Opportunity to work with Future Health Systems

One of the Future Health Systems partners, the Institute of Development Studies in Brighton, UK, is seeking applications for a new FHS-related position: Post-Doctoral Researcher: Health systems, health markets and the diffusion of innovation.

IDS are looking for someone with a doctorate degree in social science or public health, who combines excellent research skills, a knowledge of the messy contexts within which poor people seek health care and drugs and a desire to find practical ways to improve health system performance.

The successful candidate will have special expertise in one or more of the following topics:

• intervening in health markets.
• analysing institutional development in the health and social sectors.
• studying diffusion of pro-poor innovations.

They should have a very good knowledge of development and development challenges in Africa or Asia. Substantial work, research and/or programme experience in low and middle-income countries is essential along with excellent analytical, research methods (qualitative and/or quantitative) and writing skills, demonstrated by a record of projects, publications and reports. Fluency in one of the languages of the partners of the Future Health Systems Consortium would be an asset.

For more details and to apply, please visit the IDS website.
 

Ghana: take 70,900 metric tons of frozen chicken, add politics

A billboard advertising chicken in Accra, Ghana.
By alew on Flickr

By Jim Sumberg and John Thompson

The well known expression – that [something] is 'as likely as turkeys voting for Christmas' – makes an intriguing and to date poorly understood link between poultry and electoral politics. But in some parts of the world, poultry has a wider political – and psychological – significance for how voters and politicians behave.

During some recent field work in Accra, Ghana, while researching pathways to sustainability in the poultry sector, we took the opportunity to conduct a series of rapid, opportunistic 'interviews' with taxi drivers. Our focus was on chicken consumption: the last time they ate chicken; the way it was prepared; the origin of the chicken; how often they eat chicken etc.

The 'sample' was 24 male taxi drivers aged between approximately 25 and 50 working in the nation's capital. We obviously make no claim that these respondents are in any way representative of consumers at large. Nevertheless, a number of interesting points emerged:

1. While nearly all the taxi drivers reported eating chicken, and some several times a week, nearly two thirds of our informants expressed a preference for fish. They also noted that fish had become more expensive in recent years.
2. Most had fairly well developed views and preferences in regard to the different qualities (price, flavour, texture, 'hardness' or 'softness') of different kinds of chicken (e.g. frozen imported, 'fresh local' or 'village'). While many expressed a preference for 'fresh local' or 'village' chicken, the relatively low price of imported frozen chicken (which can be less than half the price of local chicken) weighs heavily in its favour.
3. Most expressed a preference for a particular chicken 'part', with thighs being the most commonly identified. One young man explained this choice by saying: 'that piece is a heavy meat'. (Thighs seem to account for a large proportion of the estimated 70,900 metric tons of frozen chicken imported into Ghana annually). Only one said he had no preference and could not tell which part he was eating.
4. A number of taxi drivers highlighted the fact that when they were children they consumed chicken only very occasionally: one told us that in those days in the village his family ate chicken and jollof rice only once in a year – at Christmas. This shift in consumption appears to be specific to chicken as opposed to all forms of meat. Few of the taxi drivers mentioned either recently eating or having a preference for other kinds of meat (beef, goat, pork, etc).
5. The 'turn to chicken' may have an important generational element, with young people giving chicken a central place on their plates. In the words of our research assistant, a recent university graduate, 'I cannot even remember the last time I ate beef''. He frequents 'chicken and chips' shops and other fast food eateries, as do his friends.
6. Health and safety concerns were very apparent. The fact that you could never be sure where the frozen chicken came from or how long it has been frozen arose several times. A number of our informants linked their preference for local or imported chicken, and particular chicken parts, to fat content. They also mentioned radio, newspaper and internet stories about foreign operators having purchased sick and dead birds and dressed them for sale in Ghana, or chicken parts being injected with preservatives or water before being imported.

Our field work coincided with the final weeks of campaigning before the December 7, 2012 presidential election. We took the opportunity to ask each of the taxi drivers whether they intended to vote. With only one exception (he did not have the proper identity documents), everyone came back with an immediate and emphatic, 'Of course!' and most responded in a way that implied: 'Why would you even ask such a silly question?'



Frozen chicken on sale in Ghana. By ethanz on Flickr

Which brings us back to the link between poultry and politics. Colleagues in the Future Agricultures Consortium are exploring the effects of democratisation on the political economy of agricultural policy in Africa. One of their concerns is to understand in what situations policy processes result in outcomes that are favourable to smallholder agricultural development. How do the distinctive features (social, political, institutional and agro-ecological) of individual African countries influence the incentives for agricultural policy making and implementation? And how do these incentives lead to divergent 'politically feasible' policy actions?

