Programmes in chronically vulnerable areas: challenges and lessons learned

Sustainability of health services in refugee hosting districts: a qualitative study of health services in three west Nile refugee hosting districts, Uganda

BACKGROUND

Humanitarian health assistance programmes have expanded from temporary approaches addressing short-term needs to providing long-term interventions in emergency settings. Measuring sustainability of humanitarian health services is important towards improving the quality of health services in refugee settings.

OBJECTIVE

To explore the sustainability of health services following the repatriation of refugees from the west Nile districts of Arua, Adjumani and Moyo.

METHODS

This was a qualitative comparative case study conducted in three west Nile refugee-hosting districts of Arua, Adjumani, and Moyo. In-depth interviews were conducted with 28 purposefully selected respondents in each of the three districts. Respondents included health workers and managers, district civic leaders, planners, chief administrative officers, district health officers, project staff of aid agencies, refugee health focal persons and community development officers.

RESULTS

The study shows that in terms of organization capacity, the District Health Teams provided health services to both refugee and host communities with minimal support from aid agencies. Health services were available in most former refugee hosting areas in Adjumani, Arua and Moyo districts. However, there were several disruptions notably reduction and inadequate services due to shortage of drugs and essential supplies, lack of health workers, and closure or relocation of health facilities in around former settlements. To minimize disruptions the district health office reorganized health services. In restructuring health services, the district local governments closed or upgraded health facilities to address reduced capacity and catchment population. Health workers employed by aid agencies were recruited into government services while others who were deemed excess or unqualified were laid off. Equipment and machinery including machines and vehicles were transferred to the district health office in specific health facilities. Funding for health services was mainly provided by the Government of Uganda through the Primary Health Care Grant. Aid agencies, however, continued to provide minimal support health services for refugees who remained in Adjumani district.

CONCLUSION

Our study showed that while humanitarian health services are not designed for sustainability, several interventions continued at the end of the refugee emergency in the three districts. The embeddedness of the refugee health services in the district health systems ensured health services continued through public service delivery structures. It is important to strengthen the capacity of the local service delivery structures and ensure health assistance programmes are integrated into local health systems to promote sustainability.

Constraints to addressing food insecurity in protracted crises

A substantial portion of the world's people have not made adequate progress toward overcoming hunger or achieving sustainable livelihoods. The classic approach to addressing chronic food insecurity has been a strategy of agricultural development, supplemented by humanitarian assistance in the event of a shock or crisis--an approach predicated on assumptions that do not fit the context of protracted crises. This article describes protracted crises and argues that they are sufficiently different to warrant special consideration, but there are unique constraints to engagement in protracted crises. The article explores the constraints promoting sustainable livelihoods in these contexts and proposes elements of an alternative approach. It evaluates the limited evidence available about such an approach and outlines important questions for further research.

Child survival during the 2002-2003 drought in Ethiopia

Droughts in Ethiopia have commonly been associated with increased child mortality. Early indications were that the 2002/03 drought, which affected 13.2 million people, was no exception, despite a large relief operation. Humanitarian agencies reported sharp increases in child deaths and pockets of acute distress in some hard-hit localities. In response, the 2004 Ethiopia Child Survival Survey (ECSS) was designed to investigate the impact of the drought on child survival in the general population. The survey covered 4816 households in both drought-affected and non-drought affected, as well as rural and urban localities. Data from the ECSS indicate that child mortality was indeed higher in drought-affected areas. However, a closer analysis reveals that this differential is attributable to chronic conditions in those localities, rather than the immediate impact of the 2002/03 drought. Multivariate analysis was used to construct a model for the determinants of child survival in the sample population. Household-level demographic factors, household-level food and livelihood security, community-level economic production, and access to potable water, were predictive of child survival. Additionally, household receipt of food aid had a small but significant positive association with child survival, even though the ECSS cannot determine either the underlying causal mechanisms of this association or the role of confounding factors. Nonetheless, it is remarkable that the most extensive drought in the country's modern history passed without a measurable increase in child mortality among the general population. Yet Ethiopian children still suffer unacceptably high rates of chronic malnutrition and poor life chances, and large populations continue to live at the brink of destitution and calamity.

Cracking the code: the genesis, use and future of the Code of Conduct

This paper reflects on the genesis of the Code of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organizations (NGOs) in Disaster Relief, on the tenth anniversary of its adoption. The origins, usage and future of the code are examined with respect to three debates, current at the time of its inception, namely: the debate about the core content of humanitarianism; the debate about coherence and the consensual nature of the humanitarian community; and the debate about the need for, and the ability to demonstrate, accountability. The paper concludes that although the Code of Conduct was very much a product of its time, its content remains relevant today. However, its future application hinges on the capacity of those who purport to follow it to realise true accountability, and on proving that the code, written essentially for natural disasters, is relevant to contemporary complex emergencies.

Assistance, protection, and governance networks in complex emergencies

This article presents an introduction to the causes and characteristics of armed conflicts. It reviews some of the key humanitarian crises that broke new ground in terms of the technologies and practices that developed at the field level in response to each new complex emergency, with particular focus on the health sector. It introduces the concept of humanitarian governance as a framework for addressing the consequences and implications of the failure of worldwide governance for the protection of civilians in armed conflict. Here, we term humanitarian governance to include the use of international humanitarian law and human rights instruments to govern the behaviour of state and non-state organisations in conflict zones in a way that protects the lives and livelihoods of affected populations. We note, however, that terrorist concerns appear to be replacing humanitarian logic in the network of worldwide governance.

The health sector gap in the southern Africa crisis in 2002/2003

The southern Africa crisis represents the first widespread emergency in a region with a mature HIV/AIDS epidemic. It provides a steep learning curve for the international humanitarian system in understanding and responding to the complex interactions between the epidemic and the causes and the effects of this crisis. It also provoked much debate about the severity and causes of this emergency, and the appropriateness of the response by the humanitarian community. The authors argue that the over-emphasis on food aid delivery occurred at the expense of other public health interventions, particularly preventative and curative health services. Health service needs were not sufficiently addressed despite the early recognition that ill-health related to HIV/AIDS was a major vulnerability factor. This neglect occurred because analytical frameworks were too narrowly focused on food security, and large-scale support to health service delivery was seen as a long-term developmental issue that could not easily be dealt with by short-term humanitarian action. Furthermore, there were insufficient countrywide data on acute malnutrition, mortality rates and performance of the public health system to make better-balanced evidence-based decisions. In this crisis, humanitarian organisations providing health services could not assume their traditional roles of short-term assistance in a limited geographical area until the governing authorities resume their responsibilities. However, relegating health service delivery as a long-term developmental issue is not acceptable. Improved multisectoral analytical frameworks that include a multidisciplinary team are needed to ensure all aspects of public health are dealt with in similar future emergencies. Humanitarian organisations must advocate for improved delivery and access to health services in this region. They can target limited geographical areas with high mortality and acute malnutrition rates to deliver their services. Finally, to address the underlying problem of the health sector gap, a long-term strategy to ensure improved and sustainable health sector performance can only be accomplished with truly adequate resources. This will require renewed efforts on part of governments, donors and the international community. Public health interventions, complementing those addressing food insecurity, were and are still needed to reduce the impact of the crisis, and to allow people to re-establish their livelihoods. These will increase the population's resilience to prevent or mitigate future disasters.