Episode 66

The Health Workforce in Times of Crisis

In this episode, we discuss the challenges faced by the health workforce in fragile settings such as conflict zones and areas hit by political and economic crises. Our guests share their first-hand experiences and insights on how health systems and workers strive to provide care under extreme conditions. This episode is part of the six-part mini-series "Stories of Resilience: Local Lives and Health Systems," brought to you by ReBUILD for Resilience (see 'useful links' for links to the other episodes from this series).

During this episode, there are repeated references to war and conflict with first-hand experiences of illness and trauma which you may find distressing.

Chapters

00:00 Welcome to Connecting Citizens to Science

00:42 Introduction to the Health Workforce in Fragile Settings

01:20 Insights from Dr. Nasher Al-Aghbari in Yemen

01:46 Global Challenges with Dr. Jim Campbell

02:32 Welcoming Remarks by Dr. Kim Ozano

02:53 Dr. Wesam Mansour on Health Workers in Gaza

04:08 Dr. Nasher’s Experiences in Yemen

07:39 The Role of WHO with Dr. Jim Campbell

10:53 System vs. Individual Resilience

12:46 International Support and Building Resilience

15:18 Emergency Response vs. Long-Term Efforts

17:21 Health Worker Migration Issues

21:55 Key Advice for Strengthening Resilience

24:48 Concluding Remarks and Call to Action

In this episode:

Dr Wesam Mansour, Post-Doctoral Research Associate, Liverpool School of Tropical Medicine, UK.

Wesam is a physician, a Paediatric and Neonatology Specialist and a Fellow at the International Society for Quality in Healthcare (ISQua), with a Ph.D. in Health Policy and Management. At Liverpool School of Tropical Medicine, Wesam is a research associate at the Department of International Public Health. For the ReBUILD programme, she coordinates the work with ReBUILD’s country partners, particularly those in Lebanon.

Dr Nasher Al-Aghbari - Head of Paediatric Department, Al-Thawra General Modern Teaching Hospital, Sana'a, Yemen.

Nasher Al-Aghbari is a paediatric consultant in the Paediatric Department at Al-Thawra General Teaching Modern Hospital in Sana’a, Yemen. He is the Head of the Paediatric Emergency Department. He is also a member of the Teaching Panel in the Arab Board Membership. He has undertaken research for the past 15 years. As part of his Masters degree and PhD at LSTM, Dr. Al-Aghbari worked on blood diseases in children in Africa and Yemen and pulmonary childhood tuberculosis in Yemen.

Mr Jim Campbell - Director of the Health Workforce Department, World Health Organization, Geneva.

Jim Campbell is the Director of the Health Workforce Department at the World Health Organisation. He oversees the development and implementation of global public goods, evidence and tools to inform investments in the education, employment and retention of the health and care workforce in pursuit of global health security, universal health coverage and the Sustainable Development Goals.

Useful links:

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Transcript
Speaker:

Dr Kim Ozano: Hello listeners and welcome

to Connecting Citizens to Science.

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I'm Dr.

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Kim Ozano, and this is a podcast where

we discuss the ways that researchers

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connect with communities across the

world to solve challenges together.

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Today's episode is the third of

a six part mini series brought

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to you 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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And the focus of today's episode

is the health workforce in fragile

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settings, including those that have

been affected by conflict, disease,

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outbreaks, political and economic crisis.

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Today we hear from Dr.

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Nasher Al-Aghbari, who is a pediatrician

providing healthcare and war-torn

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Yemen at the Al-Thawra General

Modern Teaching Hospital in Sana'a.

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Dr.

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Nasher shares firsthand experiences of the

challenges faced by the health workforce.

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As they struggled to deliver health care

with limited resources, minimal to no

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salary, inadequate equipment and medicines

necessary to save lives, and all while

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attacks are occurring on the doorsteps

of health facilities and hospitals.

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The prolonged conflict has taken a

devastating toll on the physical,

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psychological, and professional

wellbeing of the health workforce.

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We are also joined by Dr.