Our interviews with taxi drivers in Accra point to another dimension of the story of democratisation, agriculture and food. How is the vibrant, multi-party electoral environment in Ghana affecting food and agricultural policy, and how does this link to the lives of politically aware, informed urban citizens with rising incomes and expectations (such as our taxi drivers)?

Simplistically, policy processes around poultry in Ghana can be conceived of as dealing with a set of trade-offs between the interests of four groups: small-scale maize and soya producers; commercial poultry producers; urban consumers; and politicians.

The massive increase in the importation of frozen chicken over the last decade would suggest that, despite much rhetoric about support for the domestic poultry industry, policy makers have consistently favoured the interests of urban consumers over those of domestic poultry producers.

Put another way, policy makers seem to have prioritised food policy (i.e. to increase the supply of inexpensive, protein-rich foods to consumers) over agricultural development policy.



Three-storey KFC in Accra.
By sportivetricks on Flickr

Part of the reason may be that chicken meat has become a much more central part of everyday food consumption, particular for town and city-dwellers. Indeed, chicken meat may be becoming what has been termed a 'psychological staple', associated, particularly among the younger generation, with self-identity as part of a modern, middle income country.

If this is indeed so, it would be a brave (or foolish?) politician who would make any move likely to result in a significant increase in the retail price of chicken meat. Chicken might be thought of as a 'politically charged' food (along with, for example, rice), with important implications for policy processes and electoral outcomes. Just as sensible turkeys don't vote for Christmas, politicians may not risk making chicken more expensive for consumers – even if local agriculture might benefit in the long run.

For more information about the STEPS Centre's project on poultry in Ghana, visit the Livestock project page on their website.

References:

• SRID. 2011. Agriculture in Ghana: Facts and Figures 2010. Accra: Ministry of Food and Agriculture (full report - pdf)
  
• Iwasaki, I. (2004) Rice as Psychological Staple: The Role of Rice in the Creation and Maintenance of Individual and National Identity. Unpublished MA thesis. University of Sheffield, Sheffield

Depression in the delta: Women in the Sundarbans face serious mental health challenges

A recent article from the Women's Feature Service featured in the Hindu and written by Sharmista Chowdhury explores the complex issue of mental health among women in the Sundarbans. The article features several quotes and findings from recent FHS research in the area. According to FHS research:

The average of such cases [of deliberate self harm or attempted suicide] per month in each BPHC [Block Primary Health Care Centre] has gone up from 11 to 15 between 2001 and 2008. The share of pesticide or chemical poisoning in total DSH cases has also increased to 89 per cent.

Professor Barun Kanjilal, the principle investigator from FHS-India explains that:

The livelihood insecurity, which is a product of a complex link between repeated climatic shock and chronic poverty, is the main reason why Sundarban women are disproportionately affected by mental health problems. Ironically, the easy availability of modern agricultural inputs, like insecticide, has made it easier for them to find a ‘solution’ in suicide.

In addition to frequent climatic shocks, like Cyclone Aila that came through the area in 2009, mental stress can also arise from post-traumatic stress following animal attacks. The article notes:

In villages adjacent to the forests, where communities depend on fishing and collecting forest produce, people are especially vulnerable to animal attacks. Women, who often spend hours standing knee-deep in the water, collecting spawn, are dangerously exposed to sudden attacks by tigers or crocodiles. In addition, there is always the lurking fear of widowhood – every time the man ventures out on a fishing trip or in the forests.

FHS book, Health Markets in Asia and Africa, launched in India

Abhijit Vinayak Banerjee of J-PAL and Barun Kanjilal of IIHMR
introduce the new FHS book to researchers interested
in rural health care providers in India.

Members of the Future Health Systems consortium in India took the opportunity of a recent gathering in Kolkata, India on the role of Rural Health Care Providers (RHCPs) in India to launch its new book Health Markets in Asia and Africa: Improving quality and access for the poor. The learning and sharing meeting, which was convened by the Liver Foundation, West Bengal and the Bristol Myers Squibb Foundation from the USA, took place on Sunday, 18 November 2012 at the University of Calcutta.

Within the Indian context, RHCPs (also called RMPs, or rural medical practitioners) provide the majority of primary health care as compared to both formal private sector and public sector providers, especially in rural areas. However, this important part of the Indian health system has been ignored for too long. To begin to address this, the meeting convened over forty participants from diverse backgrounds, including: clinicians from both private and public health care institutions, organisations engaged in capacity building interventions for RMPs, research organisations, academic institutes, donor agencies and the media.

