Hello Listeners! In this episode we are joined by the Centre for Health Systems Strengthening at the Liverpool School of Tropical Medicine, also known as CHESS. In this first episode of a two-part mini-series focusing on health systems strengthening, we talk about health diplomacy and why it is needed.

We hear from Dr. Joanna Raven and Dr. Kerry Millington, who have both been working in global health for over 20 years and are passionate about embedding both health systems strengthening approaches and community knowledge into political commitments and policy reforms.

Bringing a perspective from the fields of maternal and child health, lung health and tuberculosis, Dr Uzochukwu Egere co-hosts this episode where we discuss health diplomacy as a new field for academics and healthcare professionals. One that is about making connections, sharing intel and learning how the United Nations and other High-Level Meetings work, so we can effectively share evidence quickly in often extremely short windows of opportunity, so policy makers can listen and act.

Dr Uzochukwu Egere - Senior Research Associate, Emergency Obstetric and Quality of Care Unit, Department of International Public Health (Liverpool School of Tropical Medicine)

Uzo is a paediatrician and public health researcher with extensive experience in multidisciplinary global health research. His research interest is in implementation research and health systems strengthening to tackle inequities in the fields of Maternal and Child health, Lung health and Tuberculosis. Uzo’s work focuses on health and health systems challenges relevant to low-and middle-income settings and facilitates interactions between researchers and consumers of research outputs (the community) to ensure timely policy change, uptake of interventions, and universal health coverage.

Dr Joanna Raven - Reader in health systems, Liverpool School of Tropical Medicine

Jo has worked in global health for more than 25 years, focusing on strengthening health systems. Jo is a researcher with a passion for co-designing and implementing health system research with local stakeholders including community members, health workers, health managers and decision makers. As a health worker herself, Jo’s work focuses on supporting the health workforce to deliver people-centred care that is of good quality and leaves no one behind.

Dr Kerry Millington – Research Uptake Manager, Liverpool School of Tropical Medicine

Kerry has been working in global health for over 20 years with a keen focus on ending the tuberculosis epidemic. A key part of her work is developing trusted relationships with range of stakeholders to work in partnership, in collaboration and in a coordinated way ensuring the academic and health professional voice credibly informs decisions that impact on health. This can range from co-creating research ideas to influencing policy and political commitments. A key stakeholder to engage with is the voice of TB survivors and advocates to accelerate action for those in most need of innovations in TB care and prevention to transform lives.

Research programme links:

ReBUILD for Resilience - Research on health systems in fragile contexts

PERFORM2scale – Scaling up PERFORM

ReDRESS - Strengthening people-centred health systems for people affected by severe stigmatising skin diseases in Liberia

LIGHT - Aims to support policy and practice in transforming gendered pathways to health for people with TB in urban settings

Want to hear more podcasts like this?

Follow Connecting Citizens to Science on your usual podcast platform or YouTube to hear more about the methods and approaches that researchers apply to connect with communities and co-produce solutions to global health challenges.

The podcast covers wide ranging topics such as NTD’s, NCD’s, antenatal and postnatal care, mental wellbeing and climate change, all linked to community engagement and power dynamics.   

If you would like your own project or programme to feature in an episode, get in touch with producers of Connecting Citizens to Science, the SCL Agency.  

Dr. Kim Ozano: Hello listeners

and welcome to the Connecting

2

Citizens to Science podcast.

3

I'm Dr.

4

Kim Ozano and I am joined today by the

Centre for Health System Strengthening at

5

the Liverpool School of Tropical Medicine.

6

We have a brand new two part mini

series for you focused on health

7

system strengthening, what it is,

how to do it, and what action is

8

needed to ensure that the approach is

embedded in discussions at key global

9

events and discussion platforms.

10

This episode is the first of

two, and today's guests are Dr.

11

Joanna Raven and Dr.

12

Kerry Millington.

13

Both have been working in global health

for over 20 years and are passionate about

14

embedding both health system strengthening

approaches and community knowledge into

15

political commitments and policy reforms.

