Unless tragic emergencies are unfolding – as it is sadly the case now in West Africa – little attention is given to fragile and post-conflict countries. Not only do donors contribute to fragile states 40% less aid than predicted given socio-economic indicators, researchers also quite often refrain from working on/in these contexts. It is only during such emergencies that we (suddenly?) realize that health systems in these settings are – unsurprisingly — extremely weak and the evidence base relatively thin. Yet evidence and operational lessons are exactly what we need post-crisis and in the long term to improve health outcomes and reduce the potential for these countries to be seen mainly as ‘reservoirs’ of disease, conflict and terrorism.
One of the unresolved challenges in post-crisis settings is the balance between humanitarian aid and the longer-term development approach to rebuilding the health system. We agree that decisions made in the early recovery phase could determine the long term development of the health system. But how, when, why and by whom are those decisions made? We know surprisingly little about that. A common hypothesis is that the period of early recovery and reconstruction in the aftermath of a conflict allows for the opening of a political ‘window of opportunity’ for reform. The fluidity of new arrangements, not yet stabilized and defined by long-established interactions between actors, would create room for deviation from historical ‘paths’, bring about more radical reforms and allow countries to avoid path dependency. At least, that’s the theory. By way of example, how did that work out in Sierra Leone, now one of the Ebola-affected countries in West Africa, over the last decade of post-conflict reconstruction?
Human resources for health policy making in Sierra Leone
In a recent paper by the ReBUILD Consortium (or a shorter brief, if you prefer), we set out to verify these hypotheses. We tried to understand what had happened in human resources for health (HRH) reforms in Sierra Leone, from the end of the conflict in 2002 until 2012. Our aim was to retrace key points in time at which reforms had happened, and the actors and factors that enabled them. We found that HRH policy making in Sierra Leone between 2002 and 2012 can be roughly divided into three phases. At first, between 2002 and 2009, the context was characterized by a relatively high degree of political uncertainty, leading to fragmented, incremental policies with a high number of stop-gap measures. However, the context substantially changed in 2009, when the President launched his Free Health Care Initiative (FHCI). The FHCI proved to be an instrumental event and a catalyst for broader health system reform, including in terms of HRH. A series of HRH strategies were designed at the time to revise the health workforce incentive package and boost numbers. However, shortly after the launch of the initiative, the pace of decision-making slowed down again and momentum for reform was not sustained long enough to address the issues of HRH and the health system in a comprehensive way and ensure proper implementation of all of the strategies.
What lessons can be learnt?
We found, perhaps unsurprisingly, that the weak, fragmented health system initially proved a poor reformer, as can be seen in other countries, and that the pace of reconstruction was slower than expected. A ‘window’ for reform did certainly open, but only eight years after the onset of peace. This ‘window’ seemed to have less to do with timing (the immediate aftermath of the war), but to be more politically determined. At the same time, the trajectory of policy making was – inevitably – determined by path dependency. Some of the choices made, explicitly or implicitly, in the immediate post-conflict period, such as not contracting out health services, seem to define the future development of the health system. However, once sufficient political will had been found, the agenda set and broad, internal and external support mobilized, the need for change did prevail over the apparent ‘stickiness’ of paths till then.
Our findings highlight the critical role of domestic political will and external (donor) support for funding and technical assistance, in order to open up political space for reforms at all levels of the health system. On the other hand, they also show the potential limits of short-lived political pressure for change and should let us reflect on the challenge to sustain momentum for reform, both in terms of design and implementation, over time.
This paper was researched and written just before the Ebola outbreak began in Sierra Leone. As has been noted by many observers, the emergency tragically highlights the weakness of the Sierra Leonean health system and issues that, despite the momentum generated by the FHCI for a while, had remained unsolved. It is perhaps too harsh to draw a parallel between the current emergency and the decade-long war in Sierra Leone, but some in Freetown do point to the striking similarities between the two, and for good reason: both originated in the same districts, did initially not seem to reach Freetown but instead slowly but steadily paralyzed the whole economy, one district after another, until the whole country was affected.
War left the health system in shambles, with most facilities destroyed and few health workers remaining. It is difficult to predict the impact of this game-changing emergency and foresee what the overall context and the health system will look like in the medium term, when all this is (hopefully) over. However, reflections on, and efforts to support the reconstruction of the health system are urgently needed. In moving forward we will need to learn lessons from the past. When this will be over, we need to ensure that the ‘windows’ of opportunity for reform and health systems strengthening are not only opened in a timely way, but are kept open wide and for long enough to enable the health system to be comprehensively strengthened.
We now know that these ‘windows’ are not a given in post-emergency settings, but instead must be created and sustained, capitalising on the political will and ownership of domestic actors and the coordinated support of external ones. And that they are fragile themselves.
Maria Paola Bertone is a PhD candidate at the London School of Hygiene and Tropical Medicine, focusing on Health Workers remuneration structure and its consequences on performance and accountability. The work for this paper was carried out in collaboration with the ReBUILD Consortium including institutions from the UK, Cambodia, Uganda, Sierra Leone and Zimbabwe looking at health systems, health financing and HRH issues in post-conflict settings. The ReBUILD Consortium is funded by UK aid from the UK government; however the views expressed do not necessarily reflect the UK government’s official policies.