War, Health and Recovery

By Sean Deely This chapter presents an overview of the impact of war on health and health systems, and examines three major challenges faced by low-income, conflict-affected countries to recover health services, before analyzing a number of recent developments which may improve prospects for sustainable recovery. The first challenge is how to secure the large-scale, international assistance that will be needed to rebuild and recover. Many conflict-affected states are struggling to restore stability, but the gap between their needs and their resources is too great to allow them to even begin planning for recovery, let alone address the structural conditions that lock them into a cycle of poverty and underdevelopment. Without long-term, large-scale donor support, recovery will remain beyond them and their populations will continue to suffer severe deprivation, with the wider effects of conflict and disease posing increasing threats to regional stability. If they can secure some level of reconstruction assistance, the second challenge is how, in the short-term, to scale up services quickly to meet the needs of underserved populations and those without access? Typically starting from a point of extremely limited public finance and a weak health system, these countries face overwhelming needs at a time when conflict has wiped-out much of the health system infrastructure, destroyed the professional staff base and disrupted access to essential services. At the same time, an influx of NGOs implementing short term, projectbased and vertical programs, and a sharp increase in informal service provision, present real problems to align services within a national system. The third challenge is how to sustain these services in the long term. Emerging administrations need to reform health policies and institutions to increase their effectiveness and efficiency, and harness the local-level involvement that will be needed to ensure sustainability of services in the long run. But war will have contracted or destroyed the limited tax base of the economy and severely weakened national policy-making and planning capacity. Consequently, as experience shows, lowincome, conflict-affected countries tend to suffer chronic failure of basic service provision (WB, 2002).

The Impact of Conflict on Health and Health Systems

The main targets in todays violent conflicts are civilians, driven out of their homes and villages or maimed and killed, often with impunity. They constitute between 60 and 90 percent of the victims of all conflicts today (ICRC, 1998). Their health and welfare are threatened not only by gunfire and bombardment, but also by lack of access to food, water, basic health services and disease control measures. Three main effects can be discerned: - Increased health needs of the affected population;

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- Reduced capacity of health services; and - Distortion of the health system.

Increased Health Needs of the Conflict-Affected Population

During violent conflict and war, mortality, morbidity and disability can increase drastically as a result of fighting, displacement, hunger and disease. Battlefield injuries however, may represent only a small proportion of the health problems: war results in displacement, hunger, the erosion of coping capacities and the breakdown in community health systems. Major problems can arise from preventable infectious and parasitic diseases such as malaria, measles, tetanus, acute respiratory infections and diarrhea. The burden of these diseases falls disproportionately on children and women of reproductive age. War Wounds, Disability and Mutilation At least two-and-a-half million people were killed by conflicts occurring in the nineties, while a further 31 million people were injured, displaced or otherwise affected (IFRC, 2001). Although war only takes third place behind epidemics and famines in causing deaths, it is the worst disaster for inflicting injuries (Barakat and Hoffman, 1995). War requires continuous, high level surgical capacity, often in the most adverse security conditions for medical staff. Injury through bombardment, landmines and unexploded ordnance such as cluster bombs frequently results in permanent disability. Over thirty million landmines were laid in Afghanistan in the 1980s: today four per cent of the population is disabled and in Cambodia, 36,000 people have lost at least one limb as a result of landmines (WHO, 2002a; WHO, 2002b). In some conflicts involving modern technologically-advanced weaponry, high levels of cancer have been reported both among the local populations and among servicemen and women. Studies in Iraq report incidences of cancer in 40-48 percent of the population in some areas (Pilger, 2003). This has been attributed to the use of depleted uranium (DU) munitions: in the Gulf War more than 300 tons of DU munitions were fired, including tank shells containing up to 4.5 kg of uranium and hundreds of thousands of rounds of fighter aircraft ammunition made of solid uranium 238. These rounds disintegrate upon impact, with up to 30 percent turning to dust. Inhalation or inadvertent consumption when this dust makes its way into the food-chain result in cancer, birth deformities, high levels of miscarriage and other health problems (Pilger, 2003; HRW, 2000). Mutilation has also been used deliberately as a weapon of war: in Mozambique people had their ears and lips cut off during the war; and in Sierra Leone, RUF fighters hacked off peoples limbs during attacks on civilian areas (HRW, 2001; Pavignani & Colombo, 2001). Communicable and Non-communicable Diseases

