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.


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