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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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

Seven things we can learn from the Ebola epidemic in Uganda in 2000 – 2001

By Sarah Ssali, Senior Lecturer, School of Women and Gender Studies, Makerere University

Diseases such as Ebola highlight the importance of a holistic focus on health systems, as opposed to assuming that health is the preserve and concern of health professionals alone. This was the lesson Uganda learnt very quickly in managing the Ebola outbreak in 2001. Until the current epidemic in West Africa, Uganda held the unfortunate record for the greatest number of infections, with 425 recorded cases of Ebola, of which 224 people sadly died (Omaswa 2014, Kinsman 2012).

Gulu district, in the north of the country, bore the greatest brunt of the epidemic, with 393 people falling ill and 203 deaths (Kinsman 2012). But it was not the only affected district. Mbarara district in the south west, recorded five cases of people contracting Ebola of whom four died and Masindi district in the west recorded 17 deaths.

Ebola causes community panic and mistrust in the health system

Initially, the epidemic caused a lot of fear, panic, and anger within communities. As is the case in West Africa now, communities: stigmatized the sick; stormed Ebola isolation units (in Masindi) causing the unit to seek another site; and scared off relief burial teams, forcing them to abandon work (Kinsman 2012). Elsewhere in the country, fear and stigmatization grew, causing those who suspected that they had Ebola to hide and patients to flee hospitals once they knew Ebola treatment was being carried out there. In Kampala, religious leaders held prayer rallies against the epidemic, while in nomadic Karamoja anti-Ebola rituals were carried out.

Very quickly, the Uganda Directorate of Health Services learnt that they needed to do something to restore community trust if they were going to tackle the epidemic. Treatment alone was not enough. They needed the community to understand that those treating Ebola patients and burying the dead meant well and needed the community’s support.

Seven measures taken to tackle Ebola in Uganda

Measures were undertaken to gain the trust of the community and help them fight the epidemic. Okware et al (2002) and Omaswa (2014) provide a list of the interventions undertaken by Uganda’s Ministry of Health, which included the following:

1. Partnerships with communities

Upon realizing that they could not do everything by themselves, the Ministry of Health decided to build partnerships with other actors within the community, such as non-governmental organisations like the Red Cross and World Vision. These partnerships were crucial for mobilizing communities, information dissemination, and early case detection. Okware et al (2002) even state that anti government rebels stopped fighting and supported the anti-Ebola efforts

2. Community-based disease surveillance

The Ministry of Health trained community members to provide a network for surveillance and public information. These community members rapidly reported suspected cases from households, who were rapidly assessed using history of contact and clinical assessment. This strategy was important in that it was not very costly to manage.

3. Work with the Media

Realising the role of the media in informing and misinforming the masses, given their previous role in propagating myths and rumours about Ebola, the Ministry of Health learnt very quickly that they needed to partner with the media to provide prompt and factual public information. Information dissemination could no longer be the preserve of health workers. The media was trained in Ebola and barrier nursing to protect themselves, after which they were charged with providing factual updates about the disease on a daily basis. This way, the media helped curb rumours, myths and risks associated with the disease.

4. Technology for quick field diagnosis of new infections

Because there was no special laboratory for testing Ebola in the country, a field laboratory for spot screening was provided with help from the Centre for Disease Control (CDC) and the World Health Organization. The South African Institute of Virus Research helped customize certain procedures to make them simpler and less costly. This helped with early detection, while those suspected but found to be negative were able to return to their normal lives. This helped reduce stigma and re-build trust between the communities and the health facilities managing Ebola.

5. Infection control and hospital waste management

While health facilities should routinely manage waste professionally, this is not the case, especially in rural communities. Moreover, no one had been prepared for the kind of waste management that accompanied an Ebola epidemic. Sometimes, health workers thought that ensuring that isolating people with Ebola was all they needed to do. In addition, there was need to protect non-health workers in the Ebola response, such as drivers. The Ministry of Health developed a programme to promote infection control in hospital and health facility settings. However, this training was not restricted to health workers, but to others such as drivers who transported people to referral centres.

6. Work on the legal, ethical and social issues

One of the biggest challenges in combating infectious diseases arises from people’s traditions and cultural norms. Such traditions, with respect to the Ebola epidemic, relate to burials in ancestral grounds, funeral ceremonies, and the handling of the dead. People were provided with information about the dangers of touching those who had died of Ebola and encouraged to leave burials to the specially trained burial committees.

In addition, there were issues of disclosure and confidentiality, which posed ethical challenges to medical workers, and the several children (about 500) orphaned by Ebola. To address these, the government enacted the Workman Compensation Act which entitled infected health workers and their close kin some form of compensation. Individual confidentiality was suspended for public information sharing and counseling services provided to the orphans. In addition, a Post-Ebola Association and a special clinic opened to provide services to survivors.

