Rebuilding health systems to improve health and promote statebuilding in post-conflict countries: A theoretical framework and research agenda
Introduction
In 2008, there were 39 wars and severe crises, defined as conflicts in which violence is used systematically for a long duration (Heidelberg Instiute for International Conflict Research, 2008). According to the United Nations Development Program (UNDP), since 1989, 35 countries have entered the post-conflict phase—59% of these are low-income (2008). Post-conflict countries, particularly developing countries, face daunting economic and social challenges including high mortality and morbidity, economic stagnation, population displacement, human and capital flight, and infrastructure destruction (Ohiorhenuan & Steward, 2008). Moreover, an estimated 23 to 50% of post-conflict countries experience renewed conflict. This risk is highest among low-income countries (Collier & Hoeffler, 2004).
Although deaths due to conflict-related violence—so-called direct mortality—have fallen in the past 30 years because of the rise in low-intensity conflicts that do not involve large armies or heavy weapons, deaths among non-combatants are on the rise. The UNDP recently estimated that battleground deaths comprised between 2 and 29 percent of all conflict-related deaths in nine countries with available data (Ohiorhenuan & Steward, 2008). Population-based surveys from the Democratic Republic of the Congo, which has recently emerged from large-scale violent conflict, suggest that the majority of deaths in the surveyed zones were caused by fever/malaria, diarrhea, respiratory infection and malnutrition, rather than violence (Coghlan et al., 2006). High morbidity and mortality can persist long after the conflict ends. For example, the infant mortality rates in Angola, Liberia, and Sierra Leone, all war-affected countries, have remained stagnant for the past 15 years (Ohiorhenuan & Steward, 2008). This “indirect” mortality is due to the disruption of livelihoods, inadequate food and water supplies, and the destruction of health systems, as well as to continued insecurity.
Indeed, the national health system is also a victim of conflict, with destruction of clinic and hospital infrastructure, the flight of health professionals, and the interruption of drugs and other medical supplies (Betsi et al., 2006, Ghobarah et al., 2004, Nagai et al., 2007, Rytter et al., 2006). Health systems are vulnerable even before conflict begins as governments redirect spending away from health care to the military(Plumper & Neumayer, 2006). In East Timor, three-quarters of the health infrastructure was damaged during the 1999 conflict (World Bank, 2000). In Côte d'Ivoire, the loss of health personnel and a crumbling health infrastructure limited public distribution of contraceptives and antiretroviral medications (Betsi et al., 2006). During the current Iraq war, laboratories have been extensively looted, reducing the country's ability to respond to day-to-day challenges as well as to health crises, such as cholera outbreaks (Dyer, 2003). Health systems are sometimes a direct target of fighting. During escalating conflict in the early 1980's in Mozambique, health workers and clinics were targeted by rebels to destabilize the government (Cliff & Noormahomed, 1988). Over the course of the Mozambique conflict, at least 21 health workers were murdered and, by 1985, rebels had completely destroyed at least 50% of health care infrastructure (Cliff and Noormahomed, 1988, Keane, 1996).
International humanitarian agencies have stepped in where local health systems have failed, providing a rapid emergency response during and in the immediate aftermath of conflict. Humanitarian assistance is frequently characterized by highly structured vertical programs ranging from mass immunization campaigns to specialized field hospitals although many humanitarian organizations have broadened their work to include preventive medicine, reproductive health services, emergency surgical interventions, mental health, and HIV prevention (Betsi et al., 2006, Pavignani and Colombo, 2005). Humanitarian agencies, such as the International Federation of Red Cross and Red Crescent Societies, Médecins sans Frontières, and the International Rescue Committee, are highly professional organizations that have, at times, achieved impressive successes in extremely difficult conditions (Balasegaram et al., 2009, Ritmeijer et al., 2007). For example, under-five mortality rates in refugee camps tend to be lower than in non-displaced populations remaining in the area (Singh, Karunakara, Burnham, & Hill, 2005).
As the number of post-conflict states grows and with it concern about their impact on regional and global instability, the global community has made ever-larger investments in reconstruction, including the restoration of essential services such as health care. In 2006, $26.8 billion of global Official Development Assistance went to fragile states—states at risk of or recovering from conflict (Organisation for Economic Co-operation and Development, 2007). Some conflicts with consume a disproportionate share: the United States has spent $49 billion dollars for Iraq reconstruction overall since 2003 and other global donors have contributed an additional $17 billion (Tarnoff, 2008).
Given the scale of the problem and the magnitude of financial commitments, there is surprisingly little empirical evidence about when and how to transition most effectively from relief to development programming (Vergeer, Canavan, & Rothmann, 2009). Tensions emerge between achieving quick results and building state capacity and donors often disagree on how best (or even whether) to strengthen weak governments to manage reconstruction dollars (Vergeer et al., 2009). There is frequently overlap and duplication in reconstruction efforts reducing effectiveness and creating inefficiency (Bacchus et al., 2004, Ball and Hendrickson, 2005). For example, in Liberia multiple parallel reintegration programs, including vocational training and cash-for-work programs, were operating simultaneously resulting in inconsistent implementation and poor effectiveness (UNDP Liberia, 2007). Priority-setting is made difficult by the many simultaneous needs of the population, although infrastructure (e.g., roads, bridges), health, and education are usually some of the first sectors targeted for rebuilding (Haidari, 2008, Pavignani, 2005).
