Suzanne Fustukian

Health after conflict – Rebuilding the system 13th December 2016Wellcome Trust, London

Institutions: cross-cutting theme

Actors, networks and power• Changing roles and identities of institutional actors in the transition from emergency to post-conflict• Lack of coordination between actors may lead to a more chaotic system rebuilding: their different priorities and approaches to rebuilding health systems post-conflict increases the potential for fragmentation in the system.•New networks and relationships will be needed between these diverse actors, but with awareness of potential power imbalances

Northern Uganda – different priorities between sub-national DHMT and donors

• Study on inter-organisational networks • focused on links between organisations working on HIV,

maternal health and health workforce strengthening in three districts (Gulu, Kitgum and Amaru). • Much greater support for HIV and maternal health

from donors and significantly less support for HRH resources • Networks and distribution of external resources

extremely limited in newly created district (Amaru).

• Disadvantage of newer district will be sustained over the longer term.

Responsive policy• Life histories showed that the vulnerabilities of many

groups, such as people with disabilities, orphans and older people are often more pronounced post -conflict.• Services to meet needs for these groups are essential but

combined with effective social protection policies. • Too often, delays in policy impact on the re-engagement

between health systems and vulnerable populations

• Important role of donors in supporting post conflict countries to re-engage and build responsive policy: • ‘Free Health Care Initiative’ (Sierra Leone)

• Critical role of strengthening local and national governance capacity

Unresponsive policy – N Uganda

• Gender roles and relations are affected: e.g. for women, widowhood compounded their war suffering, loss of property, displacement and family disruption.• Opportunities to address gender equity in health

systems post conflict/crisis are often missed.• Limited support given to survivors of gender

based violence (with male survivors particularly neglected)• much more attention paid to the hardware of

health infrastructure (e.g. building clinics) over the ‘software’ of health approaches, including strategies to ensure vulnerable groups can access care.

Resource flows• Flows of resources to the health system

(re)commence once the signals of peace arrive. • Governance is key to ensuring that resource flows

(HRH, funding, drugs, other equipment/infrastructure) are coordinated/scrutinised by domestic actors, who are accountable to the population for allocative decisions.• Rebuilding the health system equitably requires

allocating resources on the basis of population and geographical need, rather than ease and availability of capable organizations in the area, a situation often experienced in many post-conflict countries.• Frequently, the districts and services already well

established receive intensified resource flows post conflict, as was seen with the establishment of SOAs in Cambodia

Northern Uganda – social network analysis

• The study showed that resource flows can be unpredictable and beyond control of local health managers leading to future vulnerability. The predicted loss of 16 organisations – many of them fund-holders – in Gulu District by 2015 would affect almost 70% of the ties (relationships or interactions) in the networks, and could leave major resource gaps that cripple the performance of the health system.

Northern Uganda – social network analysis

A more resilient system would be based on more robust networks.

Building individual and institutional capacity

• In spite of the devastation health systems suffer as a result of conflict and crisis, they can demonstrate remarkable resilience. • Many health workers continued working during the

conflict in northern Uganda, while local managers did their best to support health workers in northern Uganda and Zimbabwe.

• Where individual or institutional capacity exists, external actors must avoid undermining it inadvertently. • Studies in Cambodia (contracting ) and Sierra Leone (HRH)

suggest that external support did not build capacity in the Ministries effectively or sustainably

Group model building• Group Model Building with health system stakeholders in

conflict-affected Northern Nigeria identified positive practices within the health system

Conclusions – 1 • All actors working in post-conflict or post-crisis

settings should aim to support the development of sustainable health systems, and be aware of and address possible unintended consequences of their actions that might undermine this goal.• Local actors should be included in policy

development and implementation, and as soon as possible, and should be supported to take a leadership and coordination roles at national and sub-national levels, to ensure local ownership and individual and institutional capacity building.

Conclusions – 2 • Conflict exacerbates multiple vulnerabilities and

there is need to ensure the policies developed in the post-conflict/crisis phase build health systems to support gender equity and access to those in greatest need.• Tools such as social network analysis and group

model building may be useful for understanding the dynamic situation in the post-conflict/crisis period.