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…

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.

BuzzFeed: Everything You’ve Ever Needed To Know About Health Systems

If you work on health systems research you may be asking yourself – what on earth is BuzzFeed, and why should I care?

Well, BuzzFeed is an online news portal that creates and aggregates content (using the term news lightly as there are a lot of ‘fun’ stories on the site, kittens in dresses, that kind of thing). BuzzFeed authors have a fondness for lists, infographics and quizzes. It is the type of content that you regularly see shared on Facebook and other social media sites. It is very popular with younger people. In terms of audience an estimated 24 percent range between the ages 18-24; 28.7 percent are between 25 and 34 (figures from May 2013).

If we are serious about making health systems research accessible then we need to be experimenting with new formats for sharing ideas. We need to find routes to audiences who are never going to engage with our research through a journal article or even an editorial in the daily newspaper. Which is why we are delighted that our colleague Jeff Knezovich of Future Health Systems has put together a fabulous BuzzFeed ‘Everything You’ve Ever Needed To Know About Health Systems.’ He explains:

“New to the wonderful world of health systems? Then this post is for you! Whether you’re a wonk that needs to brush up, a student, a health care practitioner or just an interested and engaged citizen – this primer is full of everything you’ve ever needed to know about health systems and how they function around the world.”

So visit, give it a ‘LOL’, maybe ReTweet. It’s the future!

Photo courtesy of Nina J. G.

A view from Australia on Ebola

This week our Director Barbara McPake has been in the news in Australia talking about Ebola:

Global Health’s Professor Barbara McPake, speaking ahead of a conference on global health security in Melbourne on Wednesday, said although it is likely we will see the Ebola within our borders, Australia is well placed to deal with an outbreak.

“As the epidemic gets larger and larger in west Africa the likelihood of the odd case emerging in Australia is quite high, but I do think Australia will deal with it very well,” she said. “If anybody dies in Australia it’s likely to be somebody who has come already at a fairly advanced stage of the infection.”

Read the full article…

In a second article in the West Australian she explains:.

“Australia has a very strong health system.” 

“I think what Australians need to be worried about is if future outbreaks like this are being adequately prepared for and prevented by the strengthening of health systems in countries in the region.”

Read the full article…

Question time: Health systems in fragile and conflict-affected states

By Helen Carlin and Kate Hawkins

As part of the ReBUILD annual meeting we ran a Question Time event which was very ably chaired by Sarah Ssali. The panel brought together Prof Barry Munslow, Prof Mukesh Kapila and Mr. Alex Jones to answer questions from the consortium on health systems in fragile and conflict-affected states. What did we learn?

Do you see the long lens of life histories as useful to answering the ReBUILD questions?

Alex: In Sierra Leone we frequently look back over three years, and sometimes further, but rarely further than 15. Often the information isn’t there and it would be helpful to have this analysis. Impact evaluation of the free health care initiative needs historians as well as economists working on it. You can go to the Archive office which has two people working voluntarily with amazing documents about the construction of Sierra Leone and the country it is today. But this needs more academic attention, and the health lens is important here.

Barry: Ethics committees being what they are it is increasingly difficult to have the voices of the people heard. Life histories bring a sense of change and changing circumstance.  My daughter is a lecturer in post-colonial literature this provides an interesting perspective. However much we think about it we are very top down – bringing in other voices and perspectives into the dialogue is very important.

What is your experience on health care need and provision of health services with respect to disability in post conflict settings?

Mukesh: It is generally neglected, and this is well established. Like the ‘gender lens’ on system development the ‘disability lens’ allows you to design programmes in a way that improves access across the board.

Barry: Humanitarianism does not do disability, which is chronic and long term, whereas humanitarianism is quick fix and short term. There is a disconnect. Handicap International and those dealing with problems of the elderly are critical.  Often disability doesn’t fit the budgetary lenses we have. This is how disempowered they are – the elderly and the disabled are at the back of the queue.

How can we build multi-sectoral cooperation to ensure health worker retention in rural areas?

Barry:  There is a problem of coordination – everyone loves coordination but nobody wants to be coordinated. This is a serious problem regarding the way the UN and cluster system has gone – it gathers and tries to tackle the problems of coordination. Nationals are rarely included in this. That compromises neutrality, impartiality and independence as they are pulled into a political agenda. John Holmes’ book highlights that there is always a problem with the compromises that go with this. What are the compromises that have to be made in the coordination stakes? I have just examined a PhD on maternal and child health in Sudan. There are lots of women doctors who can’t go out the rural areas alone – you need deployment of husbands and wives and schooling etc. It is not just about salaries it’s about families. People ask themselves, “Will I be safe and secure? What about the kids and husbands? Is everyone going to be safe?” The Ministry of Health will have to talk to the other Ministries to coordinate this and it needs dealing with at the local level.

Mukesh: I was chair of the first health cluster under John Holmes’ times – a fluster of clusters and an inert cluster mechanism. Having been someone whose title was Humanitarian Coordinator in Sudan I see that not to be coordinated is part of the human condition. Trying to invent mechanisms to do it better are all going to fail. Humanitarianism is not about logic it is about the heart. We are in the post-coordination age –  where we have to work out how to operate in a world where there are multiple political interests and the skill lies in being able to navigate them. Actor coordination is inherently inefficient – trading business efficiency against a policy of interests. We need to be relaxed do good where we can work with like-minded people. The natural economy of this situation sorts out who’s good and bad.

Is there an opportunity in the post conflict/crisis period to replace ineffective human resource administrative systems?