7. National and international collaborations

One thing that has been associated with Uganda’s success in combating epidemics such as HIV and Ebola is the leadership and commitment from government. With the suspicion of Ebola in Uganda, despite meager finances, the government embarked on a process of providing essential resources to help combat the epidemic. These essentials included but were not limited to; supplies, funding, expertise, communication, and information. Where resources became a challenge, the government called on the international community to help. Some of these, such as CDC, provided the expertise in field testing. All external actors were coordinated by the National Task Force. In addition, other tasks forces were established at the district (DTF) and between ministries (IMTF). These task forces included policy makers, such as district leaders, Members of Parliament, religious leaders, and the police along with people from the health sector.

References:

Kinsman John (2012), “A Time of Fear”: Local, National, and International Responses to a Large Ebola Outbreak in Uganda, in Biomed Central 8 (15), Pgs 1-12

Okware S. I et al (2002), An Outbreak if Ebola in Uganda, Tropical Medicine and International Health, 7(12), Pgs. 1068-1075

Omaswa Francis (2014), Regaining Trust: An Essential Prerequisite for Controlling the Ebola Outbreak, The Lancet Global Health Blog, 11th August 2014

Photo courtesy of Josh Zakary https://www.flickr.com/photos/joshzakary/6864103297

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.

Health systems and gender in post-conflict contexts: building back better?

If you haven’t seen it  yet you might want to check out ‘Filling the void: Health systems in fragile and conflict affected states’ a special issue of the journal Conflict and Health. ReBUILD authors have contributed papers to this series. The most recent one is an analysis of gender in health system reconstruction. The authors – Valerie Percival, Esther Richards, Tammy MacLean and Sally Theobald – explain:

The post-conflict or post-crisis period provides the opportunity for wide-ranging public sector reforms: donors fund rebuilding and reform efforts, social norms are in a state of flux, and the political climate may be conducive to change. This reform period presents favourable circumstances for the promotion of gender equity in multiple social arenas, including the health system. As part of a larger research project that explores whether and how gender equity considerations are taken into account in the reconstruction and reform of health systems in conflict-affected and post conflict countries, we undertook a narrative literature review based on the questions “How gender sensitive is the reconstruction and reform of health systems in post conflict countries, and what factors need to be taken into consideration to build a gender equitable health system?” We used the World Health Organisation’s (WHO) six building blocks as a framework for our analysis; these six building blocks are: 1) health service delivery/provision, 2) human resources, 3) health information systems, 4) health system financing, 5) medical products and technologies, and 6) leadership and governance.The limited literature on gender equity in health system reform in post conflict settings demonstrates that despite being an important political and social objective of the international community’s engagement in conflict-affected states, gender equity has not been fully integrated into post-conflict health system reform. Our review was therefore iterative in nature: To establish what factors need to be taken into consideration to build gender equitable health systems, we reviewed health system reforms in low and middle-income settings. We found that health systems literature does not sufficiently address the issue of gender equity. With this finding, we reflected on the key components of a gender-equitable health system that should be considered as part of health system reform in conflict-affected and post-conflict states. Given the benefits of gender equity for broader social and economic well-being, it is clearly in the interests of donors and policy makers to address this oversight in future health reform efforts.

Read the full paper…

Photo courtesy of Sojoud Elgarrai – UNAMID https://www.flickr.com/photos/unamid-photo/8046318272/in/photostream/

 

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.

NEW! Brief on post-conflict reform in Sierra Leone

One of the challenges when a conflict is over is the balance between emergency aid to save lives and a longer-term approach based on rebuilding the health system. Some researchers believe that the decisions taken shortly after a conflict can influence how the health system will develop and that a political “window of opportunity” for reform exists at this time. To test these two concepts and to understand how reform takes place, it is helpful to analyse how, when and why policy is made after conflict. In order to do this, the ReBUILD Consortium focused on the factors shaping policy on human resources for health in Sierra Leone after the war had ended in 2002. The findings are published in an article which begins by setting the context of the health system in Sierra Leone before the war; explains the methods used to collect information for the study and the difficulties encountered, and looks at how policy on health workers was made from 2002 to 2012. Three stages in policy-making are identified and discussed in detail. The article concludes that decisions taken early on after the war in Sierra Leone did have an impact on the development of human resources for health policy and ultimately the health system. However, the window of opportunity for reform did not open immediately after the end of the conflict but eight years afterwards when a key initiative came into force which introduced free health care at the point of delivery, for mothers and children. This event – propelled by increased political will from high-ranking government officials as well as international pressure and support – sparked off major changes throughout the health system.

Read the brief