Delivering Health Services in Fragile States and Difficult Environments 13 Key Principles Sarah Oswald and Jerry Clewett November 2007 Any comments warmly welcomed: j.clewett@healthunlimited.org Health Unlimited, Unit 6, Park Place, 12 Lawn Lane, London, SW8 1UD, UK. Tel: + 44 (0)20 7840 3777  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Acknowledgements The authors would like to thank all those who helped in the preparation of this report. Although the list would be too long if all were mentioned, we would like to especially thank the Health Unlimited Country Managers for coordinating the input from the featured countries: Ms Somatheavy Khou from Cambodia; Dr Zhang Jun from Burma/ Myanmar; Dr Tadesse Kassaye from Ethiopia; Mr Chrys Alakonya Shem from Somalia; Ms Rosa Malca from Peru; and Mr Thomas Hart from Guatemala. Ms Ebony Riddell from Health Unlimited London also contributed significantly. However, having mentioned those names, we also wish to acknowledge the tremendous work of the hundreds of Health Unlimited staff throughout the world, our partners, and those volunteers in the communities where we work, who are working to improve the health of marginalised communities in fragile states and difficult environments day after day, year after year. It is their work that has generated the lessons learnt in this report. And it is their work that we seek to strengthen. Front and back cover pictures shows children in Special Region 4, Burma/Myanmar 2 Executive Summary Health Unlimited has been working in fragile states and difficult environments in Africa, Asia and Latin America for over 20 years, to secure access to effective primary health care for marginalised people affected by conflict, instability or discrimination. Based on these first-hand experiences, this paper draws out key policy recommendations and operational implications for stakeholders involved in delivering health services in fragile states and difficult environments. These are defined as countries, or areas within countries, where the government lacks the capacity and/or willingness to ensure the provision of appropriate basic services to the whole population; in some cases, the legitimacy of the government may be questionable. In many fragile states and difficult environments, governments are not working towards meeting their citizens’ right to health, resulting in poor health outcomes for a large proportion of their populations. Drawing on examples and case studies from six countries (Burma/Myanmar, Cambodia, Ethiopia, Guatemala, Peru and Somaliland1), this paper highlights 13 key principles for policy makers and implementers which improve the delivery of health services in fragile states and difficult environments. Although the focus is on reaching marginalised communities, following the principles – including the direct targeting of such communities – will improve service delivery for all communities. Background Right to health Throughout the world, and as enshrined in numerous international and national agreements, people have the right to health. This can be understood as, “a right to an effective and integrated Community outreach in health system, encompassing health care and the underlying Preah Vihear, Cambodia determinants of health, which is responsive to national and local priorities, and accessible to all,” (Hunt, 2006) which includes the right to access health services on the basis of equity and non- discrimination. Fragile states Approximately 14% of the world’s population live in fragile states. These states are more likely to become unstable and can impact well beyond their national borders, for example through refugee movements, increased transmission of infectious diseases and reduced economic growth. Donors are also increasingly recognising that fragility has a major, negative impact on service delivery. Health indicators in fragile states are considerably worse than other developing countries: for example, child and maternal mortality are around 2.5 times higher than in other developing countries. There is 1 Somaliland is a de facto independent state but has not yet been internationally recognised. It is therefore officially still part of Somalia. 3  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments therefore a moral and social justice imperative to work in such countries, to support those in dire need and enable them to claim their right to health. Difficult environments As difficult environments can be considered as ‘mini fragile states’, there is a danger that the effects of this marginalisation can spill over into the country as a whole, or even across borders; the country’s economic growth will also be affected. Inequity in access to health services and health outcomes means that mortality and morbidity rates in difficult environments are generally higher than for the population as a whole. For example, in most countries in Asia and the Pacific, the infant mortality rate amongst indigenous populations is about twice that of the general population. Marginalised communities Communities can be marginalised for a variety of reasons, such as geographic isolation, political discrimination, cultural/linguistic intolerance or poverty. Marginalised communities exist in all countries, but are particularly invisible in fragile states and difficult environments, despite their needs being even greater than the general population. For example, in Special Region 4, Burma/Myanmar, 4% of births are attended by a skilled health worker, compared to 56% for the country as a whole; amongst Quechua communities in Peru, skilled health workers attend 38% of births, compared to a national average of 71%. Health service delivery Health service delivery in fragile states can offer an entry point for triggering long-term, pro-poor social and political change, as well as providing an opportunity to support the development of the host government’s capacity, engage with civil society and encourage accountability structures to develop. In the last couple of years, donors and think tanks have pulled together a number of papers which analyse the difficulties of delivering health services in fragile states and recommend how these obstacles could be overcome. In 2005, the Organisation for Economic Cooperation and Development’s Development Assistance Committee (OECD DAC) agreed a set of draft Principles for Good International Engagement in Fragile States. Wider determinants of health Although this paper focuses on health services, it Collecting water in Wa state, should be remembered that the health of individuals Burma/Myanmar and communities is determined by a wide range of factors. Non-Governmental Organisations (NGOs) can often bridge the gap between health-related sectors that are traditionally in separate vertical government departments, for example water and sanitation, nutrition, housing and agriculture. 4 Executive Summary 13 Key Principles 1. Understand the context Understanding the social, economic, political and historical context is particularly crucial when working in fragile states and difficult environments.In fragile states and difficult environments, there is often little – if any – health information available, so external support can be useful in developing an appropriate national health management information system or conducting representative national surveys. As national-level data generally bears little resemblance to the situation faced by marginalised communities, it is crucial that external organisations working in a particular area assesses and monitors the (often changing) local situation, as well as specific issues such as health. 2. Build trust In fragile states and difficult environments, people often take longer to ‘open-up’ and trust outsiders. External organisations need to not just work with the relevant government authorities and key stakeholders, but also commit to working there long-term. Staff should be recruited locally and employed on long-term contracts. 3. Share information and evidence 3.1 With key stakeholders Organisations should not be ‘extractive’ when monitoring a situation and Focus group, Guatemala information should be shared with communities and other key stakeholders; ideally, community members can also be involved in actually collecting and analysing data. 3.2 To influence policy & practice The relatively few organisations working in fragile states and difficult environments should work together, to maximise effectiveness: lessons learned should be shared and partnerships developed to influence key decision-makers. 5  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments 4. Provide long-term support Long-term financial commitments from donors are particularly important in fragile states, as governments need to re-establish or develop health infrastructure, management systems and human resources from a very low point and so need confidence that their plans will be supported not just for 3-5 years, but for the long-term. Fragile states can sometimes ‘fall between’ donors’ funding streams for NGOs, with only short- term ‘humanitarian’ funds being available, rather than longer-term ‘developmental’, which makes long-term planning very difficult. 5. Take a rights-based approach Fundamental principles of human rights such as universality, indivisibility, responsibility, and participation provide a useful framework for development practice. Adopting a rights-based approach to development is particularly crucial in fragile states and difficult environments due to the systematic violations of rights which accompany political, economic and social collapse. Such an approach includes: expressed linkage to rights; accountability; empowerment; participation; and non-discrimination and attention to marginalised groups. 6. Reach marginalised communities 6.1 Target those which are hardest to reach By targeting support to marginalised areas and tackling the issues surrounding how to provide services to those that are the most difficult to reach, there will be a trickle-up effect, as all communities along the ‘marginalisation’ continuum will benefit from lower access barriers and the associated improvements in service delivery. 6.2 Disaggregate data and target indicators In fragile states and difficult environments, lack of information on basic demography and health is a challenge. However, the data available for marginalised communities is even more limited. Stakeholders are generally focused on national averages and targets e.g. Millennium Development Goals (MDGs), which are most easily achieved by concentrating on those communities which are easiest to reach. The health situation of marginalised communities, which are harder to reach, whose service provision requires a change from doing ‘more of the same’, therefore becomes even worse. National-level targets need to be disaggregated, so that the situation can be clearly seen and support can focus on those who have the most need for assistance. 6.3 Tackle barriers to access There are numerous obstacles which prevent marginalised communities in fragile states and difficult environments from realising their right to health, including: 6 Executive Summary MAKING THE DECISION • Lack of information/understanding: of the public health services which do exist. • Cultural/Gender constraints: e.g. sub-groups with little status (such as women) may be dependent on other people (e.g. husband) to decide whether they can actually visit a health facility. • High indirect costs: The need to accompany family members or find a carer for their children means that visiting Mobile health clinic, Ethiopia a health facility can have a knock-on impact on a family’s labour productivity. REACHING THE HEALTH FACILITY • Location: Static facilities are often located where infrastructure is good; outreach services may be more appropriate for communities in remote, rural areas. • Poor transportation: Marginalised communities often have to walk for long distances – or find money to pay for what limited transportation exists – to reach health facilities. • Insecurity: can restrict communities’ ability to reach static health facilities. RECEIVING SERVICES OBSTACLES FROM HEALTH WORKERS • Communication difficulties: In many fragile states and difficult environments, few health workers speak indigenous languages, there are few pictorial aides and most of the limited health materials assume literacy in the dominant language. • Discrimination: Many marginalised communities face overt or covert discrimination by health workers, who may feel that they are ‘stupid’ to be living by different cultural norms or may disrespect them if they are deemed to have no ‘status’. • Unpredictable service availability: Health workers in remote areas are often poorly motivated and so may not regularly turn-up for work; this can influences people’s decision as to whether to seek care at all. • Lack of human resources: The shortage of skilled health workers faced by many countries is exacerbated in fragile states and difficult environments, as the skilled staff that do exist do not often want to live in remote, difficult areas. 7  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments OBSTACLES WITHIN THE SYSTEM • Culturally inappropriate services: For communities with cultural practices and expectations different from the majority or ruling government, norms at health facilities may be culturally inappropriate. • High direct costs: For many marginalised communities, user fees Culturally appropriate are well beyond their ability to pay. birthing room, Peru In those countries where exemption schemes officially exist, lack of awareness means that they are not consistently implemented in practice. • Under-resourced services: Lack of equipment and drugs – as health facilities in areas inhabited by marginalised communities are not prioritised – means that accurate diagnoses or appropriate treatment may not be given. 7. Build on what exists External organisations should work with and build on whatever already exists, rather than establish new systems, guidelines or providers which will not fit long-term within the local context or national situation. 7.1 Work in partnership Existing local authorities, health structures and civil society organisations (CSOs) should form the basis of any external support for health, so working in partnership with these institutions is therefore essential. 7.2 Work with appropriate government authority(s) In fragile states and difficult environments, it can be difficult to determine the ‘appropriate government authority’ with whom to work. External organisations should develop relationships with all key stakeholders, which may include indigenous authorities or an authority not recognised internationally; the key question is which ‘authority’ has the confidence of communities and the potential to address health issues. 8 Executive Summary 7.3 Support a range of service providers In the short/medium-term, a range of initiatives and service providers (e.g. government, NGO, community and for-profit) need to be supported, so that current health service provision can be improved. In the longer-term, decisions can be taken (and appropriate support provided) on the appropriate role for national government. Direct service provision by international NGOs should be considered carefully, as difficulties may arise when they leave if insufficient local capacity has been built. 7.3.1 Avoid parallel systems Parallel systems should be avoided. However, if the government is unwilling or unable to expand health services to reach marginalised communities, then it may be necessary to develop a separate system which can be incorporated into the national health service at a later stage. As far as possible, any new system should follow national structures. 7.3.2 Strengthen government service providers In most situations, it is appropriate for NGOs to support government health services to improve their approach to marginalised communities and their provision of services, developing the capacity of health workers and facilities 7.3.3 Support community-based service providers If government health services are inaccessible to marginalised communities, then community-based providers (e.g. traditional birth attendants (TBAs) and drug sellers) are often the first people that community members turn to if they are ill. It is therefore important that these providers are supported to ensure that their service is appropriate. 7.3.4 Develop links between public and private service providers Closer working between community and health facility workers should be encouraged and community- based referral systems established. 7.3.5 Develop new organisations, if appropriate If a long-term need is identified, but there is no local capacity to fill the gap, then it may be appropriate to support the development of a CSO to address this issue. 8. Develop accountability mechanisms 8.1 Support the establishment of accountability structures Accountability mechanisms should be established so that marginalised (and other) communities can participate in their local health services, and hence improve their effectiveness. Ideally, structures should be agreed nationally, with support provided to ensure their implementation. 9  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments 8.2 Build communities’ capacity to advocate for their rights If communities are to be able to claim their right to health, they need to understand their rights (and responsibilities) as citizens and their government’s responsibilities towards them. They may also need specific support to analyse and solve problems, provide constructive feedback and vocalise their views. 8.3 Strengthen government capacity to fulfil their responsibilities In many fragile states and difficult environments, government health staff do not feel accountable to their clients, so it is important to support them and increase their understanding of both clients’ rights and their own responsibilities. 9. Facilitate an appropriate mix of aid modalities In order to promote equity and equality, a range of instruments should be used – the key criterion being its effectiveness in assisting poor people. In regions which are remote or neglected by government, a cross- border approach may be the most effective way to reach marginalised communities. Donor support for cross-border initiatives should therefore be available. 10. Focus on health systems as a whole 10.1 Support integrated health systems As health issues are interlinked, an integrated, equitable, well-functioning health system, accessible to all, is crucial if the long-term health of a population is to improve; focus should therefore be on strengthening health systems as a whole. 10.2 Develop / Use national protocols Existing health policies and protocols should be the basis of any services, with changes made only in-line with World Health Organisation (WHO) guidelines, following agreement with local stakeholders and the government authority. If national protocols do not exist, their development is an important step in ensuring that different norms are not established. 11. Address human resource constraints Many developing countries, and in particular fragile states and difficult environments, face severe human resource constraints, which obviously have a detrimental impact on the quality and equity of services provided. 11.1 Provide long-term support As part of their long-term commitment, it is crucial that donors increase their support to governments to invest in human resources for health. 10 Executive Summary 11.2 Advocate for flexible entry requirements for health staff Many individuals from marginalised communities are unable to work as health workers as they have not had access to the appropriate educational opportunities. In the short/medium-term, the requirements to be trained as an entry-level health worker should be lowered, so that numbers of workers can increase and local services can be more appropriate to local needs and situation (e.g. language and cultural understanding). 12. Utilise appropriate communication approaches Communication for health is essential if the poor are to benefit from improved service provision. Support to the “demand” side of health services is as important as the supply. 12.1 Support radio ‘edutainment’ programmes In fragile states and difficult environments, radio is often the only means of mass communication. Culturally-appropriate radio can help break taboos, such as those surrounding sexuality, and raise awareness of important health issues, increase health service usage and positively change behaviour. 12.2 Support culturally appropriate media Health communications should not only be conducted in the appropriate language, but also using culturally appropriate techniques. 13. Promote co-operation among agencies Resources in fragile states and difficult environments by definition tend to be scarce. It is important that those resources are used to address the health status of the communities and not absorbed into unnecessary transaction costs or in providing duplicate services. 13.1 Reduce transactions costs Donors have choices when it comes to distributing their resources and have a responsibility to get the best value for money. However, creating competitive tendering processes means that the resources of each bidder that are used in preparing the bid is in effect “wasted” and therefore not available to be used in addressing poverty issues. 