This innovative FCDO-funded research programme in six countries explored how to improve the resilience of social services during and after external shocks
The programme, which ran from 2018 to 2021, sought to improve health, education, nutrition and social protection outcomes for affected populations, especially the poorest and most vulnerable people and therefore play our part in improving response to shocks. Maintains operated a Research component, alongside a Technical Assistance (TA) component; this made technical expertise available on a call-down basis to develop knowledge and inform the design of enhanced and appropriate shock-responsive essential services in the six Maintains countries. Within these components, and as well as the four noted policy areas above, we also looked at the cross cutting areas of Gender Equality and Social Inclusion (GESI) and Disaster Risk Financing (DRF). The intended outcome of the Maintains programme was to enable our six focus countries to more effectively manage their risk, ensuring their social services and humanitarian response are able to act more quickly, more reliably, and at lower cost, during and after a shock or disaster.
Publications that emerged from the programme, relating to these cross cutting themes are: DRF COVID-19 literature review, our report on Crisis modifiers for health shock response and GESI COVID-19 literature review.
Areas of work
Maintains research in Bangladesh informed the development of shock-responsive social protection systems. There is consistent evidence from Bangladesh of the tight and mutually reinforcing nexus between poverty, vulnerability, and exposure to shocks. The country is susceptible to a range of hazards and shocks which hit poor people hardest, as they have uncertain and insecure livelihoods, fewer resources and often live in the most exposed and vulnerable areas.
Well-designed social protection systems are proven to support vulnerable people during crises, but currently only 32% of vulnerable households in Bangladesh have access to such systems. To help build the resilience of poorer households before and after shocks, the Government of Bangladesh is committed to expanding social protection coverage.
Research focus: Social protection
Our research was guided by the question, how can formal and informal social protection systems become more shock-responsive?
Maintains explored historical evidence on the roles government, civil society, communities, and the private sector can play in delivering different forms of social protection.
The programme undertook field work in four locations to explore how this works in practice, considering a range of operational issues (such as what data is used, how systems are targeted, and how delivery can be optimised and dovetailed with complementary programmes and services). Our research and technical assistance publications from our research in Bangladesh are available below.
Bangladesh publications and resources:
- Bangladesh research plan
- Shock-Responsive Social Protection in Bangladesh literature review
- Support for an emergency cash transfer in Bangladesh in response to COVID-19 Technical assistance report
Our research in Ethiopia generated evidence on health system resilience to shocks, supporting the ongoing design and implementation of government, FCDO, and other stakeholder programmes.
Droughts, floods, disease outbreaks, and internal displacement present significant, recurring public health shocks that affect millions of people in Ethiopia every year. As the country’s rural population relies on rain-fed agriculture, droughts and floods can have a particularly significant impact, and contribute to severe food crises.
In response, the Ethiopian government has placed disaster management as a key national priority. The Federal Ministry of Health, Ethiopian Public Health Institute and other stakeholders are working to overcome public health emergencies through strengthening the preparedness and response capacity of key public and social services.
Research focus: Health and Nutrition
Does the Second Generation Health Extension Programme improve rural health post capacity to be shock responsive?
Following over 15 years of the Health Extension Programme (HEP), the Government of Ethiopia has been implementing a Second Generation HEP to strengthen frontline primary healthcare through upgraded health post infrastructure, more qualified health extension workers, and an expanded package of health services.
Maintains’ research was to assess the impact of the Second Generation HEP on health post capacity to prepare for, prevent, and respond to shocks, examining activities such as immunisation, nutrition screening, and surveillance as well as community trust in health systems. The research would suggest ways to maximise preparedness and provide effective services in times of crisis.
Maintains developed a comprehensive Research plan for Ethiopia.
In Kenya, our research explored how to strengthen health, nutrition, and social protection services and systems so that they can be maintained and adapted during ﬂoods and droughts. Kenya experiences persistent and harsh droughts as well as frequent floods, causing food insecurity, high levels of malnutrition-related illnesses and deaths, and disruption to livelihoods. For example in 2017, according to UNICEF, almost 370,000 children required treatment for acute malnutrition, including 72,600 with the most severe form who required specialised, life-saving care. Acute malnutrition rates were at least double the emergency threshold of 15% in some areas of northern Kenya. Turkana, in particular, was badly affected.
Research focus: Social Protection and Health and Nutrition
Our social protection research focused on what role the Enhanced Single Registry (ESR) would play in enabling the social protection system to respond to shocks.
- What are the opportunities and barriers around use of the ESR by other government and non-governmental stakeholders?
- What are the institutional capacity requirements to manage the ESR as a tool to deliver shock-responsive social protection?
