Tracing health system challenges in post-conflict Côte d'Ivoire from 1893 to 2013

While scholarship on health in conflict-affected countries is growing, there has been relatively little analysis of how armed conflict affects health systems in specific African countries, especially former French colonies. There is even less literature on the role of history in shaping health systems and how historical factors such as inequity may influence health impacts of armed conflict. Based on Côte d'Ivoire, this article argues that historical multidisciplinary analysis can provide valuable insight into the macro-level political, economic and social determinants of the health system over time. It explores how armed conflict has affected health services and exacerbates historically inherited challenges to the health system including unequal distribution of health services, bias towards curative care in urban areas, inadequate human resources and weak health governance. In the post-conflict period, this understanding may assist governments and other stakeholders to develop more appropriate health policies that address both urgent and long-term health needs.     

Rebuilding health systems to improve health and promote statebuilding in post-conflict countries: A theoretical framework and research agenda

Violent conflicts claim lives, disrupt livelihoods, and halt delivery of essential services, such as health care and education. Health systems are often devastated in conflicts as health professionals flee, infrastructure is destroyed, and the supply of drugs and supplies is halted. We propose that early reconstruction of a functioning, equitable health system in countries recovering from conflict is an investment with a range of benefits for post-conflict countries. Building on the growing literature about health systems as social and political institutions, we elaborate a logic model that outlines how health systems may contribute not only to improved health status but also potentially to broader statebuilding and enhanced prospects for peace. Specifically, we propose that careful design of the core elements of the health system by national governments and their development partners can promote reliable provision of essential health services while demonstrating a commitment to equity, strengthening government accountability to citizens, and building the capacity of government to manage core social programs. We review the conceptual basis and extant empirical evidence for these mechanisms, identify knowledge gaps, and suggest a research agenda.     

Human resource management in post-conflict health systems: review of research and knowledge gaps

In post-conflict settings, severe disruption to health systems invariably leaves populations at high risk of disease and in greater need of health provision than more stable resource-poor countries. The health workforce is often a direct victim of conflict. Effective human resource management (HRM) strategies and policies are critical to addressing the systemic effects of conflict on the health workforce such as flight of human capital, mismatches between skills and service needs, breakdown of pre-service training, and lack of human resource data. This paper reviews published literatures across three functional areas of HRM in post-conflict settings: workforce supply, workforce distribution, and workforce performance. We searched published literatures for articles published in English between 2003 and 2013. The search used context-specific keywords (e.g. post-conflict, reconstruction) in combination with topic-related keywords based on an analytical framework containing the three functional areas of HRM (supply, distribution, and performance) and several corresponding HRM topic areas under these. In addition, the framework includes a number of cross-cutting topics such as leadership and governance, finance, and gender. The literature is growing but still limited. Many publications have focused on health workforce supply issues, including pre-service education and training, pay, and recruitment. Less is known about workforce distribution, especially governance and administrative systems for deployment and incentive policies to redress geographical workforce imbalances. Apart from in-service training, workforce performance is particularly under-researched in the areas of performance-based incentives, management and supervision, work organisation and job design, and performance appraisal. Research is largely on HRM in the early post-conflict period and has relied on secondary data. More primary research is needed across the areas of workforce supply, workforce distribution, and workforce performance. However, this should apply a longer-term focus throughout the different post-conflict phases, while paying attention to key cross-cutting themes such as leadership and governance, gender equity, and task shifting. The research gaps identified should enable future studies to examine how HRM could be used to meet both short and long term objectives for rebuilding health workforces and thereby contribute to achieving more equitable and sustainable health systems outcomes after conflict.     

Health systems and gender in post-conflict contexts: building back better?