13.2 Avoid duplicating services NGOs and non-state providers have a responsibility to ensure that any interventions that they plan to implement do not duplicate the work of others. If this is not done and two providers are “competing” in the same area, resources that could be used effectively elsewhere, will be wasted both because services are duplicated and also in the costs of communicating with the other agency. 11  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Conclusion From Health Unlimited’s experience, the keys to success in developing appropriate, effective health services, accessible to all, are: flexibility, understanding the context, establishing trust, and providing long- term commitment. The benefits of supporting health systems as a whole in developing countries – rather than disease- specific vertical interventions – are increasingly recognised, and this is particularly crucial in fragile states and difficult environments where capacity is limited. It is also important that marginalised communities are reached, not just because they are in most need of assistance, and are generally ignored, but because by targeting support to marginalised areas and tackling the challenges of how to provide effective services to those that are the most difficult to reach, there will be a trickle-up effect, as all communities along the ‘marginalisation’ continuum will benefit from improved service delivery. As governments in fragile states and difficult environments are, by definition, unable or unwilling to deliver core services to their entire population, recommendations focus on the roles of international donors and NGOs. Siblings in Special Region 4, Burma/Myanmar 12 Executive Summary Recommendations Donors 1a) Support national and regional monitoring, whether by NGOs or government bodies, including the disaggregation of data 2a) Employ staff on long-term contracts, and give them the opportunity and encouragement to develop expertise in one particular country 3a) Share information with other stakeholders 3b) Be open to learning from the experiences of implementing organisations 3c) Use lessons and experiences to influence the policies and practice of governments and other donors 4a) Provide long-term, predictable financial support to government and non-government organisations 5a) Support a rights-based approach to working in fragile states and difficult environments 6a) Advocate for, and fund, targeted support to marginalised communities 6b) Promote the use of indicators (e.g. MDGs) disaggregated by relevant factors e.g. ethnicity, location 6c) Support policies, and their enforcement/ implementation, which reduce barriers to accessing health services e.g. outreach services, differing cultural needs, capacity of health workers, abolition of user fees 6d) Fund grassroots research into access barriers and approaches to overcoming them 7a) Overcome any political difficulties of directly supporting certain quasi-government authorities by supporting CSOs that work directly with the populations of these states 7b) Fund and support a range of public and private service providers (either directly, or through NGOs), to improve the likelihood of all sectors of the population benefiting 7c) Support the development of new civil society or private organisations, if there is an identified need, but no local capacity 8a) Support the design and establishment of nationwide accountability structures 8b) Strengthen national government capacity to appropriately use the accountability mechanism and respond to issues raised 9a) Use a range of funding instruments, including support to cross-border initiatives (e.g. through coordination between neighbouring country offices, or from a regional base) 10a) Support the strengthening of health systems and horizontal health initiatives 10b) Support the development of national protocols, where needed 11a) Provide long-term support, to enable government authorities to plan ahead 11b) Advocate for flexible entry requirements for health staff, particularly for those based in communities or lower level health facilities, in order to improve access to health services for marginalised communities 12a) Support radio ‘edutainment’ programmes and other culturally appropriate communications 13a) Promote cooperation rather than competition (e.g. through the use of non-competitive tendering processes) 13  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments NGOs 1a) Conduct a comprehensive situational analysis before beginning work in an area, followed by regular monitoring 2a) Employ local staff wherever possible, considering ethnicity when appropriate 3a) Share information with key stakeholders 3b) Work with other organisations where appropriate, use lessons and experiences to influence policy and practice 5a) Take a rights-based approach to working in fragile states and difficult environments 6a) Specifically target marginalised communities Health workers with infant, Kachin, 6b) Tackle local barriers to accessing health services e.g. outreach Burma/Myanmar services, cultural constraints, capacity of health workers 6c) Undertake grassroots research to analyse access barriers and appropriate local approaches to overcoming them 7a) Work with the appropriate government or de facto government authority(s) of most relevance to the target communities 7b) Avoid developing a parallel system or an NGO service; instead, strengthen the capacity of the range of service providers (e.g. government, private-for-profit, community-based) which already exist 7c) Support the development of new local organisations, if appropriate 8a) Develop awareness of rights at community level to facilitate advocacy 8b) Build communities’ capacity to participate effectively in national accountability structures 8c) Strengthen the capacity of local government to fulfil their responsibilities within the accountability mechanism 10a) Provide support to the health system as a whole, rather than focusing on disease-specific interventions 10b) Use national protocols (or WHO advice, if protocols don’t yet exist), rather than developing separate guidelines 11a) Support advocacy efforts by providing evidence of the need for flexible entry requirements for health staff 12a) Use radio ‘edutainment’ programmes to address sensitive issues 12b) Use culturally-appropriate communication approaches 13a) Ensure that planned interventions do not duplicate the work of others. 14 Contents Acknowledgements 2 Executive Summary 3 Background 3 Right to health 3 Fragile states 3 Difficult environments 4 Marginalised communities 4 Health service delivery 4 Wider determinants of health 4 13 Key Principles 5 1. Understand the context 5 2. Build trust 5 3. Share information and evidence 5 4. Provide long-term support 6 5. Take a rights-based approach 6 6. Reach marginalised communities 6 7. Build on what exists 8 8. Develop accountability mechanisms 9 9. Facilitate an appropriate mix of aid modalities 10 10. Focus on health systems as a whole 10 11. Address human resource constraints 10 12. Utilise appropriate communication approaches 11 13. Promote co-operation rather than competition 11 Conclusion 12 Recommendations 13 Contents 15 15  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Background 18 A. Introduction 18 B. The Right to Health 19 B.1 Rights-based Approach 22 C. Fragile States 22 C.1 Why do Fragile States matter? 23 C.2 Health in Fragile States 23 D. Difficult Environments 24 D.1 Why do Difficult Environments matter? 25 D.2 Health in Difficult Environments 25 E. Marginalised Communities 25 E.1 Why do Marginalised Communities matter? 26 E.2 Health for Marginalised Communities 26 F. Health Services 27 G. Challenges in service delivery 28 H. Solutions proposed to date 29 I. Wider Determinants of Health 31 J. Health Unlimited 32 13 Key Principles 34 1. Understand the context 34 2. Build trust 35 3. Share information and evidence 37 3.1 With key stakeholders 37 3.2 To influence policy & practice 37 4. Provide long-term support 38 5. Take a rights-based approach 40 6. Reach marginalised communities 43 6.1 Target those which are hardest to reach 43 6.2 Disaggregate data and target indicators 44 6.3 Tackle barriers to access 45 16 Contents 7. Build on what exists 52 7.1 Work in partnership 53 7.2 Work with appropriate government authority(s) 54 7.3 Support a range of service providers 55 8. Develop accountability mechanisms 63 8.1 Support the establishment of accountability structures 63 8.2 Build communities’ capacity to advocate for their rights 64 8.3 Strengthen government capacity to fulfil their responsibilities 65 9. Facilitate an appropriate mix of aid modalities 66 10. Focus on health systems as a whole 68 10.1 Support integrated health systems 68 10.2 Develop / Use national protocols 69 11. Address human resource constraints 69 11.1 Provide long-term support 69 11.2 Advocate for flexible entry requirements for health staff 70 12. Utilise appropriate communication approaches 71 12.1 Support radio ‘edutainment’ programmes 71 12.2 Support culturally appropriate media 72 13. Promote co-operation among agencies 73 13.1 Reduce transaction costs 73 13.2 Avoid duplicating services 74 Conclusion 74 Recommendations 76 Bibliography 79 Annexes 81 Annex 1: Acronyms 81 Annex 2: Proxy List of Fragile States 82 17  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments A. Introduction Based on first-hand experiences, this paper draws out the key policy recommendations and operational implications for stakeholders involved in delivering health services in fragile states and difficult environments. Health Unlimited has been working in fragile states and difficult environments in Africa, Asia and Latin America for over 20 years, to secure access to effective primary health care for marginalised people affected by conflict, instability or discrimination. Throughout the world, as enshrined in numerous international and national agreements, people have the right to health, including the right to access health services on the basis of equity and non-discrimination. In many fragile states and difficult environments, governments are not working towards meeting this right, resulting in poor health outcomes for a large proportion of their populations. The health of marginalised communities is particularly poor, as they are not considered a priority (due to their geographic isolation or poverty) or they are specifically discriminated against, perhaps because of their political or cultural beliefs. There is increasing recognition from policy makers2 that more has to be done to support populations in fragile states, including improvements in service delivery. However, marginalised communities in these countries (and in difficult environments) are still generally ignored, despite their even lower standard of living and poorer health outcomes. Indigenous Drawing on examples and case studies from six countries communities are where Health Unlimited works3 (Burma/Myanmar, Cambodia, marginalised. Ashaninka woman Ethiopia, Guatemala, Peru and Somaliland4), this paper and children, Peru highlights 13 key principles for policy makers and implementers that improve the delivery of health services in fragile states and difficult environments. Although the focus is on reaching marginalised communities, following the principles – including the direct targeting of such communities – will improve service delivery for all communities. The paper begins by considering the right to health, and then moves on to discuss the definitions of fragile states and difficult environments, and the health situation faced by their populations, particularly marginalised communities. A summary of the key challenges surrounding health services and solutions 2 For example the recent establishment of the Fragile States Group within the OECD to enhance development effectiveness - www.oecd.org/dac/ fragilestates (accessed 3 April 2007) 3 Health Unlimited also works in Laos, China, Sierra Leone, Rwanda, Kenya, Namibia, Nicaragua, Brazil and El Salvador. 4 Somaliland is a de facto independent state but has not yet been internationally recognised. It is therefore officially still part of Somalia. 18 Background proposed to-date is presented, and an overview of Health Unlimited’s work is included so that stakeholders understand the experience from which this paper is drawn. The second part discusses the 13 key principles in detail, using case studies for illustration. The paper concludes with recommendations for donors and NGOs (non-governmental organisations). Health service delivery in fragile states and difficult environments brings many challenges, so it is important for stakeholders to learn from each other, in order that the health of marginalised communities, and the wider population, can be improved effectively. Feedback on this paper is therefore encouraged and should be sent to Health Unlimited’s Deputy Director, (Programmes), Jerry Clewett: j.clewett@healthunlimited.org B. The Right to Health “The right to health can be understood as a right to an effective and integrated health system, encompassing health care and the underlying determinants of health, which is responsive to national and local priorities, and accessible to all.” (Hunt, 2006) The right to health is codified in a number of legally binding treaty standards, such as the International Covenant on Economic, Social and Cultural Rights (United Nations,1966) and the Convention for the Elimination of all forms of Discrimination Against Women (UN, 1979). The constitutions of many states also contain provisions which expressly protect the right to health (see figure 1 below). The right to health includes the right to access health care, on the basis of equity and non-discrimination. Health care can be considered as the provision of adequate and accessible health facilities (see section 6.3 for discussion on ‘access’), trained health professionals and essential medicines. Importantly, the right to health is also dependent upon the realisation of other human rights, which can be interpreted as the broader determinants of health. According to the UN Committee on Economic, Social and Cultural Rights, the right to health is: Vaccination outreach, Special Region 4, Burma/Myanmar 19  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments “…an inclusive right extending not only to timely and Women and children waiting appropriate health care but also to the underlying outside a health post, Peru determinants of health, such as access to safe and potable water and adequate sanitation, and adequate supply of safe food, nutrition and housing, healthy occupational and environmental conditions, and access to health-related education and information, including on sexual and reproductive health. A further important aspect is the participation of the population in all health-related decision- making at the community, national and international levels.” (Committee on Economic, Social and Cultural Rights, 2000) The right is made up of freedoms and entitlements, such as freedom from discrimination and involuntary medical treatment, and the entitlement to essential primary health care and equal access. In low and middle income countries, there are clearly resource constraints that affect governments’ ability to ensure the right to health of their citizens, particularly when they are affected by conflict or instability. International law recognises this through the concept of ‘progressive realisation’. This means that whilst progressively realising the right to health, states are at a minimum required to prepare national plans aimed at guaranteeing the right to health and the active participation of communities and individuals in health decision-making. Such plans should include indicators and benchmarks to chart the progressive realisation of the right to health, and the establishment of accountability mechanisms to monitor the fulfilment of obligations and entitlements. Importantly, certain provisions of the right to health are not subject to progressive realisation, such as the obligation of states not to discriminate in access to health care and health services. This is because the rights to equality and non- discrimination are non-derogable rights under international human rights law that states are obliged to respect, protect and fulfil at all times. Figure 1 shows the legal standards on the right to health which have been ratified in the countries discussed in this report. 20 Background Figure 1: Legal Standards on the Right to Health in selected Fragile States and Difficult Environments referred in this report Instrument Details Ratifications International Article 12 (supplemented by General Comment 14) is Cambodia Covenant on the most comprehensive international, legally-binding Ethiopia Economic, Social & provision on the right to health. Guatemala Cultural Rights Peru Somalia Convention on the Article 5 (e) (iv) prohibits discrimination in the Cambodia Elimination of All enjoyment of the right to public health and medical Ethiopia Forms of Racial care. Guatemala Discrimination Peru Somalia Convention on Articles 11 & 12 cover: Burma/Myanmar the Elimination Cambodia of All Forms of • the right to the protection of health in the Ethiopia Discrimination workplace Guatemala Against Women Peru • reproductive health rights • equal access for women to health services • access to services and adequate nutrition during pre- and post-natal period Convention on the Article 24 obliges States to: Burma/Myanmar Rights of the Child Cambodia • Ensure the right to health and access to health care Guatemala Peru • Diminish infant and child mortality Somalia 5 • Develop primary health care • Combat disease, malnutrition and environmental pollution • Provide adequate health education and information • Develop preventive healthcare programmes • Abolish traditional practices prejudicial to children • Promote international cooperation to enable the progressive realisation of children’s rights Constitutional Cambodia Provisions on Right Ethiopia to Health Guatemala Peru Somaliland 6 5 Signed only 6 Although not recognised as a sovereign state, the 2001 Constitution includes provisions on the right to health 21  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments B.1 Rights-based Approach The rights-based approach to development has transformed developmental approaches from that of ‘trickle-down’ development assistance and purely service delivery, to a focus on equity, pro-poor empowerment and participation, in line with human rights standards in international law. It is widely recognised amongst development actors (such as UN agencies, bilateral donors and NGOs) that applying a human rights lens to poverty and structural inequality facilitates analysis of the root causes of rights denial, which is crucial to sustainable change. Through a rights-based approach, this analysis can then be translated into practical action at community, civil society, private sector, government and international levels through human rights education, advocacy and social mobilisation. It also informs the way in which development actors (including non-state entities) relate to individuals and communities with whom they work by emphasising their responsibility to promote rights. Raising the awareness of health rights A common criticism of discussions on human rights is that they among young people, Guatemala are too legalistic and state-centric, which is particularly relevant in the case of fragile states and difficult environments where the likelihood of an effective legal remedy being in existence, let alone accessible, is very slim. However, rights-based approaches recognise that political and social processes, not just legal ones, play an important role in securing civil, political, economic and social rights. C. Fragile States There is no standard definition of a ‘fragile state’. All states may be considered fragile in some respects and the different definitions in use reflect the varying priorities of organisations: the Centre for Global Development in the USA assesses states in terms of security; the World Bank (through its Country Policy and Institutional Assessment (CPIA) scores) focuses on economic development; The Department for International Development (DFID) describes fragile states as “those where the government cannot or will not deliver core functions to the majority of its people, including the poor” (DFID, 2005); and the DAC’s (Development Assistance Committee of the OECD) definition includes the “inability or unwillingness Fragile states: Countries of a state to deliver services to its people, or where the government lacks to ensure their delivery” (OECD, 2005a). In all the capacity and/or willingness these frameworks, the key issues are those of to ensure the provision of effectiveness (including capacity and willingness) appropriate basic services to the and legitimacy. A number of proxy lists are used, whole population. In some cases, such as the bottom two quintiles of the World the legitimacy of the government Banks’ performance index (CPIA), or the Fund for may be questionable. 