An update from the frontline of health systems research in Sierra Leone by Dr Haja Wurie

By Haja Wurie

The aim of the WHO Ebola roadmap is to stop the transmission of the virus in affected countries within 6-9 months and prevent international spread. However, as of today, the Ebola outbreak continues to spread in alarming ways in Sierra Leone and Liberia and has now crossed international boundaries, with cases in Spain and the USA.

In Sierra Leone, the virus has spread to all 14 districts in the country, and the country is still struggling to control the escalating outbreak against a backdrop of severely weak health systems, and significant deficits in capacity. There are reports of five new cases per hour in Sierra Leone and an alarming prediction of 1.4 million people infected in both Sierra Leone and Liberia, if efforts to control the spread of the virus are fruitless.

If uncontained, the outbreak has the potential to cause a collapse of the affected countries, something that will take years to recover from. The only positive thing about the Ebola outbreak is that is has created a window of opportunity to prioritise health systems research and strengthening. Resilient and responsive health systems should be built, or rebuilt in this case, with concerted efforts needed by the Government, researchers, implementers and donors. Most importantly, long term solutions should focus on ensuring that universal health coverage becomes a reality. Resources, strategic planning and capacity development is needed to build to recover from this crisis.

Health systems in Sierra Leone

In Sierra Leone, the health sector is divided into six main pillars, governance, human resources for health, service delivery, infrastructure, drugs and technology and research and monitoring and evaluation. The current Ebola outbreak has highlighted the challenges in all the six pillars and the irresponsive nature of the current health sector, which contributed to the delayed response. In my opinion, the health sector needs to be completely reformed as it is just not working.

There are historical challenges regarding the implementation of policies the health sector in Sierra Leone, with a number of health policies on paper but not implemented. This might be a capacity issue which health systems research will shed some more light on. Systems within central government need to be reviewed, and possibly reformed, as the current practice causes inordinate delays.

The slogan ‘Health is Wealth’ can be seen everywhere at the Ministry of Health and Sanitation, Sierra Leone. Accordingly, the local leaders should ensure that sustainable investments are made in the health sector. This can range from investing in new or upgrading health facilities, diagnostic tools and technology, to investing in the health workers, the unsung heroes and heroines.

With only 2 medical doctors per 100,000 of the population, the human resources available for health are inadequate. Findings from the ReBUILD’s health worker incentive project in Sierra Leone, highlighted that building the capacity of health workers and developing a motivated health work force is an ongoing issue. Health workers in general are demotivated even before the outbreak. Health facilities are chronically understaffed by poorly trained, overworked healthcare personnel, with very little or no training on infection control practices. Working conditions are generally poor, lacking adequate logistics. The basics of sanitation, electricity and personal protective equipment to ensure the safety of health workers from infection are not always available when required. This has resulted in the majority of health specialists at the forefront of the outbreak being international experts flown in by international development partners, highlighting the heavy dependence on foreign expertise.

Attraction and retention of health workers in rural and remote areas of Sierra Leone is an on-going challenge, which has resulted in a mal-distribution of the health work force. Not having equitable access to health care services can influence one’s health seeking behaviour. With no health facilities within easy reach or poor quality of service delivered in the health facilities, service users might seek for health care services via the traditional route. This heavy dependence on traditional healers can only address by ensuring that universal health coverage is available to all. Hence, it is important for more health workers to be trained, that are motivated to work and stay in adequately functioning rural health facilities.

It is a common occurrence in recent weeks for health workers and burial boys – at the forefront in the fight against the virus – to go on strike, citing non-payment of risk allowances, inadequate supplies of PPEs and death of their colleagues. This implies that the health workforce feel both undervalued and ill equipped to do their job effectively, even during the outbreak. Health workers should be motivated and protected. A benefits package for health workers should be developed and their voices should be instrumented in the design. Thus investment is needed in the health workers in terms of remuneration and professional training/development and also in the health facilities in terms of improving the working conditions.

