The fact that the sustainable development goals have only one solitary goal for health has been criticised by many. There are concerns that it signals a more diluted and less ambitious era in global health.

We disagree. We believe that the sustainable development goals promise a significant improvement for global health over what went before.

Of the eight anti-poverty millennium development goals, three focused on global health. They committed the global community to reduce child mortality, improve maternal health and combat HIV/AIDS, malaria and other diseases. The benefit of the eight was that they helped propel global health into the public’s consciousness and into aid agencies’ budgets. But they also led to unintended consequences.

By contrast, of the 17 proposed sustainable development goals, only one focuses on health. And this is framed in a very broad fashion:

To ensure healthy lives and promote well being for all at all ages.

Under this goal there are nine targets. These encompass diverse health objectives, from averting road traffic accidents to reducing substance abuse and improving environmental health along with the more traditional fields captured in the millennium development goals.

More is not always better

One of the major challenges with the millennium development goals was the way in which they compartmentalised specific health goals.

By casting a spotlight on specific diseases and conditions they drove resources to particular types of programmes. In practice, an individual’s health is indivisible. They may be saved from dying during childbirth only to face a chronically debilitating illness later in life. Or the treatment someone receives for HIV/AIDS may be undermined by inadequate nutrition.

To deliver any of these essential health services, countries need a functioning health system. It should be responsive to people’s multiple needs and enable them to access affordable qualified health practitioners. These practitioners must be equipped with necessary drugs and technologies and operate in a regulated and supported environment.

In the early days of the millennium development goals, the laser-like focus on specific goals at times created distortions in health systems – for example, sucking in scarce health workers to work on well-funded programmes that supported the goals, or creating parallel systems for the procurement and distribution of drugs and commodities that bypassed (and undermined) regular government systems.

Over time, global health funders grew savvy to these concerns and sought to address them through complementary funding for systems strengthening. But the sustainable development goals should further help steer clear of this problem. The target on universal health coverage clearly adopts a much more holistic perception of health.

Second, one of the significant challenges with the health millennium development goals was the standard prescription that they offered for health sector priorities.

Regardless of epidemiological or demographic profile, countries were pointed to the same priorities. While these priorities are important in most developing countries, it has been argued that outsized spending on HIV/AIDS, for example, did not match countries’ own priorities.

Tailored approaches make more sense

Unlike their predecessors, the sustainable development goals are meant to be equally relevant to countries at all different income levels. This, together with the participatory process used to develop the sustainable development goals, has brought about a much broader health agenda that may be tailored to the needs of different countries.

The fact that low-, middle- and high-income countries all have shared health goals creates new and promising opportunities for cross-country learning and exchange.

There is certainly much that low-income countries can learn from their high-income counterparts about how to organise health services to address a multiplicity of health problems. But there is also much that high-income countries can learn from developing ones. This includes shifting simple tasks to less qualified but adequately skilled health workers, building community support for health services or employing information and communication technologies within the health system.

Finally, while only one of the sustainable development goals speaks directly to health, concerns relevant to health are threaded through many of the other goals. There are obvious linkages between ending poverty and hunger, improving education, ensuring water and sanitation and promoting gender equality and health.

But health priorities may also be sustained through several of the other goals. These include:

• Goal 8: decent work for all;

• Goal 11: making cities and human settlements safer and more sustainable;

• Goal 13: combating climate change;

• Goal 16: promoting peaceful and inclusive societies; and

• Goal 10: reducing inequality.

Too frequently those working within the health sector place artificial boundaries around the scope and mandate of the sector. This is despite the fact that one of the earliest and most significant global health policies, the Alma Ata Declaration, defined health in a very broad and encompassing fashion as “a state of complete physical, mental and social well-being”.

A new approach

In the next 15 years many of the major challenges to human health will originate outside of the health sector. These range from emerging zoonotic diseases to pollution, climate change and the growing epidemic of obesity.

Tackling these challenges effectively will require health experts to better understand and intervene in the health system. But they will also have to consider and effect change in broader social systems that encompass health – such as housing, transport, animal health, urban land use and agriculture.

The sustainable development goals are a timely reminder of the complexity of human health and the systems that support it.

Achieving the goals presents a truly challenging new agenda for global health. Attainment of these goals will require us to learn collaboratively about how to strengthen health systems and break down artificial boundaries across systems. As we do this we should sustain the inclusive spirit in which the goals were developed, and the collective quest to build healthier societies.

This blog first appeared on The Conversation on October 1, 2015

By Nasreen Jessani, Chrispus Mayora, Ermin Erasmus, Rosanna Rörström and Surekha Garimella. 

Code Blue! Code Blue!

While you must be wondering what we allude to, it’s neither a hospital emergency code, nor the late ‘70s band from the UK. It was the code assigned to our panel – the color dedicated to sessions falling under the conference track “country-led capacity strengthening for health research and innovation.”

What was immediately striking was that amongst all other blue coded sessions, “The network approach to strengthening health systems research capacity: experiences from the Global South” was rather unique in that it highlighted innovations in research capacity strengthening in contrast to the majority, which highlighted capacity strengthening in research and innovation. A subtle but important point with respect not the intentions and approach of an initiative. However, clearly the two are not mutually exclusive.

Understanding this subtleties and the context-specific nature of local and/or regional networks was a key aspect of the convened panel, which consisted of:

• Future Health Systems Africa Hub (FHS Africa Hub): a regional network of 7 East and Central African Schools of Public Health (SPHs)
• The Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA): a regional network of 7 East, West and Southern African universities and 4 European SPHs
• The African/Asian Regional Capacity Development project (ARCADE): a multi-regional network of 16 partnering institutions across Europe, Asia and Africa to deliver online and blended pedagogical approaches to learning HPSR
• KEYSTONE: a national network of HPSR researchers from 15 organizations in India focused on individual and organizational HPSR capacity strengthening.

The hot seat

In order to keep the session interesting for the audience as well as provide boundaries for panelist responses, the chair employed a non-conventional “talk show” format (in contrast to individual presentations) whereby relevant questions about key aspects of the networks were directed at the panelists. In some cases, the questions were relevant to all (eg: governance mechanisms) and in others quite specific (eg: power dynamics between Northern and Southern network partners).

Governance processes guided by partner attributes, core network values

The variety of regions in which these networks operate provided for interesting insights with respect to capacity strengthening priorities as well as baseline capacities of network members and how those shape network traction, action, reaction. Furthermore, the distribution of the networks also determined the governance structures that were adopted with each highlighting its own processes and challenges. Although CHEPSAA and FHS Africa Hub had formal secretariats for communication and coordination, it was interesting to note KEYSTONE’s modus operandi where the network is voluntary but the secretariat is a formal one.

