Stabilizing and rebuilding state infrastructure in post-conflict settings has been increasingly recognized as critical to aiding the population and preventing renewed conflict. The United States has increasingly invested in rebuilding health systems, and in some cases assisting in the delivery of health services for the first time.

While global health concerns have recently received significant attention, as witnessed by President Obama’s Global Health Initiative, the importance of health system reconstruction to stabilization efforts remains unevenly recognized. On November 10, 2009, experts met at the Global Health Council’s Humanitarian Health Caucus to discuss investing in health services in the wake of war and the challenges of funding this investment.

“Deconstruction from violence extends beyond the time of war and often leads to severe damage of health infrastructure, decreased health workers, food shortages, and diseases…resulting in increased morbidity and mortality from causes that are not directly related to combat,” shared Leonard Rubenstein, a visiting scholar at Johns Hopkins School of Public Health. Rubenstein argued that while relieving suffering in post-conflict settings should be a sufficient reason to include health reconstruction in U.S. foreign policy, policymakers narrowly define rationales for engagement based on claims that investments increase peace and improve the image of the U.S. government.

Investing in Health Systems Builds State Legitimacy

The evidence for investing in health systems to deter future conflict is limited and this approach is dangerous, according to Rubenstein, because it distorts spending decisions and fails to consider comprehensive capacity development strategies. Additionally, the Department of Defense’s approach of “winning the hearts and minds” is too short-term and neither linked to “system-building activities that are effective and sustainable…nor consistent with advancing the health of the population,” he said.

Instead, Rubenstein recommended that the United States invest in health systems after conflict because it advances state legitimacy. Although additional evidence is necessary, Rubenstein maintains that the promotion of state legitimacy enhances the perception that the government is responding to their long-term needs and encourages local ownership and accountability. Developing health systems in post-conflict settings is complex and cannot be done quickly, he noted, and thus increased financial and human resource capacities will be essential.

Coordination and Transition Funding

“We need to recognize that the U.S. is not the only funder, as there are many stakeholders involved,” argued Stephen Commins, strategy manager for fragile states at the International Medical Corps. Commins argued that there is a “desperate need to coordinate donor funding … both within and across government systems, as well as an increased need for transparent donor tracking systems.”

As countries come out of conflict and start to gain government legitimacy, they need increased support to stabilize conflict and avoid collapse. Transition funding for health systems needs to support both short and long-term efforts, maintained Commins, but unfortunately the donors driving these timelines are often driven by self-interest, not the rights of the individual living in conflict.

Without a transparent donor tracking system, it is hard to demonstrate actual monetary disbursements versus commitments, so Commins called for a system that tracks allocations and spending in real time. These are not our countries, he argued, and responding to health systems in post-conflict settings should be tailored to the country’s needs, not the donor’s. He also called for increased research that describes, over time, the costs for rebuilding and transitioning from international NGO-driven systems to self-sustained governments.

Rebuilding Health Systems in Sudan

George Kijana, health coordinator in southern Sudan for the International Rescue Committee, discussed reasons for why Sudan’s health system remains poor five years after conflict. According to Kijana, the government in Southern Sudan has not been held accountable by its donors, leading to a breakdown in infrastructure and a lower quality of health workers.

Additionally, a majority of the available health data comes from non-state actors that are not easily accessible. Kijana shared that in order for Sudan to move forward, more research and data are needed to help target long-term capacity building projects, as well as short-term interventions that address infant and maternal mortality. While progress is slow, he pointed out encouraging signs of progress, as the Ministry of Health now recognizes their weaknesses and positively engages with its development partners such as the United Nations.

Photo: Romanian Patrol administers medical treatment to Afghan communities, courtesy of Flickr user lafrancevi.

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The Center for Global Development’s latest report, Start With A Girl: A New Agenda For Global Health, sheds light on the risks of ignoring the health of adolescent girls. Like other reports in the Girls Count series, it links broad social outcomes with adolescent health. “Adolescence is a critical juncture for girls. What happens to a girl’s health during adolescence determines her future–and that of her family, community, and country,” state coauthors Miriam Temin and Ruth Levine.

Between childhood and pregnancy, adolescent girls are largely ignored by the public health sector. At the same time, programs and policies aimed at youth do not necessarily meet the specific needs of girls. Understanding the social forces that shape girls’ lives is imperative to improving their health.

Like recent books by Michelle Goldberg and Nicholas Kristof, the report argues for increased investment in girls’ education to break down the social and economic barriers that prevent adolescent girls from reaching their full potential. Improving adolescent girls’ health will require addressing gender inequality, discrimination, poverty, and gender-based violence.

