Health Diplomacy as a Tool to Build Resilient Health Systems in Conflict Settings—A Case of Sudan

Round 1

Reviewer 1 Report

Pattanshetty et al. describe Health Diplomacy as a tool to build resilient health systems in Sudan and other conflict Zones. 

This is a well-written, interesting paper that shows the extent of damage that war can inflict on primary care. It does not offer solutions as such but presents the bigger picture well and emphasizes the areas that require attention if a framework to combat this issue is to be constructed. 

Well done 

Author Response

Point 1: This is a well-written, interesting paper that shows the extent of damage that war can inflict on primary care. It does not offer solutions as such but presents the bigger picture well and emphasizes the areas that require attention if a framework to combat this issue is to be constructed.

Response 1: We have addressed the comment in lines 405-487 

Reviewer 2 Report

I would like to thank the authors for the effort to look into the matter of Health Diplomacy in the context of mindful attempts to build resilient health systems during conflicts.

Overall: I have read the article with great interest and a hope to find meaningful research findings.  Health diplomacy receiving added attention in the recent period represents an area of research, which could benefit the responsible actors in terms of policy recommendations and measures.  However, the research methodology - and findings – section need to be strengthened to provide new insights. The title suggests a focus on health diplomacy as a tool for peace, while the abstract seems to suggest a focus on health diplomacy as a tool to build resilient health systems, which are two different things. Such methodological approach blurs the research question and confuses the reader about what is being scrutinised – and what results may be expected as conclusions. Furthermore, there is a notable number of generic statements throughout the text, particularly in the introduction, that add little to the existing pool of knowledge. Such themes as vulnerability of health systems, emergence and re-emergence of diseases, global health challenges may be implicit in advance - which make qualitative research shallow. Additionally, their connection with conflict societies - as announced in the title – need to be pronounced more. I really see the benefit in expanding on the available findings and strengthening the analytical component of the draft. Additionally, please find a few specific suggestions and observations below.

Introduction:  I would suggest to add a definition of health diplomacy, which is multifaceted, and the specific aspect of it, as per draft’s focus.

28-31: “over the years” – repeated in sentences, can this be more specific? Since when?  If not, perhaps to rephrase?

31-32: “emergence and re-emergence of diseases”; “global health challenges” ; “vulnerabilities in health systems” – what do these refer to what exactly?

32: “The vulnerabilities in a health system that have been exposed due to globalization” – this reads rather broad – please explain how this is relevant to the article research theme, add references to research findings confirming this, particularly in case of conflict societies?

34-35: has it ever been? What about the centuries’ histories of quarantine islands and other forms of exclusion of foreigners for quarantine purposes, closure of city states’ walls during the epidemics of infectious diseases in the middle ages across Europe, etc.?  

I have similar comments on nearly every sentence of the draft, which to me reads as a compilation of generic statements of limited scientific value. I welcome the research on this specific topic very much, and I suggest the authors to re-work the draft to comply with minimal academic standards of research.

I would recommend to proof read 

Author Response

Point 1: Overall: I have read the article with great interest and a hope to find meaningful research findings.  Health diplomacy receiving added attention in the recent period represents an area of research, which could benefit the responsible actors in terms of policy recommendations and measures.  However, the research methodology - and findings – section need to be strengthened to provide new insights. The title suggests a focus on health diplomacy as a tool for peace, while the abstract seems to suggest a focus on health diplomacy as a tool to build resilient health systems, which are two different things. Such methodological approach blurs the research question and confuses the reader about what is being scrutinised – and what results may be expected as conclusions. Furthermore, there is a notable number of generic statements throughout the text, particularly in the introduction, that add little to the existing pool of knowledge. Such themes as vulnerability of health systems, emergence and re-emergence of diseases, global health challenges may be implicit in advance - which make qualitative research shallow. Additionally, their connection with conflict societies - as announced in the title – need to be pronounced more. I really see the benefit in expanding on the available findings and strengthening the analytical component of the draft. Additionally, please find a few specific suggestions and observations below.

Response 1: 

We have tried to strengthen the findings of the paper by adding additional examples of how health diplomacy has been applied in conflict regions, the challenges and the way forward. We have also added a paragraph on how health diplomacy can be used to mitigate the crisis in Sudan. This can be found in lines 405-487.

The mismatch between the title and the abstract that the reviewer pointed out has been addressed.  (14-15 and 20-25)

The generic statements have been revised to ensure that they are relevant to building the context of the paper.

 

Point 2: Introduction:  I would suggest to add a definition of health diplomacy, which is multifaceted, and the specific aspect of it, as per draft’s focus.

