Hello listeners and welcome to the Connecting Citizens to Science podcast. I'm Dr. Kim Ozano and I am joined today by the Centre for Health System Strengthening at the Liverpool School of Tropical Medicine. We have a brand new two part mini series for you focused on health system strengthening, what it is, how to do it, and what action is needed to ensure that the approach is embedded in discussions at key global events and discussion platforms. This episode is the first of two, and today's guests are Dr. Joanna Raven and Dr. Kerry Millington. Both have been working in global health for over 20 years and are passionate about embedding both health system strengthening approaches and community knowledge into political commitments and policy reforms. Our follow up episode, will hear from communities about the mechanisms they are using to get their voices heard and actioned in health system strengthening initiative. Well, we need to know what this means more in reality. So I have a wonderful co host with me, Dr. Uzo Egere. Uzo, welcome to the podcast. Tell us a little bit about yourself and then set us up a little bit about why is health system strengthening so important?

Hi, Kim. Thank you for having me, and hello colleagues. Yeah, so I'm Uzo, and um, I'm a pediatrician by training. In the past few years I've been involved in research in public health, but more importantly in implementation research around health systems and health systems strengthening childhood tuberculosis and all that. I come from a setting where health systems are really weak and fragile. Coming from that kind of setting, you can understand my interest, um, in, in the topic today. We know the world is ravaged by so many conditions, things like tuberculosis, things like malaria, we're still struggling to deal with these diseases. And we know that there's no way we can make a headway with weak, um, health systems. I'm glad that we've got Jo and Kerry here today and, uh, they are the experts. So I would like to ask Jo, Jo, can you tell us what exactly is health system strengthening?

Okay, thanks, Uzo. I'm very happy to be here to talk about this extremely important topic of health system strengthening. So let's think about what a health system is to start with. So a health system is all the organisations, peoples and actions whose primary sort of purpose is to promote, restore or maintain health. And what do we really mean by that? It's, it's the people who provide services. It's the communities who engage with those services, the buildings that we provide services in, whether it's a small clinic in northern Uganda or a large tertiary hospital in Nepal, or under a tree! It's the drugs and treatments and how these are all organised and governed. And I think there's a real big need to strengthen these health systems, to make them resilient, so that they can deliver quality and equitable health care services at all times, including when there are shocks such as COVID, Ebola, earthquakes, conflicts, but also managing those long term stresses, such as economic pressures, so the health system can adapt and respond, delivering services needed at that time, but ensuring that routine services are maintained.

It's so interesting to know that virtually, um, everything that we do affects health system.

Building on what Jo says is that really having a strong, resilient, sustainable, inclusive and effective health system are critical for effective responses to ensure that people have access to the quality care that they need it when and where they need it. I work in the field of tuberculosis and health system strengthening is really a foundation block to support an effective response to ending this TB pandemic, but we can also see that the response to TB also contributes to strengthening the public health functions to prevent, prepare and respond to new pandemics, new health threats, like antimicrobial resistance, and the health impacts of climate change. So ensuring that these health systems are resilient to what is coming. This was seen during COVID, for example, when TB functions, such as infection prevention and control that were already in place were then leveraged to strengthen the response to another airborne pathogen, such as COVID 19. So you can see the interplay between the diseases and the health system and how they can benefit each other and how essential they are for each other.

I think it's really clear how important it is to strengthen health systems. I think the case is there. So, the Centre for Health Systems Strengthening at the Liverpool School of Tropical Medicine, what does the centre do and how can it influence political commitments and policy reforms?

The Centre for Health Systems Strengthening, or CHESS for short. It's a group of researchers, of programme managers, of PhD students working at Liverpool School of Tropical Medicine, coming together who have a common passion and goal for strengthening health systems to promote better and improved health and well being amongst the poorest and the most marginalised in low and middle income countries. And we're researchers, so we do research. That's what our strength is, and we share learning and resources about health systems, and develop and deliver leading edge health systems research with our partners to have policy and practice impact. Also we've got a range of research that looks more sort of at the, at the health system in general. So things about leadership of the health system. How do we make sure that, um, the leaders of the health system at all levels of the health system, so whether it's a facility or at district level or at the national level, have got these approaches to strengthening the health system that has that equity at the heart of it. Um, also a lot of work on health workforce. Now that's an area I'm absolutely and utterly passionate about. I'm a health worker by background. I was a midwife and a nurse for many years and I've worked in lots of different settings with that. So I know what it's like to be sitting in a health system, wanting desperately to provide good quality services and really look after the people that are in my community and area, but know what the, the health system challenges are.

