Browsing by Person "Raven, Joanna"

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Health justice in fragile and shock-prone settings: from theory to practice towards building resilient health systems
(BMJ, 2025-09-10) Loffreda, Giulia; Regmi, Shophika; Khalil, Joanna; La, Thazin; Idriss, Ayesha; Raven, Joanna; Witter, Sophie; Mansour, Wesam
Health justice is an emerging imperative in global health and health policy and systems research, particularly in fragile and shock-prone settings where inequities are deepened by political instability, conflict and structural violence. This practice paper explores how the ReBUILD for Resilience consortium has sought to operationalise health justice as a guiding principle and embedded practice in four diverse contexts: Myanmar, Nepal, Lebanon and Sierra Leone. Drawing from political philosophy, public health ethics and the capability approach, we outline a framework that positions health justice not only as an aspiration but also as an actionable, community-rooted agenda that centres equity, power redistribution and inclusive governance. Through participatory action research, political economy analysis and embedded learning sites, the ReBUILD teams engaged with communities and health system actors to co-create interventions that respond to local needs while addressing entrenched exclusion and marginalisation. Country experiences demonstrate both the potential and challenges of advancing health justice: from establishing inclusive Municipal Health Committees and revitalising health facility governance to promoting leadership among marginalised groups such as people with disabilities and displaced populations. This paper reflects on tensions around facilitation, participation and positionality and acknowledges the broader political economy, subnational, national and transnational, that shapes opportunities for transformation. We argue that health justice must be pursued through politically astute, reflexive and participatory research approaches, grounded in long-term relationships and a commitment to amplifying community voices. While the road is complex and contested, the pursuit of health justice is essential for building more equitable, inclusive and resilient health systems in the face of protracted crises and global inequities.
Health workers' experiences of coping with the Ebola epidemic in Sierra Leone's health system: A qualitative study
(BioMed Central, 2018-04-05) Raven, Joanna; Wurie, Haja; Witter, Sophie
The 2014 Ebola Virus Disease epidemic evolved in alarming ways in Sierra Leone spreading to all districts. The country struggled to control it against a backdrop of a health system that was already over-burdened. Health workers play an important role during epidemics but there is limited research on how they cope during health epidemics in fragile states. This paper explores the challenges faced by health workers and their coping strategies during the Ebola outbreak in four districts - Bonthe, Kenema, Koinadugu and Western Area - of Sierra Leone.
How do health workers experience and cope with shocks? Learning from four fragile and conflict-affected health systems in Uganda, Sierra Leone, Zimbabwe and Cambodia
(OUP, 2017-11-11) Witter, Sophie; Wurie, Haja; Chandiwana, Pamela; Namakula, Justine; So, Sovannarith; Alonso-Garbayo, Alvaro; Ssengooba, Freddie; Raven, Joanna
This article is grounded in a research programme which set out to understand how to rebuild health systems post-conflict. Four countries were studied-Uganda, Sierra Leone, Zimbabwe and Cambodia-which were at different distances from conflict and crisis, as well as having unique conflict stories. During the research process, the Ebola epidemic broke out in West Africa. Zimbabwe has continued to face a profound economic crisis. Within our research on health worker incentives, we captured insights from 128 life histories and in-depth interviews with a variety of staff that had remained in service. This article aims to draw together lessons from these contexts which can provide lessons for enhancing staff and therefore health system resilience in future, especially in similarly fragile and conflict-affected contexts. We examine the reported effects, both personal and professional, of the three different types of shock (conflicts, epidemics and prolonged political-economic crises), and how staff coped. We find that the impact of shocks and coping strategies are similar between conflict/post-conflict and epidemic contexts-particularly in relation to physical threats and psychosocial threats-while all three contexts create challenges and staff responses for working conditions and remuneration. Health staff showed considerable inventiveness and resilience, and also benefited from external assistance of various kinds, but there are important gaps which point to ways in which they should be better protected and supported in the future. Health systems are increasingly fragile and conflict-prone, and shocks are often prolonged or repeated. Resilience should not be taken for granted or used as an excuse for abandoning frontline health staff. Strategies should be in place at local, national and international levels to prepare for predictable crises of various sorts, rather than waiting for them to occur and responding belatedly, or relying on personal sacrifices by staff to keep services functioning.
