Research for stronger health systems during and after crisis

Making Health Systems work in Poor Countries affected by Conflict and Fragility

Thursday, 26 Jun 2014

On Tuesday 24 June the International Development Committee began an inquiry into health system strengthening.  Health systems are context specific and this is an important factor in understanding their performance. However the committee made limited reference to the particular context of post conflict and fragile states. On Thursday 26th June the Guardian held a live discussion on Making health systems work in poor countries. ReBUILD researchers Sally Theobald, Liverpool School of Tropical Medicine, UK and Sarah Ssali, School of Women and Gender Studies, Makerere University,Uganda took part in this and ensured that the needs of fragile and conflict affected states and the opportunities that can arise after conflict were put on the agenda.

As the reasons for health systems not being prioritised were discussed Sarah Ssali introduced the importance of recognising conflict , ‘There are several factors, which lead to under-funding, which consequently leads to human resources shortfalls, limited facilities, no equipment, medicines and distance. Conflict is also a factor which limits access to conflict affected areas in a special way.’

This was echoed by Sally Theobald, ‘I think there is particular need to take this forward in fragile and post conflict contexts. Fragile and conflict affected states (FACS) have been neglected to date in health systems research and are important contexts in which to better understand and build strong and equitable health systems. Key decisions in health systems planning that take place in this period may affect the nature of a state’s health system, and ability to deliver health services that support the poorest populations, for many years in the future. We are taking forward work in ReBUILD to understand the health systems challenges in post conflict contexts with a particular focus on health financing and human resources.

This was supported by Dina Balabanova, London School of Hygiene & Tropical Medicine, who stated that ‘Given the increasing recognition of path dependency in health systems development, are we paying enough attention to these settings? One idea I find inspiring is that even the worst events (political, economic) can be used to trigger reforms that may not be otherwise possible.’

Simon Wright, Head of child survival at, Save the Children reflected on how the ‘UK created a universal health system in the aftermath of WW2, at a time of austerity. The political and technical processes that allowed this to happen have important lessons for other governments’.

The ReBUILD programme seeks to capture exactly these kinds of changes that set the health system of on a particular trajectory, and understand how this learning can be applied as future states emerge from conflict and crises situations. 

Contributors agreed that sufficient financing for health systems was key and this was often in competition in LMIC settings with resources for education, water and sanitation systems. Sally Theobald argued for the need for cross sectoral approaches as well as ‘strategic partnerships with those who hold the purse strings – Ministries of finance and donors amongst others’.

Dina Balabanova argued that ‘Good governance is a key driver of health system strengthening, as has increasingly been demonstrated empirically. It includes effective leadership and vision, sustained political commitment, effective bureaucracies and institutions that have adequate regulatory and managerial capacity, ability to innovate, and resilience to political and economic crises. Governance matters for development and for health generally.’

This can be no more important than in fragmented and conflict affected states where governance has broken down.

Sian K Maseko Director, Sexual Rights Centre, Zimbabwe, Africa view was that if systems as is the case in Zimbabwe are generally weak (governance, rule of law, deteriorating services, reluctance of donors to fund state services) then the health system will definitely suffer. The governance of the country determines priorities at budgetry, but also ideological level and political will. Equally, the strength of civil society to lobby around governance, accountability and transparency issues are key because healthcare systems do not exist in a vacuum and certainly in Zimbabwe healthcare systems have suffered because of the focus on good governance from within the countries and externally. This is reflected by high maternal mortality rates to name but one example.’

Sara Ssali highlighted that ‘we need accountability mechanisms, especially social accountability to ensure that local leaders do not become a class apart and become less accountable to the local communities.

The role of donors was considered. Sian K Maseko argued that ‘donors need to balance the importance of rights accountability and 'do no harm' with inclusive dialogue in countries. Discussions about the right to health need to be comprehensive and cogniscent of the wider legislative, socio-economic etc. context’ An example was raised in relation to  how the approach of the new global fund model being applied in ReBUILD partner country Zimbabwe will impact. In places recovering from conflict there is need to discuss health in safe and open spaces.’

In summing up the discussion Sally Theobald commented on the vibrant community working on health systems, that there is agreement on the need for equity and health systems that are responsive to need across marginalised groups, and that contexts really do matter with some being more challenging than others.   ‘In post conflict contexts we need to understand how health systems can best play a part in building recovery and peace and dealing with challenging issues such as strong and holistic services for survivors of sexual and gender based violence’.

 ReBUILD is supporting a thematic Working Group into Health Systems in Conflict affected States at the Health Systems Global Symposium in Cape Town South Africa, 30th September – 3rd October 2014. Join it on Health Systems in Fragile and Conflict Affected States | LinkedIn