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.

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