Hello listeners and welcome to Connecting Citizens to Science, a podcast where we hear about the ways that researchers connect with communities across the world to solve challenges together. I'm Dr. Kim Ozano and today's episode is the fourth in a six part miniseries by ReBUILD for Resilience. ReBUILD is a research consortium that examines health systems resilience in fragile settings that experience violence, conflict, pandemics, and other shocks. Today we will be hearing about the complex world of non-state actors and informal providers in health systems. Our guests will discuss the legitimacy of non-state actors and informal providers in fragile settings from initial response to longer-term roles. Often we see humanitarian organisations step in during disasters or conflicts, absorbing these initial shocks, but they face challenges in transformation. In some settings, where local governments are either absent or dysfunctional due to war, political instability or a lack of capacity non-state actors often fill the void, but formalising their roles remains challenging. To delve deeper into these critical issues we have Dr Kyu Kyu Than, who is a public health specialist and a health systems researcher with a speciality in sexual reproductive and maternal health. She is also a medical doctor with a PhD from the University of Melbourne and is currently the research director for the Myanmar country programme at the Burnett Institute. She has been leading and managing a variety of research and service delivery projects for the Myanmar programme, which includes ReBUILD for Resilience. We also have with us Ayesha Idriss, who is a pharmacist and multidisciplinary researcher. Ayesha has worked on a range of groundbreaking projects in collaboration with international partners throughout her career. Ayesha has also contributed significantly to the National Institute for Health Research Unit on Health in situations of fragility and is a researcher with ReBUILD. And as always to help us guide the conversation, we have a technical expert, Dr Karin Diaconu, who has over 10 years' experience in health policy and systems research. Karen has worked across several contexts effected by fragility where health systems rely on the help of civil society and non -state actors or informal providers for the planning or delivery of care. Karen welcome to the podcast. Please do set us up by describing what non-state and informal actors are, and why is it important to consider them in fragile settings.

Thank you very much, Kim. In many settings, it is not just the formal health system that provides health services or support to populations. In many places and particularly in emergencies we see a large international NGO presence that comes in to support populations. But also, local groups, civil society groups, or informal providers who have been there in the countries for a long time, they also step in to support health of people and communities. So, Kyu Kyu and Ayesha, it would be great to hear what's the current situation in your countries and where do you actually see any informal or non-state providers.

Hello everyone and I'm from Myanmar, a beautiful country in Southeast Asia, but currently in a fragile and conflict state at the moment. We were faced by the COVID pandemic, and then after the COVID pandemic, there was a change of political situation, which created more fragility and conflict into the country. So, I think, within this fragility and conflict settings, we see a lot of non-state actors, we see a lot of donors, international NGOs, civil society organisations, and also, we must not forget the people like community health workers, and also some of the people working on ground as volunteers.

I'm Ayesha, I'm from Sierra Leone, which is a West African country, and Sierra Leone faces significant health challenges. Our health system is marked by history of underfunding and infrastructural weaknesses. We also have a lot of non-state actors like the international organisations, and also there are community based organisations, civil societies and the informal providers that provide services, especially in the remote areas, where these health facilities are lacking. And we have traditional healers, faith-based healers as well, and they come in, and because of the trust people have in them, they really help the health system during times of crisis and shock.

Could you talk a little bit more about that and what you've seen in practice, what they're actually doing and how they're supporting people?

So, because of the trust that communities have, especially in informal providers, like traditional healers within the communities, um, the health system was able to utilise them in containing the disease in terms of messaging, in terms of things that they should do with the Ebola. So, we're trying to respond to the Ebola as a health system, but we're really going nowhere, until they were brought in, because the idea of the Ebola was in terms of contact through the dead fluid. And we have our culture, for example, we have to wash the dead, you know, prior to burial. And that was still going on. So until they brought in these informal providers, they actually helped in sensitising, the communities and the people. So there was a massive change and turnaround in terms the spread of the disease. So, they do play a critical role, they're very critical because they're close to the communities, they trust them. And most of the time bringing them on, and sometimes even in campaigns... in what we're doing now with the ReBUILD that we're working at community levels, you know, they've reported that during campaign like immunisation campaigns, stakeholders and all these other community members, you know, coming in really had helped.

