Health workers and fee exemption schemes. ReBUILD’s new paper on how Sierra Leone’s Free Health Care Initiative has affected health workers.

In a new paper published in Health Policy and Planning, ReBUILD researchers Sophie Witter, Haja Wurie and Maria Bertone explore the effects and implications for health staff of Sierra Leone’s introduction in 2010 of the Free Health Care Initiative (FHCI).

Addressing a previous gap in the literature, their analysis shows how a high-profile policy fee-exemption policy, supported by financial and technical resources can galvanise real systemic changes. They show how the FHCI led to reforms which had a major effect on health workers in Sierra Leone, and that motivation has improved, but that there remain tensions between different health worker cadres as well as a demand for a more consistent package of incentives, particularly in rural areas.

Key messages that come from their analysis include how a broad, well supported health financing change like the FHCI can be a catalyst for broader health system reforms, and that reforms in human resources for health are at the core of making such a change function effectively. However, key challenges remain, intensified by the devastation of the Ebola epidemic, especially in ensuring that changes support good quality of care and an effective rural service, and in sustaining the momentum for reform which remains dependent on external resources.

This paper is open access and can be accessed via this link.


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.

The Question of Ethics in Research Uptake Processes and Products – more from ResUpMeetUp

Millie Nattimba, Research Uptake manager with ReBUILD‘s team from Makerere University School of Public Health, starts getting to grips with the tricky issue of ethics in research uptake activities, after another interesting session at the ResUpMeetUp Symposium and Training Exchange in Nairobi. Millie is part of the 8-strong team from ReBUILD attending ResUpMeetUp, from all ReBUILD’s partner countries.

While we are still struggling to understand what research uptake really entails, how to do it effectively and how to measure its impact; the matter of ethics has reared its fierce head. At the ongoing ResUpMeetUp Symposium and Training Exchange in Nairobi, brilliant discussions are going on, on what is known and unknown in the area of research uptake. One matter with not-so-much known in terms of how to handle it is ethical review for research uptake products.

This issue first popped up in Monday’s parallel session on Multimedia, arising out of photos and videos that featured (i) a young HIV-positive boy living on his own, and (ii) a recovering mentally-ill person and poor resident of a community in South Africa. The issue generated quite a debate during the parallel session, and continued in the plenary discussions the next morning.

While research projects include (sometimes) a research uptake plan in their research protocols for ethical review, it was not clear in the meeting what research uptake teams do when the specifics begin to form. Do video scripts and story lines get ethical clearance before recordings are done? What about the matter of interviewing research participants with mental disorders? Are they able to understand the process of informed consent? In the matter of children living with HIV and living on their own, who consents on their behalf? Should one seek separate ethical clearance to conduct a video interview or is a consent form on its own enough?

Is digital story telling (where the research participant tells his/her story in digital format (pictures and illustrations/drawings) part of the overall research process for which ethical clearance has been obtained, or a separate process for which ethical clearance should be separately obtained? Chances are that many institutions do not actually seek ethical clearance for such processes and products.

Some of these issues may be explored more deeply at one of tomorrow’s training sessions, being run by Sarah Ssali and Nick Hooton, on “Identifying and managing opportunities for ‘user-voice’ as part of research uptake strategies”.

In any case, this seems to be the beginning of what promises to be an interesting, timely and quite frankly intimidating discussion.

Reflections from my time in Sierra Leone

Rosalind McCollum is a PhD student with the REACHOUT Consortium at the Liverpool School of Tropical Medicine who has recently returned from Sierra Leone where she had been working with Concern Worldwide to train health workers and community members in infection protection control. In her blog, she reflects on her time back in Sierra Leone and on some of the weaknesses in the health system that have affected the progress of the Ebola outbreak and the response to it, and some actions that could improve the resilience of the health system for this outbreak and future shocks.

