Shownotes
In this episode, we explore the critical role of non-state actors and informal providers in health systems within fragile settings. Our guests share insights on the legitimacy, roles and challenges of informal and non-state actors. This is the fourth episode in the six-part miniseries "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 the series).
Chapters
00:00 Introduction to Connecting Citizens to Science
00:14 Overview of ReBUILD for Resilience
00:31 Non-State Actors and Informal Providers in Health Systems
01:12 Introducing the Guests
02:31 Understanding Non-State and Informal Actors
03:19 Current Situations in Myanmar and Sierra Leone
04:59 Roles and Impact of Informal Providers
07:59 Challenges and Coordination in Crisis Situations
14:02 Advice for Improving Health Systems in Fragile Settings
18:04 Conclusion and Final Thoughts
In this episode:
Dr. Karin Diaconu - Reader, Research Lead, Institute for Global Health and Development
Karin is a health policy and systems researcher interested in how to achieve better health outcomes for disadvantaged groups and persons living in fragile, conflict affected and vulnerable settings. She has been involved with the ReBUILD for Resilience programme since it began and is interested in understanding how communities and health systems can better work together to support health, particularly in situations where communities have often been disempowered due to longstanding crises.
Dr. Kyu Kyu Than - Research Director, Burnet Institute Myanmar
Kyu Kyu is a health system researcher from Myanmar who is passionate about advocating for gender-equitable and inclusive healthcare access for the most vulnerable population. She is currently a Research Director at Burnet Institute Myanmar and is also one of the Principal Investigator for the ReBUILD consortium. Her expertise and leadership in public health have earned her recognition both nationally and internationally, making her a pivotal figure in shaping health policies and initiatives in Myanmar. She is a researcher who is well known for her dedication and courage towards health policy shift for the health care workers in the least developed communities.
Ayesha Idriss - Principal Investigator, ReBUILD for Resilience - Sierra Leone, Institute for Development (IfD)
Ayesha is a seasoned pharmacist, dedicated educator, and accomplished multidisciplinary researcher. As the research lead at the Institute for Development (IfD) for the ReBUILD for Resilience programme, Ayesha focuses on strengthening health systems in fragile and conflict-affected states. Her research addresses critical health challenges in Sierra Leone, including non-communicable disease interventions, Community Health Workers (CHW) motivation and health policy implementation. Pursuing a PhD in Global Health at Queen Margaret University, Edinburgh, her doctoral research enhances healthcare delivery in diverse communities, including the informal health sector, emphasising culturally sensitive approaches. Ayesha’s work bridges research and practice, fostering positive change in healthcare systems and promoting equity in access to healthcare services.
Useful Links;
- The Health Workforce in Times of Crisis - Connecting Citizens to Science - This episode is the third part of the six-part mini-series "Stories of Resilience: Local Lives and Health Systems," brought to you by ReBUILD for Resilience. 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.
- Gender, health systems resilience and equity - Connecting Citizens to Science - In the second episode of a six-part mini-series by ReBUILD for Resilience, we explore the intersection of gender and health systems in fragile settings. Hosted by Kim and co-hosted by Abriti Arjyal from HERD International, the episode features insights from Dr. Rouham Yamout from the American University of Beirut and Dr. Val Percival from the Norman Paterson School of International Affairs (NPSIA) at Carleton University. The discussion covers the impact of gender dynamics on health systems during crises like the COVID-19 pandemic and armed conflicts, emphasising community-led, participatory approaches to promote gender equality and resilience in health systems.
- Revisiting Resilience in Health Systems Research - Connecting Citizens to Science - This conversation is the first part of a mini-series titled 'Stories of Resilience - Local Lives and Health Systems', powered by the ReBUILD for Resilience research consortium. This podcast episode, hosted by Dr. Kim Ozano and co-hosted by Professor Sophie Witter, engages in an insightful discussion on health systems resilience, particularly in fragile settings affected by violence, conflict, pandemics, and other shocks.