Various participants offered their perspectives on why RMPs remained a taboo topic in Indian politics and academia. For example, Swati Bhattacharya, Editor of Anandabazar Patrika, the local-language daily with the widest circulation, noted that the media’s take on RMP is more like society’s view on child labour: a necessary evil. As such, the media mostly remains non-committal on the topic, while paying lip service to the cause of capacity building for the RMPs. That RMPs do not constitute a voting block does not help either: they are a sort of political orphan. Finally, media coverage on health is more focussed on hospitals, in-patients and sudden deaths, which broadly ignores issues of access to most primary health services.

But working with RMPs is itself a challenge. As Arijita Dutta, a professor at Kolkata University, put it, working with RMPs ‘is essentially a trade off between quality and access’. In other words, it’s impossible to get the level of coverage that these RMPs provide through the formal health sector, but the care that they offer is not always of high quality.

Overall, most participants felt that it is necessary to get a complete understanding about the service delivery quality of the entire health system. Merely singling out RMPs and building their capacity while keeping all the rest the same would not help in sustaining the interventions. They stressed that future research should focus on demand-side dynamics related to what health care users perceive as quality and effective treatment.
Abhijit Vinayak Banerjee, Professor of Economics at MIT and Director of J-PAL in the US, and Gerry Bloom, Research Fellow at the Institute of Development Studies in the UK, launched of the FHS book, hoping that it could inform discussions of the future scope of research to find out what works and what does not in mainstreaming the RMPs to achieve universal coverage in health in the remote areas and for the vulnerable populations.

At the end, key questions raised at the meeting include:

• Training for RMPs was questioned as a way of improving care. This assumes that it is a lack of knowledge that prevents quality care – but there are other incentives (like selling unnecessary drugs) at work.
• As such, are there ways to shift incentives? In other words, is the profit earning potential compatible with desired health outcomes?
• RHCPs should not look more qualified than they are, or it risks legitimising sub-par practices.
• Instead of training, are schemes to increase coverage of formal health providers, like rural doctors schemes, a better alternative? What are the costs and benefits of each approach?

"Pastoralism" book launch, 29 November, London

On 29 November, we're launching the book Pastoralism and Development in Africa with a panel debate and drinks reception in Central London, held in association with the Royal African Society.

Book launch
Pastoralism and Development in Africa: Dynamic Change at the Margins

edited by Andy Catley, Jeremy Lind and Ian Scoones

29 November 2012
London House Large Common Room
Goodenough College
Mecklenburgh Square
London WC1N 2AB

6.00 pm, followed by refreshments

To register, email Harriet Dudley: h.dudley@ids.ac.uk

Chaired by Dr Camilla Toulmin
Director, International Institute for Environment and Development (IIED)

Dr Jeremy Lind (Institute of Development Studies, University of Sussex) and Prof Hussein Mahmoud (Pwani University College, Kenya) will present some key themes from the book. Prof Katherine Homewood (University College London) and Dr Zeremariam Fre (Executive Director, Pastoral and Environmental Network for the Horn of Africa – PENHA) will respond.  Followed by open discussion.

For more information, see the event page on the STEPS Centre website.

This book is part of the STEPS Centre's Pathways to Sustainability book series.

Are informal providers a dangerous detour on the road to universal health coverage?

At the Second Global Symposium on Health Systems Research, the unifying theme was 'universal health coverage' (UHC). A commitment to achieving UHC was enshrined in the Beijing Statement, and much discussion at the symposium targeted the post-2015 agenda with one health goal.

But the road to universal health coverage is long, and the devil is in the details. Human resources for health is critical in meeting the access element of universal health coverage, and working with informal providers to improve care is one way of bolstering the health workforce. Some, however, argue that working with informal providers in the private sector is a dangerous distraction from meeting UHC. Several panels, however, were quick to point out the critical role informal providers play across health systems, especially one convened by the Center for Health Market Innovations entitled, which Tom Feeny of HANSHEP blogged about before.

In the videos above, several respondents challenge the notion that informal providers are a dangerous distraction. Dominc Montagu, of UCSF, for example, takes a pragmatic stance by suggesting that millions of people around the globe already get their health services from informal providers, and that 'their not going to change that just because someone has a vision'. Meenakshi Gautam, of the Centre for Research on New International Economic Order, India, stresses that primary care must be within a half-hour walk from the village, but that in India there are over 600,000 villages -- more than the number of formally trained doctors in the entire country. She suggests that informal providers are better placed to fill this gap. And Oladimeji Oladepo from the University of Ibadan gives an example from Nigeria where informal providers have played a key role in getting anti-malarial drugs to the rural poor at low costs.

