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The 4Cs of the Health Systems in Asia Conference

Health Systems in Asia conference participants argue over their 4Cs

By Jeff Knezovich, Policy Influence and Research Uptake Manager, Institute of Development Studies


During the Health Systems in Asia conference last weekend in Singapore, I was able to identify a clear trend. No, not pluralism in Asian health systems, we already knew that one.

But rather, on two of the four days the closing thoughts from different speakers involved 4Cs. JK Lakshmi, in discussing mixed human resources on Saturday suggested that:

(OK I missed capturing one of the ‘Cs’ in that Tweet – I think it was ‘condition’)

And then on Sunday, Dina Balabanova, in describing an analytical framework for analysing new cases for Good Health at Low Cost 25 Years On, described her analytical framework as:

In keeping with this important new trend, I’ve decided to frame my blog similarly. And so I present to you my four takeaways from the conference using the same ‘4C framework’:

  • Confucius: In opening the conference, Professor Tan, the President of NUS, presented on the ‘tangled web of health’, starting with a quote from none other than Confucius. ‘The beginning of wisdom is to call things by their proper name’, he noted. Perhaps Professor Tan himself is very wise, as this proved to be an important theme throughout the conference. Much of the discussions throughout were centred on describing Asian health systems as they actually are: messy, pluralist systems with diverse actors working with diverse aims and intentions. It’s too easy to fall into the trope of considering health systems only from a governmental perspective, but the Bangladesh example, which was trotted out time and again throughout the conference, should serve as a good case against doing so.
  • Context: This ‘C’ was present in both Lakshmi’s and Dina’s frameworks, and I couldn’t leave it out of mine. The winner of my favourite quote from the conference competition definitely goes to T. Mirzoev from the University of Leeds who proclaimed something to the effect of: ‘Too often we social scientists draw a box around everything and call it context. But we need to unpack that to really understand what it is about the context that matters’. Too true! He was presenting on the similarities and differences in health policy processes in Nigeria and India. One finding was that Indian policy-makers relied much more on locally produced evidence than their counterparts in Nigeria. However, they also analysed different types of policies and found little difference in each of the contexts in how the different types of policy were approached. It's a great example where only part of the context matters.
  • Communication: At the previous Health Systems in Asia conference, one of the clear foci at the time was the notion of ‘poly-centric governance’ as a response to pluralistic health systems. And while it was certainly touched upon this time, a very different response to pluralism was foregrounded: Information and Communication Technologies (ICTs). Part of a pluralist model is a questioning of the overall health knowledge economy. Information asymmetries, where doctors and other health professionals control access to information about health, necessarily start becoming more balanced in pluralist systems. Patients (AKA health consumers) need to be able to navigate the disjointed system, and ICTs are proving an interesting way to do so, though maybe not in the way mHealth experts are imagining. Several studies presented at the conference found that text messages as part of health promotion campaigns were mostly just deleted without being read. Linda Waldman from IDS, who presented on an FHS-related study in Bangladesh, noted that people were using mobile phones for health there not to call health lines, but rather to call several trusted friends or family members who could provide advice on which health approaches and services to use. She even noted an example of calling a cleaner who worked in a hospital for health information – an example that shows just how ripe this area of work is for disruption.
  • Coverage: The closing plenary session took a deeper look at the U, H and C of universal health coverage (UHC) in Asia. Quite frankly, it was one of the most constructive discussions on UHC I’ve seen. Several of the panellists argued that, when it came to coverage, the discussion of ‘breadth’ (i.e. the number of people covered) had totally overshadowed discussions of the ‘height’ of coverage (i.e. the proportion of total costs covered) and the ‘depth’ of coverage (i.e. which services are actually catered for). The latter two are critical in Asia, where an ageing population is increasingly burdened by non-communicable diseases (such as diabetes, hypertension, etc.).


We livetweeted throughout the conference, and have captured a good lot of the discussion (including the live Twitter Q&A for the closing plenary) in a Storify, in case you’d like to explore the conference further.

And after you have a look, I’d be curious – what other ‘Cs’ am I missing?


Storify from Health Systems in Asia Converence

One of the benefits of livetweeting from the conference, is the ability to pull together a blog in relatively short order that highlights some of the key discussion points from the confence into a Storify. See our Storify from the conference below! 





