Rebuilding health services after conflict: lessons from East Timor and Afghanistan

The response of the public health community to international political emergencies has been the subject of a growing body of literature since the mid-1980s. Descriptions of the epidemiological characteristics of different emergency settings and narratives of the experiences of NGOs are, fortunately, beginning to appear with increasing frequency in a number of peer-reviewed public health and medical journals, as well as in other fora. In addition, since the heavily-criticised humanitarian effort in Goma in 1994, a number of projects seeking to establish professional standards, guidelines and recommendations for the conduct of emergency relief have emerged.

The same cannot be said for the transition from emergency relief to longer-term development, however. While there are a number of overviews of the subject, some quite comprehensive and keenly analytical, and a few sets of guidelines aimed at helping those working on the ground to avoid some of the many potential pitfalls of a post-conflict environment, there are few experience-based accounts of what it takes to rebuild a destroyed health system.

Filling the gap

A recently published monograph from the National Research Council of the National Academies (US) and the Mailman School of Public Health of Columbia University takes a giant step toward filling this gap. It is an instructive, readable essay that discusses what went right, and what went wrong, with the attempts to rehabilitate the health system in East Timor after independence from Indonesia in May 2002. The authors, from the UN Transitional Administration in East Timor (UNTAET), the World Bank and the international health authorities that ultimately became the fledgling Ministry of Health, present an honest, and at times self-critical, picture of both the strengths and weaknesses of the various actors, including international NGOs, bilateral donors, UN agencies and themselves.

The authors recognise and address the fact that, in all post-conflict settings, an important set of competing priorities must be resolved. National authorities, donors, NGOs and international agencies all have programmatic and institutional objectives. Perhaps the most important message is that pressure on donors to disburse funds as quickly as possible, frequently through international NGOs, and to achieve measurable results in the short term, should be resisted in order to achieve a full transition from international to national control; to enable adequate attention to capacity-building; and to ensure that efforts can be sustained when external funds begin to dwindle.

Key recommendations

While the authors recognise that, at the time of writing, it was too early to pass judgment, they describe a series of successes and failures of process in an attempt to forge recommendations for the international community to apply in other, similar, circumstances. Specifically, they cite the following:

1. A sector-wide approach to planning should be adopted from the outset; individual donors’ needs for specific, ‘vertical’ programming should be resisted.
2. The involvement of national authorities is more important than making the most rapid progress possible – the focus should always be on sustainability.
3. A full and professional assessment of the physical health infrastructure, as opposed to the rapid assessments of the health situation that are standard practice during the emergency phase, should be carried out by experts.
4. In order to achieve reasonably rapid results, compromises should be made, given the limited capacity of national authorities, in standards of quality, procurement procedures and mechanisms of financial accounting.

East Timor and Afghanistan compared

Since the independence of East Timor, a number of other post-conflict interventions have attracted the attention (and the money) of the donor and humanitarian communities. From Bosnia to Sierra Leone, Kosovo to Somalia, and Cambodia to Angola, different courses of action are being taken, for different reasons, and with different results.

The East Timor team found that a sector-wide approach was ‘critical’ to soliciting cooperation between all of the actors – UN agencies, NGOs and bilateral donors – throughout the course of the reconstruction effort. Rather than pursuing individual, ‘vertical’, projects, the East Timor Health Sector Rehabilitation and Development Program (HRSDP) developed district health plans. These represented a substantial reduction of the system that had existed prior to independence.While this was threatening to NGOs, which might be put out of business, and to health workers, who might not find jobs in the leaner structure, the sum of the district plans constituted a more sustainable health system that could still meet at least the basic health needs of the population. Although no ‘common basket’ was established into which donors would contribute, an adequate level of donor coordination was achieved to ensure support to core programmes, and to minimise duplication.

In contrast, although development issues were not entirely neglected, the early thrust of health sector rehabilitation in Afghanistan following the conflict there in late 2001 came through vertical programmes. National immunisation days aimed at the eradication of polio and the interruption of measles transmission were highly successful. Spearheaded by UNICEF and WHO, with the cooperation of many of the NGOs operating in the health sector, these mobilised and motivated a previously near-dormant cadre of health personnel; showed a sceptical populace that the new government was intent on bringing essential health services to the most peripheral communities; and established an early record of success that was convincing to both donors and implementing agencies, including the then-rudimentary Ministry of Health. From a technical standpoint, these programmes helped to establish a health information system that functioned reasonably well, and was able to provide sorely-needed data on a number of essential health conditions and services.