16

Our follow up episode, will hear

from communities about the mechanisms

17

they are using to get their voices

heard and actioned in health

18

system strengthening initiative.

19

Well, we need to know what

this means more in reality.

20

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

21

Uzo Egere.

22

Uzo, welcome to the podcast.

23

Tell us a little bit about yourself and

then set us up a little bit about why is

24

health system strengthening so important?

25

Dr. Uzochukwu Egere: Hi, Kim.

26

Thank you for having me,

and hello colleagues.

27

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

a pediatrician by training.

28

In the past few years I've been involved

in research in public health, but

29

more importantly in implementation

research around health systems

30

and health systems strengthening

childhood tuberculosis and all that.

31

I come from a setting where health

systems are really weak and fragile.

32

Coming from that kind of setting,

you can understand my interest,

33

um, in, in the topic today.

34

We know the world is ravaged by so many

conditions, things like tuberculosis,

35

things like malaria, we're still

struggling to deal with these diseases.

36

And we know that there's no

way we can make a headway

37

with weak, um, health systems.

38

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

here today and, uh, they are the experts.

39

So I would like to ask Jo, Jo,

can you tell us what exactly

40

is health system strengthening?

41

Dr. Joanna Raven: Okay, thanks, Uzo.

42

I'm very happy to be here to talk

about this extremely important topic

43

of health system strengthening.

44

So let's think about what a

health system is to start with.

45

So a health system is all the

organisations, peoples and actions

46

whose primary sort of purpose is to

promote, restore or maintain health.

47

And what do we really mean by that?

48

It's, it's the people

who provide services.

49

It's the communities who engage with those

services, the buildings that we provide

50

services in, whether it's a small clinic

in northern Uganda or a large tertiary

51

hospital in Nepal, or under a tree!

52

It's the drugs and treatments and how

these are all organised and governed.

53

And I think there's a real big need

to strengthen these health systems, to

54

make them resilient, so that they can

deliver quality and equitable health

55

care services at all times, including

when there are shocks such as COVID,

56

Ebola, earthquakes, conflicts, but also

managing those long term stresses, such

57

as economic pressures, so the health

system can adapt and respond, delivering

58

services needed at that time, but ensuring

that routine services are maintained.

59

Dr. Uzochukwu Egere: It's so interesting

to know that virtually, um, everything

60

that we do affects health system.

61

Dr. Kerry Millington: Building on what

Jo says is that really having a strong,

62

resilient, sustainable, inclusive and

effective health system are critical for

63

effective responses to ensure that people

have access to the quality care that

64

they need it when and where they need it.

65

I work in the field of tuberculosis

and health system strengthening is

66

really a foundation block to support

an effective response to ending this

67

TB pandemic, but we can also see that

the response to TB also contributes

68

to strengthening the public health

functions to prevent, prepare and respond

69

to new pandemics, new health threats,

like antimicrobial resistance, and

70

the health impacts of climate change.

71

So ensuring that these health systems

are resilient to what is coming.

72

This was seen during COVID, for example,

when TB functions, such as infection

73

prevention and control that were

already in place were then leveraged

74

to strengthen the response to another

airborne pathogen, such as COVID 19.

75

So you can see the interplay between

the diseases and the health system and

76

how they can benefit each other and

how essential they are for each other.

77

Dr. Kim Ozano: I think it's

really clear how important it

78

is to strengthen health systems.

79

I think the case is there.

80

So, the Centre for Health Systems

Strengthening at the Liverpool School

81

of Tropical Medicine, what does the

centre do and how can it influence

82

political commitments and policy reforms?

83

Dr. Joanna Raven: The Centre for Health

Systems Strengthening, or CHESS for short.

84

It's a group of researchers, of programme

managers, of PhD students working at

85

Liverpool School of Tropical Medicine,

coming together who have a common

86

passion and goal for strengthening

health systems to promote better and

87

improved health and well being amongst

the poorest and the most marginalised

88

in low and middle income countries.

89

And we're researchers, so we do research.

