Twitterchat: People-centred research methods for health systems development


Another Twitterchat on health systems research is coming up, again hosted by Health Systems Global. The theme is people-centred research methods for health systems development and the chat will take place on Thursday 20th August at 14.00 BST. Some excellent panel members are lined up already, representing a number of health systems Research Programme Consortia, including ReBUILD’s own Sarah Ssali and Joanna Raven (representing the PERFORM programme).

After the 2014 Global Symposium on Health Systems Research, the Cape Town statement on People-Centred Health Systems suggests that as researchers we should: “Allow the experience of communities and health workers to be heard, through use of innovative research methods that engage and empower communities including participatory action research, photo-voice, simulations and games.” In support of this, the Twitterchat will involve a panel of researchers working on health systems, who will explain what novel approaches they have taken, challenges and un-anticipated consequences in the research process and the gains that they think these methods have brought.

The panel:

Lucy Gilson (University of Cape Town/London School of Hygiene and Tropical Medicine, South Africa/UK) is representing the Resyst RPC, and will speak about their learning sites. You can learn more in this video

Kingsley Chikaphupha (REACH Trust, Malawi), is a member of the REACHOUT RPC, and will talk about their Quality Improvement Cycles and the work he has done with the SHARP project in South Sudan

Sarah Ssali (College of Humanities and Social Sciences, Makerere University, Uganda) represents ReBUILD and RinGs and will talk about her work in Northern Uganda using life histories.

Valéry Ridde (University of Montreal, Canada) will talk about action research.

Edwine Barasa (KEMRI-Wellcome Trust Research Programme, Kenya) is also representing Resyst and will talk about their learning site.

Joanna Raven (Liverpool School of Tropical Medicine, UK) will represent the PERFORM project which is working in Ghana, Tanzania and Uganda using action research to improve health workforce performance. Read her blog on ‘Addressing the human resources for health crisis’.

Miriam Taegtmeyer (Liverpool School of Tropical Medicine, UK) will also represent REACHOUT and will bring insights on the Quality Improvement Cycle method that they have used to strengthen Community Health Worker programmes in six countries in Africa and Asia.

How to join the Twitterchat:

The chat will take place on Thursday August 20th at 14.00 BST. It will use the hashtag #HSR2015. If you are not able to attend the live discussion, you can tweet your comments to @H_S_Global or @REACHOUT_Tweet using the hashtag #HSR2015.

An edited summary of the event will be produced as a Storify post shortly after the session. We will share the link.

Health systems financing – what’s gender got to do with it?

On 1st July, the RinGs programme held an open webinar on gender and health systems financing – ‘Health systems financing – what’s gender got to do with it?

Chaired by ReBUILD’s Sophie Witter (who also gave one of the presentations), this event brought together an excellent and diverse panel, who started off by presenting various perspectives on issues of gender in health systems strengthening which included: macro perspectives (through the lens of working towards universal health coverage); reviews of what the literature says, and the key gaps; experiences and case study from India on the effects of health sector reforms from a gender perspective. After a commentary from ReBUILD’s Sarah Ssali, with her own perspectives from Uganda, the panel addressed a wide range of questions and comments from the on-line audience.

You can access a recording of the whole webinar here. The very active exchanges on social media during the webinar have been summarised in a short Storify. And don’t miss Sophie Witter’s excellent blog on this webinar!

This is the second webinar that ReBUILD has been actively involved in recently with our partners, following another successful webinar on research needs for health systems in fragile and conflict affected states in May, by the Thematic Working Group on Health Systems Research in Fragile and Conflict Affected States. We are finding this format is an excellent way both of communicating research and experiences, and of getting high quality input and discussions from interested colleagues throughout the world.

The RinGs programme is a partnership between three health systems focused Research Programme Consortia (RPC): Future Health SystemsReBUILD and RESYST, and is working to understand and encourage a gendered approach to the study of health care-seeking; financing and contracting; governance; and human resources. RinGs is funded by the UK Department for International Development

Register now, for a Webinar on Gender and Health Systems Financing, 1 July 2015

On 1st July 1:00 PM – 2:30 PM BST (GMT + 1 hour) the RinGs programme is hosting an open webinar on Gender and health systems financing. Full details can be found here. Registration is free, via this link.

