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
Citizens to Science podcast.
Kim Ozano and I am joined today by the
Centre for Health System Strengthening at
the Liverpool School of Tropical Medicine.
We have a brand new two part mini
series for you focused on health
system strengthening, what it is,
how to do it, and what action is
needed to ensure that the approach is
embedded in discussions at key global
events and discussion platforms.
This episode is the first of
two, and today's guests are Dr.
Joanna Raven and Dr.
Both have been working in global health
for over 20 years and are passionate about
embedding both health system strengthening
approaches and community knowledge into
political commitments and policy reforms.
Our follow up episode, will hear
from communities about the mechanisms
they are using to get their voices
heard and actioned in health
system strengthening initiative.
Well, we need to know what
this means more in reality.
So I have a wonderful co host with me, Dr.
Uzo, welcome to the podcast.
Tell us a little bit about yourself and
then set us up a little bit about why is
health system strengthening so important?
Dr. Uzochukwu Egere: Hi, Kim.
Thank you for having me,
and hello colleagues.
Yeah, so I'm Uzo, and um, I'm
a pediatrician by training.
In the past few years I've been involved
in research in public health, but
more importantly in implementation
research around health systems
and health systems strengthening
childhood tuberculosis and all that.
I come from a setting where health
systems are really weak and fragile.
Coming from that kind of setting,
you can understand my interest,
um, in, in the topic today.
We know the world is ravaged by so many
conditions, things like tuberculosis,
things like malaria, we're still
struggling to deal with these diseases.
And we know that there's no
way we can make a headway
with weak, um, health systems.
I'm glad that we've got Jo and Kerry
here today and, uh, they are the experts.
So I would like to ask Jo, Jo,
can you tell us what exactly
is health system strengthening?
Dr. Joanna Raven: Okay, thanks, Uzo.
I'm very happy to be here to talk
about this extremely important topic
of health system strengthening.
So let's think about what a
health system is to start with.
So a health system is all the
organisations, peoples and actions
whose primary sort of purpose is to
promote, restore or maintain health.
And what do we really mean by that?
It's, it's the people
who provide services.
It's the communities who engage with those
services, the buildings that we provide
services in, whether it's a small clinic
in northern Uganda or a large tertiary
hospital in Nepal, or under a tree!
It's the drugs and treatments and how
these are all organised and governed.
And I think there's a real big need
to strengthen these health systems, to
make them resilient, so that they can
deliver quality and equitable health
care services at all times, including
when there are shocks such as COVID,
Ebola, earthquakes, conflicts, but also
managing those long term stresses, such
as economic pressures, so the health
system can adapt and respond, delivering
services needed at that time, but ensuring
that routine services are maintained.
Dr. Uzochukwu Egere: It's so interesting
to know that virtually, um, everything
that we do affects health system.
Dr. Kerry Millington: Building on what
Jo says is that really having a strong,
resilient, sustainable, inclusive and
effective health system are critical for
effective responses to ensure that people
have access to the quality care that
they need it when and where they need it.
I work in the field of tuberculosis
and health system strengthening is
really a foundation block to support
an effective response to ending this
TB pandemic, but we can also see that
the response to TB also contributes
to strengthening the public health
functions to prevent, prepare and respond
to new pandemics, new health threats,
like antimicrobial resistance, and
the health impacts of climate change.
So ensuring that these health systems
are resilient to what is coming.
This was seen during COVID, for example,
when TB functions, such as infection
prevention and control that were
already in place were then leveraged
to strengthen the response to another
airborne pathogen, such as COVID 19.
So you can see the interplay between
the diseases and the health system and
how they can benefit each other and
how essential they are for each other.
Dr. Kim Ozano: I think it's
really clear how important it
is to strengthen health systems.
I think the case is there.
So, the Centre for Health Systems
Strengthening at the Liverpool School
of Tropical Medicine, what does the
centre do and how can it influence
political commitments and policy reforms?
Dr. Joanna Raven: The Centre for Health
Systems Strengthening, or CHESS for short.
It's a group of researchers, of programme
managers, of PhD students working at
Liverpool School of Tropical Medicine,
coming together who have a common
passion and goal for strengthening
health systems to promote better and
improved health and well being amongst
the poorest and the most marginalised
in low and middle income countries.
And we're researchers, so we do research.
That's what our strength is, and
we share learning and resources
about health systems, and develop
and deliver leading edge health
systems research with our partners
to have policy and practice impact.
Also we've got a range of research
that looks more sort of at the,
at the health system in general.
So things about leadership
of the health system.
How do we make sure that, um, the leaders
of the health system at all levels of
the health system, so whether it's a
facility or at district level or at the
national level, have got these approaches
to strengthening the health system that
has that equity at the heart of it.
Um, also a lot of work
on health workforce.
