Community and institutional preparedness and resilience

of health systemsAnthony Zwi

Health Policy UnitLondon School of Hygiene and Tropical Medicine

WHO, December 13-14 1999

Objectives and structure of presentation

u General commentsu Different stages, potential responses

u vulnerability u early warningu resilienceu mitigationu rehabilitation

u Identifying a way forward…?

‘The opportunities and rewards of globalization spread unequally and inequitably - concentrating power and wealth in a select group of people, nations, and corporations, marginalizing the others’

‘Competitive markets may be the best guarantee of efficiency, but not necessarily of equity’

UNDP, Human Development Report, 1999

‘Collective hatred gains veracity and allure most easily wherever a group of people lives in genuine want, in an environment of human misery’

Vaclav Havel, Oslo, August 28 1990

Features of current conflicts

u Development of ‘particularist identities’l among those perceived to be marginalised by

globalization, construction of new identities -drawing local and diaspora communities together, using new technologies and media

u Changed mode of warfarel destabilisation and terror, linkages between local

warlords and criminal activity

u Globalized war economyl decentralized systems, fighting units financed

through plunder and black marketKaldor, 1999

Contemporary nature of war

... ‘conscious attempt by armed parties to subdue or inflict harm on the individual members of an opposed group, to dominate or shatter the social structures of their enemy, and/or to capture, damage or destroy their enemy’s material resources’.

Meyers, 1991

Health damage … more than a by-product of war

Conflict ADAPTATION

Adjustment strategies

Mediating variables

STRESS

State of disequilibrium

Characteristics of conflict

Characteristics of affected systems and communities

OUTCOME

Maladaptive

Adaptive

Adapted from Stress and Coping framework, Ward, 1988 and Ward, 1995

Characteristics of responseindividualcommunitysystems

Elements of appropriate response:

A. VULNERABILITY REDUCTION: reduce potential for violence to occur

B. EARLY WARNING: identify early stage risk of violence

C. BOLSTER RESILIENCE: boost ability of systems to function

D. MITIGATION: reduce impact of violence and instability

E. REHABILITATION & REFORM: utilise opportunities to develop more appropriate system given context

Internalconflict

DFID

WHOUNHCR

INGO

LNGO

GOV

SCHEMATIC DIAGRAM OF ACTORS INVOLVED IN COMPLEX EMERGENCY SETTINGS- MULTIPLE SYSTEMS WOULD BENEFIT FROM SUPPORT

GOV

REFUGEES

IDP

LNGO

EU

USAID

LNGO

INGO

Relevant health care systems in conflict-affected and surrounding countries

u Public health system (national, provincial, local, municipal)

u Community-based systemsu Private for profit system (traditional,

conventional for-profit medical system) u Non-governmental organisations u United Nations ‘family’u Otheru NB Consider within and external to affected

country

A. Vulnerability reduction:

u Upstream actionu Identify and understand better causes of

violenceu Appreciate increasing inequalities as contributoru Seek enhanced UN, international civil society

and international relations responsesu Preparedness at country levelu Develop more humane globalisation:

u fair trade vs. free trade u ongoing role of government u maintenance of health and social safety nets

Definitions:

RESILIENCE:act of rebounding or springing backpower of resuming the original shape after

compression, bendingrising readily again after being depressedMITIGATE:render milder, render less violentmoderate, reduce the severityVULNERABILITY:susceptibility to wounding or injury

Developments linking globalisation & collective violence

Economic:– Global production and trade in arms– Emergence and availability of private armies– Increasing inequalities within and between countries

Political:– Diminished role of state; reduction in social safety nets– Rapidity of political and economic transitions

Cultural:– Use of media to incite hatred– Role of diaspora communities in fomenting change

Environmental:– Acceleration and intensification of resource depletion

Social:– Heightened ethnic identity and intolerance– Nurture of individual vs. social ethic

Characteristics of many unstable environments

• Contested government legitimacy

• Limited ability to govern: identify needs, determine priorities, mobilise resources, allocate resources, organise services, absorb funds, provide policy framework, direct & regulate

• Weak political and social institutions

• Dispersed and dispossessed communities

• Disarticulated civil society

• Potential for organised violence present

B. Early warning:

u Anticipate and appreciate early increases in risk of violence

u Identify relevant health and social indicatorsu Ongoing system for central data collation and

analysis u ?health and social system watch; regular audit to

assess risks and levels of preparednessu gov’t policy, human rights situation, media,

u Uses of data : debate, analysis, preparedness u contingency planningu scenario developmentu futures analysis

Information relevant to early warning

Changing differentials in:

• Impact: macropolitical and macroeconomic developments on local economies and households

• Access: human, financial and material resources• Health status: morbidity, mortality, disability• Health services: coverage, access, quality• Perspectives: role of state/others• Attitudes: race, ethnicity, geography, culture

Dimensions to social inequality

• Substantive: magnitude and form of inequalities in economics, culture, politics

• Distributional: distribution of assets and resources between individuals and groups

• Relational: formation of hierarchies as a result of inequalities present

• Mobility: movement between different hierarchies

Pakulski, 1999

Typical health system problems

u INEQUITYu INSUFFICIENCYu INEFFICIENCYu INADEQUATE QUALITYu INFLATIONu INSECURITY

Source: Frenk, 1995

C. Bolster resilience:

u Preparedness = anticipation and planningu Understanding response to instability

u individualsu communitiesu health and health care systemsu social systems

u Identify mechanisms of providing supportu Identify short and medium term objectives (relief