Research priorities

Sierra Leone faces a number of challenges in building its research for health systems, the greatest of which is the absence of national ownership of health systems research. Limited government commitment, inadequate funding, poor coordination and networking, a small number of health researchers who are typically combining multiple tasks or jobs, limited grants and research management skills, and very limited capacity in general, are some of the problems encountered in this country.

Sierra Leone’s research for health strengthening is mostly donor driven, which raises the issue of sustainability. Being heavily dependent on international aid, means that research initiatives are fragmented, and largely led by international researchers with little or no local capacity being built. This should be addressed as a matter of urgency.

The Government of Sierra Leone should make health systems research a priority and take national ownership. In the event of any further outbreak it will be necessary to ensure that local professionals adequately trained are on the ground, and local institutions are involved in health systems strengthening research.

Donor investment and coordination

There is an element of mistrust of the government’s role in how Ebola has come about and is spreading. Sierra Leone being a post-conflict country is still recovering from the effects of the conflict has definitely contributed to the spread of the virus. The eleven year conflict crumbled the health sector and fuelled social conflict and mistrust in the government. International donors should also consider supporting health civil society organisations, and tasking them with activities in health promotion and education, amongst other things.

Donors need to be coordinated to avoid fragmentation. There are reports of high profile meetings at central government, but so far coordination on the ground is ineffective. In the same vein gap between researchers and decision makers should be bridged to ensure that knowledge gaps are identified and incorporated into a tried and tested national health emergency response policy. This will have a ripple effect on leadership and governance systems in place.

Advertisements

You could ask Barbara anything…How did she respond?

By Kate Hawkins

A couple of weeks ago the Nossal Institute for Global Health set up a Reddit IAmA. Our Director Barbara was available to answer any questions that you had on health systems in post-conflict settings. So, what were you interested in? I’ve put together a selection of questions from the Internet and answers from Barbara to shine a light on some of the issues that were highlighted:

Q. How much should the USA worry about the Ebola virus? Does it have the potential to spread like in other parts of the world? (Asks: ScumBucket84, yes really)

A. I think the general American public has little to worry about. Undoubtedly there will be more cases arriving from West Africa, but I think the Dallas events have alerted other American hospitals to the pitfalls. Although the American health system has its problems – I believe the gentleman who died was sent from one hospital to another because he didn’t have health insurance – I’m sure as more cases emerge, protocols will be followed. Some health workers will be infected but they will receive excellent care and I doubt there will be deaths.

It will spread to other parts of the world equally easily, and it is those countries with weak health systems that have the most to worry about. In this context, it’s helpful that transport systems around Africa are not good. It’s easier to fly to Europe or the US from West Africa than to North, East or South Africa for example. This might protect the health systems in the immediate region to some extent.

Q. Considering the state of infrastructure in much of rural India and China is abysmal at best do you believe that introducing Ebola to either of those two regions will be as catastrophic as people say? (Asks: King_of_Carcosa, according to Wikipedia Carcosa is a fictional city. It was recently referenced in the popular American drama True Detectives. He is unlikely to be a genuine member of any royal family, although this is the Internet so you never know.)

A. It’s true that there are huge problems in India and China with their health systems, though both have been improving greatly recently and some states in India now have much more functional public systems. It’s useful to remember what happened with SARS in China. At first, the government was in denial, and this allowed the virus to take hold. But when the problem was recognised, the Minister of Health was sacked, the system geared up to tackle prevention and treatment and the virus was eliminated. In the end, the government in China is very strong and can do things when it wants to.

The situation in India is a bit different, State governments are more powerful than the national one in relation to health matters which would make things more complicated. But there are huge resources in India – health professionals, disease control experts, capacities to develop isolation facilities and to protect health workers which would enable a response once the situation is taken seriously. The problem would be identifying cases in remote areas and getting them to where help can be found.

Overall, I think the two countries would be able to control things before they got catastrophic.

