Ebola requires a robust health systems response

By Sally Theobald, Liverpool School of Tropical Medicine

Ebola is threatening gains made in health systems strengthening in post conflict Sierra Leone. The ReBUILD consortium working in partnership with College of Medicine and Allied Health Sciences (COMAHS) in Freetown has been assessing the opportunities and challenges of the post conflict window(s) for health systems strengthening with a particular focus on human resources for health and health financing. Important gains have been made across the country in recent years with investment in health staff of all cadres and the roll out of the Free health Care Initiative for children under five and for pregnant women and breast feeding mums. With the recent outbreak of Ebola the landscape has changed dramatically. During our ReBUILD partners meeting in Liverpool in September we discussed health systems as complex adaptive systems and the implications of the latest shock, in the form of Ebola, to the Sierra Leonean health system.  Haja Wurie from COMAHS, explained how the health system in Sierra Leone is divided into six pillars, and how the Ebola outbreak requires action and response across all areas. Examples discussed include:

1. Governance: there is need for a coordinated and swift response at all levels. In Sierra Leone the health system is decentralised but in reality this can lead to delays in response as district teams cannot act without decisions at national level. The situation is complicated by the influx of a number of international players. The methods deployed in ReBUILD (life histories) enable a long historical view and analysis of past relationships and experiences, which are also emerging in current responses to Ebola. In our ReBUILD question time panel, Alex Jones, ex-ODI fellow, highlighted how the international response reflects past political histories and relationships with UK largely supporting Sierra Leone; the USA Liberia and France, Guinea. This is turn brings challenges to the notion of a joint West African approach and strategic lesson learning about what works well in different contexts and why.

2. Human resources for health: Sierra Leonean health workers of all cadres need urgent support. Health workers across the board have limited supplies for infection control and are massively overworked. Training in and supplies for infection control in Sierra Leone is limited, exacerbating the infection spread. This has resulted in many of the health specialists at the forefront of the outbreak being much needed international experts flown in by international development partners, who in turn often get flown out to receive medical care if infected; an option rarely open to Sierra Leonean health care workers, who in many cases experience high levels of stigma amongst their communities because of the risks associated with their job.

3. There is need to develop robust systems and approaches for research and M&E. Sierra Leone’s research for health priorities are mostly donor-driven, with little ownership by the MOHS. There have been promising gains made in Ebola research in recent months and we can expect further research in this area in West Africa. Dr. Mohamed Samai from the MOHS in SL and ReBUILD colleague raised the importance of supporting the ethics committee in Sierra Leone to be able to respond quickly and appropriately to research protocols and ensure research meets national priorities.

4. Service delivery: Rebuilding trust with communities and ensuring health promotion messages get to those who need them is vital.  Ebola is fuelling mistrust between health services and communities and in some cases health services are being abandoned by both health workers and communities. This has the potential to seriously undermine recent positive steps Sierra Leone has taken to increase health service utilisation and build trust between health systems and previously neglected rural communities. Sarah Ssali from the Department of Women and Gender Studies at Makerere University in Uganda, highlighted how lessons learnt from the HIV response were critical in addressing the Ebola outbreak in northern Uganda in 2001. Key to this was building trust and collaborative working relationships with different community groups and structures particularly community health workers; and developing effective multi-sectoral responses. Gender also matters. The links between gender and infectious diseases are well established and also sadly playing out in the latest Ebola epidemic; where the roles of women as girls as carers within households and communities means they are especially vulnerable to infection. In Liberia it is estimated that 75% of Ebola cases are female and in Sierra Leone women have comprised 55 to 60 percent of the dead.  Within Sierra Leone the newly constituted Maternal Health Promoters are embedded in communities and have trusting relationships with women and could play an important and strategic role in spreading health promotion messages and support.

