By Sally Theobald and Nick Hooton
Universal Health Coverage in a world of conflict
As we mark Universal Health Coverage (UHC) Day 2015, and with UHC now firmly established in the Sustainable Development Goals (SDGs) which will guide health interventions to 2030, we do this against a global background of widespread ongoing conflict and numerous post-conflict states. Some of the most disadvantaged people are the worst affected, and this represents one of the greatest challenges to progress towards UHC whilst ‘leaving no one behind’.
Millions of the world’s poorest people already live in conflict-affected settings, with the proportion of the world’s poor living in these settings growing and projected to reach 50% by 2018. And of course the poor and their health are disproportionately affected by conflict.
So how can we hope to move towards UHC in the complex and uncertain contexts of conflict and fragility? The ReBUILD Consortium has been researching issues of health systems strengthening in these settings, and our findings are starting to give some insight into this challenging question.
Health systems are severely affected by conflict, and the poorest and disenfranchised are disproportionally affected
The health needs of the many poor people in conflict and post-conflict states have increased and their access to services is either poor or non-existent. Maternal deaths and under-five mortality rates are much higher in fragile and post-conflict states. On average, FCAS are four times more likely to be off track or lack sufficient data to monitor MDG targets than they are to have met or be on track to meet targets. ReBUILD research used a life histories approach with affected communities in northern Uganda. This work clearly demonstrates the catastrophic costs of seeking care during and post conflict, and how some groups – such as widows – who often have large numbers of dependents and very limited livelihoods strategies, are particularly adversely affected.
To achieve UHC, we need to build resilient, responsive and equitable health systems in fragile contexts. ReBUILD researchers have been exploring the experience of health workers through times of conflict in northern Uganda, Sierra Leone, Zimbabwe and Cambodia, using the same life histories approach. During conflict, health workers can be targeted or captured, and many flee; infrastructure is damaged; records are lost or destroyed; drug supplies can be fragmented and unreliable. Yet many health workers remain in post and show great resilience in maintaining service to communities in conflict, including disguising themselves to get to work, and often risking their own lives to deliver vital health care. The factors underpinning such resilience need to be reinforced and rewarded if UHC is to be achieved.
It is no coincidence that Ebola has spread in countries in West Africa that have emerged from conflict with severely weakened health systems. And Ebola has shone a spot light on the critical importance of strong health systems that are accessible to, and trusted by, poor and marginalised communities. Our ReBUILD platform of research in Sierra Leone on health workers’ experiences during and after conflict, and during the Ebola outbreak has informed the post-Ebola recovery plan and highlighted the importance of strong support packages for front line health workers.
Realising universal health coverage in fragile and conflict-affected contexts also means understanding and addressing the ways in which gender, power and conflict shape the experiences and needs of different communities and their ability to access services, as well as ensuring efforts to support and rebuild health systems that meet the needs of all citizens.
The rallying calls of Universal Health Coverage and the Sustainable Development Goals are a platform for further action on health and conflict
Better understanding of how to build strong and equitable health systems in conflict-affected settings is critical to action for progress towards both Universal Health Coverage and the Sustainable Development Goals. SDG 3 on good health and well-being for all is arguably inextricably linked to SDG 16 on peace, justice and strong institutions. And donors’ own strategies are increasingly reflecting the need to work differently in fragile and conflict-affected states, whilst maintaining commitments to achieving health goals, including through research.
UHC is not only a noble, but an achievable goal. In line with nobody being left behind, we must continue to work hard to include those living in conflict-affected settings, and we are starting to understand a little more about the approaches needed. Much more needs to be done, beyond the work which will be coming from ReBUILD and others. But with the current global situation, we need not only to understand how better to build resilient, responsive and equitable health systems in conflict-affected settings, but to ensure this knowledge is used – or the goal of UHC will not be achieved for huge numbers of the world’s most vulnerable people.
Be part of the solution
Join a growing community: The Health Systems Global Thematic Working Group on Fragile and Conflict Affected States has over 400 members and is a forum for policy makers, practitioners, advocates and researchers to share best practice on building strong and responsive health systems in these challenging and critical contexts.
Access resources: The ReBUILD website has a growing number of resources from our research on health systems from Sierra Leone, Zimbabwe, northern Uganda and Cambodia. The new online resource Building Back Better has ideas and resources (including case studies) for all groups about how to address gender and equity in health systems rebuilding in post-conflict contexts, and encourages all stakeholders – researchers, advocates, donors and practitioners – to ‘be part of the solution’.