Q. In a perfect world – assuming everything was to run perfectly! – how should emergency responses to health crises function? And how does Australia/US/global response to the current ebola crisis measure up to that? (Asks scalesthefish)

A. There are many versions of perfect, but what we need is ‘good enough’.

Ebola is not the most difficult of diseases to manage. The worst viruses (like HIV/AIDS) cause people to become infectious long before they are symptomatic. In Ebola, symptoms and infectivity develop about the same time, which makes it much easier to control.

What’s needed is that cases of Ebola are identified, isolated, treated and cared for by health workers who are equipped and trained to protect themselves from the infection. In a ‘good enough’ health system, the requirements of that will all be in place.

If Ebola appears in a ‘good enough’ health system, the international community doesn’t have to get involved, the health system will cope. Of course, the outbreak we’re dealing with emerged in three not good enough health systems and international support was needed.

WHO is the key organisation that provides that support and it has done so successfully on multiple previous occasions. It has helped local health workers set up treatment centres and ensured protective equipment is available. It has isolated communities affected, treated all cases until the last one runs its course and then packed up – that’s good enough, if not perfect.

What went wrong this time is that the WHO response was slow and weak as a leaked report over the weekend admits. This seems to have resulted from a WHO official in the African regional office seeking to downplay the outbreak to avoid economic damage and relates to larger problems of the functioning of that office, and the overall governance of WHO in which regional offices are fully autonomous. Erosion of funding to WHO over a long period is also a factor.

The virus also hit a population in a more densely settled area than it has before, and across 3 national boundaries, making co-ordination more difficult.

What US, Australian and other international governments need to do is 3 things:

  1. Get the current outbreak under control – it is far from that. This is now going to require a massive effort of resources, troops and international health staff. Apparently this is still not happening.
  2. Recognise that this is not a one-off. If future similar events are to be avoided, there needs to be international investment in strengthening health systems – something hugely neglected despite unprecedented levels of health related aid, because that has been narrowly targeted on individual diseases rather than system strengthening.
  3. Strengthen the UN system which has been allowed to lose potency because of its governability difficulties. It needs reform but it also needs to be maintained with adequate levels of funding if global threats – health among them – are to be effectively managed.

Q. How can a common man help out in such cases of crisis? (Asks: ataturk1993)

A. As far as emergency response is concerned, I don’t think this requires a large scale participatory effort. What ordinary folks can do is become active citizens in debate on global health. Most people only wake up to major issues when there’s a crisis. Those issues are daily realities for populations in poor countries in Africa and Asia, and if there were more consistent and considered concern from the general populations of richer countries, funds that originate from our taxes might be better used. Also, we can all contribute to keeping the current crisis in proportion – keep images of the Walking Dead at bay and encourage others to do the same.

Q. How does society react to and contend with Ebola where it actually a problem? The meltdown, freakout panic I’ve seen here over two or three cases makes me shudder to think how this country would handle a genuine crisis, health or otherwise. (Asks: CMarlowe)

A. I have a research partnership with a team based in Freetown, Sierra Leone. Their office is in the Connaught Hospital where Ebola cases are bring brought. I met one of the team in the UK a few weeks ago and she describes a society in which people are staying indoors as much as possible, no longer embracing or even shaking hands, trying to keep their circles of contact as small as possible. People are very scared and it sounds miserable. But in Sierra Leone, people have weathered many crises and they are robust. I doubt we would manage so stoically here, but I also don’t see mass disturbance of any kind because any mass activity would expose people to risk they would best protect themselves by avoiding.

Q. Do you think that health systems in fragile states and post-conflict settings get the attention that they deserve from donors and international agencies? If not, why not? (Asks: Kate Hawkins, for it is I. Rather naively using by own full name. I wish I had been more imaginative now.)

A. No they don’t. The main reason is that international agencies are in a bind. They’re expected to show that their aid is effective, but also that it goes to the places where it’s most needed. It’s most needed in fragile and conflict affected states but those are usually the most difficult to achieve results in. Without a good understanding, funders may not have the patience to allow things time to be effective in these kinds of states.