[Editor's note: This blog and videos were originally co-produced by Future Health Systems and the Center for Health Market Innovations for the Private Sector in Health.]

Participatory action research for health systems

A mother in Kamuli district smiles with her new baby after using the voucher scheme for transport to a local health facility to access a safer delivery.

There were many methodologically focused sessions during the 2^nd Sympsoium on Health Systems Research, including several focusing on more qualitative methods. Future Health Systems participated in one on participatory action research, highlighting their research in Easter Uganda to help improve mothers’ access to safe deliveries. Below are some reflections from the two FHS participants.

HARRIET NAYIGA, SENIOR NURSING OFFICER, KAMULI DISTRICT
What are my responsibilities as part of the District Health Management Team (DHMT) in Kamuli District?
My responsibilities include: the planning, soliciting, receiving and distributing of additional resources for district health needs; monitoring and providing feedback on the implementation of programs; and providing supportive supervision, mentoring and coaching to health providers so as to improve the quality of health care services provided. I have been a senior nursing office for many years and more recently part of the DHMT.
What have I learned from the panel on action research and being at the conference?
It has been an educative experience for me, pushing me to think how best I am learning, doing, improving. Action research has enriched our program as it makes us think broadly, strengthens our planning, makes us prioritize the issues of concern. It has made me think of contingency plans required, to come up with a plan B, in case things change. It has made me consider things not usually talked about, such as what the community is doing today and tomorrow, rather than always depending on technocrats, especially when concerned about sustainability. The conference has been a wide, wide, wide exposure. It has made me think out of the box. I have done a,b,c, now what about d? What can I share with others and contribute?

ASHA GEORGE, ASSISTANT PROFESSOR, JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH
What was I presenting at the symposium?
I have been working with Makerere University and Ministry of Health, Uganda over the past year while they have been re-strategising the Safe Deliveries project to ensure more local action, ownership and sustainability. We strengthened our skills in participatory action research and undertook a series of dialogues at national, district and community level in iterative phases with multiple stakeholders including adolescent mothers, male partners, transport workers, local leaders and other district and national officials. We first discussed the current project and identified challenges or issues that had to be addressed to support local action, ownership and sustainability. After identifying the most important challenges, we worked with stakeholders to brainstorm possible strategies to address the challenges and prioritize them in order of feasibility.
What did I learn from the action research panel?
While I was familiar with action research used by those involved in community health, I was very impressed by the number of health systems researchers engaged with action research methodology at the conference and in the panel audience. It was motivating to know that one is not working in isolation.
I realized that we got lost in the challenge of documenting the process (number of meetings, at what stage, with whom) and failed to present how participatory action research is particularly suited for addressing power relations. I perceived our team addressing power by being critically aware of who is involved and what is discussed. Despite the success of the voucher scheme in increasing women’s access to facility services, through this participatory process the following issues were identified as being critical: lack of male engagement in supporting women’s health savings or decision making; low awareness by women of their entitlements; community transport and savings systems still requiring strengthening; and poor quality of care at facilities, including providers being rude, insisting on unofficial payments and making women delivery in positions that ran contrary to their local social norms.  Makerere played a critical role in consulting with marginalized groups on their own, before facilitating dialogues that included their participation with other more powerful stakeholders, and ensuring that the issues they raised didn’t get swept under the table. Most striking were my memories of local religious leaders and politicians; as their involvement was not always a one way monologue.  Interestingly, the district managers on the panel discussed power in a different way. While I as a researcher was concerned about how power can exclude stakeholders and their concerns or stereotype them in frames that perpetuate their marginalization, the district managers viewed power as a positive force. They felt it was their responsibility to unleash power at every level to support positive change.
It was striking to see the commonalities across the projects presented. That action research helped to change perceptions of district managers reorienting them to more community and public health needs; foster trust relationships;  and provide a space to focus, reflect and support more strategic planning in the middle of routines and environments that are more typically characterized by diminished resources, competing demands, overburdened workloads.
Valuable concerns raised by the audience included:

• the duration of time or number of action cycles that needed to be undertaken to see effects
• similarities between action research and quality improvement cycles
• whether action research efforts stay on islands of excellence or whether the skills seep into other areas of practice
• the challenge of generalizing the experience to other contexts
• the challenge of influencing change at levels higher than where the action research initiatives are taking place, especially when higher level officials maybe less process oriented and more demanding for visible, quick results  

Most striking for me was realizing the experience it takes to know when to follow the rules or power configurations and when to break them. It was sobering to recognize how challenging it is to present such a rich experience amidst strangers in a foreign land far from the familiar. It takes time to open up, understand and trust one another in order to freely discuss all the questions and issues that arose from the panel and audience interacting. The room was full of ideas, energy, questions, experiences and it seemed rather unfair but entirely understandable and pragmatic decision to stay within the time constraints that bounded the panel. No doubt the discussions sparked and intrigued interests that will go beyond the boundaries of the panel workshop and conference.  

