Synthesising evidence from other sectors to strengthen health system responses to mass displacement: supporting Rohingya refugees in Bangladesh

Since August 2017, a large influx of Rohingya refugees have fled Myanmar and settled in Cox's Bazar in south-eastern Bangladesh, where two registered refugee camps, Kutupalong and Nayapara are operational. The health system in the region is facing tremendous pressure in serving such a large population, although 150 national and international partners coordinated by WHO and the Civil Surgeon's Office of Cox's Bazar, are providing health service delivery through 270 static and mobile health facilities. Several health system challenges include large host and refugee populations; responding to immediate, emerging health needs during the upcoming monsoon season and mitigating risks related to floods, landslides and cyclones, which could damage health infrastructure, and limit population access to health facilities.

A team of researchers from London School of Hygiene and Tropical Medicine in the UK and University of Dhaka and BRAC University in Bangladesh are proposing to synthesize lessons from other humanitarian sectors to strengthen health system responses to support displaced Rohingya in Bangladesh. During this 18 month project we will investigate the following question 'What lessons can the health sector apply from other sectors to strengthen local health system responses to mass displacement?'

This foundation study will have three components:
1. Evidence synthesis: We will conduct a review of non-health literature following from recently published evidence synthesis reviews.
2. Framework development: We will draw from the evidence synthesis to develop a health systems resilience framework.
3. Case study: We will conduct a case study in Balukhali refugee camp in Cox's Bazar, Bangladesh, to test our framework by examining how the local health system has been affected by and adapted to the refugee influx.

We propose to conduct a dissemination workshop in Dhaka, to engage with regional stakeholders and incorporate their inputs on the robustness and resilience of health system responses to mass displacement. We will submit at least one manuscript to an international peer-reviewed journal and prepare a technical report to enable non-academic practitioners to benefit from the research.

1. Health system relevance and importance
The proposed study will draw from learning in other humanitarian sectors to inform health system responses to large-scale and protracted humanitarian displacement (e.g. internally displaced populations in CAR, Nigeria, DRC, Yemen, and Ukraine; Syrians in Lebanon, Turkey, and Jordan; Palestinians in Jordan). While humanitarian responses have developed significantly in the past decades, different sectors (e.g. health, shelter, livelihood, education) have generally maintained siloed approaches, with minimal cross-sectoral engagement and learning. The key health system relevance of this proposed study is therefore in cross-sectoral engagement and translational learning.

2. Theoretical framework
We will use the process of evidence synthesis to develop a new framework using a systems theory approach to examine physical, social, economic, environmental, and epidemiological aspects of health system adaptation, coping, and resilience in the context of socio-environmental shocks such as mass displacement.

3. Study site and population
The Kutupalong and Balukhali refugee camps are estimated to host 350,000 people.
4. Data collection and analysis
This will be conducted in three phases.
a. Evidence synthesis: A review of non-health studies and literature following from recently published evidence synthesis reviews will be undertaken.
b. Development of framework: A health systems resilience framework will be developed with components drawing from the evidence synthesis.
c. Case study approach: We will undertake a case study in Balukhali refugee camp in Cox's Bazar, Bangladesh, drawing on Yin's case study methodology, to test our framework, by examining how the local health system has been affected by and adapted to the refugee influx.

1) Application and exploitation - The partnership between LSHTM, University of Dhaka, and BRAC University will enhance the reach and potential uptake of research findings, for policy and practice in Bangladesh and within the broader global research and development communities. The application and exploitation of both the research process and its findings will be jointly undertaken by LSHTM, University of Dhaka, and BRAC University teams. LSHTM standards and guidelines for research best practice (see Data Management Plan) will be used to manage, exploit and protect intellectual assets and outputs from the research, during and at the end of the grant lifecycle.

2) Communications and engagement - LSHTM, University of Dhaka, and BRAC will jointly conduct communications and engagement activities. University of Dhaka will lead in coordinating local ethics approval, while BRAC University will lead in negotiating with service providers and community leaders in Cox's Bazar study sites. LSHTM will lead in engaging with research communities and health policy and systems practitioners through networking, publication, and presentation of research findings at international conferences. All partners will work in summarising research outcomes in a way that Bangladesh stakeholders will be able to understand and use (e.g. public discussions, dissemination workshop). All partners will engage with MOH through meetings, workshops, and development of a policy brief.

3) Collaboration and co-production - While LSHTM will formally lead the grant partnership for administrative purposes, the research is based on an ethos of co-production, with priorities determined by the academic team working in Cox's Bazaar and Dhaka. Indian and Bangladeshi team members identified this research gap and established this partnership. This is a newly-established partnership, and all partners have been involved with research design to maximise potential uptake and ownership. Research implementation will be in close partnership with MoH and Rohingya community leaders, as end-users and beneficiaries.

4) Capacity and involvement - As a co-designed study, partners in Bangladesh will, as much as feasible, contribute to the evidence synthesis and conduct fieldwork in Cox's Bazar, assist with translation/transcription of interview recordings, and lead data analysis for the case study. LSHTM staff, based in the UK and India, will support evidence synthesis, framework and research tools development, and conduct required trainings. The PI and co-PI will support other researchers in overall study design, interpreting results and preparing articles for publication. Both researchers have a strong track-record of relevant publications and of building capacity among junior researchers. Bangladeshi and Indian researchers will lead on academic papers, to increase their international exposure and increase the profile of the research among academics in South Asia.

5) Contribution to achieving HSRI's strategic aims - This joint initiative aims to foster robust interdisciplinary research that will contribute to improved healthcare delivery. It will contribute to the evidence base on health systems response and resilience during mass displacement.
Potential for improving medical and social science - Findings will inform development of health system strengthening interventions to improve the health of displaced populations in need and add to the knowledge-base on non-health interventions with applicability for the health system.

6) Value-for-money - The proposed research stands to influence global design of humanitarian health services across different thematic areas of health, and improve health service provision for a large population of vulnerable refugees, within a very reasonable budget. This is due largely to the use of mid-level and junior researchers, supported at a smaller FTE proportion by an experienced senior researcher and by a multisectoral advisory committee.