Join our #HSRFCAS Twitter chat! Health workforce strengthening in fragile and conflict affected states

By Natasha Salaria, Journal Development Editor at BioMed Central

The “Filling the void: Health systems in fragile and conflict affected states” series is an initiative of Conflict and Health, in collaboration with the Thematic Working Group on Health Systems in Fragile and Conflict Affected States.

Healthcare in fragile and conflict affected states remains critical and this series aims to provide evidence on health policies and programmes that work in fragile or conflict-affected situations. The series launched in November and has a growing range of articles touching on various aspects of health systems in fragile and conflict affected states.

In recognition of the ‘Filling the void’ series @Conflict_Health will be hosting a 1 hour Twitter-chat to discuss human resources for health  – one of the key pillars of health systems – based on these papers from the series:

Community health workers of Afghanistan: a qualitative study of a national program

Engaging frontline health providers in improving the quality of health care using facility-based improvement collaboratives in Afghanistan: case study

Human resource management in post-conflict health systems: review of research and knowledge gaps

A window of opportunity for reform in post-conflict settings? The case of Human Resources for Health policies in Sierra Leone, 2002–2012

Questions for discussion during the Tweet chat are:

  1. Why is strengthening the health workforce so important in FCAS (fragile and conflict affected states)? #HSRFCAS
  2. What particular role is there for close-to-community workers e.g. community health workers #HSRFCAS
  3. What do we know about what needs to be done to strengthen the workforce in this context? What are the knowledge gaps? #HSRFCAS
  4. What windows of opportunity are there for strengthening the health workforce in conflict and post-conflict states? #HSRFCAS
  5. What things can be done to ensure health systems are adequately staffed in times of conflict? #HSRFCAS

For a chance to have your say, join us @Conflict_Health and the prominent group of researchers involved in the discussion Tim Martineau (@TimMartineau), Suzanne Fustukian (@IIHD_QMU), and Maria Bertone (@mpbertone) on 6 February 2015 at 16:00 UK Time.

If you are not able to attend the live discussion, please feel free to tweet your comments to @Conflict_Health using the hashtag #HSRFCAS. An edited summary of the Twitter chat will be published in a Storify post shortly after the session.

If you haven’t done so yet, we also invite you to join our LinkedIn group, where more discussions on the topic on health systems research in fragile and conflict affected states take place.

We look forward to your participation!

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Ten arguments for why gender should be a central focus for universal health coverage advocates

To make universal health coverage (UHC) truly universal we need an approach which places gender and power at the centre of our analysis. This means we need a discussion about who is included, how health is defined, what coverage entails and whether equity is ensured. To celebrate Universal Health Coverage Day RinGs has put together a list of ten arguments for why gender should be a central focus within UHC. If you agree, spread the word. Mail this list to a colleague or put it up on your website. If you think of other arguments in favour of a gender approach do let us know!

1. Gender affects both vulnerability to illness and access to health care.

Gender influences how women, men, and people of other genders perceive, behave, interact and this impacts the social experience of being sick, seeking and receiving care. For example, gender norms and relationships in the Dominican Republic mean that women with lymphatic filariasis experience more social exclusion and shame than men, which in turn affect their health care seeking.

2. Gender combines with other social determinants in varied ways.

How gender is experienced can change when interacting with other forms of inequality, such as age, poverty, geography, caste, race, ethnicity, disability, and sexuality. Women and men from different socio-economic or ethnic groups can have vastly different experiences of the health system, which influences their access to health care, their treatment by health professionals, and their health outcomes. In rural India, while nonpoor men and poor women were at opposite ends of ability to access care, among middle groups, non-poor women and poor men had similar health care seeking outcomes, but their decision-making and pathways differed significantly.

3. Recognise power if you want to tackle inequalities in health systems.

Marginalized people (ethnic minorities, inhabitants of informal settlements, people employed in illegal occupations, etc.) may have different access to health care or receive different treatment by health care workers compared to others. Power relations between individuals (for example, husbands and wives or health care professionals and patients) influences the effectiveness of policies and programmes to achieve universal health coverage. Despite being inclusive of the poorest, community based insurance in India still generated inequities among rural populations with those more financially better off, closer access to care and men submitting more claims than other populations. Moreover, access facilitated by insurance was not always appropriate with insured women having higher rates of hysterectomies and hospitalisation for fever due to the lack of effective and quality primary care services.