Two hops from FHS: What can our Facebook page tell us about our network?

By Jeff Knezovich, FHS Policy Influence and Research Uptake Manager, Institute of Development Studies


The other week I had the good fortune of participating in an excellent meeting in Prague hosted by the Open Society Foundations: Policy Research, Technology and Advocacy Event @ the Hub. The event was designed to bring experts together from across Central and Eastern European think tanks to share ideas and learn from each other on innovative approaches to evidence-based advocacy and communications.

There were a number of interesting sessions from the two days (which I've expanded upon elsewhere) -- but I particularly appreciated a hands on session led by Josef Slerka, a lecturer in new media at Charles University in Prague. He showed us how to use some freely available tools to gain a better understanding of our position within social networks.

Making a network map

Based on any given page on Facebook, he walked us through how to find and map a network of other 'pages' (not individuals!) that like or follow that page. We started by scraping information from Facebook using Netvizz. They allow for mapping of up to two hops from any Facebook page, so I thought I'd start with the Facebook page for Future Health Systems (but Netvizz can also help you create a map of your own personal network, which I also did -- it was interesting to see the relationships!).

Netvizz produces a GDF file designed to be integrated with the network mapping programme Gephi (open source and free to download – but if you’ve recently upgraded to Mavericks on your Mac you may need to re-install Java first).

But it effectively creates a CSV file (comma delimited), which I imported into Excel, tidied with the vlookup function (probably my favourite Excel function, if I'm honest!), and then imported the whole thinginto GoogleFusionTables. If you haven't used FusionTables before, I recommend highly that you give them a go -- they can help create maps and lots of other interactive charts, not just network maps. Here's the result:

Click through for an interactive version!

One of the nice things about the interactive version is that you can reduce the number of nodes that it shows so you can really get a clear sense of how connected various parts of the network are. Also, if you'd like to open up the hood/bonnet and see how simple this really is, you can see the full Fusion Table (it also allows you to filter the nodes to explore specific relationships).

What does this tell us?

So we've got this map, but what's it good for? I haven't sat down to do a massively detailed analysis of this network, but even cursory glances can start to tell us a lot about the organisations that are particularly connected in this network.


  • Follow the donor: It's probably not that surprising, but some of the biggest nodes in this network are funders -- DFID, the Bill and Melinda Gates Foundation, UNICEF and USAID certainly stand out.
  • Birds of a feather cluster together: It's interesting to see some of the 'outlying' clusters that come together. There's a little New York Times cluster in there, and Johns Hopkins cluster (not surprising considering that they are the lead FHS partner), and a massive UNICEF cluster. 
  • Strategies for developing a following: It's not entirely fair, as this is network is only two hops from the FHS page (and so it doesn't paint a ful picture -- but it is possible to add to the network!), but it's interesting to see the patterns of who follows whom on Facebook and the different strategies that the organisations are employing. Some follow many, while others hardly follow other pages at all. I'd be interested to see how the relates to cross-sharing of information.
  • Media still matter: Two clear nodes from the traditional media stand out. The New York Times and the Economist. Time to strenghten those media relationships, I guess!
  • Two hops to hop: The Guardian did a great interactive graphic relating to the NSA leaks on how quickly a network expands from hop to hop. This network map already gives me a clear sense of how quickly that expands, but it also gives me some great ideas of other pages to follow that I didn't know existed to grow a closer network.

But all in all, it was great to get the practice in developing a network map. Several FHS projects have been experimenting with social network analysis (SNA) to the policy influence and research uptake planning in their interventions. Knowing how to use tools like this can hopefully help directly strengthen our programme implementation. We'll keep you posted!



The ethics of emergent knowledge intermediaries

Flickr/nyayahealth - Bi-weekly health catch up at a community health centre

By Paula Boddington, Hertford College, Oxford University

[Editor's note: This blog is the final in the FHS blog series Exploring the Implications of New Technologies for the Self-Management of Illness]


The use of new knowledge intermediaries in the public health sphere gives rise to a host of ethical issues. These include questions about fairness of access; the quality of the technology used and information generated; who has access to and control of such information; the impact of commercial interests within a healthcare setting; and regulation across borders. How do we address all of these from within our current frameworks of ethical thinking in medicine? In fact, can we?

