WORLD HEALTH ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

CONSULTATION

ON

PLANNING AHEAD

FOR THE HEALTH IMPACT

OF COMPLEX EMERGENCIES

WHO, Geneva

13-14 December 1999

Department of Emergency and Humanitarian Action

Table of contents Introduction 3 Proceedings 3 Conclusions 8 Planning Ahead: points identified for further action: 9 LIST OF ANNEXES 11 General Objective: 12 Draft Discussion Paper 13 Expected outputs of consultation 23 List of participants 24 Provisional Programme 37 Hints for Groupwork 39 Statement of Dr Gro Harlem Brundtland 49 The Evolution of Complex Emergencies and The Future Role of WHO Dr Ronald Waldman 52 Lessons from Algeria By Dr D. Deboutte 59 The Impact of the Financial Crisis and Recent Political Changes on the Health Sector in Indonesia Presentation of Dr M. Toole 63 Community and Institutional Preparedness Presentation of Dr A. Zwi 108 Health Services Presentation of Dr A. Paganini 109 Health, Governance and Conflict Presentation of Dr C.G. De Macedo 111 United Nations Framework for Coordination Early Warning Mechanism Presentation of Dr P. Calvi Parisetti 112 Concluding Comments Dr X. Leus, Director EHA 113 Taxonomy of countries suggested for further studies 115 Formats for country studies and national partners 116 Afterthoughts from the rapporteur of the Consultation, Dr Rodrigo 117

Consultation on Planning Ahead for the Health Impact of Complex Emergencies

WHO Geneva, 13-14 December 1999

Introduction The Consultation was organized by WHO’s Department of Emergency and Humanitarian Action to look at courses of action to better equip countries to cope with complex emergencies. More specifically, the Consultation aimed at stimulating debate on the public health aspects of mitigation, preparedness, response and recovery from complex emergencies and at identifying avenues for WHO corporate approaches in this context (objectives and expected outputs are in Annexes 1 and 3). The Consultation brought together about 100 participants from UN agencies, governmental, intergovernmental and non-governmental organizations, academic institutions, WHO HQ, country and regional offices (list of participants and program of event come in Annexes 4 and 5). The first day of the two-day meeting began with a series of presentations of case studies, then a number of working groups were formed to debate the methodologies and future prospects of case studies. The second day began with presentations related to an essential health care package, then working groups discussed use and delivery of these packages.

Proceedings 1. In her welcome address, The Director General of WHO, Dr. Gro Harlem Brundtland stated that health is the cornerstone of humanitarian assistance, its ultimate objective and the true yardstick of its overall performance. She explained that the Consultation was the next logical step in a process that WHO started in 1997 in order to more clearly define its role in emergencies. She invited the participants to look at ways health could contribute to prevention of and preparedness for humanitarian emergencies. She reiterated WHO's view that humanitarian aid must be accompanied by investment in civil society. She emphasized the need for local/national health systems to be more resilient during a crisis, more prepared to absorb humanitarian assis tance and more capable of moving towards recovery once the crisis is over. Finally, Dr. Brundtland spoke of the need to consider how this will effect WHO's current modus operandi (see Annex 7). 2. The initial presentation on the evolving nature of complex emergencies highlighted the interactions between health, risk and vulnerability. Any discussion on complex emergencies brings into focus the failure of many governments, society’s inability to cope with violent conflict and the difficulty in developing uniform courses of action for mitigation. A complex emergency can be seen as a situation in which public health systems have broken down; formulating a cohesive response requires a thorough understanding of the constraints. Further investigation is needed to fully understand the underlying determinants of complex emergencies - scarcity, crime, overpopulation, ethnic exclusion and intolerance, disease and poor governance. In the meantime, a number of steps can be taken by WHO in order to better prepare for and manage these emergencies. WHO should first support the development of appropriate