4. Coverage can’t be universal if some services and service users are routinely left off the list.

Financial protection packages (i.e. prepaid health services under universal health coverage schemes) often exclude essential and routine sexual and reproductive health services, such as delivery and emergency obstetric care, family planning, and safe abortion. Where sexual and reproductive health care is offered, it often exclusively focuses on maternal health and doesn’t address the needs of adolescent girls and older women or men. Trans people all over the world survive despite inadequate provision of services and financial coverage.

5. Coverage can’t be universal unless it extends to all contexts.

Universal health coverage will not be achieved without additional research, resources and health system development in fragile and conflict affected contexts. Realising universal health coverage in these neglected contexts means understanding and addressing the ways in which gender, power and conflict shape the experiences and needs of different communities and their ability to access services, as well as ensuring efforts to support and rebuild health systems meet the needs of all citizens.

6. Paying out-of-pocket expenses for services adversely effects women.

This reflects hardship and injustice as women tend to have less income and less control over it and yet have to pay for health services that are more likely to not be covered by financial protection schemes.

7. Health system researchers must factor gender into their research.

To properly understand whether health systems are universal, we need data disaggregated by sex as a matter of good practice, regardless of whether sex or gender is perceived to be a factor. Once identified, inequities need to be recognised and addressed. If this doesn’t occur we will continue to put in place policy and programmes which are inefficient and discriminatory.

8. Policy makers need to use evidence that incorporates gender and power in their decision making around access to services.

For example, social roles for women in many societies include childcare and infant feeding and a potential consideration would be whether health facilities provide services for women and children at the right times (daylight, after school timings), with appropriate conditions (shelter from sun/rain in the waiting area, functional toilets, separate lines or waiting rooms for men and women), and with appropriate staff (breastfeeding consultants, female clinicians). When health centres are predominantly seen to cater to maternal and child health, mechanisms need to be explored to ensure access for men and other people.

9. Gender permeates all aspects of the health system and must be dealt with on different levels.

Gendered norms affect the health workforce (whether informal care provided at home is recognized and supported, recruitment and retention policies, staff security in remote areas or slums, maternity policies, workplace harassment policies and procedures). We need to address the gendered needs of all health workers, including close-to-community health providers who act as bridges between marginalised communities and health systems and are critical to universal health coverage. Gender also affects health financing (budgets for gender audits, the extent of financial protection available to different groups, out-of-pocket expenditures of different groups); and governance (representation of women and men in planning and oversight of all areas of health care; male involvement in maternal and child health).

10. We need this conversation to take place within and beyond the health system.

For example, men usually have more power and privilege than women, but they also have particular health needs. Men may be more likely to do dangerous jobs which can cause illness and disability, they are often influenced by harmful gender norms which encourage risk-taking, and in many settings they are less likely to visit a doctor when they are ill. Addressing these harmful manifestations of gender norms will require work beyond the health sector. We need to work with government ministries tasked with dealing with financing, gender, employment, education, and equality. Universal health coverage truly is everyone’s concern.

Want to read more? This article is based on:

Baker P, Dworkin SL, Tong S, Banks I, Shand T, and Yamey G (2014) The men’s health gap: men must be included in the global health equity agenda. Bulletin of the World Health Organization 92(8): 618-20.

Desai S, Sinha T, Mahal A, Cousens S. (2014) Understanding CBHI hospitalisation patterns: a comparison of insured and uninsured women in Gujarat, India. BMC Health Serv Res. 2014 Jul 26;14:320. doi: 10.1186/1472-6963-14-320.

O’Connell T, Rasanathan K, Chopra M (2014) What does universal health coverage mean? Lancet. 2014 Jan 18;383(9913):277-9. doi: 10.1016/S0140-6736(13)60955-1.

Khanna R (2012) Gender and universal health care in India http://uhc-india.org/uploads/RenuKhannaUHC12April.pdf 

Percival V, Richards E, Maclean T, Theobald S (2014) Health Systems and Gender in Post-Conflict Contexts: Building Back Better? Conflict and Health, 8(19).

Person B, et al., (2008) “Can it be that god does not remember me”: a qualitative study on the psychological distress, suffering, and coping of Dominican women with chronic filarial lymphedema and elephantiasis of the leg. Health Care Women Int,. 29(4): 349-65.