22 Background Peace and Foreign Policy magazine’s Failed States Index. See Annex 2 for a proxy list, taken from the World Bank’s CPIA ratings. Using Annex 2 as a proxy, there are approximately 46 fragile states, containing 870 million people – 14% of the world’s population – and one-third of the world’s poor (Moreno Torres & Anderson, 2004). Since the mid-1990s, increased donor emphasis on effective government and stable macroeconomic policies has led to the neglect of fragile states. Even taking account of their poor performance, fragile states have received 43% less aid than would have been appropriate, given the extent of poverty within them (Dollar & Levin, 2005). C.1 Why do Fragile States matter? Fragile states are more likely to become unstable (DFID, 2005) and be susceptible to criminal or non- state armed groups, which can aggravate their fragility. An unstable country (even if entirely peaceful) can impact well beyond its national borders, for example through migration and refugee movements, increased transmission of infectious diseases and reduced economic growth (Moreno Torres & Anderson, 2004). Poor governance characterises most fragile states and inhibits poverty reduction; it is estimated that growth can be reduced by up to 1.6% if a neighbouring country is fragile (OECD, 2005b). Donors are increasingly recognising that fragility has a major, negative impact on service delivery (World Bank / WHO, 2005a), reflecting several factors including: loss of financing for services; increased social insecurity due to violence; exclusion of disempowered groups; endemic corruption; and the failure or misuse of security and justice systems (OECD, 2006a). To start to address this inequity, the production of an annual report on ‘Monitoring Resource Flows to Fragile States’ was approved by the OECD DAC Senior Level Meeting in December 2005, in order to provide an information tool for policy makers to make better informed decisions on resource flows to fragile states. The first report was published in June 2006 (OECD, 2006b) and confirmed that aid to fragile states was not keeping-up with the recent growth in aid to other low-income countries. C.2 Health in Fragile States Health indicators in fragile states are poor and considerably worse than other developing countries; Children in Somaliland fragile states are unlikely to meet the Millennium Development Goals (MDGs) (Branchflower, 2004). There is therefore a moral and social justice imperative to work in such countries, to support those in dire need and enable them to claim their right to health. 23  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Figure 2: Health-related MDG Status: Fragile States & Other Developing Countries Fragile Other States Developing Countries MDG 4: Child mortality rate, per 1000 138 56 MDG 5: Maternal mortality rate, per 100,000 734 270 MDG 6: % of people living with HIV/AIDS 2% 0.5% MDG 6: Malaria death rate per 100,000 90 7 Source: Branchflower, 2004 – 2002, 2000, 2001 and 2000 data respectively People who live in fragile states are more likely to die early or live with chronic illness. Nearly half of all children who die before the age of 5 are born in fragile states. As shown in the table above, child mortality is almost 2.5 times higher than in other developing countries, and maternal mortality more than 2.5 times greater. Some non-fragile states may have health indicators that are similarly poor to countries considered ‘fragile states’; however, the crucial issue is the country’s capacity to try to improve their situation. Fragile states, by definition, lack that capacity as the government is unable and/or unwilling. D. Difficult Environments In ‘early’ literature produced by DFID (e.g. Moreno Torres & Anderson, 2004 & Berry et al, 2004), ‘difficult environments’ was the phrase used to describe countries which are now commonly referred to as ‘fragile states.’ In this paper, difficult environments are taken to mean areas of ‘non-fragile states’ which have similar characteristics to those of fragile states, i.e. areas of a country where the government is unable or unwilling to deliver core functions to the majority of its people, including the poor. Difficult environments are not restricted to low income or unstable countries and, for example, include areas inhabited by indigenous communities in Guatemala and Peru, as well as insecure areas of Northern Uganda. They also include those areas of a ‘country’ (often a fragile state) which have disputed or internationally unrecognised governance. Difficult environments: Areas For example, the within a country where the government ceasefire areas of lacks the capacity and/or willingness Ashaninka communities Burma/Myanmar to ensure the provision of appropriate of Peru (disputed basic services to the whole population. governance) In some cases, the legitimacy of the and Somaliland (internationally government may be questionable. unrecognised). 24 Background D.1 Why do Difficult Environments matter? As difficult environments can be considered as ‘mini fragile states’, there is a danger that the effects of this marginalisation can spill over into the country as a whole, or even across borders, for example through (perhaps violent) protests, refugee flows, urban migration, or increased transmission of infectious diseases. The country’s economic growth will also be affected, as a portion of the country is unable to maximise its economic potential. People living in difficult environments within states where the government is disputed or internationally unrecognised particularly suffer, as the ‘country’ as whole receives even less aid and development assistance than other fragile states, and of that which does exist, only a small proportion (if any) reaches those communities most in need. D.2 Health in Difficult Environments Inequity in access to health services and health outcomes means that mortality and morbidity rates in difficult environments are generally higher than for the population as a whole. Taking the case of northern Uganda, the crude mortality rate in the Acholi camps (in Northern Uganda) in 2005 was three times that of the rest of Uganda (1.54 per 10,000 people per day, compared to 0.46), and the under 5 mortality rate was more than three times higher (3.18 per 10,000 per day, compared to a Uganda average of 0.98) (CSOPNU7 2006). As discussed, difficult environments also arise in areas where the population is intentionally marginalised by the government, for example indigenous peoples: • In most countries in Asia and the Pacific, the infant mortality rate amongst indigenous populations is about twice that of the general population (Asian Development Bank, 1999) • In Guatemala, life expectancy among Mayan communities is 17 years shorter than for non- indigenous population groups (WHO, 1999a) • Human Development Index8 for the San in Namibia is less than a third of that for German speakers (~0.3, compared to ~0.9) (quoted in Ohenjo et al, 2006). E. Marginalised Communities “Today, most indigenous peoples are marginalised socially, economically, politically and culturally. … [This is] most clearly reflected in the health status of indigenous peoples around the world, with wide disparities between the health status of indigenous peoples and non-indigenous peoples within the same country.” (WHO, 1999b) Communities can be marginalised for a variety of factors, such as geographic isolation, political discrimination, cultural/linguistic intolerance or poverty – the exact reason for marginalisation will obviously vary between countries and communities. 7 Civil Society Organisations for Peace in Northern Uganda 8 The score combines measures of life expectancy at birth, education and income 25  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments E.1 Why do Marginalised Communities matter? The discussions above, on the importance of engaging appropriately and effectively in fragile states and difficult environments (e.g. right to health, humanitarian needs, meeting the MDGs, improving security and increasing economic growth), are just as valid when considering the potential consequences of not supporting San boys skipping marginalised communities in these states. Internal discontent will work as a strong in Namibia brake on any efforts to reduce a state’s fragility. The exclusion of disempowered groups in fragile states and the related negative impact on service delivery is increasingly recognised by donors. As highlighted in a recent paper produced by the Fragile States Group of the OECD’s DAC, skewed budget allocations that favour particular ethnic or religious groups – along with the systematic exclusion of women, minorities and disabled individuals – undermine the foundations of public service delivery systems (OECD, 2006a). E.2 Health for Marginalised Communities Although the vast majority of national governments theoretically recognise the right to health, this does not always translate into action. Even considering the concept of ‘progressive realisation’9 , the health services that do exist should not discriminate in access, and national health plans should include the active participation of communities and individuals in decision-making. However, one feature of most fragile states, and by definition, all difficult environments, is overt discrimination against one population sub-group in favour of another (Carlson et al, 2005). Marginalised communities exist in all countries, but are particularly invisible in fragile states and difficult environments, despite their needs being even greater than the general population (which, as discussed above, are already greater than those living in developing countries). Examples of their poor health status are shown in figure 3 below: Figure 3: Relative Health Status of Marginalised Communities Community Indicator Community National Social Determinants of Status Status Poor Health Ratanakiri Under-5 Mortality 165* 83 per Poverty, Discrimination, Province, Rate a 1,000 Geographic isolation per 1,000 Cambodia Special Region 4, Births attended 4% 56% Poverty, Political isolation, Burma/Myanmar by skilled health Discrimination, Geographic worker b isolation Quechua Births attended 38% 71% Poverty, Discrimination, communities, Peru by skilled health Geographic isolation worker c 9 Which recognises that resource constraints may limit a government’s ability to ensure the right to health of their citizens (see section B) 26 Background Community Indicator Community National Social Determinants of Status Status Poor Health Lowest wealth Measles 18% 71% Poverty, Discrimination, quintile, Ethiopia immunisation Geographic isolation, Tribal coverage (1 yr conflict olds) d *–Ratanakiri and Mondulkiri Provinces; Sources: a - Cambodia Demographic and Health Survey (DHS) 2005; b - Health Unlimited, 2003a; c - Health Unlimited, 2005a; WHO, 2006; d - WHO, 2006 F. Health Services A state’s fragility and the health status of its population can be locked in a vicious cycle. Health is an established area for external stakeholders to support, and in fragile states, service delivery may offer an entry point for triggering long-term, pro-poor social and political change in wider development areas (Carlson et al, 2005), as well as potentially helping some states to not slide into, or back into, civil conflict (OECD/DAC, 2001). It also provides an opportunity to support the development of the host government’s capacity, as well as engaging with civil society and encouraging accountability structures to develop. The health sector in fragile states may have a number of weaknesses, affecting: SERVICES • Inequitable services e.g. inappropriate or insufficient services for rural, poor and marginalised communities (at primary, secondary and tertiary levels); fragmented service delivery through vertical programmes • Limited government involvement in provision e.g. a substantial proportion of services is often provided by private providers, with limited (if any) government monitoring or regulation RESOURCES • Inappropriate or insufficient infrastructure, equipment and supplies e.g. health facilities, equipment, drugs • Inappropriate or insufficient human resources e.g. quality (qualification, experience, linguistic ability) and quantity Nurses in Kachin, (location, numbers available) of personnel Burma SYSTEMS • Lack of information e.g. basic demographic data, disease profile, health facilities infrastructure, human resource availability • Limited management systems e.g. systems to develop budgets and monitor accounts, supervise and manage workers, or plan for the following year 27  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments POLICY • Inadequate policy development e.g. government lacks the capacity to provide direction and develop appropriate health-related policies, which leads to poor or inadequate budgetary support • Poor implementation of policies and enforcement of laws e.g. poor communications leading to lack of policy/legal awareness, lack of incentives to implement or enforce policies/laws G. Challenges in service delivery The difficulties of working in fragile states and difficult environments, and the weaknesses of health services in particular, have been briefly touched on above. In addition to these health-specific issues, other key challenges of working with marginalised communities in fragile states and difficult environments surround: STAKEHOLDERS • Government unwillingness to address the needs of marginalised communities • Weak civil society, with limited capacity to advocate for the rights of the poor to basic services, or to work with members of professional organisations to improve the quality of services • Difficulty in defining the ‘appropriate’ government authority, e.g. the ‘national government’ may have taken control through a military coup, or may not be internationally recognised ACCESS • Difficulty in physically accessing areas, as marginalised communities often live in remote areas with poor transportation links, or which remain insecure due to fighting • Numerous access barriers to health services – as well as physical and security obstacles, service users in marginalised communities also face barriers such as discrimination by health workers, direct/indirect financial costs, gender constraints, language difficulties, lack of information on health services available, and often weak motivation (if services are of poor quality, then there may be little incentive to try to overcome the other barriers) 28 Background SYSTEMS • Poor accountability, between beneficiaries/service users and service providers/ government • Funding limitations, due to ‘gaps’ between donors’ humanitarian and long-term development funding streams, and the inflexibility of some funds. For example, in Burma/Myanmar, the centrally run Fund for HIV/AIDS in Myanmar (FHAM) was inaccessible to NGOs (such as Health Unlimited) that work cross-border with ‘ceasefire’ communities and who do not have a Memorandum of Understanding (MOU) with the State Peace and Development Council (SPDC) government • Difficulties in strategic planning and hence developing sustainable capacity, due to the short nature of donors’ funding commitments H. Solutions proposed to date In the last couple of years, donors and think tanks have pulled together a number of papers which analyse the difficulties of delivering health services in fragile states and recommend how these obstacles could be overcome (e.g. Berry et al., 2004; Carlson et al., 2005; OECD, 2005c). In March 2005, DAC Development Ministers and Agency Heads agreed that a set of draft Principles for Good International Engagement in Fragile states (OECD, 2005a) would be piloted in 2005/06. These overarching Principles emphasise the need to: (i) Take context as a starting point (ii) Move from reaction to prevention (iii) Establish state building as the central objective (iv) Align with local policies and or systems (v) Recognise political-security-development nexus (vi) Promote coherence between donor government agencies (vii) Agree on practical co-ordination mechanisms (viii) Ensure all activities ‘do no harm’ (ix) Mix and sequence instruments to fit the context (x) Act fast… (xi) …but stay engaged e.g. 10 year plans (xii) Avoid ‘aid orphans’ (characterised by low engagement and field presence) 29  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments In November 2005, the High-Level Forum on the Health MDGs (World Bank / WHO, 2005b), proposed the following, more specific, guidelines for donors involved in post-conflict health recovery processes: Pre-conditions required to achieve adequate coverage of quality services: • Genuine and accurate understanding of political and operational environment • Adequate resource levels • Effective and efficient coordination Training healthcare workers in mechanisms Special Region 4, Burma/Myanmar • Willingness to take calculated risks Principles and practical guidelines: Strategy & planning • Try to inject post-conflict recovery process with convincing ideas • Be parsimonious with priority setting • Place considerations of equity firmly at the top of the policy agenda • Be realistic about long-term sustainability • Encourage the development of realistic sector-wide plans • Proceed with the technical groundwork needed to inform the policy discussion and the drawing-up of recovery plans • Encourage the balanced recovery of the health care network • Adopt a realistic, incremental approach to encourage the emergence of local capacity Financial • Establish appropriate aid management tools • Make available some funding to be managed locally • Provide un-earmarked funding to cover key expenses that are not paid for by earmarked funds Operational • Deploy experienced staff with the appropriate skills • Negotiate with partners and introduce tools for standardisation • Set achievable challenges • Maintain a variety of policy and operational instruments 30 Background I. Wider Determinants of Health “Health…is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity… [T]he attainment of the highest possible level of health… requires the action of many other social and economic sectors in addition to the health sector.” (Alma Ata Declaration, 1978) The health of individuals and communities is determined by a wide range of factors. To a large extent, factors such as where people live, the state of the local environment, genetics, income, education level, and relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact.10 The wider determinants of health include: • Income and social status: higher income and social status are linked to better health • Education: low education levels are linked with poor health, more stress and lower self- confidence • Physical environment: safe water, sanitation, clean air, healthy workplaces, safe houses, communities, roads, and employment all contribute to good health • Social support networks: greater support from families, friends and communities is linked to better health; culture (e.g. customs, traditions, and the beliefs of Improving water and the family and community) is also a sanitation factor (Ratanakiri Province, Cambodia) • Genetics: inheritance plays a part in Health Unlimited has been working determining lifespan, healthiness and the likelihood of developing certain in Ratanakiri Province, Cambodia, illnesses; personal behaviour and since the early 1990s. One of the coping skills also affect health crucial issues affecting the indigenous • Health services: access and the use of communities in the province is that information and services that prevent of inadequate water and sanitation, and treat disease influence health and the resulting negative impact • Gender: men and women suffer from on health. Working with the Ministry different types of diseases at different of Rural Development, a number of ages successive projects have increased Although this paper focuses on health services, access to adequate water supplies NGOs can also bridge the gap between health- and appropriate sanitation for related sectors that are traditionally in separate households and improved knowledge vertical government departments, for example on hygiene, particularly amongst water and sanitation, nutrition, housing and women and children. (Health agriculture. Unlimited 2005a, 2006a) 10 www.who.int (accessed 3 April 2007) 31  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments J. Health Unlimited Health Unlimited was founded in 1984 by a group of British aid workers, to meet the gap in the provision of medical aid to people affected by prolonged and complex conflicts. It started working in southern Afghanistan in the same year. Although most assistance in conflict and post-conflict areas traditionally focuses on emergency relief (which, essential though it is, does not address long-term needs and, more importantly does not invest in the potential of local people to take control of their lives), Health Unlimited has pioneered a development approach to working these areas. It also extended its remit to include work with indigenous people whose lives and lands are threatened. These countries and areas are now often referred to as ‘fragile states’ or ‘difficult environments’. Health Unlimited’s vision is “a world in which the poorest and most marginalised enjoy their right to health.” We work in fragile states and difficult environments in Africa, Asia and Latin America to secure access to effective primary health care for marginalised people affected by conflict, instability or discrimination. We work in partnership with local organisations (from community organisations to provincial health departments) to strengthen government health services and build sustainable community-based services, as well as building capacity at community level to enable communities to identify and address their health needs, and hence advocate for their right to health and services. Our health communications programmes use radio, theatre, print and other media to provide information and encourage discussion of public health issues. Health Unlimited believes that everyone should be able to exercise their right to health and well-being and is committed to the promotion of the individual and collective right to “the highest attainable standard of physical and mental health” (International Covenant on Economic, Social and Cultural Rights, Article Young girl in Wa state 12.1, 1966). We seek to enable poor Burma/Myanmar drinks people, excluded from accessing clean water from tap health services and information, to improve their health and well-being through, for example, strengthening local capacity to deliver sustainable services. Annually, we reach over 2.3 million people through our primary health care programmes (and 26 million through our health education radio programmes) in Ethiopia, Namibia, Rwanda, Sierra Leone, Somaliland, Burma/Myanmar, Cambodia, China, Laos, Guatemala, Nicaragua and Peru. 32 Background Crucially, Health Unlimited believes that every human being has a right to health and that we in the North have a responsibility to promote this right. We and others may justify this by citing the MDGs or arguing that non-investment may lead to political instability. But in reality, the justification can be a basic belief that every human being, however poor, however marginalised, has an equal right to health. Putting that into practice can be costly in many ways, but if we are serious then we in the North must be prepared to pay that cost. Unlike other organisations whose work spans the humanitarian-development continuum, Health Unlimited focuses purely on supporting long-term development. Health Unlimited does not directly provide health services, but develops the capacity of local providers (both public and private) to deliver effective, appropriate services, and of marginalised communities to hold service providers accountable and claim their right to health. Health Unlimited ambulance for emergency obstetric care in Sierra Leone 33  13 Key Principles Health Unlimited’s experience of supporting the delivery of health services in fragile states and difficult environments has highlighted 13 key principles to be considered if the health status of marginalised communities is to improve. Principles are illustrated through our experience in six varied states: Somaliland (a de facto independent state, but which has not yet been internationally recognised and is therefore officially still part of Somalia); Burma/Myanmar (where there is non-engagement from the government in certain regions); Ethiopia and Cambodia (examples of post-conflict/recovering states, but where there is still insecurity in the former); and Guatemala and Peru (difficult environments for indigenous populations such as the K’iche’ and Quechua). 