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Secondary threats from waterborne, personal contact and vector-borne diseases increase as a result of overcrowding, damage to the infrastructure and inadequate clean water supply. For example, WHO estimates that there are 72,000 new cases of Tuberculosis and more than 15,000 deaths per year in Afghanistan, and over 15,400 new cases per year in Somalia (WHO, 2002b; WHO, 2001). Threats from communicable diseases are worsened by the decline in immunization coverage, discontinuation of public health campaigns, and disruption of routine disease monitoring, prevention and control programs. Infant and child mortality increase as a result of vaccinepreventable diseases such as measles, tetanus and diphtheria. During the eighties, infant mortality in conflict-affected areas of Uganda rose to 600 per 1000 (WHO, 2002a) and in 1992 in Somalia, child mortality rates between 500 and 750 per 1000 have been reported (Green, 1994). Displacement, in particular, heightens exposure to health problems from communicable diseases, increasing the risks of measles, diarrhea and respiratory infections. During conflict and other disasters, refugees and displaced people experience massively raised mortality rates at their worst, up to 60 times the expected rates during the acute phase of displacement (WHO, 2002a). Lack of access to medical care also increases the incidence of mortality from noncommunicable diseases such as heart-disease, and from other conditions like asthma and diabetes. Womens Health Womens health suffers disproportionately during conflict: maternal mortality in Afghanistan and Somalia (1,700 and 1,600 respectively per 100,000) are among the highest in the world (WHO, 2002b; UNICEF 1999). In Afghanistan the lack of basic health services was compounded by the shortage of female health personnel, gender segregation and restrictions placed on women and girls (WHO, 2002b). In Somalia restricted access to health services is exacerbated by the widespread practice of Female Genital Mutilation (Deely, 2001). Women are also particularly vulnerable to HIV and sexually transmitted disease during periods of conflict. HIV/AIDS and Sexually Transmitted Diseases Risks from HIV/AIDS and sexually transmitted diseases also increase significantly during conflict, through prostitution, rape and the suspension of traditional cultural mores. Fighters from both insurgent and government forces, who often have a high HIV prevalence rate, frequently engage in forced or commercial sexual activities. Infection rates continue to

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increase as a function of fighters mobility, including during the post-conflict period when they return home after demobilization (WHO, 2002a). Refugee women in particular are more vulnerable to infection from HIV because of the lack of security in camps and host communities and because they are more likely to be forced into prostitution when they have been deprived of normal sources of income (ibid). Mental Health The psychological effects of conflict are widespread and profound. Frequent confrontation with death, proximity to bombardment, shelling and shooting, witnessing death or injury, loss of, or separation from family members, and the prolonged fear of invasion, capture, injury or abuse result in widespread post-traumatic-stress disorder (Maynard, 1997). Although many people manage to deal with the mental suffering and stress caused by exposure to violent conflict, it has been shown to produce increased rates of depression, substance abuse and suicide (WHO, 2002a). During the war Bosnia registered a high incidence of suicide among both young female victims of rape and sexual abuse, and elderly people who had given up hope as a result of the long siege of Sarajevo (Deely, 1998). In both Sri Lanka and El Salvador violent conflict is also credited with triggering sharp increases in suicide among the civilian population (WHO, 2002a). Substance Abuse Substance abuse increases dramatically as a function of depression and stress, and the increased access to drugs as a result of the breakdown of law and order. The production and supply of heroin, cocaine and qat have fuelled war economies sustaining conflicts in Afghanistan, Colombia, Kosovo, Somalia, Tajikistan, Myanmar, Peru and West Africa in recent years (UNODCCP, 2002). Heroin addiction among conflict-affected civilians is a major cause of ill-health. According to UNODCCP there are more than six million opiate users in Asia, mainly in and around Afghanistan and Myanmar (UNODCCP, 2002). Aid workers and journalists have documented cases of parents and grandparents of Afghan refugees in Pakistani camps, taking opium and administering it to their children or grandchildren, to relieve stress and depression (TVE, 2003). In Somalia, qat addiction is a major social problem, directly affecting the health of hundreds of thousand of addicts throughout the country and indirectly affecting the health of family members by diverting scarce household income needed for food and health (Barakat & Deely, 2001). Disrupted Access The increased level of injury, disease and disability is compounded by the effect of the conflict in disrupting access to health care. Isolation from health services through damaged infrastructure, reduced mobility, landmines, curfews, fear and insecurity, prevents people from seeking treatment for everyday or war-related conditions. For those who may be able to reach

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a nearby health facility, increased poverty at household level, due to loss of employment, decreased economic activity and high inflation, reduces access to increasingly privatized health care. Available treatment if any is further restricted by disrupted lines of access and referral within the health system as a result of fighting and territorial divisions (Macrae, 1995).

Diminished Capacity of Health Services

A number of factors combine to directly reduce the availability of health services: killings or displacement of health personnel, damage to facilities and equipment, and interrupted medical supplies. Indirectly, restrictions in local and central government budgets affect supervision, management and maintenance, while the lack of resources at national level weakens policymaking and planning. Loss of Health Personnel Attacks on health staff are an all too common feature of modern conflict. In Mozambique, health workers were systematically targeted, kidnapped and killed by RENAMO fighters (Pavignani & Colombo, 2001). In Uganda, half of the doctors and eighty per cent of qualified pharmacists fled the country between 1972 and 1985 (WHO, 2002a); in Rwanda over eighty per cent of the health care staff were killed or fled as a result of the genocide (Kumar, 1997); in East Timor most of the professional health staff were driven out during a three week rampage of violence and destruction in 1999: only 25 doctors remained (Tulloch et al, 2003). In the Occupied Territories ambulance drivers have been singled out and killed by snipers and regular Israeli forces during the current Intifada (PRCS, 2001). Morale among surviving staff is further eroded by shortages of supplies, inability to deal effectively with patients needs, and the devaluation or non-payment of salaries. In disputed or insecure areas, fear of being associated with one side or another and consequent persecution keeps staff away from public health facilities. Often rural facilities are abandoned completely as staff move to safer urban centers. Damage to Infrastructure and Equipment Clinics and hospitals are often systematically targeted during campaigns of violent conflict and war, as forces attempt to destroy the support base of their adversaries, displace perceived sympathetic populations, or terrify them into submission. Buildings are destroyed or seriously damaged, and vehicles, equipment and supplies are looted or stolen. For example, during the war in Somalia, eighty-five percent of the health infrastructure was destroyed or damaged beyond repair (Barakat and Deely, 2001). Following the referendum in East Timor in August 1999, pro-Indonesian forces demolished the Timorese health system, completely destroying thirty-five percent of the infrastructure and leaving only twenty-three buildings without major damage. Almost all medical supplies or equipment were looted or damaged beyond use and the central health administration was completely ruined (Tulloch et al, 2003).

