Global Health Governance Building the Reset initiative : Some touch stones for the reset

Six months into the unrelenting waves of global deaths and disruption caused by the Covid-19 outbreak, the depth of revelation stirred by this pandemic has become profound. The gigantic economic, environmental and social interconnectedness of our world now has become clear for everybody to see. The pandemic has forced many people to reflect on the deeper intricacies of our human interdependencies, our relations in trade and all our economic pursuits, our scientific exchanges; our interactions in daily life, in arts, culture, and leisure; our media connectivity and frenetic communications more generally. The massive environmental, social and economic interlinkages can no longer be denied. With much human activity grinding to a hold, and with no clear end of the scourge in sight, humanity - with its 7 billion+ people - has been shaken to the bone, forced to stop, and think.

Many of our immediate reactions have been filled with anxiety. For all pre-existing inequities of chance and opportunity resurfaced too – and brutally so. The strengths and weaknesses of our institutions, their degrees of sagesse but also of corruption have become blatantly exposed. Our fragility, the preciousness of our human existence and the precariousness of our social fabric have been driven home to us, once more, but now with special vehemence: including to those, who had long forgotten what poverty, uncertain livelihoods, and destitution really look like.

In such an overwhelming crisis we are thrown back to basics: who are we, and what to do?        

Over the last couple of months, some of us have been engaged in the Building the Reset initiative,[1] a spontaneous campaign supported by a number of global health networks and people with a keen interest in advancing actionable health (systems) governance. Early in the day, we decided that out of all the possible ways to respond to this crisis, facing its complexity, embracing its deeper ‘warning signals’, and moving as energetically as possible to ‘new constructions’ could be one - our - way forward.  

Many of us also acknowledged that in this crisis, very little was actually ‘new’ other than the sheer scale and force with which the pandemic and its fall-out have hit people this time. Otherwise, Covid-19 has merely laid bare our collective predicament as humans. Social injustice, economic inequities, dysfunctional institutions: none of these diagnoses – unfortunately - are novel. Poor adaptivity of systems that are supposed to function for the common good, huge power disbalances and exclusion, painful negligence of planetary degradation or environmental extraction: all these flaws and failures of our contemporary world were there before.

So, we decided not to start from zero, but try to connect some dots between people who were already working on fundamental resets in health governance, prior to Covid-19.  While at the same time keeping in mind, that some structures and mechanisms which helped create the crisis in the first place would not necessarily be the best places from which to start change.

With the overall objective of co-constructing a vision for health governance and inclusive health systems, we identified seven workstreams at the start of our exploration: (i) common goods for health; (ii) adaptive systems for health; (iii) upgrading equity and new agency/decolonizing global health; (iv) envisaging new forms of public health; (v) new multilateralism in health and (vi) planetary health as the next frontier; while keeping (vii) pathways of change and cross-cutting action.

We moved to organize a webinar series around these workstreams. It became an ongoing conversation called Building the Reset: What, How, Now. The webinars put the spotlight on the basic challenges now clearly emerging in the seven domains of reflection, and made us pause, think, and explore what positive forces collectively we can muster and mobilize. Governance for health and health systems was our overall focus, but it was clear soon enough that this conversation went much further.

Out of the richness of the five webinars so far, i.e. the launch and the webinars on Common goods for health, on Equity and Agency, on Adaptive Health Systems and Planetary Health as the next frontier, we draw here a few key thoughts which will guide our further work together. They are work in progress; and contain some fundamental considerations, potential directions and practical reflections.

Some key considerations

1. Before talking about ‘doing’, the Covid-19 crisis urges us to think about our forms of ‘being’, as individuals and as collectives. The pandemic has opened many fundamental discussions around the globe regarding our values, current practices and senses of self. As became very clear in the common goods for health webinar, the heterogeneity of senses of self, the different degrees of ‘individualization’ and the divergent notions of individual and collective ‘entitlement’ need to be much better understood, in order to comprehend why ‘collective action’ is harder to achieve in some places than in others and why fundamental change may be hard to come by.

2. The crisis has thrown many people and institutions back into existential anxiety about survival and senses of power and agency. It is unclear whether these anxieties will lead to constructive reconfiguration and progress, to moving to better existence, or to a violent clinging to the existing power disbalances and status-quo or even further regression. Examples of these conflicting tendencies are currently observable all around us.

3. The crisis and the ways in which it has been ‘handled’ have foregrounded the divergence in social contracts that exist around the world, such as between nations/states and people. As touched upon in almost all the webinars, the current crisis has underscored the huge importance of trust and has exposed the levels of trust/distrust built into the social fabric of groups of people, communities, nations, globally.

4. While the crisis in its dramatic economic fall-out has laid bare once again the persistent inequities in the world, it is not yet clear whether and how a real rebalancing of power and a shift towards more equity, social justice, full agency and inclusion will actually emerge. For many it is not easy to be innovative under duress.

5. So, more reflection on pathways of change is certainly required. The crisis has reminded us, that while many diagnoses about the dysfunctionalities in our world may be clear, formulating the diagnoses does not necessarily constitute an easy road to therapy. Change will not happen automatically, but requires rethinking, reconfiguring and active dismantling, strategizing, mobilizing and reorganizing with all the nitty-gritty this involves. It asks for sustained commitment over longer periods of time, tedious, off-camera, to which the fast pace of life around the globe is often no longer congenial.  

