The WHO Global Health for Peace Initiative

WHO’s association with peace is not new. The WHO Constitution2 recognises the connection between health and peace, stating that ‘the health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States’. In a 1981 resolution,3 the World Health Assembly underlined the role which the health sector can play in preserving and promoting ‘peace as the most significant factor for the attainment of health for all’ and in the 1980s the concept of health as a bridge for peace emerged as a part of WHO’s approach to the provision of healthcare in conflict situations.4

Africa is particularly affected by conflict and of the over 1.8 billion people estimated to currently live in fragile, conflict-affected and vulnerable (FCV) settings,5 many of them live in Africa. Sub-Saharan Africa and Middle East and North Africa (MENA) show higher aggregate fragility than any other regions, especially with the highest levels of overall, economic and environmental fragility in sub-Saharan Africa and the highest political, security and societal fragility in MENA.6 Many countries in the region have weak health systems unable to meet the health needs of populations. Conflict-related deaths are a much higher proportion of total deaths than any other region.7 In addition, Africa houses over 9 million refugees and internally displaced persons.8 Reaching Sustainable Development Goals (SDGs), especially SDG 3 targets for UHC, will be difficult to achieve unless the underlying causes of these FCV settings are addressed.

Several developments at the global policy level resulted in the health sector being solicited to contribute to peace: the World Humanitarian Summit in Istanbul in 20169 brought together humanitarian and development actors with member states and donors. At the summit, the idea of a humanitarian–development–peace nexus, the so-called triple nexus, was introduced and actors were urged to work together to bridge the gaps.

Also in 2016, the United Nations (UN) General Assembly and UN Security Council both unanimously adopted identical resolutions on a review of the UN’s ‘peacebuilding architecture’ which introduced the concept of ‘sustaining peace’ into the UN’s peacebuilding goals.10 The resolutions asked all UN bodies and the World Bank to mobilise capacities for mediation and conflict resolution in order to prevent ‘outbreak, escalation, continuation and recurrence of conflict’. The UN and its Member States were called on to ‘address root causes, assist parties to conflict to end hostilities, ensure national reconciliation, and move towards recovery, reconstruction and development’.

The WHO’s Global Health for Peace Initiative builds on that tradition and on current global policies and aims to position the health sector as contributor to peace by making health interventions conflict sensitive and aiming at delivering peace dividends in addition to the inherent health outcomes. It aims at working on conflict, in addition to working in conflict, achieving health benefits in conflict situations but also delivering additional peace benefits through health activities.

By using the legitimacy, influence and neutrality of health programmes, powerful messages about humanitarian principles, equity of services and non-discrimination of disadvantaged groups will work on the triggers of conflict. By working on improving citizen–state cohesion through health equity, by facilitating collaboration in health governance with all parties to a conflict and by promoting community healing through dialogue and inclusion, health programmes can deliver peace dividends in addition to health benefits.

A theory of change underpinning the project posits that if individuals and groups enjoy equitable access to health services and are empowered to cope—physically and mentally—with adversities, then they are more likely to live in harmony, make peaceful contributions to society and resist violent behaviour.

Cascading from the global theory of change above, peace-relevant health interventions can help improve the prospects for local peace in three ways:

• By improving the vertical two-way relationship of trust between state and citizens through the expansion of social protection and justice in underserved areas.

• By providing the opportunity for confidence-building measures between all sides in a conflict by serving as a platform that restores contact, collaboration and cooperation.

• By helping mend horizontal relations between individuals and communities, through trust-building and inclusive processes that promote dialogue and social cohesion.

Implementing this health and peace approach will set new standards for health programmes in FCV countries by harnessing the power of health to influence the peace process in a positive way. As demonstrated during the COVID-19 outbreak, health emergencies can be a trigger for instability and conflict by exacerbating political, social and economic inequalities. But health programmes jointly responding to common risks and shared threats can also be powerful enablers to build trust and peace. When health activities are carefully developed and implemented, peace dividends can be derived in addition to health benefits.

Applying the WHO Global Health for Peace Initiative in Africa

The African region has already started to implement the health for peace approach and a number of activities have been identified that contribute to peace: approaches that build sustainable and equitable health systems, community-based and participatory approaches, flexible and adaptive management approaches, approaches that build trust between patients and healthcare workers, coordinated and intermediated health interventions across conflict lines, and mental health and psychosocial support (MHPSS).

The introduction of the health and peace approach in the African regions requires projects to include the following three asks:

1. Do a conflict analysis of the current situation before starting a project. This means an analysis must be made to identify root causes and stakeholders of the conflict as well as the context’s dividers and connectors. Dividers are the factors that create and elevate tensions between people or groups and obstruct their ability to resolve conflicts non-violently, and the ‘connectors’ are the ones that contribute to social cohesion and reduced tensions between people or groups, and promote constructive collaboration and non-violent dispute resolution.

