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Joshua Bloom Research Fellow London School of Hygiene and Tropical Medicine

Lessons Learned from the Inclusion of Peace-Building Objectives in the Reform and Development of Health Systems Emerging from Civil Conflicts: South Africa, Croatia and Kosovo. Joshua Bloom Research Fellow London School of Hygiene and Tropical Medicine jbloom@post.harvard.edu

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Joshua Bloom Research Fellow London School of Hygiene and Tropical Medicine

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  1. Lessons Learned from the Inclusion of Peace-Building Objectives in the Reform and Development of Health Systems Emerging from Civil Conflicts:South Africa, Croatia and Kosovo Joshua Bloom Research Fellow London School of Hygiene and Tropical Medicine jbloom@post.harvard.edu Funded by the UK’s Economic and Social Research Council May 2005 McMaster-Lancet Challenge Conference Peace through Health: Learning from Action Hamilton, ON, Canada

  2. Peace through Health • Definition: Health sector initiatives that are specifically designed to contribute to peace in conflict-affected and volatile political environments. • Applied to health sector reform and development in multiple post-conflict settings by WHO’s Health as a Bridge for Peace Program and other actors. 

  3. Hypothesis • TEST: The inclusion of peace-building objectives in the reform and development processes of health systems emerging from civil conflicts. • EXPECTED RESULTS: Health sectors can contribute to stability and security. • HOW: By addressing underlying issues of conflict within their spheres of influence.

  4. Objectives Equity. Non-segregation. Professional ethics. Human rights. Other objectives should be covered in future research. Apply to Policies and laws. Service provision. Human resource management. HP Education. Regulatory bodies, associations, journals, research & public info. Key Peace-Building Objectives for Post-Conflict Health Sectors

  5. Equity Key Peace-Building Objectives for Post-Conflict Health Sectors

  6. Non-Segregation Key Peace-Building Objectives for Post-Conflict Health Sectors

  7. Professional Ethics Key Peace-Building Objectives for Post-Conflict Health Sectors

  8. Human Rights Key Peace-Building Objectives for Post-Conflict Health Sectors

  9. Objectives Equity. Non-segregation. Professional ethics. Human rights. Other objectives should be covered in future research. Apply to Policies and laws. Service provision. Human resource management. HP Education. Regulatory bodies, associations, journals, research & public info. Key Peace-Building Objectives for Post-Conflict Health Sectors

  10. Case Studies • South Africa • Croatia • Kosovo

  11. Apartheid Health Care in South Africa • Strict segregation in the health professions and in health care services. • Gaping disparities in access to healthcare, quality of care and health outcomes. • Serious breaches of medical ethics & human rights. • Complicity by management of the health system.

  12. Post-Apartheid Health Care in South Africa • Transformation of the health system. • Merged 14 Health Departments • Constitutional right of access to health care. • Redistribution of resources.

  13. Post-Apartheid Health Care in South Africa • Special TRC hearings for the health sector. • Reflection and reform processes as well as affirmative action policies extended to health professional councils, associations, journals, schools and employment. • Dire HIV/AIDS crisis and mismanagement by Health Minister.

  14. Conflict in Croatia • Relatively harmonious ethnic relations pre-independence. • Homeland War in 1991. • 4 different experiences based on geography. Not Seriously War Affected War Affected Remained in Croatia in 1991 Fell to Serb Rebels in 1991 Re-conquered by Military in 1995 Reintegrated peacefully in 1995

  15. Post War Health Care in Eastern Slavonia, Croatia • Health sector reintegrated as part of UN’s multi-sectored approach to peace-building. • Some setbacks after UN left. Ethnic disputes over employment downsizings. • Nonetheless, eastern Slavonia achieved relatively successful ethnic balance within its health sector employment, especially in comparison to Croatia’s other former conflict regions.

  16. Ethnic Breakdown of Health Professionals Employed in Vukovar-Sirmium County, 2001 Ethnic Breakdown of All Health Professionals Employed in Lika-Senj County, 2001 Source: 2001 Census Data

  17. Ethnic Breakdown of Health Professionals Employed in Vukovar-Sirmium County, 2001 Ethnic Breakdown of All Health Professionals Employed in Šibenik-Knin County, 2001 Source: 2001 Census Data

  18. Pre-War Health Care in Kosovo • Kosovo’s autonomy status revoked in 1989. Majority of ethnic Albanian health workers lost their jobs. • Kosovar Albanians responded by opening parallel health care institutions. • Violence escalated; War; NATO; and UNMIK.

  19. Post War Health Care in Kosovo • Stressed peace-building objectiveslikenon-discrimination, equity, ethicsandpatients’rights. • Restricted freedom of movement, resurgence of violence and insufficient efforts by Kosovar authorities.

  20. Post War Health Care in Kosovo • Parallel healthcare system for most ethnic Serbs. • Many Serb HPs won’t recognize the UN administration. • Many Serb HPs continue to receive salaries from Belgrade. • International actors partially acquiesced to the parallel system.

  21. Conclusions • Peace-building should be conducted with multi-sector approaches that are inclusive of all sectors of society and governance, including health systems. • Peace-building within health systems should be considered a necessary component of post-conflict health sector reform and development.

  22. Conclusions • The adoption of Peace through Health objectives can contribute to stability and security within conflict-affected health systems, but the success of these efforts is dependent on a series of variables.

  23. The greater socio-political environment, Whether there was a lopsided end to the conflict, The scope and length of the conflict, Whether there was pre-existing oppression, Whether there were language divides, Whether there was a collective sense of belonging and identity. Variables that Impact the Success of Peace through Health Efforts

  24. Whether peace-building was imposed by outsiders or domestically driven, Whether multi-track approaches to peace-building are used, Whether reflections on errors from the past guide future reforms, Whether there is strong positive leadership, Whether there’s a surplus supply or demand of health workers, Whether long-term strategies are employed. Variables that Impact the Success of Peace through Health Efforts

  25. Other Lessons • Health is not apolitical. • A rights-based approach to health can lead to improved equity, transparency and justice, but does not necessarily lead to improved health. • Level of development does not effect ability to implement Peace through Health approaches.

  26. Objectives Equity. Non-segregation. Professional ethics. Human rights. Other objectives should be covered in future research. Apply to Policies and laws. Service provision. Human resource management. HP Education. Regulatory bodies, associations, journals, research & public info. Key Peace-Building Objectives for Post-Conflict Health Sectors

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