- Austausch & Vernetzung
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Von Verena Wieland
How do we ensure good health services in fragile contexts? Can health programmes have a mitigating impact on fragility? These were the central questions of the conference “Health in Fragile Contexts” hosted by the Swiss Red Cross, the Swiss Agency for Development Co-operation and Medicus Mundi Switzerland. The presentation of case studies on South Sudan, Somalia and the Ebola crisis served as a starting point for discussion by practitioners, researchers and policy-makers. Covering issues such as the roles of, and complementarities between, those involved, and the nature of the commitment of international organisations in fragile contexts, the participants expressed divergent points of view, for example with regard to the contribution of health system strengthening to State-building. But they also came to unanimous conclusions on the importance of communityled approaches and staying engaged when working in fragile contexts.
In a growing number of countries, the implementation of health programmes is challenged by a fragile context. At the same time, State fragility is considered one of the main causes of malfunctioning health services. Emergencies aggravate such situations and bring to light systemic weaknesses. They raise questions relating not only to how to adapt to a shaky working environment or programme sustainability, but also to whether health programmes can help reduce fragility. In order to consider these multifaceted challenges more closely, the Swiss Red Cross (SRC), the Swiss Agency for Development Cooperation (SDC) and Medicus Mundi Switzerland (MMS) hosted a conference in August 2016 that focused on three key questions:
The presentation of three case studies, on health programmes in South Sudan and Somalia and on the Ebola response in West Africa, provided the basis for in-depth discussions in working groups and with the concluding panel of experts (Health in Fragile Contexts: Documentation).
The conference brought together practitioners, researchers and policy-makers representing NGOs, the academic world and government agencies, all of them working in the field of either health or peace/State-building. It provided a broad picture of knowledge, experiences and positions. Points of view diverged in particular with regard to controversial issues such as the potential contribution of health system strengthening to State-building, the role of government in service delivery and the risk that humanitarian aid will undermine State legitimacy. The discussions clearly showed that the three key questions above also had to be considered in the light of the players’ development policies; technical solutions on their own did not suffice.
A first question mark came up with regard to the term “fragility”: What is specific about a fragile context? How does it differ from a “conventional” development setting? The OECD report States of Fragility 2016 defines fragility “as the accumulation and combination of risks combined with insufficient capacity by the state, system, and/or communities to manage it, absorb it, or mitigate its consequences. This situation of exposure to risk can lead to negative outcomes, including violence, conflict, protracted political crises, and chronic underdevelopment”. The OECD’s updated fragility framework provides a comprehensive picture of fragility. Risks and coping mechanisms are measured in five dimensions that include societal, political, economic, environmental and security aspects. The model is part of the OECD’s larger effort to move away from the “fragile States list” – a binary view of the world – towards a universal concept of fragility. It builds on the recognition that fragility affects States and societies in different ways, and not only developing but potentially all countries (OECD report States of Fragility 2016).
The updated OECD definition of fragility broadens the focus from the previous State-centred view to a system-based conceptualisation of fragility. This includes formal and informal mechanisms societies can draw on to cope with negative events and shocks.
The three case studies presented in the morning showed that many key issues and dynamics driving fragility directly influence community-based health programmes.
At government level:
At community level
Among international stakeholders
“Social cohesion is not only an important component of the natural pathway to stability, but it also allows health systems to remain resilient, even though dysfunctional, through major crises.” (B. Profeta, SDC)
One essential finding of the conference is that fundamental change processes take place at local level. The case study on South Sudan illustrated that community-based health programmes can have a positive influence on key drivers of fragility – “do good” – particularly by improving equity in access to quality health services, promoting social cohesion, and fostering self-reliance and resilience; and by strengthening locally anchored organisations, ownership and processes at local level, linking national processes to the local level (and vice versa), and fostering the (health) authorities’ accountability and legitimacy at the local level. If we want to better understand what kind of services are needed and how access can be improved, it is important both to consider the community as part of the health system and to understand the impact of fragility or conflicts on the community.
However, we have to be aware that positive change processes are not sustainable if they remain isolated or stop at the community level. They need to be scaled up, and broader dialogue engaged between the stakeholders at different levels. In addition, improving health services or health system strengthening can contribute to State- or even peacebuilding, but only if change processes take place at all levels and respond to complex dynamics. At the political level in particular, political approaches are needed that go beyond technical solutions and the scope of health programmes.