You can read the whole discussion by clicking on this link…

BuzzFeed: Everything You’ve Ever Needed To Know About Health Systems

If you work on health systems research you may be asking yourself – what on earth is BuzzFeed, and why should I care?

Well, BuzzFeed is an online news portal that creates and aggregates content (using the term news lightly as there are a lot of ‘fun’ stories on the site, kittens in dresses, that kind of thing). BuzzFeed authors have a fondness for lists, infographics and quizzes. It is the type of content that you regularly see shared on Facebook and other social media sites. It is very popular with younger people. In terms of audience an estimated 24 percent range between the ages 18-24; 28.7 percent are between 25 and 34 (figures from May 2013).

If we are serious about making health systems research accessible then we need to be experimenting with new formats for sharing ideas. We need to find routes to audiences who are never going to engage with our research through a journal article or even an editorial in the daily newspaper. Which is why we are delighted that our colleague Jeff Knezovich of Future Health Systems has put together a fabulous BuzzFeed ‘Everything You’ve Ever Needed To Know About Health Systems.’ He explains:

“New to the wonderful world of health systems? Then this post is for you! Whether you’re a wonk that needs to brush up, a student, a health care practitioner or just an interested and engaged citizen – this primer is full of everything you’ve ever needed to know about health systems and how they function around the world.”

So visit, give it a ‘LOL’, maybe ReTweet. It’s the future!

http://www.buzzfeed.com/futurehealthsys/everything-youve-ever-needed-to-know-about-health-qpaw

Photo courtesy of Nina J. G. https://www.flickr.com/photos/nicasaurusrex/1340360099

Health systems and gender in post-conflict contexts: building back better?

If you haven’t seen it  yet you might want to check out ‘Filling the void: Health systems in fragile and conflict affected states’ a special issue of the journal Conflict and Health. ReBUILD authors have contributed papers to this series. The most recent one is an analysis of gender in health system reconstruction. The authors – Valerie Percival, Esther Richards, Tammy MacLean and Sally Theobald – explain:

The post-conflict or post-crisis period provides the opportunity for wide-ranging public sector reforms: donors fund rebuilding and reform efforts, social norms are in a state of flux, and the political climate may be conducive to change. This reform period presents favourable circumstances for the promotion of gender equity in multiple social arenas, including the health system. As part of a larger research project that explores whether and how gender equity considerations are taken into account in the reconstruction and reform of health systems in conflict-affected and post conflict countries, we undertook a narrative literature review based on the questions “How gender sensitive is the reconstruction and reform of health systems in post conflict countries, and what factors need to be taken into consideration to build a gender equitable health system?” We used the World Health Organisation’s (WHO) six building blocks as a framework for our analysis; these six building blocks are: 1) health service delivery/provision, 2) human resources, 3) health information systems, 4) health system financing, 5) medical products and technologies, and 6) leadership and governance.The limited literature on gender equity in health system reform in post conflict settings demonstrates that despite being an important political and social objective of the international community’s engagement in conflict-affected states, gender equity has not been fully integrated into post-conflict health system reform. Our review was therefore iterative in nature: To establish what factors need to be taken into consideration to build gender equitable health systems, we reviewed health system reforms in low and middle-income settings. We found that health systems literature does not sufficiently address the issue of gender equity. With this finding, we reflected on the key components of a gender-equitable health system that should be considered as part of health system reform in conflict-affected and post-conflict states. Given the benefits of gender equity for broader social and economic well-being, it is clearly in the interests of donors and policy makers to address this oversight in future health reform efforts.

Read the full paper…

Photo courtesy of Sojoud Elgarrai – UNAMID https://www.flickr.com/photos/unamid-photo/8046318272/in/photostream/

 

What should the Australian government be doing about global health threats like Ebola?

By Kate Hawkins

ABC radio in Australia interviewed one of our colleagues Barbara McPake to get her views on what the national response to Ebola and other health crises should look like.