surveillance tools and systems. Next, the Organization must provide technical guidance to humanitarian workers. Thirdly, WHO should adopt appropriate policies and programs for health development, to cover all areas and population groups in emergency-prone countries. Finally, it should promote research in emergency preparedness and disaster mitigation. WHO needs to be a proactive and forceful advocate for those whose lives it seeks to improve. The Organization should not embark on this alone; it must forge partnerships with non-governmental agencies, the private sector and the affected communities themselves. On the other hand, it must take a stand on the basis of public health evidence and respond effectively to the issues which confront us in complex emergencies (see Annex 8). 3. The following presentation was a case study on Algeria . The study described how the country's Ministry of Health succeeded in mitigating the health consequence of the political crisis by reviewing priorities and reallocating resources. Much of the presentation dealt with the methodology of the case study, showing how all the data needed had, in fact, come from various national institutions (see Annex 9). 4. The next case study on Indonesia described the response of the Ministry of Health to the economic crisis of 1997-98. The Government expanded and restructured the Social Safety Net with the support of external donors, particularly the World Bank and the Asian Development Bank. Reportedly, this safety net would have been more effective if health care delivery had been more decentralised. Evidence suggests that the impact of economic crises is worse on the urban poor. Thus, information systems and basic health care services should be strengthened in urban areas in order to protect the most vulnerable through primary health care, mainly by ensuring availability and rational use of drugs. A special mention was made of the need to strengthen and expand HIV/AIDS surveillance. The study concluded that emergency interventions should build on existing systems without or replacing them, or -worse- weakening them (see Annex 10). 5. A fourth presentation dealt with community and institutional preparedness as pre-conditions for the resilience of health systems during armed conflict. Resilience was defined as the capacity of rising again, after being depressed. Vulnerability was defined as susceptibility to injury. Mitigation was defined as the set of measures taken to reduce the severity of an injury. Looking at the evolution of armed conflicts and at the links between globalization and collective violence, Kaldor (1999) was quoted in describing the features of current wars: marginal communities developing particular identities, warfare by destabilization and terror, links between warlords, criminality and a global war economy. Various factors of protection and risk were described. Also in complex emergencies, vulnerability and suffering can be reduced by preparedness measures: early warning systems, mechanisms that bolster resilience. In a continuum of instability, preparedness must somehow integrate rehabilitation and reform. The health sector needs to adopt transparent, evidence-based policies and strategies and optimize international inputs. The potential and limitations of all stakeholders must be fully recognised. Conflict-analysis, documentation, scenario-planning and constant monitoring become essential mitigation measures (see Annex 11). 6. Four working groups i ) reviewed the methodology used for the two case studies and discussed ii) how to identify vulnerable countries for further case studies, iii) the criteria for identifying partners to conduct them and iv) the prospects for a medium-term process of study and applied research in this field.

6.1 The groups concluded that the criteria used in the Algeria and Indonesia studies need to be further developed to cover all the political, socio-economical and environmental factors needed to identify countries at risk. There is a need to develop innovative methods of data collection, analysis and presentation. Interventions in situations of instability can either aim to support coping strategies or to meet vital needs; the selection of indicators and approaches would differ accordingly. The use of both soft and hard indicators was advocated. Indicators should be disagregated in order to better reflect the reality at the local level, and sensitive enough to capture the situation of the more silent groups. 6.2 Case studies should be conducted in a number of countries in order to ensure good geographical coverage. The studies should include conflict areas in nation states, while border and cross-border studies should be included in regional assessments; a taxonomy was suggested for a provisional list of countries (see Annex 16). There was strong agreement on the need to focus on operational research in all the country studies. A clear formulation of the objectives of the studies would be essential to identify which countries to investigate and the quality of information, i.e. level of detail required. 6.3 Very general comments were made on how to identify partners at country level to conduct the case studies. Both the process and the content of the studies would be important considerations. The process should foster trust, transparency, knowledge and institutional growth. Studies should consider issues of sustainability, fairness and harmony, together with readiness and preparedness. Data should be more than health indices; they should pinpoint when and where to act, what to do and how to do it. The core partners should represent local groups and institutions, with external organizations co-opted into the partnership. The lead agency could be selected by mutual agreement. 6.4 Developing a plan of action for preparedness vis-à-vis complex emergencies at country level was described as very difficult. Ideally, a broad national consultation process could start by identifying focal points for situation analysis and vulnerability assessment. Information should be freely shared with all concerned. The exercise would be more effective and sustainable if mainstreamed in the country's preparedness planning process, and supported by dedicated program officers, advocacy and resource mobilization. 7. Day 2 opened with a presentation reviewing the value of essential health services packages as tools for mitigation. There was general consensus on the composition of such packages. However, the mode of delivery is as important as the content, not only in reducing death and suffering, but also in fostering reconciliation. The physician's principle of doing no harm is all the more important (and difficult to observe) in prolonged complex emergencies. Making local health systems more democratic makes them more robust, too, and better equipped to withstand a crisis. Nonetheless, external operators should be aware that the capacity of communities to participate can vary greatly. Some choices made in complex emergencies may jeopardize the empowerment of local bodies and undermine reconciliation; caution is needed. Rehabilitation and reconstruction offer opportunities for reform of health care systems; they should be rebuilt so as to be more equitable and effective than before the crisis. Complex emergencies need more than dedication; professionalism is the key to fostering peace and avoiding exacerbation of the conflict (see Annex 12).

