Bielefeld School of Public Health

Current Trends of Uncertainty

Uncertainty is an important feature of the present. The existential character of events such as pandemics, environmental change, wars and migration movements repeatedly challenge society's need for security and their ability to plan and respond to events. Thus, the present experience of uncertainty is first and foremost a crisis of the experience of security. As such, uncertainty often receives a negative connotation in society as something which needs to be controlled or tamed. However, this views and perceptions fall short on the complex nature of the phenomenon. Uncertainty as a crisis of security can be treated neither as a singular nor limited phenomenon. As a phenomenon of the present, uncertainty gains a new quality on three different levels:

Experiences of Uncertainty: Today, new events and phenomena continue to emerge that directly challenge the safety and functioning of society. Pandemics such as COVID-19 pose an elementary threat to health security. Armed conflicts highlight the limited capacity for action of the existing security institutions of international relations. Migration flows cause discussions in the countries of arrival about the inclusiveness and efficiency of social security systems. Environmental changes such as climate warming threaten the security of biological survival, because ecological change affects habitats, food, water systems and other essential needs. Many such events are happening simultaneously and with layers of complex interactions, reflecting an enormous experience of uncertainty that is constantly observed in all areas of life. As a consequence, an increasing number of people are finding that there are hardly any safe spaces to retreat to. Without these safe spaces, there are no limits to the experience of insecurity. A society of uncertainty would be the result.

Communication of Uncertainty: Information today is not only communicated faster and more directly, but also at a high level of abstraction. The same is true about uncertainty. Through the new media, issues of uncertainty are discussed rapidly and unfiltered in the public. Many people have increased awareness about and pay increased attention to these topics, relaying relevant information promptly through their communities and networks. In addition to changes in the mediums of communication, the communicated information about uncertainty itself has changed. Uncertainty today is often communicated on the basis of data, models and future projections, rather than in a more general or diffuse form. These are the outcome of scientific findings and scientific knowledge, and science communication therefore stands at the centre of the current communication of uncertainty today.

Processing Uncertainty: The confrontation with uncertainty has already led to awareness in society of the need for systematic social responses to it. Concepts like resilience, preparedness and responsiveness are broadly discussed. Resilience is a general concept for the society to respond to the challenges of uncertainty. Within the context of public health, approaches of prevention and evidence play an important role when it comes to dealing with uncertainty. Hence, the current discussion on the processing of uncertainty has to deal with different and potentially competing concepts of how to respond. Any scientific approach to uncertainty has to position itself in relation to these concepts.

From these changes, it is possible to identify new trends in the perception of uncertainty as well as the resulting discussion about its relevance and the ways of processing, managing and addressing it. Is it the unknown, the unexplored, or the unforeseen? In the graduate school, we assume that uncertainty today is primarily associated with non-knowledge or ignorance. Non-knowledge comprises still unknown knowledge, known unknows as well as unknown unknowns. This non-knowledge becomes a major challenge when crises lead to dynamics of ignorance that threaten the security of society as a whole. Understanding how institutions and agents of the health systems process uncertainty, and identify the modes in which they navigate such uncertainty as well the related societal effects is paramount to improve systemic responses for the benefit of society.

Uncertainty in Public Health

Modern systems of public health are promising not only medical treatment in case of individual health impairment, but also the best possible prevention of and protection from health threats at an individual, community and population level. Equipped with the necessary resources, public health systems can offer a maximum security for the health of the people in a society. In addition to the optimal provision of resources, this also requires an efficient organisation of institutions for medical and health care as well as for the monitoring and evaluation of possible health hazards. As many threats to health sit outside of the health system, this also requires that a range of stakeholders and sectors collaborate in multi-sectoral and cross-cutting ways. The institutions for monitoring also need to be able to anticipate possible emergencies and develop plans for crisis management and preparedness.
However, the Covid-19 pandemic has clearly shown the limits of systems of public health that promises certainty and security.  The pandemic exposed the limits of the assumptions of achieving security through order and control or through securitised, biomedical approaches. Instead of security, uncertainty is the defining feature of the present and the decisive, still unsolved challenge for public health. At the same time, the crisis of public health has demonstrated a new level of uncertainty. Until this crisis, it was assumed that uncertainty is mostly consisted in terms of non-knowledge about possible dangers. For example, within the meaning of the risk society, the lack of knowledge about the potential dangers of new large-scale technologies such as nuclear energy has been discussed. Therefore, new approaches to systematic observation have been developed. But it has also been realised that achieving comprehensive or perfect knowledge in complexity is unrealistic.
In the case of Covid-19, but also the climate crisis, the contribution of uncertainty by non-knowledge is limited. Emergency plans, training exercises within the WHO, global monitoring of diseases provide sufficient knowledge about the hazards. Instead, the current factors that cause uncertainty in public health systems are the “known unknowns”, i.e. (affective) dynamics of non-knowledge and competing strategies of the management of non-knowledge, as well as “unknown unkowns” which require a true paradigm shift in the approach to deal with uncertainty.
Consequently, the question is how public health systems can fulfil their promise of producing security while moving beyond the conventional paradigm of taming and controlling uncertainty, towards approaches that inherently incorporate, effectively deal with and eventually even use uncertainty to design their systems of preparedness and response.

