Anne Muendi Musuva: Why global health needs a health systems social movement

Anne_Musuva_photoThis blog reflects discussions I had with fellow young people who attended the Third Global Symposium on Health Systems Research, which was held in Cape Town from 29 September to 3 October 2014. We attended the symposium as part of the Emerging Voices for Global Health, an initiative of the Institute of Tropical Medicine, Antwerp, Belgium.

The 2014 Global Symposium on Health Systems Research saw an outburst of intellectual energy. For those of us from the Emerging Voices group, it was exciting to mix with the giants of health and research, and to raise our voices during the symposium. But as I stopped to reflect, I wondered what the impact of this symposium would be.

We seem to know what needs to be done in global health, but we all agree that there remains a lot of room for translating this evidence into policy. We have been talking about failures to achieve universal health coverage and the people who have died owing to weak health systems in a very clinical manner, with hardly any sense of urgency.

A classic example is the Ebola epidemic, which is currently ravaging west Africa. Its continued spread clearly demonstrates the glaring weaknesses in our health systems. News of Ebola casualties trickled in throughout the conference. It appears we need a health systems social movement. Perhaps we need to borrow a page from the book of the HIV community, who have built political will around their issues by being vocal. We need to get activists in the room and politicians. Where are the journalists, I wondered. Heck, where were the people we were talking about anyway? Where were those who are experiencing the consequences of our weak health systems? It is time that we health systems researchers took the subjects of our research seriously.

We need to move beyond evidence to action. One of my fellow 2014 Emerging Voices (EVs), Befirdu Jima from Ethiopia, gave a presentation on the exploitation that Ethiopian migrant workers face, particularly those migrating to the Middle East. In his audience was Amal Shafik from Egypt—a 2010 EV alumnus and an EV facilitator during the symposium in Cape Town. They got talking, trying to identify solutions within their reach and within their spheres of influence. They came up with a solution between the two of them. Amal would create an online WhatsApp® platform for Ethiopian migrant workers in Egypt. This would act as a safe space for any of these workers facing exploitation and extortion to speak up. Amal would involve the authorities in Egypt. And Befirdu, who worked with workers migrating to the Middle East, would link those migrating to Egypt to Amal and to this WhatsApp platform. Similarly, a group of EVs have started a “one dollar campaign” to raise funds to fight Ebola.

Why do I highlight these? I often feel that as health systems researchers, we don’t quite see ourselves as part of the system, but rather as experts, little gods if you may, generating evidence from without and trying to push it into the system.

This may be owing to the colonial heritage of global health. But in this age of global health 4.0, in which research is increasingly being led by researchers from low and middle income countries (see an earlier blog by Richard Smith for definitions of global health 1.0 to 4.0), we researchers from low and middle income countries must embed ourselves in these systems we are researching. We must get our hands dirty and become an active part of the change we need to see. We must see ourselves not only as researchers, but as active advocates for social justice.

With a social movement for health systems, our current struggles with knowledge translation and evidence based public health would likely be lessened. As a young researcher just starting out in my career, my progression and growth will be determined by the number of articles I publish in major peer reviewed journals. But how many papers in these journals are read by those who can do anything about it? How many papers will be read by my local health minister in Kenya? Why can’t my opinion pieces in my local journals and newspapers count as much as, if not more than, my future publications in The BMJ or the Lancet?

I think we need to step back and re-evaluate the way we evaluate ourselves, and perhaps focus more on whether we are actually making a difference. We need to redirect ourselves from chasing publications to chasing impact. One example given by a fellow 2014 EV, Dorcus Henriksson, was the closing remarks from a presentation during the symposium: “We didn’t involve the community and one of the main lessons learnt was to involve the community.” Henriksson had naively expected a lot of reaction when she heard this closing statement, but it did not draw any. Her proposal was that “lessons not learnt from the past” should be part of every scientific presentation on health systems research.

So what would a health systems social movement look like? It would have the passion of Rene Loewenson, whose determination to ensure that health systems research is participatory and people centred shone through during one of the plenary sessions at the symposium. It would have the energizer batteries that power Lucy Gilson’s physical and intellectual commitment to the development of health systems research as an innovative field at the cutting edge of global health. It would have the bottomless budget of Bill and Melinda Gates, whose philanthropy restructured the architecture of global health governance (because we’d like to do that too). It would reflect the audacity of Sisonke Msimang, who moderated the opening plenary, the only woman on stage, goading an all male panel out of their comfort zones (because gender equity is also one of our missions).

And, finally, it would have the idealism of the Emerging Voices, who cannot wait to see a more equitable world. At the centre, of course, would be the concerns of the very people who were not there with us: the users of our weak health systems. Wasn’t it the social scientist Margaret Mead who said, “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”

Anne Muendi Musuva is director, Malaria and Child Health, Population Services, Kenya.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I have no competing interests.