After violence and unrest spread across the Middle East and North Africa (MENA), emerging post-conflict nations face many challenges in reconstructing civil society and the instruments of government to support it. The establishment of the legitimacy of a transitional government is crucial in avoiding a return to renewed conflict and unrest. One of the most powerful signals to a population of the legitimacy of their transitional government is its early attention to the redevelopment of healthcare services.
Broad principles for reconstruction of health services after conflict have been formulated by international governments, NGOs, donors and academics over the last 20 years. Insights have been derived from experiences in settings such as Afghanistan, Iraq, Southern Sudan, Liberia, Cambodia and East Timor.
In embarking on reconstruction of healthcare, many factors must be considered including:
- the health status of the nation
- the acute and future needs of the population for healthcare
- the state of healthcare infrastructure after violence
- how healthcare was delivered prior to the conflict, and
- the availability and capabilities of the health workforce.
Among the many lessons learned from prior experiences is that each country and situation is unique. The health status of Arab Spring countries have all been different and they have had a variety of approaches to organizing, financing and delivering health care prior to the uprisings. For example:
- In Yemen, the health system is seriously underdeveloped with few well qualified professionals. A small percentage of GDP is spent on healthcare and there is a lack of training for doctors and nurses.
- In Bahrain, where the medical workforce is largely imported from South Asia, there is a Ministry of Health responsible for policy, finances, provision and regulation of healthcare. Professional standards including those for education and licensing of professionals are problematic in this kingdom.
- There is a pluralistic healthcare system in Egypt with many public and private agencies delivering care and a variety of funding mechanisms. The private hospital sector in Egypt has undergone development in recent years and government providers (unlike in Libya) have been permitted to generate additional income beyond that provided through the government social welfare system.
- The Tunisian healthcare system is a mix of public and private institutions with growth in the latter sector over recent years. The Ministry of Public Health had usually expended about half its annual expenditure on tertiary care and the remaining half split roughly equally between primary and secondary care. Tunisia has had the benefit of having had a strong influence in professional development over the years from French trained doctors. It is of interest to note the development of a very robust corridor of private healthcare facilities on the Tunisian side of the Libya-Tunisia border. Many Libyans, including those with limited incomes, have traditionally sought care in Tunisia due to their distrust of the standards of healthcare in Libya.
- Healthcare in Libya has been provided to all citizens under a government program. However, as in many MENA countries, the affluent seek care in modern centers in Europe, UAE or Jordan. A small private sector of hospitals and clinics have operated in Libya and, before the conflict, a fledgling private health insurance market was emerging with international underwriters becoming involved (e.g. Alliance)
This very brief snapshot of just a few of the issues shows how truly different all these Arab Spring countries are with respect to healthcare. Corruption and cronyism have also been persistent problems in many of these environments with individuals frequently appointed to senior positions and leadership roles in ministries or clinical facilities with no regard to their qualifications, experience or aptitude for the role.
Critical Stages in Healthcare Redevelopment
Redevelopment of healthcare after conflict requires urgent prioritization to save lives and tend to those in need of emergency medical care. Often this occurs concurrently with humanitarian relief initiatives providing basic services such as clean water, food, sanitation and prevention of outbreaks of communicable disease. Humanitarian organizations usually work closely with government authorities, health ministries (if they are functional) and local organizations. Acute relief activities and reactivation of emergency care typically attract significant financial support internationally and much media attention.
However, there are broader considerations in healthcare that are equally important and urgent for the sustainable future of a post-conflict nation. In this arena, planning for medium and long term healthcare reconstruction should begin just as soon as possible with staged but overlapping activities in:
- Developing a national policy framework – among the many important issues here there are two which deserve particular mention:
– As the initial emergency crisis abates (and, if possible, before), careful consideration on the degree of decentralization of healthcare management from the new government is needed. Due to the frequent collapse of existing government healthcare agencies during conflict (hospitals, clinics, medicine supply chains), decentralization of any care that is available becomes the norm during the conflict – local people and communities do the best they can to help the sick and injured, often aided by fragmented international agencies. Once a semblance of calm reappears, it is very tempting to recentralize control of all healthcare. Current opinion suggests that this is a time for vigorous community engagement to ensure that the emerging policies and practical operations of a healthcare system involve local communities and do not recreate the appearance of authoritarian centrism.
