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Making sense of apparent chaos: health-care provision in six country case studies

  • Enrico Pavignani, Markus Michael, Maurizio Murru, Mark E. Beesley and Peter S. Hill...

This research examines the impact on health-care provision of advanced state failure and of the violence frequently associated with it, drawing from six country case studies. In all contexts, the coverage and scope of health services change when the state fails. Human resources expand due to unplanned increased production. Injury, threat, death, displacement, migration, insufficient salaries, and degraded skills all impact on performance. Dwindling public domestic funding for health causes increasing household out-of-pocket expenditure. The supply, quality control, distribution, and utilisation of medicines are severely affected. Health information becomes incomplete and unreliable. Leadership and planning are compromised as international agencies pursue their own agendas, frequently disconnected from local dynamics. Yet beyond the state these arenas are crowded with autonomous health actors, who respond to state withdrawal and structural violence in assorted ways, from the harmful to the beneficial. Integrating these existing resources into a cohesive health system calls for a deeper understanding of this pluralism, initiative, adaptation and innovation, and a long-term reorientation of development assistance in order to engage them effectively.

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* Enrico Pavignani has worked in poor countries for thirty years, in a variety of roles: district doctor, trainer, planner, and policy analyst. Since 2002 he has concentrated his interests on the analysis of war-torn health-care arenas, and on their post-conflict recovery.

Markus Michael is a public health physician working as an independent consultant. His main field of expertise and interest is health system analysis in disrupted contexts, in countries in armed conflict or failed states.

Maurizio Murru is a public health consultant mainly interested in health services management in environments disrupted by poverty, conflict, or both.

Since 1989, Mark Beesley, a UK-registered nurse, has supported recovering provincial and national health authorities in Mozambique, Somaliland, Angola, Somalia, and South Sudan in the delivery of HR development. A keen in-service trainer, he is now a freelance technical adviser.

Peter S. Hill is a public health physician and Associate Professor of Global Health Systems at the University of Queensland. His research interests examine the development of global health policy and its translation within low- and middle-income countries, in particular where country health systems are disrupted by conflict.

This research was partly funded by the Danish Ministry of Foreign Affairs.

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