To make people centred health systems a reality all Thematic Working Groups need to extend their focus to include Fragile and Conflict Affected Contexts

HSG board member, Sara Bennett, and the TWG secretariat – Jeff Lazarus and Ida Sperle – encouraged TWGs to seize strategic opportunities to work collaboratively and maximise strategic links.

To make people centred health systems a reality all Thematic Working Groups need to extend their focus to include Fragile and Conflict Affected Contexts

Sally Theobald

There are currently 9 Health Systems Global endorsed Thematic Working Groups (TWGs). HSG board member, Sara Bennett, and the very able but slim TWG secretariat – Jeff Lazarus and Ida Sperle – encouraged TWGs to seize strategic opportunities to work collaboratively and maximise strategic links. Suzanne Fustukian from the ReBUILD consortium  pointed out that the Health Systems in Fragile and Conflict Affected States was the only TWG that focused on specific contexts but that the focus and action of all of the other TWGs is relevant to fragile settings. Below drawing on the experiences to date from ReBUILD and insights from the conference I discuss how and why:

Medicines in Health Systems Alex Jones, ex-ODI fellow, participated in a ReBUILD “question time” session we ran last week as part of our annual consortium meeting and explained that in FCAS settings such as Sierra Leone, counterfeit and out of date medicines can proliferate with wide reaching implications for health. There is need to better understand these impacts and put in place processes and structure for regulation. Professor Martin Mckee , in Plenary 2, at HSG, argued that the pharmaceutical and drug development companies have been far too slow and non responsive in developing drugs and vaccines for Ebola; and that this current crisis calls for a sea change in the priorities for drug development and medicines in health systems. How can drug development companies be more responsive to the realities and needs of fragile and post conflict settings?

SHaPeS: social science approaches for research and engagement in health policy & systems We have constituted a learning community with the ReBUILD consortia to reflect on the challenges and opportunities of conducting ethical and trustworthy social science research in post conflict contexts. Experience shared to date highlights how some participants were unwilling  to speak due to anxiety and lack of trust and the fear of reliving previous traumatic experiences. In post-conflict contexts participants may be more vulnerable and have reasons to be fearful of research encounters. Discussions included how far does the informed consent process stretch? – Many researchers shared experiences of participants telling a different or ‘real’ story once the recorder had been switched off and the ethical challenges of reconciling both “formal and informal stories” in the analysis process; and the particular need to spend time and effort establishing rapport. Researchers need to act with integrity and be aware of the legacy we leave.  Conducting social science approaches for research and engagement in health policy and systems is always challenging, working in post-conflict contexts may pose additional challenges which it would be important for the SHAPES TWG to explore.

Ethics of Health Systems Research  In FCAS contexts informed consent procedures needs careful thinking through.  Written consent may bring l concerns with participants fearing that a signature may have negative repercussions. In context where there is a real and justified fear of putting pen to paper verbal  consent  should be considered and there may be other adaptions required too. There have been promising gains made in Ebola research in recent months and we can expect further research in this area in West Africa and the ethical implications here will need careful but swift consideration. Dr. Mohamed Samai from the health ministry in Sierra Leone to and ReBUILD colleague raised the importance of supporting the ethics committee in be able to respond quickly and appropriately to research protocols and ensure such research meets national priorities.

Supporting and Strengthening the Role of Community Health Workers in Health System Development  CHWs can be critically important in FCAS where there are often massive shortages of human resources for health at all levels. At the health systems conference in Beijing in 2012 there was a specific session on CHWs in conflict, which highlighted strategic innovation in Afghanistan where women CHWs (many of whom can’t read) have been trained to support their communities’ health using pictorial guides.  In the 2014 CHW TWG discussions, Mohsin Sidat, from University Eduardo Mondlane, Mozambique and REACHOUT discussed how Mozambique’s post conflict trajectory has shaped the experience and make up of CHWs today. A legacy of the war is that unlike many contexts most CHWs are men; and communities are actively requesting more women CHWs and the gender make up of CHWs is currently under discussion.  Health systems responses to Ebola have been a central thread of discussion throughout the Cape Town conference; including the need to rebuild trust between health systems and communities. There appear to have been some missed opportunities here in current responses in W. Africa. Sarah Ssali from the Department of Women and Gender Studies at Makerere University, highlighted how building trust and collaborative working relationships with different community groups and structures particularly community health workers was critical to the swift response to the  2001 Ebola epidemic in  conflict affected northern Uganda.

Teaching and Learning Health Policy and Systems Research In a recent blog Barbara McPake argues that “A critical issue is the weakness of local capacity for careful analysis that more often than not characterises countries emerging from conflict. Educated populations tend to have greater opportunity to escape conflict affected situations; and sometimes a higher conflict related mortality among those that fail to do so”. During the FCAS TWG business meeting Mahdi Ashour from Palestine argued for urgent resources for capacity and research monies for national researchers in FCAS that is relevant and responsive to local contexts. This requires new knowledge, case studies, frameworks and guidelines that are relevant to the realities of health systems challenges in FCAS. As Kumanan Rasananthan, from UNICEF, argued in Plenary 3, we need to put local, district and national research organisations first. This is all the more urgent in FCAS settings where we need to invest in capacity building at institutional levels to support the development of sustainable and responsive health systems research.

The Private Sector in Health The private sector TWG highlighted the importance of working in FCAS, where the public sector can be weak and the private sector in its multiple forms prolific.  Within ReBUILD, our colleagues from Makerere School of Public Health have been analysing the mushrooming of organisation and providers  – mainly private sector – in post conflict Uganda and in Gulu in particular. Freddie Ssengooba has applied social network analysis to illustrate the connections between these multiple players and the challenges to the coordinating role of District Health Officer, while Justine Namakula is analysing HR movements between the public and private sectors. Further insights on the role of the private sector in FCAS and their implications for people centred health systems is required.

Translating Evidence into Action This is another key area of discussion throughout the Cape Town conference; how do we ensure research is relevant to and conducted in partnership with those who most need it. Following a thorough consultation process the Alliance for Health policy and Systems Research, The World Bank and USAID have produced a statement on the importance of Implementation Research and Delivery Science. In the satellite session discussing this, Khalifa Elmusharaf drawing on experience from South Sudan raised the importance of investing in institution, structures and processes in fragile and conflict affected states to make the opportunities IRDS brings a reality. There are clear overlaps here with the Training and Learning for HSR TWG and further dialogue here should be fruitful.

Quality in service provision

NGOs and international providers such as MSF often provide critical and high quality health service provision in conflict and in humanitarian contexts. Developing and sustaining quality health services in the public health sector in fragile and conflict affected settings is challenging as there are often human resource shortages as well as limited supplies. Multiple players can bring challenges to governance and oversight of service quality. Yet these are the contexts where accessible, equitable and quality health services are vital and people centred health systems are arguably critical to rebuilding  the social fabric of countries. Further knowledge is required on the best ways to do this.

In summary fragile and conflict affected settings are critical to achieving universal health coverage and making the (currently under discussion) sustainable development goals and people centred health systems a reality. On behalf of the Health Systems in Fragile and Conflict Affected States TWG I would like to challenge the 8 other TWGs to ensure they include a focus in these critical but too often neglected contexts.

Sally Theobald, ReBUILD consortium

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