Health systems in post-conflict states - Learning from the ReBUILD programme
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Presentation given by Joanna Raven on ReBUILD's work on health systems in post-conflict states, at a Workshop on Rebuilding Health in Yemen after Conflict, 4th June 2016 in Liverpool
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Health systems in post-conflict states - Learning from the ReBUILD programme
- 1. Health systems in post-conflict states Learning from the ReBUILD programme Joanna Raven Liverpool School of Tropical Medicine Workshop on Rebuilding Health in Yemen after Conflict 4th June 2016, Liverpool Research for stronger health systems post conflict
- 2. Background on ReBUILD Post conflict is a neglected area of health system research Opportunity to set health systems in a pro-poor direction Useful to think about what policy space there is in the immediate post-conflict period Choice of focal countries enable distance and close up view of post conflict Decisions made early post-conflict can steer the long term development of the health system Research for stronger health systems post conflict
- 3. ReBUILD’s research and partnership • Countries: • Sierra Leone • Cambodia • Northern Uganda • Zimbabwe • plus several ‘affiliate’ projects in other countries • Partners: • In all cases, working with national partners • UK partners: • Liverpool School of Tropical Medicine • Queen Margaret University, Edinburgh Health financing Gender & equity Health workforce Aid architecture Contracting models ReBUILD’s research Research for stronger health systems post conflict
- 4. Health Needs of population (demand) Health services (supply) Conflict and crisis creates change Howcandecisionsmadeearlypost-conflictor crisissteerthelongtermdevelopmentofthe healthsystem? Thematic areas Actors & networks Policy and power Vulnerability Household structure Accessing healthcare Resource flows Attraction/retention Posting Policy making Effects and responses Institutions Health workers Communities Strongerhealthsystemspostconflictandcrisis Research question Enhancedvulnerability Gender
- 5. Institutions • Post-conflict brings networks of diverse actors • Different priorities; fragmented approaches • Can overwhelm national/local capacity • State actors role must be kept strong • Resource flows controlled by external actors: • ‘Vertical programmes’ v ‘systems’ • Resources must follow need • Need national coordination/scrutiny • Policy & power: • Policy often externally driven. • Lack of local ownership; weak implementation. • External actors powerful at local level Gulu District HIV Treatment Service Networks; Gulu, northern Uganda
- 6. Institutions • Post-conflict brings networks of diverse actors • Different priorities; fragmented approaches • Can overwhelm national/local capacity • State actors role must be kept strong • Resource flows controlled by external actors: • ‘Vertical programmes’ v ‘systems’ • Resources must follow need • Need national coordination/scrutiny • Policy & power: • Policy often externally driven. • Lack of local ownership; weak implementation. • External actors powerful at local level Gulu District HIV Treatment Service Networks; Gulu, northern Uganda Service delivery Relevant building blocks Financing Governance
- 7. Health workers • Attraction and retention in underserved areas • Local staff & mid-level cadres more likely to work in remote areas • To work in remote areas workers need: • recognition of role and achievements in challenging circumstances • practical measures to improve their security • provision of decent housing, working conditions and pay • trust, communication and teamwork • Posting • Take workers’ preferences in terms of job location increases retention • Policy making • Local actors need to lead health worker policy process • Gender • Gender needs to be integrated in all new health worker regulations and policies
- 8. Health workers • Attraction and retention in underserved areas • Local staff & mid-level cadres more likely to work in remote areas • To work in remote areas workers need: • recognition of role and achievements in challenging circumstances • practical measures to improve their security • provision of decent housing, working conditions and pay • trust, communication and teamwork • Posting • Take workers’ preferences in terms of job location increases retention • Policy making • Local actors need to lead health worker policy process • Gender • Gender needs to be integrated in all new health worker regulations and policies Relevant building blocks Human resources
- 9. Communities • Household structure • Increased proportion of female headed households • Conscription, impact of conflict and the missing generation of children • Vulnerability and resilience • Increasing numbers of people with disability • Female headed households - disadvantaged or resilient? • Accessing healthcare • Draw on resources from households, extended family, gifts and small loans from communities
- 10. Communities • Household structure • Increased proportion of female headed households • Conscription, impact of conflict and the missing generation of children • Vulnerability and resilience • Increasing numbers of people with disability • Female headed households - disadvantaged or resilient? • Accessing healthcare • Draw on resources from households, extended family, gifts and small loans from communities Financing Service delivery Relevant building blocks
- 11. More information, resources & networks • ReBUILD Consortium website – www.rebuildconsortium.com • All ReBUILD resources, updates and further information • HSG Thematic Working Group on Health Systems in Fragile and Conflict Affected States • A wider network of actors interested in health systems research and strengthening in fragile and conflict-affected settings • Building Back Better • Resources and case studies on gender and post-conflict health systems
- 13. BUILDING BACK BETTER A NEW E-RESOURCE: WWW.BUILDINGBACKBETTER.ORG
