Presentation for "The annual medicine overseas conference: Research and response in the midst of chaos" at the UK Royal Society of Medicine. http://www.rsm.ac.uk/academ/ccd03.php

1. Health Care for Post Conflict
Stabilization
V. Harutyunyan M.D.

2. Conflicts and their effects
“An armed conflict is a contested incompatibility that concerns government
and/or territory where the use of armed force between two parties, of which at
least one is the government of a state, results in at least 25 battle-related
deaths in one calendar year”
Uppsala University Department of Peace and Conflict Research
• “Major Wars“ are military conflicts inflicting 1,000 battlefield deaths per year
• Currently there are 9 major wars and around 34 smaller scale conflicts waged
around the World.
• Unclear distinction between conflict and post conflict status
• Conflicts disrupt the ability of states to to perform basic functions [such as]
maintaining security, enabling economic development, and ensuring the
essential needs of the population are met. (OECD/DAC)
• An estimated one-sixth of the world’s population live in fragile or conflict-
affected states.

3. Conflicts and their effects
• Both health facilities and health personnel often become direct targets (Iraq,
Syria, Nepal, Kosovo)
• Health facilities and symbols used by health care providers used for military
purpose (Syria, Palestine)
• Rapid reduction of access to health care in conflict affected areas
• Increased morbidity and mortality
• High incidence of non violent deaths
• Disproportionately affected civilian population
• Unequal distribution
• Masked by the national data
• Distorted due to inappropriate use of data collection techniques
• Data manipulation

5. National hospital at Azaz in northern Syria

6. Health Care and its role in humanitarian
phase
• Provision of access to life saving health services
• Preventing excess morbidity and mortality
• Strengthening emergency preparedness capacity
• Providing basis for health system recovery
• Promoting peace and protecting humanitarian space:
• Health as a Bridge for Peace (HBP)

7. Health, State Building, Stability, and
Governance
• Stabilization and peacebuilding in fragile and postconflict states have become
major features of international policy and foreign assistance
• High rate of conflict recidivism (31 percent of conflicts restart within ten
years of concluding)
• Destructive impact on population health and well-being
• Creates conditions for expansion of instability and violence
• Role of Health System in post conflict stabilization and peace building
• Link between health of the population, greater productivity, economic
growth, and state stability.
• Mounting evidence that improved health services can increase trust in
government and thus modestly contribute to reinforcement of the
authority and legitimacy of the state.

8. Health, State Building, Stability, and
Governance (theoretical framework)
Inputs: Outputs:
• Improved access to
quality, reliable
Functioning, equitable
health services for
health system:
priority health
Outcomes:
problems
• National government
• Enhanced social
stewardship Reduced mortality and
solidarity and
• Rehabilitated primary morbidity
cohesion
care facilities More capable, resilient
• Greater confidence in
• Re-established health state
government and
workforce Reduced risk of conflict
support for social
• Fair financing recurrence
contract
• Guaranteed package
• Stronger government
of health services
capacity to
• Equitable allocation
administer public
of services
programs
M.E. Kruk et al. / Social Science & Medicine 70 (2010) 89–97

9. Health, State Building, Stability, and
Governance
“We understand that addressing global health challenges is not just a
humanitarian imperative – it will also bolster global security, foster political
stability and promote economic growth and development”
Hillary Rodham Clinton, former US Secretary of State

10. Health System Reconstruction: principles
• The enjoyment of the highest attainable standard of health is one of the
fundamental rights of every human being without distinction of race, religion,
political belief, economic or social condition.
• Governments have a responsibility for the health of their peoples which can be
fulfilled only by the provision of adequate health and social measures.
WHO constitution
• Access to health is a development issue:
“We also recognize the importance of universal health coverage to enhancing
health, social cohesion and sustainable human and economic development. We
pledge to strengthen health systems towards the provision of equitable
universal coverage”
Rio+20 United Nations Conference on Sustainable Development 2012
• Health systems is a core social institution (Report of the special rapporteur on the
right of everyone to the highest attainable standard of health to the commission on human
rights. 2006)

11. Health System Reconstruction: Lessons Learned
and Challenges
• Lack of evidence supporting links between providing health care and conflict
stabilization.
• Success of health reconstruction and its effect on post conflict stabilization will depend
on the importance that parties to the conflict and people attach to health care
(Lebanon, Mozambique, DRC, Somalia)
• Health services are a necessary but hardly sufficient feature of the government
• Equity in services may be a more powerful predictor of confidence in government than
the general sufficiency of services.
• The traditional dichotomy of development and humanitarian aid is counterproductive
• Health interventions in fragile and conflict-affected states are limited to
humanitarian relief, which does not advance either health systems development or
state legitimacy.
• Conflict and fragility tend to be protracted, but health systems development can
often proceed before peace and stability are established
• Meeting short term health needs is important for addressing populations health
problems and maintaining stability

12. Health System Reconstruction: Lessons
Learned and Challenges
• Government’s leadership is critical for rebuilding health systems (Liberia vs
Somalia)
• Authorities in post conflict states often need substantial financial and
operational support to provide equitable health services (Afghanistan,
Southern Sudan, Liberia)
• Donor and aid agency policies and interests have considerable effect on both
the success of heath system reconstruction and its contribution to post
conflict stabilization
• Military involvement in civilian health systems development in conflict-
affected and postconflict states. (Iraq, Afghanistan)
• Health reconstruction post crisis is a long term process and often requires
sustained investment for decades

13. Remaining questions
• How can health interventions contribute to stability?
• How to assist fragile states in building effective health systems?
• How to structure aid programs in poorly governed states so as to develop
health systems without supporting corrupt or repressive governments?
• How to restructure humanitarian aid programs so that long-term emergency
funding supports health systems development?
• How to meet short-term health needs while developing a coherent system?

14. Conclusions