Lessons from The Centre for Health Systems Strengthening; Health Diplomacy

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Dr. Kim Ozano: Hello listeners

and welcome to the Connecting

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Citizens to Science podcast.

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I'm Dr.

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Kim Ozano and I am joined today by the

Centre for Health System Strengthening at

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the Liverpool School of Tropical Medicine.

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We have a brand new two part mini

series for you focused on health

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system strengthening, what it is,

how to do it, and what action is

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needed to ensure that the approach is

embedded in discussions at key global

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events and discussion platforms.

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This episode is the first of

two, and today's guests are Dr.

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Joanna Raven and Dr.

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Kerry Millington.

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Both have been working in global health

for over 20 years and are passionate about

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embedding both health system strengthening

approaches and community knowledge into

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political commitments and policy reforms.

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Our follow up episode, will hear

from communities about the mechanisms

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they are using to get their voices

heard and actioned in health

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system strengthening initiative.

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Well, we need to know what

this means more in reality.

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So I have a wonderful co host with me, Dr.

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Uzo Egere.

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Uzo, welcome to the podcast.

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Tell us a little bit about yourself and

then set us up a little bit about why is

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health system strengthening so important?

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Dr. Uzochukwu Egere: Hi, Kim.

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Thank you for having me,

and hello colleagues.

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Yeah, so I'm Uzo, and um, I'm

a pediatrician by training.

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In the past few years I've been involved

in research in public health, but

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more importantly in implementation

research around health systems

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and health systems strengthening

childhood tuberculosis and all that.

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I come from a setting where health

systems are really weak and fragile.

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Coming from that kind of setting,

you can understand my interest,

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um, in, in the topic today.

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We know the world is ravaged by so many

conditions, things like tuberculosis,

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things like malaria, we're still

struggling to deal with these diseases.

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And we know that there's no

way we can make a headway

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with weak, um, health systems.

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I'm glad that we've got Jo and Kerry

here today and, uh, they are the experts.

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So I would like to ask Jo, Jo,

can you tell us what exactly

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is health system strengthening?

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Dr. Joanna Raven: Okay, thanks, Uzo.

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I'm very happy to be here to talk

about this extremely important topic

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of health system strengthening.

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So let's think about what a

health system is to start with.

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So a health system is all the

organisations, peoples and actions

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whose primary sort of purpose is to

promote, restore or maintain health.

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And what do we really mean by that?

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It's, it's the people

who provide services.

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It's the communities who engage with those

services, the buildings that we provide

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services in, whether it's a small clinic

in northern Uganda or a large tertiary

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hospital in Nepal, or under a tree!

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It's the drugs and treatments and how

these are all organised and governed.

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And I think there's a real big need

to strengthen these health systems, to

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make them resilient, so that they can

deliver quality and equitable health

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care services at all times, including

when there are shocks such as COVID,

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Ebola, earthquakes, conflicts, but also

managing those long term stresses, such

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as economic pressures, so the health

system can adapt and respond, delivering

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services needed at that time, but ensuring

that routine services are maintained.

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Dr. Uzochukwu Egere: It's so interesting

to know that virtually, um, everything

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that we do affects health system.

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Dr. Kerry Millington: Building on what

Jo says is that really having a strong,

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resilient, sustainable, inclusive and

effective health system are critical for

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effective responses to ensure that people

have access to the quality care that

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they need it when and where they need it.

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I work in the field of tuberculosis

and health system strengthening is

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really a foundation block to support

an effective response to ending this

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TB pandemic, but we can also see that

the response to TB also contributes

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to strengthening the public health

functions to prevent, prepare and respond

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to new pandemics, new health threats,

like antimicrobial resistance, and

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the health impacts of climate change.

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So ensuring that these health systems

are resilient to what is coming.

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This was seen during COVID, for example,

when TB functions, such as infection

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prevention and control that were

already in place were then leveraged

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to strengthen the response to another

airborne pathogen, such as COVID 19.

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So you can see the interplay between

the diseases and the health system and

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how they can benefit each other and

how essential they are for each other.

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Dr. Kim Ozano: I think it's

really clear how important it

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is to strengthen health systems.

