There are rare moments in the global health calendar when those with an eye on the past are given space to speak in the present. Over the last decade working in this field, I have mostly kept my historical leanings secret and worn my anthropologist ‘hat’ instead. Who wants to think about the detritus of the past when there is so much pressure to move as quickly as possible towards the ‘next big thing’? This year, however, the past is inescapable. We are on the eve of marking the anniversary of the Alma Ata “Health for All by 2000” declaration. We are in a period defined by a renewed global commitment to achieve Universal Health Coverage by 2030 and at IDS we have just launched the new IDS Bulletin Accountability for Health Equity: Galvanising a Movement for Universal Health Coverage. Given that inequities in health have stagnated, and in some cases worsened, over these last forty years, we need to think more critically about what UHC2030 means in light of past efforts and the nature of change over time.
History as a way of ‘holding to account’
This is my slant on accountability – the practice of history is one way of ‘holding to account’ powerful actors who helped shape, and in some cases distort, the outcomes of the Alma Ata-era’s attempt to expand health coverage and basic health services. The practice of history is also an opportunity to check our hubris, and by ‘our’ I refer to all those who work in favour of achieving greater health equity at any level (local, regional, national, transnational) and in any capacity. We are not unique in our current efforts, but rather we are part of something much bigger that stretches back in time. In this sense, the ‘holding to account’ is not only directed outwards, but also inwards. As we seek to improve accountability relationships and processes ‘out there’, to the benefit of poor, marginalised and vulnerable populations, we should also seek to improve accountability relationships and processes in the places where work and gather in this shared endeavour of ‘global health’.
These thoughts were on my mind when the IDS hosted a workshop in July 2017, in collaboration with Future Health Systems, the Impact Initiative, the Open Society Foundation, Unequal Voices and Health Systems Global. The objective of the workshop was to spur new thinking and practical approaches to improving accountability relationships and processes in favour of greater health equity. It occurred to me that ‘accountability,’ while a slippery concept and term in practice, offers a useful entry point to asking challenging questions about the nature of power in the exercise of this thing we call ‘global health’. If all this money has been spent, and all this effort has been expended, why is it that certain groups in certain places are still struggling to have their most basic health needs met? If you take away all the verbiage and the vaunted promises of change, this is what accountability for health equity is really about – it is about taking a very honest look at the human condition and our individual and collective role in improving it.
Accountability for health equity – three principle themes
Since July, I have had the privilege (together with my co-editors) of continuing in conversation on the meanings and possibilities of accountability for health equity with a fantastic group of authors and filmmakers, whose work is now shared with the publication of the latest IDS Bulletin. This issue focusses on three principal themes that emerged from this workshop as needing particular attention. First, the nature of accountability politics ‘in time’ and the importance of longitudinal approaches to change. Second, the contested politics of ‘naming’ and measuring accountability, and the intersecting dimensions of marginalisation and exclusion that are missing from current debates. Third, the shifting nature of power in global health and new configurations of health actors, social contracts, and the role of technology.
For the first time in IDS Bulletin history, themes are explored not only in text but also through film and photography. These other mediums allow for a different way of ‘looking’ at, and therefore understanding, the complexity of accountability relationships as they are lived and experienced off the page. The content of this issue reflects the fact that while the desired outcome might be the same – better health for all – accountability strategies are diverse, accountability meanings are multiple, and accountability relationships of the present and future can only be understood and imagined with reference to their past.
The dialogue sparked at the workshop and developed into this issue of the IDS Bulletin, will continue over these next weeks at a CEBRAP-hosted launch event in Sao Paulo on the 11 May (in collaboration with the Unequal Voices project) and in a Accountability for Health Equity webinar jointly organised with the UHC2030 core group on the 17 May. As the date of the Alma Ata anniversary draws nearer, and the planned declaration of ‘Alma Ata 2.0’, I hope that these debates continue and that the movement towards UHC grows in both strength and numbers. Here’s to the next forty years of collective effort.
Erica Nelson is a Research Officer at IDS and a Research Fellow at the London School of Hygiene and Tropical Medicine at the Centre for History in Public Health, working on Health Systems in History.