Lost opportunity for cross-network learning

Given that all these networks have the same end goal in mind, there was a sense that more collaboration and cross-learning over the past few years would have been welcome and appreciated. For instance, FHS Africa Hub and CHEPSAA began with capacity assessments in each of the partner institutions as a baseline for identifying priorities for capacity strengthening – both at the same time, in the same region, with the same intent – but without knowing about each other until almost into their 4th year of existence – at which point several experiences were shared. Furthermore, each has designed new modules for HPSR curricula to meet some of the identified capacity gaps and perhaps could have worked together on these. On the other hand, CHEPSAA’s open source materials as well as capacity development activities led to KEYSTONE’s deliberate use and adoption of content for the courses delivered in India. A great example of redundancy reduction, knowledge normalization, and content adaptation and enhancement. ARCADE also subscribes to open source values. Of course multi-network interactions while desirable come with their own set of complexities with respect to the involvement of more stakeholders, timing, funding agreements etc.

The advantages of a network approach to capacity strengthening

Although the format of the panel was designed to allow for discussion rather than presentation, the similarities across the networks at times overshadowed opportunity to discuss differences (and perhaps a lesson learned on more effective means of moderating “talk shows”). For instance it was striking how the emphasis on curriculum development dominated the “achievements” across the panel to the detriment of discussions regarding the nature and type of training, mainstreaming of the training, the standardization across the network, and the tailoring by partners within the network for their local contexts. Although, curiosities about other capacity building achievements received little “airtime,” CHEPSAA highlighted other achievements in areas of capacity strengthening such as how to conduct an organizational capacity assessment, stimulating discussions on the nature and boundaries of HPSR, nesting an emerging leaders program within the larger initiative, focusing on other skills important to the professional workplace such as listening skills, communication, managing meetings etc.

One strategy, two goals

Recognizing that educators in universities are generally hired for their research prowess with little or no training in teaching, CHEPSAA as well as ARCADE colleagues highlighted a strong argument for strengthening not only curriculum content but also curriculum delivery. Pedagogical innovations across network organisations contributed to the design of new and revised online courses, case studies, scenarios, simulations etc to create a more engaged learning environment – an effort that benefitted from co-learning, co-creation, and co-adaptation across network partners. In addition, CHEPSAA deliberately included training of HPSR researchers in curriculum development and delivery with the assumption that many next-generation researchers will eventually become educators.

Network management challenges The logistical, communication and financial challenges of convening partners across the network for decision-making as well as for capacity strengthening initiatives were ubiquitous – much to the relief of the panelists! While they felt that clearly their challenges were not unique, it did raise questions about how communication and leadership can be effectively distributed across dynamic and geographically disperse networks such as these. What was surprisingly positive with respect to power dynamics however was the role of Northern partners in these networks. It appeared that in all cases, partners had each brought their own strengths to bear on the network and therefore each had a distinctive place and part in their contributions. Historically entrenched power differentials seemed to have dissipated – at least in these examples. Unfortunately we didn't have enough time to dig deeper into this aspect. Donors for the most part engaged only at times of reporting.

The role of donors

But this brings the issue of donors starkly on the table. What role can donors play in sharing their initiatives with each other and how can synergies between these be facilitated? Furthermore, at the end of these 5-year cycles, the lack of sustained funding subjects these initiatives to a perilous death just at they have gained momentum. While many of the capacity strengthening activities have of course gone beyond individuals to the organizations and networks to which they belong, sustained capacity strengthening is required for institutionalization of values, processes and skills. The lack of sustained funding and transition processes subject donor investment to fewer dividends than possible.

People, power, politics and more…

The panelists had enthusiastically planned to engage in discussions on aspects of donor relations, the role of Northern vs Southern partners, trickle-down effects, implementation challenges, balancing priorities of partners versus network as a whole, power relations, distributive leadership, network evaluation and much more. Unfortunately time sped by leaving little time to explore all the exciting aspects of using a network approach to capacity strengthening. We have therefore decided to find a way to harness all these experiences and lessons in a different format and share it as soon as we can. Stay tuned…for code blue take two!

Authors and panellists

Dr. Nasreen Jessani works in global public health policy and systems based in Johannesburg, South Africa. Her work spans health system strengthening through evidence-informed decision-making. She contributes to FHS Africa Hub as part of Johns Hopkins Bloomberg School of Public Health’s technical support role. In addition she led the external evaluation of CHEPSAA. She is on the advisory board of Academy Health’s Translation and Dissemination Institute and a WHO Foodborne Diseases Burden Epidemiology Reference Group (FERG) task force on knowledge translation and policy. Twitter: @NasreenJessani

Chrispus Mayora is currently a Lecturer in the Department of Health Policy, Planning and Management (HPPM), School of Public Health, Makerere University Uganda. Chrispus is currently the coordinator of the Future Health Systems Africa Hub. He joined the project in 2013 while it was in its 3rd year of programming and has played a critical coordination and management role across the network.

Dr. Surekha Garimella is a senior scientist with the Health Governance Hub at Public Health Foundation of India. She co-coordinated the KEYSTONE Course, which is a key component of the KEYSTONE initiative. She has a multi-disciplinary background and is interest in the software of health systems and what gendered health systems may look like and achieve.

Ermin Erasmus has worked in the field of health policy and systems research (HPSR) for the past 13 years and deeply entrenched in the South African context. Ermin has served as the principal project coordinator of CHEPSAA since its inception 5 years ago. His experience with the network encompasses strategic planning, partner coordination, communication management, and CHEPSAA documentation.

Rosanna Rörström joins us from Karolinska Institute in Sweden where she has been involved with the ARCADE project as a research assistant. Originally engaged with the Africa aspect of ARCADE which ended in May 2015, she is now also involved with ARCADE Asia which ends in November this year after 4 years of programming. Rosanna’s experiences span work with Swedish Ministry for Foreign Affairs, and United Nations Office on Drugs and Crime (UNODC) in South Africa.

In unchartered territory, innovation and learning have been the backbone of the Ebola response. As well as the vaccine, there have been other high-tech offerings. For example, a US$5 million mobile high containment medevac unit was hailed as a possible “game-changer” for future outbreaks.

While I do not wish to deny the importance of making sure foreign staff who risk their lives going into an epidemic context can be safely evacuated should the need arise, this is not the kind of innovation which I believe has made – or will make – the difference. Indeed, there is something amiss about the priorities and assumptions that such investments reveal.

Local efforts, local innovation

Concentrating on shipping people in and out of epidemic areas overlooks the wealth and potential of local expertise, and the need to invest in that. As Ebola is (hopefully) drawing to a close, I’d like to draw attention to the local efforts and innovation which have been central to turning the epidemic around. These are the real “game-changers”.

