Rebuilding Health Post-Conflict: Case Studies from Afghanistan, Cambodia, and Mozambique

Authors: Spencer Rutherford, Shadi Saleh

Abstract:

War and conflict negatively impact all facets of a health system; services cease to function, resources become depleted, and any semblance of governance is lost. Following cessation of conflict, the rebuilding process includes a wide array of international and local actors. During this period, stakeholders must contend with various trade-offs, including balancing sustainable outcomes with immediate health needs, introducing health reform measures while also increasing local capacity, and reconciling external assistance with local legitimacy. Compounding these factors are additional challenges, including coordination amongst stakeholders, the re-occurrence of conflict, and ulterior motives from donors and governments, to name a few. Therefore, the present paper evaluated health system development in three post-conflict countries over a 12-year timeline. Specifically, health policies, health inputs (such infrastructure and human resources), and measures of governance, from the post-conflict periods of Afghanistan, Cambodia, and Mozambique, were assessed against health outputs and other measures. All post-conflict countries experienced similar challenges when rebuilding the health sector, including; division and competition between donors, NGOs, and local institutions; urban and rural health inequalities; and the re-occurrence of conflict. However, countries also employed unique and effective mechanisms for reconstructing their health systems, including; government engagement of the NGO and private sector; integration of competing factions into the same workforce; and collaborative planning for health policy. Based on these findings, best-practice development strategies were determined and compiled into a 12-year framework. Briefly, during the initial stage of the post-conflict period, primary stakeholders should work quickly to draft a national health strategy in collaboration with the government, and focus on managing and coordinating NGOs through performance-based partnership agreements. With this scaffolding in place, the development community can then prioritize the reconstruction of primary health care centers, increasing and retaining health workers, and horizontal integration of immunization services. The final stages should then concentrate on transferring ownership of the health system national institutions, implementing sustainable financing mechanisms, and phasing-out NGO services. Overall, these findings contribute post-conflict health system development by evaluating the process holistically and along a timeline and can be of further use by healthcare managers, policy-makers, and other health professionals.

Keywords: Afghanistan, Cambodia, health system development, health system reconstruction, Mozambique, post-conflict, state-building