health cooperation in post-conflict setting

Health cooperation in post-conflict setting

July 16, 2013Hideaki NAKAJIMA

254th IDEC Asia Seminar


Liberia - Data

http://wikitravel.org/en/File:LocationLiberia.png

Stats Figure RemarksSurface area 111,369km2 -

Population 3,994,000 Estimated in 2010

GDP US$873,000,000

Current US$ in 2010

GDP growth rate

5.2% At constant 2005 prices in 2010

GDP per capita US$218.6 2010

Human Development Index ranking

174 Out of 186 countries in 2012- http://data.un.org/CountryProfile.aspx?

crName=Liberia- http://hdr.undp.org/en/statistics/

http://wikitravel.org/en/File:LocationLiberia.png

1822: Freed American slave settlers arrived 1847: Independence (first republic in Africa)→ Only “Americo-Liberians” had civil rights and politically and economically ruled Liberia 1980: Coup d’etat by Samuel Doe (indigenous

origin) 1989: Rebel by Charles Taylor→ Civil conflict 2003: Accra Peace Accord 2006: Inauguration of first democratically elected female president in Africa (Ellen Johnson- Sirleaf)


Liberia - History

No. of health facilities: 550 before conflict → 354High maternal mortality rate: 770/100,000 (2010) (7th highest in world) (*Japan: 6/100,000)Infant & under 5 mortality rates are also still high: 58/1,000 (2011) (*Japan: 2/1,000) & 78/1,000 (2011) (*Japan: 3/1,000)Infectious disease (malaria) prevalentNeglected tropical disease (NTD: lymphatic

filariasis, etc.)Non-communicable diseases (diabetes,

cardiovascular disease, etc.)Basic care such as eyes, nose & throat (ENT) is

also still to be improved


Situation in health in Liberia

BPHS:Introduced into post-conflict setting (e.g.

Afghanistan other than Liberia)Comprehensive health service package to

“effectively deliver quality health services to the people” (Liberia National Health Policy 2007-2011)

DecentralizationPerformance-based contract with NGOs &

local authority (even aiming at contract with health facilities)254th IDEC Asia Seminar

Basic Package of Health Services (BPHS)

<2007 - 2011>

Maternal & newborn careReproductive & adolescent healthChild healthCommunicable disease controlMental healthEmergency care services


BPHS (cont.)

BPHS expanded to Essential Package of Health

Services (EPHS)BPHS (2007-

2011)EPHS (2011-2021)

(1) Maternal & newborn care

(2) Reproductive & adolescent health(3) Child health

(4) Communicable disease control

(5) Mental health(6) Emergency care services

- (7) Non-communicable diseases- (8) NTD

-(9) Environmental & occupational health

-

(10) School health services (Oral hygiene/dental care, Eye care, Immunizations, Personal hygiene, Family planning counseling, etc. )

- (11) Prison health services

-

(12) Essential support services (Facility infection prevention, control & health waste management, pharmaceutical services, Health management information systems, Laboratory services, Health promotion/IEC/BCC)


Cooperation in health in Liberia

MoHSW

NGO

GAVI

Global Fund J apan

China

Ireland

Switzerland UK

EU US

WHO UNICEF

UNAIDS

UNFPA

Pool Fund

Aid coordination

Funding（PBC）

Support in services provision

TA

Funding（PBC）

- Funding

- TA

cooperatio

Support in service provision - Funding

- TA

Funding

- Funding, equipment

- Support in service provision

- TA

Funding

Funding

- Funding, equipment

- Support in service provision

- TA

- Support in service provision - TA

Funding

- Infrastructure

- Equipment

- Support in service

provision

- TA


Outcome?

1986 2000 2007 2008 2010 MDG2015

260

578

994

890

770770

145

Maternal mortality (out of 100,000 live births)


Outcome? (cont.)

1986 2000 2007 2008 2009 2010 2011 MDG2015

114117

71

7873

615858

31

Infant mortality (out of 1,000)


Outcome? (cont.)

1986 2000 2007 2008 2009 2010 2011 MDG2015

220

194

110 112 114

83 7878 80

Under 5 mortality (out of 1,000)


Vertical vs Horizontal approaches

Health systems

Governance

Finance Human resource

Services Facility/equipme

nt

Information

Malaria

Morbidity specific

HIV/AIDS

TB

- Effectively tackling diseases

- Morbidity stakeholders are not interested in put in lower priority - Lack of coordination among stakeholders >> High transaction cost

- Improving sustainable health services - Takes time to show outcomes - Lack of coordination among stakeholders >> Difficulty in strengthening all components in balance

X

XX

Policies/strategies made in the course of state reconstruction (sometimes in donors’ interest?)

Essential, BUT… Gap between what is written and what

is actually implemented


Liberal peacebuilding/development?

Midwives & nurses always scold me at clinic. Drugs are sometimes out of stock and so I have to buy ones myself. And, clinic is far! I don’t want to go to clinic…

So many people come and I’m busy and tired… No pay increase, and payment sometimes delays! I want to get new skills, to be respected. I don’t want to stay in rural area…!

Decentralization?Wait a minute…

Weak enforcement of systems, weak governance, lack of authority…

- Government and donors/NGOs are working on strengthening gov’t governance…

- But no good coordination among them…


Liberal peacekeeping/development? (cont.)

HumanitarianismHuman securityEquity/justiceNational interestsGlobal public goods


Why aid?

?

?

Public goods: Non-excludable & non-rivalrous in consumption (e.g. lighthouse, peace & security, law & order)

In this rapidly globalizing world, health GPGis…

- Health R&D- Communicable disease control(Smith R.D. & MacKellar L. (2007))254th IDEC Asia Seminar

Global public goods (GPG)

WHO’s recent report:“Global and regional estimates of violence against women: Prevalence and health effects of intimate partner violence and non-partner sexual violence”


GPG (cont.)

<Sexually transmitted infections (STIs)>

Women who experience physical/sexual partner violence are 1.5 times more likely to acquire STIs including HIV.

The politically/economically/socially disadvantaged (women) are physically (and mentally) abused and suffer from morbidity… Society, whose structure keeps the vulnerable (women as well as children) as they are, is itself vulnerable in that it is prone to conflict, isn’t it? And there is no peace, if those people are still vulnerable, in post-conflict situation.


GPG (cont.)


How health cooperation works in post-conflict setting?

1. Evoking and extending altruism generates positive feelings among parties

2. Identifying and replacing rumors with facts rebuilds mutual confidence

3. Redefining the prevalent norms changes the terms of the debate and opens new space for discussion

4. Regenerating a sense of shared identity5. Personal solidarity actions by healthcare

professionals, especially respected doctors, can have a demonstrably powerful effect(Mukesh Kapila, Healing Broken Societies: Can Aid Buy Love

and Peace?)

Capacity development Synergy between the dual approaches: top-down

(system/rule making/strengthening) & bottom-up Stakeholder coordination/collaboration Rights approach (e.g. right to health; universal health

coverage) Cross-cutting approaches (e.g. education & health;

economic development that gives people hope for future, which does not indulge people in desperate health damaging abuse)

AND… Respect for people: think & try hard to help people get

motivated, esteemed and rewarded as we wanted if we were them!


How health cooperation works in post-conflict setting? (cont.)

Takes time to achieve goals (sometimes three steps forward & two steps back…), but we can do it!


Thank you!!

health cooperation in post-conflict setting

Healthcare

health facilities

health cooperation

health promotioniecbcc

quality health services

prison health services

idec asia seminar bphs

pharmaceutical services

laboratory services