90

That's what our strength is, and

we share learning and resources

91

about health systems, and develop

and deliver leading edge health

92

systems research with our partners

to have policy and practice impact.

93

Also we've got a range of research

that looks more sort of at the,

94

at the health system in general.

95

So things about leadership

of the health system.

96

How do we make sure that, um, the leaders

of the health system at all levels of

97

the health system, so whether it's a

facility or at district level or at the

98

national level, have got these approaches

to strengthening the health system that

99

has that equity at the heart of it.

100

Um, also a lot of work

on health workforce.

101

Now that's an area I'm absolutely

and utterly passionate about.

102

I'm a health worker by background.

103

I was a midwife and a nurse for

many years and I've worked in lots

104

of different settings with that.

105

So I know what it's like to be sitting

in a health system, wanting desperately

106

to provide good quality services and

really look after the people that are

107

in my community and area, but know what

the, the health system challenges are.

108

Dr. Kerry Millington: There is that kind

of real engagement with the community,

109

the health care workers really want to

provide a quality service for people

110

in their community to enable them to

access care when and where they need

111

it, without fear of stigmatisation,

without fear of financial hardship.

112

And what we do here in CHESS is to

ensure that when we are developing the

113

research, we really are engaging with

those communities to fully understand

114

the problems, the root causes of those

problems, and to work with them to

115

co-develop the research that we're

doing and to ensure then that their

116

research findings are then taken up

into the communities, so that our

117

research has impact on the health

outcomes of those people's lives

118

and their families and communities.

119

Dr. Uzochukwu Egere: Thank you, Kerry.

120

I would just say, when both of you

were talking that it's obvious that

121

what you're doing is so important,

especially in the lower middle income

122

countries where most of the need for

health system strengthening lies.

123

And it'd be interesting to know

how you're engaging the policy

124

pathway in some of those settings.

125

Dr. Joanna Raven: Thanks, Uzo.

126

I can give a really timely example, I've

just come back from Zimbabwe, uh, last,

127

late last night, uh, where I've been

working with a group of people there.

128

So, it's a research institute in

Zimbabwe, but also we've got a group of

129

researchers from Nepal, so it's going

to be a cross country research programme

130

that's looking at how to strengthen the

health workforce to be able to respond

131

to the health impacts of climate crisis.

132

So, uh, a really important topic,

and we're taking that sort of health

133

workforce, health systems lens to that.

134

And what also we did was we've been

bringing in policy makers and health

135

workers to develop this research proposal.

136

So at this workshop, we had the director

of medical services from the Ministry

137

of Health in Zimbabwe at that workshop

to help us design that research, to make

138

sure that it's relevant and feasible.

139

That make sure that we're answering

the questions that they want to

140

have answered so that our research

findings are going to be useful.

141

They're going to be relevant.

142

They're going to be timely for

that policymaker to pick up and use

143

to develop his policies, develop

sort of practice, et cetera.

144

He said, I remember listening to him and

he said, "I am desperate for evidence.

145

I'm desperate for evidence to strengthen

our health system, to enable us to be able

146

to cope with this, this, this challenge.

147

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

research, receiving some findings, I want

148

to be part of that research now today",

and he was really happy to be involved

149

in developing that research programme.

150

Dr. Kerry Millington: I think you

really draw out some key points there.

151

Different stakeholders have to be

engaged right from the beginning to

152

have those conversations to try and

understand and build up that evidence

153

to inform policy and practice.

154

Jo's talked about what the discussions

that have been having in a research

155

programme at the national level, but

that's also scaled up to the highest

156

level at the United Nations in New York.

157

And this year, there are three

health meetings, called high level

158

meetings, that are focusing on the

fight against tuberculosis, pandemic

159

prevention, preparedness and response

and universal health coverage.

160

And it's recognised at that level,

and what's tried to happen is they've

161

tried to align across the political

declarations that will come out of those

162

three meetings, because they recognise the

interdependency of all of these different

163

approaches and applying a health system

strengthening lens to that thinking

164

behind what goes into those political

commitments at the highest level.