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Jim Campbell, the Director of the

Health Workforce Department at

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the World Health Organization.

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Dr.

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Jim Campbell reflects on the similar

experiences being shared from across 40

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countries who are also facing emergencies.

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Jim states that public health is under

threat worldwide and speaks about the role

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of international organisations in building

resilient health systems to adequately

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support the health workforce who are

working in these very difficult contexts.

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To help us understand more about

the workforce in fragile settings.

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We have our co-host Dr.

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Wesam Mansour from the Liverpool

School of Tropical Medicine.

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Through Wesam's work with ReBUILD.

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She is being focusing on understanding

the contribution of the health

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workforce to health systems resilience.

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Their role during the crisis time,

including their capacities and coping

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strategies, they use to be able to

respond to the population's needs.

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And the support needed both during and

post crisis, which is currently lacking.

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There are parts of this episode

that are graphic and some

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listeners may find distressing.

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Hello everyone.

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And a warm welcome to the podcast.

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We're very pleased to have you all

here for this important conversation.

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Dr.

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Nasher Al-Aghbari and Dr.

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Jim Campbell, we're very much looking

forward to your insights, but before we

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begin, let's hear from our co-host, Dr.

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Wesam Mansour.

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Wesam, welcome to the podcast.

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Perhaps you could set us up a little bit

by highlighting some of the key things we

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need to be thinking about when considering

the health workforce in fragile contexts.

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Dr Wesam Mansour: Thank you for the

introduction, Kim, and welcome to

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our broadcast today, Nasher and Jim.

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Let me start by clarifying that

I'm a medical doctor by background,

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and I can understand well how it

could be for health workers to

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work on the frontline in fragile

context or in low resource settings.

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I know about the challenges that

health workers can face, the

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stressors they are prone to.

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But when we speak about the armed

conflict situation, this is, of

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course, another level of stress.

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Unfortunately, for a few months

now, I'm hearing from my colleagues

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in Gaza about what they face.

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I hear about the daily struggles

of providing care under fire, where

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health facilities are under attack.

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And they see their friends,

family members, children, dying

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every day in front of them.

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I hear from them about how they feel.

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They feel low sense of self efficacy,

vulnerability, helplessness,

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and inadequacy because they

cannot help their patient.

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And of course, they cannot

provide the health services

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that their populations need.

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But at the end of the day, I

can see how they can still show

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incredible resilience and dedication.

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Nasher, I know you can relate to this

situation as a medical doctor in Yemen.

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And today I want you to share with us

your own experience and the experiences

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of your colleagues during the

protracted conflict situation in Yemen.

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Dr Nasher Al-Aghbari: Thank you Wesam.

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As you know, Yemen is a very poor, uh,

country the health system in Yemen before

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war the health system is very fragile.

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Now during this war, the health

worker is facing many problems,

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like financial problem, economic

problem, also psychiatric problem.

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They are suffering for everything.

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They cannot come to our hospital

working because they have no transport.

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The road is broken, bombing all time

morning, afternoon, evening, so they

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are not coming all day to the hospital.

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Our health worker, they didn't give

them salary since nine year or 10

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years, they didn't give them any money.

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They are working no salary.

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So, some relative not allow the health

worker to go to the hospitals because

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they are no secure, because they

are bombing in front of the hospital.

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Also, there is some

physical trauma for him.

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From the glasses broken in the

hospital, they are wounded.

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Also, they are crying all the time.

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They are afraid from bombing

because the bombing is very loud.

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You cannot imagine what is this.

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This is very difficult working in the

hospital because they are bombing the

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street, just the street near the hospital.

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I see many patient.

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I remember one woman to

come to the hospital.

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She can't pay for the drugs, and

this child two months old only.

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She came to me to told

me 'I will go home'.

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I thought why you are going to home

because your child is very sick?

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He had renal failure.

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He cannot pass urine at all.

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I told 'Why you are going to

home because this child will

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die?' She told me 'Let him die'.

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Very easy.

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I told 'No, but this is very difficult.

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He will die in the street'.

