what's happening in health systems today versus what's going to happen to them in the future.

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And of course, nobody can really tell what's going to happen in the future. But we do have clues.

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We have some really big, glaring heads staring right at us in the face.

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And I think it's important to look at some of those big hints and think about what the future might hold for us.

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So the first kind of skipping on a bit, the first, just like four parts have gone away from the rule of threes,

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one should never say have more than four topics because of more than three topics because they don't really hold attention.

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But still, I'm going to try and plough through and go to the fourth as well.

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So the first big shift in my thinking and in the thinking, not just of myself, but a lot of other people working on health systems,

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has been on this idea of seeing health systems and social systems that I'm going to talk about that in a little bit.

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Uh, then I'm going to talk a little bit about governance. And, uh, my focus has been on health systems governance.

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So that's the idea I specialise in. And I'll say a little bit about why I think that's important.

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Uh, and then a bit more about the work I've done, which is not research per se,

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but more like institution building around research to make research matter.

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Uh, and then finally I'll end up with a little bit about the future of the field and what I think we should all be focusing on.

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Of course, I might be wrong, but please tell me if I am. So health systems are social systems.

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So when I first joined this sort of community of people working on health systems, we used to talk about primary health care all the time.

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I mean, I think it was the big, big, uh, topic, right,

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in the 90s through the 80s and primary health care, as you've probably been exposed to very much,

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especially if you've had professors like those sitting in the front row here is

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not just about the level of care that we deliver primary health care at the front,

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on the front lines. It is about that. But it also goes beyond that.

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And it also speaks to this idea of a philosophy that it's not just about, um,

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you know, uh, providing services, but we also need to empower communities.

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We need to engage across sectors. We need to make sure that referral networks are well established.

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And actually, a lot of that comes from the principles of Alma-Ata that were enshrined in a famous declaration from the 1970s.

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Uh, and, and a lot of us are kind of be influenced not only technically but also politically by that declaration,

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because it was really quite radical in some of its thinking.

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Uh, and if you go back to the original declaration, they talk a lot about things like community leadership and health planning.

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They talk about reducing elitism in modern medicine. I mean, it's really like these issues are still very, very prominent right now.

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Uh, and they talk about tackling social inequalities. And that's really what the basis of that was.

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So so that was really driven by recognising specific social and systemic trends that exist in very wide systems and responding to them.

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Yeah. And and redressing them. On the other hand, when universal health coverage came up in the early 2000s and that became another big sort of.

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Beacon flagship right now. Universal health coverage is extremely important.

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And, you know, it's much more scientific, it's much more comprehensive.

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But what you see is give gave shape to our understanding of what health systems are,

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because that led to the building blocks, uh, framework, which you guys are probably studying today.

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Uh, and it laid out certain goals, like aspirations on equity and on health, get access.

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But the thing is that the universal health coverage,

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so that lends itself to a lot more different types of interpretations that primary health care, primary health care is very clear.

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These are the problems of society. And this is what we need to tackle.

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Universal health coverage says these are the goals we want to achieve and how can we achieve them.

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So there was a very different sort of set of ideas there which pulled us in different directions.

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And one of the kinds of thought processes that.

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Well, it's quite prevalent and is still quite prevalent. Is this idea of health systems as machines?

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Uh, that you sort of put inputs in at one end and you get outcomes out at the other end.

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Uh, and a lot of the frameworks that were developed, that's the building blocks framework, an excellent framework.

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I'm not. I'm not here to, uh, you know, uh, denigrate these frameworks.

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Uh, they are really important and really useful frameworks.

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But they didn't lend themselves to a particular, quite technocratic view of health systems in which we think about systems as machines.

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Uh, and my experience was that that's important.

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That's interesting, but it's really insufficient to explain what actually happens in health systems,

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uh, to, uh, to, uh, either as a descriptor device or as an extended device.

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So, uh, and that sort of, again, came from my experience of working in the health system in a low income setting.

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And then I found a lot of people agree with me. And, you know, there were there was a lot of thinking already in the space about, you know, fantastic.

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Uh, uh, uh, researchers who had already written about that system of social institutions.

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Lucy Jensen was a major leading light in the field. She wrote extensively about this.

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And, uh, I think that John Carter Hanson, a lot of other people have been thinking about these issues.

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So, uh, we got together and wrote a series of papers that really kind of identified some of this understanding of,

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um, you know, so placing health systems being social institutions, uh, and not only as machines.

