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.
1 Galtung, Johan, ‘Violence, peace, and peace research’, in Journal of Peace Research, Vol. 6, No. 3, 1969, pp. 179–183.
2 Department for International Development, Results in Fragile and Conflict-Affected States and Situations, 28 February 2012, available at: http://www.dfid.gov.uk/documents/Publications1/managing-results-conflict-affected-fragile-states.pdf (last visited 16 August 2012); see also World Bank, Fragility, Conflict and Violence, available at: http://web.worldbank.org/WBSITE/EXTERNAL/PROJECTS/STRATEGIES/EXTLICUS/0,,menuPK:511784∼pagePK:64171540∼piPK:64171528∼theSitePK:511778,00.html (last visited 16 August 2012).
3 Fund for Peace, ‘Failed States Index 2011–12’, interactive grid available at: www.fundforpeace.org/global/?q=fsi-grid2012 (last visited 16 August 2012).
4 The project was hosted by the University of Queensland, which administered funding for the research and provided research ethics approval for the proposal. The research was undertaken by a core team of four public health researchers, two of whom have appointments at the University of Queensland. All researchers have extensive experience in post-conflict health systems. Additional expertise was contracted to provide specific experience where necessary. The use of independent public health consultants with extensive post-conflict health systems experience to undertake the bulk of the research was both advantageous and necessary, enabling access to more volatile areas where travel would not be approved under University travel guidelines.
5 Duffield, Mark, ‘The symphony of the damned: racial discourse, complex political emergencies and humanitarian aid’, in Disasters, Vol. 20, No. 3, 1996, pp. 187–191.
6 Palestine is not recognised as a state by the international system based on UN membership, and therefore is not listed in the Fund for Peace Failed States Index.
7 Antonio Giustozzi, ‘Afghanistan: transition without end. An analytical narrative on state-making’, Working Paper No. 40: Development as State-Making, Crisis States Research Centre, November 2008, available at: www2.lse.ac.uk/internationalDevelopment/research/crisisStates/download/wp/wpSeries2/wp402.pdf (last visited 16 August 2012).
8 International Crisis Group, Central African Republic: Anatomy of a Phantom State, Africa Report No. 136, 13 December 2007, available at: www.crisisgroup.org/∼/media/Files/africa/central-africa/central-african-republic/Central%20African%20Republic%20Anatomy%20of%20a%20Phantom%20State.pdf (last visited 20 April 2012).
9 Jeffrey Herbst and Greg Mills, ‘There is no Congo’, in ForeignPolicy.com, 29 March 2009, available at: www.foreignpolicy.com/story/cms.php?story_id=4763 (last visited 20 April 2012).
10 James, Erica Caple, ‘Ruptures, rights and repair: the political economy of trauma in Haiti’, in Social Science and Medicine, Vol. 70, No. 1, 2010, p. 107.
11 International Crisis Group, ‘The occupied territories have the dubious distinction of having become a failed state before even becoming a state’, in After Mecca: Engaging Hamas, ICG Middle East Report No. 62, 2007, p. 9.
12 Little, Peter D., Somalia: Economy without State, Indiana University Press, Bloomington and Indianapolis, 2003, pp. 161–174.
13 An earlier version of this paper was presented as ‘Health care in disrupted environments’ at the Health Care in Danger Symposium, co-hosted by the International Committee of the Red Cross and the British Medical Association, London, 23 April 2012.
14 Wim Van Damme of the Institute of Tropical Medicine, Antwerp, aptly describes this phenomenon in disrupted health systems as the ‘Anna Karenina effect’, based on Tolstoy's reflection that: ‘All happy families resemble one another, each unhappy family is unhappy in its own way’. Tolstoy, Leo, Anna Karenina, Oxford University Press, Oxford, 1980 (1918), p. 1.
15 Lucchi, Elena, ‘Between war and peace: humanitarian assistance in violent urban settings’, in Disasters, Vol. 34, No. 4, October 2010, pp. 973–995; Farmer, Paul, ‘Political violence and public health in Haiti’, in New England Journal of Medicine, Vol. 350, No. 15, 2004, pp. 1483–1486; Farmer, Paul, ‘On suffering and structural violence: a view from below’, in Race, Ethnicity, Multidisciplinary Global Contexts, Vol. 3, No. 1, 2009, pp. 305–325.
16 World Health Organization (WHO), Everybody's Business: Strengthening Health Systems to Improve Health Outcomes. WHO's Framework for Action, Geneva, 2007.
