Gesundheitszusammenarbeit in fragilen Kontexten

Excerpt from a master thesis

Impact of health projects on peacebuilding

Von Roswitha Koch

Peace and health: Two conditions of fundamental importance to the wellbeing of individuals, communities and societies. Peace and health share important elements, including social, mental and spiritual dimensions.

Impact of health projects on peacebuilding

Two emergency employment workers laying bricks at a construction site in Nkurye in the Province of Giharo-Rutana. (Photo: Aude Rossignol/UNDP Burundi, CC BY-NC-ND 2.0)


The following text is an excerpt from the Master Thesis "Impact of health projects on peacebuildung" by Roswitha Koch, who kindly give us the permittion to publish her findings.


According to the World Bank (2011), fifteen of the twenty poorest countries in the world had conflicts in the last two decades of the twentieth century. Armed conflicts cause direct casualties and have many kinds of indirect negative effects on the health of individuals, communities and populations. The need for health care increases in the context of conflict and at the same time the effectiveness of health systems and health projects tends to be strongly affected (World Bank, 2011, Percival and Sondorp, 2010 p6).

In the early nineties of the last century a number of international initiatives and interventions with the objective to stop armed conflicts and to promote peace can be observed. Such peace enforcement or peace keeping operations, for example in Somalia, did not always have the expected effect (Wenger et. al, 2006 p23). The subsequent search for more effective ways to contribute to the creation of peace was expressed with the introduction of the concept of “Post Conflict Peacebuilding” by the Secretary General of the United Nations (UN) on June 7th 1992. He defined peacebuilding as “action to identify and support structures which will tend to strengthen and solidify peace in order to avoid relapse into conflict” (UN, 1992; Barnett et al., 2007 p36). This new approach gained increasing attention and was further developed. Some of the recent approaches to peacebuilding and statebuilding are becoming more associated with development aid, including aspects of health.

Roles of health projects and health experts in peacebuilding

Recent expert discussions and evidence base

In recent years experts in international health have taken up the subject of “health system strengthening” in the context of Fragile States (Sondrop et al, 2012 p3). In the academic world, the relation between peacebuilding / statebuilding and health system strengthening is a newly emerging theme (Fustukian, 2012 p9). Additionally, there is a need for developing a deeper understanding of health as an instrument for change (Van Eeghen, 2012 p16). In line with the WDR 2011, evaluations indicate that health system rehabilitation in post conflict situations or in Fragile States are often of limited effectiveness if their focus is purely technical, with the exclusive aim to deliver services. Some experts see “intuitive” evidence that health system strengthening can contribute to state building and that delivering basic services can contribute to enhancing the legitimacy of the state (Sondorp et al, 2012 p3).

Rachel Slater, a researcher from the Secure Livelihoods Research Consortium (Slater as quoted by Sondorp et al., 2012 p.6) shares this view and also sees a strong intuitive logic. She also points out that an increasing number of international agencies started to base their programming on this assumption. However, a review of the evidence base through consultants and a literature review process show a very thin evidence base. Slater (as quoted by Sondorp et al., 2012 p.6) sees a number of causes for this lack of evidence: the agenda is relatively new; it is complex to show the casual chain between perceptions, legitimacy and state building; the settings are very heterogenic; and it is difficult to do research and impact evaluation in fragile states. In Slater`s view, projects in the health field should not lose focus on the main priority of a health system: curing sick people and preventing disease. In addition, she points out the importance to look at the wider project context and to respect the principle “to do no harm”. There are worries that when health is placed in the political, peacebuilding sphere, health projects could be instrumentalised.

Or as Egbert Sondorp (2012) puts it, “the politisation of health, that we have seen in more recent conflicts, whereby the relation between health and peace is being increasingly used by the military in their efforts to win hearts and minds” (Sondorp, (2012 p6). He also warns of implementing health system building blocks (WHO WPR, no date) in a fragile state without looking at the context and social determinants of health. He sees fragility and poor governance as very relevant determinants which should be included in efforts to strengthen health systems.

A model to present the relation between peace and health

The information presented above suggests that peace and health are both central to the quality of life of persons and communities. Looking at the determinants of health (WHO) and at the fragile states principles (OECD), they appear interrelated. Abuelaish et al. use an approach that implies “that peace leads to health and health leads to peace” (Abuelaish et al., 2013 p4). They propose a multi-sectoral and multi-level “Peace and Health” approach and developed a model presenting the overlap between determinants of health and determinants of peace at the societal, community and individual level.

The interrelated factors promoting health and peace touch many areas of human organisation, including the traditional silos of governance, management and research. Social, economic and political conditions all influence health and peace of individuals and communities. Poverty, including the absence of adequate housing, employment and income, leads to social exclusion and can contribute to stress, mental and physical illness and violence. Thus education, jobs, adequate housing, trust and respect at the individual, community and societal level are positive for peace and health of persons, communities and societies (Abuelaish, 2013 p4).

