Return to normalcy

If, as discussed above, the presence of conflict were in itself a major risk factor for increased mortality, it would be reasonable to assume that the restoration of peace would result in lower mortality rates. Although this is usually the case, the situation is not as simple as might seem, because the destruction and disruptions caused by violence cannot be quickly undone. Instead, a major program of reconstruction of health facilities, rehabilitation of health systems, and restoration of health services is required before morbidity and mortality rates can be expected to return to those of the ante-bellum period.

One characteristic of civil and interstate violence that has not been mentioned is the gross violation of human rights that occurs when states are either unwilling or unable to discharge their responsibilities toward their citizens. Genocide and what has become known as "ethnic cleansing" are extreme examples of what can befall civilians caught up in violent settings, but even in situations of lesser conflict, instances of sexual violence and of torture have been increasingly documented (Inter-Agency Standing Committee, 2005).

Health is an integral component of human rights law, and the Universal Declaration of Human Rights states that "{e}veryone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care..." The re-establishment of a legitimate government in a country that has been torn apart by violence should therefore be accompanied by the reinstatement of this "right" (United Nations, 1948). Although there are many processes by which health services can be made available in post-war environments, there is a growing tendency in recent years for fledgling governments to define and to offer a limited number of essential health interventions - a Basic Package of Health Services - to as many of its citizens as possible. Such an approach has been adopted in Cambodia, Afghanistan, the Democratic Republic of Congo, south Sudan, and Liberia, to name a few. These Basic Packages seek to address those health problems that are the greatest contributors to mortality during both wartime and times of peace; they typically consist of essential maternal and newborn services, interventions aimed at reducing childhood mortality, nutrition activities, and the control of communicable diseases. Depending on national priorities and on available resources, programs offering services in the areas of mental health and physical disability may also be included (Ministry of Health, 2003).

Although the development of a Basic Package of Health Services is a potentially important activity in the immediate post-conflict period for the rapid reduction of morbidity and mortality, and certainly an important statement of intention on the part of a new government trying to re-establish a legitimate and effective relationship with its citizenry, its implementation can be grossly impeded by the lack of financial and human resources. For these reasons, the role of non-governmental organizations may remain critical even when the humanitarian emergency has subsided. Donors may be reluctant to invest heavily in a new state authority, and may prefer to "hedge" their financial bets by continuing to fund non-governmental organizations, working at the grassroots level, to provide social services (including health care) to the population. Governments themselves, recognizing that their health personnel have become extremely limited during the war years -because they have not been paid, because more attractive jobs became available in the private sector, or because of emigration - may find that reliance on nongovernment organizations, both international and local, to implement health services in accordance with government policies, as spelled out in a Basic Package of Health Services, allows them to reach a large proportion of the population relatively quickly - especially in more peripheral areas, where civil servants may be reluctant to work.

One mechanism for the delivery of essential services to post-conflict societies that is becoming increasingly popular is performance-based contracting (Waldman and Hanif, 2002; Soeters et al., 2006). Although there are many variations on the theme, the essential feature of this mechanism is that private-sector health personnel, usually non-government organizations, are reimbursed on the basis of how well they implement government policies; in some schemes they are given substantial financial bonuses for reaching pre-determined targets. Although there is little documentation attesting to the effectiveness of these schemes in improving the health status of target populations, early indications suggest that both access to health services and utilization of those services can be substantially increased in a relatively short time. In addition, although there is no evidence to suggest that this is in fact the case, the provision of health services to communities that had been deprived of them for years could have a stabilizing effect on shaky peace accords.

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