- Introducing ReBUILD for Resilience - health systems researchRebuild Consortium - ReBUILD for Resilience examines health system resilience in fragile settings experiencing violence, conflict, pandemics and other shocks. We are an international research consortium that aims to produce high-quality, practical, multidisciplinary and scalable research which can be used to improve the health and lives of many millions of people. ReBUILD for Resilience is funded by the UK government.
Want to hear more podcasts like this?
Follow Connecting Citizens to Science on your usual podcast platform or YouTube to hear more about the ways that researchers connect with people to co-produce solutions to global challenges.
The podcast cuts across disciplines, including health systems strengthening, gender and intersectionality, tropical diseases (NTD’s, TB, Malaria), maternal and child healthcare (antenatal and postnatal care), mental health and wellbeing, vector-borne diseases, climate change, Participatory Action Research (PAR), co-production and participatory methods - all linked to community inclusion, engagement and shifting power dynamics.
If you would like your project or programme to feature in an episode or mini-series, get in touch with the producers of Connecting Citizens to Science, the SCL Agency.
Transcripts
Dr Kim Ozano: Hello listeners and
welcome to Connecting Citizens to
2
:Science, a podcast where we hear
about the ways that researchers
3
:connect with communities across the
world to solve challenges together.
4
:I'm Dr.
5
:Kim Ozano and today's episode is
the fourth in a six part miniseries
6
:by ReBUILD for Resilience.
7
:ReBUILD is a research consortium that
examines health systems resilience in
8
:fragile settings that experience violence,
conflict, pandemics, and other shocks.
9
:Today we will be hearing about the
complex world of non-state actors and
10
:informal providers in health systems.
11
:Our guests will discuss the legitimacy
of non-state actors and informal
12
:providers in fragile settings from
initial response to longer-term roles.
13
:Often we see humanitarian organisations
step in during disasters or conflicts,
14
:absorbing these initial shocks, but
they face challenges in transformation.
15
:In some settings, where local governments
are either absent or dysfunctional
16
:due to war, political instability or
a lack of capacity non-state actors
17
:often fill the void, but formalising
their roles remains challenging.
18
:To delve deeper into these critical
issues we have Dr Kyu Kyu Than, who is
19
:a public health specialist and a health
systems researcher with a speciality in
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:sexual reproductive and maternal health.
21
:She is also a medical doctor with a
PhD from the University of Melbourne
22
:and is currently the research
director for the Myanmar country
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:programme at the Burnett Institute.
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:She has been leading and managing a
variety of research and service delivery
25
:projects for the Myanmar programme,
which includes ReBUILD for Resilience.
26
:We also have with us Ayesha
Idriss, who is a pharmacist and
27
:multidisciplinary researcher.
28
:Ayesha has worked on a range
of groundbreaking projects in
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:collaboration with international
partners throughout her career.
30
:Ayesha has also contributed
significantly to the National
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:Institute for Health Research Unit
on Health in situations of fragility
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:and is a researcher with ReBUILD.
33
:And as always to help us guide the
conversation, we have a technical
34
:expert, Dr Karin Diaconu, who
has over 10 years' experience in
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:health policy and systems research.
36
:Karen has worked across several contexts
effected by fragility where health systems
37
:rely on the help of civil society and
non -state actors or informal providers
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:for the planning or delivery of care.
39
:Karen welcome to the podcast.
40
:Please do set us up by describing
what non-state and informal actors
41
:are, and why is it important to
consider them in fragile settings.
42
:Dr Karin Diaconu: Thank
you very much, Kim.
43
:In many settings, it is not just the
formal health system that provides health
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:services or support to populations.
45
:In many places and particularly
in emergencies we see a large
46
:international NGO presence that
comes in to support populations.
47
:But also, local groups, civil society
groups, or informal providers who have
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:been there in the countries for a long
time, they also step in to support
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:health of people and communities.
50
:So, Kyu Kyu and Ayesha, it would be great
to hear what's the current situation in
51
:your countries and where do you actually
see any informal or non-state providers.
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:Dr Kyu Kyu Than: Hello everyone and
I'm from Myanmar, a beautiful country
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:in Southeast Asia, but currently in a
fragile and conflict state at the moment.
54
:We were faced by the COVID pandemic,
and then after the COVID pandemic,
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:there was a change of political
situation, which created more fragility
56
:and conflict into the country.