8. One presentation on the relationships between health, governance and conflict reviewed the general features of organised violence and the pre-conditions for its management from a public health point of view. The relationship between health, health needs and social values were analyzed together with relevant political and cultural issues. The pre-conditions for conflict management were itemized and described: a culture which promotes peace and cooperation, adequate governance, proper institutional infrastructures and civil society or social capital. This, in turn was defined as the ability to interact, independence and the perceptions and actual patterns of freedom and solidarity within the civil society, its organization, attention and respect for the needs and values of social justice, democracy, citizenship and law and order (see Annex 13). 9. The final plenary presentation gave an overview of the early warning mechanisms and frameworks for coordination of the United Nations System. These mechanisms and frameworks are continuously evolving in the context of UN reform and with the aim of making prevention and preparedness measures more effective. The UN is actively monitoring complex emergencies and has mechanisms in place to identify those countries at higher risk that require intensified attention; a worldwide inter-agency review is done monthly. Preventive action includes a range of initiatives by both the UN and other bodies. Preparedness is based on the UN agencies institutional capacities coordinated by an Inter-Agency Standing Committee (IASC) which involves the senior management of all agencies in decision making and reaches the field level through the system of Humanitarian Coordinators. 1999 activities were reviewed and plans for the year 2000 was presented (see Annex 14). 10. The four working groups discussed i) essential packages of health services, ii) how to strengthen institutions, iii) health sector reform and provision of essential services and iv) coordinating mechanisms for preparedness planning and mitigation. 10.1 Essential health packages were seen as important, but not more so than the institutional arrangements needed to define and deliver them. Their content should be tailored to the situation at hand, with the explicit objective of mitigating and containing the health impact of the crisis, particularly in its early stages; the products should "slow down the slide". Delivery mechanisms should support existing community coping strategies. Multi-disciplinary teams to identify vulnerable groups and informed sources, assess the capabilities and weaknesses of the local health structures and systems should be established early in the crisis. Besides health care, their tasks should include the direct provision of basics such as water, sanitation, shelter and food. Provisions should also be made to deal with psychosocial stress management. 10.2 Institutional presence was perceived to be as important as the delivery of services. An institutional framework is essential to monitor the situation (assessment, surveillance, etc), to maintain life-saving services and to bolster coping strategies. Motivated local health workers, i.e. those who would offer guarantees of remaining on post, should be identified and put in charge. They should be explicitly committed to work with other partners. They should be assisted in setting up structures for health coordination, training and public education. They should be empowered to provide services locally and should be accountable to their operational partners as well as the local civil society. 10.3 Traditionally, health sector reform has had a financial focus. It was felt that a wider perspective is needed and that ethical and technical issues should be better