It is a commonplace that “quality matters”, and this is even truer in fragile contexts. As one of the panellists remarked, “Trust arrives on foot and leaves on horseback”. Negative experiences have a far greater impact on how people perceive services or their government than positive ones: the positive perceptions built up over years can be destroyed in an instant. In the Ebola crisis, for example, people’s loss of trust in the health services pushed them to seek assistance outside the formal health system. Such experiences underline the importance of the “do no harm” principle.
From the user’s perspective, it is the quality of health services that matters, not the provider. As seen in the three case studies, in fragile settings quality health services are usually provided by international organisations or – as in the case of Somalia – by the private sector, and prove to be better than those provided by the State. This finding prompted the discussion of a controversial issue: the role of the State and whether service delivery by NGOs undermines State legitimacy. While most of the participants agreed that, by acting as substitutes for the State, NGOs often undermine the State’s capacity for service delivery, the consensus was less clear about the role of the government. Should the government restrict itself to issuing rules and regulations while ceding service delivery to the market or contracting it out? Or is this a domain where the State needs to assume responsibility? While some participants, mainly those with a health background, insisted on the importance of strengthening the State health system, others placed greater emphasis on effective provision, attaching less importance to the type of provider. As there is still little evidence as to whether and/or how strengthening service delivery contributes to State-building, further research is needed on this topic.
Even if there was no unanimous view on what we have to do when working in fragile contexts, everybody agreed on the importance of how we do it. The following key concepts were stressed again and again: strong focus on community-led processes and ownership; capacity building at all levels; alignment with other stakeholders; and links between local and national levels and processes
In fragile contexts, the variety of health-related stakeholders is usually larger than expected and it can be difficult to determine who plays what role in pursuit of which agenda. Positions, complementarities and synergies are influenced by political considerations and personal interests. The fluid definition of “State” and the proliferation of players at different levels also challenge coordination and alignment: where does ownership lie, who defines strategies, approaches, programmes? Careful mapping and assessment of all involved is essential in such settings.
But we also have to check and possibly re-think our assumptions; we especially have to avoid blueprint solutions. In the case of Somalia, the initial assumption that the Somali public health system was operating in a vacuum was unfounded: A chaotic but reasonably organized private health system worked following unusual patterns and relying on very unusual partners and stakeholders. The many resilience mechanisms in place were able to deliver health in a number of ways that we might not really have understood. In such cases, our interactions with hard-to-identify counterparts risk failing. Such systems offer alternative solutions for the population, but, in the interests of equity and sustainability, we also have to ask who is benefiting from the status quo and what the long-term perspectives of such systems are. Blueprint approaches can be detrimental to social cohesion, and the pursuit of personal or uncoordinated institutional agendas are likely to be at odds with the do-no-harm principle, leading to further disempowerment of existing systems.
In fragile settings and protracted crises, it is not enough “to rush in, act and rush out”. Here even more than elsewhere, uncoordinated or culturally insensitive operations do harm by undermining local systems and capacities and creating dependency. However, when emergency deliveries are urgently needed, standard development approaches do not provide an adequate response. Therefore, as one of the panellists proposed, we have to stop thinking along binary lines: fragile – not fragile; humanitarian aid – development cooperation; conflict – post-conflict; State – non-State provider. We have to rethink international cooperation in terms of new models that combine the best elements of both humanitarian aid and development cooperation.
Fragile settings call for a flexible, long-term commitment. “Staying engaged” means that we have to be prepared to react to changing situations and accept setbacks. The complex vulnerabilities of people and systems cannot be overcome in the short term, and positive change processes take place very slowly. We need to settle in for the long haul, even when we find it difficult to show the impact of our work. Unpredictable processes and insecurity raise the question of “risk tolerance” with regard to security, finances, partners, etc., and require well-established conflict-sensitive programme management as well as comprehensive and coordinated contingency plans encompassing all levels, from headquarters to the community.
Community approaches are more important than ever, but we need to keep in mind the other stakeholders, particularly the State and the health authorities, reinforcing leadership and linking the local to the national level. Locally anchored organisations are among the most relevant stakeholders. They are close to the population and provide services where external organisations don’t even have access. At the same time, they are particularly important stakeholders in change processes. While we have to be careful not to overburden our partners, fostering their leadership and building their capacities at all levels are crucial elements of working in fragile contexts.
Finally, there is an urgent need to raise awareness among donors, policy-makers and the general public about the challenges and risks, but also the great relevance of working in fragile settings. It is particularly important to explain the interconnections between fragility, setbacks in development and migration, and that such complex challenges have no quick-fix solutions.