The details below are from the RinGs website.

“There are many different mechanisms for generating health care revenue, each with implications for access and availability of care. However, as our review of the literature indicates, analyses of health care financing methods surprisingly pays little attention to how these financing reforms impact on the differential health needs of women and men.” Percival et al 2014

The push to include universal health coverage in the emerging Sustainable Development Goals has created renewed interest in how health systems are financed and how these allocations are distributed. Donors, activists, policy makers and academics are all concerned with ensuring that service users do not suffer financial hardship when accessing health care. But where is a gender analysis in all of this?

We know that health financing and reforms have gender implications, for example, in the budgets available for gender audits, the extent of financial protection for different groups, the availability of certain services, and the out-of-pocket expenditures of different groups. This webinar seeks to share information on the available evidence and highlight some of the information gaps. We hope it will stimulate a wider conversation among health sector stakeholders who are concerned with social justice. Please join our exciting panel to learn more and to have your say!


Rob Yates (Senior Fellow at Chatham House) will open the webinar with an overview of health financing and Universal Health Coverage.

Sophie Witter (Professor of International Health Financing and Health Systems at the Institute for International Health and Development, Queen Margaret University, working in the ReBUILD consortium) will set out some of the gendered questions related to health financing and the gaps in the health literature.

Veloshnee Govender (Researcher/lecturer at the Health Economics Unit at the University of Cape Town) will dig deeper into the literature to explore the gender and health implications of health financing reforms.

TK Sundari Ravindran (Professor at the Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, India) will provide lessons on health sector reforms and gender from India, and give some lessons for Universal Health Coverage.

Sarah Ssali (Senior Lecturer, School of Women and Gender Studies, Makerere University, Uganda) will act as a discussant, commenting on the points made by the panellists, while drawing on her own experiences in relation to gender and health system financing.

RinGs is a collaborative programme between three DFID-funded Research Programme Consortia: ReBUILD, RESYST and Future Health Systems in a partnership to galvanise gender and ethics analysis in health systems.

Health systems research in fragile and conflict affected states: the webinar and beyond…

Building resilient and responsive health systems in fragile states and those recovering from conflict presents many challenges, one being the lack of evidence to guide efforts for health systems strengthening in such contexts. This was the subject of a lively interactive webinar on 27th May. The webinar was organised by the Thematic Working Group on Health Systems Research in Fragile and Conflict Affected States (TWG-FCAS) and hosted by Health Systems Global.

Over 50 participants joined the webinar. They heard Egbert Sondorp from the TWG-FCAS discussing some of the challenges of conducting relevant research in fragile settings, from the difficulties in defining research priorities, to the challenges of research uptake. This was followed by Aniek Woodward who presented on some of the findings of the recent TWG study on research needs for health systems research in FCAS. Two excellent and experienced panel members, Khalifa Elmusharaf and Nigel Pearson then gave their responses and expanded further on some of these research challenges and how they might be addressed.

It was then the turn of the webinar participants, many of them clearly highly experience in this field, who posted lots of challenging questions and comments, directly via the webinar and on Twitter, which the presenters and panelists responded to.

If you missed it, you can access the recording of the whole webinar here. You can also read an excellent blog on the event by Kate Hawkins, as well as a summary of the Twitter exchange that accompanied the webinar, under the #HSRFCAS tag.

Following on from the Group’s successful Tweetchat on health workforce strengthening in FCAS earlier this year, this webinar was another excellent forum for airing and discussing the issues around this really important and challenging area of health systems research. The TWG-FCAS will now include this excellent contribution of the participants and panellists as it moves forward with its work to promote research, policy and advocacy actions to contribute to the development and implementation of responsive and context-specific health systems in fragile and conflict-affected settings. The TWG’s support of the special issue of Conflict and Health – Filling the void: Health systems in fragile and conflict affected states, has already provided an accessible outlet for publishing some new and innovative research in this area, and the group is hoping further to expand the participation and scope of the discussions through its recent call for proposals to host meetings in locations beyond the normal conference and meeting circuit.