While the humanitarian phase of response to conflict is often marked by efficient service delivery by highly professional organizations, during the transition from relief to recovery health care programming is frequently more chaotic. The pressure to produce quick and measurable improvements in service delivery leads development partners and governments to concentrate efforts on urban areas where there is some health infrastructure, leaving the rural areas without services (Waters, Garrett, & Burnham, 2007). International NGOs whose expertise is in responding to crises are more focused on alleviating immediate suffering than on planning for sustainability: for example, short courses for health workers prevail over much-needed investments in pre-service or longer-term training (Vergeer et al., 2009). A recent review of aid modalities to states recovering from conflict found that aid mechanisms selected by donors have an important effect on the success of rebuilding the health system and on improving health status (Vergeer et al., 2009). Indeed, a very different approach is required to plan health system rebuilding than that needed to coordinate mass immunization campaigns or emergency relief operations: the Cluster Working Group on Early Recovery (2008) described recovery as a process “guided by development principles that… catalyze sustainable development opportunities… to generate self sustaining, nationally owned, resilient processes for post crisis recovery.”
In this paper we argue that early investments in the health system may be a particularly promising development opportunity in countries recently emerging from armed conflict. Specifically, we propose that a functioning, equitable health system can have important health and statebuilding benefits in post-conflict countries. By health systems we mean key actors and institutions whose primary function is to promote health and prevent and treat disease as well as community-based partners (e.g., community health workers, health educators) (WHO, 2008). We define statebuilding as the process of strengthening state institutions and promoting state legitimacy to establish the foundation for a resilient state(Eldon, Waddington, & Hadi, 2008).
The paper has three parts. First, we discuss how investing in the health system can re-establish and sustain delivery of essential health services and why such investment is required to effectively reduce mortality and morbidity. Second, we explore how careful design of health system building blocks—including the regulatory framework, resource allocation, financing, package of services, mode of delivery, human resource management, etc.—can build government capacity, promote social cohesion, and strengthen the social contract, thereby promoting statebuilding and reducing the risks of conflict recurrence. The logic model outlining these potential mechanisms is outlined in Fig. 1. Throughout, we review the conceptual foundations and available empirical evidence for these links and discuss implications for countries recently emerging from civil or trans-border armed conflict. While our focus is on post-conflict countries, given the paucity of research in this area, where necessary, we cite evidence from other fragile states and from countries not afflicted by conflict. Third, we identify gaps in evidence and propose a research agenda.
Our proposed theoretical framework for the contributions of the health system in post-conflict settings builds on the literatures on health systems as social institutions and political constructs by applying these concepts to countries recovering from conflict (Bloom, 2001, Bodenheimer, 2005, Freedman et al., 2005, Gilson, 2003, Kruk and Freedman, 2008, Shi et al., 2002). The framework also reflects the current understanding that health systems should aim to improve health (in the aggregate and for sub-groups) and respond to people's legitimate non-health expectations (e.g., for respectful treatment, short waits, quality of care, and the redressing of inequities) (WHO, 2000). Lastly, our discussion of the political meanings of health services is influenced by a body of writing in the humanitarian community, loosely called “health as a bridge to peace” (HBP). The central tenet of this theory is that health is a “super-ordinate” value—one that is widely shared, irrespective of ideology or political affiliation (MacQueen et al., 1997, Santa Barbara and MacQueen, 2004, Sirkin et al., 2007). This special status accorded to health (as compared to other public services, for example), can make health care useful as a means to appeal to combatants to lay down arms. For example, combatants have been persuaded to lay down arms—albeit usually briefly—to permit polio and other vaccinations in conflict-affected areas (Rodriguez-Garcia, Schlesser, & Bernstein, 2001). While our model shares some of the assumptions of HBP (e.g., that health services are highly valued by the population), we depart from HBP in our focus on integrated health systems, rather than single interventions and on the situation of countries already at peace, with governments that are recognized as legitimate.
Section snippets
Reducing mortality and morbidity post-conflict
While estimates of indirect mortality—that is conflict-related deaths not caused by violence—are often unreliable because the causal links may be difficult to ascertain and because deaths may happen months or years after the conflict ends, it is well accepted that indirect mortality is far higher than direct mortality during and after conflicts (Coghlan et al., 2006, Lacina and Gleditsch, 2005). For example, in Angola and Sudan, indirect mortality comprised an estimated 89% and 98%,
Promoting social cohesion
The notion that health systems should redress health inequities—inequalities in health based on social disadvantage, such as higher infant mortality among the poor than the rich—is a core principle of most health systems and one that is supported by public opinion in low- and high-income countries (World Health Organization, 2008). Health systems can promote equity in two ways: through equitable service delivery and fair financing (Gwatkin et al., 2004, Rannan-Eliya, 2004). Thus health services
Implications and a research agenda
There is growing scholarship on what needs to be done to revive health systems in post-conflict countries. For example, Newbrander suggests a series of priority tasks for assisting health ministries, including, among others, addressing urgent health needs, gathering information, creating a package of basic health services, developing human resources, and financing services adequately (Newbrander, 2007). Waters et al. identify similar priorities and emphasize the role of humanitarian agencies in
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