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She told me, 'No problem.

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Let him die.

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Let him die.'

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Uh, one woman, she came to our hospital

with her child with convulsions.

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You know, we have no drugs.

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We have no canula for this

child to stop the convulsions.

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We send the mother outside to buy canula

and buy drugs to stop the convulsions.

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When she come back, the child already

expired and she just collapsed.

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She is crying all the day.

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She is shouting for the doctors, for

the nurse, for the health worker,

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shouting, but this is not our mistake.

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This is mistake due to the war.

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We haven't nothing at all.

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And also the health sister, uh, she starts

working with me and she start crying.

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She is crying, crying all day.

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And then she didn't come to the hospital.

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I asked her, 'Why you not come?'.

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She told me 'I can't because

I am crying all the day'.

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She's crying all the day.

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She cannot facing this problem.

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She told me I cannot see the

patient die in front of me.

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This is just some situation in Yemen.

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Dr Wesam Mansour: It's really a

devastating situation and I cannot

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imagine how health workers face that

constant danger, all different forms

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of violence and how that affects their

mental health, making it of course more

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difficult for them to continue providing

the health care and the requirements they

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need to fulfill for their population.

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But Jim, in such situation, what

are the role of international

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organisations like the W.H.O.

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In supporting the resilience of these

health workforce in Yemen and in other

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fragile and conflict affected settings?

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Dr Jim Campbell: So, thank you, Dr.

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Wesam and Dr.

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Nasher.

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As-salamu alaykum to you both.

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Just to, to express solidarity

with the work of Dr.

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Nasher and all his colleagues in

Yemen and the lived realities, the

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lived experience that we just heard.

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The challenges of that day to

day work environment, conflict,

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uh, resource constraints.

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Um, populations with their anxieties,

with their illnesses, the mental health

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stress, the impact that is coming into

this, and whilst Yemen is the topic

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here now, it's one of just many, many

examples around the world that W.H.O.

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Is contending with.

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So, Dr.

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Wesam, you mentioned in your introduction,

across the Middle East, in Gaza,

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some of the stories that we're, we're

seeing through our networks, through

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our engagement, but also in the media.

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Heartbreaking to see these live realities.

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So, if we look around the world

today, over 40 emergencies, the W.H.O.

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Is responding to in terms of the

conflict related events; in Gaza, in

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Ukraine, in Sudan, in the Sahel, in

Afghanistan, Iraq and many others.

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But also then the infectious disease

outbreaks, the cholera, um, multi-country

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outbreaks of cholera that we're

seeing with all the climate related

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disasters and the impact of that.

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Impacting our lived environments,

the environments where our

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populations are engaged.

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So, this is a true reality for W.H.O.

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on a multiple, multiple scale and what Dr.

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Nasher was sharing with us there, we're

hearing similar testimony from each

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and every one of these environments.

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Public health is under threat worldwide.

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When it comes then to, Wesam, the

whole issue of resilience, which I

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know is part of the ReBUILD work, then

we've got to start to look at what

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are we actually interested in here?

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Are we interested in the resilience

of the health system to respond

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to the emergency, to the conflict,

to the humanitarian disaster?

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Or are we looking at the resilience

of the individual to operate in

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a substandard system to respond

to the needs of the population?

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And those two questions

are very different.

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It's not necessarily the

system is unable to respond.

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Every worker in that system has

got this pressure upon them.

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I think, Nasher, you gave the story of

the mother and the young infant, and just

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the lack of equipment, lack of supplies.

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It wasn't the worker's fault.

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So is it the system that should be

resilient, or is it the worker that should

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be resilient in a dysfunctioning system?

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And we need to tease

out these differences.

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The W.H.O.

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perspective is we fix the broken system.

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We don't fix resilience

of an individual worker.

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Dr Wesam Mansour: Do you think

we can separate the resilience

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of the health system from the

resilience of the workforce?

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Dr Jim Campbell: I think

we can, Wesam, yes.