57
:So, I think, within this fragility
and conflict settings, we see a lot
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:of non-state actors, we see a lot
of donors, international NGOs, civil
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:society organisations, and also, we must
not forget the people like community
60
:health workers, and also some of the
people working on ground as volunteers.
61
:Ayesha Idriss: I'm Ayesha, I'm
from Sierra Leone, which is a West
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:African country, and Sierra Leone
faces significant health challenges.
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:Our health system is marked
by history of underfunding
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:and infrastructural weaknesses.
65
:We also have a lot of non-state actors
like the international organisations,
66
:and also there are community based
organisations, civil societies and the
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:informal providers that provide services,
especially in the remote areas, where
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:these health facilities are lacking.
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:And we have traditional healers,
faith-based healers as well, and they
70
:come in, and because of the trust people
have in them, they really help the health
71
:system during times of crisis and shock.
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:Dr Karin Diaconu: Could you talk a little
bit more about that and what you've
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:seen in practice, what they're actually
doing and how they're supporting people?
74
:Ayesha Idriss: So, because of the trust
that communities have, especially in
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:informal providers, like traditional
healers within the communities, um,
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:the health system was able to utilise
them in containing the disease in
77
:terms of messaging, in terms of things
that they should do with the Ebola.
78
:So, we're trying to respond to the Ebola
as a health system, but we're really
79
:going nowhere, until they were brought
in, because the idea of the Ebola was in
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:terms of contact through the dead fluid.
81
:And we have our culture, for
example, we have to wash the
82
:dead, you know, prior to burial.
83
:And that was still going on.
84
:So until they brought in these
informal providers, they actually
85
:helped in sensitising, the
communities and the people.
86
:So there was a massive
change and turnaround in terms
87
:the spread of the disease.
88
:So, they do play a critical role, they're
very critical because they're close
89
:to the communities, they trust them.
90
:And most of the time bringing them
on, and sometimes even in campaigns...
91
:in what we're doing now with the
ReBUILD that we're working at community
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:levels, you know, they've reported
that during campaign like immunisation
93
:campaigns, stakeholders and all
these other community members, you
94
:know, coming in really had helped.
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:Dr Kyu Kyu Than: Yeah, I like to echo
Ayesha's point on trust between the
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:community and the non-state actors.
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:For Myanmar during the COVID pandemic,
the trust between the community and the
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:non-state actors were really cohesive.
99
:We can see it in the first wave of
COVID-19, the first and second wave,
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:the country was in a real good
state, everyone coming in together.
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:When we look at non-state actors, even
the private sector, which normally
102
:looks to profit, they even came in
Covid and really got hand in hand and
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:helping like getting beds, trying to
move to quarantine centres and trying
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:to help a lot of the COVID cases get
their clinical care in their settings.
105
:And the second thing I think is
coordination between non-state actors
106
:themselves, the INGOs, the CBOs and
the community is also very important.
107
:The coordination was really perfect
and, uh, understanding the context,
108
:it's also another important point
that I see, especially during COVID-19
109
:and even in the political crisis.
110
:Understanding the country context,
and what is really happening on the
111
:ground, and trying to leverage some of
the rules and regulation that they had
112
:from international agencies and some of
the donors were really amazing, really
113
:tackling and reaching to the community.
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:Dr Kim Ozano: Thank you very much.
115
:it's really interesting to see
these non-state and informal actors
116
:coming in, and you've really painted
a picture of their role during the
117
:emergency situation and straight after.
118
:I wonder if you could tell me a
little bit more about how to ensure
119
:the safety and the security of these
very important actors during crisis.
120
:Dr Kyu Kyu Than: I think, especially for
health care workers from all non-state
121
:actors, and even for state actors, I
think security is the utmost importance.
122
:We really have to weigh between the
security and provision of health services.
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:For example, although you may want to
be giving some of the drugs or some
124
:of the emergency commodities into
a very conflict affected place, we
125
:really have to maintain the security
aspect as the first entity, not to
126
:harm our healthcare workers, also
at the same time ensuring that the
127
:support is given to the community.
