Title: NIHR Global Health Research Unit on Health in Situations of Fragility at Queen Margaret University, Edinburgh
Funder: Department of Health and Social Care

Abstract: Institutional Track-Record Queen Margaret University, Edinburgh has been a focus for global health work since the 1980s when it was chosen as one of three UK higher education institutions to support capacity development in primary health care in selected LMICs in the wake of the Alma Ata declaration. The Centre for International Health Studies was established in 1993, and was a founder member of the tropEdEurop consortium that began offering the MSc in International Health that year. With a growing Masters programme and doctoral school, the centre became the first Institute of the university in 2004. Staff of IGHD now hold major research funds from the MRC, ESRC, AHRC, NIH, Wellcome Trust and DFID. With clusters maximising synergies between academic staff, researchers and doctoral students, research is strictly focused in areas where the Institute has a track-record and ongoing capacity for global leadership. Our health systems research cluster jointly leads the DFID-funded ReBUILD consortium, focused on study of post-conflict health systems recovery in Sierra Leone, Zimbabwe, Uganda and Cambodia. This proposal brings strands of the work of this health systems cluster together with that of our cluster group examining processes of mental health, psychosocial well-being and protection in refugee and other vulnerable or marginalized communities [see Team Expertise section]. The recent global health research agenda-setting exercise for FCAS [3] reinforced our own growing awareness of the importance of synergizing work in these two areas. Resilience in service delivery is consistently flagged as needing to be addressed in a manner that reflects the interaction of health systems functions and processes with community agendas, capacities and constraints [7-14]. The NIHR Global Health Research Unit call now provides a mechanism to secure and exploit these synergies. Institutional Capacity and Investment IGHD employs a total of 15 staff: 8 academic staff funded through core university funds, 4 researchers funded from external sources, and 3 administrative staff (two funded from core funds). The institute additionally draws on the expertise of 10 associate staff. The institute is one of six flagship research centres of excellence at QMU to which investment is directed. IGHD is currently engaged in over 20 discrete projects, around one-third of which are domestic initiatives working with NHS and non-governmental partners (e.g. on social isolation and refugee mental health in Scotland) and two-thirds of which are overseas (across Asia, the Middle-East and Africa). The research clusters are supported by a university-funded Research Officer and two Institute Officers, focused on research programme management and communications. Project financial planning and management is supported by a university Research Grants and Contracts Office. Details of existing institutional partnerships to be consolidated by this proposal are given in the section on Collaboration and Partners. Proposed Programme of Research As noted above, fragility impacts health interventions through two major, interacting mechanisms. First, the systems and institutions underpinning public health response may themselves be fragile: Challenges include human resource capacity, health financing, procurement and supplies. This lack of institutional and systems resilience was clearly apparent in shaping the response to the Ebola outbreak in West Africa in 2014, but has been widely documented in contexts affected by conflict, in post-conflict recovery, or otherwise marked by weak state capacity [15]. Second, mechanisms for health seeking and protection in populations in these settings are often severely disrupted. Physical access to health facilities and financial capability may be compromised [16]. Trust in providers may be undermined by political conflict [6, 17]. In many contexts, internal displacement and/or migration across national borders disrupts key community-based processes supporting population health. Migrant and ethnic minority populations often face additional knowledge and cultural barriers in accessing services [18]. We will identify strategies to address these challenges and their interaction with the overall aim of answering three major framing questions emerging from the recent research agenda-setting exercise for FCAS [3] regarding: HEALTHCARE DELIVERY: What healthcare delivery models work best in these contexts? And what kind of actors can best implement such models and deliver the best results?; COMMUNITY ENGAGEMENT: What are the best approaches to bring community actors into full partnership with national health systems in order to strengthen the linkages between community capacities and the health system and strengthen accountability?; and ACCESSIBILITY: What are the key factors that influence accessibility of public health services in circumstances of fragility? We will focus our work in West Africa and the Middle East. These are regions currently marked by substantial fragility, though in significantly different forms. The former is characterized by a historically low resource-base, weak systems of governance and thus poor public services. The latter is a high resource environment with significant resources and health infrastructure that has been substantially destabilized by political conflict. Working in both regions will enhance the generalizability of our analyses to diverse settings. Ultimately extending to other countries, the initial focus is firmly on the country settings of our principal partners: Sierra Leone and Lebanon. Both are recognized as fragile states, and both face challenges in provision of NCD and mental health services. While NCDs are estimated to account for 18% of all deaths in Sierra Leone, the WHO has signalled that the country has severely limited capacity to respond [19], a finding reinforced by our ongoing ‘health life histories’ work in the country [17]. In terms of mental health services, WHO estimates a treatment gap in the country at over 80% [20]. In Lebanon, while base capacity is much higher, environmental conditions are simultaneously driving an increase in health risk and erosion of institutional and community capacities. Over the last 30 years WHO documents a 15% increase in mean BMI and 9% in mean fasting blood glucose. Over 40% of the population now has raised blood pressure [19]. The treatment gap for depression is estimated at over 70% [20], with pressures of regional migration – Lebanon is hosting a forced migrant population of over 1 million - exacerbating resource availability and community cohesion a major. The unit’s work will be structured in three phases. In the