Now that's an area I'm absolutely
and utterly passionate about.
I'm a health worker by background.
I was a midwife and a nurse for
many years and I've worked in lots
of different settings with that.
So I know what it's like to be sitting
in a health system, wanting desperately
to provide good quality services and
really look after the people that are
in my community and area, but know what
the, the health system challenges are.
Dr. Kerry Millington: There is that kind
of real engagement with the community,
the health care workers really want to
provide a quality service for people
in their community to enable them to
access care when and where they need
it, without fear of stigmatisation,
without fear of financial hardship.
And what we do here in CHESS is to
ensure that when we are developing the
research, we really are engaging with
those communities to fully understand
the problems, the root causes of those
problems, and to work with them to
co-develop the research that we're
doing and to ensure then that their
research findings are then taken up
into the communities, so that our
research has impact on the health
outcomes of those people's lives
and their families and communities.
Dr. Uzochukwu Egere: Thank you, Kerry.
I would just say, when both of you
were talking that it's obvious that
what you're doing is so important,
especially in the lower middle income
countries where most of the need for
health system strengthening lies.
And it'd be interesting to know
how you're engaging the policy
pathway in some of those settings.
Dr. Joanna Raven: Thanks, Uzo.
I can give a really timely example, I've
just come back from Zimbabwe, uh, last,
late last night, uh, where I've been
working with a group of people there.
So, it's a research institute in
Zimbabwe, but also we've got a group of
researchers from Nepal, so it's going
to be a cross country research programme
that's looking at how to strengthen the
health workforce to be able to respond
to the health impacts of climate crisis.
So, uh, a really important topic,
and we're taking that sort of health
workforce, health systems lens to that.
And what also we did was we've been
bringing in policy makers and health
workers to develop this research proposal.
So at this workshop, we had the director
of medical services from the Ministry
of Health in Zimbabwe at that workshop
to help us design that research, to make
sure that it's relevant and feasible.
That make sure that we're answering
the questions that they want to
have answered so that our research
findings are going to be useful.
They're going to be relevant.
They're going to be timely for
that policymaker to pick up and use
to develop his policies, develop
sort of practice, et cetera.
He said, I remember listening to him and
he said, "I am desperate for evidence.
I'm desperate for evidence to strengthen
our health system, to enable us to be able
to cope with this, this, this challenge.
I don't want to be at the end of the
research, receiving some findings, I want
to be part of that research now today",
and he was really happy to be involved
in developing that research programme.
Dr. Kerry Millington: I think you
really draw out some key points there.
Different stakeholders have to be
engaged right from the beginning to
have those conversations to try and
understand and build up that evidence
to inform policy and practice.
Jo's talked about what the discussions
that have been having in a research
programme at the national level, but
that's also scaled up to the highest
level at the United Nations in New York.
And this year, there are three
health meetings, called high level
meetings, that are focusing on the
fight against tuberculosis, pandemic
prevention, preparedness and response
and universal health coverage.
And it's recognised at that level,
and what's tried to happen is they've
tried to align across the political
declarations that will come out of those
three meetings, because they recognise the
interdependency of all of these different
approaches and applying a health system
strengthening lens to that thinking
behind what goes into those political
commitments at the highest level.
But what will happen is once we get
those political commitments, you then
take them back down to your country
to say, within our context, how can
we now apply these commitments that
have been made at the global level?
What works for us?
Perhaps what can we do in addition
to this within our settings?
Does it apply across the country or
are we particularly focusing on key
and vulnerable populations, which is
those that we really need to reach
by strengthening the outreach of our
health system to those who most need it?
We are research groups that
provide evidence about what works,
and why, and in what settings.
So all that sort of granular detail
is really important when it comes
to country sort of perspectives,
isn't it, to understand what
works and why in that particular
setting and how can we learn that.
How can we take that learning and apply
it to different settings to make sure that
does strengthen the health system in that
particular setting I think it's really
important and it lends us, lends it to the
types of research that we do within CHESS.
Dr. Kim Ozano: I think that's really
useful, both the examples and how
the different levels of advocacy are
needed to make sure health system
strengthening is embedded in decisions.
Kerry, we have a lot of listeners who
work in global health and they will
want to know how they can influence
high level meetings to make sure
that health system strengthening cuts
across all the different programmes.
We see a lot of programmes working
in silos and a lot of funding streams
working that way, but the Centre
for Health System Strengthening, it
seems like there's a real advocacy
to have a health system strengthening
approach that cuts across these.
Have you got any suggestions?
Dr. Kerry Millington: I think global
health diplomacy is a new field and
how to operate in that field is new to
academics and healthcare professionals.
And the experience that I've had
by getting involved this year with
particularly the high level meeting
on tuberculosis, the area I work in,
is kind of, coming together within
your own community to go through it
together, make connections, share
intel, learn how the United Nations
works and how you can put a suggestion
forward on an intervention in your three
minute slot that you're kind of given.