Nowhere is this more obvious than at the MAGic anthropology conference at the University of Sussex where I am currently – and where, exactly a year ago, the idea for ERAP was conceived. Here, there is a wealth of panels to illustrate the effectiveness of community-based and community-led Ebola response.

Presentation after presentation has revealed how learning and behaviour change was often rapid. Villages instated their own isolation techniques, households devised (heart-wrenching) strategies to deal with infected family members, people used local materials – such as plastic bags – as makeshift protection.

Crucially, much of this was in the face of confusing public health messaging, for example that no one survived Ebola, or that you caught Ebola from bushmeat. Also, as Sylvain Faye emphasised, sound infection control measures did not necessarily hinge on heterodox biomedical explanations of disease causation; often people retained their own understandings of the real causes of Ebola.

Creating new health structures

In terms of coordination, case management and surveillance, there are some striking differences across the region about the extent to which local health system capacity was used, and what that means for sustainability and preparedness in the future. In general, the tactic – at least in Sierra Leone, which I know best – has been to set up standardised systems to bypass the existing structures deemed to be ineffective in order to perform the complex logistical tasks necessary.

The Sierra Leonean response came to be organised thorough District Ebola Response Centres (DERC) reporting to a National Ebola Response Centre (NERC). This was led by the Sierra Leonean Military, with support from the British Army, and took management of the epidemic out of the hands of the District Health Management Teams.

Another example is the Ebola Community Care Centres (CCCs) in Sierra Leone. The CCCs were devised as an alternative to hospitals – which had been roundly rejected by many patients – at a time when case numbers were already outstripping the number of beds, and models predicted the situation to worsen dramatically. In Sierra Leone they became a key response strategy. However, in the end they arrived at the same time as ambulances and treatment centres were scaled up which made their original function redundant and most were empty. One of the (many) controversial aspects of the CCCs has been that they pulled nurses out of the normal health care system to staff the empty CCCs at a time when the already weak health system needed bolstering.

The Kenema case

In one district things were different, however. Kenema, in Eastern Sierra Leone, became the frontline of the country’s Ebola epidemic due to the presence of the Lassa fever ward and laboratory. From May to at least August they struggled on without the international assistance which was to come later – and Kenema Government Hospital lost over 40 staff as a result.

Kenema stands out compared to other districts as neither the DERCs or the CCCs have made a significant dent there. The DERC is a side show to the regular surveillance team meetings led by members District Health Management Team and the Lassa surveillance team. The CCCs were never built and instead staff at the Primary Health Care units stayed in their posts but were trained in infection control.

Like elsewhere, Kenema’s learning curve has been steep and painful, but at least when the epidemic is finally over they will have both the know-how and the systems integrated into the DNA of the district health system, enabling them to deal better with future epidemics.

The examples from MAGic and of Kenema shows the importance of local learning and the huge achievements that were made, under incredibly difficult circumstances and with very little monetary assistance. Investment should be made in understanding how these local responses were mounted, and how they can be supported in the future. In the face of media friendly headline-grabbing innovations, we should also recognise them for the game-changers they were.

Annie Wilkinson is a Post Doctorate Researcher at the Institute of Development Studies, UK, and a member of the Future Health Systems team. This blog first appeared on the ESRC STEPS Centre website. Photo: Ebola Prevention and Treatment in Conakry, Guinea (UN Photo/Martine Perret)

Income growth in many low and middle income countries, combined with economic constraints in some donor countries, and emerging new development agendas has led to many global health initiatives - including Gavi, The Vaccine Alliance, The Global Fund to Fight AIDS, TB and Malaria, and the President's Emergency Plan for AIDS Relief (PEPFAR) - reviewing their approaches to graduating or transitioning countries from development assistance. In the next five years it is anticipated that many middle income countries, and many geographical areas within low income countries will cease to receive support from these funders.

Dr Bennett will:

• review transition policies across these Global Health Initiatives, and how they have evolved over time;
• use a case study of Avahan, a large scale HIV/AIDS prevention project funded by the Bill and Melinda Gates Foundation in India that transitioned to local owners, to explore which factors need to be considered in assuring that programme transitions do not undermine sustainability;
• conclude with a set of policy lessons and considerations regarding the likely implications of transition.

Please join us. All welcome.

If you are unable to join us in person, the seminar will be streamed live via this page on the IDS website.

Read more about Dr Bennett and her colleagues work here.

First published on The International Health Policies (IHP) website on September 3, 2015

In last week’s New Leaders for Health (NL4H) Pre-Forum in Manila, four Emerging Voices alumni – three from Class 2014 (Renzo Guinto, Nasreen Jessani, Bhaskar Purohit) and one from Class 2012 (Beverly Ho) – participated in a panel entitled “Emerging Voices for Global Health: The Future of Health Systems Research.” The panel aimed to not only introduce the Emerging Voices for Global Health (EV4GH) program to young health researchers and innovators, but also to showcase the experiences of Emerging Voices (EV) alumni post-training and their visions for the future of health systems research across the world. We asked the four alumni to summarize in ten points the key messages that arose from their exciting ‘Manila conversation’ – and below are their answers:

1. Novel and innovative opportunities such as EV4GH help prepare the new generation of health system researchers for greater impact locally and globally. Many of the ‘soft skills’ essential to success in global health systems research are not taught inside the classroom – they require innovative approaches that allow peer-learning and ‘learning-by-doing’ modalities for example. The impact of EVs goes beyond conferences – for instance, because EVs were prepared on how to better package their research findings for evidence to policy translation, Bhaskar’s research on role-related stress among health workers in India and Bev’s study on health insurance coverage and healthcare utilization in the Philippines have been considered in policy development by government agencies and decision-makers. On the other hand, Renzo’s paper on migrant inclusion in universal health coverage in Southeast Asia has been cited several times by other researchers in articles and presentations. Clearly, programs such as EV4GH both enhance traditional presentation skills (i.e. posters and lectures) and develop contemporary public outreach skills (writing blogs and op-eds), among others. More capacity-building programs that are both innovative and impact-oriented are therefore encouraged to complement traditional education in schools of public health.

