Good evening. Um, thank you for coming either online or in person.
And then I think we've got some stragglers who are going to be joining us.
Um, it is my great delight to introduce professor A shaped from now from UCL.
As you can see, he's professor of global health systems and policy.
He's previously led the what was it, the health.
What was the one that involves the alliance?
I met him at the Alliance for Health Policy and Systems Research at the W.H.O. and and Systems Global Health Systems Global.
He's done just about everything in relation to health systems, uh, internationally.
Um, so, Kabeer, you're going to tell us about the changing dynamics of mixed health systems in low and middle income countries.
Um, and you've been speak for about 40 minutes and take some questions.
So, um, welcome everyone and thank you, Twitch, for the kind words for calling me here.
Uh, it's a bit of a long winded answer. Yeah. My, uh, my sock.
Um, and this is our system of the week, I believe, for all of you.
So I think I'm okay. You guys are all at Oxford University.
You're all super smart, so, uh, I will, uh, this is a version of my inaugural professor show that I did last year.
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,
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.
But hopefully I'll talk about my walk through my my own journey.
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.
So health systems research and policy and systems research.
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,
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.
Um, okay, let's crack on. So this is my journey.
Uh, I'm from India. I'm Indian, and I grew up in western India.
I have medicine in New Delhi.
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.
Uh, and that really got me thinking about systems,
because it was kind of I'm getting all these really complex issues coming to me, uh, and complex cases coming to me.
And I find that I can only really scrape the surface of what's going on over there.
And there's so much more happening in people's lives.
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,
we really focus on the clinical case. But there's a whole lot happening behind the scenes that that I actually found as interesting,
if not more interesting than the actual patient encounter.
Uh, and that kind of drew me into thinking about systems. Uh, and then I went and worked with a research NGO.
I did my doctorate at the London School of Hygiene.
Uh, then I worked at the Public Health Foundation of India, which is a, uh, what they call an arm's length organisation.
It's a technical agency serving the government. So we functioned pretty much like a university.
We had students, we design courses, but we also did research.
And a lot of the research was specifically focussed on answering questions that people in health systems and government health systems had,
and really trying to be responsive to their, their problems.
Uh, so it's a not a conventional university that our really our job was to support
learning and change within health systems rather than to produce knowledge per se.
And that kind of philosophy. And that approach has really informed a lot of my research and my academic career as well.
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,
a colour coded all of these because they all represent different types of, uh, uh, like sort of spheres of work, different nasal work.
And I think that's, that's been really important for me as well in my career,
that sort of overlap between teaching research but also policy and practice and
really having all of those mixed up together and having them inform each other.
And then finally, I've now joined, you'll see.
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.
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,
you know, again, I feel very kind of, uh, a little bit show off talking about this.
But that's not the idea. The idea is to just demonstrate that it's very important.
It's been very important for me to have all these different strands feeding into each other.
Uh, so I've been visiting, uh, various universities, and that experience has been very formative.
In fact, one of my first experiences teaching an international group of master students was at Brac University in Bangladesh.
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.
And that was very formative for me as well. I learnt a huge amount from them.
So Brac has this really interesting format where they actually have the whole masters in a rural setting in Bangladesh,
uh, where they are running a lot of that program. So Brac is one of the Bangladesh's biggest NGOs.
You know, there's a Nobel Prize associated with them. They've been really influential in shaping the Bangladesh story.
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,
impoverishment of health systems in challenging situations because they are literally outside your doorstep.
And you kind of you just step outside the campus and you see those, uh, every day.
Uh, and so that's, that's really important, I think,
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.
Uh, other some other associations as well. And then I've always been involved with policy groups as well,
because trying to sort of feed that practical experience back into thinking about how we can actually bring about change.
So through my work with W.H.O. and then the other bit that I've been quite involved with is,
uh, getting this community of health systems researchers together.
Uh, so we've as health systems research is not a fully evolved field, right?
It really started only about 25 years ago. Uh, W.H.O. set up a department on health systems research.
Um, there have been some publications, but there's no real canon.
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.
So a lot of people arrive on it through a very twisted path.
I mean, we are the doctors, all the social scientists, all the people working in management.
And we we arrive at this, these health systems problems.
