Health workers – the bedrock of healthcare during conflict, and central for rebuilding health systemsPosted on Friday, 06 Apr 2018
Blog by ReBUILD's Nick Hooton, for World Health Worker Week and World Health Day 2018.
“If we were to run away who would now help them? So we persisted and slowly the fear disappeared’’
(Female health worker, Amuru, northern Uganda)
Health workers are the most critical elements of health systems anywhere. And whilst there are challenges to maintaining an effective, responsive and motivated health workforce in any context, these challenges are massively increased in settings affected by conflict or crisis.
Some of these settings are daily headline news, but the overall scale of the impact of conflict, fragility and violence on people’s access to healthcare is far greater even than this. According to the World Bank, some two billion people live in countries where development outcomes are affected by fragility, conflict, and violence, and the share of global poor living in fragile and conflict-affected situations is projected to reach 46% by 2030.
In World Health Worker Week and on World Health Day, it is appropriate not only to recognise and celebrate the work of health workers in the most challenging human situations in our world, but to commit to action to support, protect and enable health workers, managers and all involved in supporting access to essential health care during conflict and protracted crises, and in the lengthy and uncertain periods of recovery after.
Health systems in conflict and crisis
Since 2011, the ReBUILD research programme has been studying how the decisions made (or not made) in the post-conflict period can affect long-term patterns of attraction, retention, distribution and performance of health workers, and thus ultimately the performance of the sector.
As described in this YouTube video, all ‘pillars’ of the health system are severely affected by conflict. It disrupts – in multiple ways – the supply of health care services and their ability to meet the health needs and demands of the population, demands which themselves change because of the way conflict affects all aspects of life. Even emergency assistance often fails to reach people, and the main source of care may come from whichever local and indigenous health providers remain.
Despite the massive challenges and risks facing health workers in conflict and crisis affected settings, which force many staff to flee, or make it too difficult for them to work, ReBUILD’s work has highlighted examples of great resilience in the health workforce, with innovative ways to continue to provide services when core facilities, resources and funding are lacking. Challenges continue during the ‘post-conflict’ period, and the responses of the health workforce, managers, decision makers and development partners to address these, and how these have played out in the longer term, has been the subject of much of ReBUILD’s research.
Supporting a resilient health workforce in FCAS
This research so far has led to a number of recommendations, around, for example:
reforms to HRH packages that ensure a fair balance across sectors to avoid distorting the health labour markets and draining staff from hard-to-serve areas.
investments in the immediate post-conflict period that consider longer term implications – for example, by not introducing cadres which will be inappropriate and hard to sustain longer term.
supporting, reinforcing and rewarding resilience where it is found, and providing decision spaces and flexibility for good staff to thrive and drive forward better services.
the need for balanced incentive packages which help retain staff in hard-to-serve areas, and go beyond short-term financial measures, to include, for example, practical measures to improve security; provision of decent housing, working conditions, training and career development; and which help re-establish trust, communication and teamwork.
the need to address gender equity in the health workforce in fragile and post-conflict settings, ensuring both that gender is integrated into policy and that dialogue and action is supported for gender equity within institutions and households. ReBUILD’s work on this is included in the Building Back Better resource on gender and health systems in FCAS.
“I was motivated by the community […] They were in total support of my well being and able to provide food for me. Another […] was the district which was able to provide means of transport.”
(Male health worker, Pader, northern Uganda)
Finally, community level health systems are critical in fragile and conflict affected settings, and community health workers (CHW) can play a vital role in healthcare delivery. ReBUILD is currently extending its research to identify how the CHW cadre might be better supported to play an effective and long-term role in the broader health system in fragile contexts.
Along with many other actors who are coming together to produce and support the use of health systems evidence, ReBUILD continues to engage with national and international level policy processes, collaborating with partners, to support progress towards equitable health systems and universal health coverage, including through an effective, motivated and responsive health workforce, in conflict and crisis affected settings.
Nick Hooton is Research, Policy and Practice Advisor for the ReBUILD Research Programme Consortium.
All quotations are from health workers interviewed as part of ReBUILD's research.
- Ugandan health workers. Courtesy of Photoshare.
- A provider at a government-run medical facility in Aden, Yemen, examines Somali refugees who recently fled across the Aden Sea. Thousands of people fleeing civil strife in Somalia have fled safely to Yemen, where refugees are given automatic political asylum. © 2009 Micah Albert, Courtesy of Photoshare