Evolution of policies on human resources for health: opportunities and constraints in four post-conflict and post-crisis settings

Our findings on the HRH challenges faced in these four setting are consistent with one another and with the wider literature [5, 40, 41]. As a result of conflict and crisis, the number of health workers diminishes because of death and migration and additionally health workers are likely to move to the more secure or economically stable areas, therefore increasing the unbalanced distribution within the country. The skills and quality of health workers worsen, because of the lack of in-service training and supportive supervision, but also because of the expansion of below-standard training institutions. Their productivity also decreases because of absenteeism, poor working conditions, unavailability of drugs and equipment, low salaries and demotivation. Often, given the weaknesses or absence of regulation and control, health workers put in place a series of financial coping strategies which further weaken their performance and the health system, including dual practice, both in the health sector (private practice or work for NGOs and aid agencies) and outside [40].

The main differences between challenges and responses in these four settings were driven by the length and nature of the conflict or crisis, whether it was resolved effectively or lingered, and how long its aftermath lasted. In Uganda, conflict was long but only affected one part of the country, and is now resolved, at least for the moment. In Sierra Leone, the conflict was total but resolved with international assistance, although the country faces on-going fragility made worse by the consequences of the Ebola outbreak. Zimbabwe remains in a state of chronic political and economic crisis. Cambodia faced total collapse and a prolonged period of partial peace, but is now stabilised and moving beyond ‘post-conflict’, at least in the eyes of most research participants.

Our findings suggest that there is no formula for whether or when a ‘window of opportunity’ will arise which allows health systems to be reset or to break free from path dependencies defined by the choices made for the previous system. In Sierra Leone, there was a moment of reform in 2009–10 with the FHCI, but this was eight years post-conflict and related more to a constellation of political will and coordinated donor support than the earlier crisis. The current post-Ebola transition appears to be another moment of opportunity for the country due to the influx of funds, development partners and NGOs. However, in the opportunity is also a risk of loss of coordination as the capacity to manage is often lowest at these crisis moments.

There is no evidence of a moment of seismic change in human resources for health policies in the other three settings, where path dependencies are more evident. In Cambodia, the early choice of contracting out service delivery has created a legacy of long-term experimentation and fragmentation of HRH management and remuneration approaches, which the government is now looking to harmonise. In Uganda, national policies and policy processes have been extended to the north, with limited concessions to its different post-conflict needs. In Zimbabwe, political and economic stasis has prevented known HRH challenges from being resolved, except by stop-gap external programmes. This pattern may in part relate to the nature of the post-conflict or crisis political settlement: in Zimbabwe and Uganda, the post-crisis governments were a direct continuation of the past, and thus presumably less inclined to undertake drastic reform. The pattern may be different in other countries, like Mozambique, where ‘post-conflict’ came with a new regime.

The important role of development partners and NGOs in post-conflict settings comes as no surprise, but it is interesting to see how their role changes across phases of the post-conflict period, with some roles growing (e.g. funding) while others (e.g. technical support) may tail off as the MoH capacity and confidence grows. The shift from donor dependence is clearly not linear and the timeframes can be longer than suggested by previous literature [42]. The role of the MoH emerges as weaker than expected, even though policy-making processes are generally centralised in all the settings considered. This fits with some earlier studies which suggest that the Ministry of Health is often a low-status ministry in fragile states. It tends to be relatively weak politically, institutionally and financially, with insufficient authority for wider state-building [43]. Moreover, health seems to be more a pre-occupation of the international community than of governments in fragile states. Others highlight unstable “mosaic” policy-making as the prevailing feature, with alliances of actors converging on specific policy issues possessing special appeal at a given point in time, to dissolve quickly as their attention is captured by other concerns [5].

We have examined policies specifically related to HRH issues, which may of course not be typical of all health or other sectoral processes. However, we believe that they are of interest in their own right for a number of reasons. Firstly, HRH is the biggest expenditure item in the health sector and so not just a key input to service delivery but also one of the most important areas for efficiency. Secondly, as HRH offers opportunities for employment and patronage, it is high profile and political. For this reason it is often more closely guarded from external intervention, though as seen in Zimbabwe, donor support as a last resort can be accepted. Third, it is a complex health system pillar because of the important role of human agency, such that HRH policies have to be sophisticated and adaptive. Finally, HRH has implications for other sectors as it influences and is influenced by public sector pay policies.

The features of HRH may explain in part why there seems to be a lot of stickiness in addressing challenges in these settings. Problems are well understood in all four cases but core issues – such as adequate pay, effective distribution and HRH management – are to a greater or lesser degree unresolved. These problems are not confined to post-conflict settings, but underlying challenges to addressing them – including fiscal space, political consensus, willingness to pursue public objectives over private, and personal and institutional capacity to manage technical solutions – are liable to be even more acute in these settings.