She explained how the response is a broad church from lab based scientists to social scientists looking at the social determinants of ill health. The Nossal Institute is currently meeting to discuss health security and the Australian aid for health.

She suggested that the global health community is responding fairly poorly to health threats. Ebola should be quite an easy disease to control given that there is a fairly small period when people are infectious but the symptoms are invisible. In places like Syria and Iraq it is difficult to prioritise health systems when there are so many other emergencies and crises. But both their health systems have been very seriously damaged by events there.

National health systems weaknesses underpin the problem. But there have also been two major global health systems failures:

  1. The lack of sufficient investments in health systems over a long period which has left them vulnerable to shocks like Ebola
  2. A lack of investment in global emergency disease control measures

“The World Health Organisation has acknowledged the failures in its response, but longer term there has been a failure to invest in the World Health Organisation…Budget costs there have meant that it has lost a lot of Ebola experts in the last few years.”

Barbara explained how a lot of health aid has been targeted at specific health conditions over the last decade. This has had positive results and been quite effective for the particular illnesses which received support. But the ability of the health system to respond to a range of health problems in many settings is weak because of under-investment.

Both Bird Flu and SARS are threats to Australia as they emanate in the region. Countries like China have significantly strengthened their health system since the SARS outbreak. But other countries have very weak health systems.

Barbara went on to state that Australian aid has made some really good investments in the past, for example in Cambodia. The current administration continues to emphasise health and education. Health systems should be part of that. There are simple and effective investments that can be made in this area and there is also a need to innovate and find new mechanisms for the delivery of health care. Barbara is hoping that the Government will focus on these innovations in the health system as well as investments in general development as part of the mix. Weak health systems rely significantly on people paying out of their pockets for health care. There is a need to get that balance right and see these things as mutually supportive.

Listen to Barbara on ABC Radio or download the sound file…

A view from Australia on Ebola

This week our Director Barbara McPake has been in the news in Australia talking about Ebola:

Global Health’s Professor Barbara McPake, speaking ahead of a conference on global health security in Melbourne on Wednesday, said although it is likely we will see the Ebola within our borders, Australia is well placed to deal with an outbreak.

“As the epidemic gets larger and larger in west Africa the likelihood of the odd case emerging in Australia is quite high, but I do think Australia will deal with it very well,” she said. “If anybody dies in Australia it’s likely to be somebody who has come already at a fairly advanced stage of the infection.”

Read the full article…

In a second article in the West Australian she explains:.

“Australia has a very strong health system.” 

“I think what Australians need to be worried about is if future outbreaks like this are being adequately prepared for and prevented by the strengthening of health systems in countries in the region.”

Read the full article…

Question time: Health systems in fragile and conflict-affected states

By Helen Carlin and Kate Hawkins

As part of the ReBUILD annual meeting we ran a Question Time event which was very ably chaired by Sarah Ssali. The panel brought together Prof Barry Munslow, Prof Mukesh Kapila and Mr. Alex Jones to answer questions from the consortium on health systems in fragile and conflict-affected states. What did we learn?

Do you see the long lens of life histories as useful to answering the ReBUILD questions?

Alex: In Sierra Leone we frequently look back over three years, and sometimes further, but rarely further than 15. Often the information isn’t there and it would be helpful to have this analysis. Impact evaluation of the free health care initiative needs historians as well as economists working on it. You can go to the Archive office which has two people working voluntarily with amazing documents about the construction of Sierra Leone and the country it is today. But this needs more academic attention, and the health lens is important here.

Barry: Ethics committees being what they are it is increasingly difficult to have the voices of the people heard. Life histories bring a sense of change and changing circumstance.  My daughter is a lecturer in post-colonial literature this provides an interesting perspective. However much we think about it we are very top down – bringing in other voices and perspectives into the dialogue is very important.

What is your experience on health care need and provision of health services with respect to disability in post conflict settings?