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Rosalind McCollum, PhD student with REACHOUT consortium

Returning to Sierra Leone to join with former colleagues from Concern Worldwide working together in the Ebola response is a rare privilege, allowing me to reflect on some of the weaknesses within the health system which enabled the outbreak and have the potential to derail future recovery.

Ebola has revealed weaknesses within the health system, bringing to the surface gaps and inadequacies as highlighted previously by researchers in Sierra Leone such as Dr Haja Wurie. The delayed recognition of Ebola as a threat and subsequently slow response to the outbreak, allowed Ebola to spread throughout the country. Thankfully the international community has now mobilised to provide support. However, Sierra Leone’s health system is severely understaffed and under-resourced with too few trained health staff and a lack of trust between community and the health system.

Shifting priorities and multiple tasks

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Concern health officers Nancy Seisay and Mohamed Dauda prepare for training clinic staff how to don and doff personal protective equipment during infection prevention control training at peripheral health units in Tonkolili District

As the response has scaled up this has created huge pressure on existing health workers particularly community health officers (CHOs), who are clinical staff with five years training and who under normal circumstances provide and supervise health activities within their chiefdom, under overall direction of the district medical officer. As a range of different implementers have entered the districts seeking to provide a full range of interventions to tackle Ebola – from case investigation, to Infection Prevention Control (IPC) training at Peripheral Health Units (PHUs), training and mentoring for community care centres, running holding centres, working at Ebola treatment units etc. Each intervention has needed to draw on the same pool of trained health workers (particularly CHOs) within the district. As a result the most qualified staff in the district are at times seconded from District Health Management Team (DHMT) to work on various interventions, sometimes concurrently and often changing on a weekly or even daily basis as priorities change within the district. All the while these Ebola related activities are in addition to their regular activities supervising and directing routine health activities within their chiefdom.

Changing priorities within the district happens on a daily basis as new players, with new funding, and reporting to different donors with differing degrees of influence, arrived. While expansion in the response was undoubtedly positive a lack of coordination among donors could at times create confusion, since one priority would be replaced with a seemingly conflicting intervention now taking precedence. This also created challenges in ensuring coherence between so many stakeholders within such a rapidly changing situation. For example, the introduction of community care centres occurred at such a rapid pace that decisions regarding testing and referral of patients were still being determined when the first patient was admitted creating confusion for staff and patients.

The community response

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Traditional birth attendant in Sierra Leone demonstrating handwashing technique during infection prevention control training at peripheral health unit in Tonkolili District

As a PhD student studying community health workers (CHWs), I am particularly interested in the vital role volunteers have played so far in the response. Volunteers are working in a wide variety of roles from burial team members, to contact tracers and screeners. One question this raises is to what extent has the response engaged with existing CHWs? Concern has been seeking to engage with Health Management Committees and CHWs they have previously trained, who are keen to respond and to help their communities. However, there are also stories of trained CHWs being neglected during selection of contact tracers. What will be the future consequence of this? For CHWs who previously have worked for small incentives, to be ignored while others take on the role and allowances associated with contact tracing must undoubtedly be demotivating. For any CHW recruited into a contact tracing or screening role he/she will bring with them skills, experience and community acceptance. In addition there is the future benefit for strengthening the health system associated with training and experience gained by CHWs through Ebola response roles. As a country where cholera is endemic these are skills which could be modified and put to use in a variety of ways in the future.

What next?

While the number of people acquiring Ebola has reduced dramatically in Liberia, that number remained high in Sierra Leone for much longer, and has only recently shown significant reduction. This raises many questions as to the reasons behind the differing outbreak trajectory within these neighbouring counties. Why did Liberia manage to reduce the number of cases so significantly? And what lessons can Sierra Leone learn from this? Have there been significant differences in the EVD response or is it due to underlying contextual and health systems factors? Liberia has a longer history of working with established CHWs compared with Sierra Leone, who introduced their CHW programme in the last few years. Has this longer established CHW network mobilised more effectively in recent months in Liberia, contributing to their reduction of cases?

