Africa has been plagued by conflicts since the colonial era, and long thereafter. In the period between the 1960s and the 1990s, 48 African countries experienced about 80 violent changes of government. In the same period, 18 countries faced armed rebellion, 11 experienced severe political crises, while only 19 enjoyed political stability in the early 2000s.⁽²⁾ The negative effects of war on the health of populations have been well documented. For instance, Sierra Leone’s civil war, which lasted from 1991 to 2002, left the health infrastructure in that country virtually non-existent. Moreover, the country’s infant and child mortality rates were among the highest in the world in that period.⁽³⁾ This paper examines the effects of political conflict on health systems in African countries, as well as the effectiveness of any restorative measures undertaken in the post-conflict period.

Effects of war on health status and health systems

The consequences of conflict on the health of populations are wide-ranging. Mortality and morbidity are some of the direct effects of conflict. Moreover, rape, torture, post-traumatic stress, sexually transmitted diseases (including HIV/AIDS) and long-term mental health problems are common during and after wars.⁽⁴⁾ Intermediate effects of conflict include the destruction of infrastructure, equipment, and supplies; and the interruption, neglect or abandonment of essential services, such as vaccination campaigns, micronutrient supplementation programmes and other public health efforts. Another indirect effect of conflict is population displacement, with refugees further being susceptible to communicable diseases such as respiratory infections, cholera, malaria and measles.⁽⁵⁾ Furthermore, the breakdown of water, sanitation and hygiene (WASH) systems results in an increase in preventable, communicable diseases, such diarrhoea, malaria and tuberculosis.⁽⁶⁾

When Mozambique experienced civil war from 1975 to 1991, the mortality rate of children under the age of five reached 473 per 1,000 in 1986. At the height of the conflict between 1982 and 1985, the country’s National Health Service became a military target, particularly in its most vulnerable rural areas.⁽⁷⁾ After the conflict, 50% of the health infrastructure in Mozambique was completely destroyed, while the remaining facilities were inadequate and enabled only limited provision of health services.⁽⁸⁾ In addition, policy-making structures were severely weakened, which created a vacuum of authority and illegitimacy in decision-making. This was further complicated by the exodus of policymakers, academics and other necessary health policy actors.

Post-conflict rehabilitation of health systems

The framework for post-conflict rehabilitation of the health sector illustrates the importance of meeting immediate health needs by restoring basic health services, while also planning for the medium and long-term development of the health system itself.⁽⁹⁾ These measures require applicable policies to be put in place, as well as quick, tangible inputs so as to restore basic health services and reduce excess mortality and morbidity rates. The process is described in detail in Figure 1:

Post-conflict rehabilitation of the health sector can be viewed in three parts: (1) an initial response to immediate health needs; (2) the restoration or establishment of a package of essential health services; and (3) rehabilitation of the health system itself.

Figure 1: A framework for the rehabilitation of post-conflict health systems ⁽¹⁰⁾

Inputs

Key inputs that feed into the rehabilitation of health systems include financing, human resources, physical infrastructure, information systems and essential medical supplies. These inputs can be inherited from the pre-conflict health system, donated by international actors, or generated from within the country after the conflict.

Rebuilding and rehabilitating health systems require vast financial resources, especially if the health sector was chronically under-funded before and during the conflict. Capital expenditures on infrastructure and equipment can absorb much of the financial resources, but recurrent expenditures, such as salaries, are also needed for the sustainability of the health system. In post-conflict Mozambique, initial and recurrent expenditures exceed the capacity of national sources; and the government was, and still is, unable to finance and provide basic health services to the entire population without donor support.⁽¹¹⁾ In 1999, Mozambique depended heavily on external financing as the National Health Service relied on outside aid for 50% of its recurrent expenditures and 90% of capital expenditures. The annual government and donor expenditure in the health sector has since stabilised and currently stands at about US$ 100 million per year. In Sierra Leone, a Health Sector Reconstruction and Development Project that was initiated by the World Bank in 2001 was designed to re-establish the provision of health services while simultaneously improving sector capacity destroyed by the conflict.⁽¹²⁾ The first component of the project (to restore sanitation services and treatment services for malaria and tuberculosis) cost an estimated US$15-million. The second component, which was designed to develop and strengthen planning, evaluation, management, budgeting and financing of both public and private health sectors, received almost US$ 6-million in the year 2001. The entire project cost US$21.2-million. Sierra Leone depends heavily on the World Bank and donors to support health programmes.