- development) u Build evidence base

Resource availability

Health workers

Injury, killing, kidnappingDisplacement

Disrupted training/supervision

Poor morale

Equipment and supplies

Lack of drugs & maintenance

Reduced access to newer technologies and ideas

Inability maintaining cold chain

Service infrastructure

Destruction of clinicsDisrupted referral and

communication

Service management Diversion from development

More centralised, urban-based, vertical programmes

Disruption of complex programmes

Focus on short termLimited scope for consultation

Service delivery

Shift from primary to secondary careUrbanisation of

provisionDecreased activity in

peripheryDisrupted campaigns:

health promotion, disease control,

outreach

Reduced access and utilisation: fear, curfews,

landmines, informal charges

Increased private provision

Service organisation

Reduced data for decisionsLimited management training

Reduced ability to monitor funds and resource useIncreased fragmentation

Economic support

Resource diversion to militaryReduced revenue

Reduced control over fundsIncreased dependence on aid Increased health

needs; reduced ability to respond

PRE-CONFLICT

INTRA-CONFLICT

‘POST’-CONFLICT

DAMAGEADAPTATIONINNOVATIONRESILIENCE?

EMERGENT HEALTH NEEDSNEW ACTORSRESOURCE CONSTRAINTSPOLITICAL REALITIESREBUILD OR REDEFINE?VULNERABILITY REDUCTIONPREPAREDNESS

POLICYSTRATEGYSERVICESPREPAREDNESS?

Adapted from Zwi, 1996

D. Mitigation:

u Reduce lives and livelihoods lostu Local safety netu International safety netu Improve standards and accountability

u militaryu foreign relationsu NGOs - local and internationalu media - local and international

u Sufficient resources in right place at right time delivered appropriately

Key humanitarian aid challenges

• Seek balance between humanitarian, political, economic and military

• Promote effectiveness, efficiency, sustainability, equity

• Promote adoption of ethical codes and minimum standards

• Ensure humanitarian aid does more good than harm: identify and promote good practice

• Protect providers of humanitarian assistance• Appreciate role of humanitarian aid in

occasionally perpetuating or shifting balance in conflicts

Individual protective strategies

Flight - migration, exodusNew relationshipsAccess to additional resources

“Protective factors”

HEALTH and

SOCIALIMPACT

Community resilience

Family and household coping strategiesCommunity networks and structures

Service Provider responses

Enhancing protection Reinforcing constructive individual / collective responses

“Risk Factors”

ExposuresViolenceEnvironmental damage Water and sanitation lossHealth services destruction

Changes in social relationships

Loss of support structures at family, household and community levelsReduced access to resources

Service provisionInputs contribute to prolonging conflictInappropriate provisionLack of gender, ethnic & cultural-sensitivityPoor appreciation of coping strategiesLack of community participation

Health / social policy interventions

CONFLICT CONTEXT

Evidence- policy matrix

No policy Evidence

No policy No evidence

Evidence-basedPolicy

Policy No evidence

E. Rehabilitation and reform:

u Opportunity to reconceptualise health system within constraints

u Back to basics: problems, principles, purposeu Build on adaptations and earlier responsesu Address causes of violence and instabilityu Build sustainable future

Priorities in post-conflict period

• Address root causes of conflict: inequities, social injustice, human rights abuses, ethnic tensions

• Consider rehabilitation, reform, redefinition

• Consolidate positive adaptations during conflict

• Hear and build on local initiatives and viewpoints

• Emphasise data and evidence-based policies

• Support institutional capacity to manage process

PRE-CONFLICT

INTRA-CONFLICT

‘POST’-CONFLICT

DAMAGEADAPTATIONINNOVATIONRESILIENCE?

EMERGENT HEALTH NEEDSNEW ACTORSRESOURCE CONSTRAINTSPOLITICAL REALITIESREBUILD OR REDEFINE?VULNERABILITY REDUCTIONPREPAREDNESS

POLICYSTRATEGYSERVICESPREPAREDNESS?

Adapted from Zwi, 1996

‘Post’-conflict health sector issues: Process priorities

• Consultation and dialogue• Policy framework, vision (?SWAPs, CFD)• Information needs• Recognise constraints on actors• Mobilise resources• Identify and agree roles, coordinate

Principles of health system development:

u CITIZENSHIP : Care as a right

u PLURALISM : Choice

u SOLIDARITY : Contribution - ability

u UNIVERSALITY : Entire population

Source: Frenk, 1995

… contribute to reducing vulnerability

Purpose of health system development:

To promote:u EQUITY: those with same need deserve

same access to servicesu QUALITY: services produce greatest

possible improvement in health and satisfy user expectations

u EFFICIENCY: highest possible returns from resources expended

Source: Frenk, 1995… contribute to reducing vulnerability ...

Peacebuilding priorities (Ball & Halevy,1996)

• government capacity• population return• rejuvenate household

economies• community recovery• economic infrastructure• internal security

• financial institutions• stabilize currency• respond to conflict-

exacerbated needs• remove landmines• address causes of

conflict• national reconciliation

Moving forward

• Identify mechanisms for supporting different phases: vulnerability, warning, resilience, mitigation, rehabilitation

• Identify mechanisms for supporting different elements of system: communities, gov’t, civil society, UN

• Facilitate documentation, analysis, reflection, critique

• Build on evidence-base to promote appropriate policy

Summary of presentation

u Globalization will continue to contribute to ongoing instability and conflict

u Respond at key phases to reduce vulnerability, facilitate early warning, bolster resilience, mitigate impact, rehabilitate and reform

u Work with range of actors in and outside country: communities, public sector, private sector, international and local NGOs, UN

u Documentation, reflection, analysis to build evidence base

u Use data for considering scenarios, monitoring change, planning and training

u Recognise niche roles for WHO