When I introduced our ReBUILD colleagues from Sierra Leone to my LSTM colleague Dr. Tim O’Dempsey who has recently returned from the WHO effort to address Ebola in Sierra Leone, I thought they would shake hands. Instead they bumped elbows in a comradely fashion – the ‘Ebola bump’ form of greeting amongst health professionals has evolved as a way to reduce cross infection; similarly health systems in Sierra Leone must adapt and respond to the latest shock faced in the form of Ebola. This means learning past lessons I order to build resilient and responsive health systems, strengthening governance and ensuring a coordinated response, investing in and protecting all cadres of health workers and working hard to support trusting relationships with diverse affected communities.

Ebola: How Can We Help? The role of Health Systems Research in addressing Ebola and other health system crises

A meeting co-hosted by the Health Systems in Fragile and Conflict Affected States Thematic Working Group and USAID at the Global Symposium on Health Systems Research

Wednesday, October 1, 13.15 – 14.15, Auditorium 2

As the Ebola epidemic devastates West Africa, we can see how countries are facing serious health system challenges. After the epidemic is brought under control, however, countries will still face massive rebuilding of their Ebola-damaged health systems and creating more robust capacity.

Health Systems, particularly in resource constrained environments, are regularly subjected to external factors that test their resiliency. The next devastating test on a country’s health system may be epidemiological, political, economic, environmental, or any number of factors that affect its ability to provide essential services. In this session, co-hosted by the Fragile and Conflict Affected States Thematic Working Group and USAID, we will focus on the need to create a global research agenda on strengthening coverage, access, financial protection and responsiveness, plus resiliency, in vulnerable health systems. The discussion will focus on key health systems issues and the need for evidence, particularly implementation research, on creating more resilient health systems. We will also provide a google form link where individuals can submit suggested ideas and priorities after the session.


* Knowledge sharing and discussion on how health systems research can support Ebola recovery

* Identify priority areas of health systems research to advance, with a specific focus on implementation research, that can contribute to health systems recovery and creating more resilient health systems

* Identify next steps for advancing the global research agenda


Photo courtesy of UNICEF Guinea https://www.flickr.com/photos/unicefguinea/15064546832

Architects’ sketches or builders’ plans for health systems development in fragile and conflict affected states?

By Barbara McPake (Institute for International Health and Development, Queen Margaret University, Edinburgh and Nossal Institute for Global Health, University of Melbourne)

The post-2015 sustainable development goals are emerging. If they are finalised close to the form that is currently proposed, then they represent a significantly increased ambition, with old Millennium Development Goals (MDGs), such as reducing maternal mortality and incidence of HIV, embedded in the larger goal of promoting healthy lifestyles, addressing the social determinants of health and achieving universal health coverage; and entirely new areas of focus including promoting peaceful and inclusive societies. Overall the number of goals will grow from 9 to 17.

Fragile and conflict affected states (FCAS) have been among those that have been left behind in the process of pressing for the achievement of the MDGs to the extent that the 2011 World Development Report on Conflict, Security and Development reported that no low-income FCAS had yet achieved a single MDG. While the statement may be misleading, and more recently the World Bank has reported that 20 FCAS have achieved MDGs, there is no contesting that progress in such countries has been markedly slower. Critics of the MDG approach have argued that it pays insufficient attention to locally defined and owned definitions of progress and development (Sumner and Melamed, 2010) and such a view appears to have inspired the G7+ (a coalition of self-identifying FCAS) Principles for Good International Engagement in Fragile States and Situations which emphasise that: ‘A durable exit from poverty and insecurity for the world’s most fragile states will need to be driven by their own leadership and people.’

The argument that globally devised and packaged policies fail to deliver development and may even undermine it, is not new and was popularized by Robert Chambers in his 1983 text: ‘Rural Develoment: Putting the Last First. Among the critiques is the recognition that such packages are premised on a generic understanding of the problem requiring resolution which is contradicted by the multiplicity of realities that maintain fragility and conflict in FCAS (for example see Baird and Hammer, 2013 on contracting in Cambodia; and Obadare, 2005 on the rejection of polio vaccine by Northern Nigerian states). Barry Munslow, speaking at the ReBuild annual workshop last week compared the global policy package to the ‘architect’s sketch’ which imagines the future aspired to, but has not considered the terrain on which that future needs to be built. In contrast, the ‘builder’s plan’ is developed from a careful analysis of that terrain with detailed provisions for accommodating the specificities emerging from that analysis. If we accept the need for ‘builders’ plans’, from where can they come?