1. Understand the context K’iche’ woman with The importance of understanding the social, economic, child, Guatemala political and historical context when working anywhere is well documented (e.g. World Bank/WHO, 2005a). However, when working in fragile states and difficult environments, monitoring the (often changing) situation is particularly crucial. The political situation in some fragile states and difficult environments can change quickly, at both national and local levels. It is therefore important that organisations closely monitor the key stakeholders and their intentions and actions. As part of this, it is useful to develop links and relationships with stakeholders and other like-minded organisations and share information appropriately (see principle 3). In fragile states and difficult environments, there is often little – if any – health information available, so external support can be useful in developing an appropriate national health management information system or conducting representative national surveys (see also principle 6.2). If national-level data does exist, it generally bears little resemblance to the situation faced by marginalised communities. It is therefore crucial that external organisations working in a particular area assesses and monitors the (often changing) local situation and overall standard of living, as well as specific issues such as health (in the case of health- focused organisations). This monitoring may take the form of observations, regular reviews with key stakeholders and beneficiaries, conducting surveys, or by establishing basic monitoring systems for key indicators. With the latter, it is important that any monitoring system is based on national-level guidelines (if they exist), so it can be incorporated at a later stage. 34 13 Key Principles Monitoring the health situation (Kachin State, Burma/Myanmar) Health Unlimited has been working with the Kachin since 1992. There is limited information available about the population and so in 2005 a survey was conducted by Health Unlimited, in partnership with the Kachin Independence Organisation, to update the information available. The survey collected data on a broad range of areas and comprised community questionnaires, medical institutions, health worker interviews and laboratory tests. The analysis showed that malaria is the most common illness (more than 63% of the population infected in the past year), followed by diarrhoea. Due to Health Unlimited’s work in the area, nearly 90% of children had received some immunisations and around 33% of pregnant women had received some kind of antenatal care. More than 85% of women gave birth at home. The full survey findings have been shared with other key stakeholders and interested parties. (Health Unlimited, 2005b) 2. Build trust “At the beginning, Wa people didn’t trust Health Unlimited…they even suspected the project team of using their funds. However…they began to receive visible and substantial support… (and) perhaps not so obvious but highly important, software, such as trainers and training materials… To a certain extent, this change in both the reality and perception of the Wa people has contributed to building a better cooperative framework and enabled more effective project implementation.” (Health Unlimited, 2006b) In fragile states and difficult environments, people often take longer to ‘open-up’ to outsiders; it therefore takes time to build trust and really understand the context. External organisations need to not just work with the relevant government authorities and key stakeholders, but also commit – and prove their commitment – to working there long-term. It is important for any relationship between external organisations and local stakeholders to be based on mutual respect, openness and transparency, if trust is to develop. This takes time. Connected with this is the importance of recruiting staff locally – ideally from the immediate area, but if not, nationally (regional or international staff should only be recruited as a last resort) – and employing them on long-term contracts. Staff ethnicity may also need to be considered – for example in Wa State in Burma/ Myanmar, Wa or Chinese staff members are more acceptable to the target population than Burmese. This not only supports linguistic and cultural understanding, but also helps trust to develop, as local stakeholders don’t have to regularly ‘re-establish’ relationships with changing staff members. It is important that any ‘outsider’ staff – whether national or international – either already have, or are willing to acquire, a real understanding of, and empathy with, the local cultures and the powerlessness of the local communities, i.e. they must not simply be ‘job fillers.’ 35  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Building trust (Santa Lucia la Reforma, Guatemala) The legacy of a 36-year civil war which pitched neighbour against neighbour is still felt in highland Mayan communities in Guatemala. In many cases, those who carried out killings continue to live side by side with their victims. The consequences for trust within communities are obvious. When Health Unlimited began to work in Santa Lucia la Reforma in 1996, we were asked to leave one community on the grounds that we were thought Getting feedback to belong to ‘Human Rights’ – and by extension, from target perceived as being sympathetic to the guerrillas, and community, Somaliland therefore a dangerous presence in the community. During the violence, any group which met was suspected of being subversive – one traditional birth attendant (TBA) spoke movingly of her fear of coming to her first Health Unlimited training session in town: “I had understood that everyone went around with a weapon in town, and that I might be shot; I prayed, I said to myself, “Well, I’ll go, and if I’m killed, then so be it”, I was shaking when I arrived.” However, distrust sown by conflict is not the only barrier to trust. Communities divided by the conflict were also divided by bitter disputes about religion and state health services are invariably provided by people from outside the community (the non indigenous ‘Ladino’ minority who have dominated Guatemalan public life since the Spanish invasion). Indigenous communities complain that not only are they mistreated and discriminated against by state services, but that the state simply doesn’t understand them – literally, in terms of language, but also in terms of their vision of the world, and their way of being. Health Unlimited adopts three key strategies in order to overcome barriers of distrust. One of the most important is to hire local, or at least indigenous, staff, who are able not only to communicate health and development messages without a translator, but who themselves share the communities’ worldview. This can mean understanding culturally defined illnesses, such as Evil Eye, as well as styles of discourse, tone of voice, dress, and so on. Secondly, cultural sensitivity 36 13 Key Principles has allowed Health Unlimited to work alongside traditional curers, elders and Mayan religious specialists, rather than in opposition or in counterpoint to them; this has greatly enhanced our freedom to tackle previously taboo issues such as Adolescent Sexual and Reproductive Health (SRH). Finally, Health Unlimited is prepared to develop a relationship over time with the communities in which it works, rather than providing a single intervention and withdrawing just as the community is beginning to trust the organisation. 3. Share information and evidence 3.1 With key stakeholders It is important that organisations are not ‘extractive’ when monitoring a situation. At a minimum, any information should be shared with communities, as key stakeholders; ideally, community members can also be involved in actually collecting and analysing data. This enables communities to understand more about their situation and perhaps begin to take steps to improve it. Information can be politically sensitive. However, if an organisation’s aim is to improve the health status of the population, it is important that information is generally shared and made available to as wide a range of stakeholders as possible so that other implementing agencies or policy makers can take it into account when deciding priorities or appropriate approaches. This also promotes a culture of cooperation rather than competition (see principle 13); prioritising the needs of the communities above organisations’. 3.2 To influence policy & practice As there are relatively few organisations working in fragile states and difficult environments – and even fewer working specifically with marginalised communities – it is important that organisations work together, so they can be as effective as possible (see also principle 13). Evidence and lessons learned should be shared through a range of opportunities, such as the dissemination of reports or the presentation of papers at national or international forums. Local and national level policy and practice can also be improved through like-minded organisations developing partnerships and alliances and combining their experiences to influence key decision-makers. K’iche’ Youth Assembly, San Antonio Llotenango, Guatemala 37  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Influencing national policy, in partnership with local government (Peru) As discussed below (case study “strengthening culturally appropriate services”, in section 6.3.3), by working in partnership with the local-level Ministry of Health (MoH), TBAs and Quechua women, culturally appropriate birthing facilities were introduced into Huanta Province, Ayacucho, Peru, increasing the proportion of health centre deliveries and reducing the number of reported maternal deaths. In light of this evidence, Huanta Province MoH staff became strong advocates for culturally appropriate birthing facilities. Facilities were established in four further health centres and Health Unlimited supported the Ayacucho health department to introduce the model to other provinces. This evidence, supported by local-level MoH advocacy, contributed towards the development of a national MoH technical norm recommending vertical deliveries “Practical Standards of Vertical Childbirth”. The MoH is now looking to influence policy in other countries and a paper on the policy and its implications was presented in Buenos Aires, Argentina, in 2007. 4. Provide long-term support One of the main considerations in fragile states and difficult environments is that it can take considerable time to build ‘long-term development’ relationships with communities, who may be unused to external support or be expecting short- term humanitarian aid. There will certainly be a need for a commitment to long-term external support as the capacity of the national government will, by definition, be limited. In these situations – as mentioned above – using local staff and working long-term will help to build the trust and confidence of communities and hence their interest to participate and work in partnership with external organisations. Greater flexibility by implementing (and funding) organisations is also needed, as over time, the situation in fragile states and difficult environments changes and the working context becomes clearer (see principle 1). Mother and child, The benefits of long-term financial commitments from Ratanakiri, Cambodia donors, enabling countries to plan for the future, are well 38 13 Key Principles known. This is particularly important in fragile states, as governments need to re-establish or develop health infrastructure, management systems and human resources from a very low point and so need confidence that their plans will be supported to their conclusion. For NGOs, countries considered fragile states can sometimes ‘fall between’ donors’ funding streams, with only short-term ‘humanitarian’ funds being available, rather than longer-term ‘developmental’. This naturally makes long-term planning very difficult, with projects rather than programmes being implemented as a consequence. Effect of short funding cycles (Ratanakiri Province, Cambodia) For the last five years, Health Unlimited has been receiving annual ECHO (European Commission Humanitarian Aid department) funding for its primary health care and water and sanitation work in Ratanakiri Province, Cambodia. Although this funding is welcome, the short-term nature of the funding cycle produces a number of obstacles: • The short project timeframes require rapid implementation of activities, making it difficult for projects to be truly participatory. A fundamental pre- cursor to participation is the development of trust, which takes time to develop if participation is to be meaningful and not just tokenistic. • It is unusual for humanitarian funders to support interventions in the same communities that have just been targeted, making behaviour change objectives particularly difficult. • It is impossible to provide on-going support to the communities that were targeted by an intervention, or even develop links between target communities and alternative sources of support. • The development of future projects with ECHO takes place during the initial implementation stages of the ‘current’ project. This limits the ability of the later project to take account of recommendations and lessons arising during the course of the current one (unless they can be accommodated by the donor at a later stage). These issues are partly mitigated by Health Unlimited’s approach in Ratanakiri– we have worked there since 1993, gained the trust of communities, and access varied funding sources to address a range of issues – however, the difficulties of short funding cycles remain. 39  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Effective development needs a commitment of at least ten years if significant and lasting change is to take place. Whilst an individual NGO such as Health Unlimited may commit itself for this time period, transaction costs remain high, and a lot of organisational energy is wasted, as there is a repeated need to write project proposals to donors whose own timeframes are significantly shorter. Longer term funding would facilitate planning and the benefits to the communities would be immense. Even a ‘typical’ project length of three to five years cannot be considered to be sufficient in the fragile states context, and has major implications for lesson-learning as well as monitoring and evaluation. By the end of a five-year project cycle, assumptions are often made about impact without evidence: indicators may be included in project design which are not ideal, simply so that they can be measured at the end of the project. Long-term presence and support would allow indicators to be more profound. 5. Take a rights-based approach Fundamental principles of human rights such as universality (rights should be accessible to all), indivisibility (rights cannot be separated from one another), responsibility (of rights-holders and duty bearers), and participation have provided a useful framework for development practice based on universal normative standards (Richter & Rama, 2006). They have also prompted a greater focus on reaching marginalised and vulnerable groups who face discrimination and exclusion in realising their rights. Rights-based approaches are comprehensive in Discussing the right to health at an their consideration of the full range of indivisible, indigenous community centre in interdependent and interrelated rights: civil, cultural, San Sebastian, Peru economic, political and social. This calls for a development framework with sectors that mirror internationally guaranteed rights, thus covering, for example, health, education, housing, justice administration, personal security and political participation. Adopting a rights-based approach to development is even more crucial in fragile states and difficult environments due to the systematic violations of rights which accompany political, economic and social collapse. A rights-based approach to development includes the following elements : 11 (i) Expressed linkage to rights The definition of the objectives of a project/programme in terms of particular rights – as legally enforceable entitlements – as well as highlighting links to international, regional and national human rights instruments. 11 www.unhchr.ch/development/approaches-04 (accessed 3 April 2007) 40 13 Key Principles (ii) Accountability Improving levels of accountability in the development process, by identifying claim-holders (and their entitlements) and corresponding duty-holders (and their obligations), and considering both the positive obligations of duty-holders (to protect, promote and provide) and their negative obligations (to abstain from violations). This is discussed more in principle 8. (iii) Empowerment Beneficiaries are the centre of the development process, as the owners of rights and the directors of their own development. Projects/programmes should aim to give people the power, capacities, capabilities and access needed to change their own lives, improve their own communities and influence their own destinies. Empowered to improve maternal health services (Ratanakiri Province, Cambodia) Health Unlimited’s ‘Action Research for Advocacy project’ in Ratanakiri, Cambodia, aims to tackle the barriers indigenous communities face in accessing maternal health services. Through user-centred research, an inclusive advocacy strategy was developed, and hence implemented, empowering communities to work directly with health service providers to improve the situation. Action research methodology was used to highlight the experiences of the three main indigenous communities in Ratanakiri Province (the Tampoun, Jarai and Kreung). Local barriers to accessing maternal health services were identified, and needs, solutions and recommendations were discussed; the views of government health service providers were investigated and a series of stakeholder advocacy workshops for indigenous communities, health centre staff and government officials were held. The research results were presented and discussed, and stakeholders identified priority issues, explored the key concepts and developed an advocacy action plan. From this, a working group of four indigenous women, two midwives, one health centre chief and one nurse was established to take forward the advocacy agenda to improve maternal health services in the province. 