A Monday afternoon in the last days of January, in a virtual coffee meeting. Three Peruvian researchers with distinctive trajectories, different perspectives, but similar social footprints —a health systems engineer passionate about social justice; a forensic medical researcher with experience in population-based studies; and a medical researcher, Ministry of health officer—sat on a thought-provoking virtual meeting to reflect on how to rebuild and strengthen the bridge between academia and national and local health care institutions. Trying to answer few questions, they felt empowered about how to effectively convey the key message to current and future generations of medical and health sciences researchers and practitioners. What should my work as a scientist be when facing urgent health demands that appear out of nowhere? How can we effectively translate evidence-based medicine into local health policies? How can you work in collaborative ways without egos? How can be build trust among impacted communities and genuinely engage them in our research agendas?

Like many countries, Peru grapples with the challenges of a seriously fragmented and resource-constrained healthcare system. As scientists from the Global South, we must engage in a critical reflection about our role as agents of change in addressing complex ‘wicked’ problems of our health system. This editorial has a twofold aim. First, to discuss our role in co-designing biomedical and biosocial ⁽¹⁾ research agendas that work, grounded in evidence-based approaches that are accepted by key stakeholders including policy makers. Secondly, to offer an integrated perspective about the transformative role of scholars occupying a privilege seat in academia, to strengthen our current health system and ultimately, reduce persistent health inequities in resource-constrained settings in Peru and beyond.

Understanding fragmentation of health systems in the Global South demands that we move beyond our comfort zone and begin to learn to ‘speak other languages’ beyond the academic one ⁽²⁾. The healthcare system in Peru is fragmented in several dimensions, including geographical inequalities, uneven distribution of resources, and lack of effective communication between key stakeholders ⁽³⁾. Administrative bureaucracy slows down the acquisition of medicines, equipment and the application of new treatments required by patients, thus affecting the quality of care. What is written in the regulations and real life are two different scenarios ^(3,4). The fragmentation hinders the fair provision of healthcare services, with a more significant impact on our socially excluded populations. It is crucial to acknowledge and tackle these underlying issues to construct a healthcare system that is more integrated and efficient.⁽⁵⁾

Need to know when to wear the ‘right’ hat!

Hat 1 Health Equity Research and CBPR as our modus operandi; hat 2: From Evidence-Based Research to Effective Policy Implementation; hat 3: Role of multi-stakeholder & multisectoral partnerships and hat 4: Systems Perspective.

1) Health Equity Research and CBPR as our modus operandi

Academics have the capacity to interact with communities including social actors and local governments to be able to comprehend their distinct healthcare requirements. The significance of community engagement in integrated healthcare is underscored in the WHO's Framework on Integrated people-centered health services ⁽⁶⁾. By integrating community viewpoints into policy deliberations and research, scholars can guarantee that suggested remedies align with the practical realities of the populace. The local community health administration (CLAS) was one of the best initiatives to integrate the community into health decisions ⁽⁷⁾, but the excesses of both made this marriage end in divorce. Not integrating the community into health decisions would turn the system into anarchy. Researchers must be the voice for both (community/system) to be heard each-other again. The opportunities offered by Community-based participatory research (CBPR) are highly relevant but have been overlooked. CBPR is a systems approach to research that engages patients, clinicians, hospital managers, government policymakers, and the impacted communities -all from the lens of power balance and shared decision making. ^(2,8)

2) From Evidence-Based Research to Effective Policy Implementation

Academic institutions can be crucial in leading research that analyzes the fundamental reasons behind health fragmentation ^(6,9). To successfully adopt new working strategies and health policies, evidence-based medicine is essential ⁽¹⁰⁾. Evidence-based medicine (EBM) in COVID-19 demonstrated the ineffective use of ivermectin and antimalaria drugs in the hospitalization of patients with moderate COVID-19; EBM demonstrate the use of standing, ankle, or sitting births as institutionalized humanized delivery in many areas of our Peruvian Sierra, involving community midwives in this intervention and EBM the use of current dengue vaccines only in those who have previously been exposed. Academics produce evidence-based insights through rigorous studies to guide policy improvement. ⁽¹¹⁾

3) Role of multi-stakeholder partnerships

Interdisciplinary and multisectoral collaboration plays a pivotal role in effectively tackling the complex issues associated with healthcare fragmentation. Academics' diverse knowledge and skills can integrate several subjects from medicine, health sciences and public health. Academics can contribute to integrated solutions that address the underlying causes of fragmentation. The first step is to reflect and ask ourselves: How will we made this initial step? How do we begin the process of inquiring about the community's health priorities? Do we depend on national priorities, or we work in our priorities? Who sets the agenda? Should we create a roadmap with an internal checklist for all processes?

