Working paper

Re-energizing the HRH Agenda for a Post-2015 World – Responding to the needs of fragile states

TEHCNICAL WORKING GROUP (TWG) #6

This paper serves as a background report to inform the Global Strategy for Human Resources for

Health. The development of this paper has been coordinated through a thematic working group

(TWG), comprising of 2 co-chairs and a group of experts drawn from various Global Health

Workforce Alliance (GHWA) constituencies, operating under the oversight of the GHWA Board

working group. The views expressed in the paper, do not necessarily reflect the official position of

GHWA. All reasonable precautions have been taken by the co-chairs to verify the information

presented in the papers

- DRAFT FOR CONSULTATION -

Not to be quoted or referenced without prior permission

from the authors. Not for wider distribution

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Table of Contents INTRODUCTION ............................................................................................................................................... 1

RESEARCH QUESTIONS .................................................................................................................................. 2

HEALTH SYSTEMS AND THE HEALTH WORKFORCE: THE EFFECTS OF MAJOR EVENTS AND CHRONIC FRAGILITY ...... 3

REBUILDING THE HEALTH WORKFORCE: WHAT ARE THE CHALLENGES? ............................................................... 5

RECOMMENDATIONS FOR ACTION ................................................................................................................. 6

CONCLUSION ................................................................................................................................................. 8

REFERENCES ................................................................................................................................................... 9

Stilwell B. (2014) Distributed Leadership and Building Capacity for Governance. Poster

presentation and technical brief Global Health Systems Conference, Cape Town. ........................... 9

BIBLIOGRAPHY ............................................................................................................................................. 10

ACKNOWLEDGEMENTS

This paper was written mainly by Barbara Stilwell, who takes responsibility for any errors. Working

Group 6 members have contributed ideas, text, literature search (Kris Horvath) and papers.

Working Group 6 core writing group: Leek Deng, USAID, (facilitator), Elsheikh Badr, WHO, Co-chair,

Barbara Stilwell, IntraHealth International, Co-chair, Kris Horvath, IntraHealth International, Tim

Martineau, Liverpool School of Tropical Medicine, Ann Canavan, International Medical Corps, Andre

Griekspoor, WHO, Joyce Smith, Independent Consultant.

We gratefully thank all who contributed comments on the first drafts of this paper.

INTRODUCTION

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The World Development Report, in 2011 (The World Bank 2011), addressed issues of global conflict,

security and development and pointed out that no low-income, fragile or conflict affected country has

yet achieved a Millennium Development Goal. Although inter-state wars have declined throughout the

20th century, 1.5 billion people globally currently live in places that are violent, conflict-affected and

fragile. Health indicators for these people are extremely poor: for example, they are more than twice as

likely to be undernourished as people in developing countries, twice as

likely to see their children die before the age of five, and more than a

third of all maternal deaths worldwide occur in a fragile state (The World

Bank 2011; Newbrander 2007). Responding effectively to the needs

of fragile states is an ongoing challenge for the international

community of donors and implementers, requiring a high level of

coordination, setting priorities that meet short and long term

needs, and, especially relevant for health care, promoting

resilience in complex interlinking systems.

This paper explores the evidence of success in overcoming the

challenges of health workforce

development in fragile states. In doing so we acknowledge that there are many definitions of ‘fragile

states’ and we opt for a broad concept that reflects a discernable common thread in the literature. Our

conceptualization is that fragile states lack the ability to develop mutually constructive relations with

society and have weak capacity to carry out basic governance functions, which results in an absence of

essential services to the population (François and Sud, 2006, Kruk et al 2009, OECD 2012). Not all fragile

states have the same level of fragility. Newbrander suggests states may be deteriorating, collapsed,

recovering from conflict or in early recovery. This links with a discussion elsewhere of ‘difficult

environments’ (DfID 2005) where there is a recognition that conflict or disaster are not necessarily pre-

requisites for a fragile state. In some states, governments are unwilling to take on responsibility to

provide equitable health and social services, even though the government may have the ability; in

others, governments may be willing to do so but lack the capacity. In some states, there is a post-conflict

opportunity for rebuilding with the possibility of unplanned transition from donor driven humanitarian

support to the development of sustainable systems and attendant risk of “collapse back into conflict”

(Collier & Hoeffler 2004). Understanding the root causes of the failure of a state, and the stage it is at,

are the first steps in planning successful interventions.

