FCV Health Knowledge Notes Health Service Delivery in Fragile, Conflict, and Violence (FCV) Situations Five key questions to be answered SUMMARY In FCV situations, successful service delivery depends on extensive situational analysis (for example, political economy, forms of violence, rent- seeking behavior/motivations), close monitoring and flexibility and rapid response mechanism against shocks/threats. Credit: Aakanksha Pande. Q1 WHY does service delivery matter in FCV situations? • Service delivery responds to meeting basic needs of populations, which is the priority in FCV contexts. It is strongly linked with political and social favors and can be a powerful tool to legitimize groups (for example, governments) in power. • In FCV situations, providing basic health services can be challenging for the following reasons: o Limited/no service delivery functions in place o Impaired service delivery incentives Financing  Lack of govt capacity / willingness  Broken social order Manage Policy ment  Security risk of service providers o Unsustainable service delivery system Service  Deteriorating infrastructure Delivery  Poor technical & managerial capacity Technical Production Know- Capacity How • Half of the world’s poor will be in FCV situations by 2030 and Delivery in risk of being excluded from basic services. System 1 Q2 WHAT are the characteristics of FCV situations for service delivery? • Situational context, where health service delivery takes place, can positively/negatively affect its delivery. Political settlement and service providers distribution are key characteristics used for different typologies, as suggested by international agencies, such as WHO, the World Bank and USAID. Political Settlement Service providers distribution Examples • Central African Republic • Guinea Centralized, with few non-state service (1) • Sierra Leone providers on the ground • South Sudan Fragile, but legitimate political • Myanmar establishment (i.e. central govt) • Afghanistan Decentralized, with competing non- (2) • Democratic Republic of Congo state providers on the ground • Lebanon • Yemen Conflicts with competing power (3) Few providers with scarce resources • Libya holders • Parts of Afghanistan, Nigeria Q3 WHAT should be considered for distinct types of situations? • Four key questions should be asked to determine how to structure a health service delivery system, whether it is for the short-term goal of responding to humanitarian needs or the long-term objective of developing a comprehensive health system. 1. What services should be provided? (Allocation) 3. Who receives services? (Distribution) 2. Who provides services? (Production) 4. Who pays for services? (Financing) Allocation Production Distribution Financing • State (e.g. subsidy) (1) Fragile, with • User fees (e.g. copay) • Primary care services As wide a population few non-state • State providers • Donors • Hospital services as possible providers • Trust funds • Global partnership • State (e.g. subsidy) (2) Fragile, with • State providers • User fees (e.g. copay) • Primary care services As wide a population competing non- • NGOs • Donors • Hospital services as possible state providers • Private providers • Trust funds • Global partnership • Emergency response (3) Conflict, with • Epidemic control • Int'l agencies Most vulnerable (e.g. • Int’l community few providers • Essential health • NGOs mothers and children) (e.g. donors) services (e.g. MCH) 2 HOW should services be delivered in different FCV Q4 contexts? Service Delivery Possible Assistance by Type Desirable Conditions Examples Model Development Partners - Capacity building (infrastructure & human (1) Fragile, with few non-state resources) State Provision • Myanmar providers - Policies, strategies and costed action plans formulation - Policies, strategies and • Appropriate, costed action plans accountable non- formulation state providers exist - Capacity building for • (if contracted to for- purchaser (e.g. state) in profit providers) procurement, financial • Afghanistan Mature market with management, project • Liberia quality services Contracting management • Lebanon available • South Sudan • (if contracted to for- - Strengthening state • Columbia profit providers) oversight/regulations Safety net provision - Mapping out of non-state (2) Fragile, with to the poor and the providers competing vulnerable non-state - Private sector development providers (laws, policies, regulations) - Independent (third-party) monitoring for performance • Burundi verification • Central African • Accountability & - Capacity building for Republic transparency in purchaser (e.g. state) in • Democratic Republic procurement/manage Performance- of Congo ment based Contracting procurement, financial • Mali • Results monitoring management, project • Rwanda available management • Haiti - Strengthening state • Guatemala oversight/regulations - Capacity building State/Ruling • Nepal (infrastructure & human Group Provision • Pakistan resource) (3) Conflict, with few providers - Basic service provision Int'l Community • Libya assistance, while Provision • Yemen strengthening local system 3 Q5 WHAT are the key lessons from the World Bank? General lessons  Every FCV situation is different (even within the situation (sub-national difference)). Thus, No “one- solution” fits all.  