Health is Wealth, Especially in Fragile States

Health is Wealth, Especially in Fragile States

That point was made often by the Honorable Dr. Walter T. Gwenigale, Minister of Health and Social Welfare of the Republic of Liberia (also widely known as Dr. G in Liberia) at a conference, co-sponsored by MSH on June 9 and 10 at the US Institute of Peace. The event, Health in Post-Conflict and Fragile States: Challenges for the Next Decade was organized by Leonard Rubenstein, Chair of the USIP Health and Peacebuilding Working Group, and Stephen Commins, of International Medical Corps.

The two-day discussion explored the unique characteristics of health service delivery in fragile and conflict-affected states, making the point that “yes, it can be done,” but there is still a long way to go to get it right and find the balance between short-term interventions and long-term development. Speakers shared lessons learned in reconstructing health systems, especially in Afghanistan and Southern Sudan. They also took a look at human rights, governance, and vulnerable populations, particularly women. Dr. Gwenigale and Deputy Administrator of USAID, Ambassador Donald K. Steinberg provided keynotes.

Dr. Gwenigale spoke about country-ownership of development and, in particular, the importance of communicating to populations that health services are brought to them by the government (with the help of donors and partners), including via branding and marketing. It is important to build trust and confidence in post-conflict environments. He also noted the need for transparency in development by all players---donors, NGOs, and the governments. He noted the importance of funds being given to others sectors that will directly benefit health, such as building of roads and bridges in rural areas or schools that will educate people more about their health. "Health is wealth,” he said, and he counted his fellow multi-sectoral ministers as allies in the struggle to improve health.

Dr. John Rumunu, Chief of Party of the MSH-led, USAID-funded Southern Sudan Health Transformation Project (SHTP-II) talked about improvements in health in Southern Sudan (soon to become South Sudan on July 9 and currently facing some of the highest maternal and child mortality rates). Working side by side with the Ministry of Health, SHTP-II focuses on providing seven high impact health interventions, such as child health, immunizations, Vitamin A dissemination, family planning, malaria (via provision of bed nets), water and sanitation, and prevention of HIV &AIDS. He also talked about the return of internally-displaced persons (IDPs), members of the diaspora, and an influx of people fleeing the conflict-ridden border town of Abyei, creating an acute and chronic situation. One challenge he noted is that the local health services don’t have control over their own budgets to pay for health workers. Midwives and infrastructure for primary health care are particularly needed in Southern Sudan.

Steve Solter, Technical Lead for Fragile States at MSH, explained how the Minister of Health in Afghanistan made four key decisions to improve health, all controversial at the time. First they, too, focused on a Basic Package of health services (this Basic Package Of Health Services (PDF) was cited in the recent Senate Foreign Relations report on Afghanistan (PDFor maternal and child mortality instead of a comprehensive package in order to ensure services reached those most in need. Second, they worked together with local and international NGOs to implement the program, with three donors splitting the provinces they covered. This two-pronged approach has been the hallmark of MSH’s approach to development in other fragile states. The lesson learned was that local NGOs delivered the package better than the international NGOs. Third, there was a huge community-based component and half of the workers were women and able to reach women who had not had access to care before, especially in winter. And fourth, they trained thousands of women as skilled birth attendants/midwives. What was important about these four decisions was a) the importance of continuity---three Ministers of Health since 2002 have all focused on this program---and b) the key importance of partnerships---all donors and implementers on board with the plans. Solter noted three vexing problems that still need to be resolved: security, corruption, and improving the role of women in Afghan society.

Another important topic at the conference was assaults on health care workers and facilities in armed conflict---violations of international law. The ICRC called this its own humanitarian crisis and noted the current situation in Bahrain where dozens of health workers have been arrested for helping protesters and recommended that a community of concern be formed to build an information data base of incidents. Asst. Secretary of State for Democracy, Human Rights and Labor, Michael Posner, said violations of medical neutrality cannot be tolerated by governments or by opposition groups, and noted Libya and Bahrain as egregious examples. Posner also made a plea to the health and development community to assist lawmakers on defining “right to health” and reasonable benchmarks and what it means for a struggling country. He also noted the “double standard” in the US regarding universal health coverage when the US supports health systems abroad but not here in the US. But he said both are necessary and both need to be worked towards and not one or the other. Carla Koppell, Senior Coordinator for Gender Equality and Women’s Empowerment at USAID, noted that USAID was working on a National Action Plan on Women, Peace and Security. Dr. Paul Wise of Stanford reported that 63% of the total under 5 mortality of children is preventable now and that majority of deaths are in sub-Saharan Africa in areas of chronic unstable governance. He noted governance indicators are: voice and accountability, political stability, government effectiveness, regulatory quality. He said that if we want to really address the under 5 deaths, we will need to address corruption and work in countries where corruption is prevalent, noting that withholding provision of health interventions is always unjust and unacceptable.

Ambassador Steinberg emphasized the importance working with the community---“all development is local”---and that in emerging states, health improvements serve dual purposes of development and of supporting political, economic, and social reform. They are part of the “peace dividend” after a conflict and show immediate results.

Key Resources

Barbara Ayotte is Director of Strategic Communications at MSH.