Scoping, Assessment and Design Phase (Years 1-2), researchers will engage with local partners in appraising key challenges in delivery of the NCD and mental health interventions selected in both settings. Research will focus on identifying health systems and community factors contributing to fragility of the integrated ‘system for health’ relevant to delivery and uptake of these interventions. To assess health systems factors we will employ cutting-edge methodologies of clinic ethnography, participatory systems dynamics modelling [5], and tiered health systems need assessments. Alongside analysis of utilization and other routine health data, this will provide insight into institutional vulnerabilities in intervention delivery and potential points of leverage to address them. To assess the latter, we use methods of community social mapping [6], group model building and forms of participatory action research linked to verbal autopsy methods being developed with colleagues in Aberdeen. These methods generate an in-depth understanding of how social relations, connections, and capital are fragmented, and re-formed in contexts of fragility, and how these affect perceptions of health and well-being, entitlement to, and engagement with health systems. We will then integrate these analyses not only to inform policy making and care delivery efforts in real time, but also – combining insights across conditions and settings - to begin to develop a health and fragility assessment framework to inform intervention planning and health system appraisal and strengthening in LMICs globally. The Strategic Intervention and Evaluation phase (years 2 to 3) will use our rigorous appraisals of institutional and community factors facilitating and constraining interventions to identify strategic actions to increase service accessibility, accountability and quality (with our focus potentially broadening to include other interventions as guided by local partners and stakeholders). Methods used here include the application of interrupted time series analysis drawing on routine health data and periodic clinic and community surveys, process evaluations, mapping and modeling of social connectedness and systems dynamics deployed alongside key stakeholder interviews to evaluate the impact of strategic actions. We anticipate identifying novel issues affecting care delivery and uptake at the interface of health systems and communities that would lead to further refinement and testing of our health and fragility analytic framework. The Generalisation and Dissemination phase (years 3 to 4) will take learning from prior fieldwork and apply it to inform the delivery of other NCD and mental health interventions, both elsewhere in Sierra Leone and Lebanon and – through deployment of resources from the research development fund held for this purpose – to neighboring countries in our two regions of focus (e.g. Burkina Faso and Nigeria in West Africa and Jordan and Iraq in the Middle East). This phase also provides the opportunity to test, refine and validate the health and fragility analytic framework developed on the basis of initial studies. Further details on Collaborators and Partners are provided in 'Additional Information'

Lay abstract: A major commitment of HMG’s strategy for Overseas Development Assistance is increasing emphasis on contexts of fragility. Whether due to environmental and demographic conditions or issues of weak governance or conflict – influences that frequently combine – the World Bank estimates fragility to be a major barrier to development for over 2 billion people, with the proportion of the global poor living in fragile contexts set to approach 50% by 2030. Despite increasing political commitment to health sector investment in nations that are fragile, there is limited research evidence guiding implementation. The NIHR Research Unit on Health in Situations of Fragility (RUHF), at Queen Margaret University (QMU), Edinburgh, is developing a systematic programme of research that will identify means of strengthening service quality, accountability, access and uptake in two regions - West Africa and the Middle East – characterised by significant, but contrasting patterns of fragility. The primary research settings for RUHF are Sierra Leone and Lebanon. The former is characterized by a historically low resource-base, weak systems of governance and thus poor public services; the latter is a high resource environment with significant resources and health infrastructure that has, however, been substantially destabilized by the influx of Syrian displaced populations and by a long history of political conflict. Our key in-country partners in these settings are, respectively, the College of Medicine and Allied Health Sciences (COMAHS) in Freetown and the Global Research Institute of the American University in Beirut (AUB). In both contexts, our focus is on two vital but commonly neglected areas of health provision, which make major demands on continuity of care and effective links with community resources: mental health and psychosocial support (MHPSS) and the treatment and prevention of non-communicable diseases (NCDs), such as diabetes and hypertension. The Unit’s research programme is structured with respect to three key strands of work. The Scoping, Assessment and Design strand is focussed on better understanding of the challenges of health provision in contexts of fragility and formulating approaches to service design and community engagement to tackle these. Scoping studies in Sierra Leone and Lebanon have reviewed the literature and key actors in the field of mental health and NCDs, with assessment and design fieldwork now appraising key challenges in the delivery of existing services. In the transition to the Strategic Intervention and Evaluation strand, researchers use the completed scoping studies and assessments to inform focused fieldwork identifying strategic actions to increase service quality, accountability and accessibility. The Generalisation and Dissemination strand of our work will be a particular focus in latter stages of the funding period, but has been a feature of work already through engagement with key global networks working on our focus topics and other relevant initiatives in our target regions. In summary, RUHF’s work programme is working to inform policy making and care delivery regarding mental health and NCDs in real time in Sierra Leone and Lebanon and - by consistently linking our work to an analysis of fragility and its impact on services, communities and their interaction – is developing a generalizable fragility assessment framework that will extend impact to other fragile settings globally.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.5 RESOURCES AND INFRASTRUCTURE (HEALTH SERVICES)
Health categories: GENERIC HEALTH RELEVANCE;MENTAL HEALTH