Mukesh: It is generally neglected, and this is well established. Like the ‘gender lens’ on system development the ‘disability lens’ allows you to design programmes in a way that improves access across the board.

Barry: Humanitarianism does not do disability, which is chronic and long term, whereas humanitarianism is quick fix and short term. There is a disconnect. Handicap International and those dealing with problems of the elderly are critical.  Often disability doesn’t fit the budgetary lenses we have. This is how disempowered they are – the elderly and the disabled are at the back of the queue.

How can we build multi-sectoral cooperation to ensure health worker retention in rural areas?

Barry:  There is a problem of coordination – everyone loves coordination but nobody wants to be coordinated. This is a serious problem regarding the way the UN and cluster system has gone – it gathers and tries to tackle the problems of coordination. Nationals are rarely included in this. That compromises neutrality, impartiality and independence as they are pulled into a political agenda. John Holmes’ book highlights that there is always a problem with the compromises that go with this. What are the compromises that have to be made in the coordination stakes? I have just examined a PhD on maternal and child health in Sudan. There are lots of women doctors who can’t go out the rural areas alone – you need deployment of husbands and wives and schooling etc. It is not just about salaries it’s about families. People ask themselves, “Will I be safe and secure? What about the kids and husbands? Is everyone going to be safe?” The Ministry of Health will have to talk to the other Ministries to coordinate this and it needs dealing with at the local level.

Mukesh: I was chair of the first health cluster under John Holmes’ times – a fluster of clusters and an inert cluster mechanism. Having been someone whose title was Humanitarian Coordinator in Sudan I see that not to be coordinated is part of the human condition. Trying to invent mechanisms to do it better are all going to fail. Humanitarianism is not about logic it is about the heart. We are in the post-coordination age –  where we have to work out how to operate in a world where there are multiple political interests and the skill lies in being able to navigate them. Actor coordination is inherently inefficient – trading business efficiency against a policy of interests. We need to be relaxed do good where we can work with like-minded people. The natural economy of this situation sorts out who’s good and bad.

Is there an opportunity in the post conflict/crisis period to replace ineffective human resource administrative systems?

Mukesh: All post-conflict crisis periods are opportunities. The Chinese word for disaster and opportunity are the same thing. Early debate post-conflict period stretches on longer than you realise. This is not a linear process. It is a matter of judgement and seeing an opportunity when a system is broken down and being able to take some short cuts to break through barriers that have existed for a long time. My own personal experience in the Red Cross in some difficult situations is that issues everyone’s talking about for a long time could suddenly be resolved. You would be surprised how open people are, when it comes to the post-conflict moment. In this you will probably make some rash decisions you will have to unmake – these are correctional changes you will have to live with.

You institutionalise by bedding in improvements and good practices that may or may not be the norm. You can’t have human resource policies without good governance. Development is fundamentally about challenging and changing.  Revolutionary is not a dirty word. There is change that is confusing and destructive and change that requires a culture shift – and this relates to the nature of how health is seen within a nation. As a burden or as a more positive opportunity to strengthen a society?

Alex: The post-conflict period is not without its own chaos. A lot of health workers have fled the country – how do we make the most of the calm after the storm?

Funding agencies are often concentrated in one area/district. What drives the location choices of agencies and why does this pattern exist?

Mukesh: In theory you would have needs analysis and priority countries based on logical criteria. In reality other factors such as tradition, links, and lobbying play a critical part in these decisions. Gulu is over clustered because there are traditional links there. Too often the weight of past relationships, social capital, and self-interest influences this. One area that is not adequately studied is the extent to which funding organisations serve personal relations. This pays a bigger focus in funding than we realise. This matters if we want to take a fiercely equitable view of development. Development is not a science and the factors at play are about trade-offs of resources and how to do the best with what we’ve got.

Alex: In the context of Ebola outbreak the US supports Liberia, the British support Sierra Leone, and the French support Guinea. These decisions are based on relatively clear origins. The danger is that we can’t deal with Ebola one country at a time, you need a coordinated approach in the West Africa region.

