Not party politics. The quieter politics of what gets funded, who gets heard, which evidence gets acted on, and what health systems are realistically able to implement.
When I first started working in public health, I probably thought about it much more technically than I do now.
There was a health problem. We collected data. We identified gaps. We designed a programme. We monitored indicators. We evaluated whether something worked.
That sounds logical.
And sometimes it is.
However, after working across public-health programmes and research in India, Cambodia and now Canada, I have become increasingly convinced that evidence is only one part of what determines what eventually happens in a health system.
The other part is politics.
I do not mean politics only in the electoral or partisan sense. I mean something broader: how societies decide what deserves attention, where limited resources go, whose priorities matter, what governments are willing and able to implement, and what compromises are considered acceptable.
Once I started seeing public health this way, many things that had seemed frustrating or contradictory started making more sense.
India taught me that a national policy can become many different realities
Some of my earliest public-health work was in India, including district-level work with the State Health Society in Bihar and later research and evaluation across health programmes.
India is an interesting place to learn about implementation because its health system forces you to understand scale.
A programme can be designed nationally, supported by excellent technical guidance, and still look quite different from one state, district or facility to another. That is not necessarily because someone implemented it “wrong.”
India’s National Health Mission itself allows states flexibility to develop state-specific action plans within broad national priorities. WHO’s health-system review similarly describes substantial differences in health outcomes and system performance across Indian states.
When you work closer to implementation, you begin to understand why.
- One district may have stronger leadership.
- Another may have vacancies.
- One facility may have functioning data systems.
- Another may be collecting the same information on paper but struggling to use it.
- One programme may have community workers who are trusted locally. Somewhere else, the same intervention may struggle because the context is completely different.
That experience changed how I think about policy.
A policy is not the intervention. Implementation is the intervention.
What matters is what eventually reaches the person sitting in a village, a clinic, a district hospital or a community health centre.
Cambodia showed me what alignment can achieve
Cambodia taught me something slightly different.
I worked supporting malaria-elimination and case-management priorities, national treatment guidance, monitoring frameworks and coordination between government and international partners. There were many organisations involved: government, WHO, development partners, technical agencies and others.
At first glance, that can look complicated and it is but it also showed me the power of having many actors moving toward a relatively clear public-health objective.
Cambodia achieved a 91% reduction in confirmed malaria cases between 2017 and 2022. WHO attributes that progress to strengthened surveillance, case management, vector control, targeted elimination strategies and strong community engagement.
That experience taught me that politics in public health can also be constructive.
- Government commitment matters.
- Technical partners matter.
- Funding matters.
- Alignment matters enormously.
A technically excellent programme can become surprisingly weak when every organisation is pursuing a slightly different priority. Conversely, programmes can move very quickly when government priorities, funding, technical evidence and implementation structures are pointing in roughly the same direction.
Cambodia also reminded me that development assistance adds another layer of politics to public health.
External partners bring money, expertise and capacity. But countries still need to decide what belongs inside their national systems and what can be sustained after a particular grant or project ends.
That challenge has not disappeared. Cambodia is currently expanding social health protection, but WHO reports that more than 60% of health spending still comes directly from households, while roughly half the population remained outside national social-health-protection schemes in the latest reported figures. So even in a country that can make extraordinary progress on a specific disease, the broader health-system challenge continues.
Success in a programme is not automatically the same thing as strength across an entire health system.
Then I came to Canada, where the politics looks completely different
Canada could hardly look more different institutionally.
Here, the debate is usually not about whether a government should have a role in financing essential health care. Universal public insurance for core hospital and physician services is deeply embedded in the system.
But Canada does not really operate one health-care system.
Provinces and territories are primarily responsible for organising and delivering health services, setting priorities and managing their health budgets. The federal government establishes national conditions through the Canada Health Act and provides funding, among other responsibilities.
That structure creates a different kind of politics.
Health reform often requires negotiation across jurisdictions.
- Priorities differ.
- Resources differ.
- Workforce pressures differ.
Something that is relatively easy to change in one province may be much harder somewhere else. Working in applied public-health research has taught me that producing evidence is only one part of the job.
- We can measure a problem.
- We can study knowledge, attitudes and practices.
- We can identify patterns and gaps.
- But the more difficult question often comes after that:
What should happen because we found this?
That is where research meets implementation.
Even when a recommendation is well supported by evidence, putting it into practice may depend on time, workforce capacity, infrastructure, existing workflows, organisational priorities and local resources.
So the question is no longer only:
What does the evidence say?
It also becomes:
What would it take for this evidence to become workable, acceptable and sustainable in a real setting?
That is the question that has increasingly drawn me toward implementation research.
I have stopped thinking of politics as something outside public health
I used to think we had science on one side and politics on the other. I don’t think that anymore.
Public health is full of value decisions.
- Do we put more money into treatment or prevention?
- Do we prioritise a relatively small population facing a very high risk, or an intervention producing a modest benefit across millions of people?
- How much evidence is enough before acting?
- How do we distribute resources between urban centres and remote communities?
- How much responsibility belongs to individuals and how much belongs to systems?
- When resources are limited, what comes first?
Those are partly scientific questions but science cannot answer them alone.
They involve ethics, economics, public expectations, institutional capacity and political judgement and that is not necessarily a flaw in public health.
It is the reality of trying to improve health in societies where needs will almost always exceed available resources.
One lesson has followed me through all three countries
The context changes enormously.
India taught me about scale and variation.
Cambodia taught me about alignment, partnerships and the importance of implementation close to communities.
Canada is teaching me about decentralised health systems, organisational complexity and the challenge of translating research into sustainable practice.
I would be very cautious about using my own experience to declare that one country’s system is “better” than another. They have different histories, resources, institutions and population needs.
But one lesson has been remarkably consistent:
Evidence does not implement itself.
A guideline sitting on a government website changes very little.
A research paper sitting behind a journal paywall changes very little.
A dashboard that nobody uses changes very little.
Even a very good intervention changes little if the people expected to implement it do not have the time, resources, infrastructure, leadership support or belief that it will work in their context.
That is why I now find myself increasingly interested in the space between knowing and doing.
Maybe this is the part of public health we should talk about more
We often celebrate new discoveries and rightly so but many of the public-health problems we face today do not exist because humanity has absolutely no idea what to do.
We already know a great deal about vaccination, tobacco control, maternal health, infection prevention, occupational safety, hypertension, diabetes, cancer prevention and many other areas.
The harder question is often:
How do we make what we already know work consistently, equitably and sustainably in the real world?
And that question inevitably takes us beyond epidemiology.
It takes us into organisations.
- Communities.
- Budgets.
- Behaviour.
- Policy.
- Power.
- Infrastructure.
- Trust.
- And yes, politics.
For me, that has probably been the biggest lesson of working across different health systems.
Public health is not simply the science of what improves health.
It is also the work of figuring out how societies make those improvements possible.
And increasingly, that is the part of public health I want to understand better.
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