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And I think we must, I think, I

think there's a moral obligation upon

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stakeholders not to burden workers

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with the expectation that their resilience

or lack of resilience is the factor.

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I'll give you a concrete example

that helps think this through.

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During the COVID pandemic, we

standardised, uh, W.H.O's approach

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to assess the impact on health

and care workers worldwide.

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We looked across the different domains

of their physical health, their mental

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health, the infections, the morbidity,

the mortality, but we looked also

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at the role of employers, and the

role of government employers, the

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role of private employers, to create

environments which are productive,

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which remove stress from the worker,

which remove anxiety from the worker.

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Is the employer ensuring that these

workers are in situations where they

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are resourced, where they are enabled,

the equipment, the supply chain, uh, the

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remuneration is coming through, etc, etc.

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And we've got to look at those

obligations, that moral duty that exists.

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It is a duty of care to the

worker as well as to the

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population that the worker serves.

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And we need to disentangle these two.

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And Nasher's, Nasher's example that

he gave of those lived experiences

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in the hospital, in this conflict

scenario, where transferring the

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responsibility in the entire system

collapsed to an individual worker is,

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is not appropriate and it's not right.

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Dr Kim Ozano: Dr.

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Nasher, I understand you received some

support internationally how has that

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support, strengthened the resilience

of both the workforce and the system?

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Dr Nasher Al-Aghbari: Yeah, the support

from Liverpool School of Tropical Medicine

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and from Habibti Liverpool, they start

to give us a small amount of the money.

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Maybe £200 per month, and we

did small group to encourage

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the health worker to come.

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We give some money, we can buy

some medication for people.

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This amount is increased about £2, 000.

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Before that we have three

or four health worker.

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Now we have 40 health worker.

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They are working with us.

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This is because LSTM and have a

Habibti Liverpool, they help us.

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Also we buy some

medication for poor people.

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We can do some investigation for

them because everything in our

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hospital or other hospital, uh,

government hospital, they can buy

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for admission, for investigation,

for treatment, for everything.

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Uh, so sometimes we help patients

sometimes, we help health worker.

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Dr Jim Campbell: Is it acceptable that Dr.

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Nasher and his colleagues in Yemen,

that workers in Afghanistan, workers in

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Sudan should not receive remuneration

for years and years and years on end.

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Is that an acceptable proposition in the

21st century that, uh, the conflict allows

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us to continue to have that expectation?

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I would say no.

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Um, these are workers who are

owed an obligation, a duty of care

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that we should be insisting upon.

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And wonderful as it is that the Friends

of Liverpool are stepping in, and

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other friends of organisations step in

with charity, but we shouldn't expect

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health systems to be run on charity.

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And so there's a moral obligation.

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There's a solidarity obligation.

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There's a public health obligation,

to actually ensure resources are made

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available in these conflict scenarios

to ensure that we can get beyond that.

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Yes.

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As we saw during COVID, the capability

of humankind, the capability of health

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and care workers to step forward, to

volunteer, to be there, that's, that's the

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role that they take, that is wonderful and

should be continuously recognised, but we

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can't go beyond that short term emergency

phase and make it become the norm.

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Dr Wesam Mansour: Great.

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Thanks, Jim.

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And that brings me to a question;

what do you think about the tensions

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between the emergency responses

and the long term efforts to

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foster health workforce resilience?

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Dr Jim Campbell: So I think in every

environment there's always the balance

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of what are the key policy priorities

in front of us for the next 24 hours,

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the next seven days, the next 30 days?

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What is it we must deliver?

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And obviously we want to

ensure improvements in

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population health outcomes.

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We wanna be able to treat trauma, we

want to be able to treat mental health.

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The second element of it then

in parallel is to say, well,

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actually, what is the rebuild?

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What is the forward vision?

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What is the developmental phase of this?

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And when is that going to kick in?

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And when can we start to transition

to some of that thinking?

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Health workers around the world

today are exhausted, whether

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they're in conflict situations or

in their in normal environments.

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They're exhausted from

the pressures of COVID.

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They're exhausted from the

pressures of the working conditions.