- How is the ESR operationalised at county level?
Publications from Kenya social protection research:
- The full report on the Maintains Kenya Study on the opportunities of and obstacles to the utilisation of the ESR.
- Policy brief on the Maintains Kenya Study on the opportunities of and obstacles to the utilisation of the ESR.
Research focus: health and nutrition:
The Health and Nutrition focused research focused on how health and nutrition systems could become more shock responsive.
- How did health and nutrition systems respond to recent drought and floods?
- Can shock-responsive nutrition programming (CMAM Surge) be replicated in other sectors and for other shocks?
- How can early warning systems be optimised to support the scaling up of health and nutrition services?
Publications from Kenya health and nutrition research:
- The research protocol for the health and Nutrition research.
- Full report on the Climate shock responsiveness of the Kenya health system.
- Policy brief providing recommendations to improve the climate shock responsiveness of the Kenya health system.
- Innovation history of the CMAM Surge approach Towards a shock-responsive health system in Kenya
Pakistan suffers from a wide range of hazards and shocks, and is particularly vulnerable to climate change, with flooding and drought affecting millions of people.
Flooding – from monsoon rain as well as glacial melt – is the most recurring hazard, devastating infrastructure and causing a huge human cost. Unplanned urbanisation has substantially increased the exposure and vulnerability of Pakistan’s urban poor to flooding. The country is also experiencing an increase in the frequency and severity of drought due to a rise in temperatures and rainfall variability, with Balochistan and Sindh worst affected. As part of our research, we explore the viability and potential mechanisms for making BISP, Pakistan’s flagship national social protection programme, shock-responsive.
Research focus for Pakistan: social protection, and health and nutrition
- How can social protection targeting be refined for use during disaster responses, particularly drought mitigation?
- How can social protection systems and services be better adapted to drought-prone areas of Pakistan?
- How can instruments and delivery mechanisms be made more effective through the use of a more disaster-responsive National Socio-Economic Registry (NSER)?
- Health and nutrition: How can health and nutrition systems adapt and respond to droughts and floods?
- What is the current state of emergency preparedness and the response of health and nutrition services to recent droughts and floods?
- What are successful shock-responsive approaches and programmes and how can they be optimised?
- Is there a need to create greater synergy between humanitarian and sustainable nutrition goals and responses, and how might that be achieved in practice?
- What are the political economy barriers that prevent social protection systems becoming more shock responsive?
Below are the publications that emerged from our technical assistance in Pakistan:
Sierra Leone is prone to a range of shocks, and despite lessons learned during the Ebola crisis, the health system still lacks capacity to respond. Floods and landslides are a major problem due to a large number of rivers, a tropical monsoon climate, unplanned urbanisation, and poor waste management. Informal settlements and poor communities are particularly vulnerable.
Research focus: health system
- How can the health system manage new demands from shocks, whilst maintaining service delivery?
Research focus: health finance
- What are the economic and financial costs of health shocks, how are they being financed, and how can financing arrangements be improved?
Publications from Sierra Leone research and technical assistance
- The response to COVID-19 in Sierra Leone rapid report and brief.
- The role of traditional leaders in COVID-19 full report and policy brief
- The effectiveness of the Sierra Leone health sector response to health shocks: Evidence from the COVID-19 perception survey.
Uganda currently hosts around 1.3 million refugees, most of whom have come from South Sudan, the Democratic Republic of the Congo, and Burundi. This puts pressure on all social services as well as livelihood opportunities for both the host community and the refugees.
Drought is a recurrent problem in Karamoja, making it the most food insecure sub-region in the country, with persistent and widespread malnutrition. In 2018, UNICEF reported that 84% of people could not afford a nutritious diet, with particularly serious impacts on women and children.
Research focus: education
- Does the Education Response Plan improve the effectiveness of education service delivery, and thereby education outcomes for both refugees and host communities in West Nile?
Below is a list of all publications that emerged from our research and technical assistance:
- Uganda education research plan.
- Research report on Information, coordination, and financing: within the Education Response Plan
- Policy briefs from this study on coordination, information and finance management within the ERP
COVID-19 has been an extreme shock to social systems, with direct and secondary impacts in Maintains’ focus sectors of education, gender, health, disaster risk financing, nutrition, governance, and social protection. We adapted our established research programme to respond to the pandemic, and undertook new work that will focused on how best to support governments to respond, adapt and recover from COVID-19.
We completed a series of COVID-19 rapid literature reviews looking at each focus sector for Maintains: Community health workers, DRF, Education, GESI, Governance, Health, Nutrition, Social Protection.
