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Health Service Delivery in Fragile States: Lessons from the Field Emmanuel d’Harcourt International Rescue Committee Woodrow Wilson Center for Scholars.

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Presentation on theme: "Health Service Delivery in Fragile States: Lessons from the Field Emmanuel d’Harcourt International Rescue Committee Woodrow Wilson Center for Scholars."— Presentation transcript:

1 Health Service Delivery in Fragile States: Lessons from the Field Emmanuel d’Harcourt International Rescue Committee Woodrow Wilson Center for Scholars September 12, 2006

2 Outline 1.Population and fragility 2.Fragility and health 3.Health and fragility 4.Missions, health, and fragility

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4 Outline 1.Population and fragility 2.Fragility and health 3.Health and fragility 4.Missions, health, and fragility

5 … The [demographic] "wolf" is present and very busy indeed—in Rwanda. … When its population had reached 7.6 million in 1994, observers there were expecting disaster any day in the form of random violence or famine … Rwanda is demographically trapped in that it has exceeded its carrying capacity … Meanwhile, slaughter is ascribed to human rights violations, and the even more disturbing population pressure of demographic entrapment is conveniently forgotten. Demographic entrapment is so … disturbing that orthodox demography, public health, and UN agencies, particularly UNICEF, maintain a political correctness so correct that the entrapment is never mentioned… Maurice King, MD. From AJPH, July 1996

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7 Factors associated with the genocide Related to resource scarcity Not related to resource scarcity

8 Related to Resource Scarcity Popular discontent due to food scarcity Gain from previous Tutsi “pogroms” Fear of losing land to invading army Joblessness

9 Rwanda population, Source: US Census Bureau

10 Average land holding 1960s- 1990s Source: Uvin, 1996

11 Food Production per Capita Source: FAO, 1994

12 DesireAbilityPermission Resource scarcity Over- population Popular discontent

13 Population density Source: PRB

14 Population density Source: PRB

15 Not Related to Resource Scarcity Falling commodity prices Popular discontent due to mismanagement Elite worried about losing power Long tradition of social division Genocidal ideology Effective propaganda and media Highly disciplined state machinery Lack of filial bonds: state vs. tribe International inaction

16 Coffee Earnings, Source: FAO, 1994

17 DesireAbilityPermission Highly organized state Effective media Steady arms supply International Inaction Lack of filial bonds Social divisions Resource scarcity Over- population Popular discontent Elite insecurity Corruption Unfavorable terms of trade / structural adjustment Rebel attack Arusha

18 If population is so important Source: PRB

19 Outline 1.Population and fragility 2.Fragility and health 3.Health and fragility 4.Missions, health, and fragility

20 How fragility affects health Security Policies Motivation Training Management Sustainability Communities Responsibility

21 Children treated Rwanda and Sierra Leone

22 Amodiaquine + S/P

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24 Outline 1.Population and fragility 2.Fragility and health 3.Health and fragility 4.Missions, health, and fragility

25 How health affects fragility No services is a big part of fragility

26 How health affects fragility No services is a big part of fragility Good services legitimize governments

27 Cost Per Treatment FacilityCommunity Supervision$50$200 Training$400$83 Management$200$500 Equipment$250$10 Children treated41315 Drug costs$35$236 Cost per treatment$23$3

28 How health affects fragility No services is a big part of fragility Good services legitimize governments Health is entry point for building systems

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30 Safe Motherhood, Kibungo Province

31 Children treated South Sudan and Sierra Leone

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33 South Sudan example Good human resource management Good information system Simple tools Scaleable Adapted to local environment

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35 How health affects fragility No services is a big part of fragility Good services legitimize governments Health is entry point for building systems Systems may induce more responsibility

36 How health affects fragility No services is a big part of fragility Good services legitimize governments Health is entry point for building systems Systems may induce more responsibility Community work strengthens communities

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40 Distributor Information

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42 Key quality indicators Community distributors, South Sudan n = 96 supervision reports

43 Can Health Programs Help? Poor information Weak human resources Weak absorptive capacity Uncertain future Unpredictable external support Recidivism Need to address immediate needs Need to show peace dividend     x x x 

44 Can Health Programs Help? Enhance stability Improve security Encourage reform Increase capacity in key areas Address sources of fragility Seek short-term impact & long-term reform Establish measurement systems    

45 Institutional Indicators from Health Utilization rate Reported supervisions / health area / month % community workers reporting % stock out for key drugs

46 Outline 1.Population and fragility 2.Fragility and health 3.Health and fragility 4.Missions, health, and fragility

47 Health, Fragility, and Missions Missions are concerned about fragility Missions care about health status What do missions do that helps? What do missions do that doesn’t help?

48 Health, Fragility, and NGOs Field-based Innovative Collaborative Coordinated Think of scale-up Expensive Short term Small scale Not audited

49 Things that don’t help Frequent strategic redesign Process of strategic redesign Little field presence Concentrating resources Lack of DC – Mission coordination Some regulations – drugs, salaries Short-term funding

50 Things that do help Ambitious programs designed for scale Coordination of grantees Coordinating with other donors Grantee – Government mediation Inter-sector synergy Willingness to support systems Long-term funding

51 Who has the answer? iNGOs local staff Local NGOs National officials USAID DC USAID Mission Local officials Beneficiaries iNGOs HQ staff

52 Top 5 recommendations 1.Think big, think national 2.Focus on coordination and systems 3.Rethink drug procurement limits 4.Rethink salary support limits 5.Rethink strategic planning process –Less large shifts, more small adjustments –More participation

53 OFDA Recommendations Switch to long-term funding ASAP Increase monitoring of costs, results Continue focus on inputs

54 Bottom Line Fragility affects health – a lot Health programs can reduce fragility – some –Systems –Measurement Health programs can reduce suffering – a lot Missions help, could help even more –Stable strategy, stable funding –Coordinate

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