Internal contracting of health services in Cambodia: drivers for change and lessons learned after a decade of external contracting
(BioMed Central, 2018-05-22) Vong, Sreytouch; Raven, Joanna; Newlands, David; ** Funder: Department for International Development, UK Government; Grant num: Grant PO 5247
Since the late 1990s, contracting has been employed in Cambodia in an attempt to accelerate rural health system recovery and improve health service delivery. Special Operating Agencies (SOA), a form of 'internal contracting', was introduced into selected districts by the Cambodia Ministry of Health in 2009. This study investigates how the SOA model was implemented and identifies effects on service delivery, challenges in operation and lessons learned. The study was carried out in four districts, using mixed__methods. Key informant interviews were conducted with representatives of donors and the Ministry of Health. In-depth interviews were carried out with managers of SOA and health facilities and health workers from referral hospitals and health centres. Data from the Annual Health Statistic Report 2009-2012 on utilisation of antenatal care, delivery and immunisation were analysed. There are several challenges with implementation: limited capacity and funding for monitoring the SOA, questionable reliability of the monitoring data, and some facilities face challenges in achieving the targets set in their contracts. There are some positive effects on staff behaviour which include improved punctuality, being on call for 24__h service, and perceived better quality of care, promoted through adherence to work regulations stipulated in the contracts and provision of incentives. However, flexibility in enforcing these regulations__in SOA has led to more dual practice, compared to previous contracting schemes. There are reported increases in utilization of services by the general population and the poor although the quantitative findings question the extent to which these increases are attributable to the contracting model. Capacity in planning and monitoring contracts at different levels in the health system is required. Service delivery will be undermined if effective performance management is not established nor continuously applied. Improvements in the implementation of SOA include: better monitoring by the central and provincial levels; developing incentive schemes that tackle the issues of dual practice; and securing trustworthy baseline data for performance indicators.
Learning sites for health systems research: Reflections on five programs in Africa, Asia, and Central America
(2024-12-04) Witter, Sophie; Regmi, Shophika; Raven, Joanna; Nzinga, Jacinta; van der Merwe, Maria; Flores, Walter; D'Ambruoso, Lucia
Introduction: Learning sites have supported intervention development and testing in health care, but studies reflecting on lessons relating to their deployment for health policy and system research (HPSR) in low‐ and middle‐income settings are limited. Methods: This experience report draws from learning over three continents and five research and community engagement programs—the oldest starting in 2010—to reflect on the challenges and benefits of doing embedded HPSR in learning sites, and how those have been managed. Its objective is to generate better understanding of their potential and constraints. The report draws from team members' experiential insights and program publications. Results: Challenges relating to initial engagement in the sites included building and maintaining trust, managing partner expectations, and negotiating priority topics and stakeholders. Once the embedded research was underway, sustaining engagement, and managing power dynamics within the group, supporting all participants in developing new skills and managing rapidly changing settings were important. Finally, the complexity of reflecting on action and assessing impact are outlined, along with potential approaches to managing all of these challenges and the variety of gains that have been noted across the programs. Conclusions: We highlight the potential of learning sites to develop relationships, capacities, and local innovations which can strengthen health systems in the long term and some lessons in relation to how to do that, including the importance of stable, long‐term funding as well as developing and recognizing facilitation skills among researchers. Supporting spaces for learning is particularly important when health systems face resource constraints and everyday or acute stressors and shocks.
Leaving no one behind: Lessons on rebuilding health systems in conflict- and crisis-affected states
(BMJ, 2017-07-28) Martineau, Tim; McPake, Barbara; Theobald, Sally; Raven, Joanna; Ensor, Tim; Fustukian, Suzanne; Ssengooba, Freddie; Chirwa, Yotamu; Vong, Sreytouch; Wurie, Haja; Hooton, Nick; Witter, Sophie
Conflict and fragility are increasing in many areas of the world. This context has been referred to as the 'new normal' and affects a billion people. Fragile and conflict-affected states have the worst health indicators and the weakest health systems. This presents a major challenge to achieving universal health coverage. The evidence base for strengthening health systems in these contexts is very weak and hampered by limited research capacity, challenges relating to insecurity and apparent low prioritisation of this area of research by funders. This article reports on findings from a multicountry consortium examining health systems rebuilding post conflict/crisis in Sierra Leone, Zimbabwe, northern Uganda and Cambodia. Across the ReBUILD consortium's interdisciplinary research programme, three cross-cutting themes have emerged through our analytic process: communities, human resources for health and institutions. Understanding the impact of conflict/crisis on the intersecting inequalities faced by households and communities is essential for developing responsive health policies. Health workers demonstrate resilience in conflict/crisis, yet need to be supported post conflict/crisis with appropriate policies related to deployment and incentives that ensure a fair balance across sectors and geographical distribution. Postconflict/crisis contexts are characterised by an influx of multiple players and efforts to support coordination and build strong responsive national and local institutions are critical. The ReBUILD evidence base is starting to fill important knowledge gaps, but further research is needed to support policy makers and practitioners to develop sustainable health systems, without which disadvantaged communities in postconflict and postcrisis contexts will be left behind in efforts to promote universal health coverage.
