Securing Health: Lessons from Nation-Building Missions Seth G. Jones and C. Ross Anthony

1. Securing Health: Lessons from Nation-Building MissionsSeth G. Jones and C. Ross Anthony

2. What Is Nation Building? Efforts after major combat to underpin transition to peace and democracy Includes deployment of military forces and efforts to rebuild key sectors Health Security Economic Governance Education Basic infrastructure

3. Our Goals Assess past efforts to rebuild public health and health care delivery systems during nation building Germany, Japan after WWII Somalia, Haiti, Kosovo in the 1990s Afghanistan, Iraq after September 2001 Identify most important lessons for future operations

4. Our Criteria for Success in Health Reconstruction Measurable improvement in health status of population Life expectancy Infant mortality Birth and death rates Malnutrition Infectious disease rates Establishment of sustainable health infrastructure Establishment of appropriate public health sector

5. Health Is an Essential Component of Nation Building

6. Key Findings from These Case Studies Health can have significant independent effect Health reform linked to other sectors--e.g., sanitation, water, education, judicial system Security essential for all reconstruction Health sector reform should be sustainable Poor coordination have serious consequences Successful health reconstruction requires Planning and coordination Infrastructure and resources

7. Health Can Have An Independent Effect on Nation Building and Development Improved health leads to increased productivity, reduced absenteeism and increasing incomes Health is a key to social stability. Helps create an environment supportive of economic development and the rule of law. Health help support security by reducing support for criminal and insurgent groups Restoration of health-related infrastructure is essential to successful nation building

8. But Other Sectors in Turn Affect Health Without basic infrastructure such as electricity: Hospitals and clinics may operate at partial capacity Sanitation and water systems may be adversely affected Without good governance: Corruption may decrease efficiency of health system The absence of a rule of law may limit accountability of health officials With low levels of education: Doctors and nurses may be of poor quality There may be little expertise to run sophisticated equipment

9. Security Is Essential for Reconstruction Health sector is sensitive to security in two ways Direct effects Inability of patients to visit doctors Casualties caused by insurgent attacks or criminal activity Doctors may be targeted by insurgents or criminals Indirect effects Equipment/supplies are looted, records destroyed Immunization is hampered NGOs may reduce or suspend programs

10. Poor Coordination Can Have Serious Consequences Scatters resources among many projects, may miss priorities International organization as lead actor is most effective way to coordinate planning and funding Involving actors with in-country experience before and during the conflict greatly facilitates coordination

11. Health Sector Reform Should Encourage Sustainability

12. Countries with Weak National Health Capacities May Never Reach Tipping Point

13. Dimensions of Successful Health Reconstruction  Coordination between international health agencies and NGOs, and between NGOs and the military International community�s accurate appreciation of the problem Policy framework Public health information system to assess needs Public health/health, water, sanitation, power, transportation Functioning central government and health care system Extent of reliance on NGOs Population�s support for reconstruction Government support for nation building Population�s health status Security

14. What We Did Defined success in health reconstruction Profiled reconstruction efforts Identified common themes in successful and unsuccessful efforts Provided lessons learned and their implications for future efforts

15. Phases of Success in Health Reconstruction

16. What We Did Defined success in health reconstruction Profiled reconstruction efforts Summarized lessons learned Identified common themes in successful and unsuccessful efforts Provided lessons learned and their implications for future efforts

17. Success of Health Reconstruction inCountries We Examined

18. A Success Story: Japan

19. Japan Context: Efficient government structure Health care system based on German model, but rigidly stratified Competent care available only in urban areas Colonel Sams provided strong leadership and linked health reconstruction to larger goal of building a democracy Security ensured by U.S. military presence and devastation of country

20. Japan 1945 Widespread malnutrition Extensive damage to housing, sewage systems, water plants, and equipment Vaccination programs were interrupted but firebombing eliminated conditions for infectious disease in urban areas Atomic bombings posed unique physical and psychological challenges

21. Acute Shortage of Medical Facilities and Personnel

22. Japan 1952 Modern health care methods/disease prevention: increased life expectancy Public education program:  public awareness of hygiene and sanitation School lunch program: increased protein and calcium intake Reorganization of hospital system:  number of facilities returned to pre-war level Reform of medical education: more, and better quality doctors and nurses

23. Japanese Health Status Improved Significantly

24. Japan: Lessons Learned Health care reform can provide necessary groundwork for democracy Meeting basic health needs can win hearts and minds Steady, sustained leadership is critical Security directly and indirectly affects health reconstruction

