Arnold Toynbee observed in 1931 that "The twentieth century will be chiefly remembered by future generations not as an era of political conflicts or technical inventions, but as an age in which human society dared to think of the welfare [health] of the whole human race as a practical objective." 1 If this is true – then we should ensure that the twenty-first century will be remembered as the era in which we actually made this happen – in which we achieved ‘health for all’.
Barten and colleagues seem to remember, as I do, the excitement of 1978 and the few years beyond it – of the ‘rainbow’ booklet series on comprehensive primary health care (PHC) – of the promise of building sustainability, systems, processes – of being ‘inclusive’ and achieving ‘community participation’ – and of dealing with the core problems of health and health inequities in and between countries. They also recall the frustration of the early challenge halting this momentum 2 and the subsequent seemingly unstoppable drive towards technical solutions, product focus, short time horizons, and pursuit of ‘measurable objectives’.
Looking for a ‘radical new’ approach to global health, the authors return to ‘comprehensive PHC’ and towards reforming the world economic order. They question why we deviated from this in the first place, but do not offer an answer. While fully agreeing with the renewed (was it really ever there ?) focus on systems, the article does not offer much in the way of preventing that this renewed interest in comprehensive PHC will not follow the same rapid route into disuse.
With this commentary I will focus on an element in making a systems-approach work – something that was not there in 1978 but that is there now: research and management capacity in low and middle income countries. Just like the informed citizen is the cornerstone of democracy, so is the informed (low and middle income) country the cornerstone of development. Countries (and regions) with the ability to generate and use substantive national management information, conduct or commission key research and development, design tools – approaches – methods to engage, for example, the international ‘aid’ communities or their own national health, social and economic problems and potentials can much better modulate externally driven change towards local priorities and more sustainable solutions.
I remain deeply suspicious of global initiatives developed in the north ‘to deal with the problems of south’ – unless the global south has the capacity and opportunity to engage with this debate, challenge the solutions prescribed, and drive the cycle of implementation and evaluation. The complexities of achieving global health, health equity and development combined with the bureaucracies of international organisations and their lack of direct accountability to citizens of the world ensure that it is never clear what goals are really served by new campaigns. The ravages of ‘structural adjustment’ are still fresh in memory, the MDGs are far from met, and yet we are starting up ‘alignment and harmonization’ with equal gusto, equal ‘appeal’ and equal absence of any evidence that it will do more good than harm. And now – yet another new campaign – back to comprehensive primary health care.
What would really constitute a ‘radical new approach to global health’ would be to ensure that partner countries have individuals, institutions and systems that allow them to set priorities, measure progress, negotiate with donors – in fact – select with which donors they wish to work and which not – without financial penalties. Why not engage in ‘pilots and evaluations’ instead of ‘scaling up’? Why not take risks in ‘one-to-one’ national engagements instead of hiding behind large global funds where individual country-contribution – and therefore accountability - is obscured? Why not focus on increased accountability of low and middle income countries and their institutions and systems to their own ‘informed citizens’? It would be ‘radical’ if donor countries would take the many years of capacity building in Africa and elsewhere seriously: in spite of the ‘brain drain’, Africa now has substantially more individual, institutional and system capacity than ever before 3 – although, as the authors imply, it is still not enough. Why not change the new WHO research strategy into a strategy to deliver funding to such national institutions and systems instead of a strategy that builds the WHO itself ? 4
To build systems and institutions takes a long-term commitment – let us start with, say, 25 years. That would be radically new – and would take the sting out of ‘sustainability’ concerns. Spreading development resources more equitably – between populations, countries, regions and between areas of interest (why ‘just’ HIV/AIDS, TB and Malaria – while the majority of people in low and middle income countries die from other causes?). 5 Making sufficient data sufficiently easily available to hold donors and partners to account? resourcing ‘south-south’ collaboration – for example, to encourage learning and critique of the inappropriate interventions without fear of financial penalisation.
The world is inevitably divided into ‘vertical’ and ‘horizontal’ thinkers and doers. It is a ‘no-win’ debate to promote one over the other, but it may just be a ‘win-win’ proposition to enable low and middle income countries to build their systems, infrastructure and institutions so that they can do the balancing act instead. 6 Investing in information, innovation and R&D may result in involving 4 billion more brains into finding solutions to global inequity than are currently taking part. 7
COHRED is about building national systems and capacity for ‘research for health’ that enable countries to conduct ‘essential national health research’ and design solutions towards their own health, health equity and development.
So, of course, we agree with the authors and the tenets of this article. However, in line with our own suspicion of more untested global campaigns – even this approach needs to be accompanied – from the start – with substantive evaluation, monitoring, research and information – done in and by the south – and involving more than short-term outcome measures! Research and information systems are certainly not the only way forward nor perhaps a guarantee to success – but without these how are we to ‘put countries in the driver’s seat’. After all, ‘knowledge is power’ – also, or especially, if you are dependent!
Toynbee A. A study of history. 1931.
J.Walsh and K.Warren, “Selective Primary Health Care: An Interim Strategy for Disease Control in Developing Countries,” New England Journal ofMedicine 301, no. 18 (1979): 967–974.
Volmink J, Dare L. Addressing inequalities in research capacity in Africa. Brit Med J 2005;331;705-706.
WHO research strategy:Accessed 9 March 2009
Moran M, Guzman J, Ropars AL, McDonald A, Jameson N, et al. Neglected Disease Research and Development: How Much Are We Really Spending? PLoS Medicine Vol. 6, No. 2, e30 doi:10.1371/journal.pmed.1000030
Council on Health Research for Development. Responsible Vertical Programming (RVP): COHRED, Accessed on 9 March 2009.
IJsselmuiden C The role of Europe and of international science and technology cooperation. In: Responding to global challenges. The role of Europe and international science and technology cooperation. Workshop Proceedings Brussels, 4-5 October 2007. European Commission. Directorate-General for Research (Eds). Brussels, European Commission, 2008.