For some months now our team within the Thematic Working Group on Health Systems in Fragile and Conflict Affected States has been involved in a process of canvassing opinions on key research needs. This has included face-to-face meetings, a survey, and online discussion. This has enabled us to reach out to over 500 people in 28 different countries (over half of which could be characterised as fragile). This week we added a webinar to the portfolio of tools we have used to try and build a consensus with a wide range of stakeholders.
The challenges of conducting research
Our colleague Egbert Sondorp explained that as the work has developed the sheer magnitude of research needs has become apparent. We have also become aware of some of the barriers to high quality work in this area. These include infrastructural issues such as insecurity which can lead to the risk of ‘convenience sampling’. Travel bans imposed by donors can sometimes mean that bureaucracy trumps the need for good data. In many settings there is a shortage of researchers and data collectors and disruption of research infrastructures hinders health system research and can make processes like ethical clearance more challenging. Among donors there can be a lack of political will to provide ongoing, flexible financial support and so it is difficult to maintain continuity to manage the research process in a sustainable manner. There are real difficulties when it comes to research uptake. Too often research agendas are concocted by outsiders and therefore don’t necessarily tackle the issues that decision makers on the ground feel are most pressing. The plurality of stakeholders involved in the health sector post-conflict make it difficult to know who to target. Lack of state leadership and ownership of research can make it less likely that findings get used.
What have we learnt so far?
Aniek Woodward ably gave us a taste of some of the research issues that have been prominent in our discussions so far. These included the transition from emergency support to long term health system building. The importance of resilience – particularly in settings where populations experience recurrent shocks. She also raised the issue of non-state actors and how to ensure accountability in settings where the state is weak.
We were lucky to be joined by two great discussants Khalifa Elmusharaf and Nigel Pearson who interrogated some of the findings of our work. Khalifa pointed out that wars destroy trust, identity and social ties – community cohesion – and this has implications for health systems. What is needed in these settings are methods that bring the voice of marginalised citizens (women, refugees, disabled people etc.) into decisions about health systems. He made the great point:
If we don’t listen to people how will we plan accessible people-centered health services in post conflict settings?
Nigel reiterated the point that we don’t just need enthusiastic outsiders to conduct this type of research. What is required are people with a deep knowledge of the context and environment – this calls for research into the type of research partnership models we employ and how funding is delivered. He stressed that too often shortcuts are taken in the research process – either in terms cherry picking the geographical areas covered or the methods that are used. In addition research can be hampered by problems of government legitimacy and sensitivity about questioning government decision making. He also made interesting points about gender and the employment of women in research and health care delivery its potential impact on equity and the amelioration of conflict.
Ethics, community engagement, local ownership and more!
Are webinars like, ‘talking to an invisible public’, as one of our panellists put it? Not in this case. With 32 audience questions in an hour we had great participation and a lot of important inputs to the research process to mull over. It is impossible to do justice to them all here but questions and issues raised included:
- The importance of governance and leadership
- How to conduct research in areas controlled by those who are hostile to outside interference – such as Al-Shabab in Somalia
- The perception is of research not being a priority, particularly during first stages of emergency when there are pressing humanitarian needs
- The need to build capacity in local research institutions
- The ethics of research in these settings (risks to informants and ethical clearance, for example)
- Is it right to sacrifice the highest quality of the research in order to get some insights?
- What can we do in fragile settings in order to achieve community cohesion?
- The need to focus not only on volume of aid but also how it is implemented/disbursed
- Research on different service implementation strategies and models of care at the ground – health outcomes
- How to ensure cross-sharing of evidence-based best practices and fragile state comparison
One particularly perplexing question related to whether this agenda applies to countries in an economic crisis such as Greece? So we certainly have a lot to consider as we move forward!
We will be contacting people who joined the webinar and following up on the issues raised. If you would like to join our group and be part of the discussion you can find us on LinkedIn. We hope to continue a discussion of these issues online. Be part of the conversation. Read our Storify of the event. Alternatively please contact Jan Randles.