Recurrent failings of medical humanitarianism: intractable, ignored, or just exaggerated?

Humanitarian health workers operate in dangerous and uncertain contexts, in which mistakes and failures are common, often have severe consequences, and are regularly repeated, despite being documented by many reviews. This Series paper aims to discuss the failures of medical humanitarianism. We describe why some of these recurrent failings, which are often not identified until much later, seem intractable: they are so entrenched in humanitarian action that they cannot be addressed by simple technical fixes. We argue that relief health-care interventions should be contextualised. Perhaps medical humanitarianism deserves a better reputation than the one at times tarnished by unfair criticism, resulting from inapplicable guiding principles and unrealistic expectations. The present situation is not conducive to radical reforms of humanitarian medicine; complex crises multiply and no political, diplomatic, or military solutions are in sight. Relief agencies have to compete for financial resources that do not increase at the same pace as health needs. Avoiding the repetition of failures requires recognising previous mistakes and addressing them through different policies by donors, stronger documentation and analysis of humanitarian programmes and interventions, increased professionalisation, improved, opportunistic relationships with the media, and better ways of working together with local health stakeholders and through indigenous institutions.

Can we halt health workforce deterioration in failed states? Insights from Guinea-Bissau on the nature, persistence and evolution of its HRH crisis.

BACKGROUND: Guinea-Bissau is one of the world's poorest and least developed countries. Amid poverty, political turmoil and state withdrawal, its health workforce (HW) has been swamped for the last four decades in a deepening crisis of under-resourcing, poor performance and laissez-faire. METHODS: The present study aimed at analysing the human resources for health (HRH) situation in Guinea-Bissau in light of the recent literature on distressed health systems, with the objective of contributing to understanding the ways health workers react to protracted turmoil, the resulting distortions and the counter-measures that might be considered. Through document analysis, focus group discussions, 14 semi-structured and 5 in-depth interviews, we explored patterns as they became visible on the ground. RESULTS: Since independence, Guinea-Bissau experienced political events that have reflected on the healthcare arena and on the evolution of its health workforce, such as different coup attempts, waves of diaspora and shifting external assistance. The chronic scarcity of funds and a 'stable political instability' have lead to the commercialisation of public health services and to flawed mechanisms for training and deploying health personnel. In absence of any form of governance, health workers have come to own and run the health system. We show that the HRH crisis in Guinea-Bissau can only be understood by looking at its historical evolution and at the wider socio-economic context. There are no quick fixes for the deterioration of HRH in undergoverned states; however, the recognition of the ingrained distortions and an understanding of the forces determining the behaviour of key actors are essential premises for the identification of solutions. CONCLUSIONS: Guinea-Bissau's case study suggests that any policy that does not factor in the limited clout of health authorities over a effectively privatised healthcare arena is doomed from the start. Improving health system governance and quality of training should take precedence over expanding HRH. A bloated and ineffective workforce must be managed through incentives rather than administrative orders, in order to improve skills and productivity against higher remuneration and better working conditions. Donor support might be crucial to trigger positive changes, through realistic and sustained investments.

State-building and human resources for health in fragile and conflict-affected states: exploring the linkages.

BACKGROUND: Human resources for health are self-evidently critical to running a health service and system. There is, however, a wider set of social issues which is more rarely considered. One area which is hinted at in literature, particularly on fragile and conflict-affected states, but rarely examined in detail, is the contribution which health staff may or do play in relation to the wider state-building processes. This article aims to explore that relationship, developing a conceptual framework to understand what linkages might exist and looking for empirical evidence in the literature to support, refute or adapt those linkages. METHODS: An open call for contributions to the article was launched through an online community. The group then developed a conceptual framework and explored a variety of literatures (political, economic, historical, public administration, conflict and health-related) to find theoretical and empirical evidence related to the linkages outlined in the framework. Three country case reports were also developed for Afghanistan, Burundi and Timor-Leste, using secondary sources and the knowledge of the group. FINDINGS: We find that the empirical evidence for most of the linkages is not strong, which is not surprising, given the complexity of the relationships. Nevertheless, some of the posited relationships are plausible, especially between development of health cadres and a strengthened public administration, which in the long run underlies a number of state-building features. The reintegration of factional health staff post-conflict is also plausibly linked to reconciliation and peace-building. The role of medical staff as part of national elites may also be important. CONCLUSIONS: The concept of state-building itself is highly contested, with a rich vein of scepticism about the wisdom or feasibility of this as an external project. While recognizing the inherently political nature of these processes, systems and sub-systems, it remains the case that state-building does occur over time, driven by a combination of internal and external forces and that understanding the role played in it by the health system and health staff, particularly after conflicts and in fragile settings, is an area worth further investigation. This review and framework contribute to that debate.