Small farms, big farms

There is a classic debate in agricultural economics and development policy about the relative efficiencies of small and big farms. It is centred on what is known as the 'inverse relationships' which posits that as farms become smaller they become more productive per unit area, as costs – such as the supervision of labour – get reduced (or at least passed on to cheaper family labour arrangements). The argument is that small farms are the ideal, efficient solution to agricultural production.

Of course there are qualifications – and these are important, perhaps increasingly so in a globalised world. Very small farms, fragmented in different ways, are clearly not ideal, and suffer from many inefficiencies. Yet, what is 'small' and 'very small' is often not clear in the literature. Equally, there may be economies of scale in certain production-marketing systems, making larger farms more efficient. For example, getting high value products into international markets may mean complying with quality standards which small farmers would find difficult to adhere to.

• Read Ian's full post on the zimbabweland blog

Would you pee on your tomatoes? Where the HSR approach to knowledge translation is falling short

By Jeff Knezovich, Policy Influence and Research Uptake Manager for Future Health Systems

As the Policy Influence and Research Uptake Manager for the Future Health Systems research consortium, knowledge translation is central to what I do. I was very pleased to hear, then, that it was a key theme of the 2^nd Global Symposium on Health Systems Research. During the symposium, I had the opportunity to participate in several related sessions (though I wish I could have made even more!), and while there were a few interesting insights, it seems to me the health systems research (HSR) approach to knowledge translation is still falling short. Here's why.

I’m relatively new to HSR, but one of the impressions I’m left with from this Symposium is that it took the topic a long while to crystallise as an area of study because it is so inherently multidisciplinary. Health economics, medical epidemiology and the full gamut of political and social sciences, not to mention complexity science, all seem to fall under the HSR umbrella. And so I’m surprised that much of the learning and approaches to ‘knowledge translation’ discussed here seem to come from the medical sector. At one level, that’s likely because evidence-based medicine is widely recognised as the progenitor of the evidence-based policy movement. But the understanding of evidence-based policy has moved on a lot since the 90s (heck, people hardly anyone refers to it at ‘evidence-based policy’ anymore, preferring the idea of ‘evidence-informed policy’). So why aren’t health systems researchers looking elsewhere for inspiration? And why are they working so hard to re-invent the wheel?

A lot of the findings I’ve seen from the presentations are in line with some of the already well-established lessons on linking research, policy and practice, which is heavily informed by political and social sciences. For example, one paper emphasised the importance of timing to influence policy… something Kingdon has been emphasising through the idea of ‘policy windows’ since at least 1995 (though I can’t imagine Kingdon was the first person to talk about the importance of timing). In a closed satellite meeting I attended, a Brazilian policy-maker underscored the point: ‘In Brazil,’ he said, ‘we don’t talk about pilots. Why? Because we have elections every four years – we can’t say to an elected official “give me two years and I’ll give you the answer”. If the officials waited that long to take action, they’d be shot’.

And despite this well established and once-again reiterated knowledge on best practice, at the symposium another panel insisted the best way to answer a policy question was to spend up to two years on a systematic review that could be summarised in a policy brief, a mere year-and-a-half (at least) past the policy window...

Within HSR, we also need to challenge this notion of a large gap between research and policy that must be bridged. The fact is that there are a large number of mechanisms already in place in most countries to bridge that gap – technocratic networks of old school chums are a good place to start, but think tanks, the media, research institutes, patient interest groups, parliamentary libraries, professional associations, political parties and more all exist. When I hear about a ‘gap’ it’s more often than not because the researcher isn’t in the right networks to influence their target. But many of the best policy-oriented researchers have served some time in a local, regional, national or international governing body or two. And many of the best policy-makers have decent degrees and bounce between government and (quasi)academia. Indeed, I found it ironic that the person presenting on this supposed gap had already left his researcher job to work for the Ministry of Health.