integrated in the macro-political frame. If equity is a consideration, then the impact of crises on the health system and the suffering of the most vulnerable should be considered and resources allocated accordingly. Disaster reduction must be introduced in the agenda of health reform at an early stage, and preparedness should be integral part of the process. Emergency preparedness is part of development; economic planning should take into account the potential costs of not preparing. Another important consideration was that the health reform process should not be brusquely interrupted during an emergency and that assistance for capacity building should not be withdrawn. 10.4 Coordination is about strengthening systems and partnerships. In vulnerable countries, it should be proactive and give priority to mitigation. This includes preparing to work in the transition from one phase of a crisis to another and should be done on the basis of best public health practices, rather than just contingency planning. It is also important to assess the capacities of local systems when decentralizing activities and resources. Tools such as those introduced by the UN Country Framework Team need further development. Anticipating the needs of displaced populations, for instance, may require adapting the methodology of rapid need assessment, possibly drawing from handbooks of other organizations such as military, who are more versed in scenario setting. There was consensus that health information and health practitioners are essential support of coordinating mechanisms. Ideally, country-level coordination should include the Ministry of Health and other relevant ministries (e.g. defense, lifelines and other social services), national medical associations, the private sectors NGOs and community organizations: human rights, religious, traditional groups. Of course this list should be vetted case by case for legitimacy, willingness to coordinate, delivery capacity, acceptability, accountability and sustainability. 11. A structure for possible medium/long-term plan of work at global level would be useful. WHO, for instance, could facilitate the process, although it should not be perceived as running it. An ad-hoc group should be established, representing government, civil society, national NGOs, the media, minorities and academics, in order to ensure continuity and consistency. Experience, legitimacy, mandate, independence, commitment and willingness to share information and coordinate would be important criteria when selecting the members of this group. WHO, other UN agencies and international NGOs should be external members. Given the self-evident political implications of any attempt to plan for complex emergencies, it was felt that realism was needed in assessing the potential and the limitations of inter-governmental organizations (Annex 13). 12. In his concluding comments, Dr Xavier Leus, Director EHA, drew attention to the fact that WHO has the most difficult job in the world and it is perhaps the most under-funded organization. He underlined Dr. Brundtland’s vision of a world where communities can understand their vulnerability and prepare so that when the unexpected happens the impact on health is minimal. He reiterated WHO’s will to further define its role and improve its performance in emergencies and its wish to examine strategies and program options for strengthening the national and international capacity to cope with complex emergencies. The Consultation had yielded useful discussions and raised a list of issues for further debate and action. There is and always will be a strong tension between action and research, but information, analysis and documentation have an essential role to play for action and advocacy. Dr. Leus observed a need to mainstream action in technical cooperation. He stated that WHO is a mechanism to bring the international community together in

its effort to prepare better to cope with complex emergencies and the EHA’s role is that of a conscience leader. Thanking the participants and organizers of the Conference, Dr. Leus underlined the character of ‘work in progress’ opened by this Consultation. He stated his hope that the participants had learnt as much from each other as WHO/EHA had learnt from them (Annex 15).

Conclusions

Reducing vulnerability - to economic shocks, natural disasters, ill health, disability, and personal violence - is an intrinsic part of enhancing well-being and encourages

investment in human capital and in higher-risk, higher return activities1 The Consultation succeeded in contributing to the debate on a public health perspective on mitigation, preparedness, response and recovery from complex emergencies. The Consultation was well attended by international and inter-governmental agencies, donors, NGOs and the academic community. The number and the level of the participants demonstrated the interest of the topic. Unfortunately, representation was limited to countries and institutions from Western Europe and North America. As complex emergencies and crises occur mostly in developing countries, for the process to be relevant it is essential that these are more adequately represented in future consultations. Dr. Brundtland confirmed the central role public health has in humanitarian assistance as the objective and true yardstick of its overall performance. She spoke of the need for WHO to reconsider its modus operandi in all of the phases related to emergencies. From the presentations and the working groups a rich variety of issues came up. Not all of the issues were new, but they are now gathered together in a coherent whole. At this stage of the process, ideas on the general features, evolution and impact of complex emergencies need to be compared in order to contextualise public health in the prevailing circumstances, before it is possible to define blueprints for interventions. 1. Risk assessment and analysis: designing a model for determinants of health related to emergencies The meeting confirmed the need for a conceptual model addressing the relations between risks and determinants of public health in the pre-emergency phase. The various factors in the model should be measurable through indicators for potential predictive (identification of vulnerable country), analytical or monitoring purposes. The model should include elements of vulnerability and community coping capacity, as well as political, economical and environmental factors. This model could then serve as the conceptual basis for all relevant plans. 2. Health policy development for contingency and preparedness planning

1 World Development Report 2000/2001-Attacking Poverty: Opportunity, Empowerment and Security. The World Bank, September 2000

