Non-state and informal actors in fragile settings

Speaker: 00:00:04

Dr Kim Ozano: Hello listeners and

welcome to Connecting Citizens to

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Science, a podcast where we hear

about the ways that researchers

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connect with communities across the

world to solve challenges together.

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I'm Dr.

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Kim Ozano and today's episode is

the fourth in a six part miniseries

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by ReBUILD for Resilience.

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ReBUILD is a research consortium that

examines health systems resilience in

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fragile settings that experience violence,

conflict, pandemics, and other shocks.

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Today we will be hearing about the

complex world of non-state actors and

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informal providers in health systems.

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Our guests will discuss the legitimacy

of non-state actors and informal

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providers in fragile settings from

initial response to longer-term roles.

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Often we see humanitarian organisations

step in during disasters or conflicts,

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absorbing these initial shocks, but

they face challenges in transformation.

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In some settings, where local governments

are either absent or dysfunctional

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due to war, political instability or

a lack of capacity non-state actors

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often fill the void, but formalising

their roles remains challenging.

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To delve deeper into these critical

issues we have Dr Kyu Kyu Than, who is

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a public health specialist and a health

systems researcher with a speciality in

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sexual reproductive and maternal health.

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She is also a medical doctor with a

PhD from the University of Melbourne

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and is currently the research

director for the Myanmar country

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programme at the Burnett Institute.

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She has been leading and managing a

variety of research and service delivery

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projects for the Myanmar programme,

which includes ReBUILD for Resilience.

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We also have with us Ayesha

Idriss, who is a pharmacist and

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multidisciplinary researcher.

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Ayesha has worked on a range

of groundbreaking projects in

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collaboration with international

partners throughout her career.

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Ayesha has also contributed

significantly to the National

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Institute for Health Research Unit

on Health in situations of fragility

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and is a researcher with ReBUILD.

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And as always to help us guide the

conversation, we have a technical

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expert, Dr Karin Diaconu, who

has over 10 years' experience in

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health policy and systems research.

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Karen has worked across several contexts

effected by fragility where health systems

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rely on the help of civil society and

non -state actors or informal providers

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for the planning or delivery of care.

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Karen welcome to the podcast.

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Please do set us up by describing

what non-state and informal actors

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are, and why is it important to

consider them in fragile settings.

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Dr Karin Diaconu: Thank

you very much, Kim.

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In many settings, it is not just the

formal health system that provides health

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services or support to populations.

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In many places and particularly

in emergencies we see a large

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international NGO presence that

comes in to support populations.

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But also, local groups, civil society

groups, or informal providers who have

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been there in the countries for a long

time, they also step in to support

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health of people and communities.

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So, Kyu Kyu and Ayesha, it would be great

to hear what's the current situation in

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your countries and where do you actually

see any informal or non-state providers.

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Dr Kyu Kyu Than: Hello everyone and

I'm from Myanmar, a beautiful country

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in Southeast Asia, but currently in a

fragile and conflict state at the moment.

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We were faced by the COVID pandemic,

and then after the COVID pandemic,

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there was a change of political

situation, which created more fragility

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and conflict into the country.

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So, I think, within this fragility

and conflict settings, we see a lot

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of non-state actors, we see a lot

of donors, international NGOs, civil

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society organisations, and also, we must

not forget the people like community

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health workers, and also some of the

people working on ground as volunteers.

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Ayesha Idriss: I'm Ayesha, I'm

from Sierra Leone, which is a West

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African country, and Sierra Leone

faces significant health challenges.

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Our health system is marked

by history of underfunding

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and infrastructural weaknesses.

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We also have a lot of non-state actors

like the international organisations,

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and also there are community based

organisations, civil societies and the

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informal providers that provide services,

especially in the remote areas, where

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these health facilities are lacking.

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And we have traditional healers,

faith-based healers as well, and they

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come in, and because of the trust people

have in them, they really help the health

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system during times of crisis and shock.

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Dr Karin Diaconu: Could you talk a little

bit more about that and what you've

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seen in practice, what they're actually

doing and how they're supporting people?

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Ayesha Idriss: So, because of the trust

that communities have, especially in

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informal providers, like traditional

healers within the communities, um,

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the health system was able to utilise

them in containing the disease in

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terms of messaging, in terms of things

that they should do with the Ebola.

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So, we're trying to respond to the Ebola

as a health system, but we're really

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going nowhere, until they were brought

in, because the idea of the Ebola was in

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terms of contact through the dead fluid.

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And we have our culture, for

example, we have to wash the

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dead, you know, prior to burial.

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And that was still going on.

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So until they brought in these

informal providers, they actually

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helped in sensitising, the

communities and the people.

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So there was a massive

change and turnaround in terms

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the spread of the disease.

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So, they do play a critical role, they're

very critical because they're close

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to the communities, they trust them.