East Timor and Afghanistan were different in many ways, and perhaps they cannot be compared directly, but they have at least one essential feature in common – health manpower is severely limited. This is true not only for implementation capacity – the ability to adequately staff health facilities, especially at the more peripheral levels of the system – but also for management capacity, which is particularly weak. More highly-trained health personnel, such as physicians and nurses, are in short supply, demand higher salaries from the civil service system than can readily be afforded, and are reluctant to serve in distant, rural communities. How can the international community, given these circumstances, ensure both adequate service provision and a rapid handover of control of health services to national authorities? The World Bank, building on a scheme first supported by the Asian Development Bank in Cambodia, has been proposing an arrangement whereby international NGOs compete with each other in post-conflict settings for government contracts, under which they would be reimbursed in accordance with their performance. This has a number of potential advantages and disadvantages, summarised in an early analysis of the needs of the post-conflict Afghanistan health system carried out by the Afghanistan Research and Evaluation Unit (AREU) in July 2002. In East Timor, the Division of Health Services, the first successor to the Interim Health Authority, rejected this scheme, for reasons that are not well explained in the Initial Steps monograph, other than saying that the decision was ‘based on feedback from the field, of the support being provided at that time by NGOs and its cost’.

In Afghanistan, as in East Timor, the implementing role of international NGOs was discussed at length. A system of performance-based partnership agreements was instituted, whereby one or a consortium of NGOs could make proposals to the government to provide a relatively full range of health services throughout a province. Proposals were to be considered on a competitive basis, and the Ministry of Health would oversee the awards and the monitoring of NGO performance. The perceived benefits to the Ministry of Health are that rural areas would be adequately served, technical performance could be maintained at an acceptable level, and the number of civil servants for whom recurrent salaries would pose a considerable short- and medium-term burden would be limited.

Key players

The authors of the East Timor monograph are critical of the inability of the World Bank, the principal donor in that setting, to modify its usual procurement mechanisms in order to hasten the reconstruction process. (In fact, too much money may have been available in the early stages of the reconstruction programme, allowing NGOs to rehabilitate health facilities in some areas before the finalisation of district health plans. In some instances, these facilities would have been designated for closure in the streamlined health system.)

With regard to the NGOs, the authors found it difficult to make many declarative statements or recommendations because of the diversity of their organisational missions and their differing levels of competence. What they do say of the East Timor situation, if true, applies equally to Afghanistan and most other emergency settings. They observed that NGOs with expertise in responding to emergencies are frequently not equipped, both philosophically and technically, to work in post-conflict or developmental settings. In fact, the authors find little difference between the two:

the post-conflict aspect … should not be exaggerated. This can be a convenient label for NGOs … looking for a new niche … to expand their role beyond emergencies (without necessarily changing their expertise) …. most of the problems facing the health sector in East Timor were those facing developing countries in general.

The transition from emergency relief to a post-conflict stage and/or to development can be complicated. Some of the major donors have entirely separate (and poorly communicating) organisational units dealing with these settings. The passage of authority, and with it operational procedures and measures of accountability, is never as clear as one would like. From the NGO standpoint, minimum standards in disaster response, such as those laid out in the Sphere project, are increasingly used in programme planning, implementation and evaluation. But there are no minimum standards for post-conflict interventions, and there is a risk of the minimums for emergency relief becoming the mid-term targets. The extent to which this occurs is not known, but national authorities, the donor community, UN agencies and NGOs all need to be made more aware of the risks.

None of the authors’ experiences in East Timor should be taken as prescriptions for how to rehabilitate health services in a post-conflict setting. Although different decisions were made in Afghanistan, it is far too soon to tell whether these courses of action will be beneficial in the long run. In any case, the recommendations of the monograph seem to flow logically from the East Timor experience, as it is described. Undoubtedly, in each post-conflict setting, there will be a range of options to be explored in regard to programme planning and problem solving. The health care needs of the population must be carefully balanced, and the way forward should be tailored to the characteristics of the setting.

Initial Steps concludes with a call for more documentation of post-conflict experiences. ‘Unless experience is recorded and analyzed, changing the way various organizations do business, people will keep repeating the same mistakes and running into the same obstacles.’ If this message is taken to heart, this monograph will have served an admirable purpose. But, in addition, it is a unique critical analysis, by those responsible for the field implementation of a post-conflict rehabilitation programme, of the diverse factors affecting both the successes and the failures of their work.

Ronald Waldman is Deputy Director of the Center for Global Health and Economic Development at the Mailman School of Public Health, Columbia University.

References and further reading

The East Timor monograph is entitled Initial Steps in Rebuilding the Health Sector in East Timor, by J. Tulloch J, F. Saadah, R. M. de Araujo, R. P. de Jesus, S. Lobo, I. Hemming, J. Nassim and I. Morris. It is published by National Academies Press (Washington DC, 2003), and is available at www.nap.edu/books/0309089018/html.

This is the second in a series of monographs from the Roundtable on the Demography of Forced Migration of the Committee on Population of the National Research Council.

The AREU assessment, The Public Health System in Afghanistan by R. J. Waldman and H. Hanif, is available at www.areu.org.pk/publications.html.