The ultimate challenge: sustaining life in fragile states

1
The ultimate challenge sustaining life in
fragile states

• David Nabarro, WHO
• High level forum, Abuja
• December 2nd 3rd 2004

2

• What is the problem?
• Why do we face it?
• A priority for this HLF?
• Read Across
• Action Points

3

• Around 50 states are fragile (in terms of
  policies, governance, institutions)
• Fragility associated with
• un-managed, escalating conflict,
• violence and intimidation,
• breakdown in trust within and between societies
• Fragility results in reduced access to basic
  needs for hundreds of millions, distressed
  communities and increased threats to life

4

• Fragile States account for
• a third of the people who live in absolute
  poverty,
• 60 of disease epidemics
• The burden of disease and mortality borne by
  fragile states is high
• One in three of their people is malnourished,
• More than 90 of excess burden is infectious
  disease

5

• Fragile States account for a third of the
  maternal deaths, nearly half of the under-5
  deaths, a third of people living with HIV/AIDS in
  developing countries, plus much mental trauma and
  reproductive illness

6

• Health MDGs are indicators of human development
  (more than health sector performance)
• In fragile states severely affected by conflict,
  progress towards the MDGs is stagnating - or even
  reversing
• Human development is unravelling

7

• 38 of these States are far behind the goals
• HIV/AIDS control only 2 have reversed epidemic,
• Child and maternal mortality only 11 of those
  countries are on track,
• Two thirds of the countries in which child
  mortality has increased since 1990 have undergone
  a protracted crisis

8

• Conflicts, violence and political instability
• damage the local systems through which people
  access the basic needs required for life (water,
  food, sanitation, security, shelter and public
  health)
• paralyse critical institutions that safeguard the
  lives of people in need
• reduce local capacity to respond to natural
  disasters and disease outbreaks

• Why?

9

• National capacity to respond is limited
• National institutions are unable to compensate
  for local-level system breakdown
• They need extra technical and management capacity
  and additional funds
• International humanitarian response capacity is
  patchy (now being reviewed)
• The effort to sustain life in fragile states is
  way below what is needed the result is too many
  deaths.

• Why?

10
A Development Priority?

• Fragile societies show us the ultimate frailty of
  the human condition with death rates over 1 per
  10,000 per day
• This frailty provokes tension and conflict
• Violence and fear,
• Limited rule of law,
• Despair and a sense of betrayal,
• Real risks to life and increased death
• This threatens national and regional security

11
A Development Priority?

• Our collective purpose - people to stay alive
  through access to life-lines food, water (fuel,
  power), sanitation, security, disease control and
  shelter

12
Read Across

• Financing challenges
• Overall funding basket,
• Available recurrent budget,
• Fiscal management,
• Interaction of targeted interventions
  (immunisation, polio eradication, HIV),
• Assessment of health and nutiriton situation and
  needs
• Human resources

13

• Action 1 Integrate Health in Peace Process
• Priority is to make peace, reconcile differences
  and increase human security
• Overall goal rebuilding public confidence
  promoting the rule of law, leadership empowed
  State harmonising external support and basic
  needs for life
• For public services joint action, finance (user
  charges?) coping with shortages of staff
  security for users and providers

• Action

14

• Action 2 Ensure the focus is on sustaining life
• Focus on essentials for life as well as the
  control of specific diseases
• Water, sanitation and hygiene Food and
  nutrition Shelter, protection and security
  Public Health

• Action

15
Action 3 Life Saving Services

• Focus on priority needs
• Cost them right
• Harness multiple actors to work together on an
  agreed plan include civil society organisations
• The State to set standards and provide
  stewardship
• Restore the services quickly
• Reflect this progress in order to restore public
  confidence
• Communicate this progress

• Action

16
Action 4 Best Development Practice

• Planning essential basic services
• as an inclusive process by all stakeholders
• combining humanitarian, transition and
  development actions
• With clear outcomes and time-bound benchmarks
• Using short time horizons that take account of
  changing circumstances
• Including contingencies in case of breakdown in
  political processes, rule of law, governance

• Action

17
Action 5 Dependable, predictable, provision

• Provision of assistance and services from
  well-protected, accessible centres
• The centres to offer vital services, in a
  transparent and dependable way (OB-gyn, trauma,
  paeds)
• Partners work together to combine their support,
  sustain and expand dependable provision
• Public confidence grows if promises are fulfilled
• Service delivery moves into localities in a
  planned way, as capacity and security permits

• Action

18
Action 6 Repair, not reform

• Repair and build on the best parts of existing
  capacity avoid dramatic reforms unless vital
• Remember the needs of people with chronic
  conditions
• Value the health workers who stayed behind during
  difficult times

• Action

19
Action 7 State as Steward

• Lifesaving inputs provided through NGOs and other
  bodies as well as Government the national and
  local authorities and international agencies
  need to work together to offer clear and
  effective stewardship to avoid fragmentation of
  services and high transaction costs.
• Link health with other critical outcomes seek
  synergy between sectors in pursuing these outcomes

• Action

20

• Action 8 Single planning instrument
• Unitary, well-owned plan
• Results-focused implementation framework with
  overall outcomes
• Key milestones at six monthly intervals,
• Inclusive, regular, management system
• Harmonisation negotiated between actors
• National ownership ("speedy SWAPs")

• Action

21

• Action 9 Reversal are inevitable
• Anticipate political reversals and irregular
  financial flows
• Short-term planning horizons
• Remember if something can go wrong, it will
• Sustain emphasis on dependable responses

• Action

22
Darfur, Sudan
In July-August 2004 approx two million affected
persons in Darfur had a three to six fold
increase in risk of death

23

Disease surveillance verified the decline in
measles incidence, and identified and tracked
dysentery, hepatitis E and polio

• The Early Warning and Response Network (EWARN) is
  detecting and confirming disease outbreaks in
  Darfur.

24

• The principal causes of ill-health reflected
  insufficient food and clean water, poor
  sanitation and exposure to violence, and lack of
  shelter

25

Sanitation
Water Supplies
The response has focused on better access to
these basic needs
26
Dependable places for paediatric, ob-gyn and
trauma care

• As well as Primary Health Care, ensure quality
  care in 9 rural hospitals, while minimizing user
  charges, through combined effort of national
  authorities, NGOs and other partners

27

• What is the problem?
• Why do we face it?
• A priority for this HLF?
• Read Across
• Action Points
• Intersectoral