2. Posters should be in no way treated as inferior to oral presentations. Posters are essential and effective ways of communicating research to the scientific community. Often however, researchers are guilty of copying and pasting bits and pieces of their manuscripts into the poster, and of not seeking help even for seemingly minor aspects such as font, color, layout, and photos. During the EV4GH program, we alumni have witnessed how our posters dramatically evolved and transformed from Day One to poster session day. In fact, during the Third Global Symposium on Health Systems Research held in Cape Town last year, EV4GH 2014 alumni won in the poster competition in 2 out of 3 days – up against tenured researchers some of who had been creating posters for over 30 years! The EV4GH program enhanced our skills in creating powerful scientific posters for conferences – not just for the prizes as demonstrated earlier, but also for capturing the attention of interested colleagues and target audience. For instance, Renzo recalls how he got connected with fellow Southeast Asian researchers as well as enthusiasts in migrant health who visited his poster in Cape Town. Nasreen’s poster on the use of social network analysis (SNA) to identify key knowledge brokers in linking research to policy led to requests for her to conduct workshops on SNA at the ResUpMeetUp symposium in Kenya and the NL4H Pre-Forum in the Philippines.

3. It is important to distinguish advisors from mentors. Oftentimes, we come across well-established and impressive professionals who are willing to provide advice but have neither the time nor the inclination to provide constant support to aspiring early careerists. During the panel discussion, we urged participants to look for people who have a stake in their success: those who are willing to walk the path with them and willing to coach them along the way. The best mentors may not necessarily be the ones occupying the highest posts, but they are the ones who may be willing to dedicate time, the proclivity and the passion to guide the next generation.

4. Be strategic in using professional networking sites such as LinkedIn. Our generation is blessed with online networking platforms that can help emerging researchers identify and reach out to professionals locally or globally who could serve as mentors and/or collaborators. There are several mid- to advanced-career professionals engaged in relevant health research activities who have also traversed the same path as these young students, and may be interested to serve as mentors to young people whom they have same interests or can identify with. For example, during the panel, Renzo shared that through LinkedIn, he was able to meet Professor Phua Kai Hong of the National University of Singapore, who later provided invaluable inputs for Renzo’s paper on migrant health coverage in Southeast Asia. To top it off, Prof. Phua accepted the invitation to be the keynote speaker for the NL4H Pre-Forum!

5. Never commit the folly of underestimating your peers. In our pursuit for linking with those more experienced than ourselves, we forget the value of social and intellectual capital inherent in our own networks composed of fellow emerging leaders. Leveraging peers to test our ideas, practice our presentations, and critique our papers is an important part of not only enhancing our skills but also nurturing our networks. We encouraged participants to benefit from the strengths and experiences of their friends and colleagues, and to invoke principles of peer learning and feedback. Furthermore, a bit of healthy competition within our networks may drive more creativity and innovation, as long as at the end of the day, we remember that we are united under common goals of improving health and achieving health equity, no matter how diverse our backgrounds and skills may be.

6. Building capacity in institutions is critical. During the panel, we were asked by a technical staff from a government agency if we EV4GH alumni are available to work as consultants to support the creation of posters, presentations, and communication strategies both for the health research and policy community as well as the general public. First, we clarified that it is important to make a distinction between public health communication (whose aim is to modify behaviors, inform about health threats, etc.) and communicating research to decision-makers and fellow researchers – nonetheless, both forms of communication may follow similar principles. However, while the request was flattering, we emphasized the importance of institutional capacity building so that there will be no need for external consultants to perform these routine yet essential tasks. What would be perhaps worth exploring is replicating some of the EV4GH methods of training and coaching for these organizations. In this vein, multiple employees would benefit from enhanced research communication skills, a system of embedded capacity strengthening could be instituted, and a culture of effective knowledge translation could be fostered.

7. Emerging voices should demand for strengthening of national health research systems. In relation to our thoughts about institutional capacity-building, the vitality of local health research also boils down to strong health research systems that ensure long-term professional development, provide incentives for the conduct of effective and relevant research, ensure sustainable funding support and other resources, among others. There was huge enthusiasm among the attendees in the room for research; however, there was also enormous concern about low salaries, ‘contractualization’ of research positions, lack of mentors and role models, limited opportunities for postgraduate training opportunities, and in general the uncertainty of their future research careers. We urged the young leaders to proactively advocate for reforms specifically in the Philippine health research system, so by the time they have graduated, they can be guaranteed fulfilling opportunities in their journey in health research.

8. Be creative in finding resources for health research and innovation. One participant asked a very practical question – how did EV4GH panelists fund their research projects? Nasreen’s study was funded partly through a grant by DfID Future Health Systems Project, partly through awards and partly through work-study; Bev and Renzo’s research used data they collected as part of their paid work, and Bhaskar’s project was funded through his home research institution – in short, there is no single funding source for research. However, while financial resources may be limited, there is a need for new leaders to look at innovative mechanisms and novel sources for research funding, such as by tying research with social enterprise. We also encouraged the attendees to maximize online platforms such as Asia which regularly publishes funding opportunities for research projects. Finally, as demonstrated by Renzo’s research paper, one can conduct, for instance, desk reviews with collaborators from overseas even without meeting them face-to-face, thanks to e-mail and Skype (Note: His paper was published even before he has met in person two of his co-authors!).

9. Building research and innovation programs, not projects. In the panel, Bev and Renzo raised their concerns regarding “projectization” of research particularly in the Philippines, which is also happening in many low- and middle-income countries. Most of the research projects are commissioned to individuals rather than institutions; therefore, there is the tendency to commission more projects, with smaller budgets per projects rather than larger multi-year contracts. There is also often the misconception that qualitative work is cheaper and can ‘replace’ more expensive quantitative nationally representative research studies. Such a lack of holistic approach leads to unusable work (or at least inconclusive, hence cannot be used to arrive at generalizations for policy-making), poor databases (because sample sizes are small, etc.) and lost opportunities for institutional research capacity building. Moreover, it is difficult to encourage promising researchers to build a long-term research career. Therefore, thinking of research in terms of programs instead of projects is beneficial in order to avoid fragmentation, ensure coherence among component research projects, and build long-term sustainability overall. While existing research programs and consortia in health systems are predominantly funded by organizations from high-income countries (such as RESYST, REBUILD, and Future Health Systems), countries which recently allocated significant amounts for health research such as the Philippines (at around 200 million Philippine pesos or 4.3 million USD per year) already have the initial resources to build long-term impact-oriented research programs that may eventually encourage other stakeholders such as the private sector to top these resources up with additional investments.