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So sort of moving away from machine thinking. And this is a series of papers within class medicine.

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Uh, so the three kind of major things we said is the first to that software, what we call software is incredibly important for our systems.

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So software is the values, the politics, the the intangible aspects, uh, the, the rules and norms, uh, the sometimes the informal norms,

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the ideas, the interests, you know, the things that are playing around and and shaping health systems.

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But we don't actually we can't actually always measure them or really fully grasp them, but it's important to try and understand them better.

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And that's really critical to how systems function. The second, of course, is that systems are complex.

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And I think that's not something new. That's but very important to integrate that into our understanding.

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And also that decisions are not just made at the top of systems. They're made like so throughout systems.

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And actually one of the most important, uh, theories was that of street level bureaucracy,

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which is that actually the most important person in our system is the person who's at the front line,

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and they are the ones actually making the decisions because they are the ones interacting with the person who's using care or,

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you know, uh, accessing services or, you know, they're controlling resources.

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The ultimate they're the ultimate controller of these services. And what's happening about them is kind of like an ecosystem.

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Uh, so so it really shakes your idea of what our system is, what policy is, and where policies are being made and where decisions are being made.

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Uh, and the third is, of course, that health systems are social systems.

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And when I say social, it doesn't just I like to use the word societal because it actually identifies that health systems are part of society.

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And so the problems of society also reflect in the problems of health systems.

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So we'll come to that in a little bit. I give some examples. And one major example of that was this mixed health systems.

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Uh, so this very much reflects so I read some papers, uh, very influential papers, which I find are incredibly important.

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Haven't got enough importance, uh, including one by Sonia Nishtar who was uh, uh, became later became science minister of Pakistan.

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And she's now that the chief executive officer of Gavi, the immunisation uh agency, which is quite for me.

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Interesting because she's came from a very much a systems perspective, and now she's going into an extremely vertical program and heading that up.

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Uh, so, uh, she wrote this on mixed health systems, uh,

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being centrally planned government health services that, uh, operate side by side with private markets.

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And I think this is really important because this, this, this describes a large number of health systems across the world,

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especially those in low and middle income countries, those which you might call the relatively less planned systems and economies.

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Uh, there's a sort of a laissez faire approach when it comes to how private sectors operate in these countries.

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There's no real plan for them. They just sort of there's a path dependency and that they they exist side by side with the public sector.

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And why it's important also, not only for those countries,

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is that now we are seeing many countries slide back into that model, including this country.

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Uh, and we are seeing now an approach where you will see increasing competition between public and private,

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and that creates a unique set of phenomena.

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Uh. Which, you know, can ultimately compromise public services as it impacts on health equity and access to care.

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I won't go into too much detail for so if we don't have time, but there's much more to read about mixed health systems that I can point to or two.

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Uh, now. So this is kind of like.

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Something that, uh, you understand. What about in 2010?

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Uh, but I don't think it's got enough traction.

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This understanding of mixed health systems and heterogeneity in health systems at one one kind of,

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uh, reflection of that is that just a few months ago, one of the chiefs of W.H.O. made this tweet.

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He said, having a functional taxonomy of the private sector in health is important to facilitate effective engagement in health and wellbeing.

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So, I mean, we are in 2024 and we don't have an effective taxonomy of the private health care sector.

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We haven't properly understood what the private healthcare sector is incredibly diverse.

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It's not just one thing. It's many, many different things. And understanding that is really important.

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And actually he's a friend of mine.

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I don't want to I mean, I think he's he's really trying to bring about some of these changes within organisations like W.H.O.,

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who still function on a very old fashioned thinking of of what the private sector is.

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Um. And this is one framework that I developed with some other colleagues in 2017, which tries to begin to unpack what this heterogeneity is.

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And this is again gives that sort of again a reflection of why systems are social systems.

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And that will kind of illustrate that a bit hopefully.

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So this is one what we might call not a taxonomy, but almost like in a sociological sense we use the word typology in sociology.

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Uh, which doesn't necessarily say that this is like a mathematical distribution,

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but it's like a way that people can organise their thoughts around, uh, heterogeneity.

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Uh, and I, we found it useful to think about, uh, diversity in axes rather than in Japanese.

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Uh, so, for example, there's a whole range, a spectrum from the formal to the informal sector.

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There's a spectrum from the specialised to the. There's even a spectrum from the private to the public.

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It's not a clear demarcation. There's a lot of private activity that happens in public sector.