Human resources for health in six healthcare arenas under stress: a qualitative study.

BACKGROUND: Research on "human resources for health" (HRH) typically focuses on the public health subsector, despite the World Health Organization's inclusive definition to the contrary. This qualitative research examines the profile of HRH in six conflict-affected contexts where the public health subsector does not dominate healthcare service provision and HRH is a less coherent and cohesive entity: Afghanistan, the Central African Republic (CAR), the Democratic Republic of Congo (DR Congo), Haiti, the Occupied Palestinian Territories and Somalia. METHODS: The study uses a multiple-country qualitative research design including documentary analysis and key informant interviews undertaken between 2010 and 2012. The documentary analysis included peer-reviewed articles, books, unpublished research and evaluations and donor and non-government organisation reviews. A common thematic guide, informed by this analysis, was used to undertake key informant interviews. Informants thought able to provide some insight into the research questions were identified from ministry of health organograms, and from listings of donors and non-government organisations. Local informants outside the familiar structures were also contacted. In CAR, 74 were interviewed; in Somalia 25; . in Haiti, 45; in Afghanistan, 41; in DR Congo, 32; and in the Occupied Palestinian Territories, 30. In addition, peer review was sought on the initial country reports. RESULTS: The study discovered, in each healthcare arena investigated, a crowded HRH space with a wide range of public, private, formal and informal providers of varying levels of competence and a diverse richness of initiatives, shaped by the easy commodification of health and an unregulated market. The weak regulatory framework and capacity to regulate, combined with limited information regarding those not on the state payroll, allowed non-state providers to flourish, if not materially then at least numerically. CONCLUSION: When examining HRH, a reliance on information provided by the state health sector can only provide a partial and inadequate representation of reality. For policy-makers and planners in disrupted contexts to begin to appreciate fully current and potential HRH, there is a need to study the workforce using conceptual tools that reflect the situation on the ground, rather than idealised patterns generated by incomplete inventories and unrealistic standards.

The "empty void" is a crowded space: health service provision at the margins of fragile and conflict affected states.

BACKGROUND: Definitions of fragile states focus on state willingness and capacity to ensure security and provide essential services, including health. Conventional analyses and subsequent policies that focus on state-delivered essential services miss many developments in severely disrupted healthcare arenas. The research seeks to gain insights about the large sections of the health field left to evolve spontaneously by the absent or diminished state. METHODS: THE STUDY EXAMINED SIX DIVERSE CASE STUDIES: Afghanistan, Central African Republic, Democratic Republic of the Congo, Haïti, Palestine, and Somalia. A comprehensive documentary analysis was complemented by site visits in 2011-2012 and interviews with key informants. RESULTS: Despite differing histories, countries shared chronic disruption of health services, with limited state service provision, and low community expectations of quality of care. The space left by compromised or absent state-provided services is filled by multiple diverse actors. Health is commoditized, health services are heterogeneous and irregular, with public goods such as immunization and preventive services lagging behind curative ones. Health workers with disparate skills, and atypical health facilities proliferate. Health care absorbs large private expenditures, sustained by households, remittances, charitable and solidarity funding, and constitutes a substantial portion of the country economy. Pharmaceutical markets thrive. Trans-border healthcare provision is prominent in most studied settings, conferring regional and sometimes true globalized characteristics to these arenas. CONCLUSIONS: We identify three distortions in the way the global development community has considered health service provision. The first distortion is the assumption that beyond the reach of state- and donor-sponsored services is a "void", waiting to be filled. Our analysis suggests that the opposite is the case. The second distortion relates to the inadequacy of the usual binary categories structuring conventional health system analyses, when applied to these contexts. The third distortion reflects the failure of the global development community to recognise-or engage-the emergent networks of health providers. To effectively harness the service provision currently available in this crowded space, development actors need to adapt their current approaches, engage non-state providers, and support local capacity and governance, particularly grassroots social institutions with a public-good orientation.

