Health systems in fragile and conflict affected settings

Building pathways for recovery

Rebuilding health systems in conflict and crisis affected settings

A provider at a government-run medical facility in Aden, Yemen, examines Somali refugees that recently fled across the Aden Sea. Thousands of people fleeing civil strife in Somalia have fled safely to Yemen.|Micah Albert, Courtesy of Photoshare.
Edited by Alan Stanley
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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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Suzanne Fustukian 

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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). 


Health sector recovery in early post-conflict environments: Experience from southern Sudan
Wiley-Blackwell, 2010
Health sector recovery in post-conflict settings presents an opportunity for reform: analysis of policy processes can provide useful lessons. The case of southern Sudan is assessed through interviews, a literature review, and by drawing on the experience of former technical advisors to the Ministry of Health.
When does service delivery improve the legitimacy of a fragile or conflict-affected state?
Wiley Online Library, 2015
Received wisdom holds that the provision of vital public services necessarily improves the legitimacy of a fragile or conflict-affected state. In practice, however, the relationship between a state's performance in delivering services and its degree of legitimacy is nonlinear. Specifically, this relationship is conditioned by expectations of what the state should provide, subjective assessments of impartiality and distributive justice, the relational aspects of provision, how easy it is to attribute (credit or blame) performance to the state, and the characteristics of the service.
Supporting statebuilding in situations of conflict and fragility: Policy guidance
OECD DAC Guidelines and Reference Series, 2011
Functioning states are essential for reducing poverty, sustaining peace and achieving agreed development goals. Despite receiving growing international attention in recent years, fragile states are falling behind other low-income countries in human development. Fragility – and its negative consequences – can destabilise entire regions and have global repercussions. Tackling the challenges associated with fragility requires a concerted international effort to support sustainable statebuilding processes, based on robust state-society relations.

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.

Continue reading: Changing aid practices


Application of social network analysis in the assessment of organizational infrastructure for service delivery: A case study from post-conflict northern Uganda
Oxford University Press, 2017
In post-conflict settings, service coverage indices are unlikely to be sustained if health systems are built on weak and unstable inter-organization infrastructures. The objective of this study was to identify and examine the organization-level infrastructure that supports the provision of selected health services in post-conflict northern Uganda.

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.


Post-conflict health sectors: the myth and reality of transitional funding gaps
KIT Development Policy & Practice, 2008
During the transition from conflict to peace, the limited health services that exist, mainly provided by humanitarian non-governmental organisations, often come under threat of contraction. The most commonly cited reason is the so-called transitional funding gap, defined as a net reduction in monies available to the health sector during the transition from relief to development which may affect the delivery of health services. This paper was commissioned by the Health and Fragile States Network to examine these issues.
International support to post-conflict transition: Rethinking policy, changing practice
OECD DAC Guidelines and Reference Series, 2012
1.5 billion people live in countries affected by repeated cycles of violence and insecurity. These countries face tremendous challenges as they transition from conflict to peace. International support can play a crucial role in these contexts, but has so far struggled to deliver transformative results. This volume presents clear policy recommendations for better practice in order to improve the speed, flexibility, predictability and risk management of international support during post-conflict transition.
A rethink on the use of aid mechanisms in health sector early recovery
Royal Tropical Institute, 2009
States emerging from protracted crises struggle to provide basic services. This is no more crucial than in the health sector where vulnerable ‘post-conflict’ populations are frequently in dire need of care. However, development actors are frequently faced with difficult choices – particularly how much emphasis to place on ‘humanitarian’ emergency health relief in the face of a need for health systems building. Yet is it possible to simultaneously provide basic health services whilst also developing local health provision?

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.

Continue reading: Back to introduction


Promoting health equity in conflict-affected fragile states
London School of Hygiene and Tropical Medicine, 2007
This paper was commissioned by the Health Systems Knowledge Network of the WHO Commission on the Social Determinants of Health in response to their conclusion that a lack of data from conflict-affected fragile states made it difficult to delineate pragmatic ways of creating better social conditions for health for vulnerable populations.The key questions we focused on were as follows:What are the main factors that threaten health equity and health care equity in conflict and post-conflict fragile states?
Have post-conflict development policies addressed horizontal inequalities?
Department for International Development, UK, 2017
New research by CRISE reveals important gaps and inconsistencies in post-conflict reconstruction policies on Horizontal Inequalities. Based on in-depth studies of eight diverse post-conflict countries and four cross-cutting thematic studies, the findings provide a framework that helps to explain sources of success, and failure, and points to policy requirements and constraints in this area. In evaluating and explaining the sources of differences in outcomes, this In Brief identifies three key factors that explain success in tackling HIs.
The war wounded and recovery in northern Uganda
Secure Livelihoods Research Consortium, 2014
In 2012/13, SLRC implemented the first round of an original sub-regional panel survey in northern Uganda aimed to produce data on livelihoods, access to and experience of basic services, exposure to shocks and coping strategies, people’s perceptions of governance, and the impact of serious crimes committed during the Government of Uganda and Lord’s Resistance Army conflict on households’ livelihoods, access to services, exposure to crimes, and perceptions of governance.
Perceptions and experiences of access to public healthcare by people with disabilities and older people in Uganda
BioMed Central, 2014
In the year 2000, a set of eight Millennium Development Goals (MDGs) were presented as a way to channel global efforts into the reduction of poverty and the promotion of social development. A global discussion regarding how to renew these goals is underway and it is in this context that the Goals and Governance for Global Health (Go4Health) research consortium conducted consultations with marginalized communities in Asia, Latin America, the Pacific and Africa as a way to include their voices in world’s new development agenda.