And, and that's actually that interdisciplinary building of the field has really helped to shape it.
So I got together with a few people and I mean a lot of people,
and we we started a membership society called Health Systems Global, which has now become quite active.
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.
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.
Uh, and. Yeah, so it's a few different sort of. Influences in my pathway and.
Whereas whereas I wrote bridges, I think what that's helped me to do is to think about a few different kinds of,
uh, boundaries that I've spanned and I think are important for any professional and health systems to span.
So I think a lot of my work has been focussed in India a little bit in Asia, other countries in Asia.
Uh, and I think that depth, uh, of work in India,
so like ten years of working in India has helped me to look at the world through a particular set of experiences,
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,
but it gives me a way of looking at other settings that that's been quite, uh, interesting.
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,
uh, boundary for me that I've tried to span, uh, the idea of doing research and making research.
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.
And there are specific reasons for that.
It's all about the incentive structures, a lot of the ways that universities function, and I'm in a big university now,
I think is deeply flawed because we don't actually necessarily have to support learning in context where learning needs to happen.
We we have to focussed on generating information. We're not focussed enough on creating learning.
You know, I see the distinction and I'll talk a little bit about that as well. And then this what I already mentioned,
this idea of looking at what's happening in health systems today versus what's going to happen to them in the future.
And of course, nobody can really tell what's going to happen in the future. But we do have clues.
We have some really big, glaring heads staring right at us in the face.
And I think it's important to look at some of those big hints and think about what the future might hold for us.
So the first kind of skipping on a bit, the first, just like four parts have gone away from the rule of threes,
one should never say have more than four topics because of more than three topics because they don't really hold attention.
But still, I'm going to try and plough through and go to the fourth as well.
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,
has been on this idea of seeing health systems and social systems that I'm going to talk about that in a little bit.
Uh, then I'm going to talk a little bit about governance. And, uh, my focus has been on health systems governance.
So that's the idea I specialise in. And I'll say a little bit about why I think that's important.
Uh, and then a bit more about the work I've done, which is not research per se,
but more like institution building around research to make research matter.
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.
Of course, I might be wrong, but please tell me if I am. So health systems are social systems.
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.
I mean, I think it was the big, big, uh, topic, right,
in the 90s through the 80s and primary health care, as you've probably been exposed to very much,
especially if you've had professors like those sitting in the front row here is
not just about the level of care that we deliver primary health care at the front,
on the front lines. It is about that. But it also goes beyond that.
And it also speaks to this idea of a philosophy that it's not just about, um,
you know, uh, providing services, but we also need to empower communities.
We need to engage across sectors. We need to make sure that referral networks are well established.
And actually, a lot of that comes from the principles of Alma-Ata that were enshrined in a famous declaration from the 1970s.
Uh, and, and a lot of us are kind of be influenced not only technically but also politically by that declaration,
because it was really quite radical in some of its thinking.
Uh, and if you go back to the original declaration, they talk a lot about things like community leadership and health planning.
They talk about reducing elitism in modern medicine. I mean, it's really like these issues are still very, very prominent right now.
Uh, and they talk about tackling social inequalities. And that's really what the basis of that was.
So so that was really driven by recognising specific social and systemic trends that exist in very wide systems and responding to them.
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.
Beacon flagship right now. Universal health coverage is extremely important.
And, you know, it's much more scientific, it's much more comprehensive.
But what you see is give gave shape to our understanding of what health systems are,
because that led to the building blocks, uh, framework, which you guys are probably studying today.
Uh, and it laid out certain goals, like aspirations on equity and on health, get access.
But the thing is that the universal health coverage,
so that lends itself to a lot more different types of interpretations that primary health care, primary health care is very clear.
These are the problems of society. And this is what we need to tackle.
Universal health coverage says these are the goals we want to achieve and how can we achieve them.
So there was a very different sort of set of ideas there which pulled us in different directions.
And one of the kinds of thought processes that.
Well, it's quite prevalent and is still quite prevalent. Is this idea of health systems as machines?
Uh, that you sort of put inputs in at one end and you get outcomes out at the other end.
Uh, and a lot of the frameworks that were developed, that's the building blocks framework, an excellent framework.
I'm not. I'm not here to, uh, you know, uh, denigrate these frameworks.
