Citizen feedback in a fragile setting: social accountability interventions in the primary healthcare sector in Sierra Leone

Fragile and conflict‐affected states are frequently characterised by their inability to fulfil three core governance functions: provision of security, effective delivery of basic public goods and services, and managing political participation and accountability. This article explores the utility of social accountability interventions in fragile environments. Successful social accountability interventions can lead to joint examinations of public service standards by service‐users and providers, resulting in collaborative improvement efforts. The few available studies of such interventions implemented in fragile or conflict‐affected states show reasons for optimism as well as challenges. This article advocates the continued use of social accountability methods in fragile settings and provides examples of social accountability interventions in the health sector in Sierra Leone. The study suggests that social accountability can improve interaction between citizens and public service providers. Successful social accountability interventions can also lead to better quality and more accessible public services, which, in turn, can enhance state legitimacy.     

Are non‐poor households always less vulnerable? The case of households exposed to protracted civil war in Southern Sudan

Civil wars in Africa are now the leading contributory cause of vulnerability of rural communities. Understanding vulnerability during civil war is critical for humanitarian response and post-conflict rehabilitation planning. The lack of understanding of vulnerability has led existing studies to make sweeping generalizations, either by equating the dynamics of vulnerability during civil wars with vulnerability in other risk events, or by projecting people in the 'war zones' as unable to cope and subsequently becoming vulnerable. This paper is an attempt to gain a more nuanced understanding of the dynamics of vulnerability during protracted civil war. It shows that during civil war the non-poor are not necessarily less vulnerable than poor households. The idea that people caught up in civil war are all vulnerable is not supported by the findings of this paper. It shows that the 'standard' pattern of vulnerability to drought is similar to that during exogenous counter-insurgency warfare, while a different pattern of vulnerability to endogenous shocks is identified.     

Health sector recovery in early post‐conflict environments: experience from southern Sudan

Health sector recovery in post‐conflict settings presents an opportunity for reform: analysis of policy processes can provide useful lessons. 1 The case of southern Sudan is assessed through interviews, a literature review, and by drawing on the experience of former technical advisers to the Ministry of Health. In the immediate post‐conflict phase, the health system in southern Sudan was characterised by fragmentation, low coverage of health services, dismal health outcomes and limited government capacity. Health policy was extensively shaped by the interplay of context, actors and processes: the World Bank and the World Health Organization became the primary drivers of policy change. Lessons learned from the southern Sudan case include the need for: sustained investment in assessment and planning of recovery activities; building of procurement capacity early in the recovery process; support for funding instruments that can disburse resources rapidly; and streamlining the governance structures and procedures adopted by health recovery financing mechanisms and adapting them to the local context.     

Women, Health and Humanitarian Aid in Conflict

The burden of political conflict on civilian populations has increased significantly over the last few decades. Increasingly, the provision of resources and services to these populations is coming under scrutiny; we highlight here the limited attention to gender in their provision. Women and men have different exposures to situations that affect health and access to health-care and have differential power to influence decisions regarding the provision of health services. We argue that the role of women in planning is central to the provision of effective, efficient and sensitive health-care to conflict-affected populations.     

Mental health in South Sudan: a case for community‐based support

This paper² provides a snapshot of the mental health situation in South Sudan between 2013 and 2016, taking account of the personal reflections of both authors who were engaged in mental health and psychosocial support (MHPSS)³ programming in the country at this time.⁴ It begins by presenting an overview of MHPSS activities from this period, including governmental and non‐governmental organisation (NGO) services, and relevant research and coordination mechanisms. It goes on to illustrate the challenges to the provision of support, as well as the overarching structural, governance, and human resource constraints faced by the sector. Finally, recommendations are put forward for improving services and care for people suffering from psychosocial and mental health issues, as well as suggestions for areas of focus in the future. The importance of an integrated, community‐based model is emphasised, and opportunities for organisations engaged in reconciliation efforts and mental health service provision to collaborate are proposed.     

Food as an instrument of war in contemporary african famines: a review of the evidence

Famine is conventionally portrayed as a natural disaster expressed in terms of food scarcity and culminating in starvation. This view has attracted criticism in recent years as the political, legal and social dimensions of famine have become more clearly understood. This paper draws upon these criticisms to understand the particular conditions of famine creation in conflict situations. Following an examination of six contemporary African famines, it is suggested that the use of food as a weapon of war by omission, commission and provision has contributed to the creation of famine in recent decades. Despite the optimism for peace engendered by the demise of the Cold War, the momentum for conflict would seem to be sustained by internal factors, including economic and environmental decline, political instability and ethnic rivalry. Within these conflicts, the strategic importance of food is likely to remain central. This study highlights the need to link concerns with food security and public health to those of development, human rights and international relations.     