RESEARCH QUESTIONS Research questions were developed to inform the literature review. They are:

1. Is there a common definition and understanding of the meaning of fragile states among

researchers and the development community?

2. What research exists about the effects on health systems and specifically on the health

workforce, of major events that lead to fragile states (such as conflict, disasters, structural

readjustment)?

Box 1: The unique challenge

‘Fragile states present unique challenges to health care systems, whether through increased burden of disease, conflict, scarcity of health care workforce, financial limitations, fragile governance or weak institutional leadership’

From Benton et. al. (2014)

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3. Is there information from one or more fragile states to map current condition of HRH and

outstanding needs?

4. What are the global, national and regional influences on health workforce scale-up and

retention including: adequate financing; health workforce training and continuing education;

push and pull factors on retention; performance incentives or disincentives; appropriate health

workforce distribution; needed infrastructure and resources; governance and policy.

5. What is known about successful and failed interventions in scaling up HRH in fragile states?

In addition to the literature found by searching, key informants were asked to recommend papers

known to them, including any reports available from non-published sources.

HEALTH SYSTEMS AND THE HEALTH WORKFORCE: THE EFFECTS OF MAJOR EVENTS AND

CHRONIC FRAGILITY The resilience of health systems is inevitably tested by a major disruptive event, no matter what the

cause. For natural disasters, such as earthquakes and tsunamis, the health system has to be able to

respond rapidly and sustain a response as the system is rebuilt. Health workers may be killed in the

disaster and made homeless with their families, resulting in less availability of skilled help from the

health system. Where the health system is already weak complete rebuilding may be needed. One such

example is Haiti, devastated by an earthquake in 2010, but even before that a country with a struggling

health system and poor health indicators. Interestingly, the

assistance to the health sector that Haiti received after the

earthquake (and subsequent cholera outbreak and typhoon

damage) has resulted in health indicators that have

improved over the 2006 pre-earthquake measurements –

for example, improved child nutrition and increased

attendance at ante-natal clinics (USAID 2014). This could

suggest an ongoing transition from donor assisted

emergency relief to more sustainable health system

strengthening initiatives, with a population impact beyond

meeting immediate survival needs.

Other states exhibit chronic fragility, usually in the presence of a longstanding complex emergency

situation, which is characterized by a long term failure of the state to govern, the presence of violence,

and shelter and food insecurity. South Sudan is one example of a state that experiences chronic fragility,

which is now complicated by the effects of a return to war after a period of peace and state building. By

the time the civil war ended in 2003, most health professionals had left the country or had been

absorbed into the military. The lack of qualified health workers was the greatest limitation to the

expansion of health services. As the country began to rebuild its systems, it was estimated that there

was less than one health worker per thousand people and in rural areas, hardly any qualified staff.

Health workers who had remained in South Sudan during the conflict had no opportunity for continuing

education and were not up to date or safe in their practice, while faculty had also fled the country, so re-

Box 2: The health sector is vulnerable

“In the world’s most fragile countries, people seeking to undermine a community or country can find few more effective and vulnerable targets than the health sector.”

(Merlin 2010)

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establishing pre-service and in-service education was at first impossible (World Bank 2007; Pavignani

2009). And in addition to these practical challenges to rebuilding the

health sector, the government was new, and lacked expertise in

implementing policies and strategies throughout the decentralized

system. Communication was poor also, with no internet connection and

few phones. All of these factors presented multi-faceted challenges to

rebuilding the health systems, and highlights well the need for donor

coordination and for a mixture of short and long term approaches that

will build governance capacity in the longer term, while emergency

measures are being implemented.

As Haiti and South Sudan well illustrate, to rebuild health systems there

has to be a shift over time from crisis intervention to more sustainable

development. Much of the initial donor funding will aim to resolve the

humanitarian crisis and Collier and Hoeffler (2002) suggest that there will

be a drop in resources after the initial early enthusiastic donor support.

