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Health and peace are closely interlinked.
The health sector can play a role in preserving and promoting peace.
The WHO has launched a Global Health for Peace Initiative.
Doing a conflict analysis, applying conflict-sensitive planning and making programmes peace responsive are key to achieving peace dividends in health programmes.
Several countries in Africa have already successfully applied this approach.
Interlinkages between conflict, health and peace are well known. The 1986 Ottawa Charter for Health Promotion,1 which enumerates the fundamental conditions and resources needed for health, lists peace as the first on the list of prerequisites for health. There cannot be health without peace. Violence in general, and armed conflicts in particular, have a direct impact on health. Conflicts cause violent deaths not only among combatants, but also among civilians, and lead to physical and mental injuries that will have lasting effects long after the conflict has ended. Conflicts also lead to the disruption of health systems, collapse of essential medical supply chains, and breakdown of social and economic systems, making it difficult to achieve Universal Health Coverage (UHC), one of the main objectives of WHO. It also leads to an exodus of healthcare workers, attacks on healthcare, upsurges in epidemics, increased infant mortality rates, sexual violence, and mental disorders such as depression, anxiety, and post-traumatic stress.
While there cannot be health without peace, there cannot be peace without health either: lack of access to basic social services, such as healthcare, for specific population groups, often on ethnic or religious grounds, leads to feelings of exclusion, sentiments of unfair treatment by the government and perceptions of unequal treatment vis-à-vis other groups. These inequities lead to grievances, which in turn, often boil over into protests and later violence.
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:
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.
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.
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.
The health programmes in the African region have proven to be able to make a contribution to peace and will continue to contribute more by integrating the three asks into its programmes: making a conflict analysis, being conflict sensitive and being peace responsive. In doing so, health programmes work across the humanitarian–development–peace nexus and contribute to achieving the sustainable peace goals set by the UN General Assembly.
As part of the UN system, WHO is keen to attain further successes by working along the following workstreams of its Global Health for Peace Initiative:
Generating additional evidence on the impact of health for peace projects via the development of strong monitoring, evaluation and learning frameworks for such projects.
Developing awareness and capacities to implement the health for peace approach through the delivery of training and technical support across the three levels of the organisation (headquarters, regional offices and country offices).
Engaging with Member States on the Global Health for Peace Initiative through high-level advocacy work, in order to facilitate the mainstreaming of the health for peace approach by WHO and Member States into public health policies or programmes.
Working alongside other stakeholders, in partnership, so as to increase capacities and support for the Global Health for Peace Initiative.
Updating WHO’s global strategy in respect of the health for peace approach, in a consultation with all relevant stakeholders.
In this way, health programmes will be in a position to achieve WHO’s triple billion targets set by its Thirteenth General Programme of Work as well as the Secretary-General’s agenda for sustaining peace, which in turn leads not only to people’s healthier life and improved well-being but also to stability and peace.
Data availability statement
Data are available in a public, open access repository.
Patient consent for publication
Handling editor Seye Abimbola
Twitter @kevinousman, @hankht
Contributors RC wrote the article. KO, BM and H-TK contributed ideas and contributed to the writing of the article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.