The post-conflict or post-crisis period provides the opportunity for wide-ranging public sector reforms: donors fund rebuilding and reform efforts, social norms are in a state of flux, and the political climate may be conducive to change. This reform period presents favourable circumstances for the promotion of gender equity in multiple social arenas, including the health system. As part of a larger research project that explores whether and how gender equity considerations are taken into account in the reconstruction and reform of health systems in conflict-affected and post conflict countries, we undertook a narrative literature review based on the questions “How gender sensitive is the reconstruction and reform of health systems in post conflict countries, and what factors need to be taken into consideration to build a gender equitable health system?” We used the World Health Organisation’s (WHO) six building blocks as a framework for our analysis; these six building blocks are: 1) health service delivery/provision, 2) human resources, 3) health information systems, 4) health system financing, 5) medical products and technologies, and 6) leadership and governance.The limited literature on gender equity in health system reform in post conflict settings demonstrates that despite being an important political and social objective of the international community’s engagement in conflict-affected states, gender equity has not been fully integrated into post-conflict health system reform. Our review was therefore iterative in nature: To establish what factors need to be taken into consideration to build gender equitable health systems, we reviewed health system reforms in low and middle-income settings. We found that health systems literature does not sufficiently address the issue of gender equity. With this finding, we reflected on the key components of a gender-equitable health system that should be considered as part of health system reform in conflict-affected and post-conflict states. Given the benefits of gender equity for broader social and economic well-being, it is clearly in the interests of donors and policy makers to address this oversight in future health reform efforts.     

Reconstruction of health service systems in the post-conflict Northern Province in Sri Lanka

Public health problems in armed conflicts have been well documented, however, effective national health policies and international assistance strategies in transition periods from conflict to peace have not been well established. After the long lasted conflicts in Sri Lanka, the Government and the rebel LTTE signed a cease-fire agreement in February 2002. As the peace negotiation has been disrupted since April 2003, a long-term prospect for peace is yet uncertain at present. The objective of this research is to detect unmet needs in health services in Northern Province in Sri Lanka, and to recommend fair and effective health strategies for post-conflict reconstruction. First, we compared a 20-year trend of health services and health status between the post-conflict Northern Province and other areas not directly affected by conflict in Sri Lanka by analyzing data published by Sri Lankan government and other agencies. Then, we conducted open-ended self-administered questionnaires to health care providers and inhabitants in Northern Province, and key informant interviews in Northern Province and other areas. The major health problems in Northern Province were high maternal mortality, significant shortage of human resources for health (HRH), and inadequate water and sanitation systems. Poor access to health facilities, lack of basic health knowledge, insufficient health awareness programs for inhabitants, and mental health problems among communities were pointed by the questionnaire respondents. Shortage of HRH and people's negligence for health were perceived as the major obstacles to improving the current health situation in Northern Province. The key informant interviews revealed that Sri Lankan HRH outside Northern Province had only limited information about the health issues in Northern Province. It is required to develop and allocate HRH strategically for the effective reconstruction of health service systems in Northern Province. The empowerment of inhabitants and communities through health awareness programs and the development of a systematic mental health strategy at the state level are also important. It is necessary to provide with the objective information of gaps in health indicators by region for promoting mutual understanding between Tamil and Sinhalese. International assistance should be provided not only for the post-conflict area but also for other underprivileged areas to avoid unnecessary grievance.     

Eradication of poliomyelitis in countries affected by conflict

The global initiative to eradicate poliomyelitis is focusing on a small number of countries in Africa (Angola, Democratic Republic of the Congo, Liberia, Sierra Leone, Somalia, Sudan) and Asia (Afghanistan, Tajikistan), where progress has been hindered by armed conflict. In these countries the disintegration of health systems and difficulties of access are major obstacles to the immunization and surveillance strategies necessary for polio eradication. In such circumstances, eradication requires special endeavours, such as the negotiation of ceasefires and truces and the winning of increased direct involvement by communities. Transmission of poliovirus was interrupted during conflicts in Cambodia, Colombia, El Salvador, Peru, the Philippines, and Sri Lanka. Efforts to achieve eradication in areas of conflict have led to extra health benefits: equity in access to immunization, brought about because every child has to be reached; the revitalization and strengthening of routine immunization services through additional externally provided resources; and the establishment of disease surveillance systems. The goal of polio eradication by the end of 2000 remains attainable if supplementary immunization and surveillance can be accelerated in countries affected by conflict.     

An analysis of Liberia's 2007 national health policy: lessons for health systems strengthening and chronic disease care in poor, post-conflict countries

Background

Globally, chronic diseases are responsible for an enormous burden of deaths, disability, and economic loss, yet little is known about the optimal health sector response to chronic diseases in poor, post-conflict countries. Liberia's experience in strengthening health systems and health financing overall, and addressing HIV/AIDS and mental health in particular, provides a relevant case study for international stakeholders and policymakers in other poor, post-conflict countries seeking to understand and prioritize the global response to chronic diseases.