As a consequence, one can assume that collaboration and exchange between experts in the fields of peacebuilding and public health, as well as the good utilisation of their complementary aspects, has beneficial effect on the effectiveness of peacebuilding as well as on the effectiveness of health projects in Fragile States (Abuelaish et al., 2013 p6). At the community level decentralised and community based health projects have a potential for community involvement and empowerment. At the national level a well functioning health system can contribute to the increase of trust in the state and its institutions. Additionally peacebuilding can be supported by health programs through the reduction of individual suffering after trauma and the reduction of individual violence, in particular through mental health programs. The professionals working in the health system are essential for providing health care. They care for people, they earn their livelihood in the health system and they are sometimes physically at risk during conflict or they can experience stress when they are not in the position to provide health care according to their professional and ethical standards.

Health professionals and peacebuilding

Physicians, nurses, midwifes and other health professionals have the potential to play a very particular role as peacebuilding agents at the relational and personal dimension. Health professionals are usually valued and trusted by society; they work with an evidence base, value science and critical thinking and can therefore critically reflect on war making in a conflict promoting environment where myth, propaganda and lies flourish. The international health community is strongly integrated with shared values, it is a powerful learning community and information is shared quickly at a global level (Arya et Santa Barbara, 2008 p107). Health professionals in direct contact with patients and the population are often overloaded with work, especially in fragile situations. Additionally they have no special expertise in peacebuilding, such as political or mediation skills, thus their potential for peacebuilding lies mainly in the way they carry out their work and relate with people at the individual and at the community level.

The nursing profession for example is present in all settings, and has a particular potential in remote areas of poor and fragile countries, where the provision of health care is mainly secured by nurses (WHO, 2011). Nurses are part of the ones who cure and care for people, they can involve the community in health activities, and with their personal attitude and behaviour they are examples of respectful and ethical conduct. The “Global Code of Ethics for Nurses” (ICN, 2012) represents a global set of values and rules of ethics, to which over 130 national nurses associations, and their millions of members, adhere.

The following examples of paragraphs of the ICN Code of Ethics can be useful the light of peacbuilding:

“In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected.”

“The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations. The nurse advocates for equity and social justice in resource allocation, access to health care and other social and economic services. The nurse demonstrates professional values such as respectfulness, responsiveness, compassion, trustworthiness and integrity.” (ICN, 2012)

Usually ethics is part of the education of health professionals, and professional associations have their ethics committees. Nurith Wagner (no date) for example, a nurse and the chair of the Israeli Nurses Association Ethics Bureau, uses the instruments of nursing ethics to describe her dilemmas as mother of an Israeli soldier and a volunteer of “Machsomwatch”. “Machsomwatch” is a movement of Israeli women who are observing the human rights situation at some 40 checkpoints at a daily bases. They are following media reports of violations of human rights of Palestinians transiting border police checkpoints in the West Bank and Jerusalem (Wagner, no date).

Negative effects of health projects on peacebuilding

There is also a possibility for health projects to negatively affect peace-building, when they are not adapted to their fragile environment, or when health projects and their material and financial resources are used as an instrument to strengthen one particular group of a conflict. At a structural level, the lack of equitable access to health is one more symptom of injustice and one more element, likely to increase tension. Negative examples of health professionals who have acted in an unethical manner exist. They may have abused their position, peoples trust and the special knowledge about their patients and the communities they are supposed to care for - to neglect, denounce or even kill persons, as it has been reported during the genocide in Rwanda (Mayer, 2013 p52).

Rubenstein (2010) describes a more political and subtle example, which concerns the long history of cross-border cooperation between Palestinian and Israeli health professionals in health; including collaboration in disease surveillance, training and advocacy for health. Rubenstein (2010) describes this cooperation as becoming increasingly difficult because of ongoing travel restrictions on Palestinians in the West Bank. The cooperation is also more and more perceived by Palestinians as having a political aim and even as a tactic to endorse the Israeli occupation of their territory. This leads the Palestinian health professionals to renounce the collaboration with their Israeli colleagues despite its effectiveness and benefits for both sides, in order to invest their energy in creating an effective and independent health system in the West Bank.


Roswitha Koch

Roswitha Koch
Public health expert and a nurse with national and international experience in public health and clinical nursing. During her career she worked in several conflict zones, including Afghanistan, Ruanda and Somalia. Today she is the head of the department of nursing development and international affairs at the Swiss Nurses Association.  She holds a master’s degree in public health from the Liverpool School of Tropical Medicine LSTM. In 2013 she completed a Masters in European Integration at the Europainstitut Basel (Major: Peace Building).


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Related Resources

Impact of Health Projects on Peacebuilding

MAS Thesis

Roswitha Koch

Download (d | 372.7 KB| PDF document)

Related Resources

Impact of Health Projects on Peacebuilding

MAS Thesis

Roswitha Koch

Download (d | 372.7 KB| PDF document)