Raj A. (2011) Gender equity and universal health coverage in India, The Lancet, January 12, 2011 DOI:10.1016/S0140- 6736(10)62112-5.

Ranson MK, Sinha T, Chatterjee M, Acharya A, Bhavsar A, Morris SS, Mills AJ (2006) Making health insurance work for the poor: learning from the Self-Employed Women’s Association’s (SEWA) community-based health insurance scheme in India. Soc Sci Med. 2006 Feb;62(3):707-20.

Ravindran, TKS (2012) Universal access: making health systems work for women. BMC Public Health, 12 Suppl 1(Suppl 1), S4. Sen G and Iyer A (2012) Who gains, who loses and how: leveraging gender and class intersections to secure health entitlements. Soc Sci Med. 2012 Jun;74(11):1802-11. doi: 10.1016/j.socscimed.2011.05.035.

Vlassoff C, and Moreno CG (2002). Placing gender at the centre of health programming: challenges and limitations. Social Science & Medicine, 54(11), 1713–1723.

Image of men and women dancing in DRC courtesy of André Thiel 

NEW! Brief on managing the health workforce after a conflict: a review of research and knowledge gaps

During conflict, health systems can break down, with clinics and hospitals destroyed and medicine in short supply, leaving people at high risk of disease. Health workers can be targets and many leave the conflict zone. Managing human resources well can help overcome shortages in the health workforce, as well as other challenges such as workers’ skills which do not match health service needs, patchy human resource data, inadequate medical training and weak management. This area is complex, and understanding how human resource management (HRM) contributes to rebuilding health systems after conflict is valuable. The knowledge can be used to inform national and international policy-makers: this is important as decisions made immediately after a conflict can influence the development of the health system in the long term.

Research in this field is, however, limited, with few reviews providing an overview of the evidence. Therefore the ReBUILD consortium has carried out a review of publications in the area of HRM in health systems in countries affected by conflict. It was structured using a framework which looks at three areas of the health workforce: supply, distribution and performance, as well as some overlapping areas, such as finance and gender. We know most about workforce supply issues, such as training, pay and recruitment, but less about workforce distribution and performance. The review stresses the need for more primary research, with a longer term perspective. Further research will increase awareness of how effective HRM can develop the health workforce and help build strong health systems after conflict has ended.

Read the brief!

Photo courtesy of ICRC/C. Martin-Chico/www.icrc.org

Community engagement to tackle maternal mortality in South Sudan

By Sally Theobald

With 2,054 maternal deaths per 100,000 live births, South Sudan has the highest maternal mortality in the world.

South Sudan is in transition. With years of conflict and the construction of a new nation, existing gender norms which mandate women bear many children have been intensified in order ‘to replace the ones that were lost’. Gender and societal norms are in transition. Elders complain that the young no longer listen to and respect their elders, couples do not keep to the traditional three years birth spacing, and marry younger and younger. Parents worry that their girl may get pregnant before marriage so they marry her off early, especially if she is not in school. Girls and boys have very limited access to sex education or contraceptives. These factors can lead to early pregnancy.

The SHARP Programme: community engagement for change

Korrie de Koning (Royal Tropical Institute) and Kingsley Chikaphupha (REACH Trust) have been working on the community participation component of the ‘SHARP’ programme in South Sudan. They provided some insights into how it is altering community norms around maternal health.

The SHARP programme aims to improve maternal health and is funded by the Dutch Government and is a collaboration of the South Sudanese Ministry of Health, Royal Tropical Institute, IMC, Healthnet TPO and Cordaid.  .

As part of the programme the Royal Tropical Institute developed a curriculum for the training of community facilitators to support dialogue and reflection on norms and values shaping maternal mortality and health service access and use. The curriculum was shaped by various sources, but drew substantially on the GTZ developed generational dialogue The curriculum was further adapted with input from the Community District Health Department in Wau, WBeG and Aweil North in Northern Bahr el Ghazal, REACH Trust, Malawi, International Medical Corps, and Healthnet TPO . Training of facilitators focussed on dialogue between older and younger women and men, comparing social and gender norms and practices between present and past, sharing knowledge on maternal health and discussing what needs to be changed for maternal health to improve.

How does it work?

