Health Service Delivery in Fragile States: Lessons from the Field

1. Health Service Delivery in Fragile States:Lessons from the Field Emmanuel d’Harcourt International Rescue Committee Woodrow Wilson Center for Scholars September 12, 2006

2. Outline • Population and fragility • Fragility and health • Health and fragility • Missions, health, and fragility

4. Outline • Population and fragility • Fragility and health • Health and fragility • Missions, health, and fragility

5. … The [demographic] "wolf" is present and very busy indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned… Maurice King, MD. From AJPH, July 1996

7. Factors associated with the genocide • Related to resource scarcity • Not related to resource scarcity

8. Related to Resource Scarcity • Popular discontent due to food scarcity • Gain from previous Tutsi “pogroms” • Fear of losing land to invading army • Joblessness

9. Rwanda population, 1900-2000 Source: US Census Bureau

10. Average land holding 1960s-1990s Source: Uvin, 1996

11. Food Production per Capita 1961-1993 Source: FAO, 1994

12. Over-population Resource scarcity Popular discontent Desire Ability Permission

13. Population density Source: PRB

14. Population density Source: PRB

15. Not Related to Resource Scarcity • Falling commodity prices • Popular discontent due to mismanagement • Elite worried about losing power • Long tradition of social division • Genocidal ideology • Effective propaganda and media • Highly disciplined state machinery • Lack of filial bonds: state vs. tribe • International inaction

16. Coffee Earnings, 1985-1993 Source: FAO, 1994

17. Unfavorable terms of trade / structural adjustment Over-population Arusha Steady arms supply Rebel attack International Inaction Resource scarcity Corruption Highly organized state Social divisions Popular discontent Elite insecurity Lack of filial bonds Effective media Desire Ability Permission

18. If population is so important Source: PRB

19. Outline • Population and fragility • Fragility and health • Health and fragility • Missions, health, and fragility

20. How fragility affects health • Security • Policies • Motivation • Training • Management • Sustainability • Communities • Responsibility

21. Children treatedRwanda and Sierra Leone

22. Amodiaquine + S/P

24. Outline • Population and fragility • Fragility and health • Health and fragility • Missions, health, and fragility

25. How health affects fragility • No services is a big part of fragility

26. How health affects fragility • No services is a big part of fragility • Good services legitimize governments

27. Cost Per Treatment

28. How health affects fragility • No services is a big part of fragility • Good services legitimize governments • Health is entry point for building systems

30. Safe Motherhood, Kibungo Province

31. Children treatedSouth Sudan and Sierra Leone

32. Children treatedSouth Sudan and Sierra Leone

33. South Sudan example • Good human resource management • Good information system • Simple tools • Scaleable • Adapted to local environment

35. How health affects fragility • No services is a big part of fragility • Good services legitimize governments • Health is entry point for building systems • Systems may induce more responsibility

36. How health affects fragility • No services is a big part of fragility • Good services legitimize governments • Health is entry point for building systems • Systems may induce more responsibility • Community work strengthens communities

40. Distributor Information

42. Key quality indicatorsCommunity distributors, South Sudan n = 96 supervision reports

43. Can Health Programs Help? a a • Poor information • Weak human resources • Weak absorptive capacity • Uncertain future • Unpredictable external support • Recidivism • Need to address immediate needs • Need to show peace dividend a x x x a a

44. Can Health Programs Help? • Enhance stability • Improve security • Encourage reform • Increase capacity in key areas • Address sources of fragility • Seek short-term impact & long-term reform • Establish measurement systems a a a a

45. Institutional Indicators from Health • Utilization rate • Reported supervisions / health area / month • % community workers reporting • % stock out for key drugs

46. Outline • Population and fragility • Fragility and health • Health and fragility • Missions, health, and fragility

47. Health, Fragility, and Missions • Missions are concerned about fragility • Missions care about health status • What do missions do that helps? • What do missions do that doesn’t help?

48. Health, Fragility, and NGOs • Field-based • Innovative • Collaborative • Coordinated • Think of scale-up • Expensive • Short term • Small scale • Not audited

49. Things that don’t help • Frequent strategic redesign • Process of strategic redesign • Little field presence • Concentrating resources • Lack of DC – Mission coordination • Some regulations – drugs, salaries • Short-term funding

50. Things that do help • Ambitious programs designed for scale • Coordination of grantees • Coordinating with other donors • Grantee – Government mediation • Inter-sector synergy • Willingness to support systems • Long-term funding