Barry: News is generated wherever journalists gather. No journalists = no news. Maybe the same thing applies for development. In partner negotiations you never get a discussion about what’s best for me and my organisation but rather you argue by principle. Once you know that you can decode that. Under capitalism development is uneven and will remain so – we have to live with this and find ways to move round it.

To what extent can the agenda of agencies and government be aligned to achieve long term sustainability?

Barry: We have the Paris principle – what we’ve got to do is fit in with what the government says we should be doing. The real problem lies in putting together those Paris principles and then dealing with a kind of conflict situation. You are torn in the old dilemma – do you do the job or build the capacity? It’s a difficult one to get right. The MSF model is to go in and deliver top quality health care and then pull out and then the quality is then lower and the hand over extremely difficult. Hence there is an inherent tension in the agency itself and between the agency and government. The trick is not to try and railroad this but try and work with the multiple interests here.

Mukesh: It depends on the type of aid agency. For some aid agencies it is very important not to be aligned. The world is full of opportunities and possibilities. It’s possible to make progress in certain neglected areas even when the mainstream is against you. You could have a world of perfect donor alignment and the patronage of donors could drive the government agenda. Forcing NGOs to go a certain way may be counter-productive. You have got to have a degree of space of space and rebelliousness otherwise the idea of development is an oxymoron. When it comes to alignment with the host government the situation is slightly different. There is a degree of respect that is owed to the government.

Alex:  In Sierra Leone there is one plan signed up to by government and NGOs. If you want to fund something you need to pick something from the plan. But it’s fuzzy – each agency has multiple agendas – and is made up of people who have multiple agendas. Working together over a long period of time means you know where the interest lies. It is the same for people in government and the civil service.

What are the key gender considerations in the reconstruction of the health systems in the post-conflict period? Given your concern about how gender biases and ideologies shape inequity – how do you move forward?

Barry:  I know about my grandma and my mum. My grandma lost her husband through influenza and then went to the mills and as a result had economic power. During World War Two my dad went to war – my mother bought the house while he was away. It still comes down to money.

Mukesh: Men must speak up. Work on gender needs men, and they need to lead. When that happens we will see progress, when men realise it is a career advancing activity. Normally I’m not in favour of bringing bureaucracy into things but there needs to be sanctions and incentives, simple moral imperatives are not enough.

Alex: We need to keep data on it. We can’t talk about the way we feel it should be until we know how it is.

In your experience, what are the ethical challenges of conducting research in post-conflict contexts – in terms of methods employed; and areas of focus that may uncover challenging issues e.g. corruption?

Alex: In Sierra Leone we need to make sure that ethics committees are about more than about getting the research done and published. It is about the implications of what you’re finding. A stigma against academics is that they are just there for the next paper.

Barry: The ethical challenges are difficult – the problem we all face is that ethics committees have gone mad in this part of the world. The protocols are so long and involved. It creates a burden. How do you get to the voice of the voiceless? This would be seen as unethical. But not asking he question is also unethical. Antonio Gramsci says we need pessimism of the intellect and optimism of the will. As researchers we need to tell it as it is. Only if we understand how the systems operate can we find a way to translate that into a way that will move the process forward.

Mukesh: The real value of this REBUILD framework of work, which I think is great, is it leads to more questions than you can answer. And this in turn stimulates different questions and challenges. The research needs to change policy and the application of policy.  If some of the insights that are gained lead to different strands of work and stimulate greater cross-sectoral collaboration it will therefore shed light on shared issues.

Alex: A really key thing is enabling good analysis of poor quality data – we can still make valid conclusions and inferences from data that are valid even if it is a lower standard of data. If we don’t use it we are wasting data.

Barry: It’s a privilege to spend time with you all, I think it’s great. Some takeaway messages for you all: 1) What is the story? 2) Keep it simple, don’t do complicated 3) Sort out your hierarchy and sequencing and 4) Use your head but never forget your heart.