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There's a lot of public minded activity that happens in the private sector.

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Uh, and then there's what you call allopathic, which is Western biomedicine through to traditional or local health conditions going on at a party.

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Uh, and again, that's also a spectrum.

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Uh, there's a lot of it's not like you have people working only in Western biomedicine or only in local health professions.

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You'll find people mixing their practices a lot. So these are all continuums.

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They are not continuous. They are not, uh, discrete categories.

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And one thing we can take away is that.

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The segment on the right tends to be, in a way, often philosophically, physically, and practically logistically closer to communities.

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Whereas the ones we think about all the time are the big hospitals and the doctors and the nurses and the operating theatres,

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and those are all on the left. That's a lot of policy, and all kind of day to day gets focussed on when if we work in the policy sphere,

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but actually they're kind of removed in some ways from the realities of people's lives.

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Um, of course, that's a big generalisation, but I think it holds up just to a large extent.

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Um, so that's one just an example of a way of looking at heterogeneity.

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And why has the vessel socially embedded? And it tells us that we should be looking much more at this right hand side of the spectrum.

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Um, okay. That's. I'll skip this. This is just, uh, uh, uh, photograph of the my collaborators in India.

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We worked on a number of issues, uh, and some of the issues we worked on related to that sort of right side of the spectrum.

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The people in the health workforce who are relatively don't find a large voice in in the kind of policy sphere.

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Uh, we looked at rural doctors, uh, we looked at private practitioners who are often dynamic, elected from a policy perspective.

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In India, we looked at what we call Dicom practitioners traditional, complementary and alternative medical practitioners.

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Uh, and we looked at nurses again here.

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Nurses are still politically much more influential as a leadership structure than a career pathways in the UK.

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But that's not the case in many other countries. And in India certainly was the case.

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So we, uh, we undertook studies on a number of these, uh, on these sort of marginal actors.

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And I want to give one example. So a lot of this was using qualitative methodologies, ethnographic approaches and people.

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I often get to ask how is this different from journalism.

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And I say it is different from journalism because in in good quality qualitative research, we tend to avoid asking people about their opinions.

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We ask people about their experiences and that have an effect, uh, the trends in their behaviour,

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the trends of their responses from their their accounts of their experiences.

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And that's much harder to do than asking people about their opinions.

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People are extremely free with their opinions and they are extremely closed about their experiences.

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Uh, so you need a very good skill set to actually do good quality qualitative research.

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But that's just my defence of qualitative research.

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Maybe I didn't need to give it, but, uh, this was an example of some work we did with rural doctors in rural Chhattisgarh,

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which is, uh, insurgent afflicted area. It's, uh, conflict zone in eastern India.

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So this is, uh, a branch into this.

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Going to the other side is on insurgent territories, Naxalites, uh, who operate in that territory.

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So and this is, uh, one of the instances where the number of security people killed and supplied by health care sent over there.

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So really remote, really isolated area where, you know, there's barely any doctors and barely any health systems to speak of.

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But there are some.

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So we we we did this, uh, study in which we asked we sort of flipped the question on its head and we said, okay, normally when we ask about we want.

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So the bigger policy question here is doctors and distributed right across different systems.

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Uh, most of them are concentrated in cities.

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We want to get more people to the areas where they really needed.

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So the normal question to ask would be, how can we make doctors stay on in villages, right?

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Or we say, how can we can we replace doctors with other types of health workers in those area?

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We said, let's ask a different sort of question. Let's ask the people who were actually there, and let's ask them why they're there.

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Can we learn anything from those people? And so we did this sort of ethnography of those of those doctors we did see on.

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And there were only remarkable people. I mean, you know, there's this kind of narrative that they're the system makes them out to be the losers.

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They're kind of like the people who couldn't get into any better boasting.

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Right? So to the extent that actually they all have very interesting explanations for why they're there,

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and some of them are pretty intuitive, but it's really important to document that, right?

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Geographic and ethnic affinities, a lot of them were actually people from those areas with like family affinities,

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social affinities, tribal affinities, and they were just more comfortable in that environment.

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That's where they're from. And so they're back with their people. It's not like they're saints.

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They're just happy to be there and working with their people.

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Uh, some of them were also, you know, very, uh, inspiring people with like, personal values of service and, you know, wanted to go back and give back.

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Uh, and then there's also these really important sort of practical considerations and, um, make sure there's a school, you know,

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where you're going to post your doctors and nurses, uh, and make sure there's,

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you know, job security for these people and give them their basic supports.