Members and Projects

Christian Franz

Christian‘s research at the Graduate School “Health Policy and Systems in Uncertainties” inquires into the mechanisms to deal with radical uncertainty in the context of pandemic preparedness and response. Christian argues that pandemic threats confront policy makers globally with situations in which the uncertainty is so profound that it is both difficult to set up the problem structure to choose between alternatives and impossible to represent the future. If unaddressed, such uncertainties can lead to paralysis in decision making, inefficient resource allocation, and loss of public trust or non-compliance. Christian investigates the mechanisms created to avoid these consequences: How do they come about? What renders them effective or defunct? Methodologically, the PhD-project will involve expert interviews and will draw on methods from computational social science to analyse global health diplomacy as one of those mechanisms policy makers have at their disposal to address an increasingly uncertain world.
Beside his research, Christian has co-founded and led CPC Analytics – a data and policy analysis firm – since 2014. His expertise lies in policy consulting and data analytics. He has led 35+ projects at CPC Analytics for public sector clients, NGOs, and corporations. In global health, Christian has worked and published on Germany’s, the EU’s, and India’s role in global health, the commercial determinants of health, and the digital transformation of health. Until 2022, he also worked in parallel as Advisor of the Executive Board of DIW Berlin, Germany’s largest economic policy think tank.
He holds a Master in Public Policy from Hertie School, Berlin, and Georgetown University and a Bachelor of Science in Business Administration from LMU Munich.
Contact: c.franz@uni-bielefeld.de

Brogan Geurts

Brogan (he/him/his) is a community and global public health researcher. Brogan is currently a graduate researcher at the Graduate School ‘Health Policy and Systems in Uncertainty” and since 2020 a researcher and social scientist in the Evidence Based Public Health Unit of the Center for International Health Protection at the Robert Koch Institute, Germanys National Public Health Institute. Brogan completed his BA in Anthropology at Metropolitan State University of Denver in 2012 and Diploma in International Public Health and MSc in International Health from Charité Universitätsmedizin in 2018.
Brogan’s expertise and research interests span health systems strengthening and resilience, risk communication, community engagement, trust and social barriers, impact of public health emergencies on health systems, vaccine readiness, sexual health, and harm reduction. Brogan has worked across sub-Saharan Africa, the Balkans, Germany, Uzbekistan and the United States. Perspectives and attention to communities and marginalized populations has remained at the center of Brogans work throughout his career.
Brogan’s doctoral research tentatively titled ‘Navigating Uncertainty: The Daily Business of Community Health Workers in Madagascar’ focuses on community health workers experiences and response to compounding uncertainties, fragmentation of policy and program implementation, and the juxtaposed uncertainty of the two. The project aims to To identify policy and program components which can strengthen community health worker responses to uncertainty around potential health threats and support the sustainment of an adaptive and resilient health system in Madagascar. Methodologically the project takes a mixed-methods sequential exploratory and systems thinking approach, utilizing qualitative methods followed by a quasi-experimental study. The doctoral research is connected to a wider project, “Accessing and Building Capacities: The Madagascar Public Health System’ (ABCM). The wider project is implemented by the Robert Koch Institute and National Institute for Public and Community Health in Madagascar and funded by the German Federal Ministry of Health under the Global Health Protection Program.
Contact: brogan.geurts@uni-bielefeld.de
 

Paul Hennrich

Paul Hennrich, born 1997, is a research associate at the chair for health economics since 2022. Prior to joining, he studied International Management (B.Sc.) at Reutlingen and Breda (Netherlands) and Public Health (M.Sc.) at Bielefeld University. In his master thesis, he compared international policy strategies to address biosimilar market penetration. He is interested in health system financing, health policy and pharmaceutical innovation.  

