Rebuilding Health Systems in Low-income Post-conflict Countries

Abstract

Rebuilding health systems in post-conflict settings is complex and multifaceted. Despite having an overabundance of wars in the past century, efficacious policies needed to rebuild health systems in post-conflict settings are not widely known, especially in low-income countries. Furthermore, it is imperative for a country to remain conflict free if it is to successfully rebuild a health system. Implementing health programs is one strategy that has been hypothesized to help restore and retain peace; however, an analysis of investigating whether this hypothesis holds true has yet to be done. To address these gaps, we identified three research objectives, 1) to conduct a systematic review on what policies, practices, programs, principles, products and procedures are commonly used to rebuild health systems in post-conflict settings, 2) to perform a holistic multi-case study analysis and systematic search and review comparing two high performing health systems in low-income post-conflict countries, and 3) to conduct a descriptive and exploratory analysis to identify how health-related policies can promote sustainable peacebuilding in the Eastern Mediterranean Region. For the first study, we conducted a systematic review using descriptive, mixed-methods, and qualitative data examining how the 7 Ps (policies, programs, practices, principles, products, pills, procedures) of implementation science have been used to rebuild health systems incorporating the World Health Organization’s six building blocks of a health system in low-income post-conflict settings. Initial search returned 2,104 results and after applying our inclusion/exclusion criteria, 65 articles underwent full text review with a total of 35 articles included in the narrative analysis. Twenty-seven studies examined one of the six WHO health system building blocks, one study addressed two building blocks, three studies addressed three building blocks, two studies focused on four building blocks, and two studies addressed all six building blocks. Evaluating the 7 Ps of implementation science, policies were the most frequent “P” identified (25 studies) followed by programs (12 studies), and practices (1). No studies incorporated principles, products, or procedures in our review. Results of narrative analysis revealed five thematic topics used to rebuild post-conflict health systems including the importance of 1) coordinating mechanisms in policy development; 2) human resources for health policy development and recruitment; 3) gender equity policies in health systems reform; 4) finance policies; and 5) service delivery programs. The second study consisted of a systematic search and review and a holistic multi-case study using Rutherford and Saleh’s post-conflict health systems framework to identify what inputs, policies, and governance structures were used to build successful health systems. Using a novel set of health system indicators, we identified two post-conflict, low-income countries who successfully rebuilt strong health systems, Rwanda and Timor-Leste. By applying the analytic strategies of theoretical propositions, pattern matching, cross-case synthesis, and analytic generation to these two countries, we identified key policies, inputs, and governance practices that aligned with the 7 Ps of implementation science and WHO’s health system building blocks. We identified nine strategies that have a positive impact on rebuilding health systems in both Rwanda and Timor-Leste: investment in human resources, physical infrastructure, essential medications, country ownership of health system spending, partnerships with NGOs, donor coordination, national leadership, community-based care and gender equity, and anti-corruption policies. Theoretical sampling identified the dangers of structural adjustment programs and the importance of post-conflict countries negotiating more flexible loan agreements. Our third study evaluated how health can be used as a tool to promote peacebuilding in conflict and post-conflict settings. Using a literature review and key informant interviews, we explored how health systems and health frameworks historically and currently are being used for peacebuilding. In addition, we identified key lessons learned and recommendations on how health can be used as a tool to promote and sustain peacebuilding efforts, specifically for the Eastern Mediterranean Region (EMR) which contains the highest prevalence of conflict in the world. In summary, we identified a number of thematic topics that are critical in reconstructing health systems in low-income post-conflict countries including the importance of 1) coordinating mechanisms in policy development; 2) human resources for health policy development and recruitment; 3) gender equity policies in health systems reform; 4) finance policies; and 5) service delivery programs. We also identified nine strategies that have a positive impact on rebuilding health systems used in both Rwanda and Timor-Leste which builds upon the above mentioned thematic topics including investment in human resources, physical infrastructure, and essential medications, country ownership of health system spending, partnerships with NGOs, donor coordination, national leadership, community based care and gender equity, and anti-corruption policies. Lastly we identified how health programs have been used to promote peacebuilding in efforts in post-conflict countries and compiled key recommendations for how health programs can be used a tool for peacebuilding in the EMR.