Bridging the humanitarian-development divide in the health sector


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Photo © Dominic Chavez/World Bank

This blog originally appeared on the Huffington Post blog.

The bloody civil wars that wracked Sierra Leone and Liberia in the 1990s did more than kill hundreds of thousands over the course of a decade. They also decimated the health systems of both countries, setting the stage for the rapid spread of Ebola and threatening global health security.

These countries are not unique. Over 2 billion people, and a growing share of the world's poor, live in the 35 countries considered fragile or conflict states in 2016. And whether we are talking about pandemics, war, or prolonged occupation, these conditions devastate health systems and have lasting impacts on the physical and mental health of affected populations. As a result, we find some of the poorest health outcomes in fragile contexts with infant and maternal mortality rates multiples of those that in non-fragile countries at similar income levels.

There is a growing recognition that, in order to make meaningful progress towards attaining the Sustainable Development Goals and to eradicate poverty and boost shared prosperity, the development community must make special efforts to reach these settings. Which is why the focus of the Fourth Global Symposium on Health Systems Research in Vancouver -- building resilient and responsive health systems -- is so relevant.

During the course of conflict, the health sector tends to be doubly affected: as demand for health services increases due to the rise of injuries and mental health conditions, supply is disrupted due to targeting of health infrastructure and provider flight. This has been starkly highlighted in Syria where there are only 29 physicians left in Eastern Aleppo which is under siege and is home to a quarter million people. Similarly in Gaza, with an ongoing blockade and three recent wars, there remain four psychiatrists for a population of close to 2 million people.

An increased need necessitates an increased response. Traditionally, humanitarian actors have provided much needed relief in settings affected by conflict and violence. But with the average conflict lasting 17 years and the top ten engagements of humanitarian groups like the Red Cross lasting 35 years, there is an urgent need for humanitarian and development actors to work together and bridge the humanitarian-development divide. This was emphasized at the World Humanitarian Summit in Istanbul in May 2016 where over 35 humanitarian and development agencies signed onto the "Grand Bargain" where they pledged to "collaboratively work across institutional boundaries on the basis of comparative advantage".

So what is the comparative advantage of development actors?

Agencies like the World Bank Group can help finance work in fragility: providing multiyear grants to humanitarian agencies that allow for long- term planning; crowding in new players such as the private sector to help fund interventions in the humanitarian health space; and developing innovative health financing instruments such as development impact bonds for conflict or a global insurance mechanism for pandemics.

Through their neutral convening platforms, development agencies can also bring together multiple stakeholders to develop a medium to long term vision for the health sector and share islands of innovation.

Finally, the high level analytic work development agencies conduct can push the frontiers of what can be accomplished in these settings, for example by driving impact evaluations in fragile contexts to create a body of evidence of "what works" or developing cutting edge tools which employ Big Data to analyze the health needs of populations.

One example of such analytic work is the World Bank's programmatic approach to strengthening health service delivery resilience in fragile, conflict, and violence settings. The work, generously funded through the State and Peace Building Fund, tests catalytic pilots in frontier settings and aims to inform how global health efforts can best accelerate progress in fragile contexts and humanitarian crises.

The series of pilots include tools to assess the cost of conflict on the health sector; approaches to build up the health sector in South Sudan; addressing service delivery constraints in ARMM Philippines; health systems strengthening in post pandemic settings such as in the post-Ebola countries of Liberia, Guinea, and Sierra Leone; and approaches to improve emergency care under fragility and conflict in the occupied Palestinian territories. We are privileged to share this work at the 2016 Health Systems Research Symposium, joining over 2,000 leading global health thinkers and practitioners on health systems.

A bridging of the humanitarian-development divide is essential to mitigating the impacts of current crises and reducing the probability of occurrence of future ones. And while the challenges to closing the strategic and institutional gaps between humanitarian and development organizations, securing flexible and long-term financing, and building the technical know-how to work in these settings are considerable, there is increasing commitment towards these goals, with positive and collaborative partnerships centered on innovative thinking that are allowing us to move beyond shock-driven responses towards addressing underlying vulnerabilities and engendering resilience.


Ziad Obermeyer

Physician, Researcher at Harvard Medical School

Join the Conversation

Marjan Kruijzen
November 15, 2016

Happy to learn that now, a year after the Ebola crisis, the World bank will invest in analytic work to strengthen health service delivery in fragile countries. During the peak of the Ebola outbreak in Sierra Leone, the Dutch agency Cordaid unfortunately did not manage to convince the World Bank to invest in an improved Performance Based Financing, PBF/RBF model in order to revive the paralysed health system. Fortunately Cordaid found the funds itself and introduced the PBF-PLUS pilot in one full District, 105 health facilities. With an increased investment from USD 0.5 (PBF-Light) to USD 2 (PBF-Plus) per capita per year, the average performance based income of the 105 health facilities went up from USD 165 to USD 960 per month. Within 3 months time this caused remarkable results like increased and revitalised motivation of healthcare staff and renewed confidence by the public in the health system. As a result of the many trainings and strong and regular monthly verification and coaching, validated evidence showed, amongst others, an increase of 20% facility quality scores; Over 100% increase of OPD consultations; 45% increase of fully immunized children; 45% increase of 4 ANC visits, etc. The full report was shared with the World Bank and is available at Cordaid upon request.

Emre Özaltın
November 16, 2016

Thank you for sharing the Sierra Leone experience. While it is difficult to comment on decisions for providing support to individual projects – which are highly contextual and depend on factors such as budget, opportunity costs, technical quality of the proposal, and many more – overall, the World Bank believes that RBF mechanisms can be a useful tool to improve access to, and utilization of, quality health services. Thus, in over 30 countries, the World Bank supports this work coupled with evaluative mechanisms to ensure that we are constantly learning from experience and improving our approach.
More to the point, we believe that RBF can be particularly powerful in fragile contexts where central control may already be weak, with high level of facility autonomy coupled with weak capacity of the government to provide services in remote and/or affected areas, allowing us to ensure resources flow to front line workers where they are most needed. The programmatic approach to strengthening health service delivery resilience in fragile, conflict, and violence settings that I cite in the blog includes two such RBF pilots: in South Sudan and in the Autonomous Region in Muslim Mindanao (ARMM).
I hope that the positive results you cite from the Sierra Leone pilot may lead the government to consider this approach more broadly in the health sector.