10. Health systems research and innovation is an exciting field for those who want to make a difference. Today, there is a worldwide recognition that in order to improve health outcomes and achieve health equity, strengthening health systems is the way to go. The emergence of networks such as Health Systems Global is a manifestation of this sea change in global health. What is exciting about health systems research is that it requires multiple disciplines and perspectives – this is the beauty of conferences such as the NL4H Pre-Forum in which students and young researchers and innovators from a wide range of disciplines and professions were gathered in a weekend conference. It was also raised that health systems do have a complex architecture and even fuzzy boundaries, thus opening new arenas for inquiry, and therefore there is always room for emerging researchers and innovators to explore, even experiment, and examine health systems beyond the traditional ‘six building blocks.’ For instance, Renzo expressed that his research interest is investigating the interface between health systems and the broader transitions in health such as climate change, migration, trade, and urbanization, among others. Bhaskar, on the other hand, took a unique perspective on human resources management by looking at the micro level, and emphasized that understanding roles and role-related stress experienced by health workers can be a useful framework to gain better insight into health workforce issues. Nasreen’s unique approach to understanding the flow of knowledge in health systems using SNA illuminated the complexity and multidirectionality of the various elements of a health system.

Conclusion: The ‘Emerged Voices’ should reach out to the ‘emerging’

During the session, it can be noted that the demand for enhanced skills in knowledge translation and research communication was clearly high – from students as well as from institutions. The value of tailored, timely, and context-specific research uptake mechanisms that promote a variety of voices was also clearly demonstrated. It is therefore important to strike while the iron is hot and start creating opportunities to meet this demand.

The EV4GH program also evoked much enthusiasm from the floor, with many participants wondering not on how they can apply for the next edition in Vancouver in 2016, but on how such a program can be replicated in their home countries. Hungry for innovative ways of training and capacity development, the participants challenged the panel to make the global Emerging Voices program one that is more local.

We therefore call upon all fellow EVs to become mentors and trainers, and to reach out to the young voices in their respective communities. Let us capitalize on the momentum by sharing our learnings and skills with peers and fellow colleagues. We can arrange brownbags in our institutions, panels at conferences (or even separate events such as the NL4H Pre-Forum), student groups, professional committees, deliberative dialogues… whatever it may be, let the knowledge gain power, let the skills gain traction. Create an EV legacy by being the mentors that those ahead of us, behind us and beside us all seek when it comes to being a resounding voice for better health for all.

When faced with a complex public health problem there is a natural urge to find solutions. 'Solutionism' works well for circumscribed problems involving a small number of motivated individuals, where every element of the prescribed solution can be implemented as planned. However, complex problems in public health usually have elements that defy planning, because health involves people, and people are unpredictable.

Complex and dynamic public health problems require a different approach: an emphasis on the value of people. People who own the problem can anticipate the most likely social obstacles to its resolution, and their participation is essential to maintain an evolving strategy that can institutionalize an approach to the problem. Decades of community-based participatory research have shown that people from the community and their political leaders have to be included as full participants in problem solving. People are not just passive clients: they must be involved in deciding which problems need addressing, identifying the root causes and finding long-term solutions.

In this editorial, part of the International Journal of Public Health special issue "Driving the Best Science to Meet Global Health Challenges", Peter Waiswa, Makerere University School of Public Health, Uganda, says that without significant and sustained building of African research capacity, progress towards achieving development goals and overcoming health challenges will be difficult.

For countries to have greater capacity to address problems, Peter Waiswa calls for more national funding for research and for barriers, such as a lack of training for research groups and the limited mobility of researchers, to be tackled.

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Future Health Systems researcher Nasreen Jessani from Johns Hopkins University School of Public Health will be chairing a panel session at the Global Forum on Research and Innovation for Health 2015, which is taking place in the Philppines on August 24 - 27.

The Panel is titled 'The network approach to strengthening health systems research capacity: experiences from the global South', and will be taking place on Wednesday, August 26th, from 16:30 - 17:45 in Meeting Room 4 at the Philippine International Convention Centre, Manila.

Panel description

“LMIC-led” networked consortia have emerged in recent years as a novel attempt to develop health systems research (HSR) capacity. They are intended as a means of harnessing varied organizational strengths and establishing more sustained country capacity for HSR. Join Future Health Systems partners and other consortia from Sub-Saharan Africa and Asia peers at this talk show inspired panel session to share experience and learning on issues such as governance, priority setting, and donor negotiations; and to debate poignant questions around implementation challenges and longterm sustainability.

CHAIR:

Nasreen Jessani @JohnsHopkinsSPH Johns Hopkins University School of Public Health, United States of America

SPEAKERS:

Chrispus Mayora @Futurehealthsys Makerere University School of Public Health, Uganda - Africa Hub, Future Health Systems

Rosanna Rorstrom @ARCADEprojects Karolinska Institute, Sweden – ARCADE

Ermin Erasmus @hpsa_africa The University of the Witwatersrand,South Africa – CHEPSAA

Surekha Garimella @KeystoneHPSR Public Health Foundation of India, India – Keystone Initiative

Follow the discussion from the session on Twitter by following @futurehealthsys and share your experiences using #COHRED_Forum.

It is the final 9 months of implementing the three year Maternal and Neonatal Implementation for Equitable Systems (MANIFEST) study in eastern Uganda and the preliminary results are interesting.

Three progress briefs have just been produced by the Uganda Team of the Future Health Systems Research Consortium, and the preliminary findings show remarkable achievements across the three thematic focus areas/components of the study.

From the community mobilisation and sensitisation component, the preliminary lessons show that Community health workers, also known as Village Health Teams (VHTs) are an important resource for community mobilization and health information. Progress Brief No. 1 shows that from January through September 2014, VHTs reported 145 low birth weight babies and 145 (12/1000 births) newborn deaths compared to 93 newborn deaths reported by facility based HMIS. The same reporting period also saw 27,522 pregnant women and 11,752 newly delivered women being registered and visited by the VHTs. This implies MANIFEST has achieved 89% of the target for pregnant women (39,230/43848) and 19% of the target for visiting newly delivered women (15,543/43,840).

Under the savings and transport component, as indicated in Progress Brief No. 2, it is emerging that when communities understand the importance of saving money for use during pregnancy and after birth, they are willing to save money for this purpose. And, as at the end of 2014, up to 1006 saving groups (Kamuli-426, Kibuku-264, and Pallisa-316) with a maternal and child health component had been registered in the three districts.

Meanwhile, Progress Brief No. 3, focusing on mentorship under the health systems component, concludes that despite the challenges, mentorship is an important channel for skills transfer and enhancing professionalism among health workers and may contribute substantially towards the quality of care provided. It also provides an avenue for supporting critical thinking, health worker motivation and strengthens teams.

None-the-less, it was not all smooth sailing. As noted in the three progress briefs, there were some challenges, such as the waning spirit of voluntarism among the community health workers, among others.

The MANIFEST study team has also produced its first issue brief aimed at encouraging the use of partographs by midwives and health workers involved in delivering women.

