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Where is the Evidence on Building Sustainable Health Systems in a World of Unrest?

Civil unrest is spreading quicker than a pandemic across the Middle East and North Africa, with major protests or uprisings in Egypt, Bahrain, Yemen, Libya, Iran, Tunisia, Algeria, Morocco, and Jordan, to name only a few. Each day brings a new report of popular protests in the region, and I keep wondering how these events will affect people’s health and health systems in these countries? There is no doubt that any regime changes would impact the health sector. Even a scheduled change in administration can drastically affect health programs. Routine changes in priorities, political support, and funding can slow down or boost a program’s momentum and its chances for success.

So what happens to health care and the health system during and after a revolution?

It depends, of course, on innumerable factors. Who takes power? How peaceful is the transfer? What are the new political priorities? What resources are available? In part, it may also depend on how strong the health system was before the revolution. We might intuit that functioning, strong health systems with effective management, operations, and logistics mechanisms have a better chance of being supported by a new government. Health systems that were already struggling to systematize health service delivery may be all the more vulnerable to deterioration or collapse in a sudden government transition.

Then there is the question of health workers. They are at the center of a strong health system, but they are also citizens with political views and allegiances, who may find themselves deeply troubled or elated with regime changes. In an innovative example of group self-management, protestors in Egypt managed to improvise basic social services including medical services overnight, with doctors identifying themselves and their specialties on nametags. During violent protests, health workers may find themselves not only highly in demand but also at risk. In Bahrain, there are reports of doctors being assaulted for providing medical treatment to injured protesters. In countries in transition, the future of the health system is directly tied to the futures of its health workers. Will they flee the country or, perhaps, return from abroad? At times safety may determine these decisions, but such decisions may also be based on practical considerations such as how a new political environment affects salaries, working conditions, or lifestyle.

Recently, I reviewed the literature on evidence-based frameworks for developing sustainable health programs. In the back of my mind, I kept thinking about the fragile nature of sustainability given the ubiquitous political unrest, the unpredictability of political events, and the constant change in today’s face-paced world. What are we striving for when sustainability is our goal? What evidence do we have on how best to reach this goal? What is the relationship between a sustainable and resilient health system?

As expected, I found lots of literature discussing the sustainability of health programs. What surprised me, however, was the dearth of strong evidence about sustainable approaches. We have case studies, expert opinions, and anecdotal evidence, but where are the hard facts? Where are the studies that assess long-term impact years after a program has ended?

There are salient exceptions, including the Sustainability Framework originally developed through USAID’s Child Survival and Health Grants Program. The Sustainability Framework has undergone the scrutiny of scientific inquiry numerous times and continues to evolve as its evidence base grows. It is one example of an evidence-based process for designing a sustainable program. The WHO’s Framework of Action for strengthening health systems with its six building blocks of an effective health system is also an example of an influential framework. Increasingly, donors, program managers, and national leaders are recognizing that achieving sustainable health gains requires a strong health system. All health programs must achieve their aims in a way that reinforces the larger system, and yet the question of how best to do this remains largely unanswered.

Like much of the rest of the world, I will be closely following the unfolding events in the Middle East and North Africa, watching as popular protests topple, reform, or—in some cases—possibly further entrench the status quo. I am also watching for how these countries will serve as examples for whether and how a health system can withstand unexpected changes. We will learn from these events, but we also need to do more than wait for watershed moments to learn from. We need to talk about and examine sustainability, design programs to achieve it, and then measure and monitor the results. To do this, we need to invest resources in evaluating programs well after they have ended so we can really assess long-term impact.