Some notes from the business meeting of the Thematic Working Group on Health Systems in Fragile and Conflict Affected States

The business meeting of the Thematic Working Group on Health Systems in Fragile and Conflict Affected States was held on the 2nd October at the Cape Town conference. A crowd of over 30 people came together to think through some priority areas for the group’s work over the coming year and how best to organize and communicate.

Focus

There was a desire to work together to develop proposals and projects collaboratively. Some members were keen that we focus on research which is useful in practice (i.e. implementation research) which can support people working on the ground. This entails partnerships and knowledge generation with implementers.

There were also calls for a community of practice which would enable practitioners to share across different country contexts. Knowledge sharing more broadly was also thought to be important, for example creating opportunities for researchers to reflect on experiences in encouraging the uptake of evidence. Participants felt that the LinkedIn group could be used to flag up interesting/highly relevant papers/research. There could also be a mechanism by which people could post requests relevant to certain countries or areas of work.

Country ownership and leadership was also a theme that was raised. Particularly the need to support researchers and their organizations who are working in conflict zones who may lack capacity and/or funds or who could benefit from mentoring.

The importance of challenging other TWGs to reflect on what their work means to fragile and conflict affected states was raised. Our member Sally Theobald has written more on this in a Health Systems Global blog.

Some participants thought that there was scope for the group to become a ‘constituency’ which could represent its members in dialogue with donors.

Communication, governance and membership

There was some discussion about the composition of the Advisory Group or leadership of the TWG. There is currently a Steering Committee and it was proposed that an Advisory Group be set up to guide the work of the TWG. There was a desire for the leadership to be representative (i.e. include people from sub groups such as people from fragile states, implementers and academia).

We were cautioned to manage expectations about what the group can and can’t do. That we need to define the scope of the group and make it realistic. For example if the group becomes more than a network, and starts to do advocacy, the governance structure and accountability becomes more important. This is something we will be taking forward in the immediate future. Terms of reference are needed for the proposed Advisory Group and these should include monitoring the progress of the group against objectives. Whilst structure is necessary some also felt that that governance should be ‘organic’. It should facilitate activities of the group, not be a bottleneck to action.

In terms of group composition some thought that we should reach out to new members from the humanitarian community and harness their energy – perhaps what we can offer them is useful information such as providing access to relevant papers and debates from Cape Town. Furthermore, we were challenged to link with and include the Emerging Voices from the conference. It was also felt that we need to bring other non-health researchers into this process to ensure a multidisciplinary approach (for example people from the political sciences, conflict sensitivity, anthropology, and governance).

Whilst we are all LinkedIn fans it was felt that it might be an idea to follow the lead of other Thematic Working Groups who have set up a Google Group to keep in touch with each other.

The Economics of Health Professionals’ Education and Career: A quick update from Cape Town

By Sarah Ssali

In this session, Prof. McPake presented a paper “The Economics of Health Professionals’ Education and Career”, where she extended her analysis of the health labour market to the training of health professionals. She observed that failures in the market for health had led to failures of the health care market, which in turn had ended as failures in the training of health professionals (in that they were trained for elite interests than for  actual health needs in societies). In most places, the rich, who had attended elite schools were the ones who got admitted in medical schools and were unlikely to be interested to work in rural areas after their training, despite the need being greatest there. Furthermore, medical specialists dominated  all levels of policy making, making the curriculum tends to be skewed in favour of specialised curative care than primary health care, thereby serving elite interests versus the health needs of the majority. Globalisation has compounded the problem with the curriculum shifting to produce health professionals who can compete globally, as countries seek to tap into revenue from abroad, perpetuating their out-migration of health workers to the global north, where the technology exists to enable them practise what they learnt and where they can get the best returns to their training. Hence, the training curricula is driven more by the elite concerns (local and international), than by concerns about universal health coverage. She concluded with two key recommendations: taking training from elite institutions to rural, primary focused ones, and encouraging ultimate consumers of the products of private training schools (local elite and medical tourists) to do more to support better regulation and influence the quality if health professional training.

Photo courtesy of the UK Department for International Development https://www.flickr.com/photos/dfid/7138906747

Analyzing Markets for Health Workers, insights from Labour and Health Economics: Quick update from Cape Town

By Sarah Ssali

In this session, Barbara McPake from ReBUILD and the Nossal Institute for Global Health, University of Melbourne, presented a paper titled “Analyzing Markets for Health Workers: Insights from Labour and Health Economics”, in which she observed that most of the challenges that have been observed about human resources for health, such as the rural vs urban and the north vs south divides are just symptoms of the problem. In her view the real causes of the problem were the low effective demand for professional health workers in the societies where they are lacking, in that while the workers are needed, there is limited willingness to pay for health, which in turn leads to low demand for their services. She also observed that as with all markets, the health labour market follows where the good opportunities are, which culminates in health workers migrating to wherever effective demand for their services was higher (either higher pay, more dense population and curative instead of preventive care), consequently leading to higher returns to their labour. To resolve the challenges of the health labour market (such as scarcity of health care workers in rural areas or in the global south), she encouraged us to understand how markets, including health markets, operate and creating effective demand for health. For if we did not understand this we shall continue devising policies and programmes that solve the symptoms and not the real problems, compounding the problem further.