Methods

We conducted a historical review of Liberia's post-conflict policies and their impact on general economic and health indicators, as well as on health systems strengthening and chronic disease care and treatment. Key sources included primary documents from Liberia's Ministry of Health and Social Welfare, published and gray literature, and personal communications from key stakeholders engaged in Liberia's Health Sector Reform. In this case study, we examine the early reconstruction of Liberia's health care system from the end of conflict in 2003 to the present time, highlight challenges and lessons learned from this initial experience, and describe future directions for health systems strengthening and chronic disease care and treatment in Liberia.

Results

Six key lessons emerge from this analysis: (i) the 2007 National Health Policy's 'one size fits all' approach met aggregate planning targets but resulted in significant gaps and inefficiencies throughout the system; (ii) the innovative Health Sector Pool Fund proved to be an effective financing mechanism to recruit and align health actors with the 2007 National Health Policy; (iii) a substantial rural health delivery gap remains, but it could be bridged with a robust cadre of community health workers integrated into the primary health care system; (iv) effective strategies for HIV/AIDS care in other settings should be validated in Liberia and adapted for use in other chronic diseases; (v) mental health disorders are extremely prevalent in Liberia and should remain a top chronic disease priority; and (vi) better information systems and data management are needed at all levels of the health system.

Conclusions

The way forward for chronic diseases in Liberia will require an increased emphasis on quality over quantity, better data management to inform rational health sector planning, corrective mechanisms to more efficiently align health infrastructure and personnel with existing needs, and innovative methods to improve long-term retention in care and bridge the rural health delivery gap.     

Evaluation of maternal and child health services in Latin America.

A methodology has been devised for evaluating the efficiencies of maternal and child health care services in 18 countries of Latin America. The results point towards ways of developing local health systems, strengthening coordination between programmes and services, and utilizing resources more rationally.     

应对卫生人力挑战： 国际视角下的关键问题

卫生人力资源投入短缺和地区分布不均是低收入国家贫困人口不能获得卫生服务的主要原因。本文回顾了近期国际卫生人力政策研究的动向,探讨了加强卫生人力资源的几个关键问题,并且列举了一些旨在应对卫生人力挑战的可能举措。     

The health professions and the performance of future health systems in low-income countries: Support or obstacle?

This paper discusses the present and future role of the health professions in health services delivery systems in low-income countries. Unlike richer countries, most low-income countries do not have a tradition of labour market regulation and the capacity of the professions themselves to regulate the provision of health services by their members tends to be weak. The paper looks at the impact of professional monopolies on the performance of health services delivery systems, e.g. equity of access, effectiveness of services, efficiency in the use of scarce resources, responsiveness to users' needs, including protection against the financial impact of utilising health services. It identifies issues which policy-makers face in relation to opening the health labour market while guaranteeing the safety and security of services provided by professionals. The suggestion is made that a "social contract", granting privileges of practice in exchange of a commitment to actively maintain and enhance the quality of their services, may be a viable course of action. This would require that the actors in the policy process collaborate in strengthening the capacity of regulatory agencies to perform their role.     

Rethinking gender-based violence during war: Is violence against civilian men a problem worth addressing?

Gender-based violence during conflict and post-conflict situations has received increased attention in research and in the work of development agencies. Viewed primarily as a form of violence against women, this commentary questions whether male civilians have also been victims of gender-based violence during conflict, invisible due to stereotypes surrounding masculinity and a culturally permissive approach towards violence perpetrated against men, especially at times of war. The experience of civilian males of violence, including sexual violence, during the war in Bosnia and Herzegovina and other contemporary wars, suggests that the discourse on gender-based violence and public health research should begin exploring the specific needs of men. Drawing on Nancy Krieger's (Krieger, N. (2003). Genders, sexes, and health: what are the connections—and why does it matter? International Journal of Epidemiology, 32, 652–657) analysis on the differential role of ‘sex’ and ‘gender’ on a given exposure-outcome association, this commentary suggests that the impact of gender-based violence on health during conflict may be different for men and women and may require distinct therapeutic approaches. Given that perpetrators are often male, an extra level of stigma is added when heterosexual men are sexually violated, which may lead to underreporting and reduced health-service seeking behavior. Further public health research is needed to guide the work of humanitarian agencies working with survivors of gender-based violence in conflict and post-conflict settings to ensure equal access to appropriate health services for men and women.     