17 WHO, World Health Report 2000 – Health Systems: Improving Performance, Geneva, 2000, p. 5.
18 Sarah Bailey, ‘Humanitarian action, early recovery and stabilisation in the Democratic Republic of the Congo’, Working Paper, Humanitarian Policy Group, Overseas Development Institute, London, July 2011.
19 Caple James, in her paper, defines ensekirite (the Creole term for insecurity) as describing ‘the state of episodic emergency and instability that is sparked by political and criminal violence’. See E. Caple James, above note 10, p. 107.
20 Mullan, Fitzhugh, ‘The metrics of the physician brain drain’, in New England Journal of Medicine, Vol. 353, October 2005, pp. 1810–1818.
21 Zanotti, Laura, ‘Cacophonies of aid, failed state building and NGOs in Haiti: setting the stage for disaster, envisioning the future’, in Third World Quarterly, Vol. 31, No. 5, 2010, pp. 762–766.
22 Interviews with senior Ministère de la Santé Publique et de la Population personnel estimated that between 15 and 20 per cent of health facilities were under their direct control.
23 Unger, Jean-Pierre and Criel, Bart, ‘Principles of health infrastructure planning in less developed countries’, in International Journal of Health Planning and Management, Vol. 10, 1995, pp. 113–128.
24 Loevinsohn, Benjamin and Harding, April, ‘Buying results? Contracting for health service delivery in developing countries’, in The Lancet, Vol. 366, No. 9486, 20 August 2005, pp. 676–681.
25 Simmonds, Stephanie and Ferozuddin, Feroz, Support to the Health Sector in Helmand Province, Afghanistan, Department for International Development Health Resource Centre, London, 30 December 2008, pp. 24–27.
26 Waldman, Ronald, Strong, Lesley, and Wali, Abdul, Afghanistan's Health System Since 2001: Condition Improved, Prognosis Cautiously Optimistic, Briefing Paper Series, Afghanistan Research and Evaluation Unit, Kabul, December 2006.
27 B. Loevinsohn and A. Harding, above note 24.
28 Giacaman, Rita, Wick, Laura, Abdul-Rahim, Hanan, and Wick, Livia, ‘The politics of childbirth in the context of conflict: policies or de facto practices?’, in Health Policy, Vol. 72, No. 2, May 2005, pp. 129–139.
29 The DOTS programme, developed by WHO, has effectively transformed the management of tuberculosis, offsetting the higher cost of short-course therapy with the possibility of directly supervised daily treatment as an outpatient close to the patient's place of residence. Interruption to therapy, however, risks the development of resistant forms of tuberculosis, with significant implications for the patient and the community.
30 Capobianco, Emanuele and Naidu, Veni, A Decade of Aid to the Health Sector in Somalia (2000–2009), World Bank, Washington, DC, 2010, pp. 25, 34.
31 Declan Walsh, ‘Taliban block vaccinations in Pakistan’, in The New York Times, 18 June 2012, available at: www.nytimes.com/2012/06/19/world/asia/taliban-block-vaccinations-in-pakistan.html (last visited 23 August 2012).
32 Von Schreeb, Johan and Michael, Markus, Joint Assessment of Health Status and Health System among Crisis Affected populations in the Democratic Republic of Congo (DRC) and the Humanitarian Health Sector Strategy for DRC, WHO, Geneva, 2004, p. 24.
33 Human Resource Development Cluster, National Priority Programs – Program Number 5: Human Resources for Health, paper for Kabul Conference, Ministry of Public Health, Kabul, July 2010, p. 115.
34 Mansoor, Farooq, Hill, Peter S., and Barss, Peter, ‘Midwifery training in post-conflict Afghanistan: tensions between educational standards and rural community needs’, in Health Policy and Planning, Vol. 27, No. 1, January 2012, pp. 60–68.
35 Le Sage, Andre, ‘Islamic charities in Somalia’, in Alterman, Jon B. and von Hippel, Karin (eds), Understanding Islamic Charities, Center for Strategic and International Studies, Washington, D.C., 2007, p. 152.
36 World Bank, Democratic Republic of Congo: Public Expenditure Review, Report No. 42167-ZR, New York, March 2008, E44, p. 9.
37 This bleakly humorous metaphor, translated as ‘the suction pump’, draws attention to the way in which services parasitise their clients to sustain their own continuing existence, inverting the conventional duty of care relationship between the care provider and the population ‘served’.