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There are shortages in every

single country around the

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world, in some form or another.

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So how do we ensure the long term

resources are coming through accordingly?

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I would put the emphasis on the

system resilience, because we know

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if the system is stronger, the worker

is more efficient, more productive,

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more engaged, more motivated, which

gives us improvement in quality and

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improvement in patient outcomes.

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Dr Wesam Mansour: Thanks, Jim.

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Unfortunately, in such situation, we

find that most of these health workers

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leave the country and I know this is like

as a chronic problem in Yemen, right?

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For the protracted conflict situation

in Yemen for 10 years now, many of the

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health workers have left the country

looking for better opportunities, safer

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countries and places to stay and work.

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There should be a call for urgent

actions and intersectoral collaboration

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to find a way to support health

workers, to strengthen health systems

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resilience, and especially in this

context, we need strong actions.

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Dr Kim Ozano: Wesam, I think

that's really important important.

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Dr.

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Nasher, anything you would

like to share in response?

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Dr Nasher Al-Aghbari: I wish

the war is stopped, I wish this.

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Dr Kim Ozano: Of course.

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Dr Jim Campbell: Nasher, absolutely,

that’s that’s the fundamental and

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unless we tackle the root case issue

of these conflicts through national,

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regional, and global mechanisms...

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unless we look at the vested interest for

conflict, the interferences in conflict,

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and tackle those and call them out.

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We're never going to be able to

compensate for some of those issues.

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So, uh, W.H.O.

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Is preparing a new paper for publication

in November on attacks on healthcare.

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It's looking at the rise over the last

20 years and more in the last five years.

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increasing number incidents and the

prevalence of conflict on the attacks,

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the deliberate attacks, the clear,

motivation for warring parties, political

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leadership, different stakeholders to

deliberately attack health institutions,

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health facilities, ambulances, medical

and healthcare personnel to prevent

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them from serving the populations.

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This is becoming an

epidemic of its own right.

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And so we've got to come back.

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Nasher, your wish is shared by all of us.

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We must tackle the root causes of

conflict and make clear that attacks

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on health care is unacceptable.

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Dr Wesam Mansour: Could you elaborate more

on what is this paper is looking at and

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how it can help us move things forward?

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Dr Jim Campbell: Yes, you mentioned

in the Middle East in particular,

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has got the challenges that

we're seeing at record levels.

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So what is the reality?

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What is the incidence of

conflict that we're seeing?

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What's the incidence on the

numbers on attacks on health care?

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Are we reaching proportions?

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The questions become, why are we

starting to see this increase?

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Why are the international

humanitarian law, UN resolutions,

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why are they no longer having

the impact that was intended?

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Where is there a clear

breach of those provisions?

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And therefore, what are some of the

opportunities that we need to be,

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what, not the opportunity, but what

are the key points in the contemporary

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discussion, given that the sort

of empirical base of conflict.

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Where do we need to be looking?

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Do the instruments need

to be strengthened?

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Does accountability

need to be strengthened?

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Do we need to prosecute noncompliance?

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Do we need to hold people

to greater to account?

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Meanwhile, what can we do

through stakeholder engagement?

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What can we do through partnership?

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What's the role of the Gulf states.

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What's the role of the Middle East groups?

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The Arab League of Nations?

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What's the role of the African

Union in these debates?

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What's the political leadership role to

have peer mechanisms which hold people to

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account because it can't be sustainable.

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Uh, we can't accept

this as the new normal.

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Dr Wesam Mansour: Yeah, I agree.

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And I'm looking forward to reading

it because I personally, with the

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situation in the Middle East, I think

that will be a great piece of work and

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it will guide us as a researcher and

academics on how can we support health

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systems resilience and health workforce

resilience in such a fragile context.

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Dr Jim Campbell: Absolutely.

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And Wesam, it is very much in the

sharing, please help us to bring

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the evidence together on this where,

um, it's a partnership with the

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World Innovation Summit for Health.

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The paper and the debate will

continue at the forum in November.