Download Barbara’s World Bank paper on this topic

Notes of the meeting on Ebola Co-hosted by the Fragile and Conflict Affected States Thematic Working Group and USAID, Wednesday, October 1, 13.15-14.15

By Caitlin Whittmore, USAID

SUMMARY

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 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 focused on the need to create a global research agenda on strengthening coverage, access, financial protection and responsiveness, and resiliency, in vulnerable health systems.  The discussion focused on key health systems issues and the need for evidence, particularly implementation research, on creating more resilient health systems.

SESSION GOALS

  • Knowledge sharing and discussion on how health systems research can support Ebola recovery
  • Identify priority areas of health systems research to advance that can contribute to health systems recovery and creating more resilient health systems
  • Identify next steps for advancing the global research agenda

KEY MESSAGES

Responding to the Ebola crisis and preparing for future crises requires health systems

  • Response
  • Recovery
  • Resilience
  • Agility

Current gaps in knowledge that immediate and future research should address include

  • A better understanding of the historical and epidemiological evolution and escalation of the crisis
    • How did the outbreak start?
    • Why were some governments resistant to accept external help?
    • Why was there a delayed response?
    • A better understanding of the epidemiology of the current outbreak
  • Need more simulation of different scenarios and contingency plans to accompany possible trajectories
    • Why does it behave differently in different contexts?
  • Hearing the voices of health workers and communities and understanding more about the community context
    • Why haven’t ‘conventional’ social-behavioral change (SBC) models worked?
    • What SBC models will work both now and in the future?
    • How can we incorporate the voices of health workers in developing training, contingency planning, and benefits packages?
  • A better understanding of national health system interactions and how the ‘global health system’ should operate
    • How have national health systems interacted? How have they affected the epidemic?
    • How can the ‘global health system’ be organized to respond and mobilize resources faster?

SESSION NOTES

Irene Agyepong, Chair of the Board of Health Systems Global, opened the session.

Tim Martineau, Liverpool School of Tropical Medicine, representing the Fragile and Conflict-Affected States (FCAS) Thematic Working Group (TWG) introduced the group. He explained that the FCAS TWG aims to develop evidence about health systems in FCAS so that they are strong, resilient and can deal with shocks. The TWG has been working to build a network, including an active LinkedIn group with 183 members. To date it has promoted the collation and sharing of existing knowledge, primarily through a special issue in “Conflict and Health”. There is now an effort to build a shared agenda for research through an inclusive priority setting exercise (more information can be found at the LinkedIn group).

Egbert Sondorp, KIT, representing the Fragile and Conflict-Affected States (FCAS) Thematic Working Group (TWG) explained that while the meeting is about Ebola, we know that the issue is really much broader. Unpredictable external factors may make it difficult for health systems to adapt, no matter how strong they are. For example, in Haiti, after the 2010 earthquake, there was an immediate breakdown of the health system in an already vulnerable context. In Syria, the health system was less vulnerable but there has been massive and prolonged disruption resulting in the collapse of the health system, as we see with the emergence of polio. Now, with the Ebola crisis there has been a gross underestimation of the scale of the crisis, health systems in the affected countries in West Africa were incredibly weak and vulnerable and the international community was late to respond. There are, and will be, many secondary effects of the epidemic, especially for other diseases. There was a long effort after the conflict in Sierra Leone to rebuild systems, but this has now been reversed. Ebola has led to a lack of trust between the population and health care workers, including stigma towards health care workers as potential ‘carriers’ of Ebola. There will be a focus on post-crisis reconstruction, but we need to do more, we must also focus on resilience for the future.

Haja Wurie, ReBUILD Research Consortium, representing the response efforts in Sierra Leone explained how service delivery in Sierra Leone was already overburdened and the epidemic has exacerbated an already unstable situation. In Sierra Leone, the first case occurred in May, in a remote village bordering Guinea. This is important to note because it affected how the epidemic then spread. Access to health services is limited in remote parts of Sierra Leone, and people often seek care from traditional healers and other informal providers. 12 out of 13 districts in Sierra Leone now have cases of Ebola. As of September 29 there were 2,095 confirmed cases, 544 deaths, and 434 survivors.