Download PDF (3,476 KB)

As it is in most low income countries, in Uganda, health care providers at primary health care level have limited access to experienced clinicians and specialists to call upon for consultation, review of cases, problem solving and reinforcing clinical diagnosis and decision making.

This has, in turn, compromised the provision of quality health services, hence leading to poor outcomes. In light of this, the concept of clinical mentorship is increasingly becoming important in order to improve the delivery of quality healthcare services.

This MANIFEST Progress Brief is based on perspectives of mentors and mentees following a six month mentorship exercise in the districts of Kamuli, Kibuku and Pallisa in eastern Uganda. It outlines the issue, the approach taken, preliminary results, a summary of findings, improvements in clinical care, administrative improvements and challenges.

Download PDF (3,677 KB)

Some of the reasons given for the low utilization of maternal health services, which contributes to the high maternal and neonatal deaths in Uganda, include constraints such as lack of transport and cash for meeting the costs of health care.

This Progress Brief looks at the component of the MANIFEST study that aims to increase financial and physical access to maternal health services by promoting financial preparedness as well as availability of routine and referral transport. It outlines the approach taken, the preliminary findings, the challenges and the lessons learnt.

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Village Health Teams (VHTs) can support communities to plan their births better by offering critical information and encouragement through home visits. In addition, they can collect demographic and health information on critical health outcomes. Although Government introduced the VHT strategy in 2005, there are still challenges in the implementation of the strategy, with some parts of the country still not covered.

This Progress Brief brief highlights implementation experiences from the Maternal and Neonatal Implementation for Equitable Systems (MANIFEST) study using VHTs to stimulate demand for maternal and newborn health services. It outlines the approach taken, preliminary findings, challenges and lessons learnt.

Download PDF (2,057 KB)

This MANIFEST Issue Brief looks at how to increase the use of Partographs to monitor the progress of labour. It explains what a partograph is, and provides practical tips for how to improve partograph use.

This Special Report asked how Jim Kim's efforts to reform the World Bank and have it tackle new and existing global health challenges have been received by staff and development experts.

In relation to the clashing of intellectual frameworks and how the World Bank must also address the challenges that the global health and development community also face, Gerry Bloom stated: “Increasingly, the World Bank will have competition from others. And increasingly the World Bank has to prove it has effective ways of working with governments or non-governmental organisations. It is less about effective models and more towards effective methods of actually improving things”.

David Peters stated that the Bank had a comparative advantage in supporting a country's sectoral policies and linking these to the country's macroeconomic policies, rather than supporting disease-specific control programmes. The article quoted David Peters saying “The strength of the Bank was really in its country focus as opposed to providing universal dictates”. Peters was concerned that the reorgansiation could lead to "clumsiness" in the World Bank's interactions with governments, but he is hopeful that the situation will improve as the reorganisation continues.

Read the full Special Report here.

Someday soon there will be a week with zero new cases of Ebola. Prior to this, the question has to be, “What would it take to make the health systems in Africa ready to snuff out the next Ebola outbreak at the first next case?”

Now that we can glimpse a post-Ebola landscape sometime in 2015 it’s time to move from crisis management to crisis prevention. Having implicated the cacophony of African poverty as causing Ebola, once Ebola is gone it is important not to go back to the same failed health systems strategies that let us down in 2014.

We seem to have forgotten that the world already pioneered a technology that stops epidemics in their tracks and works extremely well in poor populations beset with urbanization, migration, and distrust. Many countries conquered epidemics despite poverty, without using vials and syringes or gleaming shiny hospitals and in complete ignorance of DNA and the human genome. Between 1880 and 1930 the human experience of roughly quadrennial population death spasms of typhoid, cholera, smallpox, and diphtheria vanished from Paris, London, New York, Stockholm and the surrounding populations. This was before penicillin and sulfa.

Functional local public health departments are a 150-year-old technology that makes it possible to be poor, but not prey to epidemics. Local health departments must constantly assess the local burden of disease and health threats, engage the local community to understand local health problems, devise collaborative solutions, and ensure they are implemented. Yes, global issues matter, but local conditions matter more. Ebola was both global and local. Our bodies are small—what makes us sick is people, viruses, or chemicals a few feet or miles away. Furthermore, our ability to trust is local, and the solutions to many of our health problems require us to trust each other face to face. Community engagement is the bedrock of public health practice, and health officials need to communicate health threats to community stakeholders in a manner that can be understood and acted on.

Checklists can be used to assess a local health department’s performance of essential public health functions. All the missteps that allowed the Ebola epidemic to grow would have been addressed had the essential functions of public health departments been strong enough. The containment of Ebola in some fortunate West African countries wasn’t all luck; sound public health practices played a role, too. Critical public health functions include regular monitoring of the population’s health and maintaining contact with all members of the treatment community; investigating outbreaks immediately at their source; and regular communication of health issues to the community—after building its trust. Public health practice requires ongoing partnerships with the community’s schools, mosques, churches, and civic groups to identify and solve health problems. Around the world, in some of the most challenging environments, local health officers have drawn on the common interest of communities in avoiding illness combined with the most rudimentary methods of epidemiological surveillance to stop epidemics before they happen. This technique also builds political will for the basic environmental modifications that move communities towards better sanitation and hygiene. Unfortunately local public health departments only succeed if they actually perform their duties. In too many places, everywhere, health officers have lost sight of what their duties are.

Public health’s expensive glamorous cousin—medical care—dominates the health systems of Africa, like all health systems. When the full-blown Ebola outbreak exploded, it absolutely required investments in medical care. However, a conversation about prevention means getting health systems to move beyond taking care of the pressing burden of disease. There is never a respite. The local public health officers of Africa typically are asked to manage both the public health service and the clinical service network. Faced with throngs of people in daily pain and suffering at the clinics and the need to maintain epidemiological surveillance and health education, clinics will always come first. When Westerners arrive and decry a weak health system, they are anxious for it to be strengthened enough to deliver more medical commodities like antibiotics, vaccines, and cures for dreaded diseases. This exacerbates the problem. The performance measures of health systems in Africa are heavily weighted towards clinical service delivery—children treated in the clinic, attended deliveries, vaccinations given.

There is an alternative. In the early 1990s the WHO began to build a measurement strategy for local health departments to assess and strengthen their ability to conduct essential public health functions. WHO headquarters abandoned this approach to focus on measuring global disease burden and global performance. However, PAHO, WHO’s Latin American branch, continued to emphasize measurement and currently maintains an extensive set of instruments and knowledge about public health practice. The US also developed this technology into a system of voluntary accreditation of local health departments, and many European countries also regularly assess and improve their local public health practice.