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And most of the time bringing them

on, and sometimes even in campaigns...

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in what we're doing now with the

ReBUILD that we're working at community

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levels, you know, they've reported

that during campaign like immunisation

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campaigns, stakeholders and all

these other community members, you

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know, coming in really had helped.

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Dr Kyu Kyu Than: Yeah, I like to echo

Ayesha's point on trust between the

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community and the non-state actors.

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For Myanmar during the COVID pandemic,

the trust between the community and the

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non-state actors were really cohesive.

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We can see it in the first wave of

COVID-19, the first and second wave,

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the country was in a real good

state, everyone coming in together.

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When we look at non-state actors, even

the private sector, which normally

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looks to profit, they even came in

Covid and really got hand in hand and

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helping like getting beds, trying to

move to quarantine centres and trying

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to help a lot of the COVID cases get

their clinical care in their settings.

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And the second thing I think is

coordination between non-state actors

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themselves, the INGOs, the CBOs and

the community is also very important.

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The coordination was really perfect

and, uh, understanding the context,

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it's also another important point

that I see, especially during COVID-19

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and even in the political crisis.

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Understanding the country context,

and what is really happening on the

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ground, and trying to leverage some of

the rules and regulation that they had

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from international agencies and some of

the donors were really amazing, really

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tackling and reaching to the community.

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Dr Kim Ozano: Thank you very much.

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it's really interesting to see

these non-state and informal actors

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coming in, and you've really painted

a picture of their role during the

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emergency situation and straight after.

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I wonder if you could tell me a

little bit more about how to ensure

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the safety and the security of these

very important actors during crisis.

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Dr Kyu Kyu Than: I think, especially for

health care workers from all non-state

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actors, and even for state actors, I

think security is the utmost importance.

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We really have to weigh between the

security and provision of health services.

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For example, although you may want to

be giving some of the drugs or some

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of the emergency commodities into

a very conflict affected place, we

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really have to maintain the security

aspect as the first entity, not to

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harm our healthcare workers, also

at the same time ensuring that the

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support is given to the community.

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So, I think there were a lot of strategies

and harm mitigation measures from a lot

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of non-state actors during the crisis.

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And we collectively normally share

the mitigation strategies and

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what is happening on the ground.

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Like in this area, you should not go,

there is fighting happening in this area.

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That means that really understanding

and trying to get a trust in each

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other about each other, that's

really important in crisis.

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Dr Karin Diaconu: Thank you, Kyu Kyu.

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I'm interested about something that we

were discussing earlier, particularly

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Ayesha, I think you brought this out quite

nicely, that the formal health system

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had to reach out to informal providers.

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Could you just reflect a little

bit more on what's happening on the

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ground and what the risks may be

if these two do not communicate, or

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coordinate as Kyu Kyu would put it?

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Ayesha Idriss: The informal providers

are embedded in their communities and

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there's this trust, so I believe the

formal sector should work closely with

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informal sector, you know, more in the

rural areas where, um, facilities are

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lacking, and these informal providers

are often the first point of contact for

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a lot of the population in these areas.

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So, they play that critical role.

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However, it depends on the type of

informal providers because we have

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some like the drug peddlers or sellers,

which come with more risk in terms

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of the services they provide because

they're more financially driven.

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However, I believe there's a way in which

the formal system should try to tap into

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the benefits, you know, and utilise these

benefits of the informal sector providers

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because in doing so, no one kind of

will be left behind because in terms of

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provision of services, even referrals

and other things, they could, you know,

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help with that so that services will be

provided in these underserved populations.

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Dr Karin Diaconu: I think both you and

Kyu Kyu have reflected a lot on what these

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non-state actors bring to the table, and

what the informal providers bring in terms

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of assuring trust and rapid responses.

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I'm wondering if you had any examples

of when you've encountered constraints

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or challenges in relation to the

work that these non-state actors or

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informal providers may bring to, for

example, securing health of people.

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Dr Kyu Kyu Than: Currently, in our country

context, there is a lot of conflict and

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active fighting in different parts of the

country, especially around border areas.

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So, I think, we can say forced

migration into another country,

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which is quite close to the border.

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So, when active conflict happens and

forced migration happens, as you all

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know, there are a lot of diversity,

legal boundaries, challenges

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towards one country and another.

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So, when we say emergency teams are

in border areas, I think some of the

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rules and regulation between these

countries need to be really flexible

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and understanding on the ground to reach

to the people who are really in need.

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At the moment, for a country, non-state

actors for example, you must sign a

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transportation safety protocol, but

when you go there, that safety protocol

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is not, uh, really, uh, abided by.

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You have to change your route of planning

or whatever, because that emergency.