Countries in conflict tend to see spending on health diminish

substantially. As a result, the average developing country experiencing

armed conflict has less than one health worker per thousand (WHO

2008). One large study concluded that for every one person killed in

armed conflict, as many as fifteen people die of diseases or malnutrition

that would have been prevented if not for the loss of health workers

created by the conflict (Geneva Declaration Secretariat 2008). Long term

conflict can cause a state to move from a sudden descent into fragility to

a chronic state of fragility that seems in itself to be so entrenched as to be the norm, requiring further

decades to change. The occupied Palestinian territory is one such case.

Pavignani and Riccardo (2012) describe Palestine as a ‘severely disrupted’ environment, a condition

which results from decades of intermittent violence, weak governance, occupation and aid dependency.

The Palestinian health sector is fragmented, and depends on expensive referrals outside the country to

deal with more complex medical cases. But the greatest challenge is that of implementing strong control

by the government to regulate and coordinate the sector. Many developments are donor led, with little

direction from the government to direct the investments. The result is health services that are of

inexplicably poor quality, despite the investment of resources in their production. Changing this

situation will require multi-faceted interventions over a long term, that include building leadership,

governance and management systems, a legislative framework for health professionals and service

delivery, as well as developing and implementing policies to support a high quality accountable health

sector (Stilwell 2014).

Health workers in fragile states face many challenges, and those working in rural and remote areas are

particularly vulnerable to the problems caused by shortages, the retreat of the state, and general

violence typically associated with fragility. In sudden emergencies as well as chronic fragility of the state,

Box 3: Using data

‘In Afghanistan the majority of the experienced senior health managers and teachers had either left the country or were employed by donor agencies. Initial available data on the in-country workforce through a limited health information system were unreliable……. There were only 199 midwives and 3181 nurses (of whom 29% were female). In a country with one of the highest maternal mortality rates in the world and an estimated 15% female literacy, the Ministry of Health is facing major challenges in redressing balances and, particularly, producing female health providers who can work outside the cities and reach the women in rural areas.’

WHO 2007

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there are likely to be severe shortages of trained health workers, and also of teaching faculty,

supervisors and managers. The scenario may be further complicated by well-meaning but ad hoc

training of health workers to meet immediate needs, by a variety of

nongovernmental organizations and donors. This can result in a plethora

of categories of health workers with no recognized qualifications and a

number of competencies that are not regulated (WHO 2007).

Even if there is a political will to undertake strategic health workforce

planning the likely dearth of reliable information, or functioning

information systems, will make it difficult to assess the present situation

or predict the future needs. As Box 3 shows, even knowing the number

of women in the workforce might be critical.

REBUILDING THE HEALTH WORKFORCE: WHAT ARE THE

CHALLENGES? Of all health system elements, the health workforce is most likely to be

critically weakened by failing state ability to govern (WHO 2005). Health

workers are vulnerable to the threats that all people experience in

situations of conflict and disasters, and may be injured or killed or have

their homes destroyed. They may flee sectarian violence, fearing attack

because of their political or tribal allegiances. A weak government that

fails to pay its health workers faces migration of the workforce out of the

country, and continued poor working conditions may have the same

effect. Indeed, the stress of staying to work in difficult conditions can

itself result in ‘burn out’ and absence from post (WHO 2008). And once

the health workforce is depleted it takes years to rebuild it, particularly if

universities and colleges are destroyed and faculty gone. Even with

training facilities in place, educating competent health workers takes

years of investment.

Our vision of a health system is one that provides universal health

coverage and reflects the values of availability, accessibility, acceptability

and quality of services. Rebuilding sustainable health systems and

supporting the goal of universal coverage will inevitably take time,

collaboration and smart on-the-ground programs supported by a policy

and legislative framework that might also have to be rebuilt. In

particular, the special vulnerabilities of health workers in fragile states

result in challenges in ensuring that they are on-the-job, prepared to practice, connected to the health

system and their communities, and safe from harm.