You can join the Thematic Working Group on Health Systems Research in Fragile and Conflict Affected States. And check back here soon for a video of Tim Martineau, Research Director at ReBUILD, talking about the development and the work of the TWG.

Webinar on research agenda and priorities for health systems in fragile and conflict-affected states

With talk of ‘wake up calls’ and ‘windows of opportunity’ the Ebola outbreak in West Africa has prompted attention to health systems in conflict-affected and fragile states. This focus is welcomed. But how can research support strengthened systems which suit the needs and desires of citizens from a range of countries that have been touched by conflict? How should we prioritise our support? Where do we need to build an evidence base?

On Wednesday 27th May, 2-4pm an open webinar is being held by the Thematic Working Group on Health Systems in Fragile and Conflict-Affected States, to help with the process of defining a research agenda. This webinar is an opportunity to hear more about the methodology that they are using, their preliminary findings, and to add your voice to the process to help strengthen their work. Inputs from a range of stakeholders from academia, civil society, policy, the health workforce and beyond, are encouraged. Please do circulate this invitation to people in your networks.

Click here for full details and to register for the webinar

Can health workers and health systems development contribute to state-building?

Human resources for health are self-evidently critical to running a health service and system. But in a new paper, ReBUILD researchers Sophie Witter, Alvaro Alonso-Garbayo and Tim Martineau together with their co-authors, have explored a broader issue of the contribution which health staff might play in relation to the wider state-building processes.

Through a literature review covering many key disciplines and three case studies from Afghanistan, Burundi and Timor-Leste, they look for evidence to support, refute or adapt some possible linkages. Whilst they find that empirical evidence for most of the linkages is not strong (not surprising, given the complexity of the relationships), they argue that some of the posited relationships are plausible, including between development of health cadres and a strengthened public administration. They also find very different discourses in donor-generated literature compared to external academic studies, which tend to be more sceptical.

They conclude that whilst the concept of state-building itself is highly contested, it remains the case that state-building does occur over time, driven by a combination of internal and external forces and that understanding the role played in it by the health system and health staff, particularly after conflicts and in fragile settings, is an area worth further investigation.

You can access the paper: State-building and human resources for health in fragile and conflict-affected states: exploring the linkages here

Small grants available: for Research Engagement Events on health systems issues in fragile and conflict-affected settings


Some small grants for research engagement events are available from the Thematic Working Group on Health Systems in Fragile and Conflict Affected States.

The purpose of the Group is to promote, share and support new research that draws upon the breadth of knowledge and experience of key actors in health in fragile and conflict affected states to contribute to the development and implementation of responsive health systems, and thus improved population health and well-being through support to a range of research, policy and advocacy actions. As part of this work we are undertaking a research needs-assessment exercise in order to devise a roadmap of potential priority areas for further exploration.

The Group needs to ensure that our work properly supports our stated purpose, has the desired impact and that we are in touch with stakeholders who represent the frontline of the health system. Learning from the field of research uptake suggests that research is more likely to be relevant, accessed, and used if key stakeholders are engaged in the process of knowledge generation from the outset. Communication with our members has been built into the research process through face-to-face meetings, surveys and a proposed webinar. On behalf of the Group, the secretariat would like to deepen this engagement by encouraging a series of stakeholder meetings in diverse settings to stimulate thinking and provide us with further information on practical real life challenges from fragile and conflict-affected audiences.


  • To facilitate a process of shared learning on health systems in different fragile and conflict-affected settings among researchers, policy makers, implementers, health care workers, and civil society actors
  • To capture this knowledge in the form of diverse meeting recordings and outputs
  • To feed this learning into our research process and communications strategy as we move forward with the work of the Group
  • To build our networks and create a sense of shared ownership among group members, particularly those in fragile and conflict-affected settings who sometimes struggle to be heard in these debates


We would like to make available small research engagement events grants on health systems issues in fragile and conflict-affected settings relevant to low and middle-income countries (LMICs). The total value of the grants is approximately USD6,000.  It is anticipated that each award will have a value of up to USD2,000 and that up to 3 awards will be made. This new initiative is funded by the Wellcome Trust.