The follow up

While these key considerations were expressed and few people continue to subscribe to simple notions of ‘malleability’ of changes in the world, the Building the Reset conversations did yield a wealth of ideas for potential directions and practical inspirations for actionable health governance changes, approached from different starting points.

Some potential directions

Throughout all the webinars, we could hear a number of clear pleas for where to move our actionable governance work next. There will be a time to analyze in depth the wealth of ideas coming out of the series, at this point we merely list a handful of these shared directions:

1. We should seize the moment and finally move all-of-government, all-of-society health governance efforts beyond the rhetoric. This would mean devoting energy to revisiting governance practices, relations, and institutions, focusing on developing the interconnections that will make things happen. This also involves dealing with the public-private divides in health and reconfiguring both public and private-sector engagement with health.

2. We should turn to the deeper governance subjects of rebuilding trust and social cohesion, starting as locally as possible, while taking full account of supranational and global forces that impact on health. This will involve becoming much more serious about power disbalances and agency, about broad deliberation and participation, about horizontal solidarity and starting with real needs of people and growing local governance capacities.

3. We should join others in dismantling the structural remnants of colonialism in health and their concomitant language, and address the structures of inequity and marginalization with new vigour.

4. We should reconfigure public-health and health-financing practices accordingly; and foreground the common goods for health agenda, and beyond. We should move to explore ‘commoning’ as a social strategy and facing the forces that help or hinder collective action.

5. We should move from static to complex-dynamic notions of health, and from health-systems thinking to more comprehensive ‘systems-for-health’ thinking. This was the original vision behind the Sustainable Development Goals (SDGs) which is currently warmly embraced and advanced at the new frontiers of planetary health.

Some practical inspirations

So, while these directions of work vision, time and commitment, what is doable, for each of us? Here are some of these yes-we-can reflections which emerged from the conversations, focusing on health and governance, and starting very close to home:

1. We can all start from wherever we are, in refocusing our thoughts and concrete efforts, in reconfiguring our institutions and in practicing forms of solidarity, and change our language, narratives and frames accordingly.

2. We can all start by listening more and ‘eavesdrop’ in different places than our usual (policy) hangouts.

3. We can all actively engage in creating new spaces: such as spaces and forms of deliberation in health and health policy which will do justice to the huge diversity of people, everybody’s agency and voice.

4. We can all help to make sure that efforts for health start with the real needs of people. We can be more active in putting the political weight there; for instance, in making this a point in all the actions around the current post-CoVID19 reconstruction plans.

5. We can all contribute to giving common goods for health their proper place as the ‘ground zero’ of health and make sure they are firmly embedded, organized and financed in our health systems.

6. We can all engage much more broadly with the political economy of health and the social, economic and ecological ‘systems’ that foster or prohibit health for all people. The new rich arena of Planetary Health offers a plethora of constructive options for people to link actively and address the necessary preconditions for health and wellbeing for all. The good news is that this movement is rapidly gaining ground, with lots of vital energy.

7. We can all be much more energetic in leaving our silos, and much braver in stopping to participate in processes which we know are dysfunctional. We can organize ourselves better to expose these processes for what they are and dismantle them.

8. We can all be contributory to different forms of collective action around some of the vital topics of health governance: accountability, transparency, anti-corruption etc. All according to our passion and capacities: some as thinkers or researchers, others as practical organizers; some as conveners or financiers, others as disseminators. Others again as looking after the coffee break. We can be more sharing and contributory to a sense of purpose, fostering horizontal solidarity.

9. And with public health in all its guises being firmly back on the agenda as a vital, all-of-society subject, we can all contribute to its knowledge base, and feed rich, grounded knowledge into policy and practice. We can all contribute to strengthen a culture of learning around health and health governance, from local to global.

10. So despite the chaos, the uncertainty and the confusion: as Gandhi famously had it: we can all still chose to be the change we wish to see in the world. If we wish reversals, reboots, resets… we merely have to take a first step… ourselves.

Our webinars will continue.

But at this point we wish to thank the great kick-off speakers of the first five editions, and the touch-base group supporters who helped in the preparations of the webinars with critical suggestions and feedback:

Palita Abeykoon, Seye Abimbola, Sanghita Bhattacharrya, Maryam Bigdeli, David Bollier, Jesse B. Bump, Manuel M. Dayrit, Beth Engelbrecht, Jean-Benoit Falisse, Hugo Flores Navarro, Asha George, Richard Gregory, Renzo Guinto, Chisomo Kalinga, Outi Kuivasniemi, Soonman Kwon, Benjamin Downs Lane, Rene Loewenson, Jemilah Mahmood, Bruno Meessen, Marjolaine Nicod, David Obura, Emmanuel Odame, Tolullah Oni, Stefan Swartling Peterson, Maha El Rabbat, Nicole Redvers, Marta Schaaf, Agnès Soucat, Susan Sparkes, Prashanth N. Srinivas, Stephanie Topp, and Sridhar Venkatapuram.

We also wish to really appreciate and thank all our colleagues of the four organizing networks:  theHealth Systems Governance Collaborative, UHC2030, The Collectivity and the Covid/coronovirus Ethics group. And the hundreds of participants in the Building the Reset conversations so far.

The description of the Building the Reset campaign can be found on: https://hsgovcollab.org/en/buildingthereset

The links to the videos of the Building the Reset webinars can all be found on: https://hsgovcollab.org/en/content/webinars

[1] The Global Health Governance Building the Reset campaign was started by: The Health Systems Governance Collaborative, UHC2030, The Collectivity, and CoVID-19 Ethics.