“For many girls in developing countries, well-being is compromised by poor education, violence, and abuse,” say Temin and Levin. “Girls must overcome a panoply of barriers, from restrictions of their movement to taboos about discussion of sexuality to lack of autonomy.” The report points to innovative government and NGO programs that have successfully changed negative social norms, such as female genital cutting and child marriage. However, the authors urge researchers to examine the cost-effectiveness and scalability of these programs.

In the last five years, the international community has become increasingly aware of the importance of youth to social and economic development. Some new programs are focused on investing in adolescent girls, such as the World Bank’s Adolescent Girls Initiative and the White House Council on Women and Girls, but significant additional investment and support is needed.

“Big changes for girls’ health require big actions by national governments supported by bilateral and multilateral donor partners, international NGOs…civil society and committed leaders in the private sector,” maintain Temin and Levin. They offer eight recommendations:
1. Implement a comprehensive health agenda for adolescent girls in at least three countries by working with countries that demonstrate national leadership on adolescent girls.
2. Eliminate marriage for girls younger than 18.
3. Place adolescent girls at the center of international and national action and investment on maternal health.
4. Focus HIV prevention on adolescent girls.
5. Make health-systems strengthening and monitoring work for girls.
6. Make secondary school completion a priority for adolescent girls.
7. Create an innovation fund for girls’ health.
8. Increase donor support for adolescent girls’ health.

“We estimate that a complete set of interventions, including health services and community and school-based efforts, would cost about $1 per day,” say the authors of Start With a Girl. There is no doubt in my mind that this small investment would indeed have a high return for the entire global community.

“All trafficking is not sex trafficking,” argued Woodrow Wilson Center Fellow Pardis Mahdavi, at a recent Middle East Program event. Drawing on her ethnographic research in the United Arab Emirates, Mahdavi analyzed the policy implications of the latest Trafficking in Persons (TIP) report by the United Nations Office on Drugs and Crime. The TIP report offers information on modern day slavery–human trafficking–and includes comprehensive data on policies and enforcement in 155 countries and territories.

The TIP report paradoxically hurts the people it tries to protect, claimed Mahdavi, by placing too much emphasis on sex trafficking and failing to take into consideration other types of abuse, such as those against men and migrant labor workers. Mahdavi pushed for a “breakthrough of the labeling and politicizing of sex traffickers as women and children,” which depicts women as passive and helpless, while excluding male victims.

According to Mahdavi, in Dubai, 80 percent of the population are migrant laborers. Often, these foreign workers do not trust the government to protect them against trafficking abuses, particularly if they are working in the host country illegally. Thus, civil society organizations, and not the state government, serve as the major source of protection and recourse for abused migrant workers. In the Persian Gulf region, Mahdavi argued that the “TIP report needs to be rewritten…to include increased labor inspectors and police training,” and called for the increased “accountability and transparency” of civil society organizations.

Mahdavi cautioned countries against using the TIP report to enact policies that make migration illegal. Tightening borders forces workers into the informal economy, she maintained, where it becomes difficult to track and protect these individuals.

Although the TIP report has weaknesses, it does pressure countries to act, as Mahdavi has witnessed in the United Arab Emirates, where it has provided opportunities for dialogue on the various aspects of trafficking.

As evening fell upon Yirgalem, Ethiopia, more than 70 participants from a large cross-section of Ethiopia’s NGO community—as well as a few international participants like myself—gathered in a packed conference room in the Furra Institute for the second annual General Assembly of the Consortium for the Integration of Population, Health, and Environment (CIPHE).

The global recession has “been very hard on journalists,” explained Andrea Crossan, radio producer for BBC’s “The World”. “With these kinds of cutbacks, you really feel it when it comes to foreign coverage.” Along with Stephanie Hanson, associate director and coordinating editor of CFR.org, and Margaret McElligott, senior producer for washingtonpost.com, Crossan spoke about the International Reporting Project’s (IRP) Gatekeeper trip to Kenya at a Wilson Center event sponsored by the Environmental Change and Security Program.

“You’ve seen a lot of areas of the world that just aren’t getting the coverage these places deserve, and Africa is one of those places,” said Crossan, partly due to the expense of travel, security, and satellite equipment. IRP, a project of The Johns Hopkins University’s School of Advanced International Studies, aims to fill gaps in foreign reporting left by extensive budget cuts by offering U.S.-based editors and journalists opportunities to report on international stories.

“I’ve traveled a fair amount with the BBC, and I’ve seen some really difficult living conditions for people. I’ve never seen anything like I’ve seen in Kibera,” said Crossan. “We can look at all of the things we are talking about today”—environment, health, security—“through what’s happening in Kibera.”

Poverty and Pirates

At a meeting at the University of Nairobi, a student criticized foreign reporting of Kenya, saying that it “only seems to cover poverty and pirates,” said Crossan. That’s a slight improvement over previous years, when U.S. coverage focused on “witches and war,” noted an audience member.