The grants are managed by Liverpool School of Tropical Medicine, UK which hosts the secretariat of the Group. Proposals are welcome from any member of the Group’s LinkedIn group through which this call is being exclusively advertised. These engagement events can be stand alone or part of larger initiatives that bring together a diverse range of stakeholders. We would prefer face-to-face meetings but if applicants have innovative ideas for how to engage stakeholders virtually we would be interested to learn more.  We would like the events to devote a small amount of time to disseminate the findings of our research needs study[1].

Applicants should submit a proposal (maximum 4 pages – Word file) outlining their:

  • Rationale (description of why the event is timely and necessary);
  • Description and status of the hosting organisation;
  • Audiences (a breakdown of the likely number and type of participants and their relevance to health systems in fragile and conflict-affected states);
  • Potential speakers;
  • Meeting methodology (how the event will be run);
  • Communications strategy (description of anticipated products, forms of dissemination and/or engagement with participants and other target audiences post-meeting);
  • Timetable of Work (reports and final accounts need to be submitted by 31st August 2015); and
  • Proposed budget (funds may be used towards the cost of hiring a venue; ground travel; refreshments; meeting communication, including printing and publication)


The applications will be evaluated by the Steering Committee of the Group. We aim to ensure geographical diversity in successful proposals and in the types of hosting organisations. The proposals will be assessed, in equal measure, on:

  • Their ability to help our Group meet its overall aim of “promoting, sharing and supporting new research that draws upon the breadth of knowledge and experience of key actors in health in fragile and conflict affected states to contribute to the development and implementation of responsive health systems”;
  • The relevance and diversity of proposed participants;
  • And the robustness of plans to document discussions and synthesise relevant learning.


The deadline for submissions of proposals is midnight (UK time) on 15th May 2015. Applicants should submit their proposal electronically to the TWG secretary at: Decisions on successful applications will be made and communicated to all who submit proposals by early June 2015.


Any enquiries about this call should be sent to the Group secretary at:

[1] Details will be provided along with a presentation that you can use.

Health workers and fee exemption schemes. ReBUILD’s new paper on how Sierra Leone’s Free Health Care Initiative has affected health workers.

In a new paper published in Health Policy and Planning, ReBUILD researchers Sophie Witter, Haja Wurie and Maria Bertone explore the effects and implications for health staff of Sierra Leone’s introduction in 2010 of the Free Health Care Initiative (FHCI).

Addressing a previous gap in the literature, their analysis shows how a high-profile policy fee-exemption policy, supported by financial and technical resources can galvanise real systemic changes. They show how the FHCI led to reforms which had a major effect on health workers in Sierra Leone, and that motivation has improved, but that there remain tensions between different health worker cadres as well as a demand for a more consistent package of incentives, particularly in rural areas.

Key messages that come from their analysis include how a broad, well supported health financing change like the FHCI can be a catalyst for broader health system reforms, and that reforms in human resources for health are at the core of making such a change function effectively. However, key challenges remain, intensified by the devastation of the Ebola epidemic, especially in ensuring that changes support good quality of care and an effective rural service, and in sustaining the momentum for reform which remains dependent on external resources.

This paper is open access and can be accessed via this link.

Context and Soup are what matter for health systems strengthening in fragile settings.

Tim Martineau, Research Director for the ReBUILD Consortium, gives his initial thoughts on last week’s Roundtable on health systems strengthening in fragile settings, at the Institute for Tropical Medicine in Antwerp.

Since we started the ReBUILD Consortium to carry out research on health systems in post-conflict states, we have become aware of a growing number of people with an interest in this area. In fact the Institute of Tropical Medicine in Antwerp had previously invited me a meeting in 2013, so I was very keen to attend this latest meeting to learn more, meet new people and catch up with existing acquaintances and of course, share learning from ReBUILD. I was therefore very happy to find a good mixture of people from funding agencies, implementing agencies and researchers. There will be a full report of the meeting and presentations posted on the “Be–cause” platform, but ahead of this, I wanted to share a few of the key take-home messages for me.

