Health Policy in the context of fragile state

1. Health Policy in the context of fragile state Fouad M.Fouad MD RESCAP-MED Capacity Development Workshop Health Policy Evaluation Amman, Jordan 3-6 June 2013

3. Fragile state? Failed state? OR Political crisis?

4. What is a fragile state? • A fragile state (WB) is a low-income country characterized by weak state capacity and/or weak state legitimacy leaving citizens vulnerable to a range of shocks • It includes: • post-conflict/crisis or political transition situations • deteriorating governance environments • situations of prolonged crisis or impasse The opposite of a "fragile state" is a "stable state"  Country contexts vary widely in this group of countries ranging from Haiti to Nepal, from Uzbekistan to Burundi.

6. 35 countries are classified as “ Fragile” • 8 countries from EMR: (Afghanistan, Somalia, Sudan, Yemen, West Bank and Gaza, Iraq, Libya, and Syria)

7. What’s is a failed state? • A failed state* is a state perceived as having failed at some of the basic conditions and responsibilities of a sovereign government. (fund for peace)

8. Indicators of a failed state Social  • Mounting demographic pressures. • Massive displacement of refugees, creating severe humanitarian emergencies. • Widespread revenge-seeking group grievance. • Chronic and sustained human departure. Economic  • Uneven economic development along group lines. • Severe economic decline. Political  • Criminalization and/or delegitimization of the state. • Deterioration of public services. • Suspension or arbitrary application of law; widespread human rights abuses. • Security apparatus operating as a "state within a state“ • Intervention of external political agents.

9. 33 countries are classified under “Alert”: • Seven are from EMR (Somalia, Sudan, Afghanistan, Yemen, Iraq, Syria , and Egypt)

10. What’s political crisis • It would refer to the immediate problems faced by the Government dealing with itself. 

11. A fragile state

12. Two criteria in which they judged • Legitimacy:is the determination and ability of government to work in the interest of the public and to demonstrate fairness to all groups • Effectiveness:means the ability of government to maintain security and order and to provide public goods and services to citizens These elements are interrelated because the lack of capacity or willingness of governments to respond to people’s basic needs— food, health, sanitation, security, shelter and water—means that people feel betrayed by government ineffectiveness (OECD, 2008).

13. Classifying a country in light of both legitimacy and effectiveness is more useful than looking at a single dimension. • limited legitimacy due to political events yet continue to be reasonably effective in delivering essential services. • Or some elements of a collapsed state with respect to accountability, resource management, and financing but show positive signs in delivering services and exercising stewardship.

15. Content/ scope of public health policy Wide Narrow • The focus is health care, health policy is that related to health care delivery and funding activities ‘healthcare policy’ (Walt, 1994). • Deals with the components of health care system • Health policy is concerned with improving the overall health status of the population (Walt, 1994). • It goes beyond healthcare, and considers all that have an impact on health, ‘inter-sectoral health policy’ [WHO, 2000], healthy public policy”, “Health in all Policies“.

16. Public health policy • Narrow scope: • related to health care delivery and funding activities ‘healthcare policy’ • Wide scope • considers all that have an impact on health, ‘inter-sectoral health policy’ [WHO, 2000], healthy public policy”, “Health in all Policies“.

17. Characteristics of health system (WHO, 2007) Effective health system (WHO, 2007): 1. Good health services 2. Well-performing health workforce; 3. Well-functioning health information system 4. Equitable access to medical products, vaccines and technologies 5. Good health financing 6. Solid leadership and governance.

18. “Healthy public policy” • Government responsibilityto ensure that the ‘total’ environment, which is beyond the control of individuals and groups, is conducive to health. • The “Healthy public policy”, health is mainstreamed in all public policies, by an accountability for health impact. • The main aim of “healthy public policy” is to create a supportive environment to enable people to lead healthy lives.It goes beyond healthcare, and considers all sectors that have an impact on health.

19. Health System characteristics in fragile states: • inability to provide health services to a large proportion of the population outside urban areas; • ineffective or nonexistent referral systems for the critically ill; • a lack of infrastructure (including facilities, human resources, equipment and supplies, and medicines) for delivering health services—what did exist has been destroyed or severely compromised due to war and/or neglect; • nonexistent or inadequate capacity-building mechanisms and systems, such as national clinical training programmes, to address the dearth of clinical and management capacity; • insufficient coordination, oversight and monitoring of health services by the emerging government, which may not have the capacity to manage;

20. a lack of equity in who receives the available health services: few public health services exist for the poor and in rural areas; • a lack of policy mechanisms for developing, establishing and implementing national health policies; • non-operational health information systems for planning, management and disease surveillance; and • inadequate management capacity and systems (such as budgeting, accounting and human resource management systems) for controlling resources.

21. A model for health policy analysis(Walt & Gilson, 1994).* CONTEXT • ACTORS • local NGOs • Int. organizations • UN agencies • MoH/other governmental actors POLICY PROCESS CONTENT

22. Policy Context: factors that affect health policy in fragile states • Context refers to the systematic factors- economic, political, and social, both national and international- which may have an effect on health policy. • Situational/ temporary factors: war, lack of control • Structural factors: • Political system dismantlement, question of legitimacy, international connections/disconnection • Economy and development inflation, economic collapse • Demographic displacement/refugees, fertility, mortality • Technology : changes in technology e.g. drugs, diagnostics, treatment etc. 3. International and exogenous factors: • international agencies, NGOs, World Bank, UN- WHO • international cooperation, bilateral projects and donors.