Groups used drawings, statements and proverbs to explore the relationships between communities by gender and generation. For some women, this was their first experience of holding a pen or pencil but they were skilled in drawing images of maternal health decisions, dilemmas and outcomes throughout their life cycle. The ‘but why’ technique was used to probe and understand the rationale behind different cultural norms, their meanings and whether they were seen as fair.

Kingsley facilitated the men’s groups and explained at first there was complete refusal to even entertain the possibility of a discussion on contraception but use of the “but why” technique enabled discussion on the impact of multiple births on (especially young) women and child survival rates. This led to some shifts in viewpoints. Drama was also used, and women acted out what it is like to have obstetric fistula, and how women with urinary or faecal incontinence were treated within their communities. Following work in women and men only groups, the community fed back their ideas and experiences to each other, and for many women (who are very powerful within their own domains) this was their first experience of speaking publicly in front of men.

What changed?

Through the facilitated discussions between genders and generations statements for change were negotiated and agreed. Here are some examples:

  • “If a man with more than one wife is not looking after one of his wives and their children, the wife has the possibility to refuse to produce any more children without having to pay back the cows/bride price and also has the right to not be beaten.”
  •  “We don’t want daughters to marry or be pregnant before 18 years old and we in our family will do all we can –  we want to pledge this to our family and community.”
  •  “Married women should be allowed to use contraception and have three year birth spacing.”

This is an inspiring example of how community engagement can shift gender and societal norms and shows great facilitation skills from Korrie and Kingsley. Facilitators are being trained at local level and the approach will be rolled out and hopefully continue to challenge and change views and practices that undermine women’s maternal health.

The Conversation: We are happy to be part of it

By Kate Hawkins

The Conversation is a website that was established in 2011 in Australia. Its purpose is to enable experts to comment on current affairs and to uphold high standards of journalistic integrity. Their charter expands outlines the principles that underpin their work, they aim to:

  • Inform public debate with knowledge-based journalism that is responsible, ethical and supported by evidence.
  • Unlock the knowledge of researchers and academics to provide the public with clarity and insight into society’s biggest problems.
  • Create an open site for people around the world to share best practices and collaborate on developing smart, sustainable solutions.
  • Provide a fact-based and editorially independent forum, free of commercial or political bias.
  • Support and foster academic freedom to conduct research, teach, write and publish.

Last week our colleague Barbara McPake had a piece published by the Conversation on “Fixing broken health systems in the aftermath of conflict.” We would like to extend our thanks to the site for featuring us and hope that you will visit their pages, have a browse, and support this important news portal.

Ebola emerges in fragile states: another ‘wake- up’ call?

By Kate Hawkins

Many ReBUILD researchers are also members of the Thematic Working Group on Health Systems in Fragile and Conflict-Affected States. Suzanne Fustukian (pictured), of the Institute for International Health and Development, Queen Margaret University, Edinburgh, is on the Steering Committee.

Along with Karen Cavanaugh who works at USAID she has just published a blog on Ebola for the Health Systems Global website. In it she argues:

In 2013 World Bank President Jim Kim stated that the lack of progress for many fragile states: “should be a wake-up call to the global community not to dismiss these countries as lost causes,” and that “timely and critical support [is needed] to improve the lives of people living in these fragile countries.”

If the global community has been sleeping on the job of supporting fragile and post-conflict settings, then the Ebola outbreak is certainly something to wake us up.

Read more…

What can we learn from health policy making patterns in post-conflict Sierra Leone for post-Ebola times?

By Kate Hawkins

I am a big fan of the IHP newsletter. It lands in the email every Friday and never fails to provide something to make you think, laugh, or get irritated. The editorials by Kristof Decoster are a must read and you can follow him on Twitter. What more could you ask for?

So a huge thanks to the IHP newsletter team for highlighting a blog by our colleague  last week. She argues that:

One of the unresolved challenges in post-crisis settings is the balance between humanitarian aid and the longer-term development approach to rebuilding the health system. We agree that decisions made in the early recovery phase could determine the long term development of the health system. But how, when, why and by whom are those decisions made? We know surprisingly little about that.

Drawing on evidence from a recent paper in Conflict and Health she outlines what happened with human resources for health reforms in Sierra Leone, from the end of the conflict in 2002 until 2012, and suggests some lessons that other countries can learn.

You can read all about it on the IHP website…

And subscribe to the newsletter, you won’t regret it!