I think really working together,
um, is key to understanding health
diplomacy and how you can be of use
to ensure that you are informing the
process with the evidence that you've
generated within your own research.
It then gets taken into
context of diplomacy.
So there are a lot of other things that
play also, um, but I think to be able to
be at the table with affected communities
and their advocates is a really strong and
powerful force, and enables so much more
than just attending a meeting, but enables
those connections to then continue.
Dr. Uzochukwu Egere: I think it's
amazing that those of us who are
researchers are beginning to now
get seriously involved in advocacy.
It was heartbreaking for me, say 20
years ago, practicing in Nigeria
and in the Gambia, and you see that
there are interventions that have been
working in the developed countries for
decades and they haven't yet begun to
be implemented in the settings that,
you know, don't have those resources,
where health systems are weak.
One of the big problems was the gap
between scientists who do the research
and those who do the implementation,
those who run the systems, the health
workers, the people in government.
So it's really good to see
these efforts coming together.
Co-creating, we are co-creating
interventions, co-creating designs of,
um, interventions with the people who are
directly involved in it and representing
them at the highest levels so that we
bridge that gap and ensure that it doesn't
take forever for interventions to begin
to benefit the people that need it.
Dr. Kim Ozano: So Jo, it sounds like
process is really important here, and
sharing process across different contexts.
Dr. Joanna Raven: Obviously context
is particularly important, but there
are sort of higher level learnings.
There's synthesising sort of
learning from different research
programmes about the sort of things
to strengthen the health system.
So, you can take the examples from
the different research, but then pull
that together and say, actually, this
is what would work and this is why it
will work, and this is in what settings
it would particularly work well.
We do a lot of work on community health
workers and how to support and manage that
critical cadre that sort of really links
the communities to the health system.
What can we do to support them?
Many of these community health workers
are women, you know, they've got their
family, their households to look after.
So they're juggling
multiple, multiple things.
So it's not only looking at it
from a health systems lens, but
also from a gender and equity
lens in terms of the workforce.
So we've got lots of learning that we've
shared with in our website and through
the individual programmes as well.
Dr. Kerry Millington: I work on the
LIGHT research programme, funded with
UK AID, and what we're trying to do here
is think about gender equitable access
to TB care and prevention recognising
that you need to think through what
are the challenges different genders
have in accessing care they need.
If we can get over those challenges
of why people aren't accessing the
services they need and get that delivery
mechanism running well, that as new tools
come through, or as we need to pivot
to responses, to challenges that are
coming, be it pandemics, climate change,
health threats, such as antimicrobial
resistance, we can ensure that we can
still deliver the service that we need
to those people because they're able
to easily access that without the fear
of stigmatisation, without fear that
they can't get there because the clinic
isn't open or accessible or nearby.
Dr. Kim Ozano: That's
really useful to hear.
We've talked about integrated health
systems in our past episodes and it
sounds like that does relate to that.
Kerry, just sticking with you for a
moment, I know that you've worked quite
a lot with advocates and experts by
experience, and we're going to be hearing
from those people in our next episode
who are from the community and have
quite key roles in high level meetings.
Can you tell us a bit about how that works
in practice, how are they listened to?
Is it, well, are their voices heard and
actioned on or do we need to do more?
Dr. Kerry Millington: I think there's
a spectrum of when they're heard.
I'm particularly proud of the TB field
that at the multi stakeholder hearings
in May in New York at the UN, the
affected voice of TB survivors was
given a primary slot at the opening
and closing of the stakeholder meeting.
So we could really hear what they're
saying to us and making sure that
we are kind of listening to that.
I think we have to bear in mind
that this is within the wider
context of global health diplomacy.
So we are there to say our voice, we are
there to kind of offer our information
that we have from the evidence or
experience that we have as a TB community.
Um, but then it can get taken up
into the more wider diplomacy space.
So, I think we have to realise all
of that, but we have to try, and when
we think things aren't quite right,
we keep on going and saying, well,
actually, have you really covered
this particular aspect, which we
think community is really important.
Um, so yeah, I, I think it's important
that their voices are not only
heard within their own communities,
within their national communities,
but also at the global level too.
Dr. Joanna Raven: I was recently at the
Global Forum for the Health Workforce that
was held in WHO in March, and one of the
absolutely amazing things that happened
there was having health workers there.
Health workers from all, all across
the globe were there; prime position
talking about their experiences.
This was in particularly following
COVID and the challenges and trauma
that they experienced during that time.
They had this song and dance that
they did, that they delivered.
And it had everyone up on
their feet crying and crying.
I mean, even like Dr.
Tedros was like...
It was obviously very,
very emotive and emotional.
