Health in Conflict-Affected States: Valuable Lessons and Unanswered Questions

Leonard Rubenstein
Center for Public Health and Human Rights, John Hopkins Bloomberg School of Public Health, and the U.S. Institute of Peace

In the past decade, health and health systems in conflict-affected states have been subject to intensified study and intervention.  Despite certain knowledge gaps, our understanding of the indirect effects of war and instability on population health – ranging from infectious disease to severe psychological distress – has grown.  At the same time, initiatives to both expand services and establish, support, or rebuild health systems have taken place in countries as diverse as Liberia, Afghanistan, Pakistan, Democratic Republic of the Congo, Timor-Leste, Kosovo, Iraq, South Sudan, Rwanda, and Sierra Leone.   

Donor commitments to post-conflict health systems have been mostly driven by pre-existing political commitments rather than strictly health-related considerations.  And while the results of these efforts are decidedly mixed, they have nevertheless yielded experience and growing consensus about methods for developing systems of care in these challenging environments – with an emphasis on increasing capacities of Ministries of Health to plan, organize, and manage primary care services, and meet immediate health needs while developing a system.   The experience also points to the need for changes in the structure of donors’ health programs, length of resource commitments, effective financial mechanisms, and decision-making control.  

These adjustments have been hampered not only by traditional structures of development aid, but lack of clarity about policy on health development in conflict-affected states. Despite the fact that the worst health indicators are associated with conflict-affected or unstable states, U.S. global health policy, including the Global Health Initiative, remains largely silent about them.  To the extent these countries’ needs are addressed at all in development strategy, they are increasingly linked to security goals, such as the stabilization of states at risk of or emerging from conflict. The purported connection between health system development and stabilization and security, however, remains uncertain at best.  There has been scant articulation of the security objectives health interventions can be expected to achieve and a paucity of evidence whether there is any basis to believe they can be. Serious questions exist, too, as to whether interventions designed to achieve security and health-related goals are compatible.

A second policy gap concerns health systems development in repressive, undemocratic states such as Burma, Zimbabwe and North Korea.  Difficult questions arise whether it is possible to advance health systems in such states without reinforcing poor governance, disrespect for human rights, and corruption – and if so, how. Conversely, though, commitments to equity, participation, non-discrimination, and system accountability in health systems development may have the potential to impact governance and human rights protection more broadly.

Finally, the field has given too little consideration to the preservation of health facilities and the protection of health workers in the midst of armed conflict. Not only is this a moral and legal issue, but one that has profound implications for health worker retention and maintenance of health infrastructure.  WHO and other UN agencies should create mechanisms for prevention, reporting and accountability regarding assaults that can profoundly affect the well-being of populations and the health system.

*Many of these questions will be considered at an upcoming conference on Health in Conflict-Affected and Unstable States on June 9 and 10 at the United States Institute of Peace.  For information contact

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