McElligott, who previously worked for AllAfrica.com, agreed that U.S. media coverage of Africa is becoming richer, with fewer instances of racism accompanying reporting. “The world is so much smaller now,” with email, Facebook, blogs, and video providing additional venues and in-country contacts, she said.

The Kenyan press is the “most trusted institution” in the country, said Hanson. They expose corruption, report on health issues, and call the government to task. With the decline in U.S. journalists posted abroad, the support and stories provided by Kenyan reporters is crucial to getting coverage in the international media.

While pitching international stories to U.S. audiences might be a hard sell, “if it’s a good, compelling story, it will go up in a prominent place” with or without a U.S. angle, said McElligott. “It’s just about telling human stories,” said Crossan.

Kenya on the Edge: Drought and Conflict

“In the last months we’ve seen the food crisis grow in Kenya,” said McElligott. On the group’s visit to Laikipia, she noted the impacts of soil degradation, unsustainable water extraction from rivers, and the lack of governmental regulation. Lack of land and water is forcing pastoralists to travel miles away from home in order to feed cattle and goats.

“We’re desperate for water here,” said Laikipia resident Niyok Npanyaki in an IRP video report. “We’ve decided that if water is cut off, we’ll go to the water source on Mount Kenya, even if the government doesn’t let us. Otherwise we will die. People don’t start wars for no reason. If I am hungry, but if you have food, I’ll come to you and find it.”

“Loss of natural resources puts people under extreme pressure and people will go to extreme lengths in order to get those fundamentally important natural resources,” says Dr. Anthony King, director of Laikipia Wildlife Forum, in the video. Adding to the tension between farmers and pastoralists is the easy access to firearms in the Horn of Africa. “Almost every pastoralist will have an automatic weapon,” says King.

The IRP fellows visited the headquarters of the UN Environment Programme in Nairobi, but found it difficult to gauge the effectiveness of UNEP at addressing Kenya’s drought and deforestation. According to Crossan, UNEP has invested in a number of local programs, but the UNEP officials they spoke with seemed frustrated that the Kenyan government was not more involved in tackling the country’s environmental problems.

“Something I struggle with in my own work is trying to understand what actual effect these large multilateral agencies have on the ground. What is the World Bank actually doing in Ghana? What are they actually doing in Kenya?” said Hanson. “Does the money get distributed? Who does it go to? Having more Kenyans or Ghanaians who could report on these things and look into them in terms of transparency and accountability would be incredibly helpful.”

Malaria: A Disease of the Poor

“Malaria was, to be honest, not a disease that was really on my radar,” said Hanson. “I had, in a way, discounted its importance to what has happened on the continent.” At a children’s critical care unit in Nyanza Province, one of the poorest areas in Kenya with one of the highest rates of HIV and malaria, she saw beds filled with sick children. “This was shocking to me.”

When a family member is stricken with malaria, the burden of care is typically falls upon the mother, who often must travel long distances to the nearest hospital—“some of them had walked hours with a sick child,” said Hanson—leaving their other children at home and farms largely untended.

“When these women have to leave their farms to come to the clinic, they’re losing work days on the farm,” said Hanson. “That just means that their farms are less productive. They have less money to send their children to school, give their children medical care, and feed their children.”

“These macro-political issues—disputed elections, post-election violence—are actually connected to daily issues like malaria infections, hospital capacity rates, agricultural yields, and without a government that can address those things it is very difficult to see how a place like Kenya can move forward,” concluded Hanson.

Drafted by Sajid Anwar and Meaghan Parker.
Edited by Meaghan Parker.

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“Family planning is one of the biggest success stories of development cooperation,” said Bert Koenders, Dutch Minister for Development Cooperation, via video at a Wilson Center roundtable discussion on the future of family planning funding. Koenders was followed by representatives of three of the field’s largest donors, Musimbi Kanyoro, director of the David and Lucile Packard Foundation’s Population and Reproductive Health Program; José “Oying” Rimon, senior program officer for Global Health Policy and Advocacy at the Bill and Melinda Gates Foundation; and Scott Radloff, director of USAID’s Office of Population and Reproductive Health.

“The downward trend, in terms of donor funding for international family planning, since the middle of the 1990s to around 2006 has been reversed,” José Rimon II, senior program officer for global health policy and advocacy at the Bill and Melinda Gates Foundation, told ECSP Director Geoff Dabelko following a discussion on the future of family planning at the Woodrow Wilson Center.

“Poor countries can’t begin to deal with food issues, with economic pressures, with conflict and shortages of water and grassland that may lead to social conflict, unless they begin to deal with population problems,” journalist Nicholas Kristof tells ECSP Director Geoff Dabelko in a video interview.