38 Health Systems 20/20 Project, Comptes Nationaux de la Santé 2008–2009, Abt Associates, Bethesda, MD, May 2011.
39 Canavan, Ann, Vergeer, Petra, and Bornemisza, Olga, Post-Conflict Health Sectors: The Myth and Reality of Transitional Funding Gaps, Health and Fragile States Network and Royal Tropical Institute, Amsterdam, 2008.
40 Donini, Antonio, ‘Between a rock and a hard place: integration or independence of humanitarian action?’, in International Review of the Red Cross, Vol. 93, No. 881, March 2011, p. 150.
41 Mazzilli, Caitlin, Ahmed, Rehana, and Davis, Austen, The Private Sector and Health: A Survey of Somaliland Private Pharmacies, UNICEF and the European Union, 2009, p. 49.
42 Jeene, Harry, The Health System in Karkaar Region, Puntland, Somalia, Save the Children UK, London, 2010, p. 25.
43 Kohler, Jillian C., Pavignani, Enrico, Michael, Markus, Ovtcharenko, Natalia, Murru, Maurizio, and Hill, Peter S., ‘An examination of pharmaceutical systems in severely disrupted healthcare systems’, in BMC International Health and Human Rights, Vol. 12, No. 34, December 2012.
44 Jones, Seth G., Hilborne, Lee H., Anthony, C. Ross, Davis, Lois M., Girosi, Federico, Benard, Cheryl, Swanger, Rachel M., Garten, Anita Datar, and Timilsina, Anga, Securing Health: Lessons from Nation Building – Chapter 5: Haiti, Rand Corporation, Center for Domestic and International Health Security, Santa Monica, CA, 2006, p. 117.
45 Barthes, Olivier, Analyse du Système d'Information Sanitaire: Rapport de Mission à Court Terme, Project Amélioration des Soins de Santé de Base dans les Régions Sanitaires 1 et 6 en République Centrafricaine, Ministère de l'Economie et du Plan, Bangui, 2009, p. 9.
46 WHO, UNICEF, UNFPA, and World Bank, Trends in Maternal Mortality 1990 to 2008: Estimates Developed by WHO, UNICEF, UNFPA and the World Bank, WHO, Geneva, 2010, p. 23.
47 S. Simmonds and F. Ferozzudin, above note 25, pp. 24–27.
48 Bierschenk, Thomas and de Sardan, Jean-Pierre Olivier, ‘Local powers and a distant state in rural Central African Republic’, in Journal of Modern African Studies, Vol. 35, No. 3, September 1997, pp. 441–442.
49 J. Von Schreeb and M. Michael, above note 32.
50 Murru, Maurizio and Pavignani, Enrico, Democratic Republic of Congo: The Chronically-Ill Heart of Africa, University of Queensland, Brisbane, 2011, p. 37. See also Australian Centre for International and Tropical Health, Health Services in Severely Disrupted Environments, available at: www.sph.uq.edu.au/acith (last visited 23 August 2012).
51 Hill, Peter S., Mansoor, Farooq and Claudio, Fernanda, ‘Conflict in least developed countries: challenging the MDGs’, in Bulletin of the World Health Organization, Vol. 88, No. 8, August 2010, p. 562.
52 Bloom, Gerald, Standing, Hilary, Lucas, Henry, Bhuiya, Abbas, Oladepo, Oladimeji, and Peters, David H., ‘Making health markets work better for poor people: the case of informal providers’, in Health Policy and Planning, February 2011, pp. 45–52.
53 Fox, Sarah, Witter, Sophie, Wylde, Emily, Mafuta, Eric, and Lievens, Tomas, ‘Paying health workers for performance in a fragmented, fragile state: reflections from Katanga Province, Democratic Republic of Congo’, in Health Policy and Planning, 2013, pp. 1–10 (e-pub ahead of print; doi:10.1093/heapol/czs138).
54 Logical framework analysis is a methodology for structuring the main elements in a project, facilitating its monitoring and evaluation. For more information, see, for example, Logical Framework Approach: Handbook for Objectives-Oriented Planning, Norad, 1999.
55 MSF, Central African Republic: A State of Silent Crisis, Amsterdam, 2011, pp. 13–15, available at: www.msf.org.au/static/central-african-republic/a-state-of-silent-crisis.html (last visited 1 February 2013).
56 Collier, Paul, The Bottom Billion: Why the Poorest Countries are Failing and What can Be Done about It, Oxford University Press, Oxford, 2011, pp. 109–111.
57 Gordon, Stuart, ‘Health, conflict, stability and statebuilding: a house built on sand?’, in Journal of Intervention and Statebuilding, Vol. 7, No. 1, 2013, pp. 29–44.
* 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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