Lessons Learned from the Inclusion of
Peace-Building Objectives in the Reform and Development of
Health Systems Emerging from Civil Conflicts:
South Africa, Croatia and Kosovo Joshua BloomResearch Fellow
London School of Hygiene and Tropical [email protected]
Funded by the UK’s Economic and Social Research Council
May 2005McMaster-Lancet Challenge Conference
Peace through Health: Learning from ActionHamilton, ON, Canada
Peace through HealthDefinition: Health sector initiatives
that are specifically designed to contribute to peace in conflict-affected and volatile political environments.
Applied to health sector reform and development in multiple post-conflict settings by WHO’s Health as a Bridge for Peace Program and other actors.
Hypothesis TEST: The inclusion of peace-building
objectives in the reform and development processes of health systems emerging from civil conflicts.
EXPECTED RESULTS: Health sectors can contribute to stability and security.
HOW: By addressing underlying issues of conflict within their spheres of influence.
Key Peace-Building Objectives for Post-Conflict Health Sectors
Objectives Equity.
Non-segregation.
Professional ethics.
Human rights.
Other objectives should be covered in future research.
Apply to Policies and laws.
Service provision.
Human resource management.
HP Education.
Regulatory bodies, associations, journals, research & public info.
Key Peace-Building Objectives for Post-Conflict Health Sectors
Equity
Key Peace-Building Objectives for Post-Conflict Health Sectors
Non-Segregation
Key Peace-Building Objectives for Post-Conflict Health Sectors
Professional Ethics
Key Peace-Building Objectives for Post-Conflict Health Sectors
Human Rights
Key Peace-Building Objectives for Post-Conflict Health Sectors
Objectives Equity.
Non-segregation.
Professional ethics.
Human rights.
Other objectives should be covered in future research.
Apply to Policies and laws.
Service provision.
Human resource management.
HP Education.
Regulatory bodies, associations, journals, research & public info.
Case Studies South Africa
Croatia
Kosovo
Apartheid Health Care in South Africa
Strict segregation in the health professions and in health care services.
Gaping disparities in access to healthcare, quality of care and health outcomes.
Serious breaches of medical ethics & human rights.
Complicity by management of the health system.
Post-Apartheid Health Care in South Africa Transformation of the health system.
Merged 14 Health Departments
Constitutional right of access to health care.
Redistribution of resources.
Post-Apartheid Health Care in South Africa Special TRC hearings for the health
sector.
Reflection and reform processes as well as affirmative action policies extended to health professional councils, associations, journals, schools and employment.
Dire HIV/AIDS crisis and mismanagement by Health Minister.
Conflict in Croatia Relatively harmonious ethnic
relations pre-independence.
Homeland War in 1991.
4 different experiences based on geography.
War AffectedNot Seriously War
Affected
Remained in Croatia in 1991
Fell to Serb Rebels in 1991
Re-conquered by Military in 1995
Reintegrated peacefully in 1995
Post War Health Care in Eastern Slavonia, Croatia Health sector reintegrated as part of
UN’s multi-sectored approach to peace-building.
Some setbacks after UN left. Ethnic disputes over employment downsizings.
Nonetheless, eastern Slavonia achieved relatively successful ethnic balance within its health sector employment, especially in comparison to Croatia’s other former conflict regions.
Total Ethnic Croats Ethnic Serbs Others
# # % # % # %
General Population 204,768 160,277 78.3% 31,644 15.5% 12,847 6.3%
Employed as Doctors 274 217 79.2% 33 12.0% 24 8.8%
Employed as Nurses 1,141 935 81.9% 149 13.1% 57 5.0%
Employed in All HealthRelated Fields
1,994 1,620 81.2% 269 13.5% 105 5.3%
Ethnic Breakdown of Health Professionals Employed in Vukovar-Sirmium County, 2001
Total Ethnic Croats Ethnic Serbs Others
# # % # % # %
Population 53,677 46,245 86.2% 6,193 11.5% 1,239 2.3%
Employed as Doctors 72 69 95.8% 1 1.4% 2 2.8%
Employed as Nurses 174 166 95.4% 5 2.9% 3 1.7%
Employed in All Health Related Fields
405 385 95.1% 13 3.2% 7 1.7%
Ethnic Breakdown of All Health Professionals Employed in Lika-Senj County, 2001
Source: 2001 Census Data
Total Ethnic Croats Ethnic Serbs Others
# # % # % # %
General Population 204,768 160,277 78.3% 31,644 15.5% 12,847 6.3%
Employed as Doctors 274 217 79.2% 33 12.0% 24 8.8%
Employed as Nurses 1,141 935 81.9% 149 13.1% 57 5.0%
Employed in All HealthRelated Fields
1,994 1,620 81.2% 269 13.5% 105 5.3%
Ethnic Breakdown of Health Professionals Employed in Vukovar-Sirmium County, 2001
Ethnic Breakdown of All Health Professionals Employed in Šibenik-Knin County, 2001
Total Ethnic Croats Ethnic Serbs Others
# # % # % # %
Population 112,891 99,838 88.4% 10,229 9.1% 2,824 2.5%
Employed as Doctors 290 277 95.5% 2 0.7% 11 3.8%
Employed as Nurses 714 669 93.7% 28 3.9% 17 2.4%
Employed in All Health Related Fields
1,413 1,331 94.2% 45 3.2% 37 2.6%
Source: 2001 Census Data
Pre-War Health Care in Kosovo Kosovo’s autonomy status
revoked in 1989. Majority of ethnic Albanian health workers lost their jobs.
Kosovar Albanians responded by opening parallel health care institutions.
Violence escalated; War; NATO; and UNMIK.
Post War Health Care in Kosovo
Stressed peace-building objectives like non-discrimination, equity, ethics and patients’ rights.
Restricted freedom of movement, resurgence of violence and insufficient efforts by Kosovar authorities.
Post War Health Care in Kosovo
Parallel healthcare system for most ethnic Serbs. Many Serb HPs won’t recognize
the UN administration. Many Serb HPs continue to
receive salaries from Belgrade.
International actors partially acquiesced to the parallel system.
Conclusions Peace-building should be conducted with
multi-sector approaches that are inclusive of all sectors of society and governance, including health systems.
Peace-building within health systems should be considered a necessary component of post-conflict health sector reform and development.
ConclusionsThe adoption of Peace through
Health objectives can contribute to stability and security within conflict-affected health systems, but the success of these efforts is dependent on a series of variables.
Variables that Impact the Success of Peace through Health Efforts The greater socio-
political environment,
Whether there was a lopsided end to the conflict,
The scope and length of the conflict,
Whether there was pre-existing oppression,
Whether there were language divides,
Whether there was a collective sense of belonging and identity.
Variables that Impact the Success of Peace through Health Efforts Whether peace-
building was imposed by outsiders or domestically driven,
Whether multi-track approaches to peace-building are used,
Whether reflections on errors from the past guide future reforms,
Whether there is strong positive leadership,
Whether there’s a surplus supply or demand of health workers,
Whether long-term strategies are employed.
Other Lessons Health is not apolitical.
A rights-based approach to health can lead to improved equity, transparency and justice, but does not necessarily lead to improved health.
Level of development does not effect ability to implement Peace through Health approaches.
Key Peace-Building Objectives for Post-Conflict Health Sectors
Objectives Equity.
Non-segregation.
Professional ethics.
Human rights.
Other objectives should be covered in future research.
Apply to Policies and laws.
Service provision.
Human resource management.
HP Education.
Regulatory bodies, associations, journals, research & public info.