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Interruption of Supplies Shortages and infrequent supplies of medicine cause increases in medically preventable conditions. This often leads to avoidable deaths from asthma, diabetes and a range of infectious diseases and is compounded by interruptions in cold chains for vaccines and maintenance of medical equipment for diagnosis and treatment. The imposition of sanctions exacerbates and prolongs this problem. Before the 1991 Gulf War health services in Iraq reached ninety percent of the population and children were routinely vaccinated against the major childhood diseases (WHO, 2002a). The sharp reduction in health system capacity as a result of damage and disruption during the war was compounded under the sanctions regime. Imports of cold-chain equipment, spare-parts and supplies needed to maintain medical equipment, including heart and lung machines, radiotherapy equipment, chemotherapy drugs and analgesics, were delayed or blocked completely by the Sanctions Committee (Sikora, 1999). As many as one million people are estimated to have died as a result of the combined affects of conflict and sanctions between 1990 and 1997 (UNICEF, 1998; Cortright and Lopez, 2001; Pilger, 2003). Reduced Health Financing Conflict-affected governments generally experience a reduction or redirection of resources away from health spending that jeopardizes their ability to maintain normal levels of public health services and inform planning and policy. During war, the economy contracts as commercial activity declines and resources are diverted away from normal activities, leading to a shrinking of the governments tax base and the impoverishment of ordinary people. Collier (2000) estimates an average decline of 2.2 percent for each year the conflict continues. As conflict looms or escalates, public finances are diverted to military expenditures and central and local government health budgets are reduced. Typically inflation soars and the reduced health budgets are devalued further. This devaluation quickly translates into shortages of medical supplies, fuel for ambulances or other vehicles, spare-parts, and a general failure to maintain facilities and equipment. Public sector salaries fall below subsistence in real terms and staff increasingly resort to private practice to supplement or maintain incomes. Over time, services deteriorate further as staff performance is affected by diminished supervision and training (WHO, 2002a; Macrae, 1995, 1997). Weakened Policy-making, Planning and Management Capacity National capacity for policy-making, planning and management is dramatically reduced by the loss of senior health staff and the reduction in financial resources available for health. The exodus of senior health personnel often deprives post-conflict countries of their most experienced and capable professionals who seek safety and a future for themselves and their families in neighboring or third countries. Many of them never return (Macrae, 1995).

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Countries like Afghanistan, Somalia, Congo and Iraq which have been affected by conflict for years have been unable to participate fully in international debates about changes to health systems, for example to address the HIV/AIDS crisis, or the increased incidence of TB. For example, in Somaliland, a WHO study revealed that only 7 percent of registered private practitioners knew the correct TB regimens and only 13% apply direct observations (WHO, 2001). Because conflict-affected countries experience high levels of displacement and migration, they act like weak links in a chain, preventing the eradication of diseases like polio, and increasing the transmission of HIV/AIDS and TB. Inability to participate in international mechanisms for policy-making and planning also increases the risk that these countries and as a corollary their neighbors suffer major outbreaks. In Gulu, Uganda in 2000, an outbreak of Ebola hemorrhagic fever was linked to the return of troops who had been fighting in the Democratic Republic of Congo (WHO, 2002a).

Distortion of the Health System

As a result of the increased need and reduced public sector capacity, the structure, source and concentration of health services change dramatically during and after periods of conflict. The health system may undergo significant transformation or even fragmentation, and it is not uncommon for public services to be marginalized as a series of domestic and international actors take over the responsibility for the provision of services. Although they may provide a temporary solution, considerable problems are also associated with the proliferation of informal and unregulated services and the predominance of NGO relief health programs. Diversion As conflict escalates the focus of health services shifts away from primary to tertiary care. Increasingly resources are diverted to deal with war-related problems such as the treatment of battlefield injuries, malnutrition and disease. Preventive and promotive activities are reduced or suspended. Vector control and public health programs are compromised. Community-based activities in general are reduced or suspended and outreach services are cut back dramatically or halted completely due to lack of resources or insecurity. Disease control and surveillance programs are interrupted and health information systems are disrupted. Privatization The structure of health service provision can change dramatically during and after conflict as public health workers who are forced to leave their normal place of employment due to fear, destruction or the lack of remuneration, turn increasingly to private practice to earn a living (Macrae, 1995). As cutbacks and inflation drive government salaries below subsistence levels, workers either supplement their incomes by referring clients for private consultations at their residence or in a local pharmacy, or they leave their public sector jobs and focus solely on

