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!

Advertisements

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

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!

An update from the frontline of health systems research in Sierra Leone by Dr Haja Wurie

By Haja Wurie

The aim of the WHO Ebola roadmap is to stop the transmission of the virus in affected countries within 6-9 months and prevent international spread. However, as of today, the Ebola outbreak continues to spread in alarming ways in Sierra Leone and Liberia and has now crossed international boundaries, with cases in Spain and the USA.

In Sierra Leone, the virus has spread to all 14 districts in the country, and the country is still struggling to control the escalating outbreak against a backdrop of severely weak health systems, and significant deficits in capacity. There are reports of five new cases per hour in Sierra Leone and an alarming prediction of 1.4 million people infected in both Sierra Leone and Liberia, if efforts to control the spread of the virus are fruitless.

If uncontained, the outbreak has the potential to cause a collapse of the affected countries, something that will take years to recover from. The only positive thing about the Ebola outbreak is that is has created a window of opportunity to prioritise health systems research and strengthening. Resilient and responsive health systems should be built, or rebuilt in this case, with concerted efforts needed by the Government, researchers, implementers and donors. Most importantly, long term solutions should focus on ensuring that universal health coverage becomes a reality. Resources, strategic planning and capacity development is needed to build to recover from this crisis.

Health systems in Sierra Leone

In Sierra Leone, the health sector is divided into six main pillars, governance, human resources for health, service delivery, infrastructure, drugs and technology and research and monitoring and evaluation. The current Ebola outbreak has highlighted the challenges in all the six pillars and the irresponsive nature of the current health sector, which contributed to the delayed response. In my opinion, the health sector needs to be completely reformed as it is just not working.

There are historical challenges regarding the implementation of policies the health sector in Sierra Leone, with a number of health policies on paper but not implemented. This might be a capacity issue which health systems research will shed some more light on. Systems within central government need to be reviewed, and possibly reformed, as the current practice causes inordinate delays.

The slogan ‘Health is Wealth’ can be seen everywhere at the Ministry of Health and Sanitation, Sierra Leone. Accordingly, the local leaders should ensure that sustainable investments are made in the health sector. This can range from investing in new or upgrading health facilities, diagnostic tools and technology, to investing in the health workers, the unsung heroes and heroines.

With only 2 medical doctors per 100,000 of the population, the human resources available for health are inadequate. Findings from the ReBUILD’s health worker incentive project in Sierra Leone, highlighted that building the capacity of health workers and developing a motivated health work force is an ongoing issue. Health workers in general are demotivated even before the outbreak. Health facilities are chronically understaffed by poorly trained, overworked healthcare personnel, with very little or no training on infection control practices. Working conditions are generally poor, lacking adequate logistics. The basics of sanitation, electricity and personal protective equipment to ensure the safety of health workers from infection are not always available when required. This has resulted in the majority of health specialists at the forefront of the outbreak being international experts flown in by international development partners, highlighting the heavy dependence on foreign expertise.

Attraction and retention of health workers in rural and remote areas of Sierra Leone is an on-going challenge, which has resulted in a mal-distribution of the health work force. Not having equitable access to health care services can influence one’s health seeking behaviour. With no health facilities within easy reach or poor quality of service delivered in the health facilities, service users might seek for health care services via the traditional route. This heavy dependence on traditional healers can only address by ensuring that universal health coverage is available to all. Hence, it is important for more health workers to be trained, that are motivated to work and stay in adequately functioning rural health facilities.

It is a common occurrence in recent weeks for health workers and burial boys – at the forefront in the fight against the virus – to go on strike, citing non-payment of risk allowances, inadequate supplies of PPEs and death of their colleagues. This implies that the health workforce feel both undervalued and ill equipped to do their job effectively, even during the outbreak. Health workers should be motivated and protected. A benefits package for health workers should be developed and their voices should be instrumented in the design. Thus investment is needed in the health workers in terms of remuneration and professional training/development and also in the health facilities in terms of improving the working conditions.

Research priorities

Sierra Leone faces a number of challenges in building its research for health systems, the greatest of which is the absence of national ownership of health systems research. Limited government commitment, inadequate funding, poor coordination and networking, a small number of health researchers who are typically combining multiple tasks or jobs, limited grants and research management skills, and very limited capacity in general, are some of the problems encountered in this country.

Sierra Leone’s research for health strengthening is mostly donor driven, which raises the issue of sustainability. Being heavily dependent on international aid, means that research initiatives are fragmented, and largely led by international researchers with little or no local capacity being built. This should be addressed as a matter of urgency.

The Government of Sierra Leone should make health systems research a priority and take national ownership. In the event of any further outbreak it will be necessary to ensure that local professionals adequately trained are on the ground, and local institutions are involved in health systems strengthening research.

Donor investment and coordination

There is an element of mistrust of the government’s role in how Ebola has come about and is spreading. Sierra Leone being a post-conflict country is still recovering from the effects of the conflict has definitely contributed to the spread of the virus. The eleven year conflict crumbled the health sector and fuelled social conflict and mistrust in the government. International donors should also consider supporting health civil society organisations, and tasking them with activities in health promotion and education, amongst other things.

Donors need to be coordinated to avoid fragmentation. There are reports of high profile meetings at central government, but so far coordination on the ground is ineffective. In the same vein gap between researchers and decision makers should be bridged to ensure that knowledge gaps are identified and incorporated into a tried and tested national health emergency response policy. This will have a ripple effect on leadership and governance systems in place.