25. Story of Mixed Success: Iraq

26. Iraq (1991) Context (after First Gulf War) Health of population declining after two decades of improvement Health, sanitation, water infrastructures severely damaged Public health expenditures severely cut Increase in infectious diseases 1.8 million refugees, 35,000 associated deaths Chronic malnutrition, especially among women and children Deteriorating security environment hampers all reconstruction efforts

27. Water Service in Iraq Before Conflict

28. Water Service Has not Returned to Pre-conflict Level

29. Malnutrition in Children Remains Serious Problem

30. Iraq December 2005 Lack of security remains major barrier to health reconstruction Most hospitals and clinics operating, but in poor condition Shortages in essential medication and equipment Many nurses cannot go to work, or fear to do so Many physicians were abducted or murdered, or have immigrated

31. Poor Security Hinders Reconstruction

32. Iraq: Lessons Learned Poor security slow reconstruction Health reconstruction tightly linked to other sectors (water, sanitation, electricity, etc.) Need parallel progress in all sectors Using one factor (e.g., number of facilities reopened) to measure success is misleading Planning by NGOs, international groups, USAID prevented epidemics and starvation Poor security hampered or terminated efforts of NGOs and UN agencies

33. Health Reconstruction Failures:Somalia and Afghanistan

34. Context: Long history of turmoil with no established government Economic, health infrastructure devastated by civil war 2 million Somalis displaced 75% of population illiterate Health policy framework developed to address current emergency and guide long-term health sector reform Leadership vacuum created problems with implementing the plan Lack of security, political uncertainly hampered humanitarian efforts, including health

35. Life expectancy among lowest in the world Widespread famine and malnutrition High rates of infectious disease and infant mortality Acute shortage of health care personnel and facilities Sanitation, sewage, waste disposal systems destroyed Landmine injuries pose major problem Somalia 1991

36. Somalia Has Always Been Highly Dependent on External Aid

37. Infectious diseases, maternal and infant mortality rates remain among the world�s highest Malnutrition still chronic Landmine injuries still significant problem Poor coordination between military and NGOs, among NGOs, and within multinational force Expansion of UN mission from securing relief operations impeded progress Lack of security curtailed delivery of basic health services, terminated operations of many NGOs Somalia 1995

38. Life Expectancy in Somalia Remains Among World�s Lowest

39. Somalia: Lessons Learned Security is essential Long-term development requires supportive central government Health policy framework critical to guide efforts, but all participants must adopt it Comprehensive planning necessary to assess crisis, secure right resources, get participant buy in Smaller projects at local/regional level may be more successful in failed states

40. Afghanistan Context: One of world�s most underdeveloped countries Complex political emergency of long duration Significant regional and gender differences in access to care Country lacked health care leadership, competency, and capacity Continued violence hampered reconstruction in all sectors

41. Afghanistan December 2001 Widespread malnutrition and poverty Fragmentary health care system, dependent on external support Few health care professionals High rates of infant mortality and infectious disease Most of population lacks safe water, modern sanitation Many health-related programs suspended, cancelled, scaled back because of security issues

42. Afghanistan: Life Expectancy at Birth

43. Infant Mortality Rates Remain Among World�s Highest

44. Violence in Afghanistan Is Increasing

45. Afghanistan: Lessons Learned Different kinds of conflict require different kinds of health reconstruction In severely degraded environments, agencies should monitor/coordinate their own efforts rather than design grand plans Addressing Afghanistan�s health challenges will require Healthier population New generation of health care professionals Changes in cultural attitudes Afghanistan will need decades of stability for real change to occur

46. What Are the Lessons for Future Operations?

47. Health Sector Reform Should Encourage Sustainability

48. Countries with Weak National Health Capacities May Never Reach Tipping Point

49. Planning Increases Chances of Successful Health Reconstruction

50. Planning Increases Chances of Successful Health Reconstruction

51. Planning Increases Chances of Successful Health Reconstruction

52. Planning Increases Chances of Successful Health Reconstruction

53. Key Findings from These Case Studies Health can have significant independent effect �Win hearts and minds� (Iraq) Provide groundwork for democracy (Kosovo, Afghanistan) Successful health reconstruction requires Planning and coordination (Somalia) Infrastructure and resources (Somalia, Afghanistan) Strong leadership (Kosovo) Health reform linked to other sectors--e.g., sanitation, water, education, judicial system (Iraq, Kosovo, Afghanistan) Health sector reform should be sustainable (Somalia, Afghanistan) Security essential for all reconstruction(Iraq, Afghanistan)

54. Health Is an Essential Component of Nation Building and Foreign Policy