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private practice. In some countries, public health sector employees were allowed to divide their time between public and private practices. This was the case, for example, in Somalia during the Barre era, and the practice continues today with many NGO health facility staff maintaining a private practice in a local pharmacy, or running a pharmacy themselves. Informalization In some cases, the de facto suspension of the regulatory role of the national health authority due to lack of resources effectively removes the requirements for health service providers, and the services and drugs they provide, to meet minimum professional requirements. An informal health sector emerges as a result of the sharp rise in need, the collapse of public health services and the increased availability of drugs and medical supplies from aid operations. An increasing number of traditional healers, pharmacies and drug peddlers appear. In the Puntland state of Somalia, UNICEF estimates that as much as eighty percent of health service provision is provided by informal or private providers. There are hundreds of unlicensed pharmacies in Bosasso, Galcaio and Garowe (Barakat & Deely, 2001). Far from improving the situation, this combination of informalization, deregulation and self-medication contributes to the worsening health status of the conflict-affected population. According to the WHO, in Somalia for example, anti-TB drugs have been prescribed in wrong regimens and are generally sold without prescriptions by the majority of pharmacies. This malpractice has taken place for many years and is contributing to the spreading of multi-drug resistance in the country (WHO, 2001). Urbanization Uncertainty and fighting generally force large numbers of people into urban areas in search of security, food and shelter. Health facilities become overwhelmed by the influx of displaced persons seeking care. Displaced health professionals and former public sector health staff may offer informal services or establish private facilities such as clinics or pharmacies. Meanwhile, under pressure from media-driven public and political interest, NGOs compete to set up relief health projects in urban centers with large populations. As health workers flee rural areas and outlying facilities are cut off due to insecurity or damage, the disparity in the availability and quality of services between rural and urban populations often becomes dramatic. In Angola in 1996, 90 percent of the health services in Huambo province were concentrated in Huambo city (Pavignani & Colombo, 2001). In Somalia only 15 percent of the rural population has access to health services, compared with 50 per cent of the urban population (UNDP, 2001). In Afghanistan, Kabul currently has one physician for every 1,700 people, while in rural areas the ratio is one physician per 450,000 people. Half of the 8,333 hospital beds available in the country are located in facilities in Kabul, while the rest of the country has 0.34 beds per 1,000 people, compared with an average of 3 per 1000 in low-income countries (WHO, 2002b).

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Internationalization Short-term, high profile relief health programs by international NGOs often ignore government policy and guidelines, supposedly in the interest of time, or perceived neutrality, effectively sidelining the already weakened health administration. Usually operating outside the control of the Ministry of Health, many NGO activities are project driven with only token participation in co-ordination mechanisms. Bounded by project objectives, agency mandates and donor agendas instead of a national framework for health service delivery; relief aid further undermines national capacity for policy-making and planning. While they bring badly needed assistance, limited technical capacity and inflexible donor funding cycles can lock NGO into a short-term relief mode long after more developmental approaches could be employed (Macrae, 1995; Jackson & Deely, 2001). Fragmentation NGO health activities often constitute parallel health and welfare networks which fragment the public health service and divert resources from the government. During the complex political emergencies of the nineties, responsibility for health service provision in affected countries was divided up between hundreds of different aid organizations, with certain NGOs or even donor countries assuming responsibility for specific zones. It was not uncommon to find different systems and even standards of health care being provided by different NGOs in neighboring provinces or districts. Designed with donor agendas and resources in mind, health services develop unevenly, even ad hoc, delaying rehabilitation and recovery of national health systems (Duffield, 1994; Stubbs, 1998). Aid agency initiatives also tend to favor vertical programs focusing on a single disease such as malaria or TB, or aiming for a single intervention such as malaria, with less integration across services (WHO, 2002a). Lack of Accountability Typically, NGOs are accountable to external donors for the effectiveness of their programs and the services they provide. There is little or no downward accountability to people in the community or health authorities at local or national level. This lack of accountability obviates the need for consultation with or participation of beneficiaries. Local people - whose resources could be drawn on to sustain the health service in the long-term often complain that their perceptions about their own health needs and wishes are ignored and that they have little meaningful involvement in decisions about the services provided. Intentionally or not, this often creates a take-it-or-leave-it impression which alienates local people and reduces their prospective willingness to mobilize resources for the services when donor support is withdrawn.

3. The Challenge of Health Service Recovery

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This gives some idea of the challenge facing post-conflict states as they set about the reconstruction of their health service. Post-conflict health service recovery requires a move away from relief-based programs towards the development of long term programs aimed at improving the overall health status of the population and establishing an effective health system. It implies a shift in focus from short-term projects to large scale rehabilitation and reconstruction programs. Any reconstruction strategy must respond to three major challenges: Access large scale international support; Rapidly increase service delivery capacity; and Develop a strategy for sustaining services during the post-recovery period.

3.1 Accessing International Support

Given the lack of resources available to the post-conflict state, and the enormity of the task of rebuilding, significant sums of international assistance will be needed to meet the cost of recovery. It takes at least a decade for post-conflict governments to build the governance capacity, policies and institutions that will be required to provide the necessary support to the health service. Recent studies have demonstrated that, even when large scale reconstruction aid is provided by the international community, too much money is provided too early during the first three years - when absorptive capacity is low, and resources are squandered. Then, just when absorptive capacity is increasing, the level of aid decreases (Collier and Hoeffler, 2002). The theory suggests that in the past donor support for reconstruction and development assistance has been conditional on (a) a formal end to the conflict; and (b) international recognition of any new government (Macrae, 1995). This is because the international aid system is based on relations between states and large scale reconstruction support cannot be granted in the absence of an internationally recognized government (Macrae, 1995). Donors continue to bypass the de facto government and channel funding for health service rehabilitation projects through the NGO sector, even though experience has shown that when such projects are not implemented within a coherent national policy framework, resources are dissipated with little long term impact on recovery. Even with a recognized government in place, donors are reluctant to risk investing the levels of aid that would be required to deliver reconstruction and recovery without a formal end to the conflict, because renewed conflict remains possible or probable. The end of a conflict and formal recognition of the government, therefore, allow states to adopt positions on support to a post-conflict country, setting the wheels in motion for engagement by macro-level institutions like the World Bank to initiate the development of plans for reconstruction and development finance. In reality however, genuine post-conflict situations are few and far between and low intensity conflict can continue for years after a formal cease-fire. Many conflicts restart within a few