There is that kind of real engagement with the community, the health care workers really want to provide a quality service for people in their community to enable them to access care when and where they need it, without fear of stigmatisation, without fear of financial hardship. And what we do here in CHESS is to ensure that when we are developing the research, we really are engaging with those communities to fully understand the problems, the root causes of those problems, and to work with them to co-develop the research that we're doing and to ensure then that their research findings are then taken up into the communities, so that our research has impact on the health outcomes of those people's lives and their families and communities.

Thank you, Kerry. I would just say, when both of you were talking that it's obvious that what you're doing is so important, especially in the lower middle income countries where most of the need for health system strengthening lies. And it'd be interesting to know how you're engaging the policy pathway in some of those settings.

Thanks, Uzo. I can give a really timely example, I've just come back from Zimbabwe, uh, last, late last night, uh, where I've been working with a group of people there. So, it's a research institute in Zimbabwe, but also we've got a group of researchers from Nepal, so it's going to be a cross country research programme that's looking at how to strengthen the health workforce to be able to respond to the health impacts of climate crisis. So, uh, a really important topic, and we're taking that sort of health workforce, health systems lens to that. And what also we did was we've been bringing in policy makers and health workers to develop this research proposal. So at this workshop, we had the director of medical services from the Ministry of Health in Zimbabwe at that workshop to help us design that research, to make sure that it's relevant and feasible. That make sure that we're answering the questions that they want to have answered so that our research findings are going to be useful. They're going to be relevant. They're going to be timely for that policymaker to pick up and use to develop his policies, develop sort of practice, et cetera. He said, I remember listening to him and he said, "I am desperate for evidence. I'm desperate for evidence to strengthen our health system, to enable us to be able to cope with this, this, this challenge. I don't want to be at the end of the research, receiving some findings, I want to be part of that research now today", and he was really happy to be involved in developing that research programme.

I think you really draw out some key points there. Different stakeholders have to be engaged right from the beginning to have those conversations to try and understand and build up that evidence to inform policy and practice. Jo's talked about what the discussions that have been having in a research programme at the national level, but that's also scaled up to the highest level at the United Nations in New York. And this year, there are three health meetings, called high level meetings, that are focusing on the fight against tuberculosis, pandemic prevention, preparedness and response and universal health coverage. And it's recognised at that level, and what's tried to happen is they've tried to align across the political declarations that will come out of those three meetings, because they recognise the interdependency of all of these different approaches and applying a health system strengthening lens to that thinking behind what goes into those political commitments at the highest level. But what will happen is once we get those political commitments, you then take them back down to your country to say, within our context, how can we now apply these commitments that have been made at the global level? What works for us? Perhaps what can we do in addition to this within our settings? Does it apply across the country or are we particularly focusing on key and vulnerable populations, which is those that we really need to reach by strengthening the outreach of our health system to those who most need it? We are research groups that provide evidence about what works, and why, and in what settings. So all that sort of granular detail is really important when it comes to country sort of perspectives, isn't it, to understand what works and why in that particular setting and how can we learn that. How can we take that learning and apply it to different settings to make sure that does strengthen the health system in that particular setting I think it's really important and it lends us, lends it to the types of research that we do within CHESS.

I think that's really useful, both the examples and how the different levels of advocacy are needed to make sure health system strengthening is embedded in decisions. Kerry, we have a lot of listeners who work in global health and they will want to know how they can influence high level meetings to make sure that health system strengthening cuts across all the different programmes. We see a lot of programmes working in silos and a lot of funding streams working that way, but the Centre for Health System Strengthening, it seems like there's a real advocacy to have a health system strengthening approach that cuts across these. Have you got any suggestions?

