As WHO has acknowledged many times in the past, in outbreak situations information is often the only effective disease-control intervention. But if it is administered too late, in the wrong way, or without a foundation of trust, it may not work at all.
For this reason, health system resilience and public health preparedness should be considered one and the same. Preparedness must not be limited to the technical aspects of disease surveillance, drug and vaccine stockpiling, or border controls. Real disease control starts with public health education. And deep trust built over time.
There is an unspoken social contract that underlies public health: professionals provide reliable advice, and individuals make (mostly) reasonable choices, while accepting a certain amount of coercion to avoid severe health threats. But this pact is fragile. And wholly dependent on people’s confidence in their advisors. Individuals that comprise populations at risk must believe that the advice they receive is for their own – or the population’s – benefit, otherwise no instruction, no matter how important, will be heeded.
It has become starkly clear in this Ebola epidemic what can happened when there is no trust. Rumours carry more weight that evidence. And professionals – with all their technical knowledge – are powerless to stop disease. Public health education should not just be an after-thought. It is the very cornerstone of health system resilience.
It may be stating the obvious to say it, but health systems are context-specific. Every country’s system is a hotch-potch of features. Some created by deliberate decisions; some stop gap-turned-permanent solutions; and many organic arrangements that have grown to fill gaps, with interesting arrays of unintended effects.
These systems usually have similar goals – to deliver effective, impactful health care equitably and accessibly – but the ways those goals are achieved are necessarily idiosyncratic. More often than not, it is the approach to implementation that determines eventual outcomes, rather than the intervention itself.
For these reasons, research that focuses on finding the “right” way to organise a health system by comparing settings is intellectually interesting but not necessarily directly useful for policy or programme design. There are many lessons that can be learnt by looking at the experiences of countries with common features, but aiming for generalizable conclusions often means finding the lowest common denominator – and losing much of the context-specific information that is crucial in determining results in the process.
The most policy-useful research is that which seeks to identify ideas and innovations with the potential to bring profound change if implemented on a large scale – and then delves deeper to understand why those ideas worked the way they did, in the place they did.
The science of systems, of real-world settings, is not so much about the what – the technical details of a policy change intervention – but about the how – what conditions led to success and how can they be replicated. Knowing which lessons and best practices can be effectively translated and scaled up – scalability – is the most valuable knowledge policymakers and programme designers can build on.
Policy makers are the doctors of health systems. They are the ones who, when faced with difficult diagnoses – such as inequalities in service access, human resource shortages, poor health outcomes, emerging diseases – select the interventions they believe will restore the patient’s (system’s) health, and oversee adherence to treatment (implementation). They are the individuals and collectives with the power to influence health on a population level. And the power to limit the opportunities of entire countries with poor decisions and inadequate service planning.
Unfortunately for policy makers, however, they are not in the privileged position of today’s doctors, with a vast array of well-researched treatments for the myriad common diseases that burden their patients. The policy makers’ toolkit is limited to the blunt instruments of budgeting, national goal setting, and guideline development. Diagnoses are equally unsubtle: high burdens of disease, low life expectancy, and catastrophic health expenditure, to name just a few.
Systems’ “medicine” is languishing in a time akin to the era when doctors could do nothing for their patients but barbaric surgeries, blood-letting, and doling out reassuring words. If health systems are going to deliver on the population health benefits that should result from medical innovations and advances, this has to change.
Health systems research has much potential to be the science that policy makers depend on to inform their professional decision-making, just as medical science is to doctors. Unfortunately, however, the field does not currently fill this need. But maybe it should.
Ebola scares everyone. But one thing we know for sure is this: the next Ebola outbreak is not going to be in the USA, or Switzerland, or the UK. It will be in DR Congo, South Sudan, or Gabon. What the doctors, nurses and health managers in those places – the front line defence against this terrifying disease – need to know is not the genetic makeup of the organism or the likelihood of vaccines they will never afford. They need to know what to do when funerals spread infections. When witchcraft is being blamed by communities. When patients refuse to stay in hospitals. When the disease is spreading in the kind of marketplaces and city conditions that only African countries share. And what to do when foreigners are too scared to come and help.
The doctors, nurses and health service managers in Liberia, Sierra Leone, Guinea and others will – when this awful crisis is finally over – have much valuable knowledge that others can, and desperately need to, learn from. We must all support them to document and publish it so that when this disease rears its head again, in the deep dark rainforests and crowded bustling cities of Africa, we, in this continent, are prepared with the real practical preparatory information that can help stop the disease in its tracks – and comfort the rest of the world.
There is a knowledge gap in health. A big one. And this gap is what prevents our knowledge about disease and how to treat it from achieving its potential impact on health burdens. Let’s take an example. Tuberculosis. This bacterial scourge has been destroying lives for centuries and has now won the dubious accolade of number one killer in South Africa – quite a feat in such a multi-burdened nation. Globally, 8.6 million people got TB last year, and 1.3 million died (25% of these deaths can be blamed on HIV).
We have known about the bacterium and how it causes illness since Nobel Laureate Robert Koch’s history-making lecture in 1882, in which he demonstrated a staining technique that made the organism visible for the first time. Effective drugs have been available since the 1940s – the first discovery was streptomycin, then a sleuth of new discoveries through the 1950s and 60s led to the combination regimens still used today. So if both disease knowledge and treatments are available, why is TB still a global emergency? That is the health knowledge gap. We simply do not know how to use our health knowledge to achieve the maximum benefits of medical innovations.
The health knowledge gap is about health systems. And health care delivery. How to organise the infrastructure, human resources and operational aspects of health services so that sick people can reap the full benefits of available treatments, and that healthy people can benefit from our knowledge of diseases to avoid them. There are lots of examples of what works and what does not, but systems are not studied in the same systematic way that diseases and medicines are. As a result, there is very little evidence – in the scientific meaning of the word – to help governments decide how to organise and reform their health systems to improve the health of their populations.
Strengthening Health Systems has been set up with the aim of addressing this knowledge gap. By helping to capture the knowledge that exists in the minds of practitioners and documenting it so that others can learn; by forging links between academics, policy makers and implementers to ensure that research targets policy and implementation-relevant questions; and by creating a strong, relevant evidence base that policy makers, programme designers and funding organisations can draw on to make better, more informed decisions. We hope you will join us in supporting this cause.
Further reading: Kikaya H. Can there really be a ‘science’ of health systems? Strengthen Health Sys 2014; 1(1): 3 SHS EDITORIAL