4) Bringing Systems Perspectives

Although academia can effect significant change, it is crucial to recognize its obstacles, including limited resources, bureaucratic complexities, and resistance to change. The WHO's Health Systems Strengthening Framework recognizes the challenges mentioned, which emphasizes the criticality of confronting barriers at the system level to attain long-lasting enhancements ⁽¹²⁾. Notwithstanding these challenges, they offer academicians fresh innovation, advocacy, and collaboration prospects.

Final Reflections: Food for thought!

Finally, the ability of academics to drive change in Peru's fragmented healthcare system goes beyond theory and motivates concrete actions. Scientists can make significant contributions to creating transformative change by using their research skills, engaging in multidisciplinary collaboration, and interacting with communities. The use of scientific evidence in decision-making permits objective assessment, the prediction of outcomes, the reduction of risks, and the maximization of beneficial outcomes. The scientific evidence that supports well-informed decision-making encourages transparency and accountability to achieve clear and unified direction, successful policy implementation, and community acceptability. It is also important to work under consensus that is achieved through strategic research alliances with key actors in the community and local governments for a successful operational implementation in the field of health, thus reducing the gaps in health equity for the country. Academics in Peru must now fulfill their duty as catalysts for change by working together with local stakeholders and international organizations to ultimately benefit the entire population of Peru.

Decolonizing of knowledge:

1. − Power shifting is key!

2. − Geopolitics can be ignored.

3. − Strengthen health systems efficiency.

4. − Technological opportunities that AI brings.

5. − Logic models

REFERENCES

1. Farmer P, Basilico M, Kerry V, Ballard M, Becker A, Bukhman G, et al. Global Health Priorities for the Early Twenty-First Century. En: Reimagining Global Health: An Introduction [Internet]. 1.. ed. California: University of California Press; 2013 [citado 6 de marzo de 2024]. p. 302-39. Disponible en: http://www.jstor.org/stable/10.1525/j.ctt46n4b2.15

2. Brunette M. Moving the needle on global health equity: a look back from 2030. Arch Environ Occup Health. 2021 Apr 3; 76(3):121-2. doi: 10.1080/19338244.2021.1892922.

3. Ballard Brief [Internet]. Lack of Access to Quality Healthcare in Peru. [citado 28 de febrero de 2024]. Disponible en: https://ballardbrief.byu.edu/issue-briefs/lack-of-access-to-quality-healthcare-in-peru

4. Aguirre G. Healthcare in Peru: From coverage on paper to real coverage [Internet]. 2023 [citado 28 de febrero de 2024]. Disponible en: https://blogs.worldbank.org/latinamerica/healthcare-coverage-peru

5. Yip W, Hafez R. Improving health system efficiency. Reforms for improving the efficiency of health systems: lessons from 10 country cases. Geneva: World Health Organization. 2015

6. World Health Organization. WHO global strategy on people-centred and integrated health services. 2015. pp: 1-50.

7. Ministerio de Salud del Perú. Los Comités Locales de Administración de Salud (CLAS): Organización y modelo de gestión - El programa de salud local. Lima: Ministerio de Salud. 1996. [Internet]. [citado 28 de febrero de 2024]. Disponible en: https://www.gob.pe/institucion/minsa/informes-publicaciones/320952-los-comites-locales-de-administracion-de-salud-clas-organizacion-y-modelo-de-gestion-el-programa-de-salud-local

8. Wallerstein NB, Duran B. Using community-based participatory research to address health disparities. Health Promot Pract. 2006 Jul; 7(3):312-23. doi: 10.1177/1524839906289376.

9. Ostlin P, Braveman P, Dachs N, WHO Task Force on Research Priorities for Equity in Health, WHO Equity Team. Priorities for research to take forward the health equity policy agenda. Bull World Health Organ. 2005 Dec; 83(12):948-53.

10.Bullock HL, Lavis JN, Wilson MG, Mulvale G, Miatello A. Understanding the implementation of evidence-informed policies and practices from a policy perspective: a critical interpretive synthesis. Implement Sci. 2021 Feb 15; 16(1):18. doi: 10.1186/s13012-021-01082-7.

11.Kotur PF, Kotur P. Challenges for the practice of evidence-based medicine during COVID-19 pandemic (practice of evidence-based medicine in the new normal). Indian J Anaesth. 2022 Apr; 66(4):290-3. doi: 10.4103/ija.ija_103_22.

12.World Health Organization. Everybody’s business -- strengthening health systems to improve health outcomes [Internet]. Geneva: WHO. 2007. [citado 6 de marzo de 2024]. Disponible en: https://www.who.int/publications-detail-redirect/everybody-s-business----strengthening-health-systems-to-improve-health-outcomes