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This is a kind of a very condensed version of what, what our findings were.

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But it influenced policy because it's a striking.

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Uh, citing, uh, evidence in support of affirmative action, for example.

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You need to get people from you need to prioritise educating people in professional, uh, medicine from those particular pockets.

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Uh, and so and so that they will go back and serve their own communities.

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It's just that simple. And we didn't have that evidence. So. So this this helped us because we did this work with the ministry.

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So in fact, directly into the ministry's, uh, the national policy for, uh, posting and transfer.

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Uh, and it has had an impact then on, uh, several state policies as well.

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So that was a bit about seeing systems. So that's already quite a lot.

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I've spoken quite a lot already, but let me maybe say a little bit about governance.

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And then I think I'll skip the next section and go straight to the third one.

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Yeah. So governance. Uh, a lot of my work has been on understanding governance.

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So there's this bit on the work force that I described, and then there's a lot more, uh, there's another big strain on governance.

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So why governance? Um. These are the kind of standard definition of the government's guidance on the health

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system when it comes to health systems guidance for the system through design,

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management, regulation, accountability. A lot of the words we hear regulation, stewardship, uh, institutions, rule systems.

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Uh, now, why did we decide to focus on governance?

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This wasn't just me. This is a whole team of us in India deciding to focus on governance.

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I think it came from a sort of a multitude of different insights as practitioners.

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So a lot of us came from the practice space. We want researchers mostly.

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And we had we we knew that governance challenges are the, uh, the roadblocks because we'd experienced it ourselves,

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uh, not only as practitioners trying to get things done in systems, but also as citizens.

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So when I try, for example, of getting, um, insurance being out in India even as, uh, where affluent.

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Uh, doctor? Um, I'm going to. I'm I'm a I'm a doctor myself.

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You know, I'm reasonably well-off. If a family member gets goes to a hospital and I try to get an insurance payout, it's almost impossible.

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Uh, it's there's so much red tape and so much bureaucracy,

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and you have standing so many lines that you almost at the end of it, just say, forget it and just be myself.

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Right. So these are the kinds of challenges that we face as, as individuals ourselves.

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And then of course, that gets amplified like ten times if you go further down the social order.

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And if you're underprivileged, then it's almost impossible if you think about getting insurance bills.

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And then we were interested in this as a from an academic perspective as well.

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And so the research was pursued. And then I'm confronting the living Constitution with the manifestation of authority.

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It's a it's a mouthful, but it's really, really important. It kind of gets to the heart of what we do as governance researchers.

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We look at the rules that exist in right written form.

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And then we look at what people are actually doing and we compare that to.

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And it's not just about saying, oh is different from me. It's about the fact that what people are actually doing.

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Is also driven by a bunch of rules, norms, batons, but those are not written anywhere.

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There's a whole informal parallel system that functions side by side with the formal system.

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So, um. Yeah. So interesting.

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Struck by.

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So, Richard Horton, the editor of The Lancet, said something about he had an editorial the other day and says the system is not working right.

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And he's talking about the global health system. And how mutual friend Shelby Bola responded to that.

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You know, with another tweet, he said, the system is working just fine. That is the system.

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It's supposed to not work for some people, and it's supposed to work for other people.

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Right. So, I mean, it's a provocative kind of polite way of looking at it,

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but essentially the parallel system exists side by side with the formal system because it works for some people.

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It just works for the wrong side of people. Think it works for the people who are benefiting from those parallel arrangements.

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It doesn't work for the people who are supposed to be working for for the benefit the poor,

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the underprivileged, the people who really need the system to function for them.

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And that gets mirrored at the local level. So when people talk about corruption, I get, I get quite.

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It's my little pet peeve. Corruption is not rent seeking.

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It's not pay outs at the bottom of the food chain.

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It's this the existence of blindness to the way that entire systems are functioning for a particular set of interested actors,

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and not for the broader public good. That's corruption.

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Uh, so anyway, that's just my pet peeve. I can get into that and more.

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Uh, so this is another way, something like this. And again, very much the same thing.

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Uh, when you say justice, we don't we shouldn't just focus on what should be happening.

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We should actually look at what's happening. Yeah.

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And that's a so that's really a strong statement for doing research on governance, doing research on health systems.

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We need to focus on what actually happens in actual lives rather than merely looking for ideal institutions and elements.

