The collapse of health and other social infrastructure is a common outcome of conflicts such as civil wars. In such settings one does not talk about â€˜health sector reformâ€™ glibly, but must consider the whole issue of health sector rebuilding. Two post-conflict countries are currently included in the US Presidentâ€™s Malaria Initiative (PMI), Angola and Liberia. Both are also recipients of GFATM malaria grants. What do lessons about malaria control can we learn from administering these two programs?
The situation in Angola is summed up succinctly by the PMI country assessment. â€œAngola recently emerged from almost three decades of civil war that severely impacted its development, particularly the health sector. It is estimated that 80% of the health facilities were looted or destroyed during the war and that the existing health system covers only about 30% of the Angolan population, with even lower utilization rates.â€ The national surveillance system â€œhas limited human and financial capacity and lacks nationwide coverage, standardized procedures for the collection and analysis of data, and an effective communication system to ensure timely reporting.â€
In addition to limited laboratory facilities, the PMI assessment found procurement problems. â€œGiven that many key agencies and systems are not yet in place or fully functional, the GFATM proposal proposes that procurement functions be carried out by WHO while providing for support not only for the program of activities under the NMCP but also for strengthening the system in general.â€ To address these challenges, PMI and GFATM recipients have been working on coordination efforts over the past two years, according to GFATM. In addition GFATM recommends moving away from an external Principal Recipient and that the â€œPR shall present a revised plan that reflects the gradual transfer of responsibilities to the NMCP staff. A plan with measurable targets for the capacity-building activities should be agreed upon.â€
Recently the US President expressed concern to the Liberian President about the continued death of Liberian children from malaria and indicated that PMI would be setting up shop soon. The GFATM Grant Performance Report of August 2007 for Liberia observed that, â€œThe internal audit section has however not been able to conduct these audits in Liberia due to staff shortage as well as the situation of insecurity prevailing in the country.â€ Human resources for health are scarce generally in much of sub-Saharan Africa, and are exacerbated in post-conflict settings. In Liberia, GFATM noted that, â€œThere is no M&E expert dedicated to this project.â€ It was further observed that, â€œThere are some tensions existent in regards to having a non-local entity (UNDP) as PR.â€
The selection of a non-indigenous Principal Recipient is not uncommon, but in post-conflict settings, lack of strong civil society organizations and weak government bureaucracies may be a factor. The Report further states, â€œThere are very few active donors in Liberia and most organizations are struggling for funds. There is as a result little organized effort for harmonization of programs and requirements.
As of the August 2007 Report, Liberia was behind target in terms of staff training and number of service points supported for malaria case management, though they appear to be on target for reaching pregnant women and distributing ITNs. ITN distribution may be done outside the formal health system, but case management requires a fairly well organized public and private sector, even when volunteer community-based workers are involved.
Some of the health systems and implementation problems mentioned above may not appear terribly different from those faced by other Sub-Saharan countries, and maybe it is a matter of scale. Key lessons appear to be a need for collaboration and coordination among the often few donors on the ground and efforts to build and re-build local capacity. Citizens of these countries have suffered enough and do not need ‘wars’ among donors and recipients and certainly must win the war against malaria.