23. A model for health policy analysis(Walt & Gilson, 1994).* CONTEXT • ACTORS • local NGOs • Int. organizations • UN agencies • MoH/other governmental actors POLICY PROCESS CONTENT

24. Power and the policy process • Understanding policy making process requires understanding the relationship between power and decision making . • Who has the power in fragile state? • Local leaders • Donors • Politicians • Military commanders • International organizations • Decision making is the result of power struggles between competing groups of actors.

25. What are the sources of power in fragile states? • Force (law) (violence, military, coercion). • Resource, economic (wealth such as money, property, food, ..) • Delegated authority (position, hierarchy, legal,……) • Social class • Expertise (ability, skills) (the power of medicine to bring about health) • Knowledge (granted or withheld, shared or kept secret) • Celebrity • Persuasion, moral persuasion (including religion) • Social influence of tradition • Personal or group charisma Motasem Hamdan, PhD.

26. What are the possible ways in FS?: • intimidation and coercion (use the stick) • productive exchanges involving mutual gain (use the carrot) • the creation of obligations, loyalty and commitment, is a function of the ability to influence others by shaping their preferences (use the hug)

27. A model for health policy analysis(Walt & Gilson, 1994).* CONTEXT • ACTORS • local NGOs • Int. organizations • UN agencies • MoH/other governmental actors POLICY PROCESS CONTENT

32. Health systems and infrastructureduring crisis • Prioritizing health services • Supporting national and local health systems • Coordination • Primary health care • Clinical services • Health information systems

33. Health systems and infrastructureduring crisis • Prioritizing health services • Supporting national and local health systems • Coordination • Primary health care • Clinical services • Health information systems

34. Prioritizing health services All people have access to health services that are prioritized to address the main causes of excess mortality and morbidity. 1. Conduct an initial assessment; 2. Identify the major causes of morbidity and mortality; 3. Use evidence-based intervention to address major causes of morbidity and mortality 4. Develop a health information system to identify epidemics and guide changes needed in interventions.

35. Proven interventions in emergencies include the following: • Provision of sufficient water; • Adequate access to sanitation; • Measles immunization; • Food aid and food security; • Shelter; and • Basic clinical services

36. shelter vaccination

37. water Non-food items

38. Ensure access to health services • Identify vulnerable groups and their specific needs • Organize services to improve access to vulnerable groups • Involve community members and other concerned groups in the initial assessment and in the design and development of interventions • Seek women’s views about health problems and ways to improve health services.

39. Health systems and infrastructureduring crisis • Prioritizing health services • Supporting national and local health systems • Coordination • Primary health care • Clinical services • Health information systems

40. Supporting national and local health systems Health services are designed to support existing health systems, structures and providers.

41. emergency phase • Support the efforts of the agency responsible for leading the health sector • Support and strengthen local health facilities • Support and integrate local health workers into health services • Incorporate or adapt the existing standards and guidelines of the host country. post-emergency phase • If parallel health services exist, integrate health services for displaced persons with the health services for the local population • Increase efforts to involve community members in health promotion activities

42. Health systems and infrastructureduring crisis • Prioritizing health services • Supporting national and local health systems • Coordination • Primary health care • Clinical services • Health information systems

43. Coordination People have access to health services that are coordinated across agencies and sectors to achieve maximum impact • Interact and participate with established coordination mechanisms within the health sector and between the health sector and other sectors; • Clarify and document the agency’s specific responsibilities in consultation with the lead health authority; and • Ensure that agency staff members attend regular coordination meetings.

45. Health systems and infrastructureduring crisis • Prioritizing health services • Supporting national and local health systems • Coordination • Primary health care • Clinical services • Health information systems

46. Primary Health Care Health services are based on relevant primary health care principles. emergency phase • Ensure access to health information for the affected population; • Provide health services at the appropriate level of the health system; • Utilize the referral system established by the lead health authority; • Base health services and interventions on scientifically sound methods; and • Utilize appropriate and socially and culturally acceptable technologies.

47. Post-emergencyphase • Ensure equity • Utilize an inter-sector approach • Expand health promotion and prevention services

48. Health systems and infrastructureduring crisis • Prioritizing health services • Supporting national and local health systems • Coordination • Primary health care • Clinical services • Health information systems

49. Clinical services People have access to clinical services that are standardized and follow accepted protocols and guidelines

50. Emergency phase • Ensure that health facilities are appropriate to meet the needs of the affected population; • Staff each health facility with a good gender/ethnic balance of workers that reflects the affected population; • Ensure an adequate number and that there is the appropriate type of staff to meet the health demands of the population without overworking the health workers; • Monitor the utilization rates of the health facilities and take corrective measures if there is over- or under-utilization; • Support the lead health authority in establishing standardized case management protocols