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. In the aftermath of conflict a youthful, poorly educated and inexperienced national bureaucracy and civil society often confronts a well-financed and enlarged, but locally inexperienced and short time horizon focused international aid industry in negotiating the policy agenda. The international aid industry brings blueprints (architects’ sketches) from other contexts while national stakeholders fail either to understand or articulate the disconnects between the sketches and the realities of the terrain; or fail to promote their understanding because such inconvenient truths are readily perceived to be unwelcome and unrewarded.

All this suggests that a critical investment in the transition from fragility and conflict is in a cadre of locally embedded, critical researchers and policy analysts who can develop the confidence to confront the international aid industry with inconvenient truth and find welcoming and rewarding audiences for their messages. Their task is to develop builders’ plans for the rebuilding of institutions. Is there a genuine interest among funding agencies to support this? DFID has funded the ReBUILD consortium (in which I declare a strong interest) with precisely this agenda in supporting the development of local capacity to analyse the terrain of the health system and the opportunities to support locally appropriate health institution building. There are other examples but they are dwarfed by investment in the purveyors of architects’ sketches whose promises of ‘best global practice’ and ‘(globally) evidence based innovation’ offer the allure of steering clear of messy realities. Ultimately, these serve development ends in such contexts poorly.

Baird, I.G. and Hammer, P. (2013) Contracting illness: reassessing international donor-initiated health service experiments in Cambodia’s indigenous periphery, South East Asia Research, 21, 3: 457-73

Chambers, R. (1983) Rural Development: Putting the Last First, Longman

Obadare, E. (2005) A crisis of trust: history, politics, religion and the polio controversy in Northern Nigeria, Patterns of Prejudice, 39. 3, 265-84

Sumner, A and Melamed, C. (2010) Introduction – the MDGs and Beyond: Pro-poor policy in a changing world, IDS Bulletin, 41, 1: 1-6

Join the Thematic Working Group on Health Systems in Fragile and Conflict Affected States in Cape Town

Tuesday 30 Sept, 09.00-11.00, Roof Terrace

If you are coming to the Health Systems Global conference do attend and participate.

09.00 – 09.15 Welcome and formal launch of the TWG (Tim Martineau). Presentation of initial draft of health systems research in fragile and conflict affected states landscaping paper (Suzanne Fustukian).

09.15 – 09.45 Presentation of selected current research published in the special issue of BioMed Central’s “Conflict and Health”: ‘Filling the void: Health systems in fragile and conflict affected states‘.

A window of opportunity for reform in post-conflict settings? The case of Human Resources for Health policies in Sierra Leone, 2002-2012 (Maria Paola Bertone, Mohamed Samai, Joseph Edem-Hotah, Sophie Witter).

The “empty void” is a crowded space: health service provision at the margins of fragile and conflict affected states (Peter S Hill, Enrico Pavignani, Markus Michael, Maurizio Murru, Mark E Beesley).

09.45 – 10.15 Presentation and preliminary results of a study conducted by the TWG into research needs of health systems in fragile states (Egbert Sondorp) followed by comments by the panel: Dr Sarah Ssali (Makerere University), Ann Canavan (International Medical Corps), Olga Bornemisza (the Global Fund to fights AIDS, TB and Malaria) and Professor Peter Hill (University of Queensland)

10.15 – 10.45 Plenary discussion on research needs and priorities regarding health systems in fragile and conflict affected states

10.45 – 11.00 Outline of next steps of research needs identification process

More information about the Thematic Working Group on Health Systems in Fragile and Conflict Affected States:http://www.healthsystemsglobal.org/ThematicWorkingGroups/HealthSystemsinFragileandConflictAffectedSt.aspx