The Consultation recognized that little is known about how to prepare for complex emergencies at country level. Health concerns could be used to initiate a collaborative, multi-sectoral process, and analyse the situation, for example according to the model described above. The products could then be used to develop a policy for preparedness. This process itself would have the potential not only to mitigate consequences of emergencies but to contribute to prevention as well. A key element in this health policy would be the definition of a package of basic health services and public health interventions that would be implemented as a matter of course, which would be resilient to a potential emergency. The importance of the mode of delivery was emphasized; this should foster reconciliation by taking into account principles of good governance and ‘do no harm’. The various constraints of such process were acknowledged. 3. Response: A health package that complements coping mechanisms and enhances resilience Bridging between preparedness and response, the ‘minimal health care package’ would be reinforced during an emergency to invest in civil society, support existing community coping strategies, build on existing systems without replacing or weakening them. Evidence-based strategies should be used to optimize international inputs, including economic planning. The need for coordination was acknowledged as well as the fact that effective coordination is dependent on sound health information. 4. Transition to post-emergency: the need for policy development and ‘health sector reform’ Most of the issues discussed above are necessary elements for a country to move towards sustained recovery. Health reform should not be brusquely interrupted during a crisis and assistance to capacity building should continue throughout the emergency. This process would require leadership and policy development that would guide the country to sustained equitable health. 5. Operational research/case studies The meeting concluded that research was required to develop strategies as mentioned above. A number of case and/or country studies were suggested, as were formats for background information and impact on health. These, and a suggested list of collaborative partners within a country, can be found in the Annex 17. In order to be effective in today’s world, WHO will have to become more proactive in its pursuit of equity in the health sector as a mean of preventing disaster.

Planning Ahead: points identified for further action:

6.1. In emergencies, WHO should do what it traditionally does in other areas – serve as a technical guide to those working in humanitarian response. Technical assistance should include health policy development for preparedness planning, developing a basic package of health services and public health programs and policy for health sector reform toward post conflict sustained health.

6.2. WHO should play a leading role in conceptualizing the ’pre -emergency’ health model and the indicators that could best predict poor health outcomes in emergencies. This model and indicators should be field -tested and followed in a number of selected countries to validate their usefulness. 6.3. WHO must make a concerted effort to have its developmental policies and programs strengthened in ALL areas and in ALL population groups of emergency-prone countries. 6.4. WHO needs to promote research in the area of preparedness, mitigation, response and health reform in emergencies.

LIST OF ANNEXES

World Health Organization Department of Emergency and Humanitarian Action _____________________________________________________________________

Consultation

PLANNING AHEAD FOR THE HEALTH IMPACT OF COMPLEX EMERGENCIES Geneva, 13-14 December 1999

General Objective: To identify key elements of preparedness planning for, and mitigation of, the health effects of complex emergencies in vulnerable countries. Specific Objectives

1. To review the methods and findings of preliminary studies on the health effects of economic and political crises in two countries.

2. To refine the country study methods, agree on a standard format, and

identify suitable countries and partners for further case studies.

3. To agree on a follow-up process of further country studies and pilot initiatives: scheduling, coordination, monitoring and feedback mechanisms.

4. To clarify how the planning and operational frameworks proposed by

IASC for countries at risk of complex emergencies affect the Organization’s modus operandi at the regional and country levels.

World Health Organization Cluster for Sustainable Development and Healthy Environments (SDE) Department of Emergency and Humanitarian Action (EHA) _____________________________________________________________________

Consultation

PLANNING AHEAD FOR THE HEALTH IMPACT OF COMPLEX EMERGENCIES Geneva, 13-14 December 1999

Draft Discussion Paper (8.12.99)