Response 2: As there exists an ambiguity of a set definition of health diplomacy we have highlighted its characteristics of being the interplay of health and international relations. (30-31)

 

Point 3: 28-31: “over the years” – repeated in sentences, can this be more specific? Since when?  If not, perhaps to rephrase?

Response 3: We have rephrased these sentences (30-34)

 

Point 4: 31-32: “emergence and re-emergence of diseases”; “global health challenges”; “vulnerabilities in health systems” – what do these refer to what exactly?

Response 4: We have provided a few examples of the emergence and re-merging diseases (32-34)

 

Point 5: “The vulnerabilities in a health system that have been exposed due to globalization” – this reads rather broad – please explain how this is relevant to the article research theme, add references to research findings confirming this, particularly in case of conflict societies?

Response 5: We have removed this sentence to avoid generic statements. 

 

Point 6: 34-35: has it ever been? What about the centuries’ histories of quarantine islands and other forms of exclusion of foreigners for quarantine purposes, closure of city states’ walls during the epidemics of infectious diseases in the middle ages across Europe, etc.?  

Response 6: The sentence has been revised. (34-36)

 

Point 7: I have similar comments on nearly every sentence of the draft, which to me reads as a compilation of generic statements of limited scientific value. I welcome the research on this specific topic very much, and I suggest the authors to re-work the draft to comply with minimal academic standards of research

Response 7: We have revised and avoided the generic statements.

Reviewer 3 Report

This article provides a thoughtful exploration of the role that health diplomacy can play in mitigating conflict and building resilient health systems, specifically within the context of the ongoing Sudan conflict. The authors aptly argue that investment in health systems can serve as a neutral starting point for peace negotiations and conflict mitigation, and that health itself can function as a tool for peace. The incorporation of the Sustainable Development Goals (SDGs) within this argument strengthens the authors' claims. By tying their discussion to widely recognized and accepted international goals, the authors underline the universal relevance and significance of their topic. However, the article can be improved in the following ways:

1.     The authors should further elaborate on the specific context of Sudan. They could include more detailed information about the current health system, how it has been affected by the ongoing conflict, and which health diplomacy strategies have already been attempted and with what results.

2.     Adding specific examples or case studies of where health diplomacy has been used effectively in other conflict settings would strengthen the argument by providing tangible evidence for the authors' assertions.

3.     The conclusions section raises many important points about how health can be used as a tool for peace and proposes a few broad solutions. The authors could, however, provide more detailed, actionable steps that governments, NGOs, or other relevant bodies could take to implement health diplomacy.

4.     To improve readability and enhance understanding, consider including maps, infographics, or charts to visually depict the link between health and peace, or the specific conflict-health situation in Sudan.

5.     Some parts are somewhat verbose and could be made more concise. Ensure that each sentence adds new information and avoids unnecessary repetition.

Overall, the article represents an important contribution to the discussion about the role of health diplomacy in conflict resolution. It provides a fresh perspective on the potential for health investment to serve as a pathway towards peace. These improvements can potentially deepen the impact of the article and make its arguments more compelling and actionable.

 

minor edits

Author Response

Point 1: The authors should further elaborate on the specific context of Sudan. They could include more detailed information about the current health system, how it has been affected by the ongoing conflict, and which health diplomacy strategies have already been attempted and with what results.

Response 1: The context of the health care system that existed in Sudan prior to the crisis and after has been added and elaborated further. (210-241 and 470-487)

 

Point 2: Adding specific examples or case studies of where health diplomacy has been used effectively in other conflict settings would strengthen the argument by providing tangible evidence for the authors' assertions.

Response 2: Examples of the use of health diplomacy in conflict settings have been added. (310-342)

 

Point 3: The conclusions section raises many important points about how health can be used as a tool for peace and proposes a few broad solutions. The authors could, however, provide more detailed, actionable steps that governments, NGOs, or other relevant bodies could take to implement health diplomacy.

Response 3: We have provided the way forward for collective action by all the relevant stakeholders in implementing health diplomacy. We have also provided steps in which the crisis in Sudan can be addressed using health diplomacy. (369-392 and 405-487)

 

Point 4: To improve readability and enhance understanding, consider including maps, infographics, or charts to visually depict the link between health and peace, or the specific conflict-health situation in Sudan

Response 4: The type of attack on health provides insight into the conflict-health situation in Sudan. However, we have added the tables and graphs in the supplementary section to provide the state of health in conflict settings.

 

Point 5: Some parts are somewhat verbose and could be made more concise. Ensure that each sentence adds new information and avoids unnecessary repetition.

Response 5: We have addressed the sentences and the sections which seemed verbose, and the repetition has been avoided. 

