Research for stronger health systems during and after crisis

Action on health systems in fragile and post conflict states is critical to achieving universal health coverage

Thursday, 01 Nov 2012

By Sally Theobald, ReBUILD Consortium, Liverpool School of Tropical Medicine, UK

With crisp temperatures and an atmospheric fog enveloping the Beijing Health Conference last week, there was disquiet amongst some inside about jumping on the universal health coverage bandwagon. A sense that unless explicit pro-poor approaches are put in place – those which clearly address the needs of marginalised and disenfranchised groups – there is a danger that inequities will grow rather than decrease.

In a packed plenary on equity, Thomas O’Connell fromUNICEF showed us some powerful slides which illustrated progress towards the Millennium Development Goals. Impressive gains have been made in addressing under five mortality on a global level. As he deftly showed, however, disaggregating the data by poverty reveals a more complex picture. Alarmingly, in most countries across the globe there are growing inequities with poorer communities experiencing little by way of change. Thomas made a clear rallying call for disaggregated data and analysis by income, literacy, gender, age, and ethnicity to capture the nuances of change. Importantly, we need to understand which groups are benefiting and which are being left behind.

 In the same plenary, Walter Flores, Director, Center for the Study of. Equity and Governance in Health Systems in Guatemala, passionately argued that Guatemala’s indigenous groups face significantly worse health indicators than the rest of the population, and that achieving universal health coverage must include specific measures to address the decades of violence and neglect that they have experienced.

At the global level we need to be wary of quick gain strategies, promoting universal health coverage that lead to further neglect and isolation of those at the margins. More than 1.5 billion of the world’s population live in conflict-affected countries. It’s in these very contexts where poor and marginalised populations are least likely to access quality health services.  Conflict, post conflict and fragile states have largely been neglected in health systems research and this is a missed opportunity to promote social justice and health care amongst those most in need. It was a clear omission that no panels at the last Health Systems Conference in Montreux focused explicitly on these contexts.

Beijing moved these debates forward with three different sessions. A Wednesday satellite symposium organised by Management Sciences for Health focused on community health workers in fragile states with speakers from Iraq, Afghanistan and Haiti. On Friday, ourREBUILD panel presented on building pro-poor health systems in the aftermath of conflict, followed later by the fragile states and health panel, chaired by Steve Solter of MSH. We took the opportunity in this third session to collectively discuss the key health challenges in fragile states and agreed to jointly submit an application for a theme on health in fragile states for the 2014 health systems conference. This will highlight the importance of governance, advocacy, ethics and addressing inequities and the complex ways they play out – by poverty, ethnicity, gender, age, religion, geography and (dis)ability.

The rallying cry for universal health coverage at the conference will only be realised with an explicit focus on populations most in need. This requires more action on neglected conflict affected and fragile states and a better understanding of how to address the needs of different populations that live there. We hope to see this really brought alive now.