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I think the case is there.

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So, the Centre for Health Systems

Strengthening at the Liverpool School

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of Tropical Medicine, what does the

centre do and how can it influence

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political commitments and policy reforms?

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Dr. Joanna Raven: The Centre for Health

Systems Strengthening, or CHESS for short.

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It's a group of researchers, of programme

managers, of PhD students working at

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Liverpool School of Tropical Medicine,

coming together who have a common

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passion and goal for strengthening

health systems to promote better and

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improved health and well being amongst

the poorest and the most marginalised

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in low and middle income countries.

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And we're researchers, so we do research.

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That's what our strength is, and

we share learning and resources

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about health systems, and develop

and deliver leading edge health

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systems research with our partners

to have policy and practice impact.

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Also we've got a range of research

that looks more sort of at the,

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at the health system in general.

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So things about leadership

of the health system.

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How do we make sure that, um, the leaders

of the health system at all levels of

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the health system, so whether it's a

facility or at district level or at the

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national level, have got these approaches

to strengthening the health system that

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has that equity at the heart of it.

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Um, also a lot of work

on health workforce.

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Now that's an area I'm absolutely

and utterly passionate about.

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I'm a health worker by background.

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I was a midwife and a nurse for

many years and I've worked in lots

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of different settings with that.

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So I know what it's like to be sitting

in a health system, wanting desperately

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to provide good quality services and

really look after the people that are

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in my community and area, but know what

the, the health system challenges are.

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Dr. Kerry Millington: There is that kind

of real engagement with the community,

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the health care workers really want to

provide a quality service for people

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in their community to enable them to

access care when and where they need

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it, without fear of stigmatisation,

without fear of financial hardship.

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And what we do here in CHESS is to

ensure that when we are developing the

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research, we really are engaging with

those communities to fully understand

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the problems, the root causes of those

problems, and to work with them to

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co-develop the research that we're

doing and to ensure then that their

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research findings are then taken up

into the communities, so that our

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research has impact on the health

outcomes of those people's lives

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and their families and communities.

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Dr. Uzochukwu Egere: Thank you, Kerry.

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I would just say, when both of you

were talking that it's obvious that

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what you're doing is so important,

especially in the lower middle income

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countries where most of the need for

health system strengthening lies.

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And it'd be interesting to know

how you're engaging the policy

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pathway in some of those settings.

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Dr. Joanna Raven: Thanks, Uzo.

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I can give a really timely example, I've

just come back from Zimbabwe, uh, last,

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late last night, uh, where I've been

working with a group of people there.

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So, it's a research institute in

Zimbabwe, but also we've got a group of

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researchers from Nepal, so it's going

to be a cross country research programme

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that's looking at how to strengthen the

health workforce to be able to respond

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to the health impacts of climate crisis.

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So, uh, a really important topic,

and we're taking that sort of health

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workforce, health systems lens to that.

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And what also we did was we've been

bringing in policy makers and health

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workers to develop this research proposal.

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So at this workshop, we had the director

of medical services from the Ministry

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of Health in Zimbabwe at that workshop

to help us design that research, to make

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sure that it's relevant and feasible.

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That make sure that we're answering

the questions that they want to

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have answered so that our research

findings are going to be useful.

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They're going to be relevant.

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They're going to be timely for

that policymaker to pick up and use

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to develop his policies, develop

sort of practice, et cetera.

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He said, I remember listening to him and

he said, "I am desperate for evidence.

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I'm desperate for evidence to strengthen

our health system, to enable us to be able

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to cope with this, this, this challenge.

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I don't want to be at the end of the

research, receiving some findings, I want

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to be part of that research now today",

and he was really happy to be involved

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in developing that research programme.

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Dr. Kerry Millington: I think you

really draw out some key points there.

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Different stakeholders have to be

engaged right from the beginning to

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have those conversations to try and

understand and build up that evidence

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to inform policy and practice.

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Jo's talked about what the discussions

that have been having in a research

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programme at the national level, but

that's also scaled up to the highest

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level at the United Nations in New York.