Which brings me to another point about the role of evidence in health systems research: there seems to be a strange notion among HSR practitioners that evidence speaks for itself. If an RCT or systematic review finds something to be true, then it must be the BEST solution and should be adopted as policy. But we know that in policy-making spheres, it’s hugely important how that evidence plays in the value systems, customs, and general context of the target population. Sure, science might say the cheapest way to ensure a bumper tomato crop is to urinate on them, but that doesn’t necessarily mean that smallholder-farmers are likely to accept the advice. Need more convincing? A five-minute talk with just about any health economist should disabuse you of the acceptability of all forms of evidence in the health systems sphere. So let’s call this the tomato test – if you wouldn’t pee on your own tomatoes then you may need to rethink your approach to policy influence.

Despite these shortcomings, there were some really insightful findings and approaches presented too.

I am somewhat sceptical of the idea of a professionalised body of ‘knowledge brokers’. Researchers and policy makers need to be able to talk to each other directly – the best knowledge brokers facilitate that process, the worst insert themselves in between. And so I was pleased to hear of an interesting example of effective knowledge brokers in a study across several sub-Saharan African countries. The study noted that having ‘champions’ within the Ministry of Health was key to changing the policy. Again, the importance of champions is something we’ve known about for a long time, but the reason they were important here was not just because of their persistence, but also because they were able to effectively synthesise international and local data to determine winning arguments that would help move the agenda along within the ministry.

I was also particularly impressed with the EVIPNET/SURE Project’s rapid response units – though I was slightly worried at the suggestion that such mechanisms were unique. In fact such ‘help desks’ are institutionalised in a number of mechanisms in a wide variety of countries and on a wide number of topics: for example in the UK the Parliamentary Office on Science and Technology (POST), produces briefings based on demand. And in China, the Ministry of Health has an attached think tank, the CNHDRC – among several other academic bodies – to help ministry officials analyse key issues. And in the development arena, the new DFID-funded PEAKS projects provide rapid responses to queries from policy makers. But we don’t see these in enough countries and in enough areas, which is why the SURE initiative is important.
Overall, I’m delighted to see a focus on knowledge translation at the symposium. But I encourage HS researchers interested in linking research, policy and practice to look elsewhere for inspiration. The upcoming conference on the ‘Politics of Poverty Research and Pro-Poor Policy Development’ hosted by an agriculturally focussed institute might be an interesting place to start.

Where have all the taxis gone? Complex Adaptive Systems in Action

A Beijing taxi driver zooms past. From Flickr/borisvanhoytema

By Ligia Paina, PhD candidate, Johns Hopkins Bloomberg School of Public Health

I was cold, and I was wet – having waited for a taxi home for about an hour. And despite my interest in the subject, I somehow took little solace in the fact that getting soaked was the failure of a complex adaptive system. After the closing plenary of the 2^nd Global Symposium on Health Systems Research in Beijing, the skies opened up. And as the afternoon progressed to evening, the rain turned to sleet, and eventually even snow. Many people were heading to the airport to head home after the conference, and yet they couldn’t get a taxi. I was lucky that I wasn’t in a rush to get to the airport, but I was among the wandering masses, traipsing through the streets against the rain and wind trying to get back to my hotel, bemused that taxis were in such short supply when demand was clearly at its highest.

At one level, in a city of more than 20 million people, it’s easy to imagine that if suddenly a million plus people no longer desire to walk from point A to point B, that the traffic system must absorb a sudden tide of passengers. In this case, the metro continued, and the buses were running smoothly, and they likely bore the brunt of the increased traffic. Taxis, on the other hand, were particularly scarce.

Later, someone explained to me (and this is second-hand knowledge, I haven’t checked Beijing city policy so please correct me if I’m wrong!) that in order to keep Beijing taxi drivers in check, they made the drivers themselves directly responsible for the costs associated with an accident. That may help keep speeding and reckless driving to a minimum when the skys are blue(ish -- it is Beijing after all), but when it comes to driving in more difficult road conditions, when demand is at its peak, in means that taxi drivers make something of a different economic calculation and stay off the roads. Talk about unintended consequences.

But the local transport system was not the only complex adaptive system (CAS) on show here in Beijing. As a PhD student who is currently grappling with understanding Uganda’s complex health workforce dynamics for my dissertation research, I was unsure what to expect to hear about complex adaptive systems (CAS) at the 2^nd Global Symposium on HSR. I was fortunate to have participated in the 1^st Global Symposium on HSR in Montreux in 2010, which included a handful of discussions on this topic. In Montreux, the discourse was focused on conceptualizing CAS and systems thinking, asking what it they are and why should we apply them in health systems research.