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Um. You. Just a few more examples here.

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So basically we did work on three different sets of institutions community institutions, regulatory institutions.

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And well broadly speaking, ministries of health. Uh, so this is over a long period of time, several different projects.

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Uh, so this is a really interesting one, posting and transfer policies.

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It's kind of one of those really important functions of health systems getting making sure that people in the right place at the right time,

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doing the right jobs. It's so boring and so basic that everybody, nobody thinks about it.

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It's kind of like, oh, this is just management. But it's it's crucial, absolutely critical to the system functioning of any system.

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And there are very clear factors driving it.

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And the clear phenomenon that clear, uh, the problems that exist within that that can be understood and solved.

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So it's really important to research that. So I'll come to that in a little bit.

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So these are some findings we had organised professional interests influence regulatory design and implementation.

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I mean that's good option. That's what I was talking about. It's like infiltration of private interests into the functioning of regulatory bodies.

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Regulatory capture in other words informal parallel arrangements for health worker deployment.

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So everybody kind of makes a deal, right? If you can you can buy yourself out of a good posting.

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Uh, well and and sometimes actually there are some, uh, government state governments,

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especially in Nadu in India, which have actually implemented excellent posting and transfer policies.

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They do things like they post spouses together. They they make sure there's like an incentive system that like schools in all the areas.

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They're very imaginative about the way they do their posting and transfer. And it actually works quite well.

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Uh, yeah. So a lot of issues around design gaps, functional variety.

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So this is of course all research that fed directly into the policymakers.

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Well, not all of it was effective in bringing about change, but it did kind of throw light into some of these very dark areas of health systems.

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Then we did a bunch of stuff on community systems. So again this is documenting failure.

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That's also really important. So there are something like 300,000 village communities across India.

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And that's really the the defacto mechanism to introduce community voice into health planning.

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Uh, so to a large extent, they don't work.

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So it was important to just document that. It's like you, you get some women, you get some lower costs.

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Uh, you'll get some people from underprivileged communities being represented on those committees.

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But ultimately, the social factors militate against them having an actual voice in, in on those committees.

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Uh, but there's still there instances where you see things shifting just by virtue of the committees there.

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There are instances where people actually can exert their, uh, you know, uh, the can can have a voice.

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You actually see some changes in some improvements in service delivery as a result of communities having a voice.

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So documenting those little successes, those little gains are also important.

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Uh, and also this again, also went into the national policies for village health committees, some of the local governance laws.

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So for example, India has a. Want to see on Sunshine Beach.

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So fantastic. Just local self-determination. It's like every.

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And that's not just for health. That's it politically.

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It's like, uh, every village has the right to determine its own, you know, resource, how its resources are located.

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And there's like, that's in law that's constitutionally enshrined. So, so that that was a really positive.

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Framework, on the basis of which these village health committees could function because the Relations Committee,

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the subcommittees of the of the local government.

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So again, laws are important is very boring.

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But you know, don't get rid of the laws. They are really important because they have to sort of maintain the status quo.

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They have to maintain, they have to give opportunities for positive things to happen.

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Yeah. Then this was what created a show on. Ministries of Health.

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But this was upheld almost across the world. Uh, really stuck in the past.

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They still think they control what happens in health systems.

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How many of you work in ministries and have. Or have looked in this exhibit.

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To maybe. I mean, you could share some of your experiences maybe after that.

381
00:35:50,280 --> 00:35:54,430
And, but, uh, but unfortunately, the demands on them are very different.

382
00:35:55,020 --> 00:35:58,240
They're not just focussed on delivering services.

383
00:35:58,570 --> 00:36:02,920
Now, ministers are expected to be negotiators, stewards, regulators.

384
00:36:03,610 --> 00:36:07,450
They are supposed to handle climate change as well as, you know, delivering primary health care.

385
00:36:07,990 --> 00:36:12,260
And they're supposed to do all kinds of multi-sectoral stuff. Uh, it's really hard.

386
00:36:12,280 --> 00:36:20,950
They don't have the capacity to do that to a large extent. So we did this working on just putting up a we used to get a lot of requests and mutual.

387
00:36:22,330 --> 00:36:29,310
From ministers of health say what should be our functions. I won't name the countries, but it's a very genuine question, right?

388
00:36:30,420 --> 00:36:37,800
What should we be doing? Uh, and there is no framework for there's no next un normative framework for what you should be doing.