– Many MENA countries have had historical models of care where the government acts as both funder and provider of care. After conflict abates, an early issue should be to consider moving to a more contemporary international model of healthcare delivery where the government continues to fund care through a social insurance program and provide the regulatory oversight through contracts with private and non-profit organizations to actually deliver care. This latter model is often strongly supported by international donors. Whether the decision is to stay with an historic model or move to a public private partnership model, it should be a conscious and carefully thought through decision. It is important to note that in totalitarian regimes, professional leaders have frequently been isolated from understanding the emerging international trends in healthcare organization and delivery which sometimes tips the balance to decisions to maintain the status quo.
- Underpinning the future of a sustainable healthcare system with a reliable finance plan – a sustainable health system costs a lot of money and key considerations include:
– how to prioritize early use of donor and aid funds – this requires careful alignment of the best interests of the country, other governments and donor agencies. When large corporations are making significant aid contributions, there is clear need to respect that the company’s own interests, while not front and center, will be better served by certain types of projects than others.
– deliberate attention to how MENA countries will sustain their own health systems once contributions from donors and international aid for acute relief programs decrease, i.e. where does healthcare fit into the development of a national budget, which government revenues or tax policies will be used to support healthcare.
– clearly establishing linkages between access to funding and factors such as development /delivery of a basic package of health services for all, compliance with policy driven standards in professional licensure, hospital accreditation etc. and establishing contracting mechanisms for transparent public-private partnerships around delivery of care
- Ensuring equity of service access and expanding geographic coverage – in many nations, equity of access to care has been poor. During the period of reconstruction, it is both morally and strategically important to emphasize equity in access. In order to avoid re-emergence of conflict and violence, this is especially true when young people from working classes have risen up in a quest for freedom and basic human rights. Particular attention over time should also be paid to those in regional, rural and remote areas who have often been neglected in prior health systems.
- Building institutional capacity and a skilled health care workforce – the development and deployment of skilled healthcare workforce is perhaps the most important factor that will create sustainability. Key considerations include:
– the paucity of highly qualified trained doctors and nurses
– local standards of educating professionals in universities have not advanced under prior rulers and the models of education are outdated
– nursing is a particular problem as, unlike medicine, there are very few nurses trained as leaders
– in some cases, such as Libya, prolonged international sanctions diminished access of almost an entire generation of physicians to updated medical information and professional development
– some MENA countries have established postgraduate training bodies but practical implementation lags behind what is written down.
Healthcare workforce includes not just those who are directly involved in the care of patients. Skilled professionals and administrators for traditional public health (clean water, disease prevention, immunization etc.) and non-clinical functions of a health system are also important. These are areas of critical need for development in the post conflict MENA countries.
There are many aspects of developing the workforce that will stabilize a country to a position of long-term sustainability after conflict. These include:
– identification of the existing human resource pool
– rapid identification of leaders for key central and dispersed roles
– establishing a specific organizational unit to drive development of policy and implementing a comprehensive human resource development strategy
– basic building of capacity for all the roles required
– clear codification of roles and responsibilities
– clarifying health worker equivalencies
– bolstering training programs at all levels, both short term and long term. This includes modernizing professional education programs in universities and professional colleges especially through faculty development and train the trainer programs
- Redevelopment of physical infrastructure – beyond immediate rehabilitation of buildings and restocking, this requires careful consideration of a potentially changing care model if governments are to move out of being direct providers of care over time
- Fostering strong community development and engagement with civil society – implementation of a sound program of staged redevelopment of healthcare can be one of the most obvious public signals that leaders of a reborn nation are serious about not reinventing past authoritarianism under a new guise. Among the most basic desires of people beyond water, food and shelter are access to healthcare and education. Early and sustained investment in equitable access to good healthcare is one fundamental action that will establish the legitimacy of a new government after conflict.