Box 4: Risks of being a health worker “No one is immune from this conflict. I am as affected as everyone else. “It makes our jobs very difficult, especially at night when, because of too few staff, we are forced to work alone. “I was helping a woman in labour. We have no electricity here so it was dark, candles only. Two men arrived, both armed. They raided the clinic and stole everything I had. They tortured me for a while with a knife and then left. By the time I returned to the mother, her baby had suffocated and died. “I tried to remain calm but I was totally emotional – scared, anxious and of course angry. We are trying to save lives and they are trying to kill us. “Three health workers left last year to work in less insecure areas. It is hard to keep staff when things are so dangerous. Also in less remote places, health workers are more likely to be paid. Here you can be forgotten for a long time. “I was last paid maybe three months ago – the first time in a long time. I got 3000 Congolese francs (about $3) for 2 months work . Donald, nurse in the Democratic Republic of Congo, March 2010 (Merlin 2010)

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The gap is likely to be wide between what exists in a fragile state – wherever it may be on the

continuum of fragility – and the vision of a health system that provides universal access to high quality

health care. The goal is to create a resilient health system that can be self-sustaining, and as

Newbrander et al (2012) point out, building capacity in a fragile state is usually aimed at ‘building back

better’ rather than replacing the old. Witter (2012) also points out that as ‘health systems in fragile and

post-conflict states are often forced to innovate, they can generate useful lessons for other settings’.

In an early stage of recovery the health sector has multiple objectives, as it has to continue to provide care but also build new systems to meet longer term goals (Vergeer, Canavan and Rothman 2009). For donors – and even for those providing technical assistance – it may be difficult to focus on objectives that are have different time frames, goals and players, and yet to move past emergency relief to rebuilding requires re-framing the problems and working within a degree of uncertainty and risk.

The point here is that capacity development in this setting becomes (or perhaps should become) a

process of change rather than simply training and providing missing care. Equally important is to develop

health institutions – more difficult and time consuming, but more likely to result in resilience.

Capacity development must also be led from within the country (Vergeer, Canavan and Rothman 2009),

with a country led plan for long term assistance that leads to strong institutions that are politically

acceptable. Rebuilding the health workforce, to be truly sustainable, has to focus not only on technical

or clinical skills, but also on educating managers, so that planning, problem analysis and solution

development and securing resources are skills available within the health system. Beyond the accepted

skills of management are those of managing power relations and politics which often have undue

influence in fragile states. Economies of scarcity and conflict create opportunities for those in civil

administration to siphon funding for personal gain or engage in petty extortion, and health systems,

including workforce development, can be undermined if such issues are ignored (McKay and Aryeetey,

2004).

RECOMMENDATIONS FOR ACTION

These recommendations are targeted at the international communities and at Ministries of Health who

consider that they are part of governance of a fragile state.

1. Understand the type of fragile state and the implications of this on interventions. Each fragile

state is unique, solutions have to be developed accordingly, and the typologies of fragile state can

guide strategies and actions. This review of literature suggests that rather than apply a one

dimensional definition of fragility, it is useful to consider states as occupying points along a

continuum for each element of fragility. States may be chronically fragile in the sense that they do

not exhibit resilience, or, in keeping with the idea of a continuum, they may move in and out of

fragility. It is important to remember that once states appear to be performing satisfactorily, they

may still be in a tenuous position from which they may slip back into fragility (Newbrander 2007). In

addition, a region of a state may be considered fragile, even though the state as a whole exhibits

less characteristics of fragility.

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The debate about definitions of fragility is more than an academic preoccupation; it is relevant to

the sequencing of interventions and thus to the design of donor proposals. When a state lacks the

capacity to control and implement programs, sustained development will be difficult to achieve. This

is especially true for health workforce development, which requires institutions and policies that

ensure a regulatory framework, as well as management and supervision of service delivery. Without

a strong central system of governance, health workforce changes – indeed health systems changes –

may be more effective targeted at a decentralized level, where results can be seen more quickly,

and lessons learned for scaling up.