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But more importantly, how do we then get

this evidence into practitioners hands

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into academics and into researchers

hands to really call for accountability.

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Dr Kim Ozano: I think that brings

us very succinctly to the end of the

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podcast, where we ask for the one

piece of advice that you would give

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to researchers and others trying to

strengthen the resilience of both the

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health workforce and the health system.

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Wesam, maybe you could start

with that piece of advice.

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Dr Wesam Mansour: I believe good

governance is critical, and this should

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include strong coordination mechanisms

between international organisations and

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NGOs, especially with the role they are

playing in supporting the humanitarian

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response during and post conflicts.

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And by Having strong coordination

mechanisms between these organisations

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and the national governments

in conflict affected settings.

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I think these can support health

systems resilience and health

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workforce resilience in these contexts.

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Dr Kim Ozano: Thanks, Wesam.

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I'm a real call for collaboration

and working together there.

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So thank you very much.

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Dr.

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Nasher, firstly, I want to say thank

you so much for joining the podcast

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and for giving your lived experiences,

that are clearly very traumatic.

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I also know how difficult it was to come

to Liverpool and be able to speak to us.

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So thank you for making

that very difficult journey.

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What's the piece of advice you

would like others to hear when

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supporting the health workforce?

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Dr Nasher Al-Aghbari: Yes.

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Uh, I wish the work of W.H.O.

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and other organisation not

to be lead by politics.

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This will facilitate the aid to us,

and I wish that there is transparency

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in the distribution of aid.

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Dr Kim Ozano: Thank you very much, Dr.

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Nasher.

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I think that's a very important piece

of advice that you have shared there.

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Jim, would you like to give a

piece of advice to others who are

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very passionate to support Dr.

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Nasher and his colleagues and

people around the world who are

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trying to deliver healthcare in

very, very difficult situations?

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Dr Jim Campbell: Yeah, Kim.

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I mean, I think advice is one thing,

but I would I would suggest that we

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also need to come back to evidence.

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What does the evidence tell

us that is critical here.

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And for the workers huge appreciation

for those workers in these these

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complex scenarios who continue to

provide services, but appreciation and

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applause is not the action that we need.

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The evidence tells us that we must

come back to looking at the duty of

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care to the health and care workforce,

largely women all around the world.

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Make sure that the environment in

which they serve is protected from

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attacks, it's protected from any

harassment, it's protected with

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decent occupational health and safety.

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To Nasher and his colleagues

working at the hospital there in

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the pediatric unit, they should be

able to go to work every single day

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knowing that they are empowered,

enabled, and supported in that work.

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And every one of us has an

obligation towards that duty of care.

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That's the evidence.

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That's the moral obligation.

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It's the empirical basis, and it's

the right thing to do, irrespective

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of the country, the health

system, the conflict that exists.

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Dr Kim Ozano: I think that's a great

place to end the podcast and a wonderful

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reflection to think about moving forward.

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So at this point, I would like to say,

thank you very much to our guests, Dr.

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Nasher Al-Aghbari and Dr.

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Jim Campbell for sharing your experiences

and extremely insightful reflections.

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Also, thank you to Dr.

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Wesam Mansour for co-hosting and

adding important considerations

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to this conversation.

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Listeners just as a reminder, this

episode is part of six part mini

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series, entitled Stories of Resilience:

Local Lives and Health Systems.

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So do have a listen to all of the episodes

as they provide a really excellent

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opportunity to learn more about health

systems in fragile contexts until

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next time, thank you for listening.

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About your host

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Kim Ozano

Research and Development Director at SCL and co-founder and host of the ‘Connecting Citizens to Science’ (CCS) podcast. Kim is a health policy and systems researcher with over 15 years’ experience of designing, delivering and evaluating health and development projects in the Global South and UK. She is an implementation health research specialist, as can be seen from her publications and work at the Liverpool School of Tropical Medicine, where she remains an Honorary lecturer.
Kim creates space in Connecting Citizens to Science for researchers and communities to share their experience of co-production to shape policy and lasting positive change.