Why was the spread so fast? Governance – the country is decentralized on paper, but not in practice which means that when there were delays in the central government response, the district teams were delayed. Human Resources for Health – human resources were inadequate in Sierra Leone before the crisis with two providers for every 100,000 people. The country has lost four of their top specialists, which is a major setback when you consider the amount of time and level of investment it takes for someone to become a specialist. Health care workers are demotivated. Training in infectious disease control is basically nonexistent. There has been a heavy reliance on foreign expertise.

Service Delivery – abandoned healthcare workers are ill equipped and afraid, and service users are also afraid since there was a rumor early on that health care workers were injecting people with Ebola when they visited the health facility. Fear of seeking assistance for ill health means that people are now dying from easily preventable diseases. Health workers were guaranteed a risk allowance, but they have been going on strike every few weeks when this allowance is not received.  They are not confident and they are also victims; they have been physically assaulted and kicked out of their homes due to Ebola-stigma.

Infrastructure – isolation units bring together those who are infected as well as those waiting to be diagnosed, spreading Ebola further, in addition there is a lack of basic water, sanitation and electricity. Technology and Products – There is no way to dispose of waste products, no drugs available, no technology, and no information system.

Research – in Sierra Leone all the research has been external, there is little ownership by the Ministry of Health so we need to build capacity for local research so that in the future there won’t be delays while waiting on the global community.

Despite this grim picture, there is a window of opportunity to strengthen health systems research. We need to understand what the challenges and facilitators are to building an effective response. We need a long-term response solution and continuity with global actors and systems. Simultaneously an emergency response plan is needed, Uganda used their HIV response plan when responding to Ebola, is there something we can learn there. A benefits package needs to be developed for health care workers, and their voice should be included in discussions about the response. Community engagement should be a priority.

Ed Kelley, WHO, outlined how WHO has been involved in case tracking, training, and complementary care. To date there are 3,978 confirmed cases, 7,182 total cases when including suspected and probable, 3,332 deaths and 350 health worker cases. WHO launched the UN mission, complementary care packages, promoting real-time data, and new treatment initiatives including vaccines and plasma. There is a big push for response but we also need to focus on recovery. Preparedness plans are not enough, we need to test these plans on the ground with multiple scenarios. WHO are currently working with 25 national public health institutes to develop a manual on this.

Tim Evans, World Bank Group, suggested that any health system can be overwhelmed by an infectious threat, but this is more pronounced in health systems with underlying weaknesses. We need a global health system that can respond with agility to these kinds of crises. There has been a major global health system failure related to the WHO building blocks. Information – the epidemiology is still uncertain and what we know now doesn’t fully make sense and certainly can’t be the full picture. Human Resources – in contrast to Haiti, rather than a flood there has been a famine of external health care workers due to fear and lack of medical evacuation capacity, it’s great that the US Army is now building infrastructure, but who will staff it? Financing – the World Bank has mobilized 400 million USD even without a mechanism to spend on health emergencies. An estimated 1 billion USD that has been mobilized to date for Ebola but we need to look at disbursement which has been slow. It is interesting to compare this mobilization with the hundreds of billions that was mobilized in just one day for Alibaba. We need to develop an instrument to permit immediate access to resources for future crises, In terms of governance Tim suggested that we are “making it up as we go along” which is insufficient, we need a more disciplined crisis response and stronger global health system.

Ariel Pablos-Mendez, USAID, explained how the US Government response has been unprecedented in terms of interagency collaboration. This is the first time in history that the USG has mobilized an emergency response for a health crisis. They have sent 3,000 military personnel to help manage logistics and build infrastructure. The US strategy, which is aligned with the UN, the World Bank, and others, has four points:

  • Controlling the epidemic at its source in West Africa
  • Mitigating second-order impacts, including blunting the economic, social, and political tolls in the region
  • Engaging and collaborating with a larger global audience; and,
  • Fortifying global health security infrastructure in the region and beyond

Laurent Assogba, West African Health Organization (WAHO), explained how the immediate needs of people in isolation are not being met. That people need to be educated to know that Ebola is manageable. This is a regional issue and there is a need to establish corridors for access, keep borders open. The West Africa region leadership have developed and adopted a strategic plan to respond.

Jimmy Whitworth, Wellcome Trust, outlined how the Wellcome Trust has mounted two calls for research proposals meant for the immediate response; proposals mostly cover vaccine research, novel therapeutics, health systems, surveillance, social aspects, and diagnostics.

Ann Canavan, International Medical Corps (IMC), talked about their work in Liberia and Sierra Leone. The IMC has primarily been involved in case management, building/managing isolation units and has partnered with the USG (including CDC and DART teams) and DFID. The areas that need further research include why the ‘conventional’ social-behavioral change methodologies have not been appropriate or effective. Moving forward we need to understand what SBC models will work. At the health facility level, the competencies of providers needs to be addressed, and how do we plan for contingencies.