The approach is simple. Give health officers a checklist to determine their strengths and weaknesses in public health practice and coach them in strategies that they co-plan with experienced and committed supervisors. Checklists remind health officers about the need to reach out to the people they serve and to build partnerships with other sectors of society and government. Effective health officers convene and coordinate with law enforcement, schools, private industry, hospitals, as well as their own staff. They share the results of their own monitoring and outbreak investigations and collaboratively develop policy. With a checklist insisting on good public health practice and the expectation that they will be held accountable for improving their performance, health officers can steadily improve their ability to protect their communities.

This blog previously appeared on the Global Health Now website

Alice: “Would you tell me, please, which way I ought to go from here?"

Cheshire Cat: "That depends a good deal on where you want to get to."

Alice: "I don't much care where –"

Cheshire Cat: "Then it doesn't matter which way you go.”

~ Lewis Carroll, Alice in Wonderland

(For those unfamiliar with the story, click here for a synopsis and here for notes on some on some of the objects and places I refer to)

For a few days in June I felt like Alice in Wonderland: tumbling down a rabbit hole, only to find myself lost in a maze of rooms. Overwhelmed by the unfamiliar. Curious about what next. I opened one door and saw indistinguishable mathematical formulas flash on the screen across the hall. I opened another door and could barely see through the multitude of hands raised in question. Another U-turn, and two staircases later a sign ushered me to “Durham Hall” where the faint smell of coffee beckoned.

This was the daily experience at the annual Sunbelt Conference of the International Network for Social Network Analysis (INSNA) held in Brighton, UK from 23-28 June 2015. INSNA was created 35 years ago to bring together social scientists, mathematicians, computer scientists, ethnologists, epidemiologists, organizational theorists, and others working in the area of social networks. Having presented at several public health and evidence-to-policy conferences globally, I was keen to venture into the unfamiliar territory of SNA enthusiasts at Sunbelt, as veterans fondly refer to it. Here are a few things that struck me about Sunbelt:

Queen of Hearts's Castle: This is where the maze ended and what SNA enthusiasts came to experience. Unlike international public health conferences such as the Global Forum for Health Research and the Global Symposium for Health Systems Research, the focus was primarily on theory and methodology: new ways of thinking about social networks, different ways of measuring networks and the relations within, mathematical modeling and statistical analysis, mixed methods research etc… Several panels featured titles such as “Modeling Network Dynamics” and “Approaches to Longitudinal Ego Network Analysis”. In many ways this seemed to be the Mecca of the SNA community and of forging new frontiers. Two days dedicated to capacity building workshops in advance of the conference further anchored the conference on methodology and theory.

The Garden of Live Flowers: Take your pick! While there were no rude talking flowers at this conference, there was an impressive array of disciplines and topics, which employed SNA as a critical method, and approach of choice. These included Migration, Education, Evidence-based policy, International Trade and Investment, Entrepreneurs, and Corporations amongst others. A welcome surprise was the variety of sessions focused on health such as “Public Health Networks,” “Social Networks in health interventions”, “Social Networks and Health Inequalities”, “Infectious Diseases and Social Networks”. Definitely a colorful garden variety to pick from!

No White Rabbit: There were on average, 40 panels a day every day for 4 days, each with about 4 presenters. With 20 minutes dedicated per presenter the chairs of each session ensured that the presentations ran like clockwork. No delays; no substitutions. No White rabbit frantically stating “"I'm late! I'm late! For a very important date! No time to say hello, goodbye! I'm late! I'm late! I'm late!" This meant that if you wanted to attend presentation 1 in Preston Hall, presentation 2 in Stanmer Hall and return to presentation 3 in Preston, you could do so without worrying about missing part of any. Very impressive!

Mad Hatter’s Tea Party. Prof. Brian Uzzi’s research on the origins of deep connections (well summarized by @michaeldsimmons in Forbes magazine last year) demonstrated that shared experiences that facilitate trust building, getting to know others at a deeper level, and exposure to a diverse array of individuals often lead to important relationships. The concept clearly did not escape this bevy of network researchers who convened daily from 9pm-midnight in the hospitality suite where novice and veteran researchers alike gathered unfettered and joyous. (If social network experts, of all people, didn’t know how to establish “deep connections”, then surely the rest of us are in trouble.)

Advice From a Caterpillar: One of my session explorations brought me serendipitously to a presentation by Martin Everett – renowned SNA researcher and co-creator of the world’s most commonly used software for analyzing social network data, UCINET. While Dr. Everett is no hookah smoking storybook caterpillar, his “Whooo are youuu?” query to me certainly resembled one! A quick conversation, an exchange of contacts, and a few emails later Dr. Everett offered to review my SNA paper. A respected node and tie added to my professional network – success!

“Off With Her Head!” Given my recent venture into the field of SNA compared to most of the participants, and witnessing the sophistication of many of the papers, I was arguably nervous to present my dissertation work. While I was looking forward to professional interest and critique, I feared the worst – what if my study didn’t meet expectations? What if my methods didn't hold up to scrutiny? What if…what if… The fact that my presentation (and that of many others) kept being rescheduled without my knowledge didn’t help either. Thankfully, although my (forthcoming) paper on Academic Knowledge Brokers as a bridge between academia and health policy in Kenya was strangely slotted in the Politics and Networks session, my presentation invited friendly faces (@JessicaShearer) and, with much relief, raised no contentious issues.

The Queen’s Croquet Ground: If you like playing with pebbles, the beautiful Brighton beach made for a great obstacle croquet ground. Personally, the one and half hour lunch sessions provided the ideal opportunity for a stroll on the beach, a 99 flake and reflections on Sunbelt. Until next year perhaps!

While the Rabbit Hole in Brighton proved highly interesting, the Golden Key that unlocked ideas for me at Sunbelt were the opportunities for health policy and systems researchers to consider SNA more deliberately in order to understand actors and their relations that affect public health decision making, to unpack the structure and dynamics of the networks that facilitate or hinder innovation, and ultimately to leverage this knowledge to improve health behaviors and outcomes, strengthen health policies and governance, and manage information and financing flows. And these are only a few of many ideas! Furthermore, perhaps global health conferences should consider more multidisciplinary panels, encourage the use of new methods for research, and invite a diverse network of attendees to the tea party.

Much of the activity in global health occurs through networks - and networks of networks; some official, others informal; some deliberate, others emergent; some visible, others concealed. Connected. Interconnected. Failing to apply network theory to this obvious modus operandi will be our failure to recognize and deliver on relevant approaches to improving public health. Like every maze, the global health one is a wonder ready to explore if we can find back the Alice in ourselves. So let’s be bold, embrace the unfamiliar and unlock the door at the end of the rabbit hole!