389
00:36:38,280 --> 00:36:42,269
So that is a little bit part of the impetus for. So we would have to say no, we don't have a framework.

390
00:36:42,270 --> 00:36:47,580
I was in a research department and we didn't even have the authority to put up norms and policies.

391
00:36:48,270 --> 00:36:55,260
But what we did do is try to think a little bit about what the capacities they should have in order to perform their functions.

392
00:36:56,250 --> 00:37:00,730
Not just for the win the old fashioned way, but for some future perspective.

393
00:37:00,750 --> 00:37:11,819
How can they? So a lot of that was about just managing this sort of the unit functions, the revenue functions, but also preparing for change.

394
00:37:11,820 --> 00:37:18,590
And this became so important then when Covid happened, the ability to be ready for changes and to manage relationships.

395
00:37:18,690 --> 00:37:19,430
And when that's you.

396
00:37:19,500 --> 00:37:25,710
I mean, none of the ministers of health had actually set out to manage the relationship with the private sector or with other sectors.

397
00:37:26,250 --> 00:37:34,020
Uh, with by the sectors, I mean other like transport and education and, um, environment and so forth and values.

398
00:37:34,020 --> 00:37:35,819
So I mean, that was another big aspect.

399
00:37:35,820 --> 00:37:45,060
So I mean, how do we see ministries of health as it, as thought leaders or as, uh, as propagators of certain sets of values?

400
00:37:45,450 --> 00:37:48,510
And are they really being able to do that effectively?

401
00:37:49,710 --> 00:37:53,490
So there was a paper that came out of that. And working people are looking critical.

402
00:37:54,870 --> 00:38:01,050
Uh, so I guess all of that. That's I mean, very messy kind of broad view of the field.

403
00:38:01,680 --> 00:38:09,299
But I think I'm trying to draw some sort of inferences from that, which might help us to think about how change happens within the system.

404
00:38:09,300 --> 00:38:13,530
Then what's important to focus on. Uh, and I'm going to give three examples of.

405
00:38:14,520 --> 00:38:18,600
Problems that we typically see in health systems across the water. Gaps in primary care.

406
00:38:18,660 --> 00:38:23,370
That's a big one. Inequitable access for pretty much similarly health care quality, right.

407
00:38:24,150 --> 00:38:30,610
And these are the. Immediate explanations that we had for for these problems.

408
00:38:30,610 --> 00:38:35,530
Right. Not enough skilled health workers not distributed appropriately.

409
00:38:38,020 --> 00:38:43,870
When we try to hire people who are not physicians, they are not skilled enough to do the work that they are tasked to do.

410
00:38:43,900 --> 00:38:47,800
That's a big problem right now. That's a big issue in the UK right now.

411
00:38:48,340 --> 00:38:53,470
We are facing, you know, effectiveness of regulators. So we don't really have the governance mechanisms in place.

412
00:38:55,290 --> 00:39:00,959
So typically, what are the kind of policy solutions we throw at these problems.

413
00:39:00,960 --> 00:39:07,500
Right. We would try to find ways to equalise the availability of health workers.

414
00:39:07,710 --> 00:39:15,870
We throw technocratic solutions at these problems. Uh, we try to say skilled non physician workers more.

415
00:39:17,090 --> 00:39:21,620
Uh, we tried to find some Band-Aid solutions, but our governance institutions strengthen them.

416
00:39:22,040 --> 00:39:25,400
Or maybe even disband them. We say, oh, regulation isn't working, so just give it up.

417
00:39:26,000 --> 00:39:31,130
You know, why regulate? So, uh. But actually the.

418
00:39:33,250 --> 00:39:39,940
Issues. Underlying challenges are not always technical and technocratic, but often societal, social and societal.

419
00:39:39,940 --> 00:39:44,140
So as they relate to these issues that some of which I highlighted. Institutional capture.

420
00:39:45,350 --> 00:39:48,380
So institutions have been taken over by certain interests.

421
00:39:49,380 --> 00:39:51,140
Uh, learning? Yes, that's a big one.

422
00:39:51,680 --> 00:39:59,120
I don't think there's enough mechanisms for people to actually for institutions and mechanisms to change and adapt.

423
00:39:59,840 --> 00:40:04,790
And that's the Ministry of Health. Examples was one key one. There is no way for ministers to redefine them.

424
00:40:04,790 --> 00:40:09,020
So they don't have those inbuilt learning and institutional linkages.