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years (King, 1997). Even when there is a recognized government in place, low income countries affected by conflict tend to have very poor governance, weak institutions, and high levels of corruption, and decades of development finance have failed to improve policies and institutions (WB, 2002). Consequently, donors are reluctant to risk investing the levels of aid that would be required because prior experience has demonstrated that aid doesnt work. Regardless of legitimacy or post-conflict status, large scale assistance is unlikely to be forthcoming because donor strategies in these countries have not succeeded in producing recovery in the past

3.2 Increasing Service Delivery Capacity

In the past, health sector rehabilitation typically focused on high-visibility reconstruction of urban-based secondary and tertiary facilities and increased vertical programs to tackle the main causes of disease. This type of approach centers mainly on NGO-led interventions at the micro-level and produces an expansion in services in the short term. Because they ignore long term considerations of capacity and sustainability they contribute relatively little to the overall process of reconstruction and recovery of the health system (Macrae, 1995). What is really needed is a twin strategy that can increase access to basic health care quickly and develop the capacities to maintain that access in the future. Emerging administrations must provide essential services quickly to improve health and ensure that recovery is not retarded or jeopardized. In the short-term, a scaling up of services is urgently needed to provide essential care and expand the health system to meet the needs of rural as well as urban residents and ensure services reach previously underserved or marginalized groups. For example, a survey carried out by WHO in Afghanistan in 2002, identified one basic health centre per 40,000 people in the central and eastern regions, and one per 200,000 people in the south. Nineteen districts had no health facilities whatsoever (Waldman & Hanif, 2002). In the long term, emerging authorities need to design and build a public health system that can identify, address and monitor the most common health problems, and guarantee the quality of both preventive and curative services. Long term recovery implies determining the character and content of the public health system and the channels through which the service will be delivered. Depending on the intensity and duration of the conflict, a range of activities may be required: rehabilitating and re-equipping damaged health infrastructure; developing a cadre of technically competent health staff; establishing an effective, practical health information system; developing and imposing a regulatory framework to guide the activities of a disparate collection of NGOs, private and informal service providers; and undertake a restructuring of services to provide an even distribution in rural and urban areas. In theory, post-conflict countries require increased short-term funding for existing government facilities, while simultaneously deploying long term funding for investment in rebuilding the capacity of the public health system. In reality however, experience has shown that

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government capacity for health service delivery is poor and unlikely to produce an increase in services without years of sustained investment. Consequently, conflict-affected countries tend to suffer chronic failure of basic service provision (World Bank, 2002).

3.3 Sustainability Even if they can rebuild a health system with sufficient capacity to deliver essential services to their populations, conflict-affected countries can only hope to make small improvements in their health condition if they can sustain essential services over a long period of time. This raises two main problems: first, conflict-affected countries are generally very poor and simply lack the financial resources required to sustain a reasonable level of basic health services; second, private expenditure on health tends to be out-of-pocket spending at the time of illness, rather than pre-paid, missing the opportunity to support community-based health delivery facilities. In 1997, the average amount spent on health in the forty-eight least developed countries was $11 per capita. No government in any of the forty-four low income countries with a per capita income of $500 or less per year raised even $20 per person per year for public outlays on health and no country with per capita income of less than $600 per year spent four per cent of GNP in budgetary outlays for health (WHO, 2001). In Uganda, for example, the 1986 Ministry of Health budget was only 6.4 percent of its pre-war, 1970 level (Macrae, 1995). The Somaliland Ministry of Health and Labour budget in 2002 was $500,000, or $0.17 per person. In the Puntland State of Somalia in 2000, total public revenue was $8.36 million, of which 2 percent - $167,200 was allocated to health. Even assuming the lowest population estimate of 850,000 persons, this amounts to $0.19 per person (Barakat & Deely, 2001). According to WHO, the minimum per capita outlay to provide a set of essential services in low income countries would be $30 to $45 per year (WHO, 2001). This would support a basic system capable of addressing the major communicable diseases and maternal and perinatal conditions that cause the majority of deaths in low income countries. This would represent between 10 and 15 per cent of GNP in the least developed countries, much more than any low income country can afford to allocate from domestic resources, and far in excess of what would be available to any country struggling to rebuild after war. The inability of the government raise enough revenue to sustain a basic public health system is compounded by the inefficient use of private spending on health. Because of the poor state of public health service, private expenditure forms the main funding source for health care in low income countries, unlike established market economies, where public expenditure exceeds private spending by a ratio of 2.3 to 1 (Witter, 2002). The levels of private spending indicate that these out-of-pocket payments could make a significant contribution to sustaining community-based-health services if they were paid into a pre-payment scheme. Such schemes

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would also offer the benefit of risk-pooling, providing some form of insurance against future illness. Instead, households spend a significant proportion of their disposable income on outof-pocket payments for services at the time of illness, often squandering the money on low quality or inappropriate treatment, or informal and traditional forms of health care with little if any - positive impact on their health.