Evidence-based public health: what does it offer developing countries?

The global burden of disease and illness is primarily situated in developing countries. As developing countries have limited resources, it is particularly important to invest in public health and health promotion strategies that are effective. Systematic reviews are central to evidence-based public health and health promotion practice and policy. This paper discusses issues surrounding the relevance of evidence-based public health and systematic reviews to the health of developing countries. It argues that there is a lack of systematic reviews relevant to the health priorities of developing countries; many interventions reviewed can not be implemented in resource-poor situations; and, a limited amount of primary research is conducted in developing countries. The paper further argues that improvements in public health are determined not only by effective health services and interventions, but through an approach that includes other sectors and influences broader structural and systematic barriers to health. Given the social complexity of human development, and the inter-sections amongst different development goals, there is no question that gains in developing country public health are unlikely to emerge from systematic reviews alone, but will require decisions about inter-sectoral collaboration and social policy initiatives. Nonetheless, evidence around intervention effectiveness has an important role to play in addressing health priorities in developing countries and resource-poor areas. The public health evidence base urgently needs strengthening, with dedicated effort towards increasing the relevance of primary evidence and systematic reviews.     

The costs of hospital services: a case study of Evangelical Lutheran Church hospitals in Tanzania.

The health care systems of many developing countries are facing a severe crisis. Problems of financing services leads to high patient fees which make institutions of Western health care unaffordable for the majority of the rural poor. The conflict between sustainability and affordability of the official health care system challenges both local decision-makers and health management consultants. Decisions must be made soon so that the existing health care systems can survive. However, these decisions must be based on sound data, especially on the costs of health care services. The existing accounting systems of most hospitals in developing countries do not provide decision-makers with these data. Costs are generally underestimated. The leadership of the 16 hospitals of the Evangelical Lutheran Church in Tanzania is currently analyzing how the existing health care services should be restructured. Therefore, reliable estimates of the costs of hospitals services are required. A survey on 'Costing of health services of the Evang. Luth. Church in Tanzania' was prepared, which summarizes the results of seven months of field investigations in Lutheran hospitals. The major findings are that the costs of providing adequate services are much higher than expected. The most important factors determining these costs are the administrative efficiency of the hospital and the scope of services offered. The paper closes with some recommendations on how to improve the services in order to make them both affordable for the rural poor and financially sustainable for the Church. It is concluded that even the best improvement of technical efficiency will not safeguard the survival of the hospital-based health care services of the Lutheran Church in Tanzania. These findings call for a reallocation of health care resources to lower levels of the health care pyramid.     

A case study of health sector reform in Kosovo

The impact of conflict on population health and health infrastructure has been well documented; however the efforts of the international community to rebuild health systems in post-conflict periods have not been systematically examined. Based on a review of relevant literature, this paper develops a framework for analyzing health reform in post-conflict settings, and applies this framework to the case study of health system reform in post-conflict Kosovo. The paper examines two questions: first, the selection of health reform measures; and second, the outcome of the reform process. It measures the success of reforms by the extent to which reform achieved its objectives. Through an examination of primary documents and interviews with key stakeholders, the paper demonstrates that the external nature of the reform process, the compressed time period for reform, and weak state capacity undermined the ability of the success of the reform program.     

Women,war, and reproductive health in developing countries

Globally, millions of people are affected by war and conflicts every year. However, women have increasingly suffered the greatest harm by war in more different ways than men. We conceptualize a reproductive rights approach toward examining the effects of war on women’s reproductive health in developing countries. Given the rising concerns of exclusion to adequately address women’s rights, sexual and gender-based violence, and post-conflict accountability, we specifically focus on the limitations of the Minimum Initial Service Package, a UN-sponsored reproductive health service program in conflict zones while offering a broad reproductive rights-based conceptual lens for examining reproductive health care services in war-torn areas. In addition, we discuss the roles social workers may play at both micro and macro levels in war-torn areas to bring about both short term and long term gains in women’s reproductive health.     