Below are links to our synthesis research, produced in 2020 and looking at findings from a series of rapid situation analyses on the initial response to COVID-19 in the first few months of the outbreak.
- Initial COVID-19 responses in Bangladesh, Kenya, Pakistan, Sierra Leone, and Uganda: Documentation and learning from March to May 2020- full report.
- Executive summary from the initial COVID-19 responses in Bangladesh, Kenya, Pakistan, Sierra Leone, and Uganda: Documentation and learning from March to May 2020.
Towards shock-responsive social protection is a study from Maintains examining how the social protection systems in six countries have been adapted or expanded in the COVID-19 response. The study aims to identify policy actions to better prepare national social protection systems to respond to future shocks.
About the study
Almost all countries have adapted their social protection systems to support households and to mitigate the economic impact of the COVID-19 pandemic. The responses have differed widely and included both the development of new social protection programmes, as well as the expansion and adaptation of existing programmes.
This research examined how the social protection programmes, processes, and delivery systems in the six Maintains countries–Bangladesh, Ethiopia, Kenya, Pakistan, Sierra Leone, and Uganda–have been used to respond to the COVID-19 crisis, and to understand the factors that have enabled successful responses, as well as the factors that have constrained them.
The study aimed to identify policy recommendations to inform and influence investments in social protection systems to prepare for future shocks.
- Document the social protection responses in all six Maintains countries, particularly the use of social protection delivery mechanisms and information systems.
- Assess the social protection responses in these six countries in terms of their adequacy, coverage, comprehensiveness, and timeliness.
- Provide recommendations for future responses and investments in shock-responsive social protection systems.
The conceptual framework for this study outlines the three dimensions of our analysis:
- Response type: this includes strategies to minimise disruptions to routine service delivery; adaptations to address new vulnerabilities arising from the crisis through vertical and/or horizontal expansion or new programmes; and humanitarian assistance that leverages on or aligns with the social protection system.
- Policies and operational procedures: this focuses on how the response was operationalised, including how the policies, systems, and operational procedures used along the delivery chain were developed and/or adjusted.
- Outcomes: this is an assessment of the outcomes of each social protection response in terms of adequacy, coverage, comprehensiveness, timeliness, and long-term implications.
We conducted a literature review of key documentation and a series of key informant interviews with stakeholders involved in the response, in order to gather information in relation to the first two dimensions. For the third, we used microsimulations based on a partial-equilibrium modelling framework to simulate the impact of the pandemic on poverty and inequality, as well as the mitigating effect of the social protection responses. We conducted these for Bangladesh, Pakistan, and Sierra Leone and drew on existing simulations for Ethiopia, Kenya, and Uganda.
- Bangladesh case study, micro simulation and policy brief.
- Ethiopia case study and policy brief.
- Kenya case study and policy brief.
- Pakistan case study, microsimulation, and policy brief.
- Sierra Leone case study, microsimulation, and policy brief.
- Uganda case study and policy brief.
Over 2019–21, the Maintains programme conducted research on health system capacity to manage shocks in Bangladesh, Kenya, Pakistan, Sierra Leone, and Uganda. Background preparations for research were also conducted in Ethiopia. The research examined health sector responses to shocks such as floods, drought, and COVID-19, considering experience in scaling up to address needs that arise due to the shock, while also maintaining essential service delivery. Two key papers were produced
- What is a Shock-Responsive Health System? This working paper sets out a conceptual framework for a shock-responsive health system for the Maintains programme, drawing together ideas from the literature on health systems, resilience, and related areas. It identifies components of a health system and interactions with the wider context that may be affected by shocks, and that affect the ability of the health sector to respond. The framework supports the conceptual approach to Maintains research, and is offered as a contribution to the nascent community of practice on shock-responsive health systems.
- Health system shock responsiveness: summary findings from Maintains research. This summary paper highlights selected findings from Maintains research. It highlights key learning from the research, bringing together material on similar issues from different countries and providing a high-level overview of factors that affect health system shock responsiveness. It uses the framework of shock-responsive health services, and considers formal health system building blocks, including supplies, health workers, information, and funding; health system and wider governance; community health systems; and gender and social inclusion in shock response.
Maintains was implemented through a consortium led by Oxford Policy Management Limited together with: The Centre for Humanitarian Change who led the health and nutrition workstreams in Kenya and Uganda, the Health Resilience Consortium, led by Dalan Development Consultants who were our partners in Sierra Leone and, Ichuli who led the Uganda Education workstream.
Header image: ‘People fleeing violence in Myanmar receive UK aid in Bangladesh.’ DFID – Department for International Development on Flickr, licensed under CC BY 2.0