A call to Astana: health must not remain a privilege of the powerful alone

Forty years on from the Alma Ata declaration, those who are the most vulnerable are still the least likely to access quality healthcare and to live healthy lives. Research is critical for understanding and addressing the systems of power that undermine health and health equity. Leaders must invest in more inclusive, introspective and innovative research partnerships to strengthen robust, resilient and responsive health systems to achieve ‘health for all’.

At the recent Fifth Global Symposium for Health Systems Research in Liverpool, UK, delegates made a strong plea for action to address the ‘power and privilege’ that continues to undermine global health. In supporting health systems as a key foundation for ensuring the health and wellbeing of citizens and communities world over, we repeat this call to those participating in The Global Conference for Primary Healthcare in Astana, Kazakhstan this week. Leaders from all over the world will meet in Astana to renew and build upon a promise made forty years ago in Alma Ata, Kazakhstan to achieve ‘health for all’. The conference is a reminder for us to reflect on how far we have come, but also how far we have to go.

While the ambition remains as noble and important as it was in 1978, we are living in a completely different world with unprecedented challenges. Pollution, militarisation, unregulated commercial interests, polarising ideologies, pandemics and ageing populations to name a few. These challenges are marked by increasing and intersecting inequalities, within countries, and between. We know that the impact of these political threats and social inequities, affect those at the bottom of the ladder, if they are on the ladder at all.

At the same time, social voice and leverage, including social media initiatives like #MeToo, #TimesUp, and #PeriodPoverty, independent journalism, progressive legislative action, and everyday activism by citizens and communities, do hold those in positions of power to account. Citizen voice and community participation, a hallmark of Alma Ata, merits further consideration, scrutiny and support. They remain essential for mobilising the broader awareness, engagement and political commitment needed for domestic policies to materialize universal principles and goals, including human rights, gender equality, global solidarity, universal health coverage and the sustainable development goals.

We keep saying that this is an important year for health. The World Health Summit last week follows the anniversaries of three significant global health events – the birth of the UK National Health Service (NHS), the Alma Ata declaration for primary health care and the Commission for Social Determinants of Health.

But, what does that mean in real terms if we do not learn, or change the power structures that continue to undermine health and equity. If we are to truly make this year count, leaders must invest in science that is technically sharp, socially relevant and politically engaged to achieve ‘health for all’.

In this vein, to prevent the burden of the biggest challenges from falling on to the most vulnerable, here are some health policy and systems considerations from Liverpool to those in Astana:

  • The causes of bad (and good) health are multiple, and go beyond the health sector, so must we. Just as people’s lives and needs cannot be neatly divided into categories to match government structures or professional disciplines, our research, policy and practice needs to transcend these boundaries. Supporting effective multi-sectoral action for health needs not just greater technical understanding, but also research on how best to facilitate, monitor and govern multi-sectoral action inclusive of actors for whom health is not a shared starting point.
  • Engaging communities in policy, practice and research was stressed throughout HSR2018. While recognizing the importance of community health worker programs, further understanding of the diverse actors that make up community ecosystems and who broker social change is needed through context specific, nationally embedded research. Greater understanding of the multiple social networks and power relations within and outside of communities is needed to ensure equitable partnerships to sustain the social changes that underpin effective health interventions.
  • Advances in commercial products, services, technologies, and business models have generated diverse forms of service provision, expanding the influence of the private sector. These advances have created novel opportunities to expand the reach of the health system, as well as challenges due to the misalignment with commercial interests. We need to invest more in learning how to strengthen various government capacities to effectively steer these opportunities and ensure that vigilance and a healthy critique about private sector engagement remains.
  • While some benefit from improvements in quality, affordable healthcare, healthy environments, and economic opportunities, others remain marginalized without adequate access or voice. We must continue to include and reach the most marginalized, move beyond polarising social identities, to build social solidarity that address systems and structures of power, otherwise we will be having this same conversation in another forty years. Research must not only continue to identify who is left behind and why, but also support understanding of how best to change that.

We often talk about power and privilege in terms of ‘the other’ or ‘them’ over there in another space. But in all senses we must look inward and reflect on our own position if we are to truly address the pervasive inequities that continue to shape our society and health. This is no truer than in the field of health policy and systems research. Health policy and systems research is more inclusive of marginalized voices than ever, but certain vulnerable populations, geo-political configurations and planetary concerns remain under-represented. The assessment of power, privilege and positionality remains central to our work in health policy and systems research, and so it be must elsewhere if we are to realize health for all.

Image credit: WolfmannCreaitve Commons license 4.0 

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