Health systems in fragile and conflict affected settings
Building pathways for recovery
Rebuilding health systems in conflict and crisis affected settings
Attention on so-called fragile states began in the late 1990s with a concern that the prevailing good governance and aid effectiveness agendas of the time routinely failed to address the particular circumstances of conflict-affected or weakly governed states.
One of the key challenges in these contexts, where states are emerging from conflict or political turbulence, is to appreciate how these crises impact on the community and on state institutions, and to develop appropriate mechanisms to support their re-establishment in a more accountable, democratic and pro-poor form. In his article on state fragility and governance, Derick Brinkerhoff (2011) speaks in terms of renewing the social contract between citizens and the state, particularly its responsiveness and capacity to achieve resilience.
These renewal mechanisms need also to be seen within the broader context of promoting and consolidating the peace, re-establishing the economy, and facilitating the return of refugees and internally displaced people. Institutional and political adaptations will have taken place over time, including a move to greater decentralisation and the emergence of a range of providers including the informal and private for profit sectors, and national and international non-governmental agencies.
When it comes to rebuilding health systems, understanding how these adaptations might potentially contribute to or undermine service coherence, quality and equitable coverage is important in designing and implementing policies for recovery. Within this are important questions of transition - how the ill-defined boundaries between humanitarian interventions and state-building impact on rebuilding health systems and how health systems’ policies and interventions are influenced by relations between donor and recipient authorities.
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Bridging humanitarian and development approaches
Transition describes a period when a country or sub-national region is emerging from conflict or violent instability, and reflects a “transition from the external provision of services towards greater state ownership and responsibility for the safety and welfare of its own people” (OECD 2012:18). The type of aid provided, and policies and operational practices sanctioned are frequently blurred between humanitarian and developmental approaches. Humanitarian approaches are normally ‘state-avoiding’ with short-term horizons, reliance on external funding, expatriate staffing, and a limited capacity orientation. Development approaches, on the other hand, focus more on capacity building of local staff and providers, returning control to local authorities, and can call on a broader range of funding sources and instruments and programming opportunities.
In transitioning to working with local or national authorities to rebuild health systems and to re-engage users and providers with publicly provided health care, the OECD (2011, 2012) argues for greater flexibility in both programme design and financing than was often available during the conflict or crisis situation.. They also call for more attention to be paid to building local capacity. A review by Bailey et al (2009) highlights the pitfalls that occur in early recovery, particularly when ‘solutions’ are externally imposed. These challenges are shown in a case study of South Sudan by Cometto et al (2010) and include a considerable lack of capacity by local government agencies, delays in shifting from short-term to longer-term funding by external agencies, all hampered by a faltering peace process.
In transition periods, the legitimacy of the returning authorities is important and this is generally linked with the delivery of public services associated with the state. But, as Claire McLoughlin (2015) points out, achieving state legitimacy through effective service delivery is far from straightforward and our understanding of how to achieve it needs “a more joined up analysis of the localized effects of services on trust in local bureaucracies and citizens’ beliefs in the broader state’s right to rule” (p.352).
Changing relationships between actors
The process of transition naturally leads to a change in the roles and relationships between actors, that reflect the changed conditions. This generally means a shift in the external and state agencies involved, from humanitarian actors to the return of national and local state actors and development-oriented international NGOs(INGOs) and donors.
However ,as noted by Ssengooba et al (2017), transition often also brings a proliferation of external actors, often with different priorities and approaches to rebuilding health systems post-crisis. These can frequently overwhelm the capacity of national agencies, particularly those working at sub-national level which in turn can also undermine the stewardship function of the state actors and lead to system fragmentation.
So emphasis on building relationships and partnerships clearly becomes important in fragile and conflict-affected states, particularly after conflict. Paul Harvey (2013) highlights the difficulties experienced by this shift for various actors, particularly the adjustment away from humanitarian principles of neutrality and impartiality to working more closely with government as partners.
Changing aid practices
Evidence from fragile and conflict-affected states shows that aid can be an opportunity to accelerate developments in health systems, social protection and other welfare infrastructure. However, neither traditional humanitarian nor developmental approaches on their own may be adequate to engage with transitional processes (OECD 2011) - something which Canavan et al (2008) describes as the ‘transitional funding gap’. In states emerging from conflict or crisis, changing aid modalities are needed.
The OECD (2011) suggests that “rather than being sequential, such approaches may need to be pursued in parallel” (p.30), and advises that a “mix of different aid instruments” be introduced in order to respond to the different priorities and conditions of the transition.
Addressing inequalities in health systems
Conflict can reshape social inequities – both vertically and horizontally. Frances Stewart (2005) has highlighted that horizontal equity, which concerns inter-group access to services and other resources, is as important as vertical equity, ensuring equal access for equal need, in FCAS contexts. Two research programmes – Secure Livelihoods Research Consortium (SLRC) and Household in Conflict Network have produced a body of research that have focused on micro-level analysis of conflict on livelihoods and household welfare, including gender, age, ethnicity, and disability inequalities. Formal social protection for these groups is essential in making a difference although many vulnerable groups rely heavily on informal social protection.
Health Equity Funds (HEFs), introduced in Cambodia the late 1990s by international NGOs (INGOs) became one of the most successful formal social protection programmes in fragile and conflict-affected settings. Evidence suggests that the Cambodian HEFs are relatively successful in protecting the poor from health service costs. This has been attributed to the sustained external support for the HEFs, the coverage of fees as well as non-fee costs of accessing health care and the management of both targeting mechanisms and payment/reimbursement mechanisms by INGOs.