The discourse in Beijing this week has been quite different. Yes, there are still questions on CAS terminology, theoretical underpinnings, and, to some extent, the rationale of using CAS in health systems research. But there is a noticeable shift towards building the evidence, refining and adapting methods and tools to study health systems through a CAS lens, and moving from theory to practice.

For example, David Peters chaired a session on the last day of the conference where colleagues from Uganda, China, JHSPH, and IDS presented their work on CAS – ranging from country-level research on CAS, to reviews of the non-health literature, and to computer simulations. The launch of the recent Health Policy and Planning supplement on Systems Thinking highlights additional interesting case studies and reviews, including an analysis of FHS projects in Bangladesh, Uganda, and China through the lens of the Develop-Distort Dilemma. Applications of methods such as social network analysis to policy and health systems networks have also been presented. Several poster presentations (including my own presenting preliminary findings on local system adaptations in the management of dual practice in Uganda) also focused on using a CAS lens to explore and evaluate health systems issues.

In addition to learning about all of these applications, it has also been interesting to link up with other researchers applying CAS methods and tools in their work, such as those whose proposals have been selected to be developed within the context of the Alliance for HSPR’s next supplement on applications of CAS, professors and students using CAS in their work, and other interested colleagues from both research and non-research organizations.

CAS in health systems research is still abstract. Indeed, the applications of qualitative and quantitative methods to this topic are complicated and communicating the methods and results to research users and policy-makers (and even other researchers!) remains challenging. Nevertheless, it is an exciting time to work in this field as we are bringing in multiple disciplines and perspectives to examine the “why” and “how” in the rich and complex contexts within which we are working.

Confucius once said that “the cautious seldom err.” In the context of working on CAS, the journey forward might be somewhat risky – as researchers are trying to develop and disseminate their work. However, with a healthy dose of skepticism and a collaborative, multidisciplinary approach, the journey ahead will also be exciting and fun!

The 2nd Symposium on HSR: As daunting as Kabul?

BY KOJO OSEI-BONSU, DIRECTOR OF FHS AFGHANISTAN PROJECT, JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH

I’ve just arrived in Beijing, China, after a long journey from Kabul, Afghanistan. To say it’s a change of pace is an understatement. The sheer scale of the city is impressive – if a bit daunting – as is the 2^nd Global Symposium on Health Systems Research, which I’m here for. I hear there are more than 1,850 participants, which sounds like a lot to me, but is but a mere drop in the ocean of Beijing.
Back in Afghanistan, the team I coordinate works in partnership with the Community Based Health Care (CBHC) unit of the Afghan Ministry of Public Health (MoPH) on a project to pilot community scorecards as a community engagement strategy for improving utilization and coverage of health care. Initial findings from the research we are conducting are inspiring to the team and our Principle Investigator, Dr Anbrasi Edward, and we are looking towards the scale up of the community scorecard under the auspices of the CBHC with a good amount of optimism.

At the symposium, I will be presenting a poster detailing our initial stakeholder analysis as well as touching on highlights from the implementation of the community scorecard. Dr Arwal, the director of the CBHC department (who I have travelled with to Beijing) will be one of three panelists on the MSH convened panel “Getting to Universal Health Care in Fragile States: How Community Health Workers Contribute to Stronger Health Systems”. Dr Arwal will give an overview of the CBHC and the work our two bodies are doing together in Afghanistan.

The poster session will be a first for me, though I’m lucky to have practiced such an activity in one of my epidemiology classes at the Johns Hopkins Bloomberg School of Public Health. The poster presentation was the relatively easy practical element of the aforementioned epidemiology class, which just goes to reinforce a conclusion I came to a long time ago: the tougher classes are the ones that equip students best for work outside the classroom!

One of the main objectives of education is to train minds to enable them to operate at the frontiers of knowledge. Much of the work I am involved in in Afghanistan is, I believe, at the frontier of knowledge – the adaptation of the balanced scorecard to a nation’s health system and the use of the community scorecard, adapted to suit a post conflict setting – and I am excited to share our experiences and findings in the poster session and in informal sessions at the symposium.

I am also excited about the opportunity the symposium presents for learning from other health systems researchers all over the globe. I will be keeping an eye out for the panels, presentations and poster sessions that detail innovations. This symposium holds the potential to unmask research findings, as well as encourage further research, that will be the mainstay of health systems of the future.