Uh, they are really important and really useful frameworks.
But they didn't lend themselves to a particular, quite technocratic view of health systems in which we think about systems as machines.
Uh, and my experience was that that's important.
That's interesting, but it's really insufficient to explain what actually happens in health systems,
uh, to, uh, to, uh, either as a descriptor device or as an extended device.
So, uh, and that sort of, again, came from my experience of working in the health system in a low income setting.
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.
Uh, uh, uh, researchers who had already written about that system of social institutions.
Lucy Jensen was a major leading light in the field. She wrote extensively about this.
And, uh, I think that John Carter Hanson, a lot of other people have been thinking about these issues.
So, uh, we got together and wrote a series of papers that really kind of identified some of this understanding of,
um, you know, so placing health systems being social institutions, uh, and not only as machines.
So sort of moving away from machine thinking. And this is a series of papers within class medicine.
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.
So software is the values, the politics, the the intangible aspects, uh, the, the rules and norms, uh, the sometimes the informal norms,
the ideas, the interests, you know, the things that are playing around and and shaping health systems.
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.
And that's really critical to how systems function. The second, of course, is that systems are complex.
And I think that's not something new. That's but very important to integrate that into our understanding.
And also that decisions are not just made at the top of systems. They're made like so throughout systems.
And actually one of the most important, uh, theories was that of street level bureaucracy,
which is that actually the most important person in our system is the person who's at the front line,
and they are the ones actually making the decisions because they are the ones interacting with the person who's using care or,
you know, uh, accessing services or, you know, they're controlling resources.
The ultimate they're the ultimate controller of these services. And what's happening about them is kind of like an ecosystem.
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.
Uh, and the third is, of course, that health systems are social systems.
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.
And so the problems of society also reflect in the problems of health systems.
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.
Uh, so this very much reflects so I read some papers, uh, very influential papers, which I find are incredibly important.
Haven't got enough importance, uh, including one by Sonia Nishtar who was uh, uh, became later became science minister of Pakistan.
And she's now that the chief executive officer of Gavi, the immunisation uh agency, which is quite for me.
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.
Uh, so, uh, she wrote this on mixed health systems, uh,
being centrally planned government health services that, uh, operate side by side with private markets.
And I think this is really important because this, this, this describes a large number of health systems across the world,
especially those in low and middle income countries, those which you might call the relatively less planned systems and economies.
Uh, there's a sort of a laissez faire approach when it comes to how private sectors operate in these countries.
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.
And why it's important also, not only for those countries,
is that now we are seeing many countries slide back into that model, including this country.
Uh, and we are seeing now an approach where you will see increasing competition between public and private,
and that creates a unique set of phenomena.
Uh. Which, you know, can ultimately compromise public services as it impacts on health equity and access to care.
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.
Uh, now. So this is kind of like.
Something that, uh, you understand. What about in 2010?
Uh, but I don't think it's got enough traction.
This understanding of mixed health systems and heterogeneity in health systems at one one kind of,
uh, reflection of that is that just a few months ago, one of the chiefs of W.H.O. made this tweet.
He said, having a functional taxonomy of the private sector in health is important to facilitate effective engagement in health and wellbeing.
So, I mean, we are in 2024 and we don't have an effective taxonomy of the private health care sector.
We haven't properly understood what the private healthcare sector is incredibly diverse.
It's not just one thing. It's many, many different things. And understanding that is really important.
And actually he's a friend of mine.
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.,
who still function on a very old fashioned thinking of of what the private sector is.
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.
And this is again gives that sort of again a reflection of why systems are social systems.
And that will kind of illustrate that a bit hopefully.
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.
Uh, which doesn't necessarily say that this is like a mathematical distribution,
but it's like a way that people can organise their thoughts around, uh, heterogeneity.
Uh, and I, we found it useful to think about, uh, diversity in axes rather than in Japanese.
Uh, so, for example, there's a whole range, a spectrum from the formal to the informal sector.
There's a spectrum from the specialised to the. There's even a spectrum from the private to the public.
It's not a clear demarcation. There's a lot of private activity that happens in public sector.
There's a lot of public minded activity that happens in the private sector.
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.
Uh, and again, that's also a spectrum.
Uh, there's a lot of it's not like you have people working only in Western biomedicine or only in local health professions.
