ReBUILD travaille depuis 2011 sur les systèmes de santé dans les Etats fragiles et touchés par des conflits et tente de réunir différents groupes concernés pour réfléchir et agir sur les problèmes clés soulevés (par la fragilité et les conflits). En plus d’avoir mené de nouvelles recherches, nous avons synthétisé les connaissances acquises sur certaines questions clés, en suivant les sujets mis en évidence par un exercice de consultation. Que savons-nous de la résilience des systèmes de santé dans ces contextes, par exemple, ou de la marche à suivre pour parvenir à la couverture sanitaire universelle?

Lors d’une réunion à l’IMT en octobre 2018, nous avons appris que de nombreux pays francophones – par exemple au Sahel – sont confrontés à des défis similaires, notamment en raison de changements climatiques, de conflits et de pressions démographiques et économiques, mais que le débat sur ce que la fragilité ou une crise peut signifier pour les systèmes de santé y est moins développé. Cela nous semble être une opportunité manquée importante. En travaillant avec Collectivity, nous souhaitons aider à réunir les différentes communautés afin d’évaluer la meilleure façon de relever ces défis.

Aussi, pour atteindre et impliquer un public plus large, nous avons traduit en français la série de documents de synthèse sur certaines questions clés – vous pouvez trouver l’ensemble complet ici. N’hésitez pas à lire, partager et réagir.

Nous devons établir des liens et travailler ensemble plus efficacement dans ce monde souvent fragile. Rejoignez-nous! Quels sont les principaux problèmes et sujets qui vous intéressent dans ce domaine?

Tous les documents de synthèse de ReBuild peuvent être trouvés via les liens ci-dessous:

1. Résilience des systèmes de santé pendant et après les crises  
2. Systèmes de santé inclusifs en situations de crise
3. La couverture sanitaire universelle en situation de crise
4. Types de prestataires pendant et après les crises
5. L’économie politique des pays en situation de crise
6. Le renforcement de l’État pendant et après les crises
7. La durabilité des systèmes de santé dans les situations de crise
8. Les capacités de recherche des systèmes de santé dans les situations de crise
9. Répondre aux crises humanitaires de façon à renforcer les systèmes de santé
10. Financement basé sur la performance dans les environnements fragiles et en situation de conflit

Fragile and conflict-affected health systems – bringing together the language divide

The world is a divided place, as we know, and one of the barriers we face is language. Knowledge silos often build up, with people only reading certain bodies of work, depending on where they read and in what language. Academia is also strongly affected by these issues.

ReBUILD has been working since 2011 on health systems in fragile and conflict affected states and trying to bring together different groups concerned to think and act on the key issues raised. In addition to new research, we have tried to synthesise learning on some of the key questions, following topics raised in an agenda-setting consultative exercise. What do we know about resilience in health systems in these contexts, for example, or on how to move towards universal health coverage?

Following a meeting at ITM in October 2019, we became aware that many francophone countries – for example, in the Sahel – are facing similar challenges, including due to changes in climate, conflict, and demographic and economic pressures, but that the debate about what fragility or crisis may mean for health systems has been less developed there. This seems like an important missed opportunity. Working with Collectivity, we aim to help bring the different communities together to assess how best to respond to these challenges.

In support of this initiative, we have translated our set of briefs on some of the key issues into French – you can find the complete set here – to reach and involve a wider audience. Do please read, share and react.

We need to connect the dots and work together more effectively in this often fragile world. Join us! What are the main issues and topics of interest to you in this area?

All the ReBUILD issue briefs can be found through the links below (here in English – see above for French versions):

1. Resilience of health systems during & after crisis
2. Inclusive health systems in crisis-affected settings
3. Universal health coverage in crisis-affected settings
4. Types of health system provider during & after crisis
5. Political economy of crisis-affected health systems
6. State-building & health systems during & after crisis
7. Sustainability of health systems during & after crisis
8. Health systems research capacity in crisis-affected settings
9. Responding to humanitarian crises in ways that contribute to stronger health systems
10.  Performance based financing in fragile and conflict affected settings

1. Committed leadership

It is a cliché, but the mobilisation, prioritisation, resourcing and continued support which programmes need to flourish and survive over time cannot happen without technical and political leaders who see it as worth their while to fight for it. This in turns often relates to personal and institutional incentives – what is the return for them? Electoral returns often play a role, and why not? Health is intensely political. Sometimes a crisis can help too, generating momentum for reform and rebuilding.

2. Sweating the big stuff

Linked to this, programmes need to address health concerns which are of major social impact for universal access. How else to create the commitment which is needed at leadership and all system levels?

3. Fit for purpose funding

That resources have to match the costs of running the programme is obvious (though we all know many, if not most, where this is not the case, with predictable knock on effects on quality, morale and costs for users). However, it is not just the volume of finance but also its modalities that matter. Pooled funding allows control and clear allocation to internal priorities. Fragmented funding does not. Simple as that.

4. Ownership and adaptation

Do programmes which are simply transplanted from another setting every work?  I cannot think of any examples. It seems to me that all successful programmes are home-grown in some sense. They may be influenced by others (there are few original ideas in the world), but they have been carefully tailored and crafted to match the new context. They have been adopted actively – not through bribery or coercion.

5. Clarity on goals and means

Knowing what you are trying to achieve, as well as your boundaries, and having clear tools and guides to help you achieve them is essential. Most health programmes rely heavily on community and lower level staff.  Short, practical tools are what they need.