In order to ensure eradication of Ebola and strengthen Sierra Leone’s health system for greater resilience beyond this outbreak it is vital that actions taken now contribute towards health systems strengthening both now and in the future such as:

  • Long-term commitment to fund health systems strengthening, including training of health workers
  • Strengthened governance, coordination and accountability at district and national level
  • Strengthened coordination and reporting, building on lessons learned through case investigation and contact tracing from community level through to national level
  • Permanently improved IPC standards within all health facilities in the country, through regular ongoing mentoring following IPC training
  • Health workers empowered to demand salaries, supplies and equipment which they need for their work and protection, through strengthened supply chains and improved human resource systems which also efficiently accommodate the many volunteers working on the Ebola response to ensure their timely payment of risk allowances as well as health worker salaries
  • Integration of rapid diagnostic tests for Ebola (when available) within existing community care centres to provide early access to safe testing relatively close to patients homes for earlier diagnosis, contributing to earlier isolation and management when linked with early onwards referral to Ebola treatment unit
  • Engagement and discussions with communities and health management committees through IPC trainings and mentoring at PHU level to build trust again in their health system and promote utilisation of health facilities for non-Ebola related illnesses.

Concern Worldwide, a member of the Ebola Response Consortium (led by the International Rescue Committee), has worked in Sierra Leone since the civil war in 1996, initially providing humanitarian response before transitioning to development. Concern Worldwide has provided a range of humanitarian response actions to the current Ebola outbreak in Sierra Leone and Liberia . Rosalind temporarily left her studies with the REACHOUT Consortium to work together with Concern Worldwide in Sierra Leone to train health workers, volunteers, support staff and community members in IPC. This enables them to identify people suspected to have Ebola, to isolate them in an area separate from others, to safely don and doff Personal Protective Equipment (PPE) when entering the isolation area and how to clean safely.

Involving community stakeholders during the training helps to ensure community participation in monitoring screening, construction of isolation spaces and other IPC activities. In addition, these community leaders can share knowledge about the training with their communities so that people know that the clinic is a ‘safe zone’ therefore encouraging attendance. We hope this will contribute to improvement in utilisation rates in the future.

ReBUILD speaks up on Research Uptake; Reflections from the ResUpMeetUp meeting

Sally Theobald from LSTM and one of the strong ReBUILD presence at the ResUpMeetUp Symposium in Nairobi consortium shares some of her take-home messages from the ongoing discussions. Day 2 kicked off with a recap and discussion of key messages from yesterday’s sessions. As Sally writes, our ReBUILD colleagues are engaging fully!

  1. Research uptake is a messy, iterative strategic, process – not a linear process or one off event

In re-cap of day 1, Sarah Ssali from the School of Women and Gender Studies at Makerere University highlighted that research uptake is an ongoing process and not a one-off technical event – we need to map out stakeholders and work out their priorities and be responsive to context. It is arguably particularly critical in fluid conflict and post-conflict contexts, where there is a mushrooming of NGOs and a multiplicity of players. Rogers Amara from COHMAS in Sierra Leone, discussed the importance of working in partnership with policy makers and practitioners throughout the research cycles from agenda setting to interpretation of findings to support synergy and buy in.

  1. Research uptake requires multiple skill sets and working in partnership

Yotamu Chirwa, from Biomedical Research Training Institute in Zimbabwe highlighted the importance of the multiple skill sets for research uptake and developing strategic partnerships in this regard. This was reinforced by Nick Hooton from LSTM who discussed how research uptake goes beyond working with policy makers and how we need to also focus on a range of actors including NGOs, health practitioners and diverse communities. He stated that this is challenging but some of the critical skills sets are the same regardless of who we are working with; we need to have the capacity to understand and interpret evidence and make it accessible and relevant to different constituencies. Sreytouch Vong from the Cambodia Development Research Institute was active on Twitter, and called for further action on research uptake but also reflecting on the challenges and dilemmas of being both a researcher and a research uptake advocate.