- 14. Research for stronger health systems post conflict Website: www.rebuildconsortium.com Contact: nick.hooton@lstmed.ac.uk @ReBUILDRPC Thank you
Editor's Notes
- Slide 2: Key starting points: decisions made early post-conflict can steer the long-term development of the health system In countries affected by conflict health systems often break down, and emergency assistance is often the main source of care. As recovery begins so should the process of rebuilding health systems. However, in practice not enough is known about the effectiveness of different approaches to health systems strengthening. Consortium purpose: “Decisions on health systems financing and human resources policy in post-conflict countries draws on research evidence from ReBUILD and the wider knowledge generated on post conflict health settings” Explain how we built the ReBUILD partnership and the use of affiliates to broaden our reach Retrospective view – so weve lokked at what ha happened to the health system during the conflict through the experiences of communities and health workers during the conflict and afterwards
- We have looked at the health system in terms of both demand for health services and supply of appropriate service ReBUILD is in it’s 5th year We have covered the following areas in ReBUILD (follow animations); today we will focus on 4 areas: understanding the impact of conflict/crisis on the demand side – how might these shocks influence this; and understanding the response from the service delivery side – systems to support the health workforce and aid effectiveness; and although all our work deals with health system resilience, we finish with an example of group modelling to understand the operationalisation of health systems resilience But before we move the research, we want to say that we have been working hard to develop links with potential users of the research findings (as we are happy to be doing now). This has been done in the countries where the research has been done. But we have also been developing networks to bring together researchers, implementers, policy-makers and funders to share information on this under-researched area.
- Actors and networks: Post-conflict ‘window’ brings networks of diverse actors with different priorities and approaches to rebuilding health systems. Fragmentation will have negative impact on rebuilding health systems and can overwhelm national and sub-national capacity. Need to strengthen role of state actors to move towards a domestically owned health system Resource flows: Resource flows need to be coordinated and scrutinised by national actors, who are accountable for allocative decisions Fragmentation of systems means decisions over resource allocation often taken by external actors. Decisions favour ‘vertical programmes’ (e.g. disease control) over ‘systems’ (e.g. workforce strengthening) Resources need to follow need, not ease/availability of capable organizations in the area Policy & power: Weak national capacity may lead to policy being externally driven. Lack of local ownership therefore results in weak implementation. External actors also powerful at local level – leads to inequality of inter-organisational networks/resources
- Actors and networks: Post-conflict ‘window’ brings networks of diverse actors with different priorities and approaches to rebuilding health systems. Fragmentation will have negative impact on rebuilding health systems and can overwhelm national and sub-national capacity. Need to strengthen role of state actors to move towards a domestically owned health system Resource flows: Resource flows need to be coordinated and scrutinised by national actors, who are accountable for allocative decisions Fragmentation of systems means decisions over resource allocation often taken by external actors. Decisions favour ‘vertical programmes’ (e.g. disease control) over ‘systems’ (e.g. workforce strengthening) Resources need to follow need, not ease/availability of capable organizations in the area Policy & power: Weak national capacity may lead to policy being externally driven. Lack of local ownership therefore results in weak implementation. External actors also powerful at local level – leads to inequality of inter-organisational networks/resources
- Attraction and retention Conflict forces staff to flee or adapt. Staff can show great resilience in coping with crisis. Often they innovate to continue providing services when facilities, staff, drugs, supplies and indeed finance and pay are lacking. Local staff and mid-level cadres, commonly female, have shown more willingness to stay in remote areas in some settings. What is needed to support staff to stay and work in underserved areas after conflict – this includes more recognition of their role and achievements in challenging circumstances, practical measures to improve their security and provision of decent housing, working conditions and pay. Rebuilding trust, communication and teamwork is also key. Posting Taking into account workers’ preferences in terms of work location is always important but even more so during crises. If too rigid about where to post staff, this can lead to staff leaving, which in turn can affect service delivery (e.g. lack of HRH to deliver care and overload of remaining workers leading to low motivation and eventually more attrition). Human resources policy-making HRH policies are often driven by external players in the post-conflict period and commonly fail to engage with the realities of low financing, conflicting political priorities, weak institutions, patchy implementation and gender inequities. Gender Most human resources for health regulatory frameworks did not sufficiently address gender concerns (with the possible exception of Cambodia). Key priority areas for addressing gender equity in the health workforce in fragile and conflict-affected settings include ensuring gender is integrated into policies and regulations fostering dialogue and action to support change for gender equity within institutions and households.