425
00:40:09,740 --> 00:40:12,799
Professional dominance. I didn't talk about that in depth.

426
00:40:12,800 --> 00:40:17,300
But for example, let me give you an example. In India, the nursing council is headed by a doctor.

427
00:40:19,000 --> 00:40:23,290
Uh, professional dominance is a very well documented sociological phenomenon.

428
00:40:23,830 --> 00:40:28,090
Elliot Friedson, if you want to read, wrote about this in the 1960s.

429
00:40:28,720 --> 00:40:34,930
Uh, Roger Jeffrey wrote about it. Uh, it is in a low and middle income country context.

430
00:40:35,650 --> 00:40:39,940
Uh, it's, uh, it's not about the fact that doctors are dominant.

431
00:40:39,940 --> 00:40:47,140
It's about the organised interests of medical professionals often work in such a way as to propagate their own interests at the.

432
00:40:49,020 --> 00:40:56,350
Expense of other cadres of. And that really influences how things happen.

433
00:40:57,250 --> 00:41:01,120
It's a big determinant of health systems, social determinants.

434
00:41:01,120 --> 00:41:06,400
This is all social determinants, all the health system and the capacity to have simple capacity gaps.

435
00:41:06,970 --> 00:41:11,260
We don't have the skills to actually govern and to manage systems.

436
00:41:14,000 --> 00:41:21,470
Know what's critical here. Let me, before I go there, is that none of these problems can be solved from the outside.

437
00:41:22,410 --> 00:41:25,730
They're all issues that societies have to tackle from within.

438
00:41:26,090 --> 00:41:27,150
I mean, you can help them.

439
00:41:27,170 --> 00:41:35,840
I mean, I think the learning one is something and that then that for me, as somebody working now in a high income country institution, I work at UCL.

440
00:41:36,740 --> 00:41:41,780
You guys are all at Oxford. It really helps me to think about what my role is in all of this.

441
00:41:42,500 --> 00:41:48,450
And I think I think it's this. And that's the one we should be focusing on.

442
00:41:49,110 --> 00:41:54,960
I don't think I can sit here and solve issues around corruption and institutional capture and or professional governance.

443
00:41:54,990 --> 00:41:58,470
I mean, I can shed light on them, but that's really about learning.

444
00:41:59,370 --> 00:42:04,890
Uh, so but then that also really tells us about how health system strengthening can happen.

445
00:42:05,730 --> 00:42:09,720
And it needs to happen from the from the inside.

446
00:42:10,590 --> 00:42:15,840
Uh, and these are the different things that health systems can do about themselves.

447
00:42:18,090 --> 00:42:21,540
Um, yeah. I mean, that's a framework.

448
00:42:21,900 --> 00:42:23,460
You can touch on that more.

449
00:42:24,760 --> 00:42:31,450
So let's skip over this section, which is really about health systems, uh, the kind of institutionalising health systems research.

450
00:42:33,670 --> 00:42:38,350
And maybe talk a little bit about. Just end with this bit on changing health systems.

451
00:42:38,560 --> 00:42:46,250
Yeah. Uh, so my title was, uh, Mixed Health Systems and, um.

452
00:42:47,350 --> 00:42:50,830
Looking at both the present and the future of Pullman systems and how.

453
00:42:52,740 --> 00:42:59,010
A weekend as as researchers, as people involved in learning become more effective, become relevant in this context.

454
00:43:00,000 --> 00:43:06,540
So when we nowadays the discourse on health systems is entirely dominated by these topics, and understandably so.

455
00:43:07,740 --> 00:43:11,840
Ecological change. Pandemics.

456
00:43:13,050 --> 00:43:18,490
Current and future pandemics and preparedness for them or not, humanitarian shocks.

457
00:43:18,510 --> 00:43:22,230
I mean, I think conflict is probably a big headline right now.

458
00:43:22,990 --> 00:43:26,190
Uh. Die. Health systems are being decimated.

459
00:43:27,750 --> 00:43:33,620
Uh. Increasing applications of digital technology and AI.

460
00:43:34,250 --> 00:43:38,209
And I think along with that, this information. But I mean, I think I'll come to that.

461
00:43:38,210 --> 00:43:41,960
That's still a little bit surprising when you. So this is what's grabbing the headlines.

462
00:43:42,680 --> 00:43:49,700
But then below that kind of little attention horizon that all the headlines are focusing on are some things that.

463
00:43:51,990 --> 00:43:57,510
A much more predictable and. Clear urbanisation.