2. Use the window of opportunity: - this is the stage when there has been a major event that has

precipitated the slide into a fragile state, and is linked to 1 above. The immediate response is to

meet emergency needs, and this is a legitimate concern, but at the same time this constitutes a

rapidly receding opportunity for the health sector to benefit from donor interest by moving beyond

the emergency phase to a more sustained response. Consider the breadth of interventions planned,

and an innovative multi-faceted response that addresses not only the health workforce but the

other elements of the health system, and also addresses how progress will be achieved – how

change will be planned, implemented and measured. The window of opportunity is often perceived

as a stage of stabilization, but greater progress might be made if it is visualized also as a way of

making rapid progress towards stronger institutions.

3. Address governance issues from a health systems framework: under the New Deal1 there are five

Peacebuilding and State building Goals (PSGs) – legitimate politics; security; justice; economic

foundations and revenues and services. These are ‘an important foundation’ for effective

governance. The New Deal also recommends a shift to country-led fragility assessments, support for

capacity development, greater transparency in more predictable aid.

Governance is critical to recovering fragile states, especially when aid pours in and interventions are

in danger of being donor driven. In terms of health systems, WHO (2007) has proposed the

definition of governance as “ensuring that strategic policy frameworks exist and are combined with

effective oversight, coalition building, regulation, attention to system-design and accountability” to

manage all the building blocks of a health system. An example of a practical application of a

governance perspective in the context of fragile health systems would be the ability of the state to

manage a diverse donor portfolio in such a way that the investment resulted in sustainable health

workforce strengthening. In this example there will be many stakeholders, political interest,

economic implications, security influences and issues about equity and quality of services. Ignoring

governance implications for the health system can result in uneven development that cannot be

sustained and may not achieve its goals.

1 The g7+ group of fragile and conflict-affected states agreed on a New Deal for Engagement in Fragile States at the Busan High

Level Forum on Aid Effectiveness in November 2011 http://www.odi.org/news/477-g7-fragile-states-new-deal-budget-

strengthening-initiative

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The literature, as well as our informants, was unanimous in recommending that there needs to be a

mechanism for achieving a common understanding of context and interventions that brings all the

stakeholders together, with the state in a coordinating role. This is likely to be especially true for

health workforce development, when there is potential for strategies that may provide immediate

answers to shortages but in the long term can lead to workforce outcomes that take time to rectify.

One common example is the rapid growth of different cadres through ad hoc training usually donor

funded – in Cambodia, for example, there were eventually 59 cadres – and a mammoth task to align

them2.

4. Use health workforce development tools but use with caution! The health workforce is one of the

health systems building blocks in the WHO Framework for Action (WHO 2007) and while always

critical, the articulation of the health workforce with the other components takes on an even great

importance in situations where governance is fragile. This is because the health workforce is

vulnerable to the catastrophes that affect the population as a whole – displacement, illness, political

prejudice and persecution. Financing of the sector and of the health workers will not, alone, tackle

this complex situation: to be really effective health workforce development requires good

governance across all the elements of the health sector. Health workforce development is unlikely

to be linear in a fragile or post-conflict state – in other words, return on investment may not be seen

immediately which can make donors and implementing partners anxious. Mikkelson-Lopez et al

(2011) suggest re-conceptualizing the health systems elements in a non-linear perspective that

reflects the need for governance, in which they include participation and consensus, strategic vision

and system design, addressing corruption, being transparent and accountable. Progress in health

workforce development, if it adheres to the principles of governance, will involve all stakeholders,

seek consensus on a strategic vision for change, and hold government accountable for its actions. In

this scenario, the Ministry of Finance would be accountable for non-payment of salaries for health

workers (common in post-conflict environments), while health workers themselves would be

participants in developing new strategies (participation and consensus).

Finding new ways to measure progress – maybe using a rapid results approach where targets are

short to medium term and measured regularly – may be more encouraging than a 5-10 year vsion

that never materializes.

CONCLUSION Responding to the needs of fragile states for health systems and especially health workforce

development requires new thinking on strategic investment and likely results. A stronger commitment

2 WHO Guide to health workforce development in post-conflict environments. Geneva. WHO; 2005

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to state led governance assessments is seen in the G7+ New Deal and giving the state the lead can

ensure a collaborative, consensus-building approach and attention to governance.

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