4. Toward Recovery: Some Recent Developments

These three challenges expanding capacity, sustaining basic services, and securing access to international assistance - illustrate the complexity of the task of post-conflict health service recovery. The following section reviews some recent developments and approaches that may help address some of the weaknesses in current thinking and herald a more positive future.

4.1 The World Banks Low Income Countries Under Stress (LICUS) Approach
Last year the World Bank issued a report identifying the need for a new approach to a group of thirty very poor countries whose development has been retarded by weak policies, institutions and governance. Many of these countries categorized as Low Income Countries Under Stress (LICUS) - are affected by, or emerging from, conflict. The report notes that the underlying problems are similar in both conflict-affected and non-conflict LICUS. In addressing the specific challenges of post-conflict recovery, the approach builds on evidence from earlier studies that suggest that the pace of reform is considerably faster in post-conflict countries than elsewhere, and that early progress in social reform is more important than macroeconomic recovery (Collier and Hoeffler, 2002). The LICUS approach recommends a twin strategy of promoting policy and institutional change and improving the delivery of basic social services. It advocates direct engagement with local stakeholders to identify two or three key proposals for initial support that would have a broad appeal and give a serious boost to recovery prospects, generating expectations within society for further change and recovery. The implications for health service recovery are important. Arguing that people in countries abandoned by the international community suffer severe deprivation, and that health breakdowns in one country inflict costs across the region, the report proposes to prioritize the delivery of health care and primary education. The challenge of essential service provision in LICUS is very similar to that encountered in countries emerging from conflict: government capacity is poor and increasing budget allocations is unlikely to produce a sustainable increase in health service provision in the short or even medium term. The LICUS approach proposes a transitional solution: a surrogate system using alternative channels locally-owned and integrated and linked to relevant government ministries to ensure that the provision of essential services doesnt have to wait until the national systems have been rehabilitated or built. Options range from coordinated piecemeal

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provision through agencies such as the Red Cross or Red Crescent and UNICEF, to integrated provision through an independent service authority (ISA). The ISA would sub-contract service provision to a combination of local government, NGOs and private providers. Initially autonomous and subject to strict provisions on transparency, accountability, quality and performance, it would gradually be incorporated into the government. In the short-term this strategy allows for the provision of essential services that would be beyond central government capacity. In the medium to longer term, the government takes over a system that is already functioning effectively at a time when the relevant ministry has built the structures and capacity to be able to sustain it. A lot remains to be seen about the extent to which the LICUS strategy can begin to help conflict-affected governments access the type and scale of finance to address the structural conditions that lock them into a cycle of poverty and underdevelopment. But it may constitute an important step on the path to re-engagement with the international community and provide at least a partial solution to the problems of access to assistance for health service recovery in post-conflict countries. The LICUS approach is already being piloted in four countries in partnership with UNDP.

4.2 Increasing Service Delivery Capacity

Countries facing the re-establishment and strengthening of their national health system must, as a matter of priority, determine and adopt a core package of services that would be responsive to the epidemiological priorities of the country, and address the conditions that constitute the main causes of ill-health and mortality. A standardized set of services is one of the hallmarks of the public health approach and the early development of an essential services package can provide a foundation for the public health system and guide the expansion of service delivery capacity. In post-conflict countries, an essential services package can address the main causes of avoidable mortality in a feasible, cost-effective way. It would also ensure a more effective distribution of resources, offering low cost basic services to all. Where necessary it can be introduced progressively with some essential components being introduced relatively quickly and other interventions phased in progressively, allowing time to train health staff and build capacity. In Afghanistan, the Ministry of Health (MoH) is currently introducing an essential clinic services package that establishes the main services to be delivered by facilities throughout the country. The Basic Package of Health Services (BPHS) aims to provide a standardized set of services

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which forms the core of service delivery in all primary health care facilities, and promote a redistribution of services to provide equitable access.

The Basic Package of Health Services for Afghanistan

Maternal and Newborn Health Antenatal care Delivery care Postpartum care Family Planning Care of the Newborn Child Health and Immunization EPI services (routine and outreach) Integrated Management of Childhood Illness Public Nutrition Micronutrient supplementation Treatment of clinical malnutrition Communicable Diseases Control of Tuberculosis Control of Malaria Mental Health Community management of mental problems Health facility based treatment of outpatients and inpatients Disability Physiotherapy integrated into PHC services Orthopedic services expanded to hospital level

The MoH is using a system of Performance-based Partnership Agreements (PPAs) - contracts between the Ministry of Health, NGOs and private service providers to quickly create a network of service providers who can deliver essential services, within the framework of a national health policy. A bidding process is currently underway where NGOs submit offers to provide this package to populations in underserved areas. The contract stipulates NGOs will be paid on a per capita basis if the quality of services provided meets pre-determined indicators (Islamic Transitional Government of Afghanistan; 2002). The strategy is ambitious, but the government is committed, the level of funding and technical assistance is good and there is a

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core group of NGOs with an impressive record of service in Afghanistan. Experience with PPAs in post-conflict Cambodia has been very positive, contributing to a dramatic increase in access to facilities especially by vulnerable groups (Bhushan et al, 2002). While the preponderance of NGOs, private and informal service providers can be seen as a challenge to government efforts to set up a coherent, professional health system, it can also be seen as a potential resource; a source of capacity that can be tapped through regulation and supervision. Governed by a national health strategy setting out policy, standards, guidelines, goals and objectives and providing indicators for the achievement of pre-set targets within strict parameters, these NGO, private and informal actors can play a major role in the early recovery of the health system. The combined essential services package-PPA approach removes the burden of direct service provision from the Ministry of Health, allowing it to focus on rebuilding the infrastructure, systems and policies that will be needed to sustain the public health system in the post-recovery period.