165

But what will happen is once we get

those political commitments, you then

166

take them back down to your country

to say, within our context, how can

167

we now apply these commitments that

have been made at the global level?

168

What works for us?

169

Perhaps what can we do in addition

to this within our settings?

170

Does it apply across the country or

are we particularly focusing on key

171

and vulnerable populations, which is

those that we really need to reach

172

by strengthening the outreach of our

health system to those who most need it?

173

We are research groups that

provide evidence about what works,

174

and why, and in what settings.

175

So all that sort of granular detail

is really important when it comes

176

to country sort of perspectives,

isn't it, to understand what

177

works and why in that particular

setting and how can we learn that.

178

How can we take that learning and apply

it to different settings to make sure that

179

does strengthen the health system in that

particular setting I think it's really

180

important and it lends us, lends it to the

types of research that we do within CHESS.

181

Dr. Kim Ozano: I think that's really

useful, both the examples and how

182

the different levels of advocacy are

needed to make sure health system

183

strengthening is embedded in decisions.

184

Kerry, we have a lot of listeners who

work in global health and they will

185

want to know how they can influence

high level meetings to make sure

186

that health system strengthening cuts

across all the different programmes.

187

We see a lot of programmes working

in silos and a lot of funding streams

188

working that way, but the Centre

for Health System Strengthening, it

189

seems like there's a real advocacy

to have a health system strengthening

190

approach that cuts across these.

191

Have you got any suggestions?

192

Dr. Kerry Millington: I think global

health diplomacy is a new field and

193

how to operate in that field is new to

academics and healthcare professionals.

194

And the experience that I've had

by getting involved this year with

195

particularly the high level meeting

on tuberculosis, the area I work in,

196

is kind of, coming together within

your own community to go through it

197

together, make connections, share

intel, learn how the United Nations

198

works and how you can put a suggestion

forward on an intervention in your three

199

minute slot that you're kind of given.

200

I think really working together,

um, is key to understanding health

201

diplomacy and how you can be of use

to ensure that you are informing the

202

process with the evidence that you've

generated within your own research.

203

It then gets taken into

context of diplomacy.

204

So there are a lot of other things that

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

205

be at the table with affected communities

and their advocates is a really strong and

206

powerful force, and enables so much more

than just attending a meeting, but enables

207

those connections to then continue.

208

Dr. Uzochukwu Egere: I think it's

amazing that those of us who are

209

researchers are beginning to now

get seriously involved in advocacy.

210

It was heartbreaking for me, say 20

years ago, practicing in Nigeria

211

and in the Gambia, and you see that

there are interventions that have been

212

working in the developed countries for

decades and they haven't yet begun to

213

be implemented in the settings that,

you know, don't have those resources,

214

where health systems are weak.

215

One of the big problems was the gap

between scientists who do the research

216

and those who do the implementation,

those who run the systems, the health

217

workers, the people in government.

218

So it's really good to see

these efforts coming together.

219

Co-creating, we are co-creating

interventions, co-creating designs of,

220

um, interventions with the people who are

directly involved in it and representing

221

them at the highest levels so that we

bridge that gap and ensure that it doesn't

222

take forever for interventions to begin

to benefit the people that need it.

223

Dr. Kim Ozano: So Jo, it sounds like

process is really important here, and

224

sharing process across different contexts.

225

Dr. Joanna Raven: Obviously context

is particularly important, but there

226

are sort of higher level learnings.

227

There's synthesising sort of

learning from different research

228

programmes about the sort of things

to strengthen the health system.

229

So, you can take the examples from

the different research, but then pull

230

that together and say, actually, this

is what would work and this is why it

231

will work, and this is in what settings

it would particularly work well.

232

We do a lot of work on community health

workers and how to support and manage that

233

critical cadre that sort of really links

the communities to the health system.

234

What can we do to support them?

235

Many of these community health workers

are women, you know, they've got their

236

family, their households to look after.

237

So they're juggling

multiple, multiple things.

238

So it's not only looking at it

from a health systems lens, but

239

also from a gender and equity

lens in terms of the workforce.