Photo courtesy of Joseph Kerkulahttps://www.flickr.com/photos/communityeyehealth/5494123897

UK Parliament

Response to the Select Committee Report on Enquiry into Health Systems Strengthening In Developing Countries

By Helen Carlin, Liverpool School of Tropical Medicine

The House of Commons International Development Select Committee reported last Friday on the findings of its enquiry into the role of the UK Department for international Development (DFID) in strengthening health systems in developing countries. It recommended that DFID must use its expertise in this area to show global leadership and influence the agendas of its international partners, and build up health systems through strategic linkages with the opportunity of the post-2015 development goals which support universal health coverage.

The DFID-funded ReBUILD Consortium, which is growing the evidence base of how health systems develop in the aftermath of conflict and fragility in low- and middle-income countries, provided written evidence to this committee. We highlighted the importance of the particular needs of these states and the learning that can be applied from understanding how the decisions made after conflict can impact on the longer term development of the health system, including widening access to health care for the poorest populations. We agree with the conclusions of the report that health systems strengthening is essential to tackling the challenges faced including the growing and persistent issue of conflict-affected regions.

Fragile states and Ebola

Nowhere more, than in the post conflict areas of West Africa devastated by Ebola outbreaks, is the need for strong health infrastructures that can respond quickly to such crises needed. The cases of Sierra Leone and Liberia were both highlighted in the report. The rapid spread of Ebola and the slow response to treat those infected, the disaffection of health workers due to lack of essential materials and protective personal equipment have been indicative of the weakness of the Sierra Leone health system, a country included within the ReBUILD research portfolio.

Our colleague Haja Wurie reports:

“A weak health system and poor governance and complicated bureaucracy delayed the response to the outbreak. Infrastructural challenges, infection control practices, poor water and sanitation, electricity, communication, health promotion and education are weak. The post conflict economy was a challenge for many homes meaning seeking education was not a priority. This resulted in low levels of literacy which in turn translated into slow uptake of the sensitisation exercise about the virus in the early stage of the outbreak in conjunction with the initial denial.

The breakdown of frontline services has led to other non-Ebola related illnesses now not being treated as the population loses confidence in the health system to treat them. This threatens attempts that have been made in the post-conflict period to establish elements of universal health care through the free health care initiative for pregnant and lactating women and children under age 5.

In taking forward the findings of the report there is a need to:

  1. Understand the importance of health system strengthening as rapidly as possible following conflict and social breakdown in order to ensure resilience in the face of epidemic outbreaks.
  2. Understand what makes a health system resilient, by looking at successful systems that have successfully contained epidemics in conflict areas such as Northern Uganda. (http://online.wsj.com/articles/a-tale-of-two-africas-1408749489)
  3. Ensure that decisions made post conflict are supportive of developing the sustainability of the health system longer term as well as consolidating universal health care principles
  4. Ensure the global leadership provided by DFID considers the importance of addressing health systems development in post-conflict countries in particular.

The ReBUILD consortium welcomes the report’s recommendations that DFID increase funding for health system strengthening research. We argue that it is important for resources to be allocated to understanding the needs of the growing number of states and regions that are likely to emerge from conflict in the future.

Photo, ‘The Houses of Parliament seen from Westminster Bridge at night’, courtesy of William Warby

NEW PUBLICATION: Report from the consultation on Collaboration for Applied Health Research and Delivery

The Centre for Applied Health Research and Delivery (CAHRD) is an international network that combines individuals, disciplines and organisations based at the Liverpool School of Topical Medicine in the UK. Earlier in the year they held a far reaching consultation in order to shape their work over the next 20 years. It focused on; lung health, maternal and newborn health, Neglected Tropical Diseases, and health systems. One of the aims of the consultation was to find synergies between these different areas.

