An interview by Anna Boisgillot
| We continue our series of interviews to present knowledge management activities led by health financing experts worldwide. We interviewed Dr Sophie Witter, an associate with Oxford Policy Management, and a Professor of International Health Systems at Queen Margaret University, Edinburgh, UK. She is also the Research co-Director of ReBUILD, a research consortium focussing on health system reconstruction post-conflict. Sophie is interested in health financing in low- and middle-income countries, financial barriers to access, human resources for health, and performance-based funding mechanisms. She agreed to share her work within the ReBUILD project with the CoPs. |  |
In 2016, you published seven articles about human resources for health remuneration issues in post conflict countries and fragile states. What sparked off your interest in this specific subject?
I started working in this topic on 2011 when we got a grant for the ReBUILD programme from DFID. There has been a big increase in conflict globally and a change in the kind of conflicts - for example, there are now more unresolved crises which carry on for a long time and have very serious consequences for civilians. Health needs are now very focused in fragile and conflict affected countries. We have also seen increased migrant and refugee flows. At the same time, there did not seem to be very much research going on in relation to these issues in terms of health systems, which is my field of expertise. So, we were interested in trying to understand the implications of these kinds of shocks and conflicts on health systems. Quite a lot has been done in terms of the immediate effects, and a lot of practical guidance around managing humanitarian crises has been published. But our focus was to try to understand the long term view and look at concepts like path dependency that we thought were practically relevant but also very academically interesting.
My focus on human resources is really linked to three things: first, if you have to think of one single area within the health system that really make things happen or stop things from happening, it would be human resources. They have a lot of agency and thus a lot of ability to adapt, adopt and block change, depending on their degree of engagement with health policies. Secondly, health workers are the biggest item by far in terms of expenditure in most health systems, so how effective human resources are is absolutely critical for effectiveness of the system. And thirdly, this area is interesting as it is quite a politicized domain: a lot of governments are concerned with public employment, and of course there is often a lot of interest from unions and other stakeholder groups.
You, with others, are leading the ReBUILD consortium, a research programme for health system development in countries that have been affected by political and social conflict. What are the topics and main learning agendas you are working on within this project?
We used more historical and longitudinal methods - especially life histories with health workers and households - to understand how policies have changed and what effects they had. For example, we focused on households that have access to health care and how it changed with different health financing policies in Cambodia, Northern Uganda, Sierra Leone and Zimbabwe. Each of these countries gave us a different perspective because of their different histories and length of time since conflict or crisis. We were interested in understanding how the health system responds to different types of shocks, and in one of the projects used group modelling building with health managers and staff to establish channels of resilience. In Sierra Leone, after the Ebola crisis, we used our research to look at the resilience of the health system and how epidemiological shocks had affected health workers. Others in the group looked at the pattern of health aid through social networks analysis to understand the relationships between different players at districts level and how these affected services. We also include gender analysis in all of our projects. Another area to highlight is that we have tried to be very active in terms of research uptake, engaging with other players. For example, we facilitate a thematic working group on health systems in fragile and conflict affected states to engage with organizations and individuals who were active in this field.
The first phase of this project is coming to its end. What lessons can be drawn from this? And what will you do with the new phase of this project?
We are trying to draw together some of the lessons from the first phase, looking for patterns, though we have to emphasize the context-specificity of findings. We will be launching a set of briefs which pull together evidence from ReBUILD and from the wider literature on some important themes within crisis-affected settings, such as resilience and health systems.
I will take the example of Sierra Leone to talk about some of the lessons learned, because it would be difficult to generalize from very different contexts. The work we did in Sierra Leone illustrates some very interesting things around the organic nature of health systems - the way in which health systems have really to be understood as social institutions and the importance of elements like trust. It is understood by some people but not by everybody that health systems are not just about outcomes or producing better health. What we saw in the case of Ebola was another shock to the health system, when it was only just starting to recover from civil war. We documented the way in which the health system was redeveloped and started to pick up after conflict. This is a two-sided story - on one side, a very positive tale of resilience (e.g. health workers were very stigmatized, they were at risk and many health workers lost their lives and yet they continued to provide services), so it is a very strong story, both at community and health workforce levels, of resilience. On another hand many of the key institutions, such as the Ministry of Health, were weak and then further undermined by internal and external factors during this crisis. So I think one of the lessons there is the importance of focusing not just the immediate results, but always having an eye on building institutions, which is a long term job.
We have a two-year extension for this project. In the health worker incentives area, we will look at performance-based-financing (PBF), and we will focus particularly on what is specific about this kind of disrupted context that facilitates or blocks the use of PBF. This is important as there is a lot of interest both in PBF and in these contexts. For example, the current UK Aid strategy puts a lot of emphasis on fragile and conflict affected settings, while the UK government continues to emphasise a results-orientation in aid and public policy generally. We are also planning further research on human resources management, on the role of community health workers, on gender equitable health systems and on the demographic impact of conflict and its implications for health systems, all in fragile and conflict-affected settings. We would like to widen the scope of the countries that we have been looking at. While in the first phase we focused on a post-conflict story, we now want to study wider contexts – e.g. countries suffering from protracted crisis or complex emergencies. Another area where we really see a need for a lot of new work is in capacity development. For most of the fragile post-conflict countries health system research is a very new field, and while we have been able to build up some partnerships, it really needs a very long term engagement. So these are some areas that we hope to take forward.
To your mind, what have been the impacts on health workers and the health system in Sierra Leone? And how do you (and ReBUILD) envisage the future health system reconstruction in the country?
The research group and the team in Sierra Leone have been very involved in the development of the reconstruction plan. Findings from the research in the first phase (e.g. on health workers) has very much fed into the identification of needs. There is a window of opportunity now, with a lot of interest and resources coming into the country. ReBUILD will continue to try to ensure that evidence is used to inform how those funds are invested. But at the same time, we really are emphasizing the need to develop and not bypass national institutions, which is a big risk at this stage. We will also follow up with other areas of work, for example researching the role of community health workers, which we didn’t have a chance to look at in the first phase.
Any conclusion or comment you would like to make?
Fragile and conflicted-affected states research is an area that deserves a lot more attention and interest by different research communities and practitioners. It is also one which lends itself to interesting cross-disciplinary work (e.g. collaborations with political scientists, historians, economist, public administration experts, as well as, of course, public health and health system experts). We recently published a research agenda setting exercise in Health Research and Policy Systems. As far as ReBUILD is concerned, we really welcome collaboration with anybody who is interested in working on any of the topics which it raised. So, do get in touch!
(1) Sophie’s publications can be retrieved here.
(2) Aniek Woodward and others, ‘Health Systems Research in Fragile and Conflict-Affected States: A Research Agenda-Setting Exercise’, Health Research Policy and Systems, 14 (2016), 51.
