Why do community systems matter in fragile settings?
During its annual symposium, Medicus Mundi Switzerland focused upon community systems and bottom-up approaches in fragile states. This built upon the conference on Health in Fragile Contexts held in August 2016, which highlighted the need to have community-led, -driven and -owned programmes in situations where health systems have collapsed or are weak.
Healthcare in fragile and conflict-affected states remains a real challenge. Even if health services exist, people may be too afraid to risk the journey to a health facility or may have lost trust in them. Availability, accessibility and affordability of healthcare – the key factors for a well-functioning health system – are often not present. This can have devastating consequences for the affected population.
In such situations, civil society – in particular local organisations and communities, as well as community health-workers – often play a crucial role in delivering basic healthcare. This is because they can contribute to reaching out to the population in order to prevent diseases, provide care and support and fill all kinds of gaps in a situation where a public primary healthcare infrastructure and health professionals are scarce or lacking. In fragile contexts, the strengthening of community systems is therefore key to empowering individuals and communities to identify and manage their own health requirements.
Unfortunately, there is at present only limited evidence and guidance available on appropriate approaches to strengthening health systems in fragile settings. Symposium participants agreed that in such settings, promising approaches in response to health requirements include local community participation and flexible funding in order to respond to difficult and fast changing environments.
Children in a village in Katana, near Bukavu, DRC (2014). Photo: Carine Weiss
Two issues which I consider to be particularly important in the discussion about healthcare in fragile contexts, and which only received a minimum of attention during the MMS Symposium, are i) addressing gender inequalities and ii) measuring the effectiveness of aid.
Leaving no one behind – addressing gender inequalities
Gender inequality should never be neglected. Fragile situations and conflict affect women, men, boys and girls in different ways but it is widely acknowledged that they have the most negative impact on the poorest and on groups most at risk in society, including women and children. Women’s experiences in conflict are too often discussed only in the context of sexual and gender-based violence. This ignores the more structural issues of inequality and therefore reinforces the image of women as sexualised victims.
Gender issues are central in fragile contexts, and they need to be recognised as such. On the one hand, we should research how women and girls experience life in a fragile context – how “gendered” their lives might be – and support them in finding a way through. On the other, we need to focus on women’s full and equal participation and inclusion in good governance, post-conflict transitional justice and peace-building processes. These processes remain heavily dominated and populated by men and reflect male gendered norms and concerns. There is often little room for building and maintaining a stable and sustainable peace from a female perspective. This is not to say that women are, per se, natural peacemakers; however, their values and experiences differ from men’s and would therefore contribute to a richer decision-making process.
Effectiveness of aid – not the same in fragile contexts
In a time when the “end of aid” is being discussed, fragile countries remain the great exception because their governments, although expected to take a lead in health policies and healthcare delivery, are unable to effectively fulfil this role. For this reason, aid remains crucial. Although we did not have the opportunity to address the particular challenges of aid and its effectiveness in fragile contexts during the MMS conference, I consider this topic to be extremely important. Standard aid approaches are widely considered to be inadequate for fragile states, in part because their instruments and processes are too challenging and inflexible. Engaging in fragile countries bears potential risks including contextual risks (e.g. renewed humanitarian crises); programmatic risks (e.g. the risk of failing to achieve targets); and institutional risks (e.g. a lack of security for healthcare providers). Thus, the question is not whether to engage but, instead, how to do so in a way that does not cause harm or contribute to further destabilisation and fragility or is only achievable at an unacceptable cost.
There is a growing body of evidence that aid is more volatile, fragmented and poorly coordinated in fragile settings and there is thus significant potential for improvement. “Leaving no one behind” with services will require the channelling of (domestic) financing to community responses. The challenge of how to increase funding for community responses and how to do this effectively has not yet been sufficiently tackled. There is a resistance to expanding towards community-based service delivery programmes and this can be observed in the response to HIV, especially in the areas of advancing human rights and advocacy. One of the reasons for this is that not enough evidence exists to convince potential donors; in addition, results take a longer time to become evident.
Conclusion
Leave no fragile state behind
We are already able to predict that by 2030 extreme poverty will be increasingly concentrated in fragile and conflict-affected countries. There are estimates that one half to three quarters of the world’s extreme poor will live in such countries then (Chandy et al. (2013) and Kharas and Rogerson (2012), figure 1). In other words, the SDGs can only be achieved if fragile states receive sufficient attention.
Continue to discuss “health cooperation and fragile contexts”!
Working in fragile contexts will remain a concern for the member organisations of Medicus Mundi Switzerland. Therefore, a long-term perspective must be envisaged. NGOs and international agencies will need to adapt their approaches and procedures to fragility so they can respond with agility and speed, while at the same time considering the requirement to remain engaged over a long period.
Health in fragile contexts is at the intersection between humanitarian aid and development cooperation and this is a tricky position because two different approaches and “mind-sets” are involved. It is therefore indispensable to continue our discussions and efforts on “health cooperation and fragile contexts”.
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