Work in fragile and conflict affected settings was a prominent theme in the consultation and ReBUILD researchers participated in the dialogue. These conversations have been written up for a new paper in the journal Conflict and Health. The article addresses issues like:

  • Human resources for health from the perspective of IPASC in rural Democratic Republic of Congo
  • The health systems challenges in addressing Neglected Tropical Diseases
  • The role of intersectoral action in strengthening health systems
  • Future directions of health system strengthening in fragile and conflict affected settings

Read the full paper ‘Fragile and conflict affected states: report from the consultation on Collaboration for Applied Health Research and Delivery’

If you are interested in discussions related to the Centre you can follow Bertie Squire on Twitter.

Photo of our colleague Sarah Ssali taking a well earned coffee break at the consultation, courtesy of Matt Goodfellow.

Dates for your diary: ReBUILD presents at the Global Symposium on Health Systems Research

The Global Symposium will take place in less than a month and we are delighted that ReBUILD will be involved in a range of events and presentations. Please make a note of them and come along to meet us!

30 September

9:00-11:00 Information sharing meeting of the Thematic Working Group for Fragile and Conflict affected states, Roof Terrace

1 October

11.00-11.30 Poster: Gendered Health Care coping in Northern Uganda: What are the gender and equity considerations in post conflict health systems strengthening? (Sarah Ssali, Robert Byabasheija, Pallen Mugabe, and Justin Namakula), Conservatory

11:00-11:30 Poster: Health worker incentives in post-crisis Zimbabwe (Yotamu Chirwa, Wilson Mashange, and Sophie Witter), Conservatory

13:20-13:50 Poster: The Impact of Health Financing Policies on Household Spending in Cambodia (Tong Kimsun, Chhim Chhun, Ge Yu, Tim Ensor, Fu-Min Tseng, and Barbara McPake), Conservatory

13:50-14:20 Poster: Contracting health services in Cambodia: From external to internal contracting models and its implications (Sreytouch Vong, Joanna Raven, and David Newlands), Conservatory

13:50-14:20 Poster: Health seeking behavior and impact of health financing policy on household financial protection in post conflict Cambodia: A life history approach (Bandeth Ros, Barbara McPake, and Suzanne Fustukian), Conservatory

14:30-16:00 Oral presentation: Health worker migration between and within private not-for-profit and public sectors: lessons from post- conflict northern Uganda (Justine Namakula, Sophie Witter, and Freddie Ssengooba), Meeting Room 1.41

16:00 – 16:30 Poster: Increasing access to health services in remote and rural areas through improved retention of health workers: Evidence from Sierra Leone (Haja R Wurie and Sophie Witter), Conservatory

2 October

16:00-16:30 Poster: Mobility of health staffs during conflict and post-conflict situations in a decentralized system, a case study of Northern Uganda (Richard Mangwi-Ayiasi, James Bagonza, Tim Martineau, and Elizeus Rutebemberwa), Conservatory

3 October

09:30-11:00 Organised session: New frontiers in advancing gender analysis in health systems research: context embedded approaches; intersectionality; and engagement with power and ethics (Sally Theobald, Moses Tetui, Eleanor Macpherson, Parthasarathi Ganguly, Tamanna Shamin, and Catherine Molyneux), Roof Terrace

11:00-11:30 Poster: The challenges and opportunities of conducting ethical and trustworthy qualitative research in health systems in post-conflict and fragile contexts: Reflections from a learning community (Sally Theobald, Sarah Ssali, Sreytouch Vong, Stephen Buzuzi, Haja Wurie, Sophie Witter, and Joanna Raven), Conservatory

13:20-13:50 Poster: Organizational Infrastructure for Service Delivery: A Case Study of Post-conflict Northern Uganda (Freddie Ssengooba, Vincent Kawooya, Justine Namakula, and Suzanne Fustukian), Conservatory

14.30-16.00 Panel: Path dependency and systems thinking in analysing health systems development in the aftermath of conflict (Barbara McPake), Meeting Room 1.61-1.62