4.3 Sustainability
Long term sustainability of health services in conflict-affected, low income countries will require nothing less than a revolution in the way that finances for health are currently raised and spent. In a landmark report on health finance reform published in 2001, the Commission on Macroeconomics and Health made a series of recommendations to improve the sustainability of health services in low income countries. Forty-four of the sixty-one lowincome countries included in the study are embroiled in or emerging from conflict.

BASIC STRATEGY FOR HEALTH FINANCE REFORM IN LOW INCOME COUNTRIES 1) Increased mobilization of general tax revenues for health, on the order of 1 percent of GNP by 2007 and 2 percent by 2015; 2) Increased donor support to finance the provision of public goods and to ensure access for the poor to essential services; 3) Conversion of current out-of-pocket expenditures into pre-payment schemes, including community financing programs supported by public funding, where feasible; 4) A deepening of the HIPC initiative, in country coverage and in the extent of debt relief (with support from the bilateral donor community); 5) Efforts to address existing inefficiencies in the way in which government resources are presently allocated and used in the health sector; and 6) Reallocating public outlays more generally from unproductive expenditures and subsidies to social-sector programs focused on the poor.
(WHO, 2001, pp 59-60)

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Reforms will be required to change established government attitudes that allocate only two to three percent of the national budget to heath, and address allocative inefficiencies arising from the traditional preference for high cost, relatively ineffective tertiary facilities. The first decade after conflict, presents an opportunity to make significant progress in reforming policies and institutions before lapsing into the more inflexible environment that characterizes many lowincome countries (Collier and Hoeffler, 2002). The upheaval experienced during conflict tends to weaken systems and institutions, making societies highly amenable to reform in the early post-conflict phase. People expect change and old vested interests may have been swept away. New approaches will also be needed to harness private spending on health, and use this money to contribute to sustaining community facilities. The Commission proposed that such out-of-pocket expenditures be channeled into community-financing schemes to help cover the cost of community-based health delivery. The International Federation of Red Cross and Red Crescent Societies is currently piloting a variation of this type of scheme together with the Somali Red Crescent Society and the World Bank in northeast Somalia. The new model is based on the principle that local people would gain more control over their health condition if they were actively engaged in the planning, delivery and monitoring of services provided by their community health facility, and be more inclined to pool their resources and contribute to its upkeep. Initial results have proved encouraging and the Red Crescent is replicating the model in its other clinics in northeast and northwest Somalia (see Chapter x). But the reality is that long term sustainability of health services in low income countries cannot be achieved without a major, sustained and long term injection of external funds. Despite major advances including the creation of the Global Fund to fight Aids Tuberculosis and Malaria, an independent, public-private partnership to increase global resources to combat these diseases, donor governments have come in for increasing criticism. Funding has been slow to materialize and only $1.7 of the $4.7 billion pledged had been paid by October 2003. One government, the US has even been accused of trying to cut contributions after backtracking on another pledge to provide $15 billion for AIDS in Africa and the Caribbean (Kristof, 2003).

Conclusion

In its wake, violent conflict leaves a debilitated, traumatized and disease-burdened population, struggling to rebuild their lives in countries where the capacity of the health system to deal with their increased needs has been severely reduced. Destruction of health facilities, displacement and killings of staff, withdrawal of public funding, and poverty at household level reduce the availability of health care and restrict access to services. In low income countries,

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where a very limited health system existed before war broke out, people may find themselves with no access to professional care. Apart from the obvious effect this has in increasing the hardship and misery of an already suffering population, it serves to undermine and even jeopardize recovery: a poverty stricken and disease-burdened population contributes little toward social and economic regeneration. Yet emerging administrations tend to have neither the resources nor the capacity to scale up services to meet the overwhelming health needs and begin reconstruction of the sector. Access to international support is not easy to secure, depending on the nature of the transition from conflict, prospects for stability, and acceptance of the emerging administrations legitimacy. Even if they do receive assistance, experience suggests that they are unlikely to succeed in building the capacity needed to extend services throughout the country, and in the long run low-income countries dont have the resource base to sustain them anyway. Despite these overwhelming challenges, a more positive environment is emerging that may reverse the chronic failure of basic service provision in low-income, conflict-affected countries. New engagement mechanisms and funding windows are being put in place and new approaches are being developed that may provide at least partial solutions and allow governments and international organizations to make some progress in the reconstruction of sustainable health systems.