6. Knowledge transfer to communities

Demand and need grows exponentially, so a programme which does not increase the ability of its clients to prevent and manage their own health problems is condemning itself to an impossible fight. Prevention and promotion are key, and within that, empowering women is an essential component.

7. Linking across and up

Health programmes require effective technical supervision, so radical decentralisation which cuts lower levels off can be disastrous. Health programmes need vertical links but also horizontal ones which connect them to the local community structures (for support and also accountability).

No programme is an island – it functions effectively and sustainably by operating within the available health system resources and contributing to strengthening them. Similarly, it reaches outside the sector to support and influence other sectors which affect population health (which is almost all of them, but some more than others).

8. Learning, learning

Knowing where you are going and how well you are doing to get there is another shared feature, but learning involves more than tracking and data; it also requires sometimes painful recognition of failures and the courage to innovate in addressing them – the famous willingness to fail again, but fail better.

9. (Reasonable) accountability

Programmes which do not reward effort and performance and penalise their opposites are condemned to entropy.  However, effective programmes also know that teams and staff need support and the right conditions to deliver – this is a two-sided bargain.

10. Creating a narrative of success (but only half believing it)

To thrive, health programmes have not just to be successful but to be seen to be successful, as this nourishes the commitment which they require. Successful programmes often have outstanding champions – people who know and tell their story well. But they are also not misled by their own narratives into overlooking operational challenges and the need to continually reinvent themselves.

Finally, a bit of luck always helps – operating in an area with economic  growth, peace and stability can be very helpful too!

Those who voted in favour of leaving were predominantly old, poor, uneducated. Not, interestingly, those in areas which had actually experienced high immigration – which was the cause celebre of the leave campaign. Cities with high immigration like London voted overwhelmingly to stay. So the fear of immigrants in areas like the north-east came not from personal experiences, but presumably from the slow drip-drip of poison from our unregulated right wing press.

They were sold lies by politicians with a naked agenda of power-seeking. They were told – at least, it was cunningly implied – that if they voted to ‘get their country back’ then we would reduce immigration and all would be sweetness and light. All facts to the contrary – the obvious statement, for example, that you can’t have free trade with the EU-zone without signing up to common standards – were dismissed. ‘Experts’ were disparaged – even by our former Secretary of State for Education, Michael Gove! This was demagoguery and evidence-free policy making at its finest.

The voters in areas left behind by recent economic progress were protesting, understandably, though at the wrong target. Within hours of the results, people were saying they regretted voting ‘leave’ – they hadn’t thought it would work! A top search term the day after the referendum was: ‘what is the EU?’! Within hours, Leave campaigners were ‘clarifying’ that controlling immigration did not mean reducing the numbers!

The good politicians resign and the way is potentially open to the demagogues to profit. Britain faces uncertainty, the risk of internal break-up and potentially a decade of unravelling a 40-year relationship. Europe is weakened. We are all diminished.

What light can we find in this dark hour? Here are my top five hopes:

1. Damage limitation. We need to question the justice in bringing about such a huge constitutional shift on such a low proportion of the electorate. There is a campaign for a second referendum with a threshold of 60% for change and a minimum turn-out of 75%. All UK citizens are encouraged to sign up, if they support this view. This would at least signal our outrage at the result. One other hope may be that Scotland will block the exit. If not, we will just have to negotiate to keep as much of the relationship as we can – it will be costly, but may be the least bad outcome.
2. We failed to make the positive case for Europe. The argument that we are stronger together – which we promoted, rightly in the Scottish referendum, we never understood it for ourselves in relation to Europe. Having autonomy but the protection of being in a larger unit is the ideal set-up. We must not throw it away. We need new leaders who can communicate that passion. The campaign was dominated by old, rich men who focused on narrow, unappealing economic arguments, as if that is all that motivates us. Let us open up the leadership to wider voices. Some of the younger generation of politicians show promise. We must respect the memory of Jo Cox and all she stood for – bringing respect back to politicians for the hard work they do, rather than corrosive cynicism.
3. Which takes us straight into press regulation. While the BBC has to be scrupulously ‘balanced’ (giving equal time to both sides, even when one presents evidence and the other just sound-bites), our written press has no such restraints and pursues its ideological and personal agendas to the detriment of public understanding and debate. The false figures on how much Britain pays to the EU continued to be peddled through the campaign even after thoroughly disproved. No longer should papers be able to tell lies which sell. That way lies Trump.
4. Within Britain, we have to clean up our constitutional house. Our constitution is in a mess (no one understands it, it is semi-reformed, and devolution has thrown up more challenges as yet unsolved). The English regions are disempowered by our over-centralised government (having none of the status of the devolved nations), with almost no local powers. Our electoral system means most votes count for nothing. A lot of the anger which was redirected to the bogeyman of ‘Brussels’ needs to hit closer to home! Just as Scots need to stop blaming ‘Westminster’ for all woes, so we too, in the rest of the country need to take responsibility and grow up.
5. Addressing inequality has to be at the heart of our efforts. This includes more investment in education and training, in regional development, in industrial policy, in social protection, in infrastructure, especially in the regions – no easy quick fixes but a long steady haul towards healing our divided nation.

Yes, the EU does need reform, which we can contribute to, if we stay in, but let’s clean up our own house above all else. Let’s honour the memory of a nation which grew out of immigrants – Britons, Romans, Angles, Saxons, Vikings, Normans, children of Empire – and which always looked outwards.

In or out in legal terms, no one can take away our identity. I remain a proud (but dismayed) Briton and a proud European.

What unites is us is more important than what divides us – let’s make that a reality in our UK politics, as much as in global health.