Mukesh: All post-conflict crisis periods are opportunities. The Chinese word for disaster and opportunity are the same thing. Early debate post-conflict period stretches on longer than you realise. This is not a linear process. It is a matter of judgement and seeing an opportunity when a system is broken down and being able to take some short cuts to break through barriers that have existed for a long time. My own personal experience in the Red Cross in some difficult situations is that issues everyone’s talking about for a long time could suddenly be resolved. You would be surprised how open people are, when it comes to the post-conflict moment. In this you will probably make some rash decisions you will have to unmake – these are correctional changes you will have to live with.

You institutionalise by bedding in improvements and good practices that may or may not be the norm. You can’t have human resource policies without good governance. Development is fundamentally about challenging and changing.  Revolutionary is not a dirty word. There is change that is confusing and destructive and change that requires a culture shift – and this relates to the nature of how health is seen within a nation. As a burden or as a more positive opportunity to strengthen a society?

Alex: The post-conflict period is not without its own chaos. A lot of health workers have fled the country – how do we make the most of the calm after the storm?

Funding agencies are often concentrated in one area/district. What drives the location choices of agencies and why does this pattern exist?

Mukesh: In theory you would have needs analysis and priority countries based on logical criteria. In reality other factors such as tradition, links, and lobbying play a critical part in these decisions. Gulu is over clustered because there are traditional links there. Too often the weight of past relationships, social capital, and self-interest influences this. One area that is not adequately studied is the extent to which funding organisations serve personal relations. This pays a bigger focus in funding than we realise. This matters if we want to take a fiercely equitable view of development. Development is not a science and the factors at play are about trade-offs of resources and how to do the best with what we’ve got.

Alex: In the context of Ebola outbreak the US supports Liberia, the British support Sierra Leone, and the French support Guinea. These decisions are based on relatively clear origins. The danger is that we can’t deal with Ebola one country at a time, you need a coordinated approach in the West Africa region.

Barry: News is generated wherever journalists gather. No journalists = no news. Maybe the same thing applies for development. In partner negotiations you never get a discussion about what’s best for me and my organisation but rather you argue by principle. Once you know that you can decode that. Under capitalism development is uneven and will remain so – we have to live with this and find ways to move round it.

To what extent can the agenda of agencies and government be aligned to achieve long term sustainability?

Barry: We have the Paris principle – what we’ve got to do is fit in with what the government says we should be doing. The real problem lies in putting together those Paris principles and then dealing with a kind of conflict situation. You are torn in the old dilemma – do you do the job or build the capacity? It’s a difficult one to get right. The MSF model is to go in and deliver top quality health care and then pull out and then the quality is then lower and the hand over extremely difficult. Hence there is an inherent tension in the agency itself and between the agency and government. The trick is not to try and railroad this but try and work with the multiple interests here.

Mukesh: It depends on the type of aid agency. For some aid agencies it is very important not to be aligned. The world is full of opportunities and possibilities. It’s possible to make progress in certain neglected areas even when the mainstream is against you. You could have a world of perfect donor alignment and the patronage of donors could drive the government agenda. Forcing NGOs to go a certain way may be counter-productive. You have got to have a degree of space of space and rebelliousness otherwise the idea of development is an oxymoron. When it comes to alignment with the host government the situation is slightly different. There is a degree of respect that is owed to the government.

Alex:  In Sierra Leone there is one plan signed up to by government and NGOs. If you want to fund something you need to pick something from the plan. But it’s fuzzy – each agency has multiple agendas – and is made up of people who have multiple agendas. Working together over a long period of time means you know where the interest lies. It is the same for people in government and the civil service.

What are the key gender considerations in the reconstruction of the health systems in the post-conflict period? Given your concern about how gender biases and ideologies shape inequity – how do you move forward?

Barry:  I know about my grandma and my mum. My grandma lost her husband through influenza and then went to the mills and as a result had economic power. During World War Two my dad went to war – my mother bought the house while he was away. It still comes down to money.

Mukesh: Men must speak up. Work on gender needs men, and they need to lead. When that happens we will see progress, when men realise it is a career advancing activity. Normally I’m not in favour of bringing bureaucracy into things but there needs to be sanctions and incentives, simple moral imperatives are not enough.

Alex: We need to keep data on it. We can’t talk about the way we feel it should be until we know how it is.

In your experience, what are the ethical challenges of conducting research in post-conflict contexts – in terms of methods employed; and areas of focus that may uncover challenging issues e.g. corruption?

Alex: In Sierra Leone we need to make sure that ethics committees are about more than about getting the research done and published. It is about the implications of what you’re finding. A stigma against academics is that they are just there for the next paper.

Barry: The ethical challenges are difficult – the problem we all face is that ethics committees have gone mad in this part of the world. The protocols are so long and involved. It creates a burden. How do you get to the voice of the voiceless? This would be seen as unethical. But not asking he question is also unethical. Antonio Gramsci says we need pessimism of the intellect and optimism of the will. As researchers we need to tell it as it is. Only if we understand how the systems operate can we find a way to translate that into a way that will move the process forward.

Mukesh: The real value of this REBUILD framework of work, which I think is great, is it leads to more questions than you can answer. And this in turn stimulates different questions and challenges. The research needs to change policy and the application of policy.  If some of the insights that are gained lead to different strands of work and stimulate greater cross-sectoral collaboration it will therefore shed light on shared issues.

Alex: A really key thing is enabling good analysis of poor quality data – we can still make valid conclusions and inferences from data that are valid even if it is a lower standard of data. If we don’t use it we are wasting data.

Barry: It’s a privilege to spend time with you all, I think it’s great. Some takeaway messages for you all: 1) What is the story? 2) Keep it simple, don’t do complicated 3) Sort out your hierarchy and sequencing and 4) Use your head but never forget your heart.