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:So, I think there were a lot of strategies
and harm mitigation measures from a lot
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:of non-state actors during the crisis.
130
:And we collectively normally share
the mitigation strategies and
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:what is happening on the ground.
132
:Like in this area, you should not go,
there is fighting happening in this area.
133
:That means that really understanding
and trying to get a trust in each
134
:other about each other, that's
really important in crisis.
135
:Dr Karin Diaconu: Thank you, Kyu Kyu.
136
:I'm interested about something that we
were discussing earlier, particularly
137
:Ayesha, I think you brought this out quite
nicely, that the formal health system
138
:had to reach out to informal providers.
139
:Could you just reflect a little
bit more on what's happening on the
140
:ground and what the risks may be
if these two do not communicate, or
141
:coordinate as Kyu Kyu would put it?
142
:Ayesha Idriss: The informal providers
are embedded in their communities and
143
:there's this trust, so I believe the
formal sector should work closely with
144
:informal sector, you know, more in the
rural areas where, um, facilities are
145
:lacking, and these informal providers
are often the first point of contact for
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:a lot of the population in these areas.
147
:So, they play that critical role.
148
:However, it depends on the type of
informal providers because we have
149
:some like the drug peddlers or sellers,
which come with more risk in terms
150
:of the services they provide because
they're more financially driven.
151
:However, I believe there's a way in which
the formal system should try to tap into
152
:the benefits, you know, and utilise these
benefits of the informal sector providers
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:because in doing so, no one kind of
will be left behind because in terms of
154
:provision of services, even referrals
and other things, they could, you know,
155
:help with that so that services will be
provided in these underserved populations.
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:Dr Karin Diaconu: I think both you and
Kyu Kyu have reflected a lot on what these
157
:non-state actors bring to the table, and
what the informal providers bring in terms
158
:of assuring trust and rapid responses.
159
:I'm wondering if you had any examples
of when you've encountered constraints
160
:or challenges in relation to the
work that these non-state actors or
161
:informal providers may bring to, for
example, securing health of people.
162
:Dr Kyu Kyu Than: Currently, in our country
context, there is a lot of conflict and
163
:active fighting in different parts of the
country, especially around border areas.
164
:So, I think, we can say forced
migration into another country,
165
:which is quite close to the border.
166
:So, when active conflict happens and
forced migration happens, as you all
167
:know, there are a lot of diversity,
legal boundaries, challenges
168
:towards one country and another.
169
:So, when we say emergency teams are
in border areas, I think some of the
170
:rules and regulation between these
countries need to be really flexible
171
:and understanding on the ground to reach
to the people who are really in need.
172
:At the moment, for a country, non-state
actors for example, you must sign a
173
:transportation safety protocol, but
when you go there, that safety protocol
174
:is not, uh, really, uh, abided by.
175
:You have to change your route of planning
or whatever, because that emergency.
176
:So, sometimes those have to be understood
by the non-state actors as well, So,
177
:these are some of the small issues
that we do face on ground, and I think
178
:it's really important that both the
donors, non-state actors, and even the
179
:government of like conflict-affected
countries and non-affected countries
180
:should be really tackling it together
because we do need the togetherness
181
:in these crisis emergencies.
182
:Ayesha Idriss: I agree with Kyu
Kyu, you know that there should
183
:be way that they should work,
you know, with the government.
184
:And during that time, you know when
there's disaster, they provide their
185
:service in terms of the food, medication,
you know, other things that they provide.
186
:Which during, um, the disaster or
emergency, these parallel systems that
187
:are running are good at that time.
188
:However, when the situation is kind
of over and in a stable state, it's
189
:kind of a little bit messy, you
know, how to navigate during this
190
:stable time is sometimes difficult.
191
:If the government agencies really try
and put things in, in place, work with
192
:them closely, I believe the overall
health system will be improved, but
193
:these are some of the challenges.
194
:Dr Karin Diaconu: That's a great
reflection on how situations change
195
:and I guess it's also been a focus
for us in ReBUILD to really reflect
196
:on how does this changing situation
actually help strengthen the formal
197
:system, if you like, because they're
doing a great service in the meantime,
198
:but we should also take some of the
lessons further to the formal system.