To catch up on more reflections on the conference, search twitter hashtag #Sunbelt2015.

*Image copyright: *2011-2015 demonsaintdante

Two recent outputs from the Indian Institute of Health Management Research (IIHMR) University, a partner in the UK Department for International Development funded Future Health Systems (FHS) research consortium, have created a splash in the Indian media.

The documentary film ‘How Healthy are the Children of the Indian Sundarbans?’, which documents the critical problems faced by the children of the Sundarbans, and the booklet titled ‘Social Determinants of Health: A Photo Voice Exploration from the Indian Sundarbans’ were both launched on May 29th, 2015 at an event at the Kolkata Press Club.

You can see the press coverage here:

'A study in photos of Sundarbans health ills', May 31, 2015, The Hindu

'Sunderbans women turn lens on island life', June 9, 2015, The Times of India

'Sundarbans women use cameras to showcase plight', May 30, 2015, The Statesman

Blog originally posted on The International Health Policies (IHP) network website on June 12, 2015

All nations are currently working (hard, we hope) towards a new global climate change agreement which will hopefully materialize at the 21st Session of the Conference of the Parties to the United Nations Framework Convention on Climate Change (UNFCCC), in December this year. France will host COP 21, which is why the all-important meeting is also known as “Paris 2015”. There is some (albeit reluctant) optimism on the conference and possible outcomes, for example due to the G7 climate commitment from earlier this week. The hope is that the event in Paris may give the developing South (including emerging countries) and the developed North – to the extent one can still describe the world in these terms – a platform to negotiate responsibilities and opportunities for strengthening the international climate effort, and avoid the worst. At the very least, the hope is to do better than in Copenhagen.

A similar kind of negotiation process can also be witnessed at the local level. In local settings around the world, communities, policy makers and other stakeholders already and increasingly have to deal with climate change in their own context, against the backdrop of global (macro) changes and high-level multi-stakeholder negotiations. However, the way experts, natural scientists and modelers conceptualize climate change at the global level may have very little to do with how men and women (poor or rich, urban or rural) live with, understand and cope with the changes already taking place in everyday settings. The specific lenses through which problems are framed and actions are taken in these local contexts, deserve particular attention.

A classic case in point may be the Indian Sundarbans.

The Indian Sundarbans, literally ‘beautiful forest’ in Bengali, is the largest mangrove delta in the world, spread over the southern end of both West Bengal (India) and Bangladesh. Recently, this area is gaining more and more prominence, not only as a UNESCO heritage site or as the largest remaining natural habitat of the ferocious Bengal Tiger, but also as one of the early victims of climate change. The islanders of the Sundarbans already live and (try to) cope with the clear and more hidden impact of climate change on the basic drivers of life like health, livelihood or shelter. Let’s elaborate a bit on what this entails.

As for the immediate impact, climate change in the Sundarbans, in the form of a sudden climatic shock, like floods or a cyclone, deals direct damage to livelihoods and shelter and causes breaching of earthen embankments. It also often leads to a sudden rise in the incidence of water borne diseases. Simultaneously, climatic shocks erode the opportunities for maintaining livelihoods and trigger food insecurity at household level. As for the long term impact, the slow and gradual changes in sea level and weather patterns (like erratic rainfall or extended summers), deplete the traditional agro-fishing economy, which leads to male migration in search of an alternative livelihood. Women are more likely to face a double burden of taking care of the children and having to depend on available low-wage unskilled labour. The mothers’ increasing burden of work disrupts the (already precarious) balance of the social determinants of child health like food security, psycho-social care, seeking quality health care etc.

Now the question is which actors share responsibility (and how much responsibility) for the changing climate in the new Anthropocene” era, in which human activities have a significant impact on ecosystems worldwide. Relatedly, what kind of impact does climate related coping behaviour have in the Sundarbans?

The Sundarbans region features five different kinds of actors who are working and functioning in the local socio-ecological system. First, the islanders, who were forcedly migrated into the region around 200 years ago. Till recently, they lived mainly from harnessing nature – cutting up jungle forest for settlements, engaging in overfishing and collecting tiger prawn seed around the coast, …. These activities indeed disrupt the bio-diversity of the region. Most islanders didn’t use a conservationist approach until the major cyclone Aila struck the Sundarbans in 2009. Things have been slowly changing since then. Aila has also pushed a bit the Government – another important actor within the system, towards taking climate change more seriously. Till then, the government had been mainly interested in infrastructural development, building roads and bridges… Although this kind of infrastructural development is clearly needed in a geographically inaccessible region like the Indian Sundarbans, people’s voices were routinely ignored while planning for “development”. For example, till now, when building concrete embankments, the government does not have any master plan for the rehabilitation of displaced people in the densely populated Sundarbans region. However, a group of other actors –the climate scientists – offer a solution to this issue by suggesting to relocate all people living in the Sundarbans into nearby towns and the mega city Kolkata. Their conservationist approach starts from the assumption of the shrinking of a major part of the delta around 2020, due to the increasing sea level. They reckon the land is better left to the tigers, in other words. This view has been challenged by another group of actors –the river scientists – who claim that the Sundarbans is an active delta and that erosion and accretion are part and parcel of the process and ecosystem. They think the people of the Sundarbans are resilient enough to tackle the changes in the climate and related consequences with the help of the other actors. When it comes to helping common people by providing services in vital spheres like health, education and disaster risk reduction, local and national civil society organizations, another key actor in the system, have been playing an important role for the last four or five decades. Although they started as voluntary organisations, the work of many of these civil society organizations has now become donor driven.

These five different actors are in continuous tension with each other, all with their own interests, incentives and power dynamics, occasionally aligning with one or another. The similarity with the global level is obvious.

A key question is: what does the Sundarbans area need to cope with its changing (climate) scenario, or at least what would be a way forward? One of the answers may lie in the creation of a common knowledge platform whereby actors from each of these five different sets would have a stake in improving the minimum knowledge base necessary to combat the huge challenges posed by a changing climate.

You can view his presentation in the HEART Talks video below, and read more about what his presentation covers on the HEART website.

The initiative, which started last year under the Maternal and Neonatal Implementation for Equitable Systems Study (MANIFEST), sees the three best performing health workers and health facilities recognised at the bi annual health workers symposium in each of the three districts.

The awards comprise a certificate and a solar light kit. Ms Anek Santurinah, a midwife at Kameke Health Centre in Pallisa District says the solar lamps have always come in handy at their facility where the maternity ward is yet to be connected to the electricity grid.

“We are no longer using candles and the little lights on our little cell phones. Life is a bit easy nowadays,” says Santurinah whose health centre sees most of the mothers delivering in the night.