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Health Service Delivery in Fragile States: Lessons from the Field. Emmanuel d’Harcourt International Rescue Committee Woodrow Wilson Center for Scholars September 12, 2006. Outline. Population and fragility Fragility and health Health and fragility Missions, health, and fragility.

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health service delivery in fragile states lessons from the field

Health Service Delivery in Fragile States:Lessons from the Field

Emmanuel d’Harcourt

International Rescue Committee

Woodrow Wilson Center for Scholars

September 12, 2006

outline
Outline
  • Population and fragility
  • Fragility and health
  • Health and fragility
  • Missions, health, and fragility
outline1
Outline
  • Population and fragility
  • Fragility and health
  • Health and fragility
  • Missions, health, and fragility
slide5

… 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

factors associated with the genocide
Factors associated with the genocide
  • Related to resource scarcity
  • Not related to resource scarcity
related to resource scarcity
Related to Resource Scarcity
  • Popular discontent due to food scarcity
  • Gain from previous Tutsi “pogroms”
  • Fear of losing land to invading army
  • Joblessness
rwanda population 1900 2000
Rwanda population, 1900-2000

Source: US Census Bureau

slide12

Over-population

Resource scarcity

Popular discontent

Desire

Ability

Permission

not related to resource scarcity
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
slide17

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

outline2
Outline
  • Population and fragility
  • Fragility and health
  • Health and fragility
  • Missions, health, and fragility
how fragility affects health
How fragility affects health
  • Security
  • Policies
  • Motivation
  • Training
  • Management
  • Sustainability
  • Communities
  • Responsibility
outline3
Outline
  • Population and fragility
  • Fragility and health
  • Health and fragility
  • Missions, health, and fragility
how health affects fragility
How health affects fragility
  • No services is a big part of fragility
how health affects fragility1
How health affects fragility
  • No services is a big part of fragility
  • Good services legitimize governments
how health affects fragility2
How health affects fragility
  • No services is a big part of fragility
  • Good services legitimize governments
  • Health is entry point for building systems
south sudan example
South Sudan example
  • Good human resource management
  • Good information system
  • Simple tools
  • Scaleable
  • Adapted to local environment
how health affects fragility3
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
how health affects fragility4
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
can health programs help
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

can health programs help1
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

institutional indicators from health
Institutional Indicators from Health
  • Utilization rate
  • Reported supervisions / health area / month
  • % community workers reporting
  • % stock out for key drugs
outline4
Outline
  • Population and fragility
  • Fragility and health
  • Health and fragility
  • Missions, health, and fragility
health fragility and missions
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?
health fragility and ngos
Health, Fragility, and NGOs
  • Field-based
  • Innovative
  • Collaborative
  • Coordinated
  • Think of scale-up
  • Expensive
  • Short term
  • Small scale
  • Not audited
things that don t help
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
things that do help
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
who has the answer
Who has the answer?

USAID DC

USAID Mission

iNGOs HQ staff

iNGOs local staff

Beneficiaries

National officials

Local officials

Local NGOs

top 5 recommendations
Top 5 recommendations
  • Think big, think national
  • Focus on coordination and systems
  • Rethink drug procurement limits
  • Rethink salary support limits
  • Rethink strategic planning process
    • Less large shifts, more small adjustments
    • More participation
ofda recommendations
OFDA Recommendations
  • Switch to long-term funding ASAP
  • Increase monitoring of costs, results
  • Continue focus on inputs
bottom line
Bottom Line
  • Fragility affects health – a lot
  • Health programs can reduce fragility – some
    • Systems
    • Measurement
  • Health programs can reduce suffering – a lot
  • Missions help, could help even more
    • Stable strategy, stable funding
    • Coordinate
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