Yeah, I like to echo Ayesha's point on trust between the community and the non-state actors. For Myanmar during the COVID pandemic, the trust between the community and the non-state actors were really cohesive. We can see it in the first wave of COVID-19, the first and second wave, the country was in a real good state, everyone coming in together. When we look at non-state actors, even the private sector, which normally looks to profit, they even came in Covid and really got hand in hand and helping like getting beds, trying to move to quarantine centres and trying to help a lot of the COVID cases get their clinical care in their settings. And the second thing I think is coordination between non-state actors themselves, the INGOs, the CBOs and the community is also very important. The coordination was really perfect and, uh, understanding the context, it's also another important point that I see, especially during COVID-19 and even in the political crisis. Understanding the country context, and what is really happening on the ground, and trying to leverage some of the rules and regulation that they had from international agencies and some of the donors were really amazing, really tackling and reaching to the community.

Thank you very much. it's really interesting to see these non-state and informal actors coming in, and you've really painted a picture of their role during the emergency situation and straight after. I wonder if you could tell me a little bit more about how to ensure the safety and the security of these very important actors during crisis.

I think, especially for health care workers from all non-state actors, and even for state actors, I think security is the utmost importance. We really have to weigh between the security and provision of health services. For example, although you may want to be giving some of the drugs or some of the emergency commodities into a very conflict affected place, we really have to maintain the security aspect as the first entity, not to harm our healthcare workers, also at the same time ensuring that the support is given to the community. So, I think there were a lot of strategies and harm mitigation measures from a lot of non-state actors during the crisis. And we collectively normally share the mitigation strategies and what is happening on the ground. Like in this area, you should not go, there is fighting happening in this area. That means that really understanding and trying to get a trust in each other about each other, that's really important in crisis.

Thank you, Kyu Kyu. I'm interested about something that we were discussing earlier, particularly Ayesha, I think you brought this out quite nicely, that the formal health system had to reach out to informal providers. Could you just reflect a little bit more on what's happening on the ground and what the risks may be if these two do not communicate, or coordinate as Kyu Kyu would put it?

The informal providers are embedded in their communities and there's this trust, so I believe the formal sector should work closely with informal sector, you know, more in the rural areas where, um, facilities are lacking, and these informal providers are often the first point of contact for a lot of the population in these areas. So, they play that critical role. However, it depends on the type of informal providers because we have some like the drug peddlers or sellers, which come with more risk in terms of the services they provide because they're more financially driven. However, I believe there's a way in which the formal system should try to tap into the benefits, you know, and utilise these benefits of the informal sector providers because in doing so, no one kind of will be left behind because in terms of provision of services, even referrals and other things, they could, you know, help with that so that services will be provided in these underserved populations.

I think both you and Kyu Kyu have reflected a lot on what these non-state actors bring to the table, and what the informal providers bring in terms of assuring trust and rapid responses. I'm wondering if you had any examples of when you've encountered constraints or challenges in relation to the work that these non-state actors or informal providers may bring to, for example, securing health of people.

Currently, in our country context, there is a lot of conflict and active fighting in different parts of the country, especially around border areas. So, I think, we can say forced migration into another country, which is quite close to the border. So, when active conflict happens and forced migration happens, as you all know, there are a lot of diversity, legal boundaries, challenges towards one country and another. So, when we say emergency teams are in border areas, I think some of the rules and regulation between these countries need to be really flexible and understanding on the ground to reach to the people who are really in need. At the moment, for a country, non-state actors for example, you must sign a transportation safety protocol, but when you go there, that safety protocol is not, uh, really, uh, abided by. You have to change your route of planning or whatever, because that emergency. So, sometimes those have to be understood by the non-state actors as well, So, these are some of the small issues that we do face on ground, and I think it's really important that both the donors, non-state actors, and even the government of like conflict-affected countries and non-affected countries should be really tackling it together because we do need the togetherness in these crisis emergencies.