240

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

shared with in our website and through

241

the individual programmes as well.

242

Dr. Kerry Millington: I work on the

LIGHT research programme, funded with

243

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

is think about gender equitable access

244

to TB care and prevention recognising

that you need to think through what

245

are the challenges different genders

have in accessing care they need.

246

If we can get over those challenges

of why people aren't accessing the

247

services they need and get that delivery

mechanism running well, that as new tools

248

come through, or as we need to pivot

to responses, to challenges that are

249

coming, be it pandemics, climate change,

health threats, such as antimicrobial

250

resistance, we can ensure that we can

still deliver the service that we need

251

to those people because they're able

to easily access that without the fear

252

of stigmatisation, without fear that

they can't get there because the clinic

253

isn't open or accessible or nearby.

254

Dr. Kim Ozano: That's

really useful to hear.

255

We've talked about integrated health

systems in our past episodes and it

256

sounds like that does relate to that.

257

Kerry, just sticking with you for a

moment, I know that you've worked quite

258

a lot with advocates and experts by

experience, and we're going to be hearing

259

from those people in our next episode

who are from the community and have

260

quite key roles in high level meetings.

261

Can you tell us a bit about how that works

in practice, how are they listened to?

262

Is it, well, are their voices heard and

actioned on or do we need to do more?

263

Dr. Kerry Millington: I think there's

a spectrum of when they're heard.

264

I'm particularly proud of the TB field

that at the multi stakeholder hearings

265

in May in New York at the UN, the

affected voice of TB survivors was

266

given a primary slot at the opening

and closing of the stakeholder meeting.

267

So we could really hear what they're

saying to us and making sure that

268

we are kind of listening to that.

269

I think we have to bear in mind

that this is within the wider

270

context of global health diplomacy.

271

So we are there to say our voice, we are

there to kind of offer our information

272

that we have from the evidence or

experience that we have as a TB community.

273

Um, but then it can get taken up

into the more wider diplomacy space.

274

So, I think we have to realise all

of that, but we have to try, and when

275

we think things aren't quite right,

we keep on going and saying, well,

276

actually, have you really covered

this particular aspect, which we

277

think community is really important.

278

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

that their voices are not only

279

heard within their own communities,

within their national communities,

280

but also at the global level too.

281

Dr. Joanna Raven: I was recently at the

Global Forum for the Health Workforce that

282

was held in WHO in March, and one of the

absolutely amazing things that happened

283

there was having health workers there.

284

Health workers from all, all across

the globe were there; prime position

285

talking about their experiences.

286

This was in particularly following

COVID and the challenges and trauma

287

that they experienced during that time.

288

They had this song and dance that

they did, that they delivered.

289

And it had everyone up on

their feet crying and crying.

290

I mean, even like Dr.

291

Tedros was like...

292

It was obviously very,

very emotive and emotional.

293

So, it was sending a very powerful

message to the, um, the forum

294

and the decision makers about

supporting the health workforce.

295

Dr. Uzochukwu Egere: Kerry, you

mentioned inter-country learning,

296

which is also dear to my heart.

297

And I think it's one beautiful

opportunity that we have with health

298

system strengthening to leverage,

um, learnings from different

299

countries to benefit each other.

300

So I also wanted to find out, you

know, are there other ways in which

301

you share learnings within CHESS?

302

Whether it's within the research groups

or in countries that are involved.

303

Dr. Joanna Raven: Well, we meet.

304

We share resources, we share our

papers, we talk about different themes,

305

and we develop research programmes

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

306

learning, that's where we're sharing

examples and producing that synthesised

307

findings for people to take up.

308

Also, within our smaller groups within

CHESS, we have fora for presenting our

309

findings, like Health Systems Global,

for example, which is a research

310

uh, symposia that has policy makers

and from across the world, but also

311

global sort of level policy makers.

312

We think about targeted communications

at the right time with the right

313

people we know who to speak to.

314

We know how they would like to receive

sort of information, and how to

315

engage them in that research as well.

