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

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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
Months
Several years
Success
Health
Tipping point
Japan
Reconstruction
Immediate post-conflict
Conflict
Pre-conflict
Consolidation
12
Countries with Weak National Health Capacities
May Never Reach Tipping Point
Months
Several years
Health
SomaliaAfghanistan
Reconstruction
Immediate post-conflict
Conflict
Pre-conflict
Consolidation
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Dimensions of Successful Health Reconstruction
Infrastructure
Coordination and Planning

• Coordination between international health
  agencies and NGOs, and between NGOs and the
  military
• International communitys 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
• Populations support for reconstruction
• Government support for nation building
• Populations health status
• Security

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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
Months
Several years
Health
Reconstruction
Immediate post-conflict
Conflict
Pre-conflict
Consolidation
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

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Success of Health Reconstruction inCountries We
Examined
1.0
0.8
0.6
Infrastructure
0.4
East Timor?
0.2
0
0.8
0.6
0.4
0.2
1.0
Coordination and planning
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A Success Story Japan
1.0
0.8
0.6
Infrastructure
0.4
0.2
0
0.8
0.6
0.4
0.2
1.0
Coordination and planning
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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

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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
204,903
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
140
120
100
80
Rate
Life expectancy at birth
60
Infant mortality rate
40
(per 1,000 population)
Neonatal mortality rate
(per 1,000 population)
20
Death rate (per 1,000 population)
0
1946
1944
1942
1940
1930
1952
1950
1948
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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

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Story of Mixed Success Iraq
1.0
0.8
0.6
Infrastructure
0.4
0.2
0
0.8
0.6
0.4
0.2
1.0
Coordination and planning
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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

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Water Service in Iraq Before Conflict
Water service hrs/day
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Water Service Has not Returned to Pre-conflict
Level
Water service hrs/day
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Malnutrition in Children Remains Serious Problem
30
Chronic
25
20
Underweight
Iraqi childrenage 0-5()
15
10
Acute
5
2004
2002
2000
1994
1992
1998
1996
Years
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

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Poor Security Hinders Reconstruction
0.80
0.60
0.40
Percentagechange inhours ofwaterservice
Feb. 2003vsSept. 2004
0.20
0.00
-0.20
-0.40
0
10
20
30
40
Attacks per 100,000 population
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 FailuresSomalia and
Afghanistan
1.0
0.8
0.6
Infrastructure
0.4
0.2
0
0.8
0.6
0.4
0.2
1.0
Coordination and planning
34
Somalia

• 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

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Somalia 1991

• 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

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Somalia Has Always Been Highly Dependent on
External Aid
140
Somalia
120
100
80
Aidpercapita()
60
Sudan
Uganda
40
20
Kenya
0
1996
1992
1988
1968
1964
1960
2000
1984
1980
1976
1972
SOURCE World Bank, World Development Indicators
2003.
37
Somalia 1995

• Infectious diseases, maternal and infant
  mortality rates remain among the worlds 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

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Life Expectancy in Somalia Remains Among Worlds
Lowest
80
United States
70
Life expectancy (years)
60
Sudan
Kenya
50
40
Uganda
Somalia
30
1995
1970
1965
1960
2000
1990
1985
1980
1975
SOURCE World Bank, World Development Indicators
2003.
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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 worlds 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
80
75
United States
70
Uzbekistan
65
Russia
Iran
60
Lifeexpectancyat birth(years)
Pakistan
55
50
45
40
Afghanistan
35
30
1990
1985
1980
2000
1995
SOURCE World Bank, World Development Indicators
2003.
43
Infant Mortality Rates Remain Among Worlds
Highest
200
180
Afghanistan
160
Deaths per 1,000 live births
140
120
Pakistan
100
80
Iran
Uzbekistan
60
40
United States
Russia
20
0
1990
1985
1980
2000
1995
SOURCE World Bank, World Development Indicators
2003.
44
Violence in Afghanistan Is Increasing
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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 Afghanistans 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

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What Are the Lessons for Future Operations?
1.0
0.8
0.6
Infrastructure
0.4
0.2
0
0.8
0.6
0.4
0.2
1.0
Coordination and planning
47
Health Sector Reform Should Encourage
Sustainability
Months
Several years
Success
Health
Tipping point
Japan
Reconstruction
Immediate post-conflict
Conflict
Pre-conflict
Consolidation
48
Countries with Weak National Health Capacities
May Never Reach Tipping Point
Months
Several years
Health
SomaliaAfghanistan
Reconstruction
Immediate post-conflict
Conflict
Pre-conflict
Consolidation
49
Planning Increases Chances of Successful Health
Reconstruction
Reach political consensus on health objectives
Key steps in an illustrative planning process
50
Planning Increases Chances of Successful Health
Reconstruction
Reach political consensus on health objectives
Establish coordination unit with key actor
Key steps in an illustrative planning process
51
Planning Increases Chances of Successful Health
Reconstruction
Reach political consensus on health objectives
Establish coordination unit with key actor
Develop plan specifying what should be achieved
and how to do it
Key steps in an illustrative planning process
52
Planning Increases Chances of Successful Health
Reconstruction
Reach political consensus on health objectives
Establish coordination unit with key actor
Develop plan specifying what should be achieved
and how to do it
Compile insights lessons learned
Key steps in an illustrative planning process
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)

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Health Is an Essential Component of Nation
Building and Foreign Policy
Economic
stabilization
Education
Security
Successful
Nation-Building
Effort
Basicinfrastructure
Governance
Health
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