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And this year, there are three

health meetings, called high level

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meetings, that are focusing on the

fight against tuberculosis, pandemic

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prevention, preparedness and response

and universal health coverage.

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And it's recognised at that level,

and what's tried to happen is they've

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tried to align across the political

declarations that will come out of those

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three meetings, because they recognise the

interdependency of all of these different

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approaches and applying a health system

strengthening lens to that thinking

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behind what goes into those political

commitments at the highest level.

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But what will happen is once we get

those political commitments, you then

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take them back down to your country

to say, within our context, how can

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we now apply these commitments that

have been made at the global level?

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What works for us?

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Perhaps what can we do in addition

to this within our settings?

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Does it apply across the country or

are we particularly focusing on key

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and vulnerable populations, which is

those that we really need to reach

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by strengthening the outreach of our

health system to those who most need it?

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We are research groups that

provide evidence about what works,

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and why, and in what settings.

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So all that sort of granular detail

is really important when it comes

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to country sort of perspectives,

isn't it, to understand what

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works and why in that particular

setting and how can we learn that.

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How can we take that learning and apply

it to different settings to make sure that

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does strengthen the health system in that

particular setting I think it's really

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important and it lends us, lends it to the

types of research that we do within CHESS.

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Dr. Kim Ozano: I think that's really

useful, both the examples and how

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the different levels of advocacy are

needed to make sure health system

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strengthening is embedded in decisions.

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Kerry, we have a lot of listeners who

work in global health and they will

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want to know how they can influence

high level meetings to make sure

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that health system strengthening cuts

across all the different programmes.

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We see a lot of programmes working

in silos and a lot of funding streams

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working that way, but the Centre

for Health System Strengthening, it

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seems like there's a real advocacy

to have a health system strengthening

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approach that cuts across these.

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Have you got any suggestions?

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Dr. Kerry Millington: I think global

health diplomacy is a new field and

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how to operate in that field is new to

academics and healthcare professionals.

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And the experience that I've had

by getting involved this year with

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particularly the high level meeting

on tuberculosis, the area I work in,

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is kind of, coming together within

your own community to go through it

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together, make connections, share

intel, learn how the United Nations

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works and how you can put a suggestion

forward on an intervention in your three

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minute slot that you're kind of given.

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I think really working together,

um, is key to understanding health

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diplomacy and how you can be of use

to ensure that you are informing the

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process with the evidence that you've

generated within your own research.

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It then gets taken into

context of diplomacy.

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So there are a lot of other things that

play also, um, but I think to be able to

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be at the table with affected communities

and their advocates is a really strong and

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powerful force, and enables so much more

than just attending a meeting, but enables

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those connections to then continue.

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Dr. Uzochukwu Egere: I think it's

amazing that those of us who are

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researchers are beginning to now

get seriously involved in advocacy.

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It was heartbreaking for me, say 20

years ago, practicing in Nigeria

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and in the Gambia, and you see that

there are interventions that have been

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working in the developed countries for

decades and they haven't yet begun to

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be implemented in the settings that,

you know, don't have those resources,

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where health systems are weak.

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One of the big problems was the gap

between scientists who do the research

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and those who do the implementation,

those who run the systems, the health

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workers, the people in government.

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So it's really good to see

these efforts coming together.

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Co-creating, we are co-creating

interventions, co-creating designs of,

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um, interventions with the people who are

directly involved in it and representing

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them at the highest levels so that we

bridge that gap and ensure that it doesn't

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take forever for interventions to begin

to benefit the people that need it.

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Dr. Kim Ozano: So Jo, it sounds like

process is really important here, and

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sharing process across different contexts.

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Dr. Joanna Raven: Obviously context

is particularly important, but there

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are sort of higher level learnings.

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There's synthesising sort of

learning from different research

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programmes about the sort of things

to strengthen the health system.

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So, you can take the examples from

the different research, but then pull

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that together and say, actually, this

is what would work and this is why it

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will work, and this is in what settings

it would particularly work well.

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We do a lot of work on community health

workers and how to support and manage that

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critical cadre that sort of really links

the communities to the health system.

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What can we do to support them?

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Many of these community health workers

are women, you know, they've got their

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family, their households to look after.

