Knowledge as a foundation to effect change
We know the way forward, but it will require more adaptive and responsive strategies and focusing on areas with the biggest impact, as well as recognising the intrinsically political nature of knowledge
While I am generally an optimist, one cannot ignore the dangerous moment our world is facing. Hard-won gains and progress on improving health and well-being for all are under threat. Progress towards universal health coverage is stagnating. Global childhood vaccination rates have still not recovered to pre–Covid-19 levels. Global life expectancy declined for the first time in 30 years because of the pandemic. Only 16% of the Sustainable Development Goal targets are on track to be achieved by 2030. Those missed targets can have cascading impacts, making them more severe. Progress is hard, but backsliding is tragically easy.
Some of the reasons for stagnation and regression in health and human development are clear. We have been experiencing a series of crises concurrently, sometimes described as a polycrisis. But aside from the waning of the most acute impacts of the Covid-19 pandemic, the other crises of climate, conflict, inequality, geopolitical instability and economic hardship are not going away. Terms like ‘retrenchment’ and ‘fiscal consolidation’ are crossing the lips of policymakers in rich and poor countries alike. Meanwhile, public debt is at an all-time high, with UNCTAD estimating that 3.3 billion people now live in countries that spend more to service interest payments on debt than on either education or health.
There is also a crisis of cooperation or, more accurately, the lack of it. Agreement on a pandemic accord has been elusive, leaving the world by and large as vulnerable as ever to the next pandemic threat. Twentieth-century models of global governance seem ever more outdated. And as more countries experience conflict, and others also increase spending on defence, we are missing opportunities to invest in and work towards shared health goals that keep everyone safe.
A new approach
If that is the prognosis, what is the prescription? Perhaps the answer lies in an unrelenting focus on the politics and priorities of global health. After all, as German physician Rudolf Virchow once said, “medicine is a social science, and politics is nothing but medicine on a large scale”.
What would such a focus look like in practice?
First, it means recognising that different strategies are needed for different challenges. Shifting and shaping the policy agenda requires different approaches from those used to fill policy implementation gaps. In both cases, building coalitions and generating knowledge can help, but the type of coalition and the type of knowledge needed are not the same. The Alliance for Health Policy and Systems Research, which I chair, has recognised this well. It has supported policy analysis studies on how best to frame and implement health taxes across 16 countries. But it also has a long history of supporting practical embedded implementation research studies, often engaging decision makers as leaders in the research process.
Second, in a constrained fiscal space, it means focusing on areas that can have the biggest impact. Global health discussions can too easily descend into a form of ‘whataboutism’, where, if we care about one health issue or concern, we must prioritise all of them. It is a noble value, but it is not pragmatic. This is especially true when those outside the health sector often characterise it as a financial black hole or bottomless pit. It might make us uncomfortable to admit the need for trade-offs within the health sector, or between health and other sectors, but these are the choices policymakers face daily.
Instead, reframing the debate away from specific health issues to cross-cutting approaches can still have broad-based impact. The digital revolution may be here, for example, but it remains unequally distributed. Understanding how to introduce, integrate and maintain digital health solutions to strengthen health systems – so that bottlenecks to service delivery are overcome – is critical. So is keeping equity at the forefront of these efforts to avoid inadvertently exacerbating inequalities in service delivery. Investments in tackling the wider social determinants of health can improve access to health services and foster well-being.
Tailoring strategies
Third, if we see knowledge as a lever to effect change, we must also recognise that the knowledge generation process is itself political. There are unhelpful hierarchies of evidence that aim to depoliticise knowledge, but which instead reinforce existing social hierarchies and strip knowledge of its context. To engage effectively with politics in global health, we must ensure that knowledge production includes and represents diverse perspectives. This means supporting greater collaboration, both cross-nationally and regionally, among researchers, policymakers, implementers and communities. It also means empowering local researchers and institutions to lead relevant research.
As we face this dangerous moment for global health, we must engage with policy and politics with tailored strategies, focus on impactful and cross-cutting areas, and acknowledge the inherently political nature of knowledge generation. In this way, we can be both pragmatic and optimistic.