Round 2

Reviewer 2 Report

I would like to thank the authors for the revised manuscript, which is an improvement. I would suggest to make the introduction less generic and focus on the Sudan-specific context. SDGs etc are political objectives – it would be worth explaining how these link to the topic of the article. I understand that everything may be linked to everything, but for the purposes of an academic publication, what is the value of referencing these? I have a feeling that the title of the article does not correlate with the content. Having read the title, I expected a very different type of narrative to support the main argument - which also needs to be spelled out clearly. I professionally have engaged into diplomacy for a decade, and I fail to grasp the diplomacy elements in the draft. The narrative comes across as a mix of a policy paper/briefing with references to SDGs, with references to IO as agents of diplomacy (which is in itself an arguable statement; how many IO may be considered as such? IOs are in place to support the diplomatic/political processes, but them being agents of diplomacy is a separate subject matter) and a description of instances when states supported in developing and enhancing health systems of other states.

30: “is” or “has”?

124: against health?

189-191: “could be linked” or “was linked”?

 220: after the “well-being” – a word seems to be missing?

310-320: should the role of the USA in the demolition of the already feeble medical infrastructure in Afghanistan in the years preceding be mentioned?

Section 5: 300-352: a number of cases when countries helped with creating medical infrastructure /recovery rescue operations – it would be good to understand how are these linked to health diplomacy, beyond the fact that they involved other states.

369-392: IO as actors of health diplomacy - The list of examples suggests that they are service providers, which is not the same.

395: reference missin.g

409: check sentence

410-411: what does this sentence mean? How can health be delivered internationally?

422: how is COVID lined to the re-emergence of threat of WMD?

430: reviving?

Conclusions are simplistic and may be implicit in advance, not Sudan-specific.

Please proofread with attention as parts of sentences are missing or duplicated 

Author Response

Point 1: I would suggest to make the introduction less generic and focus on the Sudan-specific context.

Response 1: Thank you for your insightful suggestions. We have modified the article accordingly by bringing the context of Sudan in the introduction. (30-45)

 

Point 2: SDGs etc are political objectives – it would be worth explaining how these link to the topic of the article. I understand that everything may be linked to everything, but for the purposes of an academic publication, what is the value of referencing these?

Response 2: The interlinkage among SDGs 3, 16 and 17 in the context of health system strengthening and partnerships has been mentioned in the revised introduction with the relevant references. (72-83)

 

Point 3: I have a feeling that the title of the article does not correlate with the content. Having read the title, I expected a very different type of narrative to support the main argument - which also needs to be spelled out clearly.

Response 3: In this article, we have focused on how health diplomacy can be an enabler to strengthen the health system in conflict settings. We have illustrated through multiple examples, the importance of addressing the attack on health, the international measures that are in place to tackle it, and how health diplomacy is one of the tools that the international community has prominently used to mitigate health crises in conflict settings. In addition, we have explained the future directions and potential actions where health diplomacy can act as an enabler to mitigate the Sudan crisis. (72-89, 302-307, 465-521)

 

Point 4: I professionally have engaged into diplomacy for a decade, and I fail to grasp the diplomacy elements in the draft. The narrative comes across as a mix of a policy paper/briefing with references to SDGs, with references to IO as agents of diplomacy (which is in itself an arguable statement. How many IO may be considered as such? IOs are in place to support the diplomatic/political processes, but them being agents of diplomacy is a separate subject matter) and a description of instances when states supported in developing and enhancing health systems of other states.

Response 4: We respectfully concur with the reviewer that there is a distinction between International Organizations (IOs) being an agent of diplomacy and a facilitator of it. However, as health diplomacy occurs at multiple levels and with multiple stakeholders involved, mentioning the World Health Organization’s health-for-peace initiatives is vital for the paper. (378-391)

 

Point 5: 30: “is” or “has”?

Response 5: This has been revised (72-73)

 

Point 6: 124: against health?

Response 6: This has been revised (143)

 

Point 7: 189-191: “could be linked” or “was linked”?

Response 7: The sentence has been removed.

 

Point 8: 220: after the “well-being” – a word seems to be missing?

Response 8: This has been revised (236)

 

Point 9: 310-320: should the role of the USA in the demolition of the already feeble medical infrastructure in Afghanistan in the years preceding be mentioned?

Response 9: This has been revised (311-313)

 

Point 10: Section 5: 300-352: a number of cases when countries helped with creating medical infrastructure /recovery rescue operations – it would be good to understand how are these linked to health diplomacy, beyond the fact that they involved other states.

Response 10: We have brought the link on how assisting through sending healthcare professionals, infrastructural development, and capacity-building programs are elements of health diplomacy with the relevant citation (300-310).

 

Point 11: 369-392: IO as actors of health diplomacy - The list of examples suggests that they are service providers, which is not the same.

Response 11: WHO has been mentioned in the context of using health-for-peace initiatives, which is an essential component of health diplomacy in conflict settings as iterated in the introduction with the relevant reference.