Mr. Hennrich entered the GRASP programme with a project on modelling revenue and expenses of the German statutory health insurance and social care insurance system. Ongoing developments, such as the demographic shift towards an older society, put pressure on the financial situation of German statutory health insurers. While it is widely accepted that financial conditions will tighten in the future, its extent and the possibilities to mitigate these pressures are subject to considerable uncertainty. Paul Hennrichs project aims to estimate the future of SHI and SCI finances using data on demographic developments, economic performance, employment, and healthcare expenses in the inpatient and outpatient sector. The project will engage in scenario modelling and sensitivity analyses to identify the main drivers behind changes in the financial stability of insurers. Furthermore, it can serve as an instrument for policymakers and other stakeholders who propose reforms to health system financing and organisation to estimate the effect and sustainability of current and future proposals. Thereby, the project addresses a relevant and urgent problem in the German healthcare system while dealing with a number of uncertainties.
Contact: paul.hennrich@uni-bielefeld.de

Mariana Lopes Simoes

Mariana Lopes Simões, a pharmacist from São Paulo, Brazil, has extensive expertise in regulatory affairs and currently resides in Berlin, where she has transitioned into a Global Health Research role.
Mariana completed her Master's program in International Health at Charité Universitätsmedizin Berlin, where she conducted the study "Perceptions of Women from a Rural Community in Northeast Brazil on the Impact of the Programs Bolsa Família, Cisterns, and PRONAF on Their Food Practices – A Qualitative Study."
Her current research focuses on the impact of economic development on rural women's nutrition and health and the uncertainties surrounding access to antenatal care. As a PhD researcher at the Bielefeld School of Public Health’s graduate school “Health Policy and Systems in Uncertainties” (GRASP), Mariana is exploring the impact of uncertainties during antenatal care on women and healthcare providers in rural and urban settings of Paraíba, Northeast Brazil. In this project, she aims to assess the impact of sociopolitical, economic, and cultural uncertainties on the delivery and utilization of antenatal care; identify and analyze the primary sources of uncertainty experienced by users and antenatal care providers, exploring how these uncertainties manifest in different contexts and settings; and analyze and compare how uncertainties uniquely affect antenatal care in rural versus urban settings in Paraiba, Brazil, identifying disparities in service delivery and utilization between these areas.
Contact: mariana.lopes@uni-bielefeld.de

Leyla Polat

Leyla Polat, born in 1996, is a research associate at the working group for health systems, health policy and health sociology since 2022. She studied Health Communication (B. Sc.) and Public Health (M. Sc.) at Bielefeld University and is particularly interested in issues related to health sociology and (global) health policy. In her master's thesis, she examined the political economy of the global distribution of COVID-19 vaccines.
As a member of the Graduate School, Leyla Polat's dissertation will focus on securing the supply of pharmaceuticals in times of global crisis dynamics. Currently and in the past, the German health care system has been affected by supply shortages, through to an entire lack of pharmaceuticals. Various crisis dynamics interact to create or amplify uncertainties in this area, such as pandemics, climate-related and geopolitical risks. Both the nature of these singular and interrelated risks, as well as the likelihood of their occurring, are subject to great uncertainty. At the same time, political decisions need to be made where there is a gap between the knowledge available and the knowledge that decision-makers need to make a political decision. Dealing with these uncertainties is also subjective, as it is characterised by the underlying values and perspectives of the decision-makers and actors involved in the decision-making process. Referencing Michel Foucault's theory, these values and perspectives are understood as power relations that structure the social order and define what can be said on a particular topic, what should be said and what should not be said. The aim is to investigate how actors, institutions, international organizations, and also the public constitute knowledge about the crisis phenomenon of uncertainties in the supply of pharmaceuticals. Additionally, the social impact of this approach will be examined to derive recommendations for an improved systematic response and public health.
Contact: leyla.polat@uni-bielefeld.de

Pimchanok Ratanapises

Pimchanok Ratanapises is a Doctoral Research Associate at the Graduate School “Health Policy and Systems in Uncertainties” (GRASP), Faculty of Health Science at the University of Bielefeld. Her academic journey is marked by a unique blend of experiences. She holds a Bachelor’s Degree in Political Science, majoring in International Relations, from Thammasat University, Thailand. During her Master’s Degree in Public Management and Global Public Policy from the University of Potsdam, Germany, as a DAAD Scholar, she conducted her master's thesis on COVID-19 and Global Governance: Analysis of the World Health Organization (WHO)’s Management of COVID-19.
 