  1. We need to think about the ethics of research processes and products

The ethics of research uptake emerged as a key issue in Day 1 deliberations. For example as researchers are we put in positions where we feel we need to oversell the impact of research to please our donors and others? Milly Natimba from the Makerere University School of Public Health explained how focusing on log-frames may mean that researchers miss opportunities for research uptake emerging in other arenas. We need to responsive and we need to be ethical. Milly also highlighted the debates in one of the parallel sessions on multi-media outputs and ethics was a hot topic here – how and when should research uptake outputs get ethical clearance? This is important for example with films, photos or strategies that capture experiences of different groups including in post conflict areas – people affected by violence of mental health issues. We need to ensure that we do this ethically and adhere to the spirit of confidentiality, ethics and rights.

The meeting continues – ReBUILD researchers and research uptake practitioners will attend the trainings and meet as a group to maximise learning and update our action plans to intensify engagement with diverse players and practitioners on the evidence generated in ReBUILD.

The blogs will continue, and follow our active updates on Twitter

Some thoughts from Day One of ResUpMeetUp

After the first day of the ResUpMeetUp Symposium in Nairobi, an intense day of plenary and parallel sessions on wide-ranging issues around research uptake, ReBUILD researchers Yotamu Chirwa and Sreytouch Vong give their thoughts.

The first session of ResUpMeetUp had an inevitable focus on health, with both a member of Kenya’s Parliamentary Committee on Health and the Director of Medical Services presenting. But the presentations re-emphasised the centrality of research which translates into policy change for tangible and observable improvement of people’s access to sustainable quality health care. The DFID representative aptly stated that the Symposium was a gathering of researchers from diverse backgrounds with sound experience in research and evidence development that will allow exchange of experiences with research uptake from across the globe and across diverse cultural situations. The symposium was a demonstration of DFID’s support the global research and evidence gathering process, not as end in itself, but as a means to bring about positive change to policies and translation of same into programmes that impact on health outcomes. A keynote presentation on Framing big issues in research uptake reiterated the broad conceptualisation of policy that we need to keep in mind as we think and plan our research and evidence uptake strategies. Policy is not the pamphlet or documents but “all decisions, plans, and actions undertaken to achieve specific health care goals” towards fulfilment of a desired outcome, usually positive. An interesting but real challenge that confronts research uptake or translation of research into policy are the fundamental questions of credibility, robustness and comprehensiveness of research and the relevancy of the research to the demands of the decision makers. However several presentations dwelt on the means around these problems and indeed these challenges could be surmounted by having research uptake embedded in the research cycle from conceptualisation, design right up to the conclusion of the research. Packaging of messages to policy is critical, can make the desired impact and thus requires huge investment of effort. And the presentation from the Parliamentary Committee member on Utilisation of Research evidence in Government: Policy, legislation and implementation referred to perennial problem of the “what we know and what we do gap”. The analogy that there are numerous books that have been authored but that research has not changed people’s lives, implying that there is a lot that is known on many health problems but we do not use the evidence to optimise outcomes.

At one of the afternoon’s parallel sessions on overcoming barriers to research uptake, one key issue was the need to ensure that research is highly accurate (so that the question of credibility raised above is dealt with emphatically) but it should never be taken for granted that accuracy of evidence is a given; it is complex, time consuming, costly and requires huge outlay of resources.

An important lesson from the parallel session is the diversity of the landscape within which research uptake or translation of evidence into policy occurs. Diversity along many spheres including policy making environment, language, media composition and size, centralised or decentralised produce a dynamism that requires careful planning of the uptake activities. You may need to really come up with a systematic method with allocation of time to specific activities and the most important being building relationship. Such building of relationships should follow a continuum starting at the individual level to the institutional and organisational. This is very important as concentrating at the individual end of the continuum may lead to problems in the long term, if the individuals with whom you have built up relations leave, or move out of the sphere where you want to influence policy.