I agree with Kyu Kyu, you know that there should be way that they should work, you know, with the government. And during that time, you know when there's disaster, they provide their service in terms of the food, medication, you know, other things that they provide. Which during, um, the disaster or emergency, these parallel systems that are running are good at that time. However, when the situation is kind of over and in a stable state, it's kind of a little bit messy, you know, how to navigate during this stable time is sometimes difficult. If the government agencies really try and put things in, in place, work with them closely, I believe the overall health system will be improved, but these are some of the challenges.

That's a great reflection on how situations change and I guess it's also been a focus for us in ReBUILD to really reflect on how does this changing situation actually help strengthen the formal system, if you like, because they're doing a great service in the meantime, but we should also take some of the lessons further to the formal system.

I really enjoyed learning about this and, you know, those challenges have been very clear, so thank you for those descriptions. I'm wondering if all three of you, based on your experience and in your context and in your research, what advice would you give to actors in fragile settings, formal and informal, to improve health systems?

For me, the advice I'll give is um, we should not underestimate trust, so, try to build trust. You know, trust is key in gaining insights and knowledge, again, with minimum potential social bias that you may have from these providers, especially with the informal providers. So, some of the time when you work with them, they're sometimes a little bit secretive, but try to build trust and that rapport, rapport with them is very key. Also, working with them, I'll say, try to be open-minded and try to seek ways which the benefits of the work that they do could be maximised, you know, with minimum risk that they provide. And also, when working with non-state actors or informal providers that work at local level, try to see how community ownership could be brought on with your work because then when they leave, you want that sustainability, that's how you improve the communities.

Thank you, really highlighting the importance of trust, assessing risk, and developing that community ownership. Thank you very much. Kyu Kyu, please.

I think, with the lessons learned throughout these 3 years, working with non-state actors is sometimes when the formal system fails, uh, non-state actors must be coherent and also have trust between each other. Not only the trust with the community, but non-state actors themselves, the international community, the CBOs, the donors must also build trust within them and try to create a coordination body that would help the country when the real states fails. That doesn't mean that this parallel coordination mechanism has to be lifelong, because as the crisis ease out, this coordination mechanism may help other countries to learn how these non-state actors coordinate and build trust among them, and how the donors, uh, did some mitigation strategies and some of the activities. It's like a learning curve for crisis countries later on. So first it's non-state actors, between themselves, they must have trust and coordination. And the second thing is, I think we must not forget, like Ayesha said, that the ground people who are on the ground and who are really facing the difficulties. So, this may be seen from the outside world and people who are inside the country may see it very differently. So, I think, sometimes the outside world and the inside country and what's really happening on ground need to merge somewhere. So, there must be some information sharing and real insight sharing, uh, of communication mechanism so that people will really understand.

Thank you for that example. It's, it's really complex and important that we share that information and learn from it. Thank you. Karen, would you like to take us home with one last piece of advice?

I think my advice would actually build on both Kyu Kyu's and Ayesha's and really just bring home the idea that you have to think long-term and really privilege different ways of knowing and of coordinating. And I think oftentimes we stay at global levels and we talk about big INGOs and how we bring them in in emergency, but actually it's also about smaller actors and people on the ground, like all of you have been saying, who need to be there and who need to be brought in to the learning, the planning, the responding, and they have different ways of doing things, different ways of knowing, different capabilities, and maybe we should acknowledge that we have to build on that instead of setting it to the side.

Thank you very much. And that brings us to close of the episode. I've certainly learned a lot. Thank you to our guests and thank you to our wonderful co-host. For our listeners, thank you for listening. We hope you enjoyed the episode. This is the fourth in a six-part miniseries brought to you by ReBUILD. So, if you haven't heard the other episodes, please do revisit them for a more holistic view of health systems in fragile settings. Until next time, thank you and goodbye.