Providing health services in countries disrupted by civil wars
A comparative analysis of Mozambique and Angola 1975-2000
Introduction
1.1 This study has been commissioned by WHO, Department of Emergency and Humanitarian Action, under the programme Health as a Bridge for Peace, co-funded by Italy and DFID/UK. Its main aim is to analyse the health sector in Mozambique and Angola since the late seventies, in order to extract and document lessons on the possible influence of sector investment in mitigating conflict, fostering reconciliation and clearing the path for recovery, which may be useful in similar complex emergencies. Mozambique and Angola are a good case in point of two countries that, bearing many common features at independence, have evolved along strikingly divergent paths. Thus, the conflicts that have for so many years marked their politics, economies and societies have culminated in opposite outcomes. More specifically, the study attempts:
- to explore the contribution of the health sector in creating or promoting opportunities for peace;
- to compare the two countries with respect to the role of the different players, factors and context, internal and external, in shaping events in the health sector;
- to analyse the capacity of the health sector in the two countries to respond to the health needs of the population, in a context of economic crisis, war and disruption, and
- to discuss the post-conflict challenges and opportunities of the sector rehabilitation in Mozambique, which are likely to present themselves also in Angola and other countries affected by conflict, once a peace settlement will be reached.
It has been documented in several countries that Health can play a positive role in mitigating political tensions in post-conflict, as it has occurred in Mozambique. The evidence on sector’s sustained contribution to reconciliation during the crisis (or its short lulls) is, however, scantier, as the experience of Angola, and, at a lesser extent of Mozambique, show. The report, in its conclusions, attempts to analyse the conditions and circumstances under which the sector can contribute to the peace process.
1.2 Contextual, external factors exert a strong influence on the health sector, in terms of policy formulation, implementing capacity, external support, etc. A comparative analysis of the health sector in different phases of conflict and post-conflict, therefore, calls for an understanding of the histories and of the different political, economic and military contexts of the two countries over time. On the other hand, the analysis of humanitarian crises and their impact on health and on the health sector reveals a number of common features, some almost invariant from the specific context of the country or from the root causes of the emergency: “population displacement, food scarcity, malnutrition, high morbidity and mortality, including violence intentionally directed at civilians, and severe mental stress” [WHO, 1999].
1.3 The impact of conflicts on health has been documented in different countries [Zwi et al., 1999; Ugalde et al., 1999], the severity varying according to the scale and duration of violence, the possibility of fleeing to safe havens, and the degree and effectiveness of assistance provided. Attacks on health systems have become common components of military strategy in civil wars, and the consequences for sector policies, financing capacity and human resource base have been analysed in countries as diverse as Uganda and Cambodia [Macrae et al., 1993; Lanjouw et al., 1999]. In different contexts, the health sector faces similar challenges, first in meeting increasing health needs with reduced resources during the conflict, and then in defining its recovery strategy once the emergency is over. Further, publicly run health services, by belonging to states whose legitimacy is being challenged, face additional difficulties. Finally, the same dilemmas of neutrality, legitimacy and sustainability of emergency relief confront aid agencies in most conflict situations. [Macrae, 1997]. The above factors account, at least partially, for the remarkable similarities existing in international aid policy and practice [Bradbury, 1998]. However, as most current conflicts are characterised by complex political and economic dynamics, and originate from entangled historical and structural antecedents, an informed understanding of the context is crucial if neutrality and impartiality are to be preserved, and if an adequate assistance is to be provided. Duffield, in a study on Angola and Bosnia, critically argues that similar humanitarian interventions have been carried out in such dissimilar social and economic systems, concluding that “relief operations are functionally blind to the specific conditions that confront them” [Duffield, 1994a]. The implications of this peculiar insensitivity of the aid industry to context will be discussed later in relation to Mozambique and Angola.