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So, sometimes those have to be understood

by the non-state actors as well, So,

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these are some of the small issues

that we do face on ground, and I think

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it's really important that both the

donors, non-state actors, and even the

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government of like conflict-affected

countries and non-affected countries

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should be really tackling it together

because we do need the togetherness

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in these crisis emergencies.

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Ayesha Idriss: I agree with Kyu

Kyu, you know that there should

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be way that they should work,

you know, with the government.

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And during that time, you know when

there's disaster, they provide their

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service in terms of the food, medication,

you know, other things that they provide.

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Which during, um, the disaster or

emergency, these parallel systems that

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are running are good at that time.

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However, when the situation is kind

of over and in a stable state, it's

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kind of a little bit messy, you

know, how to navigate during this

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stable time is sometimes difficult.

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If the government agencies really try

and put things in, in place, work with

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them closely, I believe the overall

health system will be improved, but

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these are some of the challenges.

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Dr Karin Diaconu: That's a great

reflection on how situations change

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and I guess it's also been a focus

for us in ReBUILD to really reflect

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on how does this changing situation

actually help strengthen the formal

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system, if you like, because they're

doing a great service in the meantime,

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but we should also take some of the

lessons further to the formal system.

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Dr Kim Ozano: I really enjoyed

learning about this and, you know,

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those challenges have been very clear,

so thank you for those descriptions.

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I'm wondering if all three of you, based

on your experience and in your context and

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in your research, what advice would you

give to actors in fragile settings, formal

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and informal, to improve health systems?

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Ayesha Idriss: For me, the advice I'll

give is um, we should not underestimate

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trust, so, try to build trust.

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You know, trust is key in gaining

insights and knowledge, again, with

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minimum potential social bias that

you may have from these providers,

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especially with the informal providers.

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So, some of the time when you work with

them, they're sometimes a little bit

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secretive, but try to build trust and that

rapport, rapport with them is very key.

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Also, working with them, I'll say, try

to be open-minded and try to seek ways

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which the benefits of the work that

they do could be maximised, you know,

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with minimum risk that they provide.

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And also, when working with non-state

actors or informal providers that

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work at local level, try to see how

community ownership could be brought on

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with your work because then when they

leave, you want that sustainability,

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that's how you improve the communities.

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Dr Kim Ozano: Thank you, really

highlighting the importance

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of trust, assessing risk, and

developing that community ownership.

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Thank you very much.

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Kyu Kyu, please.

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Dr Kyu Kyu Than: I think, with the

lessons learned throughout these 3

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years, working with non-state actors is

sometimes when the formal system fails,

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uh, non-state actors must be coherent

and also have trust between each other.

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Not only the trust with the community,

but non-state actors themselves, the

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international community, the CBOs,

the donors must also build trust

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within them and try to create a

coordination body that would help the

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country when the real states fails.

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That doesn't mean that this parallel

coordination mechanism has to be

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lifelong, because as the crisis ease

out, this coordination mechanism may

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help other countries to learn how

these non-state actors coordinate

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and build trust among them, and how

the donors, uh, did some mitigation

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strategies and some of the activities.

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It's like a learning curve

for crisis countries later on.

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So first it's non-state actors,

between themselves, they must

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have trust and coordination.

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And the second thing is, I think we must

not forget, like Ayesha said, that the

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ground people who are on the ground and

who are really facing the difficulties.

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So, this may be seen from the outside

world and people who are inside the

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country may see it very differently.

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So, I think, sometimes the outside

world and the inside country

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and what's really happening on

ground need to merge somewhere.

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So, there must be some information

sharing and real insight sharing,

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uh, of communication mechanism so

that people will really understand.

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Dr Kim Ozano: Thank you for that example.

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It's, it's really complex and

important that we share that

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information and learn from it.

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Thank you.

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Karen, would you like to take us

home with one last piece of advice?

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Dr Karin Diaconu: I think my advice

would actually build on both Kyu Kyu's

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and Ayesha's and really just bring

home the idea that you have to think

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long-term and really privilege different

ways of knowing and of coordinating.

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And I think oftentimes we stay at global

levels and we talk about big INGOs and

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how we bring them in in emergency, but

actually it's also about smaller actors

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and people on the ground, like all of you

have been saying, who need to be there

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and who need to be brought in to the

learning, the planning, the responding,

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and they have different ways of doing

things, different ways of knowing,

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different capabilities, and maybe we

should acknowledge that we have to build

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on that instead of setting it to the side.

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Dr Kim Ozano: Thank you very much.

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And that brings us to

close of the episode.

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I've certainly learned a lot.

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Thank you to our guests and thank

you to our wonderful co-host.

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For our listeners,

thank you for listening.

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We hope you enjoyed the episode.

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This is the fourth in a six-part

miniseries brought to you by ReBUILD.

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So, if you haven't heard the other

episodes, please do revisit them

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for a more holistic view of health

systems in fragile settings.

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Until next time, thank you and goodbye.