In 2015, the WHO Alliance for Health Policy & Systems Research and Public Health Foundation of India had partnered to set up India’s first effort at building capacity in health policy & systems research (HPSR) through the KEYSTONE course. Half a decade later, I had the opportunity to join some lovely people from several institutions in India and abroad at launching the India HPSR Fellowship Program, which builds upon the work started off by KEYSTONE and various other small efforts at developing capacity for advancing systems thinking within public health research and a more critical engagement with policy, practice and social determinants of health.
The course was launched late last year with various leading HPSR veterans from the global north & south. A cohort of 20 fellows have already begun course-work in the online module.
In 2015, upon the launch of the KEYSTONE course, had written a short note on how the systems thinking streak across disciplines & sectors could help push the silo-specific boundaries that we often work in….reproduced below.
An ecologist friend of mine sent me a paper from the mid-80s titled What is conservation biology by Michale E Soulé that sought to build (rather define) the (then) emerging discipline of conservation biology. Soulé framed conservation biology as a crisis discipline, with strong foundations in biology (and ecology), but not entirely so, drawing analogies between going to war and political science. He says:
“A conservation biologist may have to make decisions or recommendations about design and management before he or she is completely comfortable with the theoretical and empirical bases of the analysis (May 1984, Soult and Wilcox 1980, chap. 1). Tolerating uncertainty is often necessary…..Although crisis oriented, conservation biology is concerned with the long-term viability of whole systems.”
The paper got me thinking on the whole enterprise of health systems and the recent spate of interest around health (policy and) systems research (HSR/HPSR). Ours too is arguably a crisis discipline. Health too draws from and depends heavily on medicine and the underlying biological sciences (at least for doctors), but not entirely so. The increasing realisation that the social determinants of health and the inter-connections between individuals, societies and their environments (the physical environment in terms of air and water, but also the larger social and political environment too!) and the complex web in which health and well-being of people are woven into, indeed require a much larger pool of knowledge to draw from than merely bio-medical sciences.
Building on the richness of methods rooted in the various social sciences, HPSR seeks to embrace inter-disciplinary research and allow questions to drive choice of methods than succumb to a hierarchy of methods usually organised by disciplinary assertions of rigour. One such platform that brought together rich discussions within and between various approaches within the umbrella of HPSR was the KEYSTONE course that recently concluded. Keystone was coordinated by the Public Health Foundation of India, but brought together several institutions across the country to offer a smörgåsbord of approaches to look at health systems problems. Being a question-driven field, HPSR draws heavily from the social sciences. With a pre-course and post-course online learning component, the 10-day classroom teaching was supposed to be a primer to the course participants, many of them at various stages of research, management or technical support. Methodological approaches ranging from economic approaches and policy analysis to implementation research, ethnography, realist evaluation approaches and participatory action research were discussed among a few others.
My own lens on offer at the course was realist evaluation, drawing from therealist philosophy, “which considers that an intervention (or a policy) works (or not) because actors make particular decisions in response to the intervention (or not). The reasoning of the actors in response to the resources or opportunities provided by the intervention is what causes the outcomes.”With content inputs from Bruno Marchal (of ITM, Antwerp), the one-day realist menu included a brief history of realist evaluation, its underpinnings in critical realism and its origins within the larger body of theory-driven approaches. Participants were introduced the realist way of thinking, why programmes and policies work for some and not for others, an elegant and somewhat simple question that underlies most of the important reasons for any evaluation of public policies (much beyond health). In this regard, realist evaluation approach is very much suited for the HPSR mission, in that it is not driven by particular methods or tools, but by this fundamental question that allows for the evaluator to begin the quest of unearthing the underlying (latent) mechanisms within people (and societies) that interact with particular elements in their context to contribute to outcomes (for some and not for others). In addition to the day-long lectures, discussions and group-work on the various approaches within the HPSR umbrella, the course allowed for rich discussions between the practitioners of these various approaches.
But conversations across disciplines separated by philosophical firewalls are not easy. There are bound to be classical interpretations within disciplines that are likely to conflict with HPSR’ised application of these approaches. As jt emerged in a discussion with Rakhal Gaitonde (fellow EV who introduced participatory action research at KEYSTONE) and a few others, how does an ethnographer digest the HPSR’ised ethnography-inspired approach applied by a biomedically trained researcher/practitioner? How does HPSR then reconcile with the varieties of disagreements and arguments on rigour within many of the approaches, often not reconciled within these, let alone across disciplines. These are all early (and somewhat abstract) reflections within HPSR, but what is clear is that the disciplinary firewalls can only tunnel our vision vis-a-vis strengthening health systems and field-building exercises within HPSR could help find a bring together health systems related dialogue happening within disciplinary silos.
That said, even the apparently comprehensive HPSR conversation too is happening within a slightly larger silo. Across decades, every mature discipline is possibly questioning the boundaries. Soulé’s paper on conservation biology seeks to situate it within conversations that ought to happen across genetics, biology and natural sciences as well as various social sciences. If indeed, questions of health, development or conservation ought to be so pluralistic in seeking knowledge inputs from all of these disciplines, one wonders why most of the practice of health, development or conservation within societies is still shorn of the width and depth of these various disciplines. Could this be the hard landing for the aircraft of science on the tarmac of society? Enough said, I am already feeling quite (key)stoned…