By Stephanie M Topp
The lead up to the upcoming 3rd Global Health Systems Symposium may be a good time to reflect on an emerging paradox in the world of global health. On the one hand, we are seeing a growing emphasis on the need to generate health service and clinical models that work across multiple communities and countries. This emphasis draws great legitimacy from the ‘global’ in global health, and stresses the value of cross-setting comparisons and scaled-up implementation. More recently, however, and related to a mini-renaissance for health systems and policy research, there has also been an increasing number of practitioners and researchers actively drawing attention to the importance of understanding how national and sub-national context shape the success or otherwise of policy implementation.
As is now increasingly well recognised, health systems are social, complex and adaptive – incorporating multiple and different types of actors with varying positions, view points and agendas. And the power dynamics that influence the decisions, actions and relationships of these actors is a critical element of understanding how national and sub-national context influences and shape policy implementation. Perhaps due to the amorphous nature of power, there remain comparatively few formal studies of power in health systems, particularly in low and middle-income settings, although with a growing body of research examining relational aspects of health systems (e.g. posting and transfer; abuse and disrespect; governance issues; local policy implementation), and, with the emergence of groups like SHAPES, this seems likely to change for the better.
To return to the paradox outlined above, however, a question that warrants attention is whether the increased academic attention being paid to the role of power in policy implementation will influence the trajectory of increasingly globalised global health policy? Some, consortiums such as CHEPSAA with their focus on local, ‘people centred’ interventions provide an example of one way to institutionalise the skills to assess and manage local power dynamics via improved health policy and planning. Yet the development and implementation of interventions to strengthen health systems in low- and middle-income settings often remain overly simplistic and mechanistic.
Under the pressure of donors seeking fast and easily measurable interventions, great emphasis is still placed on improving the material capabilities of individual system building blocks (e.g. infrastructure renovations, in-service training, supply chain improvements, or information systems upgrades). And, while these interventions play an undeniably important role, in isolation they fail to recognise the inter-connectivity of health systems and carry little potential to positively influence the values, work cultures or power-dynamics that shape health system actors’ decisions and behaviours over the long term.
The enormously politicised push for the universal adoption of PMTCT Option B+ makes an interesting case in point. Fuelled by a research and global policy elite who continue to privilege comparable metrics and rapid service scale-up, international advocacy has focused on the clinical efficacy of Option B+ while sidelining concerns related to the complex implementation chain, including the service conditions, behaviours, beliefs, and associated power dynamics that will inevitably shape the policy’s local effectiveness. Questions arising might include: how will health workers (especially in already overwhelmed primary facilities of many LMICs) interpret and operationalise the increased patient load associated with earlier ART initiation? How will inter-professional dynamics be negotiated to enable the level of task-shifting necessary to make Option B+ a reality? How will pregnant women themselves react to being initiated on life-long ART? What effect will this new treatment regime have on long-term community trust in public primary health services?
Raising these legitimate concerns risks being labelled a global health ‘naysayer’. But such questions remain important. And in an era of increasingly globalised health solutions, with growing pressure on researchers and policy makers to find ‘scalable’ and ‘sustainable’ solutions, inattention to such matters will play an ever more important role in undermining otherwise proud efforts to improve population health outcomes. One hopes that the upcoming Cape Town event will provide an effective platform for airing such issues and taking the challenge to the policy elite of global health.
Stephanie M Topp (@globalstopp) is a Health Systems Technical Advisor at Centre for Infectious Disease Research in Zambia; Visiting Assistant Professor at the University of Alabama at Birmingham and an Honorary Research Associate at the Nossal Institute for Global Health, University of Melbourne.