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So they're juggling

multiple, multiple things.

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So it's not only looking at it

from a health systems lens, but

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also from a gender and equity

lens in terms of the workforce.

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So we've got lots of learning that we've

shared with in our website and through

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the individual programmes as well.

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Dr. Kerry Millington: I work on the

LIGHT research programme, funded with

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UK AID, and what we're trying to do here

is think about gender equitable access

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to TB care and prevention recognising

that you need to think through what

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are the challenges different genders

have in accessing care they need.

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If we can get over those challenges

of why people aren't accessing the

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services they need and get that delivery

mechanism running well, that as new tools

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come through, or as we need to pivot

to responses, to challenges that are

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coming, be it pandemics, climate change,

health threats, such as antimicrobial

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resistance, we can ensure that we can

still deliver the service that we need

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to those people because they're able

to easily access that without the fear

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of stigmatisation, without fear that

they can't get there because the clinic

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isn't open or accessible or nearby.

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Dr. Kim Ozano: That's

really useful to hear.

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We've talked about integrated health

systems in our past episodes and it

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sounds like that does relate to that.

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Kerry, just sticking with you for a

moment, I know that you've worked quite

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a lot with advocates and experts by

experience, and we're going to be hearing

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from those people in our next episode

who are from the community and have

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quite key roles in high level meetings.

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Can you tell us a bit about how that works

in practice, how are they listened to?

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Is it, well, are their voices heard and

actioned on or do we need to do more?

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Dr. Kerry Millington: I think there's

a spectrum of when they're heard.

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I'm particularly proud of the TB field

that at the multi stakeholder hearings

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in May in New York at the UN, the

affected voice of TB survivors was

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given a primary slot at the opening

and closing of the stakeholder meeting.

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So we could really hear what they're

saying to us and making sure that

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we are kind of listening to that.

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I think we have to bear in mind

that this is within the wider

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context of global health diplomacy.

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So we are there to say our voice, we are

there to kind of offer our information

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that we have from the evidence or

experience that we have as a TB community.

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Um, but then it can get taken up

into the more wider diplomacy space.

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So, I think we have to realise all

of that, but we have to try, and when

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we think things aren't quite right,

we keep on going and saying, well,

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actually, have you really covered

this particular aspect, which we

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think community is really important.

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Um, so yeah, I, I think it's important

that their voices are not only

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heard within their own communities,

within their national communities,

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but also at the global level too.

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Dr. Joanna Raven: I was recently at the

Global Forum for the Health Workforce that

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was held in WHO in March, and one of the

absolutely amazing things that happened

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there was having health workers there.

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Health workers from all, all across

the globe were there; prime position

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talking about their experiences.

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This was in particularly following

COVID and the challenges and trauma

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that they experienced during that time.

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They had this song and dance that

they did, that they delivered.

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And it had everyone up on

their feet crying and crying.

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I mean, even like Dr.

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Tedros was like...

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It was obviously very,

very emotive and emotional.

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So, it was sending a very powerful

message to the, um, the forum

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and the decision makers about

supporting the health workforce.

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Dr. Uzochukwu Egere: Kerry, you

mentioned inter-country learning,

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which is also dear to my heart.

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And I think it's one beautiful

opportunity that we have with health

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system strengthening to leverage,

um, learnings from different

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countries to benefit each other.

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So I also wanted to find out, you

know, are there other ways in which

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you share learnings within CHESS?

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Whether it's within the research groups

or in countries that are involved.

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Dr. Joanna Raven: Well, we meet.

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We share resources, we share our

papers, we talk about different themes,

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and we develop research programmes

together, um, so that's where we're

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learning, that's where we're sharing

examples and producing that synthesised

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findings for people to take up.

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Also, within our smaller groups within

CHESS, we have fora for presenting our

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findings, like Health Systems Global,

for example, which is a research

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uh, symposia that has policy makers

and from across the world, but also

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global sort of level policy makers.

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We think about targeted communications

at the right time with the right

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people we know who to speak to.

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We know how they would like to receive

sort of information, and how to

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engage them in that research as well.