You'll find people mixing their practices a lot. So these are all continuums.
They are not continuous. They are not, uh, discrete categories.
And one thing we can take away is that.
The segment on the right tends to be, in a way, often philosophically, physically, and practically logistically closer to communities.
Whereas the ones we think about all the time are the big hospitals and the doctors and the nurses and the operating theatres,
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,
but actually they're kind of removed in some ways from the realities of people's lives.
Um, of course, that's a big generalisation, but I think it holds up just to a large extent.
Um, so that's one just an example of a way of looking at heterogeneity.
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.
Um, okay. That's. I'll skip this. This is just, uh, uh, uh, photograph of the my collaborators in India.
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.
The people in the health workforce who are relatively don't find a large voice in in the kind of policy sphere.
Uh, we looked at rural doctors, uh, we looked at private practitioners who are often dynamic, elected from a policy perspective.
In India, we looked at what we call Dicom practitioners traditional, complementary and alternative medical practitioners.
Uh, and we looked at nurses again here.
Nurses are still politically much more influential as a leadership structure than a career pathways in the UK.
But that's not the case in many other countries. And in India certainly was the case.
So we, uh, we undertook studies on a number of these, uh, on these sort of marginal actors.
And I want to give one example. So a lot of this was using qualitative methodologies, ethnographic approaches and people.
I often get to ask how is this different from journalism.
And I say it is different from journalism because in in good quality qualitative research, we tend to avoid asking people about their opinions.
We ask people about their experiences and that have an effect, uh, the trends in their behaviour,
the trends of their responses from their their accounts of their experiences.
And that's much harder to do than asking people about their opinions.
People are extremely free with their opinions and they are extremely closed about their experiences.
Uh, so you need a very good skill set to actually do good quality qualitative research.
But that's just my defence of qualitative research.
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,
which is, uh, insurgent afflicted area. It's, uh, conflict zone in eastern India.
So this is, uh, a branch into this.
Going to the other side is on insurgent territories, Naxalites, uh, who operate in that territory.
So and this is, uh, one of the instances where the number of security people killed and supplied by health care sent over there.
So really remote, really isolated area where, you know, there's barely any doctors and barely any health systems to speak of.
But there are some.
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.
So the bigger policy question here is doctors and distributed right across different systems.
Uh, most of them are concentrated in cities.
We want to get more people to the areas where they really needed.
So the normal question to ask would be, how can we make doctors stay on in villages, right?
Or we say, how can we can we replace doctors with other types of health workers in those area?
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.
Can we learn anything from those people? And so we did this sort of ethnography of those of those doctors we did see on.
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.
They're kind of like the people who couldn't get into any better boasting.
Right? So to the extent that actually they all have very interesting explanations for why they're there,
and some of them are pretty intuitive, but it's really important to document that, right?
Geographic and ethnic affinities, a lot of them were actually people from those areas with like family affinities,
social affinities, tribal affinities, and they were just more comfortable in that environment.
That's where they're from. And so they're back with their people. It's not like they're saints.
They're just happy to be there and working with their people.
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.
Uh, and then there's also these really important sort of practical considerations and, um, make sure there's a school, you know,
where you're going to post your doctors and nurses, uh, and make sure there's,
you know, job security for these people and give them their basic supports.
This is a kind of a very condensed version of what, what our findings were.
But it influenced policy because it's a striking.
Uh, citing, uh, evidence in support of affirmative action, for example.
You need to get people from you need to prioritise educating people in professional, uh, medicine from those particular pockets.
Uh, and so and so that they will go back and serve their own communities.
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.
So in fact, directly into the ministry's, uh, the national policy for, uh, posting and transfer.
Uh, and it has had an impact then on, uh, several state policies as well.
So that was a bit about seeing systems. So that's already quite a lot.
I've spoken quite a lot already, but let me maybe say a little bit about governance.
And then I think I'll skip the next section and go straight to the third one.
Yeah. So governance. Uh, a lot of my work has been on understanding governance.
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.
So why governance? Um. These are the kind of standard definition of the government's guidance on the health
system when it comes to health systems guidance for the system through design,
management, regulation, accountability. A lot of the words we hear regulation, stewardship, uh, institutions, rule systems.