Clear distinctions between “Fragility” and “Conflict, Violence” for health service delivery as political settlement and service delivery readiness differ in each context.  “Know your situation” through formal/informal assessment and intensive dialogues with inter-/intra- sectoral experts from the World Bank, development partners and NGOs (citizens engagement). Some assessment instruments include; o Situational analysis surveys: health facility, patient utilization, satisfaction o Technology: satellite imagery, geospatial information system  “Close monitoring” aims to obtain information on service utilization by beneficiaries, quality of service, effective use of resources and poor governance (i.e. corruption) and to alert any possible shocks to mitigate. Methods include, but are not limited to: o Citizens engagement (local NGOs) monitoring/evaluation o Client government monitoring/evaluation o Third-party, independent verifier (for example, international firms, UN agencies) o Technology (for example, geospatial monitoring)  “Flexibility and rapid response mechanism” in operations to adjust/adapt potential shocks. Examples include; o Reverse supervisory/monitoring mission in a safe third place o Close monitoring (for example, monthly coordination with key stakeholders) o Contingency Emergency Response Component  “Sustainability” should be always questioned when designing/implementing operations, such as; o Mid-, long-term health system development for appropriate service delivery model o Capacity building to service providers Fragile situations  Development of a basic, but high impact package of health services (including medical equipment/supplies) and investment in implementation monitoring in fragile situations can ensure continuation of health service provision against insecurity. Conflict/Violence situations  Softer service delivery methods (for example, outreach services to areas with high insurgent activities) could be safer as fixed facilities tend to be targeted by attacks. The FCV Health Knowledge Notes Series highlight operational tips to resolve health issues in FCV situations. These Notes are supported by the Middle East and North Africa Multi Donor Trust Fund and The State and Peacebuilding Fund (SPF). The SPF is a global fund to finance critical development operations and analysis in situations of fragility, conflict, and violence. The SPF is kindly supported by: Australia, Denmark, Germany, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom, as well as IBRD. Author: Takahiro Hasumi, Health Specialist, Health, Nutrition and Population Global Practice, World Bank Group For more information on other HNP topics, go to www.worldbank.org/health 4 Health, Nutrition and Population Global Practice Health Service Delivery-related Operations in FCV Contexts Project Year of Closing Country Project size Task Team Leader Project Development Objective Approval Year (million $) To increase the use of quality Reproductive, Maternal, Alain-Desire Karibwami Neonatal, Child and Adolescent Health Services, and in Health System Support Burundi 50 2017 2021 Laurence Elisabeth the event of an Eligible Crisis or Emergency, to provide Project KIRA Marie-Paul Lannes immediate and effective response to said Eligible Crisis or Emergency Guinea- Strengthening Maternal and To improve coverage of essential maternal and child 25 2018 2023 Edson Araujo Bissau Child Health Service Delivery health services in the Recipient’s territory To increase access to quality healthcare services to Lebanon Health Resilience Project 95.8 2017 2023 Nadwa Rafeh poor Lebanese and displaced Syrians in Lebanon To contribute to the provision of basic health, essential Emergency Health and Yemen 483 2017 2020 Moustafa Abdalla nutrition, water and sanitation services for the benefit of Nutrition Project the population of the Republic of Yemen Ghulam Sayed Mickey Chopra To increase the utilization and quality of health, nutrition Afghanistan Sehatmandi Project 140 2018 2021 Mohammad Tawab and family planning services Hashemi