Medical ethics has historically focused on the interactions between professionals and individual patients. It has thus been concerned with the professional’s role and responsibilities, ways of minimising harms and maximising benefit to the patient, and respect for the patients' rights. These questions make sense within an ethical framework focusing on the patient-doctor diagnoses and treatment model. But with the use of new technologies for the self-management of illness, the traditional model of medical ethics is beginning to flounder.

The current model of medical ethics has of course developed over time and in relation to changes within the health system it scrutinizes. It currently faces challenges from many quarters, including the following points of strain:

  • The model focuses on discrete interactions between a professional and an individual patient. Challenges then arise, e.g. with genetics, where the nature of genetic information means that the patient’s information may be relevant to biological relations.
  • There has been an implicit assumption that standard treatment consists of intervention for a condition which is then cured, with less attention then on chronic conditions and long-term care. This is a bigger challenge now that the burden of disease is shifting towards long term conditions.
  • There has been a focus on medical care, rather than on public health (although there has been more work on ethical issues in public health in recent years), and as Slim Slama pointed out in his blog, a focus on disease rather than social and personal aspects of health and illness.
  • There has been a focus on consent to treatment, and on patient confidentiality. Behind both of these lies an implicit model of information-giving and of action. Crudely, the professional is the agent, the patient the one upon whom actions are performed; the professional has the medical knowledge, the patient receives this; and all this within a limited time frame, in an enclosed informational setting.

Self-management of chronic illness challenges the old model of medical ethics in a myriad ways. The patient may become an expert about their own disease. Indeed, ‘the patient’ is not someone undergoing a discrete episode of illness, but more manifestly is a person living a whole life, connected to a community of others.

Furthermore, the use of technology to manage illness means that information is no longer primarily in the hands of a medical professional, but is dissipated across a much larger system, including commercial interests. Medical agency is dissipated to the patient, as technology can assist and enable them to manage and make decisions about their own condition without reliance on a doctor. In fact a professional may have taken no direct part at all in the process.

New technologies may offer highly effective means of providing both tailored and general health information. But with this, there are also many hazards in trying to provide adequate education and real understanding. In short,  it is no longer just in the standard ‘medical encounter’ within which ethical issues arise and are addressed. Technology may help potentially billions of people to manage chronic conditions, but new medical ethics needs to consider the much more dissipated agency and fragmented information that it brings.  

Interestingly, the problems now facing the traditional model of medical ethics, even within a standard clinical setting, are often remarkably similar to those faced by widespread use of technologies within a public health sphere. For example, there is a growing realisation that drug regimes prescribed are, overwhelmingly, adhered to only very poorly. It’s become clear that problems with communication between provider and patient impede delivery of effective treatments that the patient both wants and can manage effectively. Hence, addressing these issues of understanding and communication is an essential key to improving healthcare, even when there is apparently close interaction between provider and individual patient. Part of the answer might involve the use of technologies, including those which help to advance the patient’s understanding of medicine.

Medical information is now increasingly shared in both formal and informal markets. We need to understand fully how such information is controlled and accessed, whether it be by medical and research professionals, commercial interests, or by patient groups. With such dissipated agency and diffuse systems of information, circumscribed systems of medical ethics with clearly articulated professional roles and responsibilities are no longer going to apply. Ethical ways forward will involve making sure that the power to act, the power to know, and the power to understand is put firmly in the right hands those of the most vulnerable, and those needing care to manage health and illness.


Innovations on the ground: Implications for ICTs in patient self-management

This series of interviews with participants in a recent workshop on patient self-management hosted by IDS at the Brocher Foundation explores how information and communication technologies are being used to help people cope with chronic diseases in Cambodia, Bangladesh and Uganda. From Cambodia, we hear from Maurits van Pelt of MoPoTsyo, a patient peer group for diabetes sufferers in Cambodia. Dr Mohammed Iqbal from icddr,b talks about chronic disease clubs in Chakaria, Bangladesh. And William Roy Mayega discusses advances in Uganda on treating chronic diseases.