Criticality in global health cannot be thought of without questioning existing power relationships. Amidst growing global threats against health equity and the changing nature of health policy and systems research (HPSR), it is important to build critical practices in research to ensure that HPSR remains an innovative and relevant discipline that can adapt and contribute to rapidly changing contexts. In this light, six new EV ‘22 fellows share their thoughts, inspired by their thematic discussion on ‘being critical in HPSR’ during the EV distance learning phase.
What are the barriers/challenges to being critical in HPSR and global health?
Kelly: I think about these questions while sitting across from Henry Fonseca’s “The Maidu Creation Story” at the United States’ National Museum of the American Indian, which celebrates Fonseca’s Maidu ancestors and the process of creation. Global health (and HPSR) lacks truth-telling around its own creation story and current processes of creation… knowledge is still defined, valued, produced, and shared by those with most privilege and power. The greatest barrier to being critical is ourselves, still tethered to fear of interrogating ourselves and our systems and institutions.
Farchanda: An important barrier to me, is the lack of appropriate education in relation to criticality in most education systems. This causes many who recognize the need to be and who also want to be critical, to not possess or have access to relevant and effective tools to develop critical thinking patterns. I believe that critical thinking should be incorporated into teaching programs, starting at primary school and continuing to higher levels of all disciplines.
Siddharth: To me, a lack of capacity-strengthening frameworks emphasizing a systematic, contextualized approach to HPSR constitutes an important barrier. Existing initiatives incorporating complexity-conscious methodologies (e.g., systems thinking) within HPSR, are generally not calibrated well for existing stakeholder relationships between internal (individual and organizational) and external (policy and socio-political) environments. This further compounds theory-practice gaps between researchers and policymakers in this space.
Zaida: Much has been written and said about the importance of being critical in HPSR to tackle health inequalities, yet the impact of the Covid-19 pandemic has highlighted the vulnerabilities of health systems – with significant implications for progress towards the SDG goals. This points to a serious disconnect between critical discourse and action – a major barrier. We need to protect against the misappropriation of critical discourses which are used as buzzwords to fit certain agendas.
Mark: Dehumanization, disempowerment, and decolonization have been the intersecting challenges that complicate the framing of our global health approaches. I believe that being human or being humane should be at the heart of global health. It is important to start the reflective dialogue about what values go into the concept of ‘being critical’; if we do not do this, all of our leverages will only be mere optics, and remain theoretical and academic.
Oluwatosin: In the context of HPSR, a key role for academic criticism is perhaps to increase the understanding of the present reality, problems, and solutions thereby contributing to political action for change (Fairclough 2018). However, Nigeria and other low and middle-income countries are constrained due to poor funding for HPSR demand generation and uptake of evidence. HPSR should be promoted to ensure a balance between academic research and reality.
What are possible leverage points for criticality to make HPSR and global health more equitable?
Kelly: An entry point toward health equity that I wish to unpack further is language and rhetoric – how these mechanisms are (bio)power in themselves. We falter at interrogating how the “rhetoric of modernity” continues to harm those most disenfranchised. Mignolo’s seminal “Delinking” article analyzes this rhetoric; we should apply such modes of thought in global health and “development” (leaning into the critical language analysis tools as proposed by Gasper (2022).
Farchanda: I think that analyzing health systems as a whole, from a critical thinking perspective, is one of the first steps towards more equitable HPSR and global health. Functioning of these systems, from decisions made at the top all the way to ground level, should be put under a critical lens to identify which aspects need to change. This needs to be done at local or national levels as well as (and perhaps especially) internationally.
Siddharth: Building a comprehensive framework for enhancing HPSR capacity might serve as a clarion call for equitable and sustainable action. Mirzoev T et al. (2022) recently proposed such a framework. This is important, not only for boosting HPSR capacity across stakeholder groups but also for identifying key values for criticality; recognizing the inherent power imbalances in stakeholder relationships. Such frameworks may also help funders engage with, and re-examine, broader global health priorities through a critical lens.
Zaida: Leveraging criticality in HPSR to ensure equitable health outcomes involves an understanding of the contextual factors that contribute to health inequalities. Feminist movements and civil society organisations have played an instrumental role in driving change around public health issues like HIV (Horn, 2021). We need to draw on the capacity, influence and expertise of these movements and improve collaboration among multiple actors, including policy makers, health workers etc. to strengthen partnerships and develop agreed upon best practices for critical action.
Mark: Letting those with lived experiences own their story is the first step of many. I felt that pursuing global research to understand the core of history, racism, politics, and power is paramount to creating an inclusive HPSR approach – that brings back relevant voices to the fora where they are needed. We should also begin to discuss the relevance of reflexivity in all aspects of our work to ensure that we recognize our position and view of the world.
Oluwatosin: To increase demand generation and uptake of HPSR in low and middle-income countries, implementable advocacy strategies should be in place and HPSR activities included in national budgets. This will enable researchers to help drive the process, and policymakers to make policies & decisions based on research evidence/information. Finally, it is important that implementing government agencies/organisations are identified to ensure effective implementation; they also need to be accountable for their mandate.
We look forward to unpacking these themes further during our (still ongoing) distance and in-person training in Colombia!
End note: The structuring and format of this blog drew inspiration from the popular IHP article entitled “Work-life balance and work-life joy in global health: Four regional perspectives and a Call to Action” by Pragati Hebbar, Katri Bertram, Shahnaz Munshi and Guillermo Hegel (2019)