2. Apply the ‘do no harm’ principle to be conflict sensitive. Based on the previous stage of conflict analysis, possible interactions between health intervention and the context’s dividers and connectors should be considered while making all efforts to minimise and mitigate the negative effects on key conflict and peace dynamics through risk mitigation strategies.

3. Make the project ‘peace responsive’ by applying the potential pathways that will work on the connectors for peace, thus ensuring peace dividends in addition to the health dividends, such as increasing equity and building trust between citizens and the state by improving the equity, inclusiveness and participatory governance of health services; building trust between and within communities by supporting inclusive community engagement, collaboration and dialogue over health issues and services as well as through other targeted interventions that contribute to violence prevention and/or reconciliation; facilitating rapprochement and building trust between parties to a conflict by encouraging cross-line collaboration for health; and facilitating high-level health diplomacy.

These principles and approaches of ‘health for peace’ have been applied in several countries.

In Somalia, the 30-year old civil strife has severely disrupted social cohesion, broken down social norms and led to widespread psychological suffering. Long-standing conflict undermines trust between individuals, families, communities and their institutions. With 70% of Somali’s population under the age of 30 years, the vast majority of the population was born and grew up in the midst of conflict. This situation can lead children, young people and adults to normalise and potentially reproduce violence and conflict through retribution, joining armed groups and intimate partner violence. Studies of adverse childhood experiences and trauma, such as hunger, violence and neglect, have shown an association with long-term chronic health conditions including mental health and substance use. Therefore, neglecting to address the psychosocial impact of conflict will ultimately undermine peace, health and development. Through the UN Peacebuilding fund, the WHO country office in Somalia, in partnership with the IOM (International Organization for Migration), UNICEF, Somali National University and the federal government,10 is currently implementing a pilot project on youth-oriented integrated MHPSS in the context of peace building. The project seeks to improve psychosocial support and mental healthcare for conflict-affected youth and to prevent them from engaging in negative coping mechanisms driving conflict. The project has developed a harmonised MHPSS module and provides training for health facilities staff and community health workers to gain professional-level capacity for MHPSS services. The deployment of community health workers and clinicians with enhanced capacity has helped improve access and quality of community-based MHPSS services. The services have been provided in various formats (individual and group sessions) taking into account specific needs of internally displaced persons, gender-based violence survivors and youth.

In Cameroon, WHO contributes to peacebuilding and community violence reduction in the country’s Far North region which has long been affected by violence and unrest provoked by armed groups designated as terrorist organisations. In collaboration with IOM, WHO supports providing more equitable health and social services based on the needs identified through inclusive and participatory process (eg, community health dialogue fora) to increase horizontal cohesion between communities as well as vertical trust in government authorities.

The overall objective of the project is to contribute to achieving the preconditions for effective and sustainable peace by using health interventions as a neutral entry point to supporting national entities towards promoting social cohesion, dialogue and trust between and within communities, and towards national authorities in the Far North region. The project is based on the principle that the delivery of healthcare and health services—insofar as it is provided in a manner that is effective, equitable and inclusive—can serve as a neutral entry point of common concern to all stakeholders in a conflict in order to build confidence, strengthen cohesion, and reduce violence at community level while supporting the disarmament, demobilisation and rehabilitation processes in the region. Health services that have strong potential for violence reduction and community reconciliation (such as MHPSS and physical trauma care) will be enhanced through adapted and accessible responses. Provision of essential health equipment to health facilities that have lost equipment due to attacks and destruction will improve access to healthcare, thus reducing any feeling of abandonment by the system. The project therefore proposes a number of health-related entry points through which national authorities, communities, vulnerable populations and ex-associates alike can be engaged.

In Burkina Faso, a joint WHO/UN Fund for Population Activities project seeks to engage youths and youth associations to promote mental health and psychosocial well-being with a view to reinforce social cohesion and to promote dialogue and reconciliation between communities. The project offers mental health services and psychosocial support for people traumatised by the conflict. By contributing to the resilience and social cohesion, peace dividends are envisaged.

Historic examples include the 1997 experience in Angola where demobilised health personnel were integrated into the national health system. Representatives of the Ministry of Health, the Angolan armed forces and the UNITA (União Nacional para a Independência Total de Angola) military forces set up a committee that shaped legislation related to the national health workforce. As a result, demobilised ex-militia health personnel were legally recognised and pathways for training and accreditation of the UNITA health personnel were agreed on. Demobilised health personnel were then deployed to under-resourced municipalities.

Other examples are the ‘days of tranquillity’ that were organised in the Democratic Republic of the Congo (DRC) and in Sudan in 1996 to organise polio vaccination campaigns involving opposition groups, representatives from minority communities, government officials and local Non Governmental Organizations (NGOs). Other polio eradication strategies and policies were implemented including surveillance, immunisation coverage and capacity-building.