In the late twentieth century, 15 of the 20 poorest countries in the world experienced armed conflict. This has had devastating social and economic impacts, with public health one of the main casualties. Relief efforts provide short-term help but how do countries rebuild their health systems in the long term?

Researchers from the United Nations University World Institute for Development Economics Research (UNU-WIDER) looked at post-conflict reconstruction, the rebuilding of society and economy, and in particular the health sector, in countries that have experienced conflict.

The researchers analysed the experiences of different countries affected by conflict, including Afghanistan, Cambodia, East Timor, Kosovo, Uganda and Mozambique. They began by looking at the impacts of conflict on public health. They then presented a framework for understanding how programmes for rehabilitating health systems might work in post-conflict countries.

They found that in addition to death and ill-health caused directly by conflict, there were a number of indirect impacts. These included physical injuries caused by landmines, and emotional trauma, both often leading to permanent disability. Another problem was displaced populations, with a related increase in vulnerability to communicable diseases such as HIV, malaria, measles, diarrhoea and respiratory infections including tuberculosis. The authors identified further impacts on the health system itself:

• There was a lack of disease surveillance and consequently inadequate information for setting priorities.
• Financial resources were limited due to increased military spending, reduced government revenue and greater dependence on aid.
• There were severe shortages of health care staff, with many kidnapped, dying or fleeing the conflict, and a particular lack of qualified managers.
• Conflict also destroyed essential supplies and equipment, and infrastructure such as health centres, clinics and hospitals, and interrupted basic health services, with primary care suffering the most.
• There was a loss of political authority and legitimacy, made worse by the departure of academics and policymakers, leading to a breakdown in trust and social networks.

The authors suggest three interrelated approaches to health sector rehabilitation: an initial response to immediate health needs (through humanitarian assistance and relief); restoration or establishment of a package of essential health services including immunisation and obstetric care; and restoration of the health system itself.

The authors highlight the lack of co-ordination between donor organisations, whose competing needs and projects distract health officials. Non-governmental organisations (NGOs) may also delay progress by continuing to focus on relief when the country has moved on to the next stage. Specific recommendations include:

• focus on strong management and financial structures to ensure sustainability
• strengthen information systems
• attract qualified staff to the public sector, including by compensating for hardship or danger
• make the most of external assistance, starting with modest aid and then increasing it along with the country’s ability to absorb it and use it effectively
• form partnerships with NGOs
• ensure political commitment by government, including a clear national strategy for health systems development, that sets long-term priorities and allows for co-ordination of donor activities and funding; this was key to the success stories of Kosovo and Mozambique
• ensure that short-term relief and assistance work alongside medium and long-term rebuilding of the health system

Source(s):
'Rehabilitating Health Systems in Post-Conflict Situations', UNU-WIDER Research Paper No. 2007/06, United Nations University World Institute for Development Economics Research, by Hugh Waters, Brinnon Garrett and Gilbert Burnham, 2007 (PDF)

Funded by: Finnish Ministry for Foreign Affairs, Danish Royal Ministry of Foreign Affairs, Norwegian Royal Ministry of Foreign Affairs, Swedish International Development Cooperation Agency (Sida) and UK Department for International Development (DFID)

id21 Research Highlight: 19 December 2007

Further Information:
Hugh Waters
Department of Health Policy and Management
Johns Hopkins Bloomberg School of Public Health
615 N. Wolfe Street
Baltimore
Maryland 21205
USA

Tel: +1 410 955 3879
Fax: + 1 410 614 1419
Contact the contributor: hwaters@jhsph.edu

John Hopkins Bloomburg School of Public Health

Other related links:
'Running battle - international intervention in post-conflict healthcare'

'Post-conflict partners: UK helps to rebuild health service in Somaliland'

'Service delivery for sustainable peace'

'Potentials and limits of community-based service delivery in post-conflict situations'

'Life skills, peace education and AIDS prevention'

'Time to grasp the nettle? Post-conflict rehabilitation'