So, it was sending a very powerful
message to the, um, the forum
and the decision makers about
supporting the health workforce.
Dr. Uzochukwu Egere: Kerry, you
mentioned inter-country learning,
which is also dear to my heart.
And I think it's one beautiful
opportunity that we have with health
system strengthening to leverage,
um, learnings from different
countries to benefit each other.
So I also wanted to find out, you
know, are there other ways in which
you share learnings within CHESS?
Whether it's within the research groups
or in countries that are involved.
Dr. Joanna Raven: Well, we meet.
We share resources, we share our
papers, we talk about different themes,
and we develop research programmes
together, um, so that's where we're
learning, that's where we're sharing
examples and producing that synthesised
findings for people to take up.
Also, within our smaller groups within
CHESS, we have fora for presenting our
findings, like Health Systems Global,
for example, which is a research
uh, symposia that has policy makers
and from across the world, but also
global sort of level policy makers.
We think about targeted communications
at the right time with the right
people we know who to speak to.
We know how they would like to receive
sort of information, and how to
engage them in that research as well.
We've got that depth of knowledge and
experience that we can make sure that
our research doesn't just sit on a desk
or in a book or in a journal, it is
actually impactful, maybe at different
levels, you know, maybe it's at health
worker level or facility level or district
level or national level or global level,
but it just doesn't sit in a paper.
It's across everywhere.
Dr. Kim Ozano: I think this
knowledge translation is really
important to understand more.
Kerry, the term global health
diplomacy, you said this is quite
a new discipline, quite a new area.
For our listeners, if they want to
understand a little bit more how to be
involved in global health diplomacy,
where can they find out more?
Where should they start?
Dr. Kerry Millington: I think there,
um, has been a lot of discussion
about, um, the boundaries between
where we can and can't influence.
So, we are academics doing
research and healthcare workers
with experience at the front line.
So, we can inform policy and practice,
but we're not elected politicians.
So, I think there has to be a careful
discussion at that interface about how
we can inform, but we're not making the
decisions, but we need to be in a position
to provide that information, as Jo alluded
to before, they want to be informed.
They want to know what's going to
work for the benefit of why they're
in their roles for their society, and
especially when resources are constrained.
So, how can we think, you know, well, if
we strengthen the health system, this is
actually going to benefit tuberculosis.
It's going to benefit
universal health coverage.
It's going to get us ready to
really be better prepared to
respond to the pandemic of tomorrow.
So, it's that, that wider context
thinking, and I think having those
relationships, drawing on the different
stakeholder groups, when you need to
be informed in that way and having
those trusted relationships enables
that exchange of information both ways.
And also thinking, as we're talking with
the policymakers, ensuring that we're
asking the right questions in research
and that we're not going off on a tangent,
but this is actually going to be relevant.
And when is it going to be relevant?
So having that exchange of knowledge.
Dr. Kim Ozano: Perfect.
Thank you very much.
So Uzo, I have learned a lot
today, and I am sure you have too.
What's your take home from
the conversation today?
Dr. Uzochukwu Egere: I think for
me, health systems strengthening
is everyone's business.
We must continue to have that very strong,
healthy relationship between researchers,
health workers, decision makers at
all levels, politicians, community if
we are going to go anywhere towards
achieving the universal health coverage
and improving the health of people.
This is what comes up for
me very strongly today.
Dr. Kim Ozano: I would agree.
Jo, take home message from you, please.
Dr. Joanna Raven: If we really want to
influence policy and practice at the
global, national, district facility
level, then we need to understand who
we're talking to, what do they want to
hear about and how they want to hear
about it, and have the evidence ready
in that sort of package that people
will say, wow, I want to listen to that
and I want to take forward with that.
So that's, that's what we've got to do.
Dr. Kim Ozano: Thank you very much.
And Kerry, take us home
with your takeaway message.
Dr. Kerry Millington: it's, it's
really kind of joining and engaging
with the community in which you work
to understand different perspectives,
understand different processes that are
going on, and how you can all inform
each other and have a voice at the table
where every voice is, is important.
And so being part of that community,
making those relationships, uh,
trusted and credible relationships, um,
having the intel, because you can't be
everywhere all of the time and trying to
understand how you can really ensure that
evidence informs policy and practice.
Dr. Kim Ozano: Thank you very much.
I think that's really important to
talk about, trusted relationships and
speaking of which, I think it's really,
really impressive that CHESS wanted not
only your perspectives as researchers,
but to hear from the community as well.
So to our listeners, please tune into
the next episode where we will hear the
perspectives from communities who are
experts by experience, about how they
think health system strengthening can
be embedded in high level meetings and
advocacy globally, nationally, right
down to that health facility level.
Thank you for listening.
As always, do like, rate, share,
and subscribe so we can continue
to bring you discussions like this.
And until next time, bye for now.