Understanding health system resilience in responding to COVID-19 pandemic: experiences and lessons from an evolving context of federalization in Nepal
(BioMed Central, 2024-04-04) Regmi, Shophika; Bertone, Maria Paola; Shrestha, Prabita; Sapkota, Suprich; Arjyal, Abriti; Martineau, Tim; Raven, Joanna; Witter, Sophie; Baral, Sushil
Introduction: The COVID-19 pandemic has tested the resilience capacities of health systems worldwide and highlighted the need to understand the concept, pathways, and elements of resilience in different country contexts. In this study, we assessed the health system response to COVID-19 in Nepal and examined the processes of policy formulation, communication, and implementation at the three tiers of government, including the dynamic interactions between tiers. Nepal was experiencing the early stages of federalization reform when COVID-19 pandemic hit the country, and clarity in roles and capacity to implement functions were the prevailing challenges, especially among the subnational governments. Methods: We adopted a cross-sectional exploratory design, using mixed methods. We conducted a desk-based review of all policy documents introduced in response to COVID-19 from January to December 2020, and collected qualitative data through 22 key informant interviews at three tiers of government, during January-March 2021. Two municipalities were purposively selected for data collection in Lumbini province. Our analysis is based on a resilience framework that has been developed by our research project, ReBUILD for Resilience, which helps to understand pathways to health system resilience through absorption, adaptation and transformation. Results: In the newly established federal structure, the existing emergency response structure and plans were utilized, which were yet to be tested in the decentralized system. The federal government effectively led the policy formulation process, but with minimal engagement of sub-national governments. Local governments could not demonstrate resilience capacities due to the novelty of the federal system and their consequent lack of experience, confusion on roles, insufficient management capacity and governance structures at local level, which was further aggravated by the limited availability of human, technical and financial resources. Conclusions: The study findings emphasize the importance of strong and flexible governance structures and strengthened capacity of subnational governments to effectively manage pandemics. The study elaborates on the key areas and pathways that contribute to the resilience capacities of health systems from the experience of Nepal. We draw out lessons that can be applied to other fragile and shock-prone settings.
What adaptation to research is needed following crises: A comparative, qualitative study of the health workforce in Sierra Leone and Nepal
(BioMed Central, 2018-02-07) Raven, Joanna; Baral, Sushil; Wurie, Haja; Witter, Sophie; Samai, Mohamed; Paudel, Pravin; Subedi, Hom Nath; Martineau, Tim; Elsey, Helen; Theobald, Sally
Background: Health workers are critical to the performance of health systems; yet, evidence about their coping strategies and support needs during and post crisis is lacking. There is very limited discussion about how research teams should respond when unexpected crises occur during on-going research. This paper critically presents the approaches and findings of two health systems research projects that explored and evaluated health worker performance and were adapted during crises, and provides lessons learnt on re-orientating research when the unexpected occurs. Methods: Health systems research was adapted post crisis to assess health workers' experiences and coping strategies. Qualitative in-depth interviews were conducted with 14 health workers in a heavily affected earthquake district in Nepal and 25 frontline health workers in four districts in Ebola-affected Sierra Leone. All data were transcribed and analysed using the framework approach, which included developing coding frameworks for each study, applying the frameworks, developing charts and describing the themes. A second layer of analysis included analysis across the two contexts, whereas a third layer involved the research teams reflecting on the approaches used to adapt the research during these crises and what was learned as individuals and research teams. Results: In Sierra Leone, health workers were heavily stigmatised by the epidemic, leading to a breakdown of trust. Coping strategies included finding renewed purpose in continuing to serve their community, peer and family support (in some cases), and religion. In Nepal, individual determination, a sense of responsibility to the community and professional duty compelled staff to stay or return to their workplace. The research teams had trusting relationships with policy-makers and practitioners, which brought credibility and legitimacy to the change of research direction as well as the relationships to maximise the opportunity for findings to inform practice. Conclusions: In both contexts, health workers demonstrated considerable resilience in continuing to provide services despite limited support. Embedded researchers and institutions are arguably best placed to navigate emerging ethical and social justice challenges and are strategically positioned to support the co-production of knowledge and ensure research findings have impact.