Privatisation and outsourcing in wartime: the humanitarian challenges

The tendency today to privatise many activities hitherto considered the exclusive preserve of the state has given rise to sharp debate. The specific nature of humanitarian emergencies elucidates in particularly stark contrast some of the main challenges connected to the privatisation and outsourcing of essential public services, such as the provision of drinking water and health care. Privatising the realms of defence and security, which are at the very core of state prerogative, raises several legal and humanitarian concerns. This article focuses on the roles and responsibilities of the various parties involved in armed conflicts, especially those of private companies engaged in security, intelligence and interrogation work, and in the provision of water supply and health services. It highlights the need for humanitarian and development actors to grasp better the potential risks and opportunities related to privatisation and outsourcing with a view to supplying effective protection and assistance to communities affected by war.     

The 1970 Bhola cyclone,nationalist politics,and the subsistence crisis contract in Bangladesh

The devastating Bhola cyclone in November 1970 is credited with having triggered the political events that led to the division of Pakistan and the creation of Bangladesh in 1971. A callous response to the disaster by the Pakistani regime resulted in a landslide electoral victory for Bengali nationalists, followed by a bitter and bloody civil war. Yet, despite its political momentousness, the Bhola cyclone has been the subject of little political analysis. This paper examines the events, arguing that its extraordinary political significance put disaster management on the nationalist agenda; the famine of 1974 confirmed its centrality, producing a social contract to protect the population against disasters and subsistence crises on which the country's acclaimed resilience to the effects of climate change rests. The Bhola cyclone also drew international attention to this neglected, little‐known region, and in general can be seen as foundational for the subsequent developmental achievements of Bangladesh.     

Livelihoods,power, and food insecurity: adaptation of social capital portfolios in protracted crises—case study Burundi

The failure of food security and livelihood interventions to adapt to conflict settings remains a key challenge in humanitarian responses to protracted crises. This paper proposes a social capital analysis to address this policy gap, adding a political economy dimension on food security and conflict to the actor‐based livelihood framework. A case study of three hillsides in north Burundi provides an ethnographic basis for this hypothesis. While relying on a theoretical framework in which different combinations of social capital (bonding, bridging, and linking) account for a diverse range of outcomes, the findings offer empirical insights into how social capital portfolios adapt to a protracted crisis. It is argued that these social capital adaptations have the effect of changing livelihood policies, institutions, and processes (PIPs), and clarify the impact of the distribution of power and powerlessness on food security issues. In addition, they represent a solid way of integrating political economy concerns into the livelihood framework.     

Post-conflict health reconstruction: search for a policy

Despite increasing experience in health reconstruction in societies emerging from conflict, the policy basis for investing in the development of equitable and effective health systems in the wake of war remains unsettled. Consideration of post-conflict health reconstruction is almost entirely absent in donor policies on global health. Practically by default, health programmes are seen increasingly as an element of stabilisation and security interventions in the aftermath of armed conflict. That perspective, however, lacks an evidence base and can skew health programmes towards short-term security and stabilisation goals that have a marginal impact and violate the principles of equity, non-discrimination, and quality, which are central to sound health systems and public acceptance of them. A better approach is to ground policy in legitimacy, viewing health both as a core social institution and one that, if developed according to human rights principles, including equity, non-discrimination, participation and accountability, can advance the effectiveness and the quality of governance in the emerging state.     

Health and social impacts of a flood disaster: responding to needs and implications for practice

Carlisle in northwest England suffered its worse floods for more than 180 years in 2005. A study, reported here, was undertaken to assess the health and social impacts of these floods via in‐depth, taped individual and focus‐group interviews with people whose homes had been flooded and with agency workers who helped them. Respondents spoke of physical health ailments, psychological stress, water health‐and‐safety issues related to the floods, and disputes with insurance and construction companies, which they felt had caused and exacerbated psychological health problems. Support workers also suffered from psychological stress. Furthermore, it was found that people had low expectations of a flood and were not prepared. The findings are presented in five sections covering flood risk awareness, water contamination issues, physical health, mental health, and impact on frontline support workers. The discussion focuses on the implications of the findings for policy and practice vis‐à‐vis psychological health provision, contamination issues, training and support for frontline support workers, matters relating to restoration, and preparation for flooding.     

Social capital and the political economy of violence: a case study of Sri Lanka

This article examines the links between militarised violence and social capital (trans)formation. It first maps out emerging theoretical and policy debates on social capital and violent conflict and questions a number of the assumptions underpinning these debates. This is followed by an empirical analysis of several war-affected communities in Sri Lanka. The case studies illustrate that the links between militarised violence and social capital are complex, dynamic and context specific. It is argued that social capital cannot be understood in isolation from political and economic processes, and the belief that violent conflict inevitably erodes social capital is questioned. Finally, the implications for external agencies are highlighted. Rather than focusing on engineering social capital, external agencies need to focus on understanding better the preconditions for social capital formation and how they can contribute to the creation of an enabling environment. This requires as a starting-point a rigorous analysis of political and economic processes.     