41  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments (iv) Participation Rights-based approaches require a high degree of participation, from all sectors of society (including those traditionally marginalised, such as indigenous peoples, women and those living with disabilities). According to the UN Declaration on the Right to Development (UN, 1986), such participation must be “active, free and meaningful” – formal or token contact Traditional birth attendant course – with beneficiaries is insufficient. The diagnosing a difficult pregnancy, Cambodia focus is on access to development processes, institutions and information, which emphasise the need for process- based development methodologies and techniques, rather than externally conceived “silver bullets” and imported technical models. Participating in radio health communications (Somali-speaking Horn of Africa) As part of Health Unlimited’s ‘Well Women Media Project’ – which sees an estimated 62% of the population in the Somali-speaking Horn of Africa listen to the twice-weekly radio broadcast of ‘Saxan Saxo’ (‘Fresh Breeze’) – audience groups were established to provide regular feedback on the programmes. The groups discuss the relevance, appropriateness and practical nature of the messages – which tend to focus on SRH issues, including female genital mutilation (FGM) – and suggest priority issues to be addressed. This participation of beneficiaries in the style and content of the radio broadcasts ensures that ‘Saxan Saxo’ is as effective as possible: to quote a member of the Baligubadle audience group, Somaliland, “I feel that the programme is ours.” (Health Unlimited, 2004a, 2004b) 42 13 Key Principles (v) Non-discrimination and attention to marginalised groups Particular attention should be given to discrimination, equality, equity and marginalised groups. An important aspect of rights-based approaches is the incorporation of specific safeguards in development instruments to protect against threats to the rights and well- being of marginalised groups. Furthermore, all development decisions, policies and initiatives, while seeking to empower local participants, should expressly guard against simply reinforcing existing power imbalances between, for example, women and men, and indigenous peoples and the dominant ethnic group. (See the following section for further discussion). Malnourished children are fed 6. Reach marginalised communities supplemented rice in Preah Vihear, Cambodia As discussed, communities can be marginalised for a variety of factors, including geographic isolation, political discrimination, cultural/linguistic intolerance or poverty. 6.1 Target those which are hardest to reach Marginalised communities exist in all countries, but are particularly invisible in fragile states and, by definition, in difficult environments. As discussed in section E, the health status of these groups is generally far below that of the general population. Indigenous peoples represent the poorest groups in many fragile states and difficult environments: their social, political, economic and cultural marginalisation is reflected in their poor health status. In countries with large populations in need of support, by focusing on the majority, or the country as a whole, those who are most in need of assistance – the most marginalised – are generally ignored. For example, geographic marginalisation often implies a low population density, making it more expensive to physically reach communities, which leads to fewer interventions and results in health inequalities being perpetuated (and often exacerbated). Some policy makers have argued that it is actually too costly to reach these people. One Health Unlimited staff member was told by a senior UN official that if their fund did not reach the most marginalised 5% it was “okay”, because 95% of the country would be covered. In the view of Health Unlimited, this is not okay. However, by targeting support to marginalised areas and tackling the issues surrounding how to provide services to those that are the most difficult to reach, there will be a trickle-up effect, as all communities along the ‘marginalisation’ continuum will benefit from lower access barriers and the associated improvements in service delivery. 43  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Improving services by targeting the most marginalised (Preah Vihear Province, Cambodia) As part of Health Unlimited’s ‘Primary Health Care Project’ in Preah Vihear Province, Cambodia, village health volunteers, village health councils and women cluster leaders in 24 remote rural communities were trained and supported to provide health education in their communities. Their success in significantly improving the health knowledge and positively changing the health-related behaviour of their communities encouraged the Provincial Health Department to replicate the approach elsewhere. Trained community health agents are now used to provide community health education in villages that were not targeted by the project. (Health Unlimited, 2005c) 6.2 Disaggregate data and target indicators In fragile states and difficult environments, lack of information on basic demography and health is a challenge for any government or organisation aiming to improve the health status of a population. However, the data available for marginalised communities is even more limited, as these groups do not even appear on the political radar. The data that does exist, often from small-scale surveys conducted by civil society organisations (CSOs) / NGOs or from anecdotal reports, suggests that the health situation for these marginalised populations is often precarious (see figure 3 in section E). In working towards the MDGs (and other targets in Poverty Reduction Strategy Papers (PRSPs), national strategies etc), the government and other stakeholders are focused on national averages and national-level targets, which are most easily achieved by concentrating attention and resources on those communities which are easiest to reach. The health situation of marginalised communities, which are harder to reach, whose service provision requires a change from doing ‘more of the same’, therefore becomes even worse. Whilst marginalised communities remain hidden in national averages, nothing will change. If the health status of these communities is to be improved, then national-level targets – whether MDGs, PRSPs or other – need to be disaggregated, so that the situation can be clearly seen and support can focus on those who have the most need for assistance. A state can then be judged as to how well it’s reaching those most in need, rather than, for the most part, the urban elite. 44 13 Key Principles Inequity hidden by national data (Pastoralists, Southern Ethiopia) The health status of pastoralist communities with whom Health Unlimited works in South Omo Zone, Southern Ethiopia, is considered to be far worse than that suggested at a national level, but limited data is available. In partnership with the Ethiopian Pastoralist Research and Development Agency, EPaRDA (a national NGO), a survey was therefore conducted to increase understanding of the health difficulties faced (Health Unlimited, 2006c). Comparing this (and other NGO-collected) data with national figures, the needs of these marginalised communities become much clearer. Indicator Pastoralists a Nationally b % of U5 reporting diarrhoea in the previous 2 weeks, 16% 37% who were treated with ORT % of mothers who received at least 2 tetanus toxoid 5% 28% vaccinations during their last pregnancy % of adults who report that condom use can prevent 14% 47% the transmission of HIV % of population with access to safe water 9% c 22% d Sources: a - Health Unlimited, 2006c; b - Ethiopia DHS 2005; c - Water Aid, 2005; d - United Nations Development Programme (UNDP), 2006 6.3 Tackle barriers to access There are numerous obstacles which prevent marginalised communities in fragile states and difficult environments from realising their right to health, all of which need to be tackled. 6.3.1 Making the decision • Lack of information/understanding: Many marginalised communities, effectively forgotten by national government provision, are unaware of the public health services which do exist, or may not understand the benefits of visiting the health facility for advice, diagnosis or treatment. Traditional health workers, such as TBAs or private drug sellers, may be their only source of health knowledge. This lack of information is likely to be exacerbated by linguistic barriers, due to their relative lack Pastoralists, South Omo, Ethiopia of access to newspapers, radios, information leaflets etc. 45  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Increasing access to information (Kampot Province, Cambodia) In Cambodia, as in many developing countries, private drug sellers are frequently the first ‘port of call’ for communities, as they are often much easier for people to reach than government health centres. Health Unlimited in Kampot works closely with the government health system but, recognising the complementary nature of the private sector and its importance to a large proportion of the population, private drug sellers are also trained on the identification and treatment of basic health problems (e.g. diarrhoea and dehydration, fever, acute respiratory infection) and appropriate drug usage. Referrals to government health centres have increased as a consequence. • Cultural/Gender constraints: Within marginalised communities, sub-groups with little status (such as women) may be even more marginalised, as they are often dependent on other people (e.g. husband, or other male family member) to decide whether they can actually visit a health facility. • High indirect costs: Community members face indirect costs of attending a health facility, even if Gender constraints transportation costs can be resolved. amongst ethnic minority Sick children need to be accompanied communities by their mothers; women are often (Ratanakiri Province, Cambodia) accompanied by their husband or other male family member, and may “In terms of access to maternal have to find someone to care for their health services, men in the children whilst they are away. Visiting a community are strategic decision- health facility therefore has a knock-on makers… The decision [is] made impact on a family’s labour productivity by a minimum of two people, most and hence how much food they can often the husband and someone grow or how much money they can from the women’s family. This [is] earn. For families on the edge, this often a male relative, such as a may mean that a decision is taken not father or elder brother” (Health to seek health care, as the costs are Unlimited, 2006d) too high. 46 13 Key Principles 6.3.2 Reaching the health facility • Location: Static facilities are often located where infrastructure (e.g. roads, communications) is good. However these locations may be far from the communities the facilities are meant to serve. Outreach services may therefore be more appropriate for communities located in remote, rural areas. Reaching mobile populations (South Omo Zone, Ethiopia) Health Unlimited is working to improve the health status of semi-nomadic agro- pastoralist communities in South Omo Zone, Ethiopia. The way of life of these communities means that traditional government health services are inappropriate, in terms of both location and cultural approach. Working in close partnership with an Ethiopian NGO (EPaRDA), Woreda Health Committees and Pastoral Health Committees, and within local government structures, an appropriate mobile health service is being developed. Mobile Outreach Camps have been established, offering both human and animal health care services. Further outreach work is also provided from these sites. • Poor Mobile health clinic in Ethiopia transportation: Marginalised communities do not generally have easy access to a nearby public health facility, as transportation is often poor. Community members therefore have to walk for long distances – or find the money to pay for a vehicle (such as bicycle, motorbike) to take them. 47  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Lack of transportation limits access to health centres (Preah Vihear Province, Cambodia) “The utilisation of health centres is low for various reasons. Many villages are long distances, 20 to 80 kilometres, from the health centres. Rural roads are often just ox- cart tracks and impossible during the rainy seasons. Villagers neither have the money or transport to go.” (Health Unlimited, 2003a) • Insecurity: In post-conflict situations, or in countries where the status of women is low, insecurity can restrict communities’ ability to reach static health facilities. 6.3.3 Recieving services OBSTACLES FROM HEALTH WORKERS • Communication difficulties: If community members do not speak the dominant or ‘national’ language, even if they visit a health facility, they may be unable to communicate effectively with the health worker. In many fragile states and difficult environments, few health workers speak indigenous languages and there are few pictorial resources to aide diagnosis, pass on health advice, or explain how treatment should be taken. Language barriers for Most of the limited health information indigenous people materials which do exist assume literacy in the dominant language. Community (K’iche communities, members may therefore leave the Guatemala) health facility with little change in their In Guatemala, the vast majority of understanding of their own health health workers (who are generally situation, or their ability to improve it; they ‘Ladinos’, the non-indigenous are unlikely to return. minority who have dominated • Discrimination: Many marginalised Guatemalan public life since the communities face overt or covert Spanish invasion) speak only discrimination by health workers, who Spanish. However, as this is not may feel that they are ‘stupid’ to be living spoken by 21% of the K’iche by a different set of cultural norms or may population (World Bank, 2003), disrespect them if they are deemed to this reduces their access to have no ‘status’. In addition, those living government health services as with a disability or with HIV (for example), they are unable to communicate may face additional discrimination when receiving care. In such circumstances, with health staff. 48 13 Key Principles community members take nothing from their visit and will not be encouraged to visit the health facility again. They will also provide negative feedback on the health services to their communities, and so discourage them from visiting as well. Covert discrimination against indigenous peoples (Quechua communities, Peru) When Health Unlimited began working with Quechua communities in Ayacucho, Peru in 1997, many mothers complained about government health services. They wouldn’t visit health posts for check-ups or delivery, as they felt uncomfortable and embarrassed that their traditions (e.g. vertical delivery, wearing of daytime clothes, and being accompanied by their husbands) were not respected; instead they sought assistance from TBAs. See case study below (“Strengthening culturally appropriate services”), which describes how Health Unlimited improved this situation • Unpredictable service availability: Health facilities in remote areas, with poorly motivated health workers (often due to low salaries and few perceived benefits), generally suffer from very unpredictable service availability – facilities will be open when health workers turn-up for work, rather than at regular times. This service unpredictability understandably influences people’s decision as to whether to make the effort and seek care at all. • Lack of human resources: Many countries face an overall shortage of skilled health workers. In fragile states and difficult environments, where living is particularly Quechua mother and child, Peru hard and facilities are limited, the skilled staff that do exist do not generally want to live in remote, difficult areas. Staff who do man health facilities may therefore be untrained, or simply non- existent. 49  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Insufficient numbers of doctors (Special Region 4, Burma/Myanmar) In Special Region 4, Burma/Myanmar, there are just 12 SR4 (and two Burmese) government doctors for 78,542 people (Health Unlimited, 2004c). This is the equivalent of 0.18 doctors per 1,000 population, compared to 0.36 in Burma/ Myanmar and 1.06 in China (WHO, 2006). OBSTACLES WITHIN THE SYSTEM • Culturally inappropriate services: For indigenous communities, or those with cultural practices and expectations different from the majority or ruling government, norms at health facilities may be culturally inappropriate for them. Community members may therefore leave without seeing a health worker, or may feel embarrassed or humiliated – and discourage friends and family from attending in the future. Strengthening culturally appropriate services (Ayacucho Department, Peru) Health Unlimited found that culturally inappropriate health services in Ayacucho, Peru, were a strong contributing factor to a relatively low proportion of births being attended by skilled health personnel (42%, compared to 55% nationally (Peru DHS 2000)) and hence a higher maternal mortality ratio (235 per 100,000 live births in Ayacucho, compared to 180 per 100,000 live births in Peru as a whole (Peru DHS 2000). Discussions were facilitated between Quechua women, TBAs and Ministry of Health (MoH) personnel to discuss the needs and constraints on all sides. Together, these key stakeholders then designed an ‘improved’ birthing service which incorporated cultural aspects and accommodation for family members. The introduction of these birthing facilities into two health centres increased the proportion of health centre deliveries from 6% in 1999 to 70% in 2005, and the number of reported maternal deaths in the area fell from 3 in 1999 to zero in 2004 and 2005 (Health Unlimited, 2005d). See also case study in section 3.2 on how this change influenced national policy 50 13 Key Principles • High direct costs: User fees, both official and unofficial, now exist in many developing countries. For many marginalised communities, these fees are well beyond their ability to pay. In those countries where exemption schemes for the poor and other vulnerable groups officially exist, lack of awareness (on the behalf of both communities, and sometimes health workers), means that they are not consistently implemented in practice. User fees can therefore result in essential health services not being received. Even when exemption schemes are in place, and even when applied equitably, they will only impact on access if the perception of the exemption scheme in communities matches the reality. Good publicity and information campaigns are therefore essential. Poverty restricts access to health services (Ratanakiri Province, Cambodia) “Lack of money was cited by an overwhelming majority…as the most important factor that prevented them from accessing health care in the referral hospital and health centres. While this finding is also found [elsewhere] in Cambodia, this lack of access to cash is likely to be a particularly deep problem in indigenous communities, where most people depend on subsistence agriculture… Health staff often refuse to treat patients who have no money, or require them to buy drugs in the private pharmacies (often run by health staff or their families).” (Health Unlimited, 2006d) • Under-resourced services: Finally, even if all the above barriers are overcome, lack of equipment and drugs – as marginalised communities live in areas which are not a national priority or which are physically difficult to reach – means that community members may not receive an accurate diagnosis or appropriate treatment, which will then discourage them (and their communities) from seeking care at public health facilities in the future. Throughout this paper, many ways in which some of these barriers can be broken down are discussed. However, other actions include: IMPROVING SERVICES • Increasing the availability of information (on health issues, available services etc), particularly in ‘minority’ languages, including improving links between traditional health workers and public health services • Changing the focus of health services, particularly in remote, rural areas, from static centres to extensive outreach provision 51  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments INCREASING THE QUALITY AND QUANTITY OF RESOURCES • Strengthening the capacity of health workers, to increase their understanding of the different communities whom they serve, and improve their communication skills, through learning indigenous languages, or using pictorial materials • Supporting long-term solutions to improving the human resource crisis in health, including health worker motivation Vaccination outreach in IMPROVING SYSTEMS Ratanakiri, Cambodia • Locating static health services close to those who are most in need of services • Working towards the abolition of user fees for essential health care12 • Conducting further grass-roots research to analyse barriers to access and local approaches to breaking-down these barriers IMPROVING POLICIES • Supporting the implementation of existing policies which are intended to break down access barriers • National health policies and protocols recognising the differing cultural needs of communities, then supporting their implementation • Prioritising provision for marginalised communities, who have the greatest need for preventative and curative health services CHANGING SOCIAL ATTITUDES • Working to address cultural and gender constraints, including the social and economic status of women 7. Build on what exists As discussed above, the importance of understanding the context of fragile states and difficult environments, and hence recognising that their unique situations determine the appropriateness of priorities, methodologies and target outcomes, has been well documented. Each fragile state or difficult environment faces different challenges, in terms of the existence and capacity of: structures and systems, 12 This must be planned carefully and carried out in stages, and may well depend on external support from the international community 52 13 Key Principles policies and practice, and stakeholders and service providers. The over-riding lesson is that external organisations should work with whatever exists – however minimal the capacity or the practice – rather Father and child, than establish new systems, guidelines or providers South Omo, which will not fit long-term within the local context or Ethiopia national situation. 