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