Human resources

The interruption of normal health services before and during conflicts has tremendous effects on the human resource capacity of the health sector. Many Sub-Saharan African countries experience a chronic shortage in human resources in the health sector, and conflicts exacerbate the situation.⁽¹³⁾ The extent of violence during conflict increases the need for medical care by victims, but also drives out the much-needed health care workers who are in search of safer work conditions and better pay. In the on-going violence along the Chad-Sudan border, Chadian victims have to travel long distances to hospitals as they cannot be treated in clinics near the border due to lack of security in that area. Often, the nearest hospitals are quite far and victims flock there. This leads to over-crowding, which sometimes results in doctors protesting due to being overworked. During conflict there have also been cases where health workers have been specifically targeted and killed by militias in order to prevent them from doing their work. The conflict-ridden state of Kano has some of the highest rates of polio in Nigeria, coupled with other poor health indicators. A contributing factor to the polio epidemic is the fact that health workers are often targeted and pushed out, or killed by militia groups who believe that the polio vaccine kills children and sterilises young girls. In January 2013, nine polio health workers were killed by gunmen in Kano.⁽¹⁴⁾ Polio eradication efforts in Kano remain futile, while polio remains endemic in the rest of Nigeria.

Health workers may need new skills to help them effectively handle new, prevailing concerns that patients present with after the conflict period. For instance, literature has shown that there is a strong rise in domestic violence cases during times of conflict. After the 2007 post-election violence in Kenya, health workers were unequipped to deal with the sudden increase in sexual and gender-based violence (GBV) because they were not adequately trained to provide counselling services.⁽¹⁵⁾ Community health workers, who are the first point of contact in the community, were unable to effectively deal with such cases as they had not been trained on GBV. Health workers should therefore be re-trained to ensure that their service offering remains relevant in the post-conflict period.

Information systems and medical supply systems

Rehabilitating a health system in the period following conflict also requires up-to-date baseline information on the current status of the country’s health system in order to guide prioritisation and policy decisions. An effective health information system is critical as the health sector requires an enormous amount of information concerning the status of the health system and population health indicators at any given time. Since the collapse of Siad Barre’s regime in 1991 and the subsequent inter-clan clashes, Somalia lacked a central government and had been in one of the longest-running wars in Africa until 2012. The conflict ended after the Transitional National Government seized control of most regions in Somalia.⁽¹⁶⁾ During the conflict, the modest health system was shattered and most hospitals were looted and closed down. Presently, Somalia has one of the highest maternal and infant mortality rates in Sub-Saharan Africa. To help rebuild Somalia’s health sector, non-governmental organisations (NGOs) and civil society organisations (CSOs) have formed umbrella organisations with the aim of sharing information on community development needs, as well as strengthening the knowledge and skills base on these needs. Another key input to the health sector rehabilitation is a functioning medical supply system, including a list of essential medicines and systems for procurement, supply, evidence-based prescribing and quality monitoring.

Policy issues

As shown in Figure 1, the main policy issues involved in the rehabilitation of the health sector include: coordination among donors; political commitment by host governments; partnerships with NGOs and prioritisation so as to ensure sustainability of the rehabilitation effort.

There has been a proliferation of international health agencies in post-conflict African countries, and their rapid entry has fuelled a move towards greater coordination of donor inputs.⁽¹⁷⁾ As a result, many influential decisions regarding health systems rehabilitation sometimes take place outside the country, at the headquarters of multilateral and bilateral organisations. This situation presents common challenges in post-conflict health sector rehabilitation: competing objectives and expectations of donors, stakeholders and local government/politicians. It is therefore important for governments and donors to work together to ensure a shared vision, reduce wastage of scant resources and minimise competing interests.

Liberia’s 14-year civil war resulted in near-total destruction of the country’s infrastructure, including health infrastructure. Of the 293 public health facilities operating before the war, 242 were deemed non-functional at the end of the war due to destruction and looting. Doctors and other health workers fled the country, leaving only 30 physicians to serve a population of 3 million.⁽¹⁸⁾ In response to the post-war health challenges, the Ministry of Health and Social Welfare, with assistance from donors and NGOs, embarked on rebuilding the health system. To ensure better coordination between the Liberian Government and donors, the Office of Financial Management was created to help coordinate donor health investments by encouraging donors to pool their funds to permit better integration of health sector programming. Bilateral donors, such as the United Kingdom Department for International Development (DFID) and Irish Aid, among others, now contribute to the pool fund. The United States Agency for International Development (USAID) has merged funding from two Global Health Initiatives – the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative - to focus on health sector rebuilding that reflects the priorities of the Government of Liberia.

Post-conflict governments’ ability to develop national health policies for the rehabilitation of the health sector greatly influences donors’ intentions to provide support.⁽¹⁹⁾ African countries recovering from war must be able to show donors that they can effectively manage the resources, an exercise that is partly dependent on the existence of a feasible national health policy strategy, starting with clear, achievable goals. For example, Mozambique’s Ministry of Health did not have a health policy in place in 1992,⁽²⁰⁾ and the demands of reconstruction often side-lined planning activities; these incompatible goals led to the rejection of proposals by donors. By developing an extensive, achievable health policy that aligned resource reallocation with actual health needs and outlined how neglected regions would benefit, Mozambique was able to attract coordinated donor support.