7.1 Work in partnership All fragile states and difficult environments have some kind of existing local authority and health structure, whether it be village chiefs and TBAs, or the remnants of a district government and government health service; in some areas, local CSOs may also already exist. It is important that these form the basis of any external support for health – both to maximise the effectiveness of any intervention and increase the likelihood of long-term sustainability – so working in partnership with these institutions is therefore essential. Working in partnership (South Omo Zone, SNNPRS, Ethiopia) Health Unlimited’s focus on marginalised communities means that in most of the areas where it works, there are no local (or international) NGOs for it to partner. However, in the initial situational analysis of South Omo Zone, Ethiopia, EPaRDA – an Ethiopian NGO – already existed, and so an effective partnership could be developed. In the design and implementation of the ‘Pastoralists Health Development Project,’ EPaRDA contributes a deep understanding of the culture of the South Omo people and has strong relationships with local communities and their leaders; Health Unlimited provides health and organisational development support. This partnership is crucial in building the capacity of EPaRDA and hence the future sustainability of Health Unlimited’s work in the area. 53  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments 7.2 Work with appropriate government authority(s) In fragile states and difficult environments, it can be difficult to determine the ‘appropriate government authority’ with whom to work. External organisations, whose objective is to improve the quality of life for the most marginalised communities, should be as apolitical as possible and develop relationships with all key stakeholders. This may include indigenous authorities or an authority or government not recognised internationally (e.g. ceasefire groups in Burma/Myanmar, government in Somaliland). The key question is which ‘authority’ has the confidence of communities and the potential to address health issues. Flexibility is needed to ensure that support is provided with the agreement and involvement of the appropriate authority ruling the area in question. If this does not take place, then work on the ground will not be effective and will not have the buy-in and acceptance of local stakeholders and target beneficiaries. Advantageously, health is generally seen as a key social issue, and so is considered a ‘neutral’ area for an external organisation to provide support. ‘Appropriate’ government authorities (Ceasefire groups, Burma/Myanmar) Since 1987, Health Unlimited has been working with a number of Burmese ceasefire groups (e.g. the Karen, Kachin, Wa State and Special Region 4) who are the de facto government in the areas that they “rule”. Strong relationships have been developed with these quasi-government authorities, particularly with regard to the health needs of their populations. Health Unlimited has always had (and still has) the possibility of seeking an MOU with the SPDC. However, the ceasefire groups – Health Unlimited’s key partners in improving the health status of these marginalised communities – have expressed their reservation with such a relationship being developed: they have indicated that any such association would put in jeopardy the current partnership between themselves and Health Unlimited. Health Unlimited has therefore taken the decision – on a humanitarian, rather than political basis – that the most effective way for us to support populations living under ceasefire groups in Burma/Myanmar is to work with ‘local’ authorities, who may not be recognised internationally, rather than with the national government. This also has had the advantage that when restrictions have been placed on workers of INGOs with a base in Rangoon, Health Unlimited staff have been able to continue their work unhindered. 54 13 Key Principles 7.3 Support a range of service providers In any country, health services are offered by a range of service providers including: government/ public health workers; NGOs (e.g. supporting other providers, implementing directly, or as government contractors); community health workers (e.g. TBAs, village health volunteers); and for-profit providers (e.g. private medical practices, drug sellers). Health services do not have to be solely provided by the government, and in fragile states this is often unfeasible in the short/medium-term, as the public health service is in disarray and does not have the capacity to reach every community. Non-government service providers often have significant comparative advantages over government provision (e.g. less bureaucracy, greater awareness of local needs, often based within communities) and for-profit providers may be some communities’ only option – though they may lack the technical knowledge or wider links to provide a high quality service. In the short/medium-term, a range of initiatives and service providers need to be supported, so that the quality (and quantity) of the current health service provision can be improved. In the longer-term, decisions can be taken (and hence appropriate support provided) on whether national public provision of services is practical and able to reach all communities, including the most marginalised, or whether the government’s role should be one of regulation and overall direction. Providers’ capacity can be strengthened through training, facilitating links between different providers and with suppliers of health-related goods (e.g. contraceptives, insecticide-treated nets), and supporting governments’ attempts at registration and regulation. However, this can be very sensitive, and it is important to ensure that traditional health providers are not driven underground. In some areas, supporting NGOs to provide services or strengthen the capacity of community-based organisations (CBOs) may be the most effective way of Ttraditional birth attendants, improving health status. However, any direct provision South Omo, Ethiopia of services by international NGOs should be considered carefully, as difficulties may arise when they leave if insufficient local capacity has been built. Different approaches to service provision, e.g. contracting, should be piloted and reviewed. 7.3.1 Avoid parallel systems Parallel systems – such as direct provision by NGOs, or the development of new systems where existing ones exist – should be avoided. However, if government health services do not reach marginalised communities – and the government is unwilling or unable to expand services – then it may be necessary to 55  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments develop a separate system which can be incorporated into the government health service at a later stage, when national capacity and resources have been built. Any new system should follow, as far as possible, the structures of the national health service, from worker employment to the treatment guidelines followed and the monitoring system used, and should be developed in consultation with the MoH. Incorporating facilities into a national system (Ratanakiri Province, Cambodia) Ratanakiri is an isolated, mountainous province in north-east Cambodia. In terms of child mortality, nutritional status, immunisation coverage and the utilisation of health facilities (Cambodia DHS, 2005), it is among the worst provinces in the country (and therefore among the worst in south-east Asia). Use of government health services for communes remote from health centres is understandably low, and so, in discussion with key stakeholders, Health Unlimited established (or supported the establishment of) a number of innovative health posts to provide essential care to these communes. The midwives and commune health workers (drawn from the indigenous groups with whom they work) who staff the posts are linked directly to the villages in the commune through the Village Health Committees. The health posts provide antenatal care and basic care for common illnesses, support the trained TBAs in the communes, attend home deliveries (when a community midwife is present) and provide community health activities and education. The health posts were then linked to the nearest government health centre: health post and health centre staff meet monthly to exchange information, and the health centre provides monthly supplies of drugs for the health post. Health centre staff are expected to regularly supervise health posts within their catchment area. There was similar success in Preah Vihear Province. 7.3.2 Strengthen government service providers If any government health services exist, then support should ideally be given to develop the capacity of both health workers and health facilities. However, some governments may deliberately exclude certain marginalised groups or use public services as a way to enforce political control over communities, and NGOs may feel it is outside their remit to support such services. In these situations, although donors may be in a position to directly work with the government to change their political approach, parallel systems 56 13 Key Principles may be unavoidable in the short/medium- Long house term if marginalised communities are to have Ratanakiri, Cambodia access to health services. In most situations, it is within the capacity of NGOs to support government health services to improve their approach to marginalised communities and their provision of services. In these cases, and following a needs assessment, any training provided should be structured, relevant to the local context, appropriate to the cadre and their education/ experience, and in-line with any national guidelines. If local trainers are unavailable, it may be appropriate for workers to travel to the capital or over the border (if cross- Unavoidable parallel systems (Wa State, Burma/Myanmar) Health Unlimited has been working with the Health Department of the United Wa State Party (UWSP), at their request, since 2001 to establish a basic primary health care service. Neonatal tetanus was identified as a concern, and so tetanus toxoid immunisation was considered an important intervention to introduce for all women of child bearing age. EPI (Expanded Programme on Immunization) vaccinations for Wa State are sourced from China, but as tetanus toxoid is not included in China’s immunisation programme, this procurement route was not possible. The UNICEF (United Nations Childern’s Fund) office in Rangoon was approached and they agreed to provide the vaccinations. However, due to their agreement with the SPDC, they were unable to directly pass the drugs to either the UWSP or Health Unlimited, but could deliver the vaccinations to the Township Medical Officer. Unfortunately, the Township Medical Officer felt unable to handover the vaccinations to the UWSP or Health Unlimited as neither were part of the ‘official’ national health system and did not have the capacity to provide the immunisations to women of child bearing age directly. At present, women in Wa State are therefore unable to be vaccinated against tetanus toxoid, despite the drugs being available. If children are to be vaccinated against childhood diseases, a parallel procurement system for EPI drugs (imported from China) is therefore unavoidable. 57  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments border working is taking place) to attend courses. It is likely that training will take place for a number of weeks Mother and (or months), over a period of months (or years), and sick child, should be supported by further on-the-job monitoring Preah Vihear, Cambodia and supervision, so that the theoretical skills learnt can be developed in practice. Monitoring and supervision should be the joint responsibility of the supporting external organisation and local health management team (who may also need specific training to fulfil this responsibility), with the external organisation gradually withdrawing over time. The focus should be on solving problems, rather than on ticking through a checklist (see case study in section 8.3). Health facilities, equipment and drugs may also be lacking. Any support provided to these areas must be in-line with any national policy or plan, with consideration given to routine maintenance and ongoing costs. In many fragile states and difficult environments, motivation amongst health workers is low, often due to low salaries, poor working conditions and few job prospects. Training and improved conditions in health facilities can help address some of these, but if the quality of health services is to improve, it is also important to increase the average income of health workers, so that they are encouraged (and financially able) to spend more time working for the government health service, rather than going into private practice or moving overseas. Performance-related bonuses appear to be a step in the right direction in improving the quality of health services, as health workers’ incomes are directly related to improvements in heath indicators (both process and outcome). Government contracting (Preah Vihear Province, Cambodia) Health Unlimited is contracted by the Royal Government of Cambodia (through a World Bank loan) to implement the Health Sector Support Project in Tbeng Meanchey Operational District, Preah Vihear Province. The principal objectives are to increase accessibility and quality of health services, and assist the Government in implementing its Health Sector Strategic Plan and strengthen the sector’s capacity and performance. Health Unlimited directly manages health 58 13 Key Principles staff seconded by the Government in the Operational District in order to achieve a number of performance-related targets focused on maternal and child health, and increased use of the public health system. Progress has been steady, but made more difficult initially due to the demands by some MoH staff for higher incentives, beyond those agreed in the contract. Another example of supporting government health services can be found in section 8.3; further information on performance-related incentives can be found in section 11.1 7.3.3 Support community-based service providers As mentioned above, in many fragile states and difficult environments there are numerous community- based service providers, such as traditional healers, TBAs, drug sellers, and even small grocery stores. If government health services are inaccessible to marginalised communities, then these community-based providers are often the first people that community members turn to if they are ill. It is therefore important that these providers are supported to ensure that their service is accurate and appropriate. As government health services improve and are able to reach more and more communities, then the need for community- based service providers will reduce. However, in the short/medium-tem, they are vital (and often the only) components of the health service available to marginalised communities. All community-based service providers can be trained on preventative measures that can be taken to improve health, and the danger signs and symptoms of common illnesses which need to be referred to health facilities. The skills of traditional healers and TBAs can be developed to provide advice, Training of ensure that their services do no harm, or offer clean deliveries (in traditional birth the case of TBAs). Drug sellers and small grocery store owners can attendants in Cambodia be trained on the diagnosis and accurate treatment (through easily available drugs) of common illnesses, and links with suppliers of health-related products can be facilitated, increasing the availability of contraceptives, oral-rehydration salts and insecticide-treated nets (for example) to communities. Where CBOs exist, external organisations can strengthen their capacity to effectively support their communities. This could be through training of staff, organisational development, building their ability to work with external organisations and donor agencies, or increasing their advocacy skills to lobby the government. 59  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Strengthening Traditional Birth Attendants (Ratanakiri Province, Cambodia) In Ratanakiri Province, Cambodia, indigenous communities face numerous barriers accessing health facilities, including lack of transportation, cost, social issues, language difficulties and poor quality of care provided by government health centres (Brown, 2002). As such, 83% of deliveries in Ratanakiri Province are assisted by a TBA (Cambodia DHS, 2005). Given this local context, Health Unlimited felt that one important strategy to improve maternal health would be to strengthen the capacity of TBAs. TBAs therefore received training adapted from the Cambodian MoH midwifery qualification which included components of information/education for pregnant women, safe birthing practice, recognition of complications and onward referral to health centres, care of the newborn and postnatal care. At the end of the training, each TBA received a basic birthing kit. Over a period of eight years, 178 TBAs were trained in 40 villages in five districts in Ratanakiri, inhabited by predominantly indigenous communities. An external evaluation (Furey, 2004) found that these TBAs had demonstrably improved knowledge which was translated into improved safe birthing practices. In villages with trained TBAs, a higher proportion of women received some antenatal care and tetanus toxoid vaccination, compared to the whole of Ratanakiri province. Neonatal death rates also appeared to be significantly lower compared to babies delivered by untrained TBAs and in Ratanakiri province as a whole. 7.3.4 Develop links between public and private service providers More support and structure should be provided to community-based health workers – whether TBAs, community health volunteers, or other cadre – as they have the potential to form a useful bridge between Delivery room in Preah Vihear, Cambodia, funded by Health immediate community health needs Unlimited and services offered by clinically- trained health personnel. Closer working between community and health facility workers should be encouraged and community-based referral systems established. 60 13 Key Principles Referrals from TBAs to Health Centres (Kampot Province, Cambodia) In Kampot Province, Cambodia, Health Unlimited supported both TBAs (as community-based service providers) and government health services, and facilitated links between them. This increased the quality of services available to pregnant women and the likelihood of deliveries being attended by skilled health personnel, whilst recognising the realities of communities (e.g. difficulties in accessing health centres) and without ostracising traditional providers. For example: health centre midwives were involved in training TBAs in their catchment area and restocked the sterile birthing kits provided to the TBAs by Health Unlimited; some health centres provided financial incentives to TBAs who referred mothers to the health centre; and TBAs are able to observe deliveries in health centres and hence increase their skills and knowledge of safe birthing practices and when they need to refer. Monthly meetings between health centre midwives and TBAs provide a good opportunity to share information and experiences. 