 

Point 12: 395: reference missing

Response 12: This has been added (397)

 

Point 13: 409: check sentence

Response 13: This has been deleted.

 

Point 14: 410-411: what does this sentence mean? How can health be delivered internationally?

Response 14: This has been deleted

 

Point 15: 422: how is COVID lined to the re-emergence of threat of WMD?

Response 15: This has been revised to enhance clarity. (420-423)

 

Point 16: 430: reviving?

Response 16: This has been addressed (430)

 

Point 17: Conclusions are simplistic and may be implicit in advance, not Sudan-specific.

Response 17: A Sudan Specific Conclusion has been presented. (477-529)

Reviewer 3 Report

Dear Authors,

Having reviewed your comprehensive paper on "Health Diplomacy as a Tool to build resilient health systems in Conflict Settings – A Case of Sudan," I commend the depth and breadth of your analysis. I'd like to propose some insights drawn from another recent paper: "Ukraine’s Healthcare Crisis: Sustainable Strategies for Navigating Conflict and Rebuilding for a Resilient Future" (Reference: [https://www.mdpi.com/2071-1050/15/15/11602]). I believe that drawing some parallels between the two situations could enrich the discussion in your paper.

1. Intersectoral Cooperation: Both Sudan and Ukraine emphasize the value of intersectoral cooperation in health diplomacy. Incorporating Ukraine's strategy of promoting interdisciplinary collaboration and approaching health as a global concern might provide an enhanced perspective.

2. Local Population Sensitivities: Ukraine's conflict has led to various population sensitivities, just like Sudan. Detailing efforts made to counter misinformation, ensure transparency, and engage the local population could serve as a lesson in the effectiveness of these strategies.

3. Capacity Building: Your emphasis on training local healthcare professionals in Sudan is commendable. Reflecting upon Ukraine's approach to partnering with international organizations for training and resources might provide an alternative strategy for sustainable response.

4. Holistic Resilience Building: Your paper aptly highlighted the importance of holistic health system resilience. By introducing Ukraine's approach to integrating health considerations across policy sectors through a 'Health in All Policies' approach, readers might gain insight into the versatility of such strategies across diverse conflict settings.

5. Engaging the Community: The community-based approaches for healthcare delivery, as observed in both Sudan and the case of Ebola, mirrors Ukraine's efforts in ensuring effective and accepted interventions. Delving into such a strategy might offer practical insights into the applicability of community engagement in health diplomacy.

Incorporating these key points, referenced from the Ukrainian case, might not only strengthen the applicability of your findings but also provide a broader perspective to readers on the nuances of health diplomacy in varied conflict settings.

I look forward to seeing the revised version of your paper.

Warm regards,

minor edits

Author Response

Point 1: Intersectoral Cooperation: Both Sudan and Ukraine emphasize the value of intersectoral cooperation in health diplomacy. Incorporating Ukraine's strategy of promoting interdisciplinary collaboration and approaching health as a global concern might provide an enhanced perspective.

Local Population Sensitivities: Ukraine's conflict has led to various population sensitivities, just like Sudan. Detailing efforts made to counter misinformation, ensure transparency, and engage the local population could serve as a lesson in the effectiveness of these strategies.

Capacity Building: Your emphasis on training local healthcare professionals in Sudan is commendable. Reflecting upon Ukraine's approach to partnering with international organizations for training and resources might provide an alternative strategy for sustainable response.

Holistic Resilience Building: Your paper aptly highlighted the importance of holistic health system resilience. By introducing Ukraine's approach to integrating health considerations across policy sectors through a 'Health in All Policies' approach, readers might gain insight into the versatility of such strategies across diverse conflict settings.

Engaging the Community: The community-based approaches for healthcare delivery, as observed in both Sudan and the case of Ebola, mirrors Ukraine's efforts in ensuring effective and accepted interventions. Delving into such a strategy might offer practical insights into the applicability of community engagement in health diplomacy.

Incorporating these key points, referenced from the Ukrainian case, might not only strengthen the applicability of your findings but also provide a broader perspective to readers on the nuances of health diplomacy in varied conflict settings.

Response 1: We respectfully concur with the recommendations provided by the reviewer, and it has been incorporated in accordance with the relevance in the conclusion and future direction section (495-504). We acknowledge the differences in the nature of the conflict between Sudan and Ukraine, and the contrast in the existing health infrastructure, resources, and competencies between both countries. 

Round 3

Reviewer 2 Report

I would like to thank the authors for the revised draft. It represents a major improvement. It reads as a balanced narrative, with supporting evidence to the claims. The change of the title also helps as it is better aligned to the content of the article. 

I saw a couple of minor issues with EN, it is worth proof reading the draft  again before the publication.