Fragile States and Countries in Crisis

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Fragile Statesand Countries in Crisis

• Peter Morris (USAID/OFDA)
• Clydette Powell (USAID/HIDN)

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Objectives

• Introduce the concepts of fragile, failing, and
  failed states
• Describe health challenges in those settings
• Provide examples of countries in crisis where
  those concepts and principles apply - Ethiopia
  Case study
• Analyze how the treatment plan could be
  improved

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Did you know?

• There have been almost 400 disaster declarations
  around the world in the last 5 years.
• Africa 40
• Asia (Pacific) 23
• LAC 18
• Eu, ME, CA 18

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Did you know?

• In the last OFDA report, 75 of the complex
  emergencies were in Africa.
• USAID has responded in some way to all of these
  disaster declarations.
• Almost 264 million was provided in assistance
  by OFDA.

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Descriptive diagnosis

• Failing lessening ability to provide basic
  services and security losing legitimacy
  vulnerable to econ downturns, disasters
• Failed loss of control over territory, loss of
  legitimacy, erosion of social cohesion,
  politically motivated violence
• Recovering weak but upward trajectory, some
  restored capacity to provide services

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Symptoms of failed states

• ruling regime overturned and replaced actions
  outside constitution
• loss of control of gt 20 land or population to
  armed opposition
• civil or guerilla war with fatalities gt 1 of
  population or , war refugees gt 5 of pop

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Early Warning Signs
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Risk factors for the state ?
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Risk factors in the health sector

• weak and poor quality public health services
• constraints in the health workforce
• endemicity for malaria, HIV/AIDS, TB
• poor water and sanitation
• low immunization coverage
• population pyramid widening base
• destitution leading to commercial sex

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Early warning signs for health problems?
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Diagnostic tools

• Health
• Systems
• Non health

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Ethiopia 2003-2004 Case Study for Country in
Crisis
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Humanitarian Profile for Ethiopia 2003

• Characterized as a Hidden Famine with mosaic of
  hotspots of excess mortality and malnutrition
• Displacement prevented
• Recurrent Drought
• Food insecurity affected 13.2 million
• Coping Mechanisms entitlements and assets
  exhausted

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Food First Bias

• Prior famine thinking is that food shortages lead
  to starvation (food availability decline FAD)
• Famines are not always triggered by decline in
  food availability
• Death during famine related more to disease than
  starvation.

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Approximately 75 percent of Ethiopians have no
access to clean drinking water, like this young
man in Lelu Village, Boke Woreda
Photo by S. Green
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Response Challenges

• Weak PH structures
• Emergency programs in development culture
• Malnutrition and information gap
• Donor coordination

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Failed Structures

• Ministry of Health was recently decentralized
• Majority of budget is with regional health bureau
• Normative function still at Federal level and
  leaves little autonomy with regional level.

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• Skilled staff at regional level is thin
• Staffing obtained through required residencies
• Pay considered inadequate
• Little or no community outreach
• MOH unable to scale up to meet emergency needs.
• Lack of health information system

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Response Challenges

• Design and implementation of emergency public
  health strategies
• Adequate EPI
• Adequate water
• Adequate and balanced food rations
• Well conceptualized and managed nutrition
  interventions.

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Response Challenges

• Primary cause of morbidity malaria
• No tradition of ITNs
• Measles vaccinations inadequate

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Malnutrition

• Acute malnutrition levels over emergency levels
  many hotspots at 25 GAM
• Therapeutic feeding programs driven by supply and
  not demand
• Not enough capacity to address therapeutic
  feeding needs
• Many areas in SNNPR had access problems
• NGO TFCs varied in practice and protocols
• Fear of concentrating under-vaccinated population
  in TFCs

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Donor Issues

• Donors saw crisis as sub-clinical and to be
  treated with stronger development response rather
  than emergency assistance.
• Non-Food Assistance was inadequate
• ECHO saw crisis as GOE governance inadequacy
• UNICEF and WHO were slow to react in to hotspots

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What goes awry in any treatment plan?

• unwillingness/inability of state to partner to
  address the crisis
• tardy registration of implementing partners
• turf battles among implementing partners
• inability to develop trust within the community
• media forces that shape misperception and
  response

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What goes awry in any treatment plan? (contd)

• lack of consensus on standardization
• fatigue by implementing partners
• lack of flexibility between relief and
  development strategies and funds
• lack of experience in dealing with the interplay
  between HIV/AIDS, nutritional needs, and food
  assistance

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Elements of good treatment plans

• transparency
• accountability
• targeting
• community engagement and participation
• impartiality
• advocacy

• diplomatic deterrence that allows international
  intervention
• human resource management
• financial management

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Elements of good treatment plans

• solid leadership - quick, decisive, wise
• consensus building
• surge capacity and rapid response teams
• timely and reliable needs assessments
• external awareness and fundraising

• timely provision of food and non-food items
• ability to prioritize needs
• assignment of tasks
• ability to transition from relief to development

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What is needed for Ethiopia?

• Stronger commitment by GOE to addressing PH
  crisis
• Enhance general care capacities as a means of
  improving disaster response

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What is needed ?

• Health and nutrition early warning system
• Develop PH outreach and prevention at the pop
  level
• Expand clinical capacity in rural areas
• Enhance managerial authority and competence of
  regional health officials

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Delayed implementation of priority health
measures, including surveillance, results in
excess morbidity and mortality
UNHCR photo
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Health and nutrition early warning system

• Linkage of attention to actual indices of health
  and nutrition
• Deployment of a cadre of professional PH
  epidemiologists
• Linkage to regional hospitals with a mandate for
  training
• Linkage of information from health facilities to
  survey information

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Lack of consultation with the refugee
populationand women in particularresults in
health services not reaching those in need and
corresponding negative health consequences
UNHCR photo A. Diamond - Afghan refugees in
Pakistan - 1982
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PH outreach and prevention

• Commit to higher level of EPI coverage
• Accelerate recruitment, training, and deployment
  of health extension workers
• Establish fast track for a School of PH

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Other key sectors are not adequately addressed,
resulting in serious public health threats,
ultimately requiring curative health response
UNHCR photo/R. Darolle Kao I Dang refugee camp,
1983
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Expand clinical capacity

• For serious malnutrition and associated medical
  conditions, expand TFCs
• Training and resource strategy to phase-out
  reliance on international NGOs
• Enhance prestige, pay, recognition for health
  professionals
• CME for management of CHEs

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Managers and health specialists do not adequately
understand the overall health situation of large,
moving or displaced populations.
Curative, clinical care is believed by many to be
the first and dominant priority in all
45 emergencies. Its not. Rarely is it even a
high priority.
UNHCR photo
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Competence of Health Authorities

• Enhance commitment, managerial authority, and
  competence
• Select for proven capacity for leadership and
  organizational competence
• Insist on accountability for multi-sectoral
  response
• Upgrade pharmacy supply chain
• Refine protocols on TFCs, SF, community-based
  feeding

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Conclusion