Better Health For All

By Nadeem Hasan

I’m five months into a year-long stint in Sierra Leone as one of the global health fellows for 2016/17. I hope to blog about the positives of the experience, hence the format ‘in praise of’.

After all, there’s enough negativity around as it is.

I’ll be working in the Ministry of Health and Sanitation (MoHS) in Freetown, supporting their mission to strengthen the health system following Ebola, and learning as much as I can along the way.

Predictably, I’ve already learned a lot more than I’ve contributed.

I’m engaging with the financial and capacity challenges in the MoHS; the political challenges; and the complexity of operating alongside the World Health Organisation, the World Bank, UN agencies, and hundreds of NGOs and private sector implementing partners. And all of that before even getting to the content of the day-to-day work of the ministry.

Accordingly, I don’t feel too bad about the learning overshadowing my own contributions.

Not being sure what to expect when I got to my office, what first struck me was the sheer number of international staff embedded in the MoHS. I found technical experts from the Clinton Health Access Initiative (CHAI), Oxford Policy Management (OPM), Overseas Development Institute (ODI), USAID and others – all with desks inside the ministry, working hand-in-hand with national staff.

Foreigners everywhere. And now here I was adding to their number.

The ability of the ministry to pursue its goals should be improved by international experts working together with their national counterparts: on the face of it, it’s a win-win situation. However, the sheer number of international staff also leads to challenges for sustainability and country ownership of health policies and programmes – and if not managed carefully could have a negative impact in the long-term.

So what’s the appropriate balance?

Three months in, it’s clear that these long-term embedded experts have had the time to build strong relationships with their national counterparts. Through these relationships, they’ve been able to develop a deep understanding of the local context – including the enablers and barriers to successful design and implementation of policies and programmes.

Crucially, a lot of this information isn’t written down anywhere (for very good reasons), and can only be gathered through living in the country.

As a result, these individuals end up being highly skilled in their ability to compare and contrast what the evidence and data says should be done to improve health outcomes, with what can actually be achieved on the ground at any given time. Importantly, this requires taking into account the personal relationships that exist between key individuals.

Compared with short-term consultants that ‘parachute in and helicopter out’, they’re highly valued by senior national staff in the MoHS for their expertise and sensitivity to the local context. And, I think, rightly so.

All of this is fine of course, but what about the questions of country ownership (what happens after external ‘experts’ have done their bit) and sustainability (what happens when they leave)?

Well, I’ve watched how some of the more seasoned experts resist the temptation to look at the evidence and data and write the ‘ideal’ policy or strategy, presented with a shiny bow, only for it to sit gathering dust on a shelf.

Instead, they work on the sidelines; gathering the relevant data on a topic and developing the questions for discussion by national actors. They support the process of convening national actors to discuss the best way forwards without taking too active a role in those discussions themselves. They therefore support leadership by national staff, which in turn generates the momentum and wider ownership required for success.

The ‘capacity building’ aspect is harder to see at the central level than in a health facility, where the traditional ‘teaching and mentoring’ approach is more appropriate.

At the MoHS, knowledge and skills are shared (both ways) through building trusting relationships with national staff and working together on routine aspects of the job. The mutual respect that this generates in turn increases the rate of knowledge and skills transfer.

Accordingly, the longer the expert is embedded in the team, the more effective the process. In this way, the sustainability of the work done and approaches taken by international staff is to some extent ensured.

A major challenge comes in the form of convincing donors focused on results that this long-term, ‘softly, softly’ approach with no concrete ‘measurable’ outputs is worth the investment – but that’s a whole other issue.

This is of course a rose-tinted view, but the blog is, after all, entitled ‘in praise of’.

Thinking back to practice in the UK, I wonder whether there is a broader relevance of this approach for ‘health in all policies’. Embedding public health specialists in non-health teams on a long-term basis can have two major benefits. First, the use of a robust evidence and data-led approach to policy making that considers the health impacts of non-health policies. Second, the contextual understanding of how to do achieve this effectively under the leadership of the host team (thereby ensuring sustainability).

Comparing Sierra Leone to, for example, the Department for Education in Whitehall might seem odd at first glance. However, for a public health specialist they’re both new contexts that have to be learned and understood before being able to operate and influence effectively, and both places where our skillset and approach could lead to significant improvements in health outcomes.

I know this is already happening in some places such as Transport for London. If it is anywhere near as effective as it is in Sierra Leone, then we could do with a lot more of it.