Stronger health systems for more effective HIV/AIDS prevention and care

Of the 42 million living with HIV/AIDS world-wide some 90% live in developing countries. The international community acknowledges the devastating impact of HIV/AIDS on development and over the past few years resources to control HIV/AIDS have increased considerably. We argue that strengthening of health systems is a necessary prerequisite for improving the prevention of HIV infection and the care of HIV-infected persons. Sexual behaviour change requires a multidisciplinary approach, but health services play a crucial role in detection and treatment of other sexually transmitted infections; HIV counselling and testing; prevention of mother-to-child transmission of HIV; and care of HIV-infected patients. Increasing access to antiretroviral treatment especially poses formidable challenges to health authorities in developing countries. Additional resources for the prevention of HIV-infection and the care of HIV-infected persons may not have the desired impact if health systems in developing countries are not strengthened. Further, any activity in the area of HIV/AIDS prevention and care, carried out within health services, can have a positive ripple effect on other health care activities and vice versa. This interactive effect needs to be acknowledged and built on.     

Challenges and opportunities for implementation of substance misuse interventions in conflict-affected populations

Alcohol and other drug misuse are significant but neglected public health issues in conflict-affected populations. In this article, we review the literature on the challenges and strategies for implementing substance misuse treatment and prevention services in conflict and post-conflict settings in low- and middle-income countries. We identified nine studies describing interventions in conflict-affected populations residing in Afghanistan, Croatia, India, Kenya, Kosovo, Pakistan, and Thailand. Six of these nine studies focused on refugee populations. Reports revealed challenges to intervention implementation, as well as promising practices and recommendations for future implementation that we characterized as existing in the inner and outer contexts of an implementing organization. Challenges existing in the outer context included low political prioritization, lack of coordination and integration, and limited advocacy for access to substance misuse services. Challenges within the inner context related to competing priorities and a shortage of providers. Resource limitations existed in both the inner and outer contexts. Stigma was a challenge that threatened implementation and utilization of substance use services in situations when substance use interventions were not congruent with the roles, structure, values, and authority of the system or implementing organization. Future research should focus on developing, applying, and evaluating strategies for overcoming these challenges in order to make progress toward meeting the need for substance misuse services in conflict-affected populations.     

Planning for health sector reform in post-conflict situations: Kosovo 1999-2000

The restoration and development of health care systems in post-conflict situations and complex emergencies are attracting attention. Kosovo is unique in being a post-conflict situation, in a former socialist country, with an unclear political future, under temporary UN administration. The World Health Organization (WHO) led a process of developing a health policy framework for the emergency period that included elements of health sector reform, a somewhat controversial initiative. Reform elements of the policy were consistent with normative health policies in much of eastern and central Europe. There was tension between the need to have a policy in place rapidly and the desire to be participatory. Policy to deal with emergency situations that is not available at the time required is of limited value. Although there was some tension between relief and development agendas, the policy process did direct significant resources and effort in directions that contributed to longer-term reform and development. A policy framework does not ensure compliance with policy unless issues of authority, mandate, and leadership are clear. A rapidly developed health policy framework at the onset of an emergency is desirable. Policy developers should be experienced, seen as being neutral and be relatively independent of any specific donor or interest group. WHO is well situated to play this role if it meets certain conditions.     

我国农村公共卫生资源配置现状与对策探讨

分析了我国大陆农村公共卫生资源配置存在的经费投入不足、机构设置未达到全覆盖、现有人力资源难以满足需要、资源配置结构性失调等问题,提出制定引导公共卫生资源向农村流动的相关政策、强化政府公共财政投入责任、加强农村公共卫生机构建设、提升公共卫生人力资源素质、调整农村公共卫生资源配置结构、推进乡村一体化管理等对策,为提高农村公共卫生服务水平、推动基本公共卫生服务城乡均等化进程提供参考。     

Conflict,forced displacement and health in Sri Lanka: a review of the research landscape

Sri Lanka has recently emerged from nearly three decades of protracted conflict, which came to an end five years ago in 2009. A number of researchers have explored the devastating effect the conflict has had on public health, and its impact on Sri Lanka’s health system - hailed as a success story in the South Asian region. Remarkably, no attempt has been made to synthesize the findings of such studies in order to build an evidence-informed research platform. This review aims to map the ‘research landscape’ on the impact of conflict on health in Sri Lanka. Findings highlight health status in select groups within affected communities and unmet needs of health systems in post-conflict regions. We contend that Sri Lanka’s post-conflict research landscape requires exploration of individual, community and health system resilience, to provide better evidence for health programs and interventions after 26 years of conflict.