Her intellectual curiosity has developed at the intersection of Global Health Security and Public Management, driving her aspiration to catalyze positive change and strengthen global health security. Her doctoral project focuses on the WHO's Governance and Management in Pandemic Preparedness and Response. Through a comparative study, the project investigates the WHO's management role in health crises, including SARS-1 and SARS-2 (COVID-19). Driven by the critical need to address unprecedented challenges posed by pandemics like COVID-19, which originated in Wuhan, China, and escalated into a global health crisis, her research aims to analyze the successes and failures of the WHO's management in these crises. It seeks to identify gaps and shortcomings and propose actionable recommendations for future global health emergencies by adopting the theoretical framework of 'Bureaucratic Autonomy' and employing qualitative methods.

Contact: pimchanok.ratanapises@uni-bielefeld.de

Emma Schlegel

Emma Schlegel (she/her/hers) is a PhD candidate and research associate at the Graduate School “Health Policy and Systems in Uncertainties” at the Faculty of Health Sciences at Bielefeld University. She studied Nursing Science at the University of Lübeck (B.Sc.) in an integrated degree program, also earning the qualification of a registered nurse, and Public Health at Bielefeld University (M.Sc.). In her master’s thesis, she conducted an international survey on the integration of diversity and intersectionality in public health education. Before joining the Graduate School, Emma has gained research experience at the Institute of Nursing Science at the University of Cologne.
Connecting her interests in strengthening health equity and promoting the development of the nursing profession, Emma’s doctoral research focuses on planning and implementing advanced nursing roles in rural and underserved areas – the role of uncertainty and context. Uncertainties shape changes in health systems, like nursing staff shortage, ageing populations, and urbanization, that are compounded with health systems needing to adapt to socio-demographic, medical, economic, and technological changes. Especially in rural and underserved areas, the population’s healthcare needs are met with a shortage of general practitioners that is expected to aggravate in the coming years. To meet the demands of the changing healthcare landscape, advanced nursing roles are one solution to ensure the provision of primary healthcare in rural and underserved areas.
In Germany, advanced nursing roles are not yet widely implemented, despite research like the Cochrane review by Laurant et al. (2018) showing that nurses with advanced roles provide equal or better quality of care compared to general practitioners. Uncertainties surrounding the implementation of these new roles are sparked by questions like who will take on these roles, what is needed to implement them, and how a sustainable implementation can be supported. In her doctoral research, Emma aims to describe how uncertainties affect the implementation of advanced nursing roles on the individual (micro), organizational (meso), and the health system and policy (macro) level. She will use a mixed-methods approach that encompasses a taxonomy development, expert interviews, and a survey.

Contact: emma.schlegel@uni-bielefeld.de

Victoria Nastassja Touzel

Vikki Touzel, born in Jersey, studied literature in England at the University of York before specializing in postcolonial studies. After working in marketing and project management for healthcare organizations in the UK, including work for Healthwatch and NICE, she moved to Germany in 2019. She then completed her Master's degree in Public Health in Bielefeld in 2023.
With her international and intersectional approach to research, Vikki has chosen to focus on a PhD that assesses the potentially facilitating role of the social in the health outcomes of vulnerable groups. As a PhD student within GRASP, the Graduate School for "Health Policy and Systems in Uncertainties", she is researching the topic of social prescribing and examining its potential applications in Germany for refugee populations. Within this research, she will focus on exploring how uncertainty phenomena form the conditions for, and actively shape, social experiences for refugee populations. In terms of policy and practice, this work will then ask how health systems should respond to these phenomena in the design and delivery of social interventions for refugee populations, based on best available evidence.
Contact: victoria.touzel@uni-bielefeld.de