1. Health Sector Programming in Fragile States Ron Waldman, MD, MPH Mailman School of Public Health Columbia University

2. Mortality in Democratic Republic of Congo: a nationwide survey Crude Under-5 mortality rate mortality rate Health zones 3.0 6.4 reporting violence (2.6-3.4) (5.7-7.2) Health zones 1.7 3.1 not reporting violence (1.5-1.9) (2.7-3.5) Coghlan B, Brennan RJ, Ngoy P et al. Lancet 367:44-51, Jan 7, 2006 deaths/1000/month

3. Typology of Fragile States Good performers Strong but unresponsive Weak and weak Weak and willing

4. “…reductions in crude mortality [and child mortality are closely associated with reductions In violence and, by extension, improvements in security…” “…these trends…provide compelling evidence that improvements in security represent perhaps the most effective means to reduce excess mortality…“ (Coghlan B, Brennan RJ, Ngoy P et al.) “War-related violence remains the most important public health risk…” (Toole MJ, Galson S, Brady W. Are war and public health compatible? Lancet 1993 May 8;341:1193-6.

5. USAID Fragile States Strategy “Instability…is the product of ineffective and illegitimate governance” -- Legitimacy: perception that government is fair and works in the interests of the nation as a whole -- Effectiveness: ability of a government to ensure order and to deliver public goods and services

6. USAID Fragile States Strategy But also, “the United States has an interest in reducing poverty and advancing development” There is potential conflict, or potential complementarity, between the more or less political and the more or less humanitarian objectives of the fragile states strategy

7. The Fragility Framework Security Political Economic Social (including health, education, etc.) How each of these applies has been thought about but requires learning from field experiences

8. Strategic Programming in Fragile States Focus on sources of fragility Seek short-term impact linked to longer- term reform (“peace dividends”, “quick wins”, etc.) Establish appropriate measurement systems

9. Post-Conflict Settings Mitigate impact of conflict Focus on stabilization Support key actors and areas essential to peace (not necessarily on equity)

10. Post-Conflict Settings Vary DRC – transitional government with factional participation; conflict persists in some areas Sudan – two (asymmetrical) governments (GONU and GOSS) with future referendum; conflict persists in some GONU areas In both countries, power- and wealth-sharing agreements have been made. But in both, elections will result in winners and losers – how the losers react will determine the future

11. All Post-Conflict Settings Have Major Problems Poor information Weak human resources (quantity and quality) Low absorptive capacity Uncertain political, economic, and social future Unpredictable external support High rates of conflict recidivism Need to address immediate, humanitarian needs Need to show peace dividend in fact, with the exception perhaps of the last three, all fragile states have these problems

12. Problems Mean Challenges for Donors How to negotiate the transition from emergency (humanitarian) assistance to development How to ‘hedge’ donor investments, and to what extent, without crippling a government that needs support Competing priorities – both internal and imposed; especially, state-building vs. health service delivery

13. Short and Long-routes to Health

14. All Post-Conflict Settings Present Opportunities For a fresh start For increased donor funding, even if hedged For legitimacy at first, for effectiveness later on For at least temporary return of skilled health personnel

15. A Fresh Start Means Opportunities for the Health Sector Donor harmonization and alignment Experiment with new models (public management of private service delivery, like performance-based contracting in Cambodia, Afghanistan, Haiti, DRC) Rationalization of health system (E. Timor)

16. How Can These Opportunities Be Realized ? Be realistic and have modest ambitions Recognize that some changes are irreversible – if the public sector couldn’t deliver before conflict, it is unlikely that it will be able to now Allow, even oblige, harmonization (and alignment) through lending/granting instruments: be part of the solution… Pay special attention to visible and tangible elements of the health system, such as facilities and drugs But don’t focus only on service delivery – financial and personnel management, procurement, training, etc. are all crucial to longer-term recovery and stability