Too good to be true? An assessment of health system progress in Afghanistan, 2002-2012.

The bold decision was taken in Afghanistan in 2002 to provide donor-funded public health services by means of contracting-out of predefined health care packages. This study seeks to identify the extent to which progress has been made in public health services provision in the context of broader state-building agendas. The article argues that the provision of public health services was also intended to generate a peace dividend and to legitimize the newly established government. The widely portrayed success of the contracting model is backed up by very high official figures for health service coverage. This contrasts with evidence at household level, which suggests limited utilization of public health services, and perceptions that these offer inferior quality, and a preference for private providers. The dissonance between these findings is striking and confirms that public health care cannot remain immune from powerful market forces, nor from contextual determinants outside the health field.

An examination of pharmaceutical systems in severely disrupted countries.

This research assesses informal markets that dominate pharmaceutical systems in severely disrupted countries and identifies areas for further investigation. Findings are based on recent academic papers, policy and grey literature, and field studies in Somalia, Afghanistan, the Democratic Republic of Congo and Haiti. The public sector in the studied countries is characterized in part by weak Ministries of Health and low donor coordination. Informal markets, where medicines are regularly sold in market stalls and unregulated pharmacies, often accompanied by unqualified medical advice, have proliferated. Counterfeit and sub-standard medicines trade networks have also developed. To help increase medicine availability for citizens, informal markets should be integrated into existing access to medicines initiatives.

Human resources for health through conflict and recovery: lessons from African countries.

A protracted conflict affects human resources for health (HRH) in multiple ways. In most cases, the inflicted damage constitutes the main obstacle to health sector recovery. Interventions aimed at healing derelict human resources are however fraught with difficulties of a political, technical, financial and administrative order. The experience accumulated in past recovery processes has made some important players aware of the cost incurred by neglecting human resource development. Several transitions from conflict to peace have been documented, even if largely in unpublished reports. This paper presents condensed descriptions of some African HRH-related recovery processes, which provide useful lessons. The technical work demanded to resuscitate a derelict health workforce is fairly well understood. In most situations, the highest hurdles lie outside of the health domain, and are of a political and administrative nature. Success stories are rare. But useful lessons are taught by failure as well as by success.

From drought to deluge: how information overload saturated absorption capacity in a disrupted health sector.

Provision of technical assistance is a common form of support to health sectors emerging from prolonged conflicts. But what actions signal that the Ministry of Health (MoH) is, or is not, actively analysing and digesting the output of this assistance? Where are the boundaries between doing with and doing for? This article presents a qualitative description of an early post-conflict policy process in southern Sudan, which represented an opportunity to test these boundaries. The methodology of provision of technical assistance to the MoH in the formulation of a human resource plan is reviewed. Initial objectives are compared with the results accomplished. Shortcomings are discussed and recommendations for technical assistance programmes in similar contexts are provided. Between October 2005 and May 2006, World Health Organization advisers supported the MoH in conducting a human resources assessment to lay the grounds for a human resources development plan. The study employed three consultants, ten data collectors and entailed questionnaires, field visits, interviews and a review of literature. The survey shed new important evidence on the human resources situation in southern Sudan, both in quantitative and qualitative terms, and formulated specific recommendations. The formulation of the human resources plan, however, took another direction, apparently unrelated to the findings of the survey. Various factors contributed to the scope and methodology of the survey being inappropriate to the reality of southern Sudan. In the presence of systemic capacity gaps, including uncertain governance and precarious management systems, the benefit of one-off comprehensive surveys is likely to be negligible. Inaction is not always rooted in the lack of information, as too often assumed; this case study exposes the limits of a rationalistic approach to policy formulation and planning in the field of human resources for health. An alternative approach that entails incremental steps to institutional capacity building is suggested.