11/01/2016 03:51 EDT | Updated 11/02/2016 09:50 EDT

How An Impatient Doctor Got Passionate About Health Systems

While I am a doctor with a strong inner-surgeon-voice, my years working and living in countries in Africa and in urban and rural Canada convinced me long ago that we need to pay attention not just to vaccines and drugs, not even just to health care and health services, but to the ideas, money, conflicts, and energy behind what we see.

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Doctor or nurse is holding a baby. Baby's feet are most in focus. Baby is malnourished and tiny. Baby is wearing a diaper.

By Christina Zarowsky

Life, death, power and politics

I was asked recently to talk to first year University of Montreal medical students about global health, in one of their mandatory expand-your-horizons classes. I decided to take the bull by the horns and be pretty in-your-face with these young, smart, keen, skeptical would-be doctors, and talk about health systems. Groan. Boring.

Or not.

Because in all countries -- and especially in very poor and highly unequal societies like South Sudan, South Africa, the United States, and parts of Canada -- the ways in which society organizes, delivers, pays for and evaluates its health policies, regulations, governance, care services, prevention programs, research, education, drugs and technologies, are more than technicalities. They are central to who dies, who lives for how long and how well, and who counts or doesn't matter in a society. They are health systems.

People - who matters, who doesn't, who decides, and who cares

While I am a doctor with a strong inner-surgeon-voice ("Just DO something, now!"), my years working and living in Africa and in urban and rural Canada convinced me long ago that we need to pay attention not just to vaccines and drugs, not even just to health care and health services, but to the ideas, money, conflicts, and energy behind what we see. And most of all, to the people making decisions about, working in, served by, and excluded from health systems.

At heart, mine is a deeply personal and very human story. I am the still-in-love-after-20-years mother of an extraordinary young woman who is my daughter because her birth mother bled to death in childbirth in post-war Ethiopia, while her family tried to find money and transport to get her to a health facility. That mother, and that community, didn't matter enough. My greatest life work is raising that daughter. And trying to apply these personal lessons to changing things, so that other women and other communities and other societies are visible, and matter enough to get the care they need.

AIDS Miracles: Antiretroviral drugs - and health systems

Unlike the medical students I addressed, I am old enough to remember the unspeakable horror of untreated AIDS and the struggle to bring down the price of the literally miraculous anti-retroviral drugs that have increased South African life expectancy by five years over a historically unprecedented short time. I also remember the moment I realized, once the battle for affordable ARVs was temporarily won, that not one single life would be saved by container-loads of ARVs sitting in South African ports.

These drugs were worthless, without functioning health systems including labs, health workers, referral systems, accurate data, and ways to see and deal with stigma and discrimination. And without prevention of new infections, the treatment options would soon hit a dead end, whether through sheer numbers of patients requiring them, or through development of drug-resistant strains of HIV.

We have made incredible progress. South Africa successfully manages over 2 million patients on ARVs, and the elimination of mother-to-child transmission of HIV is a realistic short term goal. Neither of these achievements -- which are as miraculous to a country as ARVs are to patients -- would have been possible without smart, passionate and sustained attention to health systems.

Hamlet and Health Systems? To sleep, perchance to dream...

I wanted to intrigue at least some of these smart young idealists enough to get a few of them hooked on health systems as at least as important, and as sexy, as genomics and personalized medicine, and for all of them to at least pay attention.

The very words "health systems" were in my title and in quite a few of my slides. I dared the class to fall asleep. I pointed out that health systems -- and not just health care -- was actually a trendy topic. Famous filmmakers (these students are young but they do know about Michael Moore) make seriously funny movies about health systems in different countries.

There have been scholarly papers published comparing the controversial 2010 World Health Organization ranking of health systems against FIFA rankings of football teams. (In case you are curious, Canada was ranked 30th by WHO.) In fact, health care and the systems that make it possible are probably right up there with hockey and weather as central markers of Canadian identity and conversation starters.

The students stayed awake. Some even stayed on after class to talk. And who knows? Maybe one or two picked up a passion for health systems.

Christina Zarowsky is a physician and anthropologist, Director of the Department of Social and Preventive Medicine at the School of Public Health at the University of Montreal, and program co-chair of the 4th Global Symposium on Health Systems Research.

This blog is part of the series: "Resilient and Responsive Health Systems for a Changing World" by the Canadian Society for International Health and Health Systems Global, to share the central issues that will be explored at the 4th Global Symposium on Health Systems Research in Vancouver, 14-18 November 2016.

The views expressed are those of the authors and do not necessarily reflect the views of CCIC or its members.

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