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Most armed conflicts over the past decades have been characterised by prolonged periods of fighting between a government and one or more opposing factions, often for well over 10 years. Increasingly, civilians have become ‘instruments of war’, and civilian populations are disproportionally affected by these so-called New Wars (1). Displacement, affected livelihoods, deteriorated health status, and economic decline are some of the consequences. Morbidity and mortality typically increase substantially due to the direct effects of warfare but often also due to indirect effects such as deteriorating determinants of health, including malnutrition, increased epidemic risks, and declines in preventive and curative health services. The conflicts in Afghanistan, Democratic Republic of Congo, Somalia, Sudan, Liberia and Sierra Leone are well known examples, and recent widespread conflicts in countries like Syria, Central African Republic and South Sudan can be added to this list.
The prolonged conflicts in these countries, often already weak states at the beginning of conflict, tend to erode all institutions in the country and even affect the very fabric of society. The erosion of institutional capacity affects all levels and sectors of government, including health authorities at national and subnational levels.
During most of these conflicts, an international humanitarian response emerges. The international community, in the form of UN agencies and international relief NGOs, arrives on the scene to protect people, whereby ‘saving lives’ is the primary goal. Humanitarian health agencies aim to provide health services by setting up clinics and other services, through their own operations or through support to pre-existing health facilities. These can be large-scale operations that may last for many years. While usually some form of coordination with local health authorities takes place, the humanitarian agencies insist on being able to act independently and retain control over their own resources. In many cases, this is the only way to operate to protect citizens and save lives. But while lives are being saved, the health system usually suffers in that it becomes increasingly fragmented with an unequal distribution of services.
Post-conflict
Sooner or later conflicts are resolved through some form of political settlement. It is rare for this to occur through a one-off negotiated peace agreement that is consistently upheld by all parties. Rather, the end of conflict usually consists of a lengthy process in which the conflict gradually goes through phases of increased stability, intertwined with periods of more or less widespread re-occurrence of fighting until some form of lasting stability has been reached. If at some point in this process a sense of more lasting stability emerges, which may be the case if a negotiated change of power or other form of settlement is achieved, the international community generally changes its approach. Humanitarian funding is reduced and, more importantly, it’s necessary to ensure that a viable state emerges that is able and willing to take care of its citizens. For the health sector, this means that health authorities need to be in charge again, set policy directions, and regulate the health sector. Since the capability to do so is often marginal, a lengthy transition process can be necessary in which the state gradually takes on its role in promoting sustainable development. In the health sector, there is then a need to transition from a pure focus on health service delivery towards a more comprehensive focus on the whole range of health system building blocks. The diagram in figure 1 aims to illustrate the transition process (2).
Responding to immediate health needs
Restoring essential health services
Rehabilitating the health system
The transition is never a smooth, linear process. Bouts of insecurity may re-occur, initial political settlements may not hold, and institutional capacities will only gradually improve. Even if peace lasts and substantial resources are allocated to a reconstruction of the health system, it takes a long time to establish a truly resilient health system. The inability of the health system in Liberia and Sierra Leone to deal with the Ebola outbreak, followed by a collapse of the existing health system, resulting in even more victims due to ‘non-Ebola’ causes like malaria and maternal deaths, is a clear example of this (3).
The approach
The transition period is difficult to manage. It requires a long-term approach, but this is hindered by the ongoing instability, weak government institutions, frequent lack of accountability, and poorly harmonised donor policies with short-term horizons. There is a need to urgently meet the increased health needs, while at the same time addressing the often not fully compatible need to put a government ‘back in the driver’s seat’ for long term sustainability and to increase trust in and legitimacy of a new government.
Due to reduced capabilities within government, often coupled with low levels of accountability, the international community and its donors tend to settle for hybrid approaches. Development principles that are useful in stable development contexts are mixed with modalities more often found in a crisis context. The aim is to support the emergence of government-led policies and strategies. However, the implementation of the chosen strategy may involve NGOs, with an intermediate fund manager channelling the funds from donors to the NGOs outside the government financial systems.
A good example of the latter is the now widespread practice taking place in a range of post-conflict settings where NGOS are contracted to deliver health services on behalf of the government and within the scope of government-set general health policies. Contracts, which are usually paid for directly by a donor or its non-state fund manager, may provide the NGOs with more or less autonomy to deliver the services. Local capacity building of health authorities and health providers is usually part of the contract.
This approach tends to lead to a largely supply driven model. A more recent development is to pay much more attention to the ‘missing’ health systems building block, i.e. a focus on the needs of the people in the communities undergoing health sector recovery (Figure 2).
An example comes from South Sudan. Partly inspired by Ethiopia’s Health Extension Program, the government now endorses the Boma Health Initiative. This initiative is meant to complement the largely supply driven rollout of an essential package of health care, with the involvement of NGOs assisting country health departments, by placing much more emphasis on the role of communities. This Boma Health Initiative model is based on Boma Health Teams (3 salaried community health workers) and is constituted as a formal component of the health system to deliver an integrated package of health promotion and selected treatment services supported by volunteer home health promoters. The Boma Health Teams are meant to be the entry point for all community level health activities and for all health programmes in that community (a Boma is the smallest geographical area and administrative unit in South Sudan). The Boma Health Initiative is in line with renewed interest over the past years in Community Health Worker programmes bringing services closer to the communities. More evidence is now available on the factors that influence successful CHW performance (4). Appropriate involvement of communities, including close-to-community services, is leading to a more demand driven approach and increased accountability on the part of health authorities and providers, which in turn is believed to be an essential contributor to state building.
IN POST-CONFLICT ENVIRONMENTS, HUMANITARIAN AID MODELS HAVE TO GIVE WAY TO DEVELOPMENT AID
References
- Kaldor, Mary (2012), New and Old Wars: Organized Violence in a Global Era. Cambridge: Polity. 2012
- Canavan AP, Vergeer P, Hughes J, Ezard N. Health Sector Policy and Funding Gaps in Post-conflict Settings: A Question of Aid Effectiveness in Transition. Amsterdam: Royal Tropical Institute of the Netherlands. Report for the Health and Fragile States Network. 2008
- Brolin Ribacke KJ, Saulnier DD, Eriksson A, Von Schreeb, J. Effects of the West Africa Ebola Virus Disease on Health-Care Utilization – A Systematic Review. Frontiers in Public Health, 2016 Volume 4, Article 222
- Kok MC, Kane SS, Tulloch O et al. How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature. Health Research Policy and Systems, 2015, 13:13