7.3.5 Develop new organisations, if appropriate If a long-term need is identified, but there is no local capacity to fill the gap (which can often be the case in fragile states and difficult environments), then it may be appropriate to support the development of a CSO to address this issue. Ideally, the impetus for establishing such an organisation should come from the beneficiaries themselves. In some situations, a consultative or advisory group may be established at grassroots-level as part of an external organisation’s plan of action, and over time, the capacity of the group and its members can be developed to a stage that they are able to ‘break away’ and become a locally-registered, self-sufficient organisation. The external organisation generally needs to continue providing ongoing support in the short-term, but in the medium-term, the CSO should be able to function completely independently, pulling-in assistance from external sources as required. Strengthening civil society (K’iche’ Youth Association, Guatemala) Health Unlimited in Guatemala was concerned about the sustainability of community-based activities, which analysis showed often petered out at the 61  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments end of a project’s lifetime. What was felt to be lacking was an organisational structure which enabled a community to use its newly acquired skills, legitimise its participants, stimulate continued participation and seek to develop processes begun by the project in question. This led Health Unlimited to establish Ri Alitom, Alabom K’iche’ (K’iche’ Youth Association / Asociación Juventud K’iche’ (AJK)) with local indigenous Mayan youth. A number of key issues were considered: (i) Timing: it was rightly assumed that the Association’s membership would require accompaniment, given that its members were local youth, inexperienced with organisational responsibility; sufficient time was therefore allowed for this support to be provided; (ii) Membership: the target of grassroots membership was achieved from the start (many Guatemalan community associations are ‘local’, but their membership tends to be community elites, and so they are often less than representative ); (iii) Management: against the advice of some13 , local youth were encouraged to assume the responsibility of Association management; this has resulted in a longer period before seeing ‘results’, but has considerably enhanced the community’s sense of ownership of the Association, as well as developing their skills and experience for the future; (iv) Technical support: training was provided to AJK Board members on issues such as their roles and responsibilities, proposal writing, donor relations, budgeting and financial management, as well as general skill-sharing activities (e.g. participatory rural appraisal and problem ranking); in addition, the AJK President attends Health Unlimited’s fortnightly staff meetings, and Board members are integrated into Health Unlimited team activities at every opportunity; (v) Financial support14 : in the short term, Health Unlimited has assumed some, but not all, of the Association’s financial costs (e.g. legal registration fees, some costs of the AJK Annual Assembly); however, the AJK is responsible for its own costs wherever possible, for example by encouraging local youth to pay annual membership fees15 , and through small-scale income-generating activities; and (vi) Accountability and governance: Health Unlimited has encouraged the AJK to avoid the Guatemalan practice of employing board members as paid management or technical staff; at the Annual Assembly (with 600 (80%) members in attendance), the AJK Board presents its reports and holds secret 13 who suggested that the Association would advance more quickly if its governing board included project staff 14 The question of encouraging financial sustainability as quickly as possible is an important one in Guatemala, given the experience of numerous Associations who do not charge a membership fee and rely on a series of outside projects. In some cases, this has resulted in the Association no longer being able to hold an Annual Assembly because members won’t attend unless someone (such as the INGO who previously supported them) pays for travel and food. 15 A cost which has been paid by individuals (usually) without demur 62 13 Key Principles ballot elections for its new board. As a result of this integrated approach, the AJK succeeding in raising US$15,000 for a radio project in its first year, with Health Unlimited as its partner; upon successful completion of the project, it was awarded a second round of funding by the same donor (Population Communications International). It has also been integrated into a regional Indigenous Youth Network supported by an EC Civil Society initiative, and forms part of the wider network’s governing body. Left and right: K’iche’ Youth Association’s radio broadcasting, Guatemala 8. Develop accountability mechanisms As discussed under principle 5, accountability is a core aspect of a rights-based approach. 8.1 Support the establishment of accountability structures Accountability mechanisms should be established so that marginalised (and other) communities can participate in their local health services, and hence improve their effectiveness. An appropriate structure will enable communities to voice their concerns and hold the government to account, and also support health staff to respond effectively to the issues raised. Any accountability structure needs to be accessible to the community, with community members (or their representatives, elected or chosen because of their position) able to make direct contributions at a number of levels within the hierarchy. In addition, this ‘community-accessible’ structure can be supported by internal Ministry mechanisms which enable government staff to feed back their own concerns and locally raised issues from points of service provision (e.g. health centres) to the national decision-making level. These structures should be agreed nationally, with support made available to ensure their implementation. Any participation criteria for the ‘community-accessible’ structure should consider the constraints faced by people in marginalised communities e.g. literacy, self-confidence, transport and time availability. 63  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Implementing accountability policies (Cambodia) Implementation of Cambodia’s Primary Health Care Policy (2001), particularly the establishment of accountability structures, varies considerably across the country. In the provinces where it works, Health Unlimited supports the establishment of the nationally-agreed accountability committees (Village Health Support Groups and Health Centre Management Committees16 ), ensuring widespread participation and, importantly, the involvement of women. Committee members, particularly those in Village Health Support Groups, are trained in their roles and responsibilities, the right to health, and communication skills (so they are able to feed back the health services concerns and needs of their communities to Health Centre Management Committees); support is also provided to enable committees to regularly meet, share information and discuss pertinent issues. Management and coordination of the structures are gradually handed over to Commune Councils. 8.2 Build communities’ capacity to advocate for their rights Demonstrating If communities are to be able to claim their right to health, men and indigenous birthing women need to understand what are their rights (and responsibilities) as practices at the health post, Peru citizens – including their legal entitlements – and hence their government’s responsibilities towards them. They also need a basic understanding of the government structure, political and administrative system, relevant policies and budget, as well as details of government budgetary allocations to local services. In addition, communities may need specific support to analyse and solve problems, provide constructive feedback and vocalise their views, particularly within a hierarchical or repressive society. Any such information and support should be provided appropriately, considering literacy levels and using non-formal education methodologies. Specific attention should be paid to ensuring that women and other commonly marginalised groups are able to participate. 16 Interestingly, Health Centre Management Committees often already exist in some form, but Village Health Support Groups remain rare 64 13 Key Principles Using networks for collective advocacy (Huanta Province, Peru) Many communities in Peru have community health agents who function as TBAs, traditional healers and health promoters17 . These health workers typically work informally with no cash compensation, receive poor supervision and are not linked to each other except informally. The Regional authorities in Peru are currently involved in developing structures and policies for the Ayacucho Regional Government, and a need was identified, at this opportune time, to give voice to indigenous communities in order to guarantee the design of accessible and culturally-sensitive health systems. It was therefore felt important for Health Unlimited to support the consolidation of health workers’ associations to create communication channels for the indigenous population to demand their right to health from the Ayacucho Regional Government. At the request of the community health workers, as well as the MoH and municipal authorities, Health Unlimited supported the development of district associations of community health agents, (APROMSAs18 ) and facilitated working relationships between them. The institutional capacity of the APROMSAs was built, including their establishment as legal entities (essential in the Peru context, if they are to be recognised as legal spokespeople by other institutions). A network of APROMSAs is currently being developed, so they can advocate together at a provincial level. APROMSAs are currently promoting the importance of culturally appropriate birthing facilities with district government and health services, and are “slowly being recognised by the authorities, building for themselves an image as serious public health promotion organisations” (Health Unlimited, 2005e). 8.3 Strengthen government capacity to fulfil their responsibilities In many fragile states and difficult environments, government health staff do not feel accountable to their clients. It is therefore essential to support them and increase their understanding of both clients’ rights and their own responsibilities as government health workers. Front-line workers may need improved communication links with the MoH, regarding new or changed policies, as well as greater capacity to constructively accept feedback and respond to their clients’ needs and concerns. Training, supervision and increased resources (so that staff can perform their duties effectively) have been shown to yield positive results, as has the introduction of performance-related pay incentives. 17 Their knowledge and skills are often acquired from a parent who previously had this role 18 Asociaciónes de Promotores de Salud 65  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Supporting government health services (Preah Vihear Province, Cambodia) Working in close cooperation with the Provincial Health Department of Preah Vihear, Cambodia, Health Unlimited’s Integrated Health Care Project19 has a number of complementary components. Developing the capacity of government health services – both in terms of staff and equipment – is crucial if the quality of health services is to improve. Health workers are trained in the Minimum Package of Activities (in-line with government guidelines) and then supported with on-the-job supervision from Health Unlimited and Provincial Health Department staff. COPE (Client-Oriented, Provider-Efficient) services20 has been introduced and is enabling health centre staff to begin improving the quality of their services. In addition, a number of health posts and health centres have been constructed and equipped, in-line with the Government’s overall facilities plan. The management capacity of the Provincial Health Department has also been developed. 9. Facilitate an appropriate mix of aid modalities In order to promote equity and equality, a range of instruments should be used to support a variety of state and non-state organisations – the key criterion being the instrument’s effectiveness in assisting poor people. In regions which are remote or neglected by government for political reasons, NGOs may decide that a cross-border approach is the most effective way to reach marginalised communities. However, this can cause funding difficulties as donor country offices are generally unable to support work which is conducted beyond their geographical remit. In these situations, support for cross-border initiatives should be available either through coordination between neighbouring donor country offices, or from a regional base. In many fragile states and difficult environments, government services do not reach remote regions, disputed territories or rebel-held or insecure areas. In such circumstances, the government may resist external support to populations living there and prohibit the distribution of centrally allocated funds to 19 This is separate – though obviously complementary – to Health Unlimited’s contract to manage the operational health district on behalf of the MoH. (See case studies under principle 6.3.2) 20 COPE® is a relatively simple process for improving quality in health services. COPE encourages and enables service providers and other staff at a facility to assess the services they provide jointly with their supervisors. Using various tools, they identify problems, find the root causes, and develop effective solutions. 66 13 Key Principles Cross-border operations (Eastern Burma/ Yunnan Province, China) Since 1993 Health Unlimited has been taking a cross-border approach – from a base in Yunnan Province, China – to support ceasefire groups in Eastern Burma/ Myanmar (Kachin, Wa State and Special Region 4). The success of this cross- border cooperation is due to a close partnership between Health Unlimited, the Burmese ceasefire authorities and the Yunnan Bureau of Public Health, and by supporting marginalised communities on both sides of the Burmese/Chinese border. This strategy has enabled effective cross-border approaches to infectious disease control (e.g. HIV/AIDS), sharing of experiences between health officials on both sides of the border and a reliable supply of drugs and equipment (which are impossible to procure from the Burmese capital, due to the political relationship between the ceasefire groups and the SPDC). organisations who do work there or who do not Health Unlimited project have a centrally-agreed manager, with injecting MOU. For example, in drug users on the Burma/ Burma/Myanmar, the Myanmar- China border centrally run FHAM was inaccessible to NGOs (such as Health Unlimited) that worked cross-border with ‘ceasefire’ communities and who did not have an MOU with the SPDC government. Unfortunately, this rule remains in place with the new ‘3D Fund’ and therefore restricts the ability of INGOs to reach the most marginalised communities. 67  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments 10. Focus on health systems as a whole 10.1 Support integrated health systems It is increasingly recognised that an integrated, equitable, well-functioning health system, accessible to all, is crucial if the long-term health of a population is to improve, and the health-related MDGs – such as reductions in maternal and child mortality rates – are to be achieved. Vertical interventions have their place, but they can distort overall service delivery, particularly when existing public health infrastructure is weak. As health concerns are so interlinked, disease-specific initiatives only have limited short-term success, and also tend to be driven by donor rather than local priorities. Strengthening health systems is more complex than introducing vertical initiatives, but is vital for long-term health improvements. Distorting effect of vertical initiatives (Ratanakiri Province, Cambodia) Health Unlimited’s experience in Ratanakiri Province, Cambodia, can be seen as a microcosm of the wider situation. A range of donors provided support for a variety of different activities. As contracts are negotiated at different times, there are limited opportunities to integrate initiatives at the planning stage, resulting in four different ‘projects’ being implemented concurrently, focusing on four different health issues (malaria, maternal and child health, HIV and water and sanitation), and with four different sets of specialised staff. As there is some geographic overlap of the projects, this meant that communities are visited by different members of staff (each with different ‘specialised skills’), with no opportunity for cross fertilisation; the efficiency of Health Unlimited’s overall programme in the province is therefore reduced. Attempts to improve the situation have been hampered by the varying project timeframes and donor requirements. Although funds for vertical health initiatives are more easily available than for support to the health system as a whole, the end results are inefficient and don’t realise their potential. In fragile states, although tertiary and secondary level health institutions should not be ignored in the medium/long-term, in the short-term, it is important that quality, accessible primary level health services – where the majority of deaths in such countries are preventable – are available to all communities, including the most marginalised. As discussed above (see particularly section 6.3), comprehensive outreach provision forms an essential component of such services. 68 13 Key Principles 10.2 Develop / Use national protocols Many fragile states and difficult environments have a number of relevant policies and health protocols, even if they are old or poorly implemented. These should be the basis of any health services provided or developed, with changes made to (old) protocols only in-line with WHO guidelines, following consultation and agreement with local stakeholders and the government authority. Where existing policies do not serve the best interests of the marginalised, civil society actors such as NGOs should work with local communities to advocate for appropriate changes. If national protocols do not exist, their development is an important step in ensuring that parallel systems and norms are not established in different areas. In the interim, and in order that health services can progress, implementing or support organisations should work with local stakeholders to develop short-term local protocols in-line with WHO guidelines. 11. Address human resource constraints Many developing countries, and in particular fragile states and difficult environments, face severe human resource Somali billboard – “everyone is at risk of AIDS” - including health workers constraints, e.g. insufficient numbers of trained staff, staff unwilling to work in remote areas, low pay encouraging emigration or private sector work (often concurrent with government employment), and (in some areas) increasing numbers of staff dying from HIV/AIDS. These obstacles obviously have a detrimental impact on the quality and equity of services provided, and need to be overcome. 11.1 Provide long-term support As part of their long-term commitment, it is crucial that donors increase their support to governments to invest in human resources for health. Depending on the context and needs of the country, this may involve supporting the government to: strengthen and increase training opportunities, expand career development prospects, offer incentives to work in rural and marginalised areas, and supplement incomes. 69  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Performance-related incentives (Preah Vihear Province, Cambodia) Basic salaries for health workers in Cambodia are generally considered inadequate and so health workers have little motivation to provide the quantity or quality of health services expected. In an attempt to address this, in Preah Vihear Province, Cambodia, as part of the contracting arrangement, performance- related financial incentives are paid to government health staff to encourage actions that will improve the quality of health services provided. The financial incentives given depend upon both the proportion of the ‘expected’ (contracted) hours that an individual actually works, and the team achievement of a number of quality indicators (such as % of pregnant women receiving antenatal care, or EPI coverage). Evidence so far suggests that the use of these performance- related financial incentives – combined with capacity-strengthening activities – has a positive effect in improving the overall quality of health services provided in the province. More details on contracting in Preah Vihear can be found in principle 7.3.2 11.2 Advocate for flexible entry requirements for health staff For many marginalised communities, their marginalisation extends beyond health to education (and other) opportunities. This means that many individuals, although they may have the potential to be effective workers, are unable to work in the health sector as they do not have the minimum education qualification required by the Ministry of Health. In the short/medium-term, the education requirements to be trained as an entry-level health worker should be reduced, so that numbers of workers can increase, and local services can be more appropriate to local needs and situation (i.e. health workers could be draw from local communities and hence speak the local language, understand the cultural context, and work without prejudice). If needed, the ‘standard’ training package for entry-level workers could be extended to take into account different ‘education’ starting points, including the provision of literacy classes. Minimum education requirements for health staff (Ratanakiri Province, Cambodia) In Cambodia, the MoH stipulates that all prospective nurses and midwives must have completed grade 9 before they can begin their health training. However, few 70 13 Key Principles people in Ratanakiri, and even fewer from the remote areas and indigenous groups, have reached this level of schooling, resulting in very few health workers who can communicate in local languages or who understand local beliefs. In addition, the jobs are unlikely to attract those with the necessary levels of schooling, as their education can open up less demanding and more lucrative careers. This situation constitutes a major threat to health services, particularly in remote and indigenous areas where health staff are most needed. 