ReviewHealth financing in fragile and post-conflict states: What do we know and what are the gaps?
Highlights
► Despite a growing interest in fragile and post-conflict countries, the scope of health financing literature is limited. ► The focus is on the role of donors immediately post-conflict with less attention paid to the longer term trajectory. ► Research priorities include understanding the mix and sequence of financing mechanisms and their access and equity effects. ► In terms of methods, there is a need for more robust methods and more longitudinal studies.
Introduction
State fragility remains one of the most significant challenges for the well-being of affected populations and progress towards the Millennium Development Goals (Bornemisza, Bridge, Olszak-Olszewski, Sakvarelidze, & Lazarus, 2010). While there are many different definitions adopted for fragility (Canavan & Vergeer, 2008), many of the states classified as fragile are also post-conflict. The 46 states currently defined by the UK Department for International Development (DFID) as fragile are significantly worse off than non-fragile states in terms of key health indicators and social determinants of health. Half of these states are conflict-affected. Analysis has revealed that conflict-affected fragile states are significantly worse off in comparison with non conflict-affected fragile states (Ranson, Poletti, Bornemisza, & Sondorp, 2007). The national health system is also a victim of conflict, with destruction of clinic and hospital infrastructure, the flight of health professionals, and the interruption of drugs and other medical supplies (Kruk, Freedman, Anglin, & Waldman, 2010).
Health financing is one of the main health system building blocks (World Health Organisation, 2007), and so a key component of re-establishing health systems post-conflict. This paper reviews existing literature to examine what is known about health financing challenges in states emerging from conflict and to identify priority areas for research. It starts by setting health financing in the context of health systems development in post-conflict states and then reviews studies on a range of health financing topics, starting with resource raising and pooling strategies, followed by resource allocation, purchasing and provision of services.
Section snippets
Definitions
A country or area is considered to be post-conflict when active conflict ceases and there is a political transformation to a recognized post-conflict government (Canavan, Vergeer, & Bornemisza, 2008). The transition to post-conflict status is however not linear, as political settlements often take years, and about 40% of countries collapse back into conflict (Collier & Hoeffler, 2004). Poorer countries are more likely to be affected by conflict and are also more likely to relapse into conflict (
Research methods
This article is based on a global literature review carried out in 2011. As the study used secondary data, no ethical approval was required. The objective was to carry out an exploratory analysis of approaches, themes and findings of recent writing on health financing in post-conflict or fragile health systems. Published studies from the past decade (2001–2011) were sought, using the following search terms: conflict, post-conflict, reconstruction, fragile, combined with health, and any of the
Health financing and health systems development in fragile and post-conflict states
In fragile states, the health system building blocks are by definition weak and incomplete – they were either never fully functional or they have suffered from a period of neglect and decay (Eldon, Waddington, & Hadi, 2008). Characteristics of fragile health systems include the following (Newbrander, Waldman, & Shepherd-Banigan, 2011):
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inability to provide health services to a large proportion of the population;
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ineffective or nonexistent referral systems;
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a lack of infrastructure for delivering
Aid and aid effectiveness
Another cross-cutting theme relates to aid and aid effectiveness. The literature on post-conflict and fragile states is dominated by discussion of the role of donors. Although relevant to health financing, this will not be reviewed in full here, as it is broader in scope. Topics include how to manage the transition from humanitarian to development aid (Canavan et al., 2008; Newbrander et al., 2011). A number focus on good practices for aid in fragile and post-conflict settings, including the
Financing strategies
Few countries – in general, and perhaps especially post-conflict countries – have a clear health financing strategy, to indicate the volume and trajectory of different funding sources and their implications for sector development (Rothman et al., 2011).
As countries emerge from conflict during the early post-conflict period, NGOs generally provide most of the services and are financed by international assistance (Newbrander et al., 2011). Over time, as government is supposed to gain the capacity
Resource allocation
Resource allocation is not a common topic in literature on post-conflict or fragile states, perhaps because it implies an organised approach to distributing resources which is lacking in many weaker health systems. These are characterised by what some have called ‘fragmented, escapist decision-making’ (Pavignani & Colombo, 2009, p. 142). However, financing allocation formulae that recognize the disproportionate need in areas experiencing greater violence and with more vulnerable populations
Contracting
One of the first contracting experiments in a post-conflict setting was carried out in Cambodia between 1999 and 2003. Studies found that when contractors (who were mostly international NGOs) entered into contractual obligations to provide health services, they performed better than the government at reducing inequities (Bhushan, Keller, & Schwartz, 2002; Bloom et al., 2006; Loevinsohn & Harding, 2005). Early experiences of USAID in Haiti with partially performance-related contracts for NGOs
Working with non-state actors
There is a substantial literature on working with non-state actors in post-conflict and fragile states, which overlaps with the contracting literature. In dealing with these contexts, donors have frequently adopted a strategy that substitutes an international agency or NGO for the state. This is particularly the case in humanitarian emergencies, where there is a short-term urgent need to provide access to certain services. Internationally recognised bodies then take on some, or all, of the
Discussion and conclusions
This literature review was not exhaustive. It focussed on publications in the period 2000–2011 and on English-language publications. It sought publications that focussed on health financing, with a fragile states or post-conflict lens. There were studies about health financing in post-conflict states which were excluded because they did not explicitly consider the context implications. In addition, drawing boundaries during study selection inevitably involved an element of judgement about which
Acknowledgements
This work was carried out as part of ReBUILD research programme (Research for building pro-poor health systems during the recovery from conflict), funded by the UK Department for International Development. My thanks go to Professor Barbara McPake for comments on an early draft.
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