Making Sense of Apparent Chaos: Health-Care Provision in Six Country Case Studies

"The research calls for changes in the framing of analysis of these contexts; an acknowledgement that the state is only one of many actors in health; a recognition that current time-frames, and the current expectations that shape them, are unrealistic; and a preparedness to rethink development engagement in ways that will allow effective harnessing of the diverse actors that currently provide services."

In all contexts, the coverage and scope of health services change when the state fails, often due to violence. The degeneration of health systems may predate the conflict, may arise directly or indirectly from it, or may be compounded by local or international responses to it. This paper is based on an analysis of 6 country research case studies - Afghanistan, the Central African Republic (CAR), the Democratic Republic of the Congo (DRC), Haiti, Palestine, and Somalia - that examine health service provision in severely disrupted environments. A central purpose is to provide insight into what provision of health services exists beyond the reach of the state and to examine the implications of these often-unrecognised resources in rethinking potential health systems development.

Each case study was informed by analysis of the available peer-reviewed and grey literature. Particular attention was given to the broader historical, geographical, political, economic, and social context in which health care is provided. Field visits enabled direct observation of the current context, and in-depth interviews were undertaken with key local informants from ministries of health, non-governmental organisations (NGOs), and bilateral and multilateral development agencies, using a common question guide.

As noted here, the health sectors of each case study share commonalities in the impact of violence on their health status - life expectancy, neonatal and infant mortality, maternal mortality, and related indicators are poor relative to their regional neighbours - but the determinants of these outcomes are frequently particular to the context. This is in keeping with the observation that national health systems are themselves networks of complex adaptive systems, constantly changing and profoundly affected by local factors.

The themes around which the analysis of case studies are organised include:

• Health services and the disrupted state: The health service gaps left by the absence or withdrawal of the state do not necessarily remain a vacuum. They may be filled by health workers with limited, incomplete, or expedited training, retired staff, traditional practitioners, volunteers, or "quacks". While curative services may be offered within this emergent private sector, preventive programmes become more difficult to sustain: Immunisation and child health services may be curtailed due to the risks of congregating, or threats to staff during outreach activities.
• Human resources: In conflicts where social services are promoted by the government, any challenge to it may target such services. For example, in Pakistan, following the use of polio immunisation as a pretext for the identification of Osama bin Laden in Abbottabad, the Taliban blocked polio vaccination in tribal North Waziristan, though this does not appear to have extended to Taliban-dominated areas of Afghanistan. The loss of human resources through death and injury, relocation, and migration contributes to the distortion of the health workforce.
• Financing: Domestic public financing for health is frequently reduced during situations of conflict. In acute interventions, international humanitarian funding for health may rise exponentially but not sustainably.
• Drugs, vaccines, and technology: The absence of regulation means that poor-quality or fraudulent medicines have facilitated access. Vaccination programmes are vulnerable, as access and demand are compromised because of security concerns and the cold chain is disrupted.
• Health information: As the health sector ceases to be administered as a comprehensive system, the demand for reliable information diminishes. Data collection is compromised through loss or relocation of the staff responsible for recording, reporting, or analysing the data.
• Leadership and governance: In all the case studies, health services are compromised by the limitations of the state; for example, Afghanistan's fragile control of contracted health services, even with substantial international support, provides coverage for a very low proportion in some provinces.

One lesson to emerge, which was suggested above, is that, rather than waiting for state-provided health care, the disillusioned inhabitants of countries such as the 6 examined here have opted for alternative services, mostly privately supplied. This is because autonomous health actors respond to state withdrawal and structural violence - and they do so in assorted ways, from the harmful to the beneficial. In looking at the implications of healthcare provision beyond the reach of the state, the authors suggest that the international development community needs to understand the pluralism, initiative, adaptation, and innovation of these autonomous actors, and to reorient development assistance in order to engage them effectively and in the long term.

What is called for here, then, is "new and substantially different analytical approaches". For example, informal healthcare providers "will need to be brought into centre stage, in the analysis as well as in the policy discussion". However, collaboration with non-state actors - such as by introducing positive incentives in a pluralistic, largely informal healthcare arena, where actors play multiple, fluid roles - poses challenges. "New, agile funding mechanisms will be needed to support such an open exploratory approach, with some flexibility built into formal controls over operations."

In conclusion: "In dealing with health services beyond the reach of the state, the international community has to accept its expanded responsibility: support for the development of state functions will need to continue, but in these environments, governance will need to be sought through both local and international partnerships."