Uh, now, why did we decide to focus on governance?
This wasn't just me. This is a whole team of us in India deciding to focus on governance.
I think it came from a sort of a multitude of different insights as practitioners.
So a lot of us came from the practice space. We want researchers mostly.
And we had we we knew that governance challenges are the, uh, the roadblocks because we'd experienced it ourselves,
uh, not only as practitioners trying to get things done in systems, but also as citizens.
So when I try, for example, of getting, um, insurance being out in India even as, uh, where affluent.
Uh, doctor? Um, I'm going to. I'm I'm a I'm a doctor myself.
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.
Uh, it's there's so much red tape and so much bureaucracy,
and you have standing so many lines that you almost at the end of it, just say, forget it and just be myself.
Right. So these are the kinds of challenges that we face as, as individuals ourselves.
And then of course, that gets amplified like ten times if you go further down the social order.
And if you're underprivileged, then it's almost impossible if you think about getting insurance bills.
And then we were interested in this as a from an academic perspective as well.
And so the research was pursued. And then I'm confronting the living Constitution with the manifestation of authority.
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.
We look at the rules that exist in right written form.
And then we look at what people are actually doing and we compare that to.
And it's not just about saying, oh is different from me. It's about the fact that what people are actually doing.
Is also driven by a bunch of rules, norms, batons, but those are not written anywhere.
There's a whole informal parallel system that functions side by side with the formal system.
So, um. Yeah. So interesting.
Struck by.
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.
And he's talking about the global health system. And how mutual friend Shelby Bola responded to that.
You know, with another tweet, he said, the system is working just fine. That is the system.
It's supposed to not work for some people, and it's supposed to work for other people.
Right. So, I mean, it's a provocative kind of polite way of looking at it,
but essentially the parallel system exists side by side with the formal system because it works for some people.
It just works for the wrong side of people. Think it works for the people who are benefiting from those parallel arrangements.
It doesn't work for the people who are supposed to be working for for the benefit the poor,
the underprivileged, the people who really need the system to function for them.
And that gets mirrored at the local level. So when people talk about corruption, I get, I get quite.
It's my little pet peeve. Corruption is not rent seeking.
It's not pay outs at the bottom of the food chain.
It's this the existence of blindness to the way that entire systems are functioning for a particular set of interested actors,
and not for the broader public good. That's corruption.
Uh, so anyway, that's just my pet peeve. I can get into that and more.
Uh, so this is another way, something like this. And again, very much the same thing.
Uh, when you say justice, we don't we shouldn't just focus on what should be happening.
We should actually look at what's happening. Yeah.
And that's a so that's really a strong statement for doing research on governance, doing research on health systems.
We need to focus on what actually happens in actual lives rather than merely looking for ideal institutions and elements.
Um. You. Just a few more examples here.
So basically we did work on three different sets of institutions community institutions, regulatory institutions.
And well broadly speaking, ministries of health. Uh, so this is over a long period of time, several different projects.
Uh, so this is a really interesting one, posting and transfer policies.
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,
doing the right jobs. It's so boring and so basic that everybody, nobody thinks about it.
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.
And there are very clear factors driving it.
And the clear phenomenon that clear, uh, the problems that exist within that that can be understood and solved.
So it's really important to research that. So I'll come to that in a little bit.
So these are some findings we had organised professional interests influence regulatory design and implementation.
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.
Regulatory capture in other words informal parallel arrangements for health worker deployment.
So everybody kind of makes a deal, right? If you can you can buy yourself out of a good posting.
Uh, well and and sometimes actually there are some, uh, government state governments,
especially in Nadu in India, which have actually implemented excellent posting and transfer policies.
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.
They're very imaginative about the way they do their posting and transfer. And it actually works quite well.
Uh, yeah. So a lot of issues around design gaps, functional variety.
So this is of course all research that fed directly into the policymakers.
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.
Then we did a bunch of stuff on community systems. So again this is documenting failure.
That's also really important. So there are something like 300,000 village communities across India.
And that's really the the defacto mechanism to introduce community voice into health planning.
Uh, so to a large extent, they don't work.
So it was important to just document that. It's like you, you get some women, you get some lower costs.
Uh, you'll get some people from underprivileged communities being represented on those committees.