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Bibliography Arhin-Tenkorang, D. (2000) Mobilizing Resources for Health: The Case for User Fees Revisited. CMH Working Paper Series. Paper No. WG3:1 (Geneva: WHO) Barakat S. and Hoffman B. 1995. Post Conflict Reconstruction Strategies International Colloquium on Post-Conflict Reconstruction Strategies, (Geneva: UNDDSMS & UNIDO) Barakat, S. & Deely, S. (2001) Somalia: programming for sustainable health care, in World Disasters Report: Focus on Recovery (Geneva: International Federation of Red Cross and Red Crescent Societies) Bhusan, I., Keller, S. & Schwartz. B. (2002) Achieving the Twin Objectives of Efficiency and Equity: Contracting Health Services in Cambodia. ERD Policy Brief No. 6 Collier, P. & Hoeffler, A. (2002) Aid, Policy and Peace: Reducing the Risks of Civil Conflict (Washington: The World Bank) Cortright, D. and Lopez, G. (2001) The Sanctions Decade: Assessing UN Strategies in the 1990s (Boulder: Lynne Rienner) Deely, S. (2001) Care in the Desert, in Red Cross Red Crescent Magazine, No. 2, 2001 Diskett,P. and Nickson, P. 1997. Financing Primary Health Care: an NGO perspective in Development for Health. Oxfam (Oxford) Duffield, M. 1994a. 'The Political Economy of Internal War', in Macrae and Zwi (eds.) 1994, War and Hunger: Rethinking International Responses to Complex Emergencies Zed Books (London and New Jersey): 50-69 Green, R.H. 1994 The Course of the Four Horsemen in War and Hunger, Macrae and Zwi (Eds), Zed Books, (London) Human Rights Watch (2000) Open Letter to the Security Council Concerning the Humanitarian Situation in Iraq. Human Rights Watch www.hrw.org/press/2000/iraq0323.htm ICRC (1998) ICRC Annual Report 1998 (Geneva: ICRC) IFRC (2001) Disaster Data: key Trends and Statistics, in World Disasters Report: Focus on Recovery (Geneva: IFRC) Islamic Transitional Government of Afghanistan (2002) Basic Package of Health Services for Afghanistan (Kabul: Ministry of Health) Jackson, S & Deely, S. (2001) Food Crisis in Tajikistan: An Unnatural Disaster? in World Disasters Report: Focus on Recovery (Geneva: International Federation of Red Cross and Red Crescent Societies)

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Kahssay, H. & Oakley, P. (1999) Community involvement in health development: a review of the concept and practice (Geneva: WHO) King, E. 1997. Ending Civil Wars Adelphi Paper 308, Oxford University Press for the International Institute of Strategic Studies, (Oxford) Macrae, J. 1995. Dilemmas of 'Post'-Conflict Transition: Lessons from the Health Sector Relief and Rehabilitation Network Paper 12. ODI (London) Maynard, K.A. 1997. 'Rebuilding Community: Psychosocial healing, Reintegration, and Reconciliation at Grassroots Level', in Kumar, K. (ed.) 1997. Rebuilding Societies After Civil War: Critical roles for international assistance Lynne Rienner (London and Boulder) Kristof, N. (2003) When Prudery Kills, in New York Times, October 8, 2003 Pavignani, E. & Colombo, A. (2001) Providing Health Services in Countries Disrupted by Civil Wars: A Comparative Analysis of Mozambique and Angola (Geneva: WHO) Pilger, J. (2003) The New Rulers of the World (London: Verso) PRCS, 2001 Sikora, K. (1999) Cancer services are suffering in Iraq in British Medical Journal, 16 January, 1999 Simms, S., Rowson, M. and Peattie, S. (2001) The Bitterest Pill of All: The collapse of Africas health systems. SCF UK Briefing Paper. Stubbs, P. 1998. The role of NGOs in social reconstruction in Post-Yugoslav countries, Relief and Rehabilitation Newsletter 10, ODI (London) Tulloch, J., Saadah, F., de Araujo, R., de Jesus, R., Lobo, S., Hemming, I., Nassim, J. & Morris, I. (2003) Initial Steps in rebuilding the Health Sector in East Timor, National Research Council and Columbia University Program of Forced Migration and Health. UNDP (2001) Human Development Report Somalia 2001(Nairobi: UNDP) UNDP (2003) Human Development Report 2003 (New York: UNDP) UNICEF (1999) End Decade Multiple Indicator Cluster Survey: Full Technical Report for Somalia (Nairobi: UNICEF) UNODCCP (2002) Global Illicit Drug Trends 2002. ODCCP Studies on Drugs and Crime. (New York: United Nations Office for Drug Control and Crime Prevention) Waldman, R. & Hanif, H. (2002) The Public Health System in Afghanistan: Current Issues (AREU)

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Whitehead, M., Dahlgren, G. and Evans, T. (2001) Equity and Health Sector reforms: can lowincome countries escape the medical poverty trap? in The Lancet, Volume 358, September 8, 2001 WHO (2001) Macroeconomics and Health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. (Geneva: WHO) WHO (2002a) World Report on Violence and Heath (Geneva: WHO) WHO (2002b) Reconstruction of the Afghanistan Health Sector: A Preliminary Assessment of Needs and Opportunities (Cairo: WHO) Witter, S. (2002) Health Financing in Developing and Transitional Countries, Briefing Paper for Oxfam GB. World Bank (1993) World Development Report 1993: Investing In Health (New York: OUP) World Bank (2002) World Bank Group Work in Low-Income Countries Under Stress: A Task Force Report (Washington: World Bank) World Bank (2003) World Development Report 2004: Making Services Work for Poor People (New York: OUP)

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