The rehabilitation of the health sector after conflict involves efforts to maximise positive outcomes with constrained resources; as such, the rehabilitation process requires prioritisation when resources are allocated. Areas that need to be prioritised may be different depending on the needs and context of each post-conflict country.⁽²¹⁾ In Liberia, rebuilding rural health clinics after the war was considered a priority, including promoting equity between urban and rural areas. In Somalia, where the central government was non-existent, NGOs established relationships with health ministries to promote service development.

Failure to prioritise can lead to inefficient and ineffective use of resources, which can reduce the intended impact on health outcomes. In the 1980s, Uganda’s resource allocation patterns depended heavily on vertical programmes, capital investments, and tertiary care.⁽²²⁾ For example, of the US$202 million allocated in the national plan for health sector rehabilitation, nearly half was dedicated to infrastructure, including the construction and rehabilitation of hospitals. The majority of the remaining funds were directed towards the restoration of vertical programmes for immunisation and lists of essential medicines. Although the health infrastructure improved and immunisation coverage increased, the negative consequences of Uganda’s approach were significant. The vertical programmes addressed neither capacity building for personnel nor the integration of disease-specific priorities into the overall health system. In addition, significant increases in recurrent expenditures far exceeded Uganda’s financial capabilities, which threatened the sustainability of those programmes. Therefore, the limited availability of resources must be carefully considered before setting national health priorities and embarking on any rehabilitation programme.

Concluding remarks

Although each post-conflict situation in Africa is unique, there are some underlying valuable lessons which can be applied across contexts. Attention needs to be paid to inputs and policies before embarking on rehabilitation. It is also important to consider factors such as donor support, supportive political processes and local capacities such as human resources and efficient information systems, which all affect the success of health systems rehabilitation in varying degrees.

Written by Janet Mugo ⁽¹⁾

NOTES:

(1) Contact Janet Mugo through Consultancy Africa Intelligence's Public Health Unit (public.health@consultancyafrica.com). This CAI discussion paper was developed with the assistance of Tsholofelo Thomas and was edited by Liezl Stretton.
(2) Bujra, A., ‘African conflicts: Their causes and their political and social environment’, 2002, Development Policy Management Forum Addis Ababa,  http://dpmf.org.
(3) ‘Sierra Leone's long recovery from the scars of war’, Bulletin of the World Health Organization: Volume 88:2010, http://www.who.int. 
(4) Omoigui, N., ‘Public health implications of conflicts in Africa’, http://www.dawodu.com.
(5) Waters, H., Garrett, B. and Burnham, G., ‘Rehabilitating health systems in post-conflict situations’, World Institute for Development Economics Research, January 2007, http://www.wider.unu.edu.
(6) David R.D., ‘Violent conflict and its impact on health indicators in Sub-Saharan Africa, 1980 to 1997’, Emory University, 2002, http://userwww.service.emory.edu.
(7) Ibid.
(8) Teklemichael, N., ‘Consequences of war, health and forced migration, WHO/AFRO regional perspectives’, WHO Brazzaville, 1996, http://desastres.usac.edu.gt.
(9) Ibid.
(10) Ibid.
(11) Pavignani, E. and Durão, J., 1999. Managing external resources in Mozambique: Building new aid relationships on shifting sands? Health Policy and Planning, 14(3), pp. 243-253.
(12) Ibid.
(13) ‘Africa’s conflicts worsen health worker shortage’, Voice of America, 27 October 2009, http://www.voanews.com. 
(14) Chukwuemeka, M., ‘Gunmen kill nine polio health workers in Nigeria’, Reuters, 8 February 2013, http://www.reuters.com.
(15) ‘Report on the effects of the 2007 post-election violence on health workers and the preparedness of the healthcare system in Kenya’, Health Rights Advocacy Forum, 2008, https://docs.google.com.
(16) ‘Health systems profile - Somalia’, Regional Health Systems Observatory- EMRO, http://gis.emro.who.int.
(17) Ibid.
(18) Kruk, M. 2010. Availability of essential health services in post-conflict Liberia. Bulletin of the World Health Organization, 88, pp.527-534, http://www.who.int.
(19) Ibid.
(20) Pavignani, E. and Colombo, A., ‘Providing health services in countries disrupted by civil wars: A comparative analysis of Mozambique and Angola 1975–2000’, World Health Organization, 2001, http://www.who.int. 
(21) Haar, R. and Rubenstein, L., ‘Health in post-conflict and fragile states’, United States Institute of Peace, January 2012, http://www.usip.org.
(22) Ibid.