Conflict affected, parallel health systems: challenges to collaboration between ethnic and government health systems in Kayin State, Myanmar.

BACKGROUND: Myanmar has had a long history of civil wars with its minority ethnic groups and is yet to see a sustainable peace accord. The conflicts have had a significant impact on health in Myanmar, with ethnic populations experiencing inequitable health outcomes. Consequently, to meet the health needs of ethnic people, Ethnic Health Organisations and Community-Based Health Organisations (EHO/CBHOs) created their own health system. The EHO/CBHO and Government health systems, provided by the Myanmar Ministry of Health and Sports (MoHS), remain parallel, despite both stakeholders discussing unification of the health systems within the context of ongoing but unresolved peace processes. EHO/CBHOs discuss the 'convergence' of health systems, whilst the MoHS discuss the integration of health providers under their National Health Plan. METHODS: A qualitative study design was used to explore the challenges to collaboration between EHO/CBHOs and the MoHS in Kayin state, Myanmar. Twelve health workers from different levels of the Karen EHO/CBHO health system were interviewed. Semi-structured, in-depth interviews were digitally recorded, transcribed, and coded. Data was analysed thematically using the Framework method. Topic guides evolved in an iterative process, as themes emerged inductively from the transcripts. A literature review and observation methods were also utilised to increase validity of the data. RESULTS: The challenges to collaboration were identified in the following five themes: (1) the current situation is not 'post conflict' (2) a lack of trust (3) centralised nature of the MoHS (4) lack of EHO/CBHO health worker accreditation (5) the NHP is not implemented in some ethnic areas. CONCLUSIONS: Ultimately, all five challenges to collaboration stem from the lack of peace in Myanmar. The health systems cannot be 'converged or 'integrated' until there is a peace accord which is acceptable to all actors. EHO/CBHOs want a federal political system, where the health system is devolved, equitable and accessible to all ethnic people. External donors should understand this context and remain neutral by supporting all health actors in a conflict sensitive manner.

Humanitarianism under attack.

Attacks on humanitarianism are threefold. First, in conflict zones, over the past decade attacks on humanitarian health facilities and personnel are increasingly documented, along with a decline in respect for core humanitarian principles by state and non-state actors, and this will continue. Second, growing instrumentalisation, a failure to adequately fund the sector, antimigrant/refugee populism on the rise and the protracted nature of many crises are provoking a shift away from humanitarian to development healthcare aid over the next decade, intended to keep refugees far away from developed countries by encouraging their integration into immediate neighbouring states. This undermines humanitarian healthcare emergency response capacity. Third, the climate crisis will massively increase humanitarian healthcare needs among the most vulnerable over the next decade and challenge the sector to respond across all its programmes, not least as it absorbs a renewed youthful agency elsewhere in climate protest.

Problems of dual vulnerability in nutrition: A qualitative study of older persons caring for under 5-year-olds in post-disaster Haiti.

SITUATION: Malnutrition plays a significant role in under-five mortality rates following disasters. Older people play an important role in childcare in non-Western societies, which often increases in displacement contexts. Until now, policy, in general, and nutrition programmes, in particular, have focused on the mother-child dyad. AIM: To gather information on possible barriers to older carers accessing nutritional services for the children they care for and explore ways to overcome these obstacles. METHOD: A qualitative approach was taken to explore the experiences of the carers themselves. Focus group discussions provided data, which were analysed using grounded theory. RESULTS: Data collected showed older people have similar needs to other caregivers in emergency settings, needs that are often amplified by age. Moreover, many barriers to accessing services were elicited, including targeting and advertising of nutritional programmes, alongside physical and psychosocial barriers to assessing existing support. Participants generated potential solutions to each identified barrier. CONCLUSION: As older people in Haiti were often the sole carers of under-fives, there is a need to recognise their importance in this role and support them within. More generally, in any emergency setting, organisations need take into account all stakeholders in child nutrition when planning and implementing programmes.