I think global health diplomacy is a new field and how to operate in that field is new to academics and healthcare professionals. And the experience that I've had by getting involved this year with particularly the high level meeting on tuberculosis, the area I work in, is kind of, coming together within your own community to go through it together, make connections, share intel, learn how the United Nations works and how you can put a suggestion forward on an intervention in your three minute slot that you're kind of given. I think really working together, um, is key to understanding health diplomacy and how you can be of use to ensure that you are informing the process with the evidence that you've generated within your own research. It then gets taken into context of diplomacy. So there are a lot of other things that play also, um, but I think to be able to be at the table with affected communities and their advocates is a really strong and powerful force, and enables so much more than just attending a meeting, but enables those connections to then continue.

I think it's amazing that those of us who are researchers are beginning to now get seriously involved in advocacy. It was heartbreaking for me, say 20 years ago, practicing in Nigeria and in the Gambia, and you see that there are interventions that have been working in the developed countries for decades and they haven't yet begun to be implemented in the settings that, you know, don't have those resources, where health systems are weak. One of the big problems was the gap between scientists who do the research and those who do the implementation, those who run the systems, the health workers, the people in government. So it's really good to see these efforts coming together. Co-creating, we are co-creating interventions, co-creating designs of, um, interventions with the people who are directly involved in it and representing them at the highest levels so that we bridge that gap and ensure that it doesn't take forever for interventions to begin to benefit the people that need it.

So Jo, it sounds like process is really important here, and sharing process across different contexts.

Obviously context is particularly important, but there are sort of higher level learnings. There's synthesising sort of learning from different research programmes about the sort of things to strengthen the health system. So, you can take the examples from the different research, but then pull that together and say, actually, this is what would work and this is why it will work, and this is in what settings it would particularly work well. We do a lot of work on community health workers and how to support and manage that critical cadre that sort of really links the communities to the health system. What can we do to support them? Many of these community health workers are women, you know, they've got their family, their households to look after. So they're juggling multiple, multiple things. So it's not only looking at it from a health systems lens, but also from a gender and equity lens in terms of the workforce. So we've got lots of learning that we've shared with in our website and through the individual programmes as well.

I work on the LIGHT research programme, funded with UK AID, and what we're trying to do here is think about gender equitable access to TB care and prevention recognising that you need to think through what are the challenges different genders have in accessing care they need. If we can get over those challenges of why people aren't accessing the services they need and get that delivery mechanism running well, that as new tools come through, or as we need to pivot to responses, to challenges that are coming, be it pandemics, climate change, health threats, such as antimicrobial resistance, we can ensure that we can still deliver the service that we need to those people because they're able to easily access that without the fear of stigmatisation, without fear that they can't get there because the clinic isn't open or accessible or nearby.

That's really useful to hear. We've talked about integrated health systems in our past episodes and it sounds like that does relate to that. Kerry, just sticking with you for a moment, I know that you've worked quite a lot with advocates and experts by experience, and we're going to be hearing from those people in our next episode who are from the community and have quite key roles in high level meetings. Can you tell us a bit about how that works in practice, how are they listened to? Is it, well, are their voices heard and actioned on or do we need to do more?

I think there's a spectrum of when they're heard. I'm particularly proud of the TB field that at the multi stakeholder hearings in May in New York at the UN, the affected voice of TB survivors was given a primary slot at the opening and closing of the stakeholder meeting. So we could really hear what they're saying to us and making sure that we are kind of listening to that. I think we have to bear in mind that this is within the wider context of global health diplomacy. So we are there to say our voice, we are there to kind of offer our information that we have from the evidence or experience that we have as a TB community. Um, but then it can get taken up into the more wider diplomacy space. So, I think we have to realise all of that, but we have to try, and when we think things aren't quite right, we keep on going and saying, well, actually, have you really covered this particular aspect, which we think community is really important. Um, so yeah, I, I think it's important that their voices are not only heard within their own communities, within their national communities, but also at the global level too.

I was recently at the Global Forum for the Health Workforce that was held in WHO in March, and one of the absolutely amazing things that happened there was having health workers there. Health workers from all, all across the globe were there; prime position talking about their experiences. This was in particularly following COVID and the challenges and trauma that they experienced during that time. They had this song and dance that they did, that they delivered. And it had everyone up on their feet crying and crying. I mean, even like Dr. Tedros was like... It was obviously very, very emotive and emotional. So, it was sending a very powerful message to the, um, the forum and the decision makers about supporting the health workforce.