- Attraction and retention Conflict forces staff to flee or adapt. Staff can show great resilience in coping with crisis. Often they innovate to continue providing services when facilities, staff, drugs, supplies and indeed finance and pay are lacking. Local staff and mid-level cadres, commonly female, have shown more willingness to stay in remote areas in some settings. What is needed to support staff to stay and work in underserved areas after conflict – this includes more recognition of their role and achievements in challenging circumstances, practical measures to improve their security and provision of decent housing, working conditions and pay. Rebuilding trust, communication and teamwork is also key. Posting Taking into account workers’ preferences in terms of work location is always important but even more so during crises. If too rigid about where to post staff, this can lead to staff leaving, which in turn can affect service delivery (e.g. lack of HRH to deliver care and overload of remaining workers leading to low motivation and eventually more attrition). Human resources policy-making HRH policies are often driven by external players in the post-conflict period and commonly fail to engage with the realities of low financing, conflicting political priorities, weak institutions, patchy implementation and gender inequities. Gender Most human resources for health regulatory frameworks did not sufficiently address gender concerns (with the possible exception of Cambodia). Key priority areas for addressing gender equity in the health workforce in fragile and conflict-affected settings include ensuring gender is integrated into policies and regulations fostering dialogue and action to support change for gender equity within institutions and households.
- Household structure Conflict has impacts on household structure. For example, in Uganda, the proportion of female headed households has increased, as have the associations between households being headed by a woman, and indicators of poverty. In other contexts where children have been targeted through conscription, or have simply been more vulnerable to the indirect impacts of conflict, there is a ‘missing generation’ of children affects both household and extended family structures. Since households and extended families provide financial and social support, this affects the extent to which people are able to access health care; and are protected from impoverishing costs. Vulnerability and resilience Poverty, gender, and age are generally associated with capacities for resilience or vulnerabilities in all communities. Conflict creates new vulnerabilities, for example by increasing the numbers of: People with disability Female headed households that may for example be disadvantaged in labour markets and Households and extended families that are missing a generation through war-related deaths, abductions and migration. Sometimes these are also sources of resilience./ strength / coping - for example in some contexts, female headed households have been shown to prioritise spending on health care health expenditure more than male headed ones, even though they may have less to spend. Accessing healthcare The costs of accessing health care are most commonly sourced by drawing on resources available across the household, and in the absence of sufficient resources at household level, then from the extended family. Communities also facilitate access to health care through mutual support mechanisms such as small loans and gifts. These are important sources of resilience to health related shocks during conflict affected periods. People’s access to health care is therefore affected by changes to household and extended family structures
- Household structure Conflict has impacts on household structure. For example, in Uganda, the proportion of female headed households has increased, as have the associations between households being headed by a woman, and indicators of poverty. In other contexts where children have been targeted through conscription, or have simply been more vulnerable to the indirect impacts of conflict, there is a ‘missing generation’ of children affects both household and extended family structures. Since households and extended families provide financial and social support, this affects the extent to which people are able to access health care; and are protected from impoverishing costs. Vulnerability and resilience Poverty, gender, and age are generally associated with capacities for resilience or vulnerabilities in all communities. Conflict creates new vulnerabilities, for example by increasing the numbers of: People with disability Female headed households that may for example be disadvantaged in labour markets and Households and extended families that are missing a generation through war-related deaths, abductions and migration. Sometimes these are also sources of resilience./ strength / coping - for example in some contexts, female headed households have been shown to prioritise spending on health care health expenditure more than male headed ones, even though they may have less to spend. Accessing healthcare The costs of accessing health care are most commonly sourced by drawing on resources available across the household, and in the absence of sufficient resources at household level, then from the extended family. Communities also facilitate access to health care through mutual support mechanisms such as small loans and gifts. These are important sources of resilience to health related shocks during conflict affected periods. People’s access to health care is therefore affected by changes to household and extended family structures
- One of our successful networks is through the thematic working group that Suzanne and I help run which now has over 400 members. That’s how Bob contacted me for this session. It could be a resource for the teams working in Syria and other fragile and conflict-affected states that DFID is working in. With that, let’s move to our first presentation ….
- [notes will be updated] Slide 1: Title slide – with names of team presenting – in order of presentations Introduce team and thanks for We proposed this area of health systems research as we knew – and have subsequently confirmed through our literature reviews – that it was a neglected area of health systems research. The new DFID aid strategy, and those of other donors, has reinforced the importance of this area and we are very pleased to be given the opportunity of sharing our research findings in this important meeting.