When community reintegration is not the best option: interethnic violence and the trauma of parental loss in South Sudan.

The magnitude of violence and human loss in conflict settings often exceeds the caring capacity of traditional support systems for orphans. The aim of this study is to understand the developmental context for children experiencing armed conflict, parental loss, extreme poverty, violence and social exclusion in a setting affected by interethnic violence. This article challenges the received wisdom that community reintegration is always better than institutional provision. Using a case study employing interviews, focus groups, workshops and observations, we examined how children's experiences of armed violence and parental loss affected their mental well-being, and their relationships within their community. Emerging findings such as experienced violence and psychological distress were further investigated using a cross-sectional survey design to explore the generalisability or transferability of theories or conclusions drawn from qualitative data. Findings showed that parental loss had a major impact on children's lives in the context of armed violence. Four main outcomes of orphanhood emerged: (i) facing the situation and evading harm (feelings of rejection and stigmatisation); (ii) trauma exposure and mental health effects (associations of orphanhood with adverse mental health outcomes and the number and type of experienced trauma); (iii) dealing with psychological distress (seeking caring connections and decreased feelings of isolation); and (iv) education and acceptance (increasing knowledge, skills and attitude and being respected in their community). We discuss the role that contexts such as armed violence, parental loss and social exclusion play for children's mental well-being and their implications for psychosocial interventions and orphan care in humanitarian settings. Copyright © 2015 John Wiley & Sons, Ltd.

From war on terror to war on weather? Rethinking humanitarianism in a new era of chronic emergencies.

This special issue of Third World Quarterly makes a case for redirecting attention and resources away from the 'war on terror' and focussing as a matter of urgency on the causes and consequences of global climate change. Global climate change must be recognised as an issue of national and international security. Increased competition for scarce resources and migration are key factors in the propagation of many of today's chronic complex humanitarian emergencies. The relentless growth of megacities in natural disaster hotspots places unprecedented numbers of vulnerable people at risk of disease and death. The Earth's fragile ecosystem has reached a critical tipping point. Today's most urgent need is for a collective endeavour on the part of the international community to redirect resources, enterprise and creativity away from the war on terror and to earnestly redeploy these in seeking solutions to the far greater and increasingly imminent threats that confront us as a consequence of global climate change.

Globalisation and climate change in Asia: the urban health impact.

Asia's economic development successes will create new policy areas to address, as the advances made through globalisation create greater climate change challenges, particularly the impact on urban health. Poverty eradication and higher standards of living both increase demand on resources. Globalisation increases inequalities and those who are currently the losers will carry the greatest burden of the costs in the form of the negative effects of climate change and the humanitarian crises that will ensue. Of four major climate change challenges affecting the environment and health, two­urban air pollution and waste management­can be mitigated by policy change and technological innovation if sufficient resources are allocated. Because of the urban bias in the development process, these challenges will probably register on policy makers' agenda. The second two major challenges­floods and drought­are less amenable to policy and technological solutions: many humanitarian emergency challenges lie ahead. This article describes the widely varying impact of both globalisation and climate change across Asia. The greatest losers are those who flee one marginal location, the arid inland areas, only to settle in another marginal location in the flood prone coastal slums. Effective preparation is required, and an effective response when subsequent humanitarian crises occur.

'Mind the gap!' rethinking the role of health in the emergency and development divide.

The 'Emergency Relief-Rehabilitation-Development' model is highly problematic, especially in fragile states which fluctuate in and out of crisis. Lack of definition as to what constitutes a humanitarian emergency and the absence of rules of engagement of NGOs and donors further complicates the problem. Restricted mandates and budgets of institutions and funding bodies lead to gaps in the provision of health services for affected populations. Reducing the gap between emergency and developmental healthcare requires approaching the issue from both sides, recognizing that the emergency-development gap is not a single uniform entity but a complex dynamic of heterogeneous gaps.