Forgetting John Snow at the Beijing HSR Symposium

Posted: 30 Oct 2012 08:07 PM PDT

John Snow's mapping of the Broad Street Pump cholera outbreak
BY DAVID BISHAI, PROFESSOR, JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH
We all know the story of John Snow and the Broad Street pump.  During the 1854 cholera epidemic in London Dr. Snow painstakingly produced a map of the cases and determined that the infamous pump was the origin of the outbreak.  He used his evidence to persuade city officials and the pump handle was removed terminating the epidemic.
Now consider the counterfactual.  Suppose the good doctor had taken an online course on global health systems a few months before the outbreak.  Dr. Snow’s data would have been an excel spreadsheet repeatedly forwarded until it reached the desk of a global disease burden specialist.  Disibility Adjusted Life Years (DALYs) lost would be calculated.  Tree diagrams would be produced.  The incremental cost-effectiveness ratio of various strategies would be tabulated.  With luck, the evidence would be sufficient to host a global summit at which donors would pledge millions to launch a “Decade of Action” against cholera.  With much fanfare a fleet of carriages emblazoned with “The Cholera Project” and a highly vetted logo would be parked next to project headquarters ready to avert cholera DALYS across the globe.  No doubt there would be a research institute to develop biomedical solutions — an amazing vaccine, or special rehydration liquid that would require an army of doctors, nurses, and health workers to aid the stricken.  John Snow would be promoted to head the corps of do-gooders, and his picture would be featured prominently in The Lancet as a global health hero.
Nightmare over.  History did not turn out that way—at least not for 19^th century England.  Fortunately due to an enlightenment era faith in the responsibility and capacity of local government to improve the wellbeing of humanity, the people of England institutionalized the local solution of local public health problems. Despite tremendous economic growth in the 19^th century, health in the UK did not improve until the English invented public health.  More money was not enough to improve health and life expectancy did not top 40 years until 1870. Throughout the 1840s, 50s, and 60s England passed a series of laws that created local health boards, empowered local health officers, and developed local health codes that could be locally enforced.  Political resistance to health reforms occurred locally and was overcome locally.  Public health reforms prevailed with much more success after voting reforms in 1867 enfranchised the working men whose families stood to gain the most from transforming pestilent crowded slums into livable cities.  The John Snow strategy worked and England’s life expectancy began to climb from 40 years in 1867 to 65 by 1945 — before antibiotics and most modern 'cures' were discovered.  Other countries around the world had the same success with the same strategy.  Prior to the 1950s, economic growth alone wouldn’t bump a country’s health statistics; doctors and universal coverage offered weak remedies.  Public health strategies helped translate growing prosperity into hygienic living conditions and this was the route to good health.  It still is.
This week the world will gather at the 2nd Global Symposium on Health Systems Research in Beijing meeting to collectively forget everything that John Snow stood for. Almost all the programming is about improving the delivery and financing of medical services. Attendees will forget that the best solutions are local solutions based on local data used by local health advocates in harmony with their local community.  Few presenters seem to notice that the best and most important part of any health system is not the gleaming hospitals and ICUs.  The part that of the health system that creates health changes the social and physical determinants of health through good old fashioned public health practice.  Most participants are content to sway to the siren’s song of universal coverage and pretend that doctors are the solution to every malady.
James Joyce speaks in Ulysses of the “ineluctable modality of the visible” – what can be seen with the eye becomes the mode and draws our mind with no escape.  The unseen forces in the world may be much more powerful than the visible, but even the most well-intentioned and wise will be drawn to what they can see.  The whole world sees doctors and nurses so deploying them and fixing their business problems has become the business of global health.  Public health officers stay out of sight by preventing problems before they occur. Who has ever seen a public health officer?  What Broad Street survivor would recognize or remember that their life was saved by John Snow?
The good news is that at least one woman in Beijing remembers John Snow. Dr. Afisah Zakariah is Director of Policy, Planning, Monitoring, and Evaluation for the Ministry of Health in Ghana.  At the Thursday session of the conference she described Ghana’s plans to strengthen its essential public health functions.  Building on a World Bank measurement tool, Ghana will audit the performance of district health management teams.  The audits will give each district health official a same-day report card and form a foundation for a personalized performance improvement plan with regular follow up coaching visits.  The essential public health functions that will be graded and improved in Ghana are the essence of what John Snow did on Broad Street — collecting and using local surveillance data, mobilizing the community around the data, and collaboratively implementing local public health measures.  Lucky for Ghana that Dr. Zakariah is on board.  This is potentially lucky for Dr. Zakariah’s audience.  Maybe they won’t forget John Snow and the spirit of 1854.