The analytical framework of water and armed conflict: a focus on the 2006 Summer War between Israel and Lebanon

This paper develops an analytical framework to investigate the relationship between water and armed conflict, and applies it to the ‘Summer War’ of 2006 between Israel and Lebanon (Hezbollah). The framework broadens and deepens existing classifications by assessing the impact of acts of war as indiscriminate or targeted, and evaluating them in terms of international norms and law, in particular International Humanitarian Law (IHL). In the case at hand, the relationship is characterised by extensive damage in Lebanon to drinking water infrastructure and resources. This is seen as a clear violation of the letter and the spirit of IHL, while the partial destruction of more than 50 public water towers compromises water rights and national development goals. The absence of pre‐war environmental baselines makes it difficult to gauge the impact on water resources, suggesting a role for those with first‐hand knowledge of the hostilities to develop a more effective response before, during, and after armed conflict.     

Rebuilding and strengthening health systems and providing basic health services in fragile states

The international community has compelling humanitarian, political, security and economic reasons to engage in rebuilding and strengthening health systems in fragile states. Improvements in health services and systems help to strengthen civil society and to restore legitimacy to governments. Effective engagement with fragile states to inform the design of health programmes and selection of interventions depends on donor coordination and an understanding of health system challenges. Planning requires consideration of allocation (services to be delivered), production (organisation of services), distribution (beneficiaries of services) and financing. The criteria for selecting interventions are: their impact on major health problems; effectiveness; the possibility of scale-up; equity; and sustainability. There are various options for financing and models of engagement, but support should always combine short-term relief with longer-term development. Stakeholders should aim not only to save lives and protect health but also to bolster nations' ability to deliver good-quality services in the long run.     

Transitional coordination in Sudan (2006–08): lessons from the United Nations Resident Coordinator's Office

With the increase in internal conflicts following the end of the Cold War, the scale and scope of the United Nations' work in conflict and post‐conflict environments grew markedly. As a result, the coordination of programming and policy in the transition from relief to recovery has been a central preoccupation of academics and practitioners alike. Intergovernmental bodies such as the United Nations Economic and Social Council (ECOSOC) have made these topics a subject of regular discussion, while some countries have altered their bureaucratic structures to respond more effectively in post‐crisis settings, particularly in cases involving the deployment of national troops. The United Nations Resident Coordinator's Office in Sudan provides a model for other transitional countries and is a useful case study of the broader challenges of post‐crisis programming. Effective coordination structures and planning/programming processes are identified as interdependent prerequisites for ensuring a successful transition from relief to recovery.     

Quality design: a planning methodology for the integration of refugee and local health services,West Nile,Uganda

In an emergency, the international community responds to the immediate health needs of refugees through the establishment of action-oriented, life-saving services. Healthcare delivery is often managed with limited, if any, coordination with local health management structures. In situations where refugees remain in the host country for many years, sustainability issues inevitably arise. Refugee-hosting governments may ultimately be called upon to assume the management and funding of refugee services. Planning for service integration, while protecting against declines in service quality, is a challenge in the typically resource-poor host environments. This paper discusses these issues by presenting the experience of the West Nile districts in northern Uganda, and describes quality design as a relevant planning methodology. Quality design is a systematic planning approach that documents and directly incorporates the service users' self-defined expectations and needs.     

The public health system response to the 2008 Sichuan province earthquake: a literature review and interviews

This paper describes and analyses the public health system response to the deadly earthquake in Sichuan province, China, in May 2008. Drawing on an experiential learning project consisting of a literature review and field research, including a series of interviews with medical and public health professionals, policy‐makers and first responders, a conceptual framework was developed to describe the response. This approach emphasises the pre‐existing preparedness level of the medical and public health systems, as well as social, economic and geo‐political factors that had an impact on mitigation efforts. This framework was used to conduct post‐disaster analyses addressing major response issues and examining methods employed during the public health response to the disaster. This framework could be used to describe and analyse the emergency response to other disasters.     

Interrupting the balance: reconsidering the complexities of conflict in South Sudan

By the start of 2014, violent conflict had erupted across much of South Sudan following initial violence in Juba on 15 December 2013. The speed with which the fighting has spread raises questions regarding the impact of national‐level politics on violence at the local level. This article develops a framework in which violent conflict can be comprehended as a response to the interruption of the negotiation of the balance of power between groups; the negotiation is interrupted when that balance tips in favour of one group, such as through changes in the national political market or government reforms. The article provides two cases studies of attempts to strengthen the state that inadvertently interrupted local power relations between groups. In response, the groups engaged in violent conflict to reinstate a balance of power. Both examples involve conflict among Dinka groups from 2005 to 2008.     

Childhood Immunisation in Rural Afghanistan: The EPI Programme, 1987-91

A decade of outright war followed by civil strife and conflict has hindered the development of health care services for the population of rural Afghanistan. Despite the absence of a functional health care system and the fragmentation of the Afghan resistance, and despite widely held views to the contrary, it has proved possible to set up a technically valid and politically acceptable Expanded Programme of Immunisation (EPI). This paper discusses some of its technical and programmatic aspects and the rationale behind some of the very unusual choices made – such as the use of DPTP, the inclusion of girls 3–14 years old for TT immunisation, a vertical programme structure and a predominance of mobile and outreach strategies. The paper argues against the mindless use of global or handbook recipes. The keys to success have been strategic vision, intimate knowledge of the local context and pragmatic choices for options that are simple and effective.