Health systems in fragile and conflict affected settings
Critical factors in rebuilding health systems after crises
What are the key building blocks when it comes to rebuilding health systems in fragile and conflict-affected states?
In countries affected by conflict and crisis, particularly those with protracted crises, the functioning of the health system is significantly impaired. Often it has deteriorated to the point where public health care is no longer widely available. Those seeking to rebuild these health systems will face multiple challenges including the destruction of health infrastructure and supply systems; the lack of health workers; fragmentation and lack of co-ordination between multiple formal and informal providers; and weak governance capacity to coordinate and develop the health system anew. But there will also be opportunities to put in place elements that previously did not exist. Tackling access and coverage of health systems in fragile and conflict-affected settings, for example, means addressing the needs of long-neglected vulnerable groups, such as women-headed households, the elderly, orphaned or abandoned children and the disabled. It also requires a financing policy that aims to meet universal health coverage goals. Prioritising and sequencing are thus critical elements in rebuilding the health system, particularly as decisions made in the transition period can often determine the long-term direction of development for the health system.
The World Health Organization’s health systems framework highlights several critical factors when it comes to rebuilding health systems in these contexts. The WHO framework focuses on six building blocks - service delivery, health workforce, health information systems, access to essential medicines, financing and leadership/governance – and argues that, together, these are key to realising more equitable and sustained improvements across health services and health outcomes. Here we focus on four of these - leadership/governance, service delivery, health workforce, and financing – as a potentially useful way to think about what is required and to highlight some key readings for those of you who might want to delve further into this topic.
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Leadership and governance
Governance refers to the set of rules, institutions and relationships by which authority in a given functional zone is exercised to optimise accountability, responsiveness, rule of law and social security. WHO defines the leadership and governance building blocks as "ensuring that strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system design and accountability" ([link]WHO 2010: 86). Leadership and governance, also known as stewardship, form the foundation of the health system by enabling national and sub-national authorities to guide and organise stakeholders in health service provision to maximise the health benefits and improvements.
Service delivery - Basic Packages of Health Services (BPHS)
The concept of the essential packages of health services was introduced by the World Bank in 1993 and has been widely used in resource-scarce environments to concentrate resources on cost-effective interventions that meet priority health needs.
Over the years we have become increasingly reliant on the Basic Packages of Health Services (BPHS) model for the delivery of health services in fragile and conflict-affected situations. BPHS are frequently delivered through collaborations between the government, UN agencies and international NGOs and are often embedded in a contract. The packages are based on assessments of the country’s needs, existing resources and available funding. As highlighted by Roberts et al (2008) “the aim is to rapidly scale-up health services with proven, affordable health interventions and replace the fragmented, uncoordinated, vertically-dominant services characteristic in many post-conflict settings.” There are a number of useful examples of BPHS implementation.
Health workers are arguably the most critical resource in achieving the recovery goals of a health system. But they are often targeted during conflicts and end up seeking livelihoods and security elsewhere. This can result not only in shortages but also lower skill levels among those that remain. After conflict, low numbers of appropriately trained personnel can therefore present a major constraint in re-establishing a public health system.
In fragile and conflict affected states, human resource policies and strategies addressing recruitment, remuneration and retention are therefore an essential first step. The role of front-line or close-to-community providers is often overlooked despite the essential role they play in extending services in remote areas. Understanding how health workers have survived, what motivates them, and what coping mechanisms they used in dealing with adversity can also be a key factor in ensuring their re-engagement with the health system.
The health financing building block covers a vast range of issues, all integral to the capacity of the health systems to meet demand and supply. A challenge for any health system recovery process is to achieve a system that is "person-centred" and ensure that it is "organized around the person, not the disease or the financing" ([link] WHO 2010 p.3). The ReBuild Research consortium has noted that "health financing policies that support universal access to health care without causing impoverishment are critical for health and economic development in any setting." Linking health equity with social protection instruments, such as fee waivers, targeted cash transfers and subsidies, may boost people’s resilience.