But ultimately, the social factors militate against them having an actual voice in, in on those committees.
Uh, but there's still there instances where you see things shifting just by virtue of the committees there.
There are instances where people actually can exert their, uh, you know, uh, the can can have a voice.
You actually see some changes in some improvements in service delivery as a result of communities having a voice.
So documenting those little successes, those little gains are also important.
Uh, and also this again, also went into the national policies for village health committees, some of the local governance laws.
So for example, India has a. Want to see on Sunshine Beach.
So fantastic. Just local self-determination. It's like every.
And that's not just for health. That's it politically.
It's like, uh, every village has the right to determine its own, you know, resource, how its resources are located.
And there's like, that's in law that's constitutionally enshrined. So, so that that was a really positive.
Framework, on the basis of which these village health committees could function because the Relations Committee,
the subcommittees of the of the local government.
So again, laws are important is very boring.
But you know, don't get rid of the laws. They are really important because they have to sort of maintain the status quo.
They have to maintain, they have to give opportunities for positive things to happen.
Yeah. Then this was what created a show on. Ministries of Health.
But this was upheld almost across the world. Uh, really stuck in the past.
They still think they control what happens in health systems.
How many of you work in ministries and have. Or have looked in this exhibit.
To maybe. I mean, you could share some of your experiences maybe after that.
And, but, uh, but unfortunately, the demands on them are very different.
They're not just focussed on delivering services.
Now, ministers are expected to be negotiators, stewards, regulators.
They are supposed to handle climate change as well as, you know, delivering primary health care.
And they're supposed to do all kinds of multi-sectoral stuff. Uh, it's really hard.
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.
From ministers of health say what should be our functions. I won't name the countries, but it's a very genuine question, right?
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.
So that is a little bit part of the impetus for. So we would have to say no, we don't have a framework.
I was in a research department and we didn't even have the authority to put up norms and policies.
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.
Not just for the win the old fashioned way, but for some future perspective.
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.
And this became so important then when Covid happened, the ability to be ready for changes and to manage relationships.
And when that's you.
I mean, none of the ministers of health had actually set out to manage the relationship with the private sector or with other sectors.
Uh, with by the sectors, I mean other like transport and education and, um, environment and so forth and values.
So I mean, that was another big aspect.
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?
And are they really being able to do that effectively?
So there was a paper that came out of that. And working people are looking critical.
Uh, so I guess all of that. That's I mean, very messy kind of broad view of the field.
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.
Then what's important to focus on. Uh, and I'm going to give three examples of.
Problems that we typically see in health systems across the water. Gaps in primary care.
That's a big one. Inequitable access for pretty much similarly health care quality, right.
And these are the. Immediate explanations that we had for for these problems.
Right. Not enough skilled health workers not distributed appropriately.
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.
That's a big problem right now. That's a big issue in the UK right now.
We are facing, you know, effectiveness of regulators. So we don't really have the governance mechanisms in place.
So typically, what are the kind of policy solutions we throw at these problems.
Right. We would try to find ways to equalise the availability of health workers.
We throw technocratic solutions at these problems. Uh, we try to say skilled non physician workers more.
Uh, we tried to find some Band-Aid solutions, but our governance institutions strengthen them.
Or maybe even disband them. We say, oh, regulation isn't working, so just give it up.
You know, why regulate? So, uh. But actually the.
Issues. Underlying challenges are not always technical and technocratic, but often societal, social and societal.
So as they relate to these issues that some of which I highlighted. Institutional capture.
So institutions have been taken over by certain interests.
Uh, learning? Yes, that's a big one.
I don't think there's enough mechanisms for people to actually for institutions and mechanisms to change and adapt.
And that's the Ministry of Health. Examples was one key one. There is no way for ministers to redefine them.
So they don't have those inbuilt learning and institutional linkages.
Professional dominance. I didn't talk about that in depth.
But for example, let me give you an example. In India, the nursing council is headed by a doctor.
Uh, professional dominance is a very well documented sociological phenomenon.
Elliot Friedson, if you want to read, wrote about this in the 1960s.
Uh, Roger Jeffrey wrote about it. Uh, it is in a low and middle income country context.
Uh, it's, uh, it's not about the fact that doctors are dominant.