The challenges of redeveloping a healthcare system in a nation emerging from conflict are substantial. If we have learned anything from post-conflict situations around the world in the recent decades, it is that the real work is not just about emergency care of the sick and those injured through violence. Rapid attention to a plan and concrete steps for development of a sustainable healthcare system with progressive elevation of standards and equity of access is a demonstration of the legitimacy of a new government to donors, aid agencies, the international community and most importantly the citizens of the newly emergent nation.
Most importantly, the reconstruction of a healthcare system should never be about transplanting what works in another country onto a newly emerging fragile context. Government and professional leaders must play the key roles in developing their health system with support from the international community.
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Libya: an emerging opportunity … personal reflections
As those of us privileged to practice and hold leadership roles in Western institutions look at news about the Arab Spring, we should to ask ourselves, “what would we do if this was happening in US, UK, France, Australia, Canada etc.?”
Leading a multilateral team to work with Libyan counterparts on several projects over three years and more than 15 visits prior to the uprising against the rule of the Gaddafi family provided me an unprecedented opportunity to make observations about the status of Libyan health and healthcare. The following observations are not at all meant to be evidence based or comprehensive. They simply speak to the uniqueness of the Libyan context and the opportunity that is here right now to apply the lessons from many conflict ridden corners of the globe over the last decades and get it right.
- Libya is a youthful country with all the healthcare problems of emerging chronic diseases as the population ages and survives longer.
- Disease prevention programs, while quite effective for communicable diseases, are not well developed for chronic diseases of lifestyle and aging (heart disease, diabetes, stroke etc.).
- There is a genuine desire on the part of many Libyan doctors and nurses to learn and grow their professional skills in order to provide better care for patients.
- The quality of care in Libyan hospitals and clinics is extremely variable – Libya has some superbly trained doctors who have spent time in leading international centers, but there are few of them. It is also quite evident that some individuals in leadership roles were poorly prepared or unqualified for their roles, presumably appointed because they were close to the regime.
- The models of training for students in the universities and new graduates in the hospitals deserve modernizing and upgrading. The Libyan Board of Medical Specialties has the potential to emerge as a key contributor to redevelopment if well led and transparently funded and operated.
- Development of the nursing workforce is perhaps the most pressing issue – nursing has only recently come of age as a university program. There is, however, great enthusiasm and eagerness to learn in some of the nursing areas for postgraduate training and career development.
- The incentive systems (salary, conditions, access to additional training etc.) in the public sector (hospital and polyclinics) were inadequate to generate uniform investment and commitment by all individuals working in the public system. However, notable exceptions were evident with some very committed doctors, nurses and occasional hospital leaders working hard to deliver good care midst a bureaucracy-laden and stagnant system.
- There are serious problems at both government policy and operational levels in managing the supply chain for essential medicines and supplies. Policy changes away from a single purchaser model were introduced hastily and the mechanics of managing demand and supply are broken. This has resulted in chronic regular shortages of key pharmaceuticals and laboratory reagents in polyclinics and hospitals for managing common conditions such as diabetes, hypertension and heart failure.
- All that is written about the Libyan healthcare system and its accomplishments does not uniformly reflect the reality of what happens on the ground.
- The Libyan population is deeply distrustful of the quality of services provided in Libya. Those who can afford to go to centers in countries such as France, Germany, Austria and Jordan for care do so. Many workers, even the Tripoli drivers, go to Tunisia for basic follow-up care.
As the international community mobilizes to respond to what is ahead for Libya, we are presented with several opportunities –
- We should share all that we have learned about what does and does not work in healthcare reconstruction after conflict
- We should regularly remind ourselves that Libyans must lead in redeveloping their systems, institutions, policies, frameworks and workforce for Libya, and
- When the international community engages with Libya to assist, we will do our best work within a mindset that acknowledges that one day we may be the receivers of outside advice and support, and not the providers.
Many experts and authors have contributed to understanding the pathway to reconstruction in healthcare after violent conflict. Several useful references which were consulted in developing the above ideas include :