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We've got that depth of knowledge and

experience that we can make sure that

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our research doesn't just sit on a desk

or in a book or in a journal, it is

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actually impactful, maybe at different

levels, you know, maybe it's at health

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worker level or facility level or district

level or national level or global level,

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but it just doesn't sit in a paper.

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It's across everywhere.

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Dr. Kim Ozano: I think this

knowledge translation is really

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important to understand more.

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: 00:21:06

Kerry, the term global health

diplomacy, you said this is quite

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a new discipline, quite a new area.

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For our listeners, if they want to

understand a little bit more how to be

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involved in global health diplomacy,

where can they find out more?

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Where should they start?

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Dr. Kerry Millington: I think there,

um, has been a lot of discussion

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about, um, the boundaries between

where we can and can't influence.

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So, we are academics doing

research and healthcare workers

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with experience at the front line.

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So, we can inform policy and practice,

but we're not elected politicians.

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So, I think there has to be a careful

discussion at that interface about how

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we can inform, but we're not making the

decisions, but we need to be in a position

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to provide that information, as Jo alluded

to before, they want to be informed.

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They want to know what's going to

work for the benefit of why they're

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in their roles for their society, and

especially when resources are constrained.

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So, how can we think, you know, well, if

we strengthen the health system, this is

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actually going to benefit tuberculosis.

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It's going to benefit

universal health coverage.

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It's going to get us ready to

really be better prepared to

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respond to the pandemic of tomorrow.

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So, it's that, that wider context

thinking, and I think having those

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relationships, drawing on the different

stakeholder groups, when you need to

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be informed in that way and having

those trusted relationships enables

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that exchange of information both ways.

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And also thinking, as we're talking with

the policymakers, ensuring that we're

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asking the right questions in research

and that we're not going off on a tangent,

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but this is actually going to be relevant.

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And when is it going to be relevant?

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So having that exchange of knowledge.

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Dr. Kim Ozano: Perfect.

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Wonderful.

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Thank you very much.

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So Uzo, I have learned a lot

today, and I am sure you have too.

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What's your take home from

the conversation today?

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Dr. Uzochukwu Egere: I think for

me, health systems strengthening

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is everyone's business.

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We must continue to have that very strong,

healthy relationship between researchers,

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health workers, decision makers at

all levels, politicians, community if

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we are going to go anywhere towards

achieving the universal health coverage

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and improving the health of people.

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This is what comes up for

me very strongly today.

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Dr. Kim Ozano: I would agree.

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Jo, take home message from you, please.

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Dr. Joanna Raven: If we really want to

influence policy and practice at the

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global, national, district facility

level, then we need to understand who

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we're talking to, what do they want to

hear about and how they want to hear

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: 00:23:49

about it, and have the evidence ready

in that sort of package that people

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: 00:23:55

will say, wow, I want to listen to that

and I want to take forward with that.

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So that's, that's what we've got to do.

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Dr. Kim Ozano: Thank you very much.

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And Kerry, take us home

with your takeaway message.

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Dr. Kerry Millington: it's, it's

really kind of joining and engaging

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with the community in which you work

to understand different perspectives,

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understand different processes that are

going on, and how you can all inform

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: 00:24:20

each other and have a voice at the table

where every voice is, is important.

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And so being part of that community,

making those relationships, uh,

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trusted and credible relationships, um,

having the intel, because you can't be

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everywhere all of the time and trying to

understand how you can really ensure that

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evidence informs policy and practice.

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: 00:24:43

Dr. Kim Ozano: Thank you very much.

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: 00:24:44

I think that's really important to

talk about, trusted relationships and

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speaking of which, I think it's really,

really impressive that CHESS wanted not

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only your perspectives as researchers,

but to hear from the community as well.

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So to our listeners, please tune into

the next episode where we will hear the

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perspectives from communities who are

experts by experience, about how they

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think health system strengthening can

be embedded in high level meetings and

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advocacy globally, nationally, right

down to that health facility level.

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: 00:25:16

Thank you for listening.

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: 00:25:17

As always, do like, rate, share,

and subscribe so we can continue

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: 00:25:20

to bring you discussions like this.

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: 00:25:22

And until next time, bye for now.