This document discusses challenges in rebuilding health systems after conflict. It notes that a lack of coordination between actors can fragment the system and that priorities often differ, such as donors focusing more on HIV and maternal health over workforce strengthening in Northern Uganda. Vulnerable groups' needs are often not met in a timely manner. Resources do not always flow equitably based on population need. Capacity building of local actors and inclusion in policymaking is important to ensure sustainable health systems. Tools like social network analysis and modeling can aid understanding of post-conflict environments.

1. Suzanne Fustukian
Health after conflict – Rebuilding the system
13th December 2016
Wellcome Trust, London

2. Institutions: cross-cutting theme

3. Actors, networks and power
• Changing roles and identities of institutional
actors in the transition from emergency to post-
conflict
• Lack of coordination between actors may lead
to a more chaotic system rebuilding: their
different priorities and approaches to rebuilding
health systems post-conflict increases the
potential for fragmentation in the system.
• New networks and relationships will be needed
between these diverse actors, but with
awareness of potential power imbalances

4. Northern Uganda – different priorities
between sub-national DHMT and donors
• Study on inter-organisational networks
• focused on links between organisations working on HIV,
maternal health and health workforce strengthening in
three districts (Gulu, Kitgum and Amaru).
• Much greater support for HIV and maternal health
from donors and significantly less support for HRH
resources
• Networks and distribution of external resources
extremely limited in newly created district (Amaru).
• Disadvantage of newer district will be
sustained over the longer term.

5. Responsive policy
• Life histories showed that the vulnerabilities of many
groups, such as people with disabilities, orphans and
older people are often more pronounced post -
conflict.
• Services to meet needs for these groups are essential but
combined with effective social protection policies.
• Too often, delays in policy impact on the re-engagement
between health systems and vulnerable populations
• Important role of donors in supporting post conflict
countries to re-engage and build responsive policy:
• ‘Free Health Care Initiative’ (Sierra Leone)
• Critical role of strengthening local and national
governance capacity

6. Unresponsive policy – N Uganda
• Gender roles and relations are affected: e.g. for
women, widowhood compounded their war
suffering, loss of property, displacement and
family disruption.
• Opportunities to address gender equity in health
systems post conflict/crisis are often missed.
• Limited support given to survivors of gender
based violence (with male survivors particularly
neglected)
• much more attention paid to the hardware of
health infrastructure (e.g. building clinics) over
the ‘software’ of health approaches, including
strategies to ensure vulnerable groups can access
care.

7. Resource flows
• Flows of resources to the health system
(re)commence once the signals of peace arrive.
• Governance is key to ensuring that resource flows
(HRH, funding, drugs, other equipment/infrastructure)
are coordinated/scrutinised by domestic actors, who
are accountable to the population for allocative
decisions.
• Rebuilding the health system equitably requires
allocating resources on the basis of population and
geographical need, rather than ease and availability of
capable organizations in the area, a situation often
experienced in many post-conflict countries.
• Frequently, the districts and services already well
established receive intensified resource flows post conflict,
as was seen with the establishment of SOAs in Cambodia

8. Northern Uganda – social network analysis
• The study showed that resource flows can be
unpredictable and beyond control of local health
managers leading to future vulnerability. The
predicted loss of 16 organisations – many of them
fund-holders – in Gulu District by 2015 would
affect almost 70% of the ties (relationships or
interactions) in the networks, and could leave
major resource gaps that cripple the performance
of the health system.

9. Northern Uganda – social network analysis
A more resilient system would be based on more
robust networks.

10. Building individual and institutional capacity
• In spite of the devastation health systems suffer as a
result of conflict and crisis, they can demonstrate
remarkable resilience.
• Many health workers continued working during the
conflict in northern Uganda, while local managers did
their best to support health workers in northern Uganda
and Zimbabwe.
• Where individual or institutional capacity exists,
external actors must avoid undermining it
inadvertently.
• Studies in Cambodia (contracting ) and Sierra Leone (HRH)
suggest that external support did not build capacity in the
Ministries effectively or sustainably

11. Group model building
• Group Model Building with health system stakeholders in
conflict-affected Northern Nigeria identified positive practices
within the health system

12. Conclusions – 1
• All actors working in post-conflict or post-crisis
settings should aim to support the development of
sustainable health systems, and be aware of and
address possible unintended consequences of
their actions that might undermine this goal.
• Local actors should be included in policy
development and implementation, and as soon as
possible, and should be supported to take a
leadership and coordination roles at national and
sub-national levels, to ensure local ownership and
individual and institutional capacity building.

13. Conclusions – 2
• Conflict exacerbates multiple vulnerabilities and
there is need to ensure the policies developed in
the post-conflict/crisis phase build health systems
to support gender equity and access to those in
greatest need.
• Tools such as social network analysis and group
model building may be useful for understanding
the dynamic situation in the post-conflict/crisis
period.