464
00:43:58,710 --> 00:44:05,110
Uh. Africa is going to have 50 megacities in about 20 years.

465
00:44:06,100 --> 00:44:12,130
We're going to have more of. There's going to be more urbanisation in Africa than in all other continents put together.

466
00:44:13,030 --> 00:44:19,550
And. That will come with different forms of commercialisation of healthcare as well.

467
00:44:20,700 --> 00:44:25,550
Uh. Healthcare configurations. Health market configurations are already changing completely.

468
00:44:25,560 --> 00:44:28,710
Private equity is making inroads into health care.

469
00:44:29,910 --> 00:44:34,229
That means that health care will no longer be run by doctors or by technicians.

470
00:44:34,230 --> 00:44:38,730
That can be run by the bottom line in a way that we cannot even imagine right now.

471
00:44:39,390 --> 00:44:43,990
These are huge shifts. And these are things we can definitely predict.

472
00:44:46,400 --> 00:44:49,580
Because, I mean, you might want to sort of do something about it.

473
00:44:50,060 --> 00:44:55,010
But these are huge social changes that are happening. The spread of disinformation, I mean, I think that is undeniable.

474
00:44:56,240 --> 00:45:01,160
That's not just how it's across the world. It's it's one of the major, uh,

475
00:45:01,160 --> 00:45:10,430
the ability of information as well as misinformation to spread is and influence entire populations is a clear pattern that we are seeing,

476
00:45:10,430 --> 00:45:17,550
and not one that's just going to go away. And below that is another attention horizon.

477
00:45:17,740 --> 00:45:20,940
And below that of the problems that we've seen for the last 50 years.

478
00:45:21,120 --> 00:45:33,510
And they remain unchanged. The governance failures, market failures, the same old software problems and issues of conflict, contestation.

479
00:45:34,670 --> 00:45:40,760
And persistent inequities. And the point here is that some things are much more predictable than others.

480
00:45:40,760 --> 00:45:45,800
And I think we need to focus on all of those things together, not just in isolation.

481
00:45:45,830 --> 00:45:47,770
You can't address the climate.

482
00:45:47,840 --> 00:45:55,000
You can't make systems climate proof without meeting them, without addressing governance challenges, or without addressing marketing.

483
00:45:55,670 --> 00:46:02,240
All these things have to be taken in totality. And for that we need a social science perspective.

484
00:46:02,750 --> 00:46:07,280
So if we are to be involved in effective health systems research, I think we need to be.

485
00:46:09,140 --> 00:46:17,540
I think social science is underused. We need to throw the full weight of the social sciences to better understand and unpack these phenomena.

486
00:46:18,050 --> 00:46:28,070
We are seeing health systems as extensions of the clinic, uh, and those are not necessarily the best methodologies by which to look at those systems.

487
00:46:28,580 --> 00:46:29,719
They are to some extent,

488
00:46:29,720 --> 00:46:36,140
but I think they are generally overprivileged cons when we consider the spectrum of research methodologies that we have at our disposal.

489
00:46:38,120 --> 00:46:46,540
So from a future agenda perspective for the field. These are some big themes that I think we need to look at.

490
00:46:47,710 --> 00:46:54,640
Understanding mixed health systems better and managing them. Designing and managing systems for urbanising and migrant mobile populations.

491
00:46:55,420 --> 00:47:05,810
Integrating digital interventions. Of course, dealing with epidemics and climate and conflict and tackling the infodemic.

492
00:47:06,590 --> 00:47:15,080
Um, but along with that. Addressing the unfinished agenda of universal health coverage and primary health care.

493
00:47:17,060 --> 00:47:20,150
And how we do that. As I said already, is to, I think,

494
00:47:20,510 --> 00:47:29,330
upscale the use of social science approaches to study not only the technical aspects of hardware or health systems, but also the software.

495
00:47:30,460 --> 00:47:38,170
Uh, to prioritise a lot of the kind of slightly boring functions of our system, what we call the organisational and institutional level issues.

496
00:47:39,190 --> 00:47:43,760
Uh, to understand the patterns, to understand. And it's doable.

497
00:47:44,140 --> 00:47:52,570
There are, you know, the the social sciences have the tools and frameworks in which you can understand how have systems function.

498
00:47:53,650 --> 00:48:02,950
Uh, and we can use those much better. And to work closely with decision makers as much as possible so that our learning we generate gets used.