Leads: Prof. Tim Martineau, Liverpool University, UK Prof. Barbara McPake – Queen Margaret University, UK Date: 14 th May ReBUILD A brief introduction (Research for Building Pro-poor Health Systems During the Recovery from Conflict)

1.destruction of infrastructure; 2.flight of health professionals; 3.displacement of communities; 4.interruption of drug supply; 5.disruption of disease control programmes; 6.capacity for coordination, regulation and trust. Why ReBUILD ? Implications of conflict for health system functioning 2 Makerere University College of Health Sciences

Issues faced in rebuilding health system post-conflict 1.Pressure to produce quick and measurable improvements in service delivery; 2.Focus on urban areas where there is some health infrastructure – leaving rural areas without services; 3.Focused on alleviating immediate suffering than on planning for sustainability and long-term capacity; 4.Proliferation of non-state agencies (I-NGOs); 5.Aid mechanisms play important roles in rebuilding the system and health impacts (Kruk and Freedman, 2010) Coordination, contracting, regulation, joint financing schemes 3 Makerere University College of Health Sciences

Overall purpose and research hypothesis Purpose: to deliver new knowledge to inform the development and implementation of pro-poor health systems in countries recovering from political and social conflict. Hypothesis: decisions made in the early post- conflict period can set the long-term direction of development for the health system – path dependency 4 Makerere University College of Health Sciences

Research Themes Focus is post-conflict health system; Research themes: 1.Health Financing; 2.Human Resources for Health; 3.Intersection Between 1 and 2: Incentives for workforce management Contracting for health systems Aid architecture and effectiveness 5 Makerere University College of Health Sciences

Consortium Structure (2011 – 2017) The consortium is structured so that we have two perspectives on this hypothesis: 1.Distant conflicts (Cambodia and Sierra Leone) What was done years ago? Can we trace the implications of those decisions for todays health systems? 2.Recent conflicts (Zimbabwe and Northern Uganda) What can be implemented? How does the environment of the immediate aftermath of conflict constraint that? North – South Partnership (Liverpool & Queen Margareta Universities) Leadership of the consortium; Capacity Building, Knowledge Synthesis and Uptake Implementation partnership – Uganda MOH, Prime Ministers Office, CSOs in Gulu Gulu University – Institute for Peace and Strategic Studies 6 Makerere University College of Health Sciences

Background to post-conflict northern Uganda 20 year conflict from 1987 – 2007: Lords Resistance Army; Most affected districts = Kitgum, Pader and Gulu: 1.8 million people displaced by early 1990s; Congestion of towns & social facilities (hospitals & churches); Influx of humanitarian assistance 1990s – early 2000s: Camp-based health care services. Transition from camps to home environment since 2007; How is the health system transforming to to meet the needs of resettling communities? 7 Makerere University College of Health Sciences

Study Area: Acholi Sub-region 8 Makerere University College of Health Sciences

Transition back to rural settlements 9 Makerere University College of Health Sciences

Hardware Interventions by Govt and Development Partners Makerere University College of Health Sciences 10

Makerere University College of Health Sciences 11 Hardware Interventions by Govt and Development Partners

Software Interventions Re-establishing livelihoods Re-institutionalization of community structures –Markets & production –Leadership & community level organizations –Gender relationships –Collective governance and accountable systems 12 Makerere University College of Health Sciences

Interventions – Other Health Determinants 13 Makerere University College of Health Sciences

Thematic Studies for ReBUILD in Uganda 1.Health Financing (project 1) Evolution of household-level expenditures for health care 2.Workforce Recruitment (project 2) Process evolution for workforce posting 3.Workforce Incentives (project 4) Evolution livelihoods & incentives for workforce 4.Aid effectiveness (project 5) Evolution of inter-agency relationships for service delivery 14 Makerere University College of Health Sciences

Updates 2011 Rebuild Launch and Stakeholder consultationsAnnual Consortium Meeting Makerere University College of Health Sciences

Methodology Mix Secondary data analysis: Household surveys (1990s to 2010) Econometric analyses - health expenditures Qualitative inquiries: Livelihood of poor households - health expenditures Livelihoods of health workers & their incentives Systems mapping: Recruitment and posting process of workforce Social network analyses: Organizational surveys for aid effectiveness for key health services 16 Makerere University College of Health Sciences

Research capacity building - challenges and opportunities Sustaining researchers capacity as it is created: High attrition of Health Systems Scientists Need to anchor individuals within institutions thru research etc; Longer-term research grants to academic institutions work well; Making research institutions attractive: Institutional support systems; Laboratories, management capacity; Overhead costs and related policies Expanding research partnerships: North-South and South-South partnerships Benefits from partnerships; Need to re-balance power and resource allocation 17 Makerere University College of Health Sciences

Models for Research Capacity Building 1.Multi-theme Knowledge Programs – DIFD 1.Health Systems, Disease control, etc 2.Theme specific funding: Biomedical Research - KEMRI-Welcome Trust Research Programme Health Systems – Health Systems Trusts by South African Govt. 3.Institutional capacity grants: Welcome Trust – THRIVE Project Consortia: Institution to institution – University Twining program by the Gates Foundation 18 Makerere University College of Health Sciences

THANK YOU Makerere University College of Health Sciences 19