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George Bennet/
International Federation,
Somalia 2001
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Chapter 3 - summary
Somalia: programming for sustainable health
care
In the current operating environment of weak or failed states, chronic
emergencies and media-led donor support, community participation
is the key to restoring and sustaining social services. Local communities
bear a major responsibility for rebuilding their own services and
therefore should own the process of rehabilitation.
Agencies often use the excuses of 'context constraints' and 'lack
of resources' to implement quick-fix, project-driven relief programmes
which fail to adapt to the dynamics of local-level recovery. This
leads to missed opportunities for harnessing longer-term developmental
potential to promote recovery in conflict-affected communities.
The challenge for aid agencies is to provide assistance in a manner
that reinforces the dynamics of the recovery process which is already
under way at the local level.
Before support for post-conflict recovery begins, it is critical
to analyse the potential barriers to rehabilitation:
- Conceptual barriers include:
Defining post-conflict: since funding may depend on a peace
agreement.
Defining rehabilitation: it is both a process and an outcome,
based on increasing confidence, at community level, in opportunities
for long-term recovery.
Timing: rehabilitation doesn't wait for the signing of
a peace agreement or the approval of the donor community.
Legitimization: whose capacities do agencies choose to
strengthen?
- Programming barriers include:
Relief culture: top-down emergency aid undermines rehabilitation
initiatives.
Competence: community participation is widely advocated,
but not well implemented.
Knowledge: coping capacities of communities are neither
well researched nor understood, and often underestimated.
Attitude: agencies can be reluctant to transfer control
over resources to local communities.
Political will: donor procrastination will undermine sustainable
recovery.
Security: foreign nationals may be targeted to deter external
assistance.
- Structural barriers include:
Weak states: newly emerging administrations may have to
be built from scratch.
Structural vulnerability: an elite minority's control over
business and land at the expense of the majority is often at the
heart of violent conflict.
Changed post-war reality: intellectual and entrepreneurial
sections of society may have migrated.
Inequitable growth: post-war economies are often structured
in favour of powerful political actors who may undermine rehabilitation.
Informal sector: informal actors often represent the most
dynamic force in recovery, but are often unregulated and mask
unmet needs.
Unrealistic expectations: emergency response may raise
expectations which cannot be met long term.
To respond to these challenges, the International
Federation and the Somali Red Crescent Society (SRCS) have developed
a pilot methodology, currently being field tested through health-sector
rehabilitation programming in the Puntland state of Somalia. The
six-step methodology is based on the principle that community ability
and willingness to participate is the foundation of sustainable
service recovery.
Community involvement requires time, resources, in-depth analysis,
and an acceptance that the solutions international agencies have
in mind are not necessarily what the community will need or want.
Genuine community involvement in health sector rehabilitation planning
in Puntland would be impossible without the facilitation role played
by the SRCS.
For sustainable recovery, the key issue is neither cost recovery
nor cost sharing, but building sound and workable partnerships with
the community. The aim to share costs should be driven by the need
for long-term sustainability, not by a requirement to reduce budgets.
Community contributions can be in-kind, service-related or financial.
A sliding scale of donor-to-community contributions is best introduced
gradually.
Step one: inception of rehabilitation
The first stage of rehabilitation programming
is to recognize the need and opportunity for it. People often start
rehabilitating their lives and livelihoods before there is a formally
acknowledged end to conflict. By looking for signs of recovery rather
than 'post-conflict', agencies may identify opportunities to support
rehabilitation in 'pockets of peace' while other parts of the country
may be in conflict. Recognizing signs of confidence in recovery
requires systematic observation.
Step two: rehabilitation assessment
This step aims to analyse the context and
diagnose needs. Three main areas of analysis should be explored:
- Context: to establish opportunities
for and threats to rehabilitation initiatives;
- Actors: to establish the strengths
and weaknesses of the various actors in undertaking rehabilitation
work;
- Sector: to establish the potentials
and limitations of the particular sector being addressed.
Step three: baseline data
The extent to which community participation
and resource mobilization may be successful will depend on the capacities
and resources available at household level within the community. Baseline
data on socio-economic conditions is needed to provide a benchmark
against which all subsequent capacity and vulnerability data can be
measured. This data is best gathered through household surveys.
Step four: in-depth case-studies
Data generated through household surveys will
identify trends and opportunities that are then tested in a detailed
study of a selected sample community. In-depth studies attempt to
pilot new rehabilitation ideas, which should come from the community
itself. The most effective way of ensuring this is to employ a community-based
action planning technique, with the full-involvement of beneficiaries.
This gives them the chance to create a shared long-term vision for
the community's future and to articulate their willingness and ability
to contribute to the management and sustainability of facilities.
Step five: piloting strategy
The findings of the action planning event
are turned into specific project objectives with clear outcomes and
inputs. When considering inputs it is important to specify: what the
community is able to provide for itself and who within the community
can do so (e.g., land, structures, finance); what is needed from the
outside in order to kick-start the process (e.g., one-off payment,
technical assistance); and what is required to maintain and sustain
the service in the future.
Step six: design policy guidelines
For rehabilitation intervention to be effective, findings from the
pilot study should be fed into both policy and programme simultaneously.
To conclude, investing in rehabilitation can be a means of investing
in peace, no matter how far away peace may seem. The long-term recovery
of war-torn societies is dependent on increasing people's confidence
in their future both at household and community levels. This is best
achieved through initiating community-based rehabilitation programmes.
Timing is crucial. Rehabilitation efforts should start as soon as
possible in order to minimize relief. Programmes will only be as good
as the analysis of context, actors, sectors and communities. Good
analysis should prepare agencies to gear up relief operations into
rehabilitation; look for rehabilitation and development partners;
or hand over the programme to local partners.
Sustainable recovery is dependent on the development of local institutions.
Fostering participation and a sense of ownership by the local community
are vital for the sustainability of rehabilitation. This in turn depends
on the community's willingness to engage and their ability to contribute
in cash or kind. In the absence of a strategy to harness local capacities,
externally funded service programming will be short-lived or remain
chronically dependent on outside resources.
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Box 3.2 Analysing
Puntland's context, actors and health sector
A full context analysis will
examine the opportunities and threats which the conflict,
the socio-economic situation, and government institutions
present. In Puntland, while security has been good for the
past seven years, the conflict could spill over from southern
Somalia. The informal sector of the economy is growing swiftly
and providing increasing income, but remains unregulated.
The Puntland government's charter looks impressive, but the
ability of ministries to deliver will depend on raising enough
resources to operate effectively.
Potential actors include government, communities, and
international and national organizations. Who has the authority
to facilitate service provision? How closely will agencies
need to work with government and what kind of relationship
will it be? The role played by local authorities must be acknowledged
to acquire legitimacy and lay the foundation for sustainable
health infrastructure. Taking into account communities' capacities
and needs is crucial to avert dependency. National organizations
include the Somali Red Crescent Society (SRCS) which operates
32 integrated health clinics and 12 health posts.
The health situation across Somalia continues to deteriorate.
Maternal mortality is 1,600 per 100,000 births, while under-five
mortality is 224 per 1,000 live births – among the worst
statistics in the world. To serve such a disease-burdened
and highly mobile population would require a far greater capacity
than exists at present. The main emphasis of existing health
infrastructure is on curative care. Any effort to improve
health indicators in Puntland will require investment in preventive
health.
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Chapter 3 was written by Sultan Barakat,
director of the Post-war Reconstruction and Development Unit, University
of York, UK, and Sean Deely, the International Federation's senior
officer in post-disaster recovery.
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