This blog is part of a series of blogs written by participants at HSR 2022 reflecting on some of the key messages and learnings emerging from the symposium.
Health Policy and Systems Research (HPSR) stakeholders continuously seek to advance the field by highlighting and increasing attention to various aspects of its practice. For instance, the Ethics and Justice Technical Working Group (TWG) of Health Systems Global has been advocating for the need to be cognisant of and address everyday ethical issues which emerge during the entire research process and not to just consider ethics as a regulatory requirement for research.
Over the past several years, emerging perspectives in global health have triggered discourse on issues such as solidarity and decolonisation. These, no doubt, are matters that are relevant to HPSR practice. Several discussions on these issues were held at the just ended HSR 2020 Global Symposium held from 31st October to 4th November 2022 in Bogota Columbia, focusing on the theme, “Health Systems Performance in the Political Agenda: Sharing Lessons for Current and Future Global Challenges”. One such session was hosted by the Ethics and Justice TWG in collaboration with the Decolonisation and Global Health Research Exchange Network, and moderated by Sassy Molyneux and Seye Abimbola, a co-Chair and co-Vice Chair of the TWG respectively. A wide range of speakers explored the implications of social justice, solidarity and decolonisation for HPSR. Bridget Pratt from the Australian Catholic University, explained that ensuring social justice in HPSR includes promoting the wellbeing of beneficiaries, recognising knowledge from the Global South and ensuring that is visible and valued, promoting inclusion, avoiding the recreation of unfair power relations among HPSR stakeholders. The need for solidarity was also emphasized. According to Caesar Atuire from University of Ghana, solidarity can be operationalised in health research by addressing the conceptual ambiguity surrounding the term, seeking convergence on actionable goals, and developing tools for measuring these goals.
David McCoy from the United Nations University’s International Institute for Global Health advocated for the need to shift power in global health through decoloniality. He explained that coloniality refers to ideas, belief and narratives that legitimise and sustain colonialism and colonial relations. He highlighted the need to tackle coloniality across three dimensions: colonialism within global health (addressing power asymmetries) colonisation of global health (dominance and control of the global health system and narratives by certain actors), and colonialism through global health (using global health as a means of extraction, exploitation, and profiteering).
Incorporating Principles into Action
As these deliberations emerge, stakeholders need to carefully consider practical ways of promoting these principles in HPSR. While it may appear that several issues are being raised simultaneously, it will be essential to reconcile these multiple principles as they are not mutually exclusive. Indeed, they are mutually reinforcing and promote self-determination of all HPSR stakeholders and legitimacy of all perspectives.
How do we translate these principles into action? How do we incorporate these ideologies into practice? Some efforts are being made in the field. An example is the contribution of increased funder support for Southern-led research and capacity strengthening initiatives and the need for Southern actors to be reflexive in order not to recreate power imbalances among partners. Seye Abimbola, a journal editor, cited measures being taken by journals including requirement of reflexivity statements to promote equitable authorship, increased use of article reviewers from the research context, waiver policies for LMIC authors, and editors’ commissioning of papers to promote pertinent discourse on some of these emerging issues. Walter Flores from the Guatemala and Accountability Research Center shared an example of supporting communities to fight for their own health rights through political advocacy as a more effective approach to HPSR. Manasee Mishra from Parul University in India also pointed out the importance of qualitative approaches in HPSR as a means of recognising and mitigating power relations and the need to engage elites, who are often gatekeepers in social justice initiatives.
Making More Fundamental Changes
It is clear that many more initiatives promoting justice, solidarity and decolonisation will be required in HPSR to produce the required transformation. It may be more transformational to take several steps back and consider fundamentally different approaches to HPSR in the light of these principles. We may have to redefine HPSR by asking what it means to different actors in different contexts, and whether having a universal definition suffices. We may need to rethink HPSR through reflexivity and questioning of internal assumptions and established norms. It is important to note that these considerations are not just about North-South relations but mutual recognition of all stakeholders involved in HPSR and the varied perspectives and contextualised approaches that produce the type of health policy and systems that work for each setting. It is also important to note that there will never be one way of making change, which will require ‘all hands on deck’. Finally, it is clear that a positive transformation in the field will require continuous engagement with emerging issues and commitment by all HPSR stakeholders to taking the necessary action.
By Nadia Tagoe, Kwame Nkrumah University of Science and Technology, Ghana