199
:Dr Kim Ozano: I really enjoyed
learning about this and, you know,
200
:those challenges have been very clear,
so thank you for those descriptions.
201
:I'm wondering if all three of you, based
on your experience and in your context and
202
:in your research, what advice would you
give to actors in fragile settings, formal
203
:and informal, to improve health systems?
204
:Ayesha Idriss: For me, the advice I'll
give is um, we should not underestimate
205
:trust, so, try to build trust.
206
:You know, trust is key in gaining
insights and knowledge, again, with
207
:minimum potential social bias that
you may have from these providers,
208
:especially with the informal providers.
209
:So, some of the time when you work with
them, they're sometimes a little bit
210
:secretive, but try to build trust and that
rapport, rapport with them is very key.
211
:Also, working with them, I'll say, try
to be open-minded and try to seek ways
212
:which the benefits of the work that
they do could be maximised, you know,
213
:with minimum risk that they provide.
214
:And also, when working with non-state
actors or informal providers that
215
:work at local level, try to see how
community ownership could be brought on
216
:with your work because then when they
leave, you want that sustainability,
217
:that's how you improve the communities.
218
:Dr Kim Ozano: Thank you, really
highlighting the importance
219
:of trust, assessing risk, and
developing that community ownership.
220
:Thank you very much.
221
:Kyu Kyu, please.
222
:Dr Kyu Kyu Than: I think, with the
lessons learned throughout these 3
223
:years, working with non-state actors is
sometimes when the formal system fails,
224
:uh, non-state actors must be coherent
and also have trust between each other.
225
:Not only the trust with the community,
but non-state actors themselves, the
226
:international community, the CBOs,
the donors must also build trust
227
:within them and try to create a
coordination body that would help the
228
:country when the real states fails.
229
:That doesn't mean that this parallel
coordination mechanism has to be
230
:lifelong, because as the crisis ease
out, this coordination mechanism may
231
:help other countries to learn how
these non-state actors coordinate
232
:and build trust among them, and how
the donors, uh, did some mitigation
233
:strategies and some of the activities.
234
:It's like a learning curve
for crisis countries later on.
235
:So first it's non-state actors,
between themselves, they must
236
:have trust and coordination.
237
:And the second thing is, I think we must
not forget, like Ayesha said, that the
238
:ground people who are on the ground and
who are really facing the difficulties.
239
:So, this may be seen from the outside
world and people who are inside the
240
:country may see it very differently.
241
:So, I think, sometimes the outside
world and the inside country
242
:and what's really happening on
ground need to merge somewhere.
243
:So, there must be some information
sharing and real insight sharing,
244
:uh, of communication mechanism so
that people will really understand.
245
:Dr Kim Ozano: Thank you for that example.
246
:It's, it's really complex and
important that we share that
247
:information and learn from it.
248
:Thank you.
249
:Karen, would you like to take us
home with one last piece of advice?
250
:Dr Karin Diaconu: I think my advice
would actually build on both Kyu Kyu's
251
:and Ayesha's and really just bring
home the idea that you have to think
252
:long-term and really privilege different
ways of knowing and of coordinating.
253
:And I think oftentimes we stay at global
levels and we talk about big INGOs and
254
:how we bring them in in emergency, but
actually it's also about smaller actors
255
:and people on the ground, like all of you
have been saying, who need to be there
256
:and who need to be brought in to the
learning, the planning, the responding,
257
:and they have different ways of doing
things, different ways of knowing,
258
:different capabilities, and maybe we
should acknowledge that we have to build
259
:on that instead of setting it to the side.
260
:Dr Kim Ozano: Thank you very much.
261
:And that brings us to
close of the episode.
262
:I've certainly learned a lot.
263
:Thank you to our guests and thank
you to our wonderful co-host.
264
:For our listeners,
thank you for listening.
265
:We hope you enjoyed the episode.
266
:This is the fourth in a six-part
miniseries brought to you by ReBUILD.
267
:So, if you haven't heard the other
episodes, please do revisit them
268
:for a more holistic view of health
systems in fragile settings.
269
:Until next time, thank you and goodbye.
