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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?


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


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 2nd 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.