316

We've got that depth of knowledge and

experience that we can make sure that

317

our research doesn't just sit on a desk

or in a book or in a journal, it is

318

actually impactful, maybe at different

levels, you know, maybe it's at health

319

worker level or facility level or district

level or national level or global level,

320

but it just doesn't sit in a paper.

321

It's across everywhere.

322

Dr. Kim Ozano: I think this

knowledge translation is really

323

important to understand more.

324

Kerry, the term global health

diplomacy, you said this is quite

325

a new discipline, quite a new area.

326

For our listeners, if they want to

understand a little bit more how to be

327

involved in global health diplomacy,

where can they find out more?

328

Where should they start?

329

Dr. Kerry Millington: I think there,

um, has been a lot of discussion

330

about, um, the boundaries between

where we can and can't influence.

331

So, we are academics doing

research and healthcare workers

332

with experience at the front line.

333

So, we can inform policy and practice,

but we're not elected politicians.

334

So, I think there has to be a careful

discussion at that interface about how

335

we can inform, but we're not making the

decisions, but we need to be in a position

336

to provide that information, as Jo alluded

to before, they want to be informed.

337

They want to know what's going to

work for the benefit of why they're

338

in their roles for their society, and

especially when resources are constrained.

339

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

we strengthen the health system, this is

340

actually going to benefit tuberculosis.

341

It's going to benefit

universal health coverage.

342

It's going to get us ready to

really be better prepared to

343

respond to the pandemic of tomorrow.

344

So, it's that, that wider context

thinking, and I think having those

345

relationships, drawing on the different

stakeholder groups, when you need to

346

be informed in that way and having

those trusted relationships enables

347

that exchange of information both ways.

348

And also thinking, as we're talking with

the policymakers, ensuring that we're

349

asking the right questions in research

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

350

but this is actually going to be relevant.

351

And when is it going to be relevant?

352

So having that exchange of knowledge.

353

Dr. Kim Ozano: Perfect.

354

Wonderful.

355

Thank you very much.

356

So Uzo, I have learned a lot

today, and I am sure you have too.

357

What's your take home from

the conversation today?

358

Dr. Uzochukwu Egere: I think for

me, health systems strengthening

359

is everyone's business.

360

We must continue to have that very strong,

healthy relationship between researchers,

361

health workers, decision makers at

all levels, politicians, community if

362

we are going to go anywhere towards

achieving the universal health coverage

363

and improving the health of people.

364

This is what comes up for

me very strongly today.

365

Dr. Kim Ozano: I would agree.

366

Jo, take home message from you, please.

367

Dr. Joanna Raven: If we really want to

influence policy and practice at the

368

global, national, district facility

level, then we need to understand who

369

we're talking to, what do they want to

hear about and how they want to hear

370

about it, and have the evidence ready

in that sort of package that people

371

will say, wow, I want to listen to that

and I want to take forward with that.

372

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

373

Dr. Kim Ozano: Thank you very much.

374

And Kerry, take us home

with your takeaway message.

375

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

really kind of joining and engaging

376

with the community in which you work

to understand different perspectives,

377

understand different processes that are

going on, and how you can all inform

378

each other and have a voice at the table

where every voice is, is important.

379

And so being part of that community,

making those relationships, uh,

380

trusted and credible relationships, um,

having the intel, because you can't be

381

everywhere all of the time and trying to

understand how you can really ensure that

382

evidence informs policy and practice.

383

Dr. Kim Ozano: Thank you very much.

384

I think that's really important to

talk about, trusted relationships and

385

speaking of which, I think it's really,

really impressive that CHESS wanted not

386

only your perspectives as researchers,

but to hear from the community as well.

387

So to our listeners, please tune into

the next episode where we will hear the

388

perspectives from communities who are

experts by experience, about how they

389

think health system strengthening can

be embedded in high level meetings and

390

advocacy globally, nationally, right

down to that health facility level.

391

Thank you for listening.

392

As always, do like, rate, share,

and subscribe so we can continue

393

to bring you discussions like this.

394

And until next time, bye for now.