In our own writing within ReBUILD, as we have been describing the setting for our research, we have had challenges with terms such as geographic fragility versus that of health systems, states versus settings etc., so it was good to know that we are not alone. This is an unresolved area, though new insight often comes from discussions. For example, Enrico Pavignani talked about “systems framework” implying some kind of design, whereas in the settings we were more often dealing with, he referred to an “arena framework” to give more flexibility to the concept. Whereas it might be appropriate to develop guidelines to work with systems, negotiation is more appropriate for working in arenas.

In relation to this, appropriate actions will depend greatly on the context of the fragile setting. This was illustrated nicely by a presentation on the Central African Republic by Didier Kalombola on behalf of a team of ITM students, which demonstrated the difference of four study settings across the country, each requiring different responses. The concept of context was frequently brought up during presentations and discussion and the need for good “intelligence” (rather than often meaningless hard data) on each particular context in order to develop appropriate strategies for strengthening health systems. It was pointed out that research in these settings is difficult to do, which for me reinforces the value of the Consortium approach. Within the ReBUILD Consortium, we are working with partners from local research institutions within Cambodia, Sierra Leone, northern Uganda, and Zimbabwe.

In addition to knowing the context, it is important to be clear who the main actors are and what their interests might be. And whereas we may start by thinking of actors in the Ministry of Health, Ministry of Finance etc., Enrico Pavignani referred to “a soup of actors” (if I heard him correctly, but I like that collective noun anyway especially as with all the acronyms we have for different agencies this would be “alphabet soup”!). I hadn’t realised how powerful a part of this soup the diaspora is in some countries where the state is particularly weak and the expatriates have the money.

One of the ways we discussed for taking this work forward was the development of a community of practice, which Maria Bertone talked about. This would be an excellent way of complementing the existing Thematic Working Group on Health Systems in Fragile and Conflict Affected States, a sub-group of Health Systems Global, and currently hosted on LinkedIn. But as Maria pointed out, in any community of practice it’s important to have some face-to-face meetings, so I’m very grateful to Sara van Belle and her colleagues at ITM for bringing a good variety of people together for this meeting.

The Question of Ethics in Research Uptake Processes and Products – more from ResUpMeetUp

Millie Nattimba, Research Uptake manager with ReBUILD‘s team from Makerere University School of Public Health, starts getting to grips with the tricky issue of ethics in research uptake activities, after another interesting session at the ResUpMeetUp Symposium and Training Exchange in Nairobi. Millie is part of the 8-strong team from ReBUILD attending ResUpMeetUp, from all ReBUILD’s partner countries.

While we are still struggling to understand what research uptake really entails, how to do it effectively and how to measure its impact; the matter of ethics has reared its fierce head. At the ongoing ResUpMeetUp Symposium and Training Exchange in Nairobi, brilliant discussions are going on, on what is known and unknown in the area of research uptake. One matter with not-so-much known in terms of how to handle it is ethical review for research uptake products.

This issue first popped up in Monday’s parallel session on Multimedia, arising out of photos and videos that featured (i) a young HIV-positive boy living on his own, and (ii) a recovering mentally-ill person and poor resident of a community in South Africa. The issue generated quite a debate during the parallel session, and continued in the plenary discussions the next morning.

While research projects include (sometimes) a research uptake plan in their research protocols for ethical review, it was not clear in the meeting what research uptake teams do when the specifics begin to form. Do video scripts and story lines get ethical clearance before recordings are done? What about the matter of interviewing research participants with mental disorders? Are they able to understand the process of informed consent? In the matter of children living with HIV and living on their own, who consents on their behalf? Should one seek separate ethical clearance to conduct a video interview or is a consent form on its own enough?

Is digital story telling (where the research participant tells his/her story in digital format (pictures and illustrations/drawings) part of the overall research process for which ethical clearance has been obtained, or a separate process for which ethical clearance should be separately obtained? Chances are that many institutions do not actually seek ethical clearance for such processes and products.

Some of these issues may be explored more deeply at one of tomorrow’s training sessions, being run by Sarah Ssali and Nick Hooton, on “Identifying and managing opportunities for ‘user-voice’ as part of research uptake strategies”.

In any case, this seems to be the beginning of what promises to be an interesting, timely and quite frankly intimidating discussion.