Sally Theobald, Liverpool School of Tropical Medicine
There are currently nine Health Systems Global Thematic Working Groups (TWGs). We have all been challenged, by the board and secretariat, to seize strategic opportunities to work collaboratively and maximise strategic links. The Health Systems in Fragile and Conflict Affected States (FCAS) is the only TWG that focuses on specific contexts but the focus of all of the other TWGs is relevant to fragile settings. This gives us an opportunity to work together.
Alex Jones participated in a ReBUILD “question time” session we ran last week as part of our annual consortium meeting. He explained that in FCAS such as Sierra Leone, counterfeit and out of date medicines proliferate with wide reaching implications for health. There is need to better understand these impacts and put in place processes and structure for regulation. In Plenary 2 at this week’s Symposium Martin McKee argued that the pharmaceutical and drug development companies have been far too slow 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?
We have created a learning community in ReBUILD to reflect on the challenges and opportunities of conducting ethical and trustworthy social science research in post-conflict contexts. In post-conflict contexts participants may be more vulnerable and have reasons to be fearful of research encounters. Some research participants were unwilling to speak due to anxiety, lack of trust, and the fear of reliving previous traumatic experiences. 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.
In FCAS informed consent procedures need careful thinking through. Research participants may fear that a signature will have negative repercussions. In contexts 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 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.
CHWs can be critically important in FCAS where there are often massive shortages of human resources for health. At the health systems conference in Beijing in 2012 there was a 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. 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. 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 through community health workers was critical to the swift response to the 2001 Ebola epidemic in conflict affected northern Uganda. Further exploration is needed.
During the FCAS TWG business meeting Mahdi Ashour from Palestine argued for urgent resources for capacity and research monies for national researchers 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. Kumanan Rasananthan, from UNICEF, argued in Plenary 3, that we need to put local, district and national research organisations first. This is all the more urgent in FCAS 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 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 private sector organisations in post conflict Gulu. 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 human resource 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
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 institutions, structures and processes in FCAS. There are clear overlaps here with the Training and Learning for Heath Systems 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 FCAS 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 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 eight other TWGs to ensure they include a focus in these critical but too often neglected contexts.