Speech: The evolution of Health Policy and System Research: reflections and new horizons

Rt Hon Helen Clark, Chair of the Board of the Alliance for Health Policy and System Research.

 Speech on “The evolution of Health Policy and System Research: reflections and new horizons”

London School of Hygiene and Tropical Medicine (LSHTM), Manson Lecture Theatre.

12:00 – 13:30 session; Wednesday, 29 March 2023.

My thanks go to the London School of Hygiene and Tropical Medicine today for hosting this event marking the 25th anniversary of the Alliance for Health Policy and Systems Research.

While I became Chair of the Board of the Alliance only recently, I fully appreciate its rich history and the exceptional individuals who have shaped it. Professor Dame Anne Mills of this School played a pivotal role in the establishment of the Alliance, for she saw the need for an organisation which could focus the attention of both policy-makers and researchers on strengthening health systems.

Now, 25 years on from the establishment of the Alliance, the world looks very different. Health systems face new challenges and rapid transitions as they grapple with a range of interlinked crises and increasing risks: from changing demographics to declining trust in governance – including in health authorities, an increase in state fragility and in conflicts between and within countries, and to expanding pandemic threats and the ongoing climate crisis. There are also major health workforce recruitment and retention challenges.

On demographics, in 2020, the number of people aged 60 years and older outnumbered children younger than 5 years. More than half of the world’s population was living in urban areas.

On governance, according to Freedom House, 2020 marked the fifteenth consecutive year of democratic decline, associated with eroding trust in institutions.

On fragility and conflict, the Uppsala Conflict Data Programme recorded 56 conflicts in 2020, mostly fighting within countries.

2020 also saw COVID-19 declared a Public Health Emergency of International Concern – to date that designation has not been lifted.

And, we see every year now the worsening impact of a climate ecosystem under pressure, resulting in adverse weather events of all kinds and leading to dislocation of entire communities and to food and water shortages.

Each crisis presents unique challenges to the health and wellbeing of individuals and whole societies. Yet, they all share a common thread: they disproportionately affect the most marginalised populations and they are made worse by our underlying pandemic of inequalities.

Taken together, these crises have contributed to a regression from the hard-won progress on human development made during the era of the Millennium Development Goals. Global immunisation coverage for children dropped to 81 per cent in 2021 – the lowest rate in more than a decade. Global extreme poverty rates increased to 9.3 per cent in 2020, up from 8.4 per cent in 2019 – putting the zero-poverty target of the SDGs by 2030 increasingly out of reach. It was looking very difficult to achieve that target even before the pandemic, and the outlook is significantly worse now.

These crises exacerbate the strains already being faced by health and social systems to deliver for their populations, and put added strain on health workforces. For example, the burden of non-communicable diseases has grown, with NCDs now accounting for 74 per cent of deaths globally. Seventy-seven per cent of those deaths occur in low- and middle-income countries – NCDs cannot be considered only a high-income country problem.

Countries across income levels are struggling to tackle the social and commercial determinants of health that drive these epidemics, including junk food and sugary drinks, and tobacco and alcohol. Health systems are also struggling to deliver high quality care for those with chronic conditions, including health and social care for older people with complex health needs.

Even in tobacco control, which I know well having implemented comprehensive measures in New Zealand as Minister of Health 33 years ago, globally we are not implementing all the measures we know will work to reduce consumption, including high taxes on tobacco products.

A major challenge now is to construct, sustain, and implement policy across many sectors to promote health. This is crucial for NCDs, and it’s also crucial for pandemic preparedness and response.

Among the failures observed during the COVID-19 pandemic, which I reviewed as Co-Chair of the Independent Panel for Pandemic Preparedness and Response, was inadequate governance at the global and national levels which could not co-ordinate effectively across sectors. Effective preparedness and response need whole-of-government and whole-of-society co-ordination.

Other failures during the earlier stage of the pandemic related to the lack of resilience of health systems. Under the pressure of COVID-19, access to essential services faltered, including for sexual and reproductive health and for the detection and treatment of cancer and other serious conditions.

There has also been an inability to sustain attention to pandemic preparedness over time, meaning that many countries just weren’t ready to face a new pandemic threat.

In a world of increasing extreme weather events, and at a time when the emergence of new infectious disease threats is accelerating, attending to failings in systems, such as a lack of resilience and sub-optimal governance, is imperative.

I believe that policy and systems research can make a major contribution to addressing these challenges, and that is why I am excited to Chair the Alliance. By studying policies and systems, we can identify the barriers to and the drivers for achieving health equity, and we can identify solutions.

This field of research brings policy-makers, programme managers, clinicians, and communities together with researchers to ensure that the right questions are being investigated. With a field and community that is now mature, the Alliance can place a greater focus on the actual impact of the research it supports in helping health systems respond to the many challenges they face – and on building systems which are both resilient and able to adapt to changing contexts.

Over the last quarter century, the Alliance has brought partners together to work on solutions to major challenges which health systems face. For example, in Nigeria, in partnership with Gavi and UNICEF, it supported participatory action research which helped to reduce the rates of unimmunised children in two districts from over fifty per cent to under ten per cent. In India, it worked with the Government to improve the roll out of one of the world’s biggest national health insurance schemes. That partnership was seen as so valuable that the department in charge established its own research unit.

Going forward, the Alliance will still work within the traditional boundaries of health systems to support the drive towards universal health coverage. But this week, while we are in London to discuss the Alliance’s future strategy, we will also consider its potential contributions to addressing health emergencies, social and commercial determinants, and the climate crisis where action both within and beyond the health sector is needed.

The Alliance can help respond to changing demographics by investigating innovative models of care delivery and identifying appropriate roles for digital technologies. Similarly, it can help identify and document the most effective pandemic preparedness and response strategies, as well as the social, economic, and political factors that shape them. And, the Alliance has already begun supporting the development of climate-resilient health systems which will be better equipped to manage the impacts of climate change.

At this critical juncture in global health, there is a clear role for health policy and systems research in addressing the complex challenges facing our world which have such an impact on health and wellbeing and health systems.

The community with which the Alliance works, including all of you gathered at the London School today, has skills ranging across policy analysis, understanding political economy, implementation research, and systems thinking. These competencies are essential tools for developing health and social systems which are fit for purpose for our current world and tackling its crises.

We need to prioritize research which addresses the root causes of health inequities and promotes social justice. We need to embrace innovation and use technology to improve health outcomes and increase access to care. We need to advocate for policies which prioritise health equity and promote sustainable development. The Alliance is committed to supporting continued efforts and partnerships to meet these evolving needs.

Thank you.