Health Care for Post ConflictStabilizationV. Harutyunyan M.D.
Conflicts and their effects “An armed conflict is a contested incompatibility that concerns governmentand/or territory where the use of armed force between two parties, of which at least one is the government of a state, results in at least 25 battle-related deaths in one calendar year” Uppsala University Department of Peace and Conflict Research• “Major Wars“ are military conflicts inflicting 1,000 battlefield deaths per year• Currently there are 9 major wars and around 34 smaller scale conflicts waged around the World.• Unclear distinction between conflict and post conflict status• Conflicts disrupt the ability of states to to perform basic functions [such as] maintaining security, enabling economic development, and ensuring the essential needs of the population are met. (OECD/DAC)• An estimated one-sixth of the world’s population live in fragile or conflict- affected states.
Conflicts and their effects• Both health facilities and health personnel often become direct targets (Iraq, Syria, Nepal, Kosovo)• Health facilities and symbols used by health care providers used for military purpose (Syria, Palestine)• Rapid reduction of access to health care in conflict affected areas• Increased morbidity and mortality • High incidence of non violent deaths • Disproportionately affected civilian population • Unequal distribution • Masked by the national data • Distorted due to inappropriate use of data collection techniques • Data manipulation
Health Care and its role in humanitarianphase• Provision of access to life saving health services• Preventing excess morbidity and mortality• Strengthening emergency preparedness capacity• Providing basis for health system recovery• Promoting peace and protecting humanitarian space: • Health as a Bridge for Peace (HBP)
Health, State Building, Stability, andGovernance• Stabilization and peacebuilding in fragile and postconflict states have become major features of international policy and foreign assistance • High rate of conflict recidivism (31 percent of conflicts restart within ten years of concluding) • Destructive impact on population health and well-being • Creates conditions for expansion of instability and violence• Role of Health System in post conflict stabilization and peace building • Link between health of the population, greater productivity, economic growth, and state stability. • Mounting evidence that improved health services can increase trust in government and thus modestly contribute to reinforcement of the authority and legitimacy of the state.
Health, State Building, Stability, andGovernance (theoretical framework)Inputs: Outputs: • Improved access to quality, reliableFunctioning, equitable health services forhealth system: priority health Outcomes: problems• National government • Enhanced social stewardship Reduced mortality and solidarity and• Rehabilitated primary morbidity cohesion care facilities More capable, resilient • Greater confidence in• Re-established health state government and workforce Reduced risk of conflict support for social• Fair financing recurrence contract• Guaranteed package • Stronger government of health services capacity to• Equitable allocation administer public of services programs M.E. Kruk et al. / Social Science & Medicine 70 (2010) 89–97
Health, State Building, Stability, andGovernance“We understand that addressing global health challenges is not just ahumanitarian imperative – it will also bolster global security, foster politicalstability and promote economic growth and development” Hillary Rodham Clinton, former US Secretary of State
Health System Reconstruction: principles• The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.• Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures. WHO constitution• Access to health is a development issue: “We also recognize the importance of universal health coverage to enhancing health, social cohesion and sustainable human and economic development. We pledge to strengthen health systems towards the provision of equitable universal coverage” Rio+20 United Nations Conference on Sustainable Development 2012• Health systems is a core social institution (Report of the special rapporteur on the right of everyone to the highest attainable standard of health to the commission on human rights. 2006)
Health System Reconstruction: Lessons Learnedand Challenges • Lack of evidence supporting links between providing health care and conflict stabilization. • Success of health reconstruction and its effect on post conflict stabilization will depend on the importance that parties to the conflict and people attach to health care (Lebanon, Mozambique, DRC, Somalia) • Health services are a necessary but hardly sufficient feature of the government • Equity in services may be a more powerful predictor of confidence in government than the general sufficiency of services. • The traditional dichotomy of development and humanitarian aid is counterproductive • Health interventions in fragile and conflict-affected states are limited to humanitarian relief, which does not advance either health systems development or state legitimacy. • Conflict and fragility tend to be protracted, but health systems development can often proceed before peace and stability are established • Meeting short term health needs is important for addressing populations health problems and maintaining stability
Health System Reconstruction: LessonsLearned and Challenges• Government’s leadership is critical for rebuilding health systems (Liberia vs Somalia)• Authorities in post conflict states often need substantial financial and operational support to provide equitable health services (Afghanistan, Southern Sudan, Liberia)• Donor and aid agency policies and interests have considerable effect on both the success of heath system reconstruction and its contribution to post conflict stabilization• Military involvement in civilian health systems development in conflict- affected and postconflict states. (Iraq, Afghanistan)• Health reconstruction post crisis is a long term process and often requires sustained investment for decades
Remaining questions• How can health interventions contribute to stability?• How to assist fragile states in building effective health systems?• How to structure aid programs in poorly governed states so as to develop health systems without supporting corrupt or repressive governments?• How to restructure humanitarian aid programs so that long-term emergency funding supports health systems development?• How to meet short-term health needs while developing a coherent system?