It's about the organised interests of medical professionals often work in such a way as to propagate their own interests at the.
Expense of other cadres of. And that really influences how things happen.
It's a big determinant of health systems, social determinants.
This is all social determinants, all the health system and the capacity to have simple capacity gaps.
We don't have the skills to actually govern and to manage systems.
Know what's critical here. Let me, before I go there, is that none of these problems can be solved from the outside.
They're all issues that societies have to tackle from within.
I mean, you can help them.
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.
You guys are all at Oxford. It really helps me to think about what my role is in all of this.
And I think I think it's this. And that's the one we should be focusing on.
I don't think I can sit here and solve issues around corruption and institutional capture and or professional governance.
I mean, I can shed light on them, but that's really about learning.
Uh, so but then that also really tells us about how health system strengthening can happen.
And it needs to happen from the from the inside.
Uh, and these are the different things that health systems can do about themselves.
Um, yeah. I mean, that's a framework.
You can touch on that more.
So let's skip over this section, which is really about health systems, uh, the kind of institutionalising health systems research.
And maybe talk a little bit about. Just end with this bit on changing health systems.
Yeah. Uh, so my title was, uh, Mixed Health Systems and, um.
Looking at both the present and the future of Pullman systems and how.
A weekend as as researchers, as people involved in learning become more effective, become relevant in this context.
So when we nowadays the discourse on health systems is entirely dominated by these topics, and understandably so.
Ecological change. Pandemics.
Current and future pandemics and preparedness for them or not, humanitarian shocks.
I mean, I think conflict is probably a big headline right now.
Uh. Die. Health systems are being decimated.
Uh. Increasing applications of digital technology and AI.
And I think along with that, this information. But I mean, I think I'll come to that.
That's still a little bit surprising when you. So this is what's grabbing the headlines.
But then below that kind of little attention horizon that all the headlines are focusing on are some things that.
A much more predictable and. Clear urbanisation.
Uh. Africa is going to have 50 megacities in about 20 years.
We're going to have more of. There's going to be more urbanisation in Africa than in all other continents put together.
And. That will come with different forms of commercialisation of healthcare as well.
Uh. Healthcare configurations. Health market configurations are already changing completely.
Private equity is making inroads into health care.
That means that health care will no longer be run by doctors or by technicians.
That can be run by the bottom line in a way that we cannot even imagine right now.
These are huge shifts. And these are things we can definitely predict.
Because, I mean, you might want to sort of do something about it.
But these are huge social changes that are happening. The spread of disinformation, I mean, I think that is undeniable.
That's not just how it's across the world. It's it's one of the major, uh,
the ability of information as well as misinformation to spread is and influence entire populations is a clear pattern that we are seeing,
and not one that's just going to go away. And below that is another attention horizon.
And below that of the problems that we've seen for the last 50 years.
And they remain unchanged. The governance failures, market failures, the same old software problems and issues of conflict, contestation.
And persistent inequities. And the point here is that some things are much more predictable than others.
And I think we need to focus on all of those things together, not just in isolation.
You can't address the climate.
You can't make systems climate proof without meeting them, without addressing governance challenges, or without addressing marketing.
All these things have to be taken in totality. And for that we need a social science perspective.
So if we are to be involved in effective health systems research, I think we need to be.
I think social science is underused. We need to throw the full weight of the social sciences to better understand and unpack these phenomena.
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.
They are to some extent,
but I think they are generally overprivileged cons when we consider the spectrum of research methodologies that we have at our disposal.
So from a future agenda perspective for the field. These are some big themes that I think we need to look at.
Understanding mixed health systems better and managing them. Designing and managing systems for urbanising and migrant mobile populations.
Integrating digital interventions. Of course, dealing with epidemics and climate and conflict and tackling the infodemic.
Um, but along with that. Addressing the unfinished agenda of universal health coverage and primary health care.
And how we do that. As I said already, is to, I think,
upscale the use of social science approaches to study not only the technical aspects of hardware or health systems, but also the software.
Uh, to prioritise a lot of the kind of slightly boring functions of our system, what we call the organisational and institutional level issues.
Uh, to understand the patterns, to understand. And it's doable.
There are, you know, the the social sciences have the tools and frameworks in which you can understand how have systems function.
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.