Kerry, you mentioned inter-country learning, which is also dear to my heart. And I think it's one beautiful opportunity that we have with health system strengthening to leverage, um, learnings from different countries to benefit each other. So I also wanted to find out, you know, are there other ways in which you share learnings within CHESS? Whether it's within the research groups or in countries that are involved.

Well, we meet. We share resources, we share our papers, we talk about different themes, and we develop research programmes together, um, so that's where we're learning, that's where we're sharing examples and producing that synthesised findings for people to take up. Also, within our smaller groups within CHESS, we have fora for presenting our findings, like Health Systems Global, for example, which is a research uh, symposia that has policy makers and from across the world, but also global sort of level policy makers. We think about targeted communications at the right time with the right people we know who to speak to. We know how they would like to receive sort of information, and how to engage them in that research as well. We've got that depth of knowledge and experience that we can make sure that our research doesn't just sit on a desk or in a book or in a journal, it is actually impactful, maybe at different levels, you know, maybe it's at health worker level or facility level or district level or national level or global level, but it just doesn't sit in a paper. It's across everywhere.

I think this knowledge translation is really important to understand more. Kerry, the term global health diplomacy, you said this is quite a new discipline, quite a new area. For our listeners, if they want to understand a little bit more how to be involved in global health diplomacy, where can they find out more? Where should they start?

I think there, um, has been a lot of discussion about, um, the boundaries between where we can and can't influence. So, we are academics doing research and healthcare workers with experience at the front line. So, we can inform policy and practice, but we're not elected politicians. So, I think there has to be a careful discussion at that interface about how we can inform, but we're not making the decisions, but we need to be in a position to provide that information, as Jo alluded to before, they want to be informed. They want to know what's going to work for the benefit of why they're in their roles for their society, and especially when resources are constrained. So, how can we think, you know, well, if we strengthen the health system, this is actually going to benefit tuberculosis. It's going to benefit universal health coverage. It's going to get us ready to really be better prepared to respond to the pandemic of tomorrow. So, it's that, that wider context thinking, and I think having those relationships, drawing on the different stakeholder groups, when you need to be informed in that way and having those trusted relationships enables that exchange of information both ways. And also thinking, as we're talking with the policymakers, ensuring that we're asking the right questions in research and that we're not going off on a tangent, but this is actually going to be relevant. And when is it going to be relevant? So having that exchange of knowledge.

Perfect. Wonderful. Thank you very much. So Uzo, I have learned a lot today, and I am sure you have too. What's your take home from the conversation today?

I think for me, health systems strengthening is everyone's business. We must continue to have that very strong, healthy relationship between researchers, health workers, decision makers at all levels, politicians, community if we are going to go anywhere towards achieving the universal health coverage and improving the health of people. This is what comes up for me very strongly today.

I would agree. Jo, take home message from you, please.

If we really want to influence policy and practice at the global, national, district facility level, then we need to understand who we're talking to, what do they want to hear about and how they want to hear about it, and have the evidence ready in that sort of package that people will say, wow, I want to listen to that and I want to take forward with that. So that's, that's what we've got to do.

Thank you very much. And Kerry, take us home with your takeaway message.

it's, it's really kind of joining and engaging with the community in which you work to understand different perspectives, understand different processes that are going on, and how you can all inform each other and have a voice at the table where every voice is, is important. And so being part of that community, making those relationships, uh, trusted and credible relationships, um, having the intel, because you can't be everywhere all of the time and trying to understand how you can really ensure that evidence informs policy and practice.

Thank you very much. I think that's really important to talk about, trusted relationships and speaking of which, I think it's really, really impressive that CHESS wanted not only your perspectives as researchers, but to hear from the community as well. So to our listeners, please tune into the next episode where we will hear the perspectives from communities who are experts by experience, about how they think health system strengthening can be embedded in high level meetings and advocacy globally, nationally, right down to that health facility level. Thank you for listening. As always, do like, rate, share, and subscribe so we can continue to bring you discussions like this. And until next time, bye for now.