Lara Ho, International Rescue Committee (IRC) explained how in Guinea, we know that there has been reinfection from Liberia, so we need to not only talk about health systems within countries, but the interactions of systems between countries. We know that in some countries the government was initially resistant to outside help.  We need to understand why that was. There are only 2 of 11 airline carriers still operating making it difficult to get supplies where needed. For the surrounding countries, if you didn’t have a case, you couldn’t get funding for preparedness – this needs to change.

Mit Phillips, Medicines Sans Frontieres (MSF), suggested that people need basic commodities, there is still a major shortage of things like gloves. He felt that whilst ‘resilience’ is good, we need more than that, we need ‘agile’ health systems that can quickly adapt and respond to threats.

Michael Myers, Rockefeller Foundation, explained how Rockefeller was involved in setting up a disease surveillance network in East Africa which helped with the Ebola outbreak there, West Africa is now requesting support to translate this experience. We need to start building resilience now and there are steps that can be taken, such as integrating some SBC messaging into emergency response training. Rockefeller has found that there are four resilience ‘ingredients’:

  • Building technical capacity
  • Leadership
  • Redundancy – so that if one system fails the entire system won’t collapse
  • Transparency

David Saunders, School of Public Health, University of the Western Cape had several questions:

  • We had the first report of the outbreak in late March, it is now 6 months later, so why was there such a delay in response?
  • Why has it been so difficult to send non-complex technologies (like gloves)?
  • Why did it even start in the first place? There was a PLOS analysis showing that it spread from forested areas, meaning that economic exploration for timber and minerals led to a change in the disease ecology
  • There has been a talk of ‘Africa Rising’, and indeed Sierra Leone experienced high rates of economic growth (13-16%), so where is all the money going? There is a political economy of this problem that should not be ignored

Ariel Pablos-Mendez, the United States Agency for International Development (USAID), stated in response to David, that we now know that the outbreak probably began in December. There were no questions about the outbreak in March because it was behaving as it behaved in the past so there was no sense of alarm (except from MSF). In July, the mood changed and US government has been mobilized full time since then. Until countries themselves declare an emergency, the US government has no power to respond, and so couldn’t bring in DART teams until August. In terms of Personal Protective Equipment (PPEs) the US government had 17,000 in stock in Ouagadougou which are being mobilized, have now secured 140,000 PPEs; logistically, however it has been difficult to get these to those who need them due to overwhelmed and weak supply chains.

Tim Evans, World Bank Group, responded that there is no standard, system, or template for what an international response of this nature should look like, for instance there is no system to rapidly mobilize PPEs so we need a more codified approach. We will be called to do this again and we should be better prepared.

Janine (surname not captured), University of the Western Cape, spoke as a representative of young researchers (Emerging Voices). Emerging voices has established the “one dollar campaign” for Ebola to mobilize Africans to respond. Africans will need to play a significant role for response to be successful.

Gendered Health Care Coping in Northern Uganda: A quick update from Cape Town

By Sally Theobald,

Sarah Ssali from ReBUILD and Women and Gender Studies at Makerere University, Uganda, presented her poster on “Gendered Health Care Coping in Northern Uganda: What are the gender and equity considerations in post conflict health systems strengthening” at the Health Systems Conference in Cape Town. In discussion with poster Judge, and Emerging Voices presenter, Angelia Rawat, Sarah eloquently explained why gender needs to be taken into consideration in post-conflict reconstruction of health systems in northern Uganda. Health services are geared towards women as mothers, but in reality women have “lives beyond being mothers of babies” they have multiple identities and stages of their life cycle and many women are sadly widowed. In the post-conflict context, private providers flourish and people often have to pay for medicines. For women ability to pay is a big challenge and the choices they make are navigated by livelihoods, which in turn are shaped by access to land and animals where it is not an even playing field. Women have duties but no capital to fulfil them. Sarah concluded by arguing that gender matters in post-conflict reconstruction and needs to be taken into account in and beyond the health sector.

Household financial protection in post-conflict Cambodia: A quick update from Cape Town

By Sophie Witter

Bandeth Ros of the Cambodian Development Research Institute presented her research on ‘Health seeking behaviour and the impact of health financing policies on household financial protection in post-conflict Cambodia: a life-history approach’ at the Health Systems Research Symposium in Cape Town. The 24 in-depth interviews provided rich insights into how household coping strategies in case of illness have changed since the 1950s. While exchanging with colleagues from Cambodia and others working on related schemes, she explained how the extension of the formal health care system, new policies to provide greater financial access, and changes at community and household level had contributed to increasing use of the formal sector over time. Her research supports government efforts to extend the community-based health insurance and the Health Equity Funds.

You can download the poster from our website