12. Utilise appropriate communication approaches 12.1 Support radio ‘edutainment’ programmes In fragile states and difficult environments, radio is often the only means of mass communication. For example, 62% of the population in the Somali-speaking Horn of Africa have access to a radio and listen regularly (Health Unlimited, 2004a). Radio can reach a wide audience of beneficiaries (to some extent overcoming the often low population density in marginalised communities) and address beneficiaries’ time constraints (potential beneficiaries often report that they are too busy earning a living to be able to spend a couple of hours travelling to a training session). In particular, culturally-appropriate radio can maximise the reach of small numbers of linguistically capable trained health personnel, in areas where there are few trained health staff (in MoH or NGOs) who speak local, and especially indigenous, languages. Radio can Actors recording Saxan Saxo also help break taboos, such as those surrounding (health education radio magazine), sexuality: people are able to avoid embarrassment and Somaliland listen in the privacy of their own home; and women at home can listen even when they may not be allowed by husbands/fathers to attend group meetings where SRH issues are discussed. From Health Unlimited’s experience21 , accessible, entertaining and informative radio programmes (‘edutainment’) can successfully raise awareness of important health issues (including those related to traditionally taboo issues, such as FGM), increase health service usage and positively change behaviour. 21 Substantial experience in Rwanda, the Somali-speaking Horn of Africa and Cambodia; growing experience in Guatemala, Peru and Nicaragua. 71  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Using radio to discuss taboo issues (Somali-speaking Horn of Africa) Health Unlimited began working in the Somali-speaking Horn of Africa, from a base in Somaliland, in 1997. Given the high degree of radio access and listenership, this was chosen as the most effective vehicle for spreading health messages, if the largest number of people was to be reached. A series of 15- minute radio programmes (‘Saxan Saxo’, meaning ‘Fresh Breeze’ in Somali) was developed, using drama and a magazine format to raise awareness, and encourage discussion, of SRH issues, including HIV/AIDS, FGM and safe motherhood. Initially broadcast on the BBC Somali Service, the programmes were then moved to regional stations, which have a wider coverage – for many, this was the first time that they had broadcast a programme dedicated to SRH issues. Audience groups were established and supported, to ensure that programmes were relevant, appropriate and practicable for the target listeners. The radio programmes are combined with some outreach work, such as mobile theatre, to reinforce messages and reach those who don’t have regular radio access. Surveys have shown that knowledge of SRH issues has increased, and there is anecdotal evidence that behaviours have also begun to change. (Health Unlimited 2004 a 2004 b) 12.2 Support culturally appropriate media Marginalised communities in fragile states and difficult environments often have a different language or set of cultural norms than the ruling government. It is therefore important that health communications are not only conducted in the appropriate language, but also using culturally appropriate techniques, such as traditional entertainment. Using clowns to promote sexual and reproductive health (Guatemala) Health Unlimited’s ‘Sexual and Reproductive Health Project’ for indigenous children and young people in Guatemala uses Clowning as part of its methodology. Given the taboos surrounding discussions of sex and sexuality in traditional communities, some time was spent in finding appropriate ways to 72 13 Key Principles convey its key messages; one which has proved successful has been public presentations by clowns. The project has formed its own Clowns’ Group, “The Serious Comic”, who are themselves indigenous young people who live in the project area. Training was provided on several levels: SRH training, followed by team-building exercises, then work on juggling, acrobatics, scripting, and so on. Health Unlimited first began to offer the group to schools to perform short skits on HIV/AIDS, underage pregnancy etc. Later, public presentations were held in town squares on market day and at special events such as World Aids Day commemorations. The clowns attract attention: as they arrive in a town, they begin stilt-walking, singing and banging their drums. An audience soon forms and the clowns begin to share key messages. The use of drama and visual impact attracts the attention of the public, and the use of laughter overcomes cultural taboos surrounding public discussion of sex, condoms or prostitution. Initially clowns’ presentations were offered to the community, but now, the communities and the local Ministries of Health and Education are themselves requesting presentations, recognising the effectiveness of their entertainment in sharing sensitive information. 13. Promote co-operation among agencies Resources in fragile states and difficult environments by definition tend to be scarce. If governments are unable or unwilling to provide services, the burden will fall on non-state providers (NSPs), usually NGOs, to do so. But even NSPs have limited resources and it important that those resources are used to address the health status of these communities and not absorbed into unnecessary transaction costs or in providing duplicate services. 13.1 Unnecessary transactions costs Donors have choices when it comes to distributing their resources and have a responsibility to get the best value for money. However, creating competitive tendering processes means that the resources of each bidder that are used in preparing the bid is in effect “wasted” and therefore not available to be used in addressing poverty issues. For example, if there are 5 bidders for a contract, and each spends $20,000 preparing the bid, then $100,000 that could otherwise have been used in health care has been lost. Clowns in health education 73 theatre, Guatemala  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Duplication of efforts in an African Country After two years of research and planning, Health Unlimited secured funding to implement a health programme among semi-nomadic pastoralist communities. The implementation of this community-based project through a local partner began in 2005. Relationships with government officials at all levels had been carefully nurtured. It was therefore surprising when Health Unlimited learnt in 2006 that another international agency was planning to begin work in exactly the same district using a very similar approach. Attempts to discuss this potential duplication with the other agency are proving difficult and at the time of writing unresolved. 13.2 Avoid duplicating services NGOs and NSPs have a responsibility to ensure that any interventions that they plan to implement do not duplicate the work of others. This necessitates some research both of what others are doing, and planning to do, before embarking on programme design, resource mobilisation and implementation of programmes (see also section 3.1 on the importance of sharing information and 3.2 on the benefits of working together to influence policy and practice). Generally this can be done without spending huge resources, and involves communicating with other agencies known to be working or planning to work in a particular region of a country. If this is not done and two providers are “competing” in the same area, resources that could be used effectively elsewhere, will be wasted both because services are duplicated and also in the costs of communicating with the other agency. Children in Kachin, Burma/Myanmar 74 Conclusion 14% of the world’s population live in ‘fragile states’ and have a health status amongst the poorest in the world – child and maternal mortality is around 2.5 times greater than in other developing countries. Fragile states are unlikely to meet the MDGs and are more likely to become unstable and negatively impact on neighbouring countries, in terms of migration, transmission of infectious diseases, and reduced economic growth. ‘Difficult environments’, where certain geographic areas or ethnic populations do not receive appropriate core government services, can be found throughout the world. In many of these areas, governments intentionally discriminate against marginalise indigenous peoples, leading to higher infant mortality rates and short life expectancies. Within fragile states and difficult environments, marginalised communities are generally invisible and suffer even more than the general population, despite their needs being greater. Everyone has the right to health, through an “effective and integrated health system, encompassing health care and the underlying determinants of health, which is responsive to national and local priorities, and accessible to all” (Hunt, 2006). However, a state’s fragility and the health status of its population can be locked in a vicious cycle. Health is an established area for external stakeholders to support, and in fragile states, service delivery may offer an entry point for triggering longer term pro-poor social and political change in wider development areas, as well as potentially helping some states to not slide into, or back into, civil conflict. It also provides an opportunity to support the development of the host government’s capacity, as well as engaging with civil society and encouraging accountability structures to develop. Health services in fragile states face particular challenges, so the question is: “How can international donors and NGOs support the development of appropriate, effective services, accessible to all?” From Health Unlimited’s experience, the keys to success are: flexibility, understanding the context, establishing trust, and providing long-term commitment. Flexibility is needed in terms of funding processes, partnership approaches, working with the ‘appropriate’ government authority and supporting a range of service providers; context needs to be understood by monitoring the situation and working with what already exists; trust should be established by taking a participatory approach, working with all stakeholders, employing national staff, and developing accountability mechanisms; and finally, commitment should be long-term, so that governments, NGOs and other service providers have the opportunity to plan. The benefits of supporting health systems as a whole in developing countries – rather than disease- specific vertical interventions – are increasingly recognised, and this is particularly crucial in fragile states and difficult environments where capacity is limited. It is also important that marginalised communities are reached, not just because they are in most need of assistance, and are generally ignored, but because by targeting support to marginalised areas and tackling the challenges of how to provide effective services to those that are the most difficult to reach, there will be a trickle-up effect, as all communities along the ‘marginalisation’ continuum will benefit from improved service delivery. So, what are the key policy and practices that are needed? By definition, governments in fragile states and difficult environments are unable or unwilling to deliver core services to their entire population. Recommendations therefore focus on the roles of international donors and NGOs. 75  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Recommendations Key Principles Recommendations Donors NGOs 1) Understand the a) Support national and regional monitoring, a) Conduct a comprehensive context whether by NGOs or government bodies, situational analysis before including the disaggregation of data (principle beginning work in a area, 6) followed by regular monitoring 2) Build trust a) Employ staff on long-term contracts, a) Employ local staff wherever and give them the opportunity and possible, considering ethnicity encouragement to develop expertise in one when appropriate 22 particular country 3) Share information a) Share information with other stakeholders a) Share information with key and evidence stakeholders b) Be open to learning from the experiences of implementing organisations b) Work with other organisations where appropriate; use lessons c) Use lessons and experiences to influence and experiences to influence the policies and practice of governments policy and practice and other donors 4) Provide long-term a) Provide long-term, predictable financial support support to government and non-government organisations 5) Take a rights-based a) Support a rights-based approach a) Take a rights-based approach approach to working in fragile states and difficult to working in fragile states and environments difficult environments 6) Reach marginalised a) Advocate for, and fund, targeted support a) Specifically target communities to marginalised communities marginalised communities b) Promote the use of indicators (e.g. b) Tackle local barriers to MDGs) disaggregated by relevant factors accessing health services e.g. e.g. ethnicity, location outreach services, cultural constraints, capacity of health c) Support policies, and their enforcement/ workers implementation, which reduce barriers to accessing health services e.g. outreach c) Undertake grassroots research services, differing cultural needs, capacity of to analyse access barriers and health workers, abolition of user fees appropriate local approaches to overcoming them d) Fund grassroots research into access barriers and approaches to overcoming them 22 For example, in Wa state, Wa or Chinese staff members are more acceptable to the target population than Burmese 76 Recommendations Key Principles Donors NGOs 7) Build on what exists a) Overcome any political difficulties of a) Work with the appropriate directly supporting certain quasi-government government or de facto authorities by supporting CSOs that work government authority(s) of directly with the populations of these states most relevance to the target communities b) Fund and support a range of public and private service providers (either directly, or b) Avoid developing a parallel through NGOs), to improve the likelihood of system or an NGO service; all sectors of the population benefiting instead, strengthen the capacity of the range of service providers c) Support the development of new civil (e.g. government, private-for- society or private organisations, if there is an profit, community-based) which identified need, but no local capacity already exist c) Support the development of new local organisations, if appropriate 8) Develop a) Support the design and establishment of a) Develop awareness of rights accountability nationwide accountability structures at community level to facilitate mechanisms advocacy b) Strengthen national government capacity to appropriately use the accountability b) Build communities’ capacity mechanism and respond to issues raised to participate effectively in national accountability structures c) Strengthen the capacity of local government to fulfil their responsibilities within the accountability mechanism 9) Facilitate an a) Use a range of funding instruments, appropriate mix of aid including support to cross-border initiatives modalities (e.g. through coordination between neighbouring country offices, or from a regional base) 10) Focus on health a) Support the strengthening of health a) Provide support to the health systems as a whole systems and horizontal health initiatives system as a whole, rather than focusing on disease-specific b) Support the development of national interventions protocols, where needed b) Use national protocols (or WHO advice, if protocols don’t yet exist), rather than developing separate guidelines 77  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Key Principles Donors NGOs 11) Address human a) Provide long-term support, to enable a) Support advocacy efforts by resource constraints government authorities to plan ahead providing evidence of the need for flexible entry requirements for b) Advocate for flexible entry requirements health staff for health staff, particularly for those based in communities or lower level health facilities, in order to improve access to health services for marginalised communities 12) Utilise appropriate a) Support radio ‘edutainment’ programmes a) Use radio ‘edutainment’ communication and other culturally appropriate programmes to address sensitive approaches communications issues b) Use culturally-appropriate communication approaches 13) Promote co- a) Promote cooperation rather than a) Ensure that planned operation among competition (e.g. through the use of non- interventions do not duplicate the agencies competitive tendering processes) work of others Health Unlimited staff and local people discuss in Special Region 4, Burma/Myanmar 78 Bibliography Asian Development Bank (1999) Policy for the Health Sector, Asian Development Bank. 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Research from Preah Vihear Province, Cambodia Health Unlimited (2003b) Baseline Survey: Special Region 4, Burma/Myanmar Health Unlimited (2003c) External Mid-Term Evaluation of the Health Unlimited Programme: Across the Divide: Addressing Communicable Disease and MCH in the Upper Mekong Valley Health Unlimited (2004a) Assessment of recall of critical reproductive health messages, the extent and reasons why the messages are considered relevant, appropriate and practicable, among the Somali-speaking horn of Africa community. Health Unlimited (2004b) Well Women Media Project, Somali-speaking Horn of Africa 2002-7. Mid-term evaluation report Health Unlimited (2004c) Survey Report of Health Unlimited Cooperative Project in Special Region 4, Burma/Myanmar 2004 Health Unlimited (2005a) Access to Adequate Water & Sanitation for Vulnerable and Isolated Indigenous Communities, Ratanakiri Province, Cambodia. 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(2006) Tips for health programming in post conflict, early recovery and fragile states, unpublished draft 80 Annexes Annex 1: Acronyms AJK Asociación Juventud K’iche’ (K’iche’ Youth Association) {in Guatemala} APROMSA Asociación de Promotores de Salud (District Health Promoters Associations) {in Peru} CBO Community Based Organisation CPIA Country Policy and Institutional Assessment CSO Civil Society Organisation CSOPNU Civil Society Organisations for Peace in Northern Uganda DAC Development Assistance Committee DFID Department for International Development DHS Demographic and Health Survey ECHO European Commission Humanitarian Aid department EPaRDA Ethiopian Pastoralist Research and Development Agency {in Ethiopia} EPI Expanded Programme on Immunisation FAO Food and Agriculture Organisation FGM Female Genital Mutilation FHAM Fund for HIV/AIDS in Myanmar HIV Human Immuno-deficiency Virus MDG Millennium Development Goal MoH Ministry of Health MOU Memorandum of Understanding NGO Non-Governmental Organisation NSP Non-State Provider OECD Organisation for Economic Cooperation and Development PRSP Poverty Reduction Strategy Paper SR4 Special Region 4 {in Burma/Myanmar} SNNPRS Southern Nations, Nationalities and Peoples’ Regional State {in Ethiopia} SPDC State Peace and Development Council {Government of Burma/Myanmar} SRH Sexual and Reproductive Health TBA Traditional Birth Attendant UN United Nations UNDP United Nations Development Programme UNICEF United Nations Children’s Fund UWSP United Wa State Party {in Burma/Myanmar} WHO World Health Organisation 81  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Annex 2: Proxy list of fragile states 82 Annexes Source: Quoted in DFID, 2005 (2004 data from UNDP, FAO and World Development, 2004) * List taken from the World Bank CPIA ratings. All countries appeared at least once in the fourth and fifth quintiles between 1999 and 2003 (See Branchflower, 2004) ** Figures from 1998-2000 83  Health Unlimited - Delivering Health Services in Fragile States & Difficult Environments Health Unlimited works in Africa, Asia and Latin America. We give priority to the most marginalised, often remote, communities who are neglected by governments and virtually everyone else. We reach 3.2 million people, including over 2.4 million indigenous people, each year through our primary health care programme and an estimated 26 million through our health education radio programmes. Working with communities rather than for them, our work leads to sustainable change because we train local health staff and community volunteers. We help reduce maternal and child mortality through community based health services focusing on nutrition, water and sanitation, immunisation, safer birthing techniques, fully equipped health centres and training. Our health education programme includes radio soap operas and community theatre to promote safer motherhood and sexual and reproductive health for young people and help prevent life-threatening diseases such as malaria, TB and HIV/AIDS. We also advocate to remove the barriers to health. We believe that a commitment to health demands a commitment to environmental sustainability, poverty eradication, peace and political stability as well as high quality, accessible and culturally appropriate health services. www.healthunlimited.org UK Registered Charity No. 290535 Campaigning to make poverty history 84