In another session, one important lesson on the question of stakeholder mapping was the way stakeholders mutate and therefore require a rethink, leading to the question of whether one stakeholder mapping exercise, traditionally conducted at the inception of the research enough. With the policy landscape being highly eclectic, should a case be made for several stakeholder mappings during a project or programme.

Overall, the first day of ResupMeetup was a rich outlay of practical experiences with research uptake in different contexts. The afternoon’s panel session on From theoretical framework to practical approaches, chaired by ReBUILD’s Sally Theobald, provided an overview of different framework of research uptake, followed by the parallel sessions on Barriers to research uptake and Approaches to increase influence. So far, the ResUpMeetUp Symposium has demonstrated that a focus on research uptake and communication is integral to evidence-based policy development that results in real changes towards a better and desirable outcome.

Yotamu Chirwa is a Senior Research Fellow at the Biomedical Research and Training Institute in Zimbabwe working with ReBUILD. Sreytouch Vong is ReBUILD’s Principal Investigator at the Cambodia Development Resource Institute. They are part of the 8-strong team from all ReBUILD’s partner countries at the ResUpMeetUp Symposium and Training Exchange.


ReBUILD descends on Research Uptake meeting en masse!

Nick Hooton, Research Practice and Policy Advisor for ReBUILD, on the ResUpMeetUp Symposium and Training Exchange for Research Uptake which starts tomorrow in Nairobi, and why the ReBUILD team are there.

Members of all the ReBUILD country partners have arrived in Nairobi for the ResUpMeetUp Symposium and Training Exchange. As Research, Policy and Practice Advisor for the ReBUILD Consortium, with primary responsibility for research uptake (RU), I’ve had my eye on this meeting for a long time. And while I’m really excited about it, and so pleased we’ve got representation from all our country partners, we’re not actually sure what to expect from this meeting!

It’s a very ambitious meeting, both a 2-day Symposium with the aim of developing a deeper understanding of the concept of ‘research uptake’ and to explore specific emerging issues, as well as a 2-day ‘Training Exchange’.

It’s the breadth of the meeting that makes it both interesting and a challenge. From keynote addresses on ‘The evidence-gap challenge in parliament’ from a member of one of Kenya’s Parliamentary Committees, to the links between theoretical frameworks for RU and practical approaches, how much to ‘synthesise’ evidence for RU, and discussions on a large number of technical and technological tools and approaches. Plus lots on IT and social media. Some of these areas will be explored more deeply in a number of parallel sessions.

And the sessions on offer for the Training Exchange are themselves very wide-ranging, from one on the broad development of a RU strategy from a donor’s perspective, a training on ‘crafting issue briefs’, one on media engagement in southern contexts, to a large number of ‘technical’ training sessions on data visualisation, video, some specific IT programmes and tools for RU, including monitoring the use of the growing range of IT and social media outlets for research programmes. And many more!

We’re even delivering a training session ourselves, myself together with Sarah Ssali from our Makerere University School of Public Health team. We’re doing an as-yet untried training session on issues around the use of the voices of poor stakeholders themselves as part of research uptake activities.

If we didn’t know already, it shows how immensely diverse and complicated this area we call ‘research uptake’ actually is, and the range of understanding and skills we need to operate effectively in it. So it will be great to have this opportunity to benefit from the discussions and training on offer to develop and broaden our own skills.

But more than anything else, I am hoping that our team members from Zimbabwe, Uganda, Sierra Leone, Cambodia and the UK will get enthused with 4 days of discussions and practical training on this complex and challenging area, and be even more motivated to apply our collected skills, working to support each other in our diverse contexts. Immensely challenging, but after all, it’s what ReBUILD is all about – working in a way that maximises the chances of our research evidence actually changing things for the benefit of the poor in post-conflict environments.

It all kicks off tomorrow, and we hope to be sharing as we go along. So watch our Twitter feed @REBUILDRPC, and watch this space as well!