Nadeem Hasan is a public health registrar

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By Professor John Ashton

The statue near the site of the Christmas truce football match.

Granny Ashton’s half brother, my great uncle Arthur Anderton, died on the Somme in 1918.

According to the Commonwealth War Graves Commission, ‘Private Arthur John Anderton 283444, serving with the 2nd/ 4th Battalion, London Regiment (Royal Fusiliers), died on 25 April. Sadly he has no known grave and therefore he is commemorated by name … on Panel 86 on the Pozieres Memorial, France. Pozieres is a village about 6 kilometres north-east of Albert.’

Great uncle Arthur was from Liverpool but unlike many of his fellow Liverpudlian victims of the First World War his name does not appear with the thousands of others on the walls of the memorial room in Liverpool Town Hall. Rather, at the time of his death resisting the last German attempted push to Paris in the dying months of the war, he found himself in a London regiment.

Reading the daily log of his commanding officer, as we retraced his final weeks’ footsteps some years ago, the reason becomes clear. A typical morning entry would record that two or three hundred men had joined the regiment and an evening entry would record that at least a similar number were missing presumed dead, with no body to be found.

The result was a constant forming and reforming of battalions.

Spending several days immersed in the tragedy of such inhumanity, I was struck by the relatively small size of the battle area of the river Somme; space which saw so much death and maiming.

I was also reminded that this tragedy affected so many nations and people. Arriving at the cemetery at Poitiers we were surprised by the arrival of two young Germans on a motorbike whose relative was remembered in a British cemetery. Tears were never far from my eyes.

That trip made a lasting impression on me and the fragility of the peace of 1918 and that of 1945 has become ever more apparent as our 21st century world fragments, instability and ancient hatreds return and battle lines are drawn up. On average, in recent years around 200,000 people have been killed in conflict each year.

In the First World War 90% of those killed were soldiers and 10% civilians. Today that ratio is nearer 25%:75%. Never has it been more important to learn the lessons of history.

So this year when political biographer Sir Anthony Seldon decided to do something about establishing the Western Front as a cultural reference point for peacemaking, I was up for the challenge.

While writing a book about the First World War, Sir Anthony came across the story of Douglas Gillespie who was killed in the Battle of Loos in September 1915. Shortly before his death, Douglas had suggested in a letter home the creation of a ‘Via Sacra’ when the war was over. He wanted it to run from Switzerland to the English Channel, a secular pilgrim route to help future generations understand the need for peace.

And so, on 22 June this year, a varied group of us met on the steps of the Mairie in Pfetterhouse, close by the Swiss-German-French border, and set off to walk north to the Channel. It was a remarkable experience. It was bitter-sweet; poignant and sad; a significant challenge; great fun; and a unique opportunity to share in an adventure with some remarkable people.

In some ways it felt like a contemporary re-run of Chaucer’s Pilgrims Tales; everyone had stories to tell, including Gillespie’s descendants and others who had lost family or had family members taken prisoner of war.

But it was also a three dimensional education.

On the second day we got lost in the Vosges mountains in temperatures well into the 30s and discovered the price the French paid to hold the Germans in the south, dug in for the freezing winter of 1914 at 3000 feet.

On the last day of June we reached the Somme itself, ready for the centenary ceremonies near Albert the next day and I felt the spirit of Great Uncle Arthur once again. We moved on to Vimy, Armentieres, Ypres and Passchendale; past the spot where a British soldier spared Adolf Hitler’s life and where Winston Churchill served his country.

We passed by the ever so poignant field of the Christmas truce and the football match, now part of folklore (the statue commemorating the truce is in the photograph above). We walked on past the Menin Gate with English schoolchildren laying wreaths at the sound of the Last Post; and finally to the coast at Diksmuide, where a local farmer had the presence of mind to open the sluice gates, flood the marshes and cut off the German troops.

Sir Anthony’s vision is of a long distance path which will be trodden for hundreds of years to come; perhaps long after the Commonwealth War Graves Commission has ceased to exist.

It is a necklace-like path punctuated by educational oases – like the remarkable little museum created out of a German medical field station in Cernay, where we were shown such hospitality by the local mayor. A path which will engage with future generations and steer them away from the path of intolerance, hatred, war and death. A path which will mean no more great uncle Arthurs cut down in the prime of life.

It is Sir Anthony’s intention to repeat this year’s walk in 2017 and 2018. You can find details on the Via Sacra website (http://www.viasacrawalk2016.org.uk/).

John Ashton 7 November 2016

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