From 14-18 November 2016, 2,062 delegates from 101 countries assembled in Vancouver, Canada, for the Fourth Global Symposium on Health Systems Research on the theme of ‘Resilient and responsive health systems for a changing world’. This year’s Symposium consisted of five days of 53 organised sessions, 248 oral presentations, 74 satellite and skills building sessions, 385 posters, and 155 e-posters. Social media played a great part in whipping up the spirit of engagement, before and during the Symposium. Blogs also played a role in generating energy before the Symposium; the most popular of these was a blog from the SHAPES thematic working group challenging the concept of resilience in health systems.
Progress since Cape Town
Since Cape Town, the world has shifted from efforts to achieve the MDGs to the launch of the SDGs, which maintain a focus on UHC, but call more strongly for a systems-orientated approach by embedding health in broader social and environmental perspectives. In support of these goals, there is even greater focus on research to reduce inequities in relation to marginalised and vulnerable groups. On the policy and implementation front, there has been a transition in the funding landscape from donor funding for interventions, towards emphasis on locally generated funds. In this context, the local production of health policy and systems research is also increasingly valued.
Since Cape Town, our Health Systems Global membership has spread even further across the world, with the majority in LMICs. The Emerging Voices group has been institutionalised as one of the thematic working groups of HSG, making 10 in all. The Society also has a new strategic plan from 2016-2020, the result of broad-based member consultation. HSG and the Alliance for Health Policy and Systems Research have been successful in ensuring greater numbers of policy-makers in the Vancouver meetings. Outreach, particularly to Latin American colleagues, and simultaneous translation has further diversified participation. While sub-national implementers, journalists and civil society voices were present, the Society needs to seek out, engage and ensure even greater participation of these constituencies in future Symposia.
Several themes emerged from the discussion and debate during this Symposium. First, it is important to recognise the many meanings of resilience. Health system resilience and responsiveness is anchored in people living and working within their communities. But, we need to be cautious not to romanticise communities as resilient, when what they are doing is coping in difficult situations. Systems need to be resilient precisely so that the burden of such resilience does not fall on the most vulnerable in our societies. Health systems resilience needs to be qualified by an explicit focus on equity and social justice, and support the empowerment of the most vulnerable.
Second, discussions amongst participants highlighted the importance of resilient and responsive health systems as ones which provide integrated, people-centred services, with a focus on primary health care as the frontline of routine services and outbreak response. Subnational actors, including communities, are reservoirs of resilience for health systems. Resilient health systems are those which operate from the “end-user back”, and not from the organisation forward. Nevertheless, governments have the responsibility for steering all actors – public and private – in the interests of the broader community.
Third, while some discourse on resilience emphasises health security, such a perspective can sometimes be counter-productive, and should be balanced with the protection of health rights and health system strengthening. Health security should be an inclusive concern of the entire global community, and never a reason to exclude or marginalize.
Fourth, the resilience discourse should be positioned within achieving the SDGs and mobilising collaboration and leadership across sectors. This together with integration and a move away from vertical approaches will help achieve the sustainable management of health systems. Symposium delegates repeatedly stressed the importance of people and relationships, flexibility and the capacity to mobilize new resources.
Fifth, the Symposium gave occasion to highlight the struggles of indigenous peoples against historic privileges, including in high income countries. This has received insufficient attention in the Symposia to date. People in high income countries have much to learn from the experiences of low and middle income countries as well as from their own indigenous or marginalized populations.
The Symposium identified several areas for action for HSG as a whole community:
• In addressing researchers
o Flexibility, adaptation, learning and innovation are features of resilient and responsive health systems – these must be fostered. To do this, we need more innovative research and more nuanced frameworks and assessment tools to understand the meanings of resilience and responsiveness.
o There is a need to support the translation of evidence to action across decision making interfaces much more. Our response must include embedding our research within policy-making processes and practice, and improving the science of implementation.
o The 2018 Symposium in Liverpool should therefore showcase the new research methods tested over the next two years, especially applying the concepts of intersectionality and resilience, and developing new approaches to measure health systems performance in various settings.
• In addressing donors and research funders
o Donors should more frequently embed research and analysis within support to policies and programs, so as to ensure that quality evidence informs such programs.
o In a rapidly changing world, some flexibility of budgets is essential to facilitate innovation, responsiveness, and resilience. We urge donors and funders to respond to this.
o We ask funders to invest further in supporting the participation of policy-makers, sub-national implementers, journalists and civil society in dialogues with researchers, including in future Symposia.
• In addressing practitioners, policy-makers and communities
o The active inclusion of policy-makers in the Symposium has been invaluable in strengthening insights into the everyday realities of governing health systems. However, there are still voices which need further amplification. Thought should be given to ways of using different technologies and media to widen inclusivity for remote participation in future symposia.
The Fourth Global Symposium has allowed our community to hold a light to the concept of resilient and responsive health systems, recognising their importance for achieving UHC and the SDGs, while acknowledging the potential shortcomings. Resilience adds a useful lens to our existing concepts and approaches, but it does not replace or supersede them.
The world is changing, and resilience and responsiveness are needed now more than ever. The accumulated knowledge we have as a community builds on the continuing Symposia agenda of improving the science needed to accelerate Universal Health Coverage; to be more inclusive and innovative towards achieving UHC; and to make health systems more people-centred.
For the next two years, Health Systems Global as a community of practitioners and researchers will look to remain at the vanguard of defining the field of health policy and health systems, while impacting our broader communities, and improving our global society.