Since the end of the Cold War, there has been a perception that the world has been engulfed in a series of violent armed conflicts and resulting mass population displacements. Iraq, Somalia, Bosnia, Rwanda, Chechnya, Sudan, Kosovo, and East Timor are some of the more publicised examples of conflicts whose roots have not (at least obviously) been based on political ideologies. These conflicts have largely been attributed to ethnic and religious tensions; however, many have arisen during a period of economic instability. Certainly, many appear to have evolved from “suppressed tensions” that have been released in the context of profound political change and uncertainty. The term “complex humanitarian crisis” has been coined to describe these events; however, some critics who prefer the term “complex political emergency” have recently challenged that phrase. It is the politics that are complex while the humanitarian effects remain as they always have been: population displacement, food scarcity, malnutrition, high morbidity and mortality, including violence intentionally directed at civilians, and severe mental stress. In many countries affected by civil strife, tensions and violence between groups within the population have been intensified by anxiety related to economic uncertainty. In some instances, political leaders or parties have exploited this anxiety and therefore have heightened the perceived differences between these groups. This appears to have occurred in the republics of the former Yugoslavia, Chechnya, Georgia, and Azerbaijan. In other countries, a sudden economic downturn has contributed to overall political instability unleashing communal violence, such as in Ambon, Ternate, Kalimantan, and West Timor in Indonesia. In addition, latent secessionist movements have found new life, such as in East Timor, Aceh, and Irian Jaya in the same country. As the leading global public health agency, WHO is grappling with these new complexities, and seeks to identify options for acting to mitigate the impact of evolving economic and political crises on the health of populations. These options need to be explored firmly within the context of the organization’s mandate, structure, and member state expectations. WHO does not have an international mandate to directly address the root political causes of conflict; however, it has an obligation to respond to identified risk factors for the deterioration of population health in any

given setting. Briefly, this requires an early recognition of a vulnerable population, an analysis of the direct and indirect health consequences of economic and political instability, and the identification of critical health programs that need the support of the international community. Like most international agencies during the past decade, WHO has focused on improving the response to humanitarian crises, with disaster reduction and mitigation largely confined to natural hazards, such as earthquakes, hurricanes, and tsunamis. The search for a strategic paradigm for country-level work in situations of transition and instability has become urgent and of the utmost relevance for WHO. In 1997, with the support of the Australian Government, the WHO Department of Emergency and Humanitarian Action (EHA) organised a meeting on “Health Coordination in Emergencies: Options for the Role of WHO”. The meeting opened an important process of reflection on the Organization and EHA's priorities in response. This reflection was furthered by a second consultation on needs for Applied Health Research in Emergency Settings, held in October of the same year. This was followed by the establishment of an Advisory Group on Applied Health Research in Emergencies. However, WHO's mission also covers disaster reduction and prevention; preparing for the response to emergencies; mitigating their health consequences; and creating a synergy between emergency action and sustainable development. EHA's mandate specifies that this has to be pursued through a concerted effort across the various departments and offices of WHO, and includes the ultimate goal of increasing the capacity and self-reliance of member countries. Therefore, EHA, with the support of the Macfarlane Burnet Centre for Medical Research (Australia) and of the Scuola Superiore Sant'Anna/ International Training Programme for Conflict Management of Pisa, Italy, is organising a third consultation. This will aim to broaden the debate on WHO’s role in emergencies to include preparedness for, mitigation of, and recovery from the health effects of complex emergencies in vulnerable countries. Together, WHO and its operational partners should examine strategies and programme options for strengthening the national and international capacity for contingency planning, risk analysis, prevention, mitigation, and response vis-à-vis the health and nutrition consequences of complex emergencies. Key Issues 1. Economic and political transition The post-cold war era has seen a variety of tensions being released among and within nations. These tensions interact with swift economic transformations and result in political instability and violent conflicts in several areas of the world. Indonesia (and East Timor), the Balkans, and Caucasus region are only the most recent and most media-covered crises. Estimates based on data of May 1999 from the UN Office for the Coordination of Humanitarian Affairs (OCHA), suggest that as many as 73 countries, with a total population of almost 1800 million people are passing through differing degrees of instability. Globalization demands high levels of economic and technological competitiveness. It risks marginalising entire regions - mainly but not only Africa - and exacts high social costs from countries undergoing economic and political transformation. This is

illustrated by the steep reduction in life expectancy observed in Russia between 1992 and 1997, or by the case of the Democratic People's Republic of Korea, where the annual crude death rate increased from 6.8 per 1000 in the early '90s to 9.3 per1000 in 1998. The rapid changes that have been occurring in the last 10 years include and interact with the redefinition of the role of the State. These include the crisis of the welfare system in industrialized countries, the collapse of states, and the explosion of violent conflicts in contexts of greater vulnerability, where changes can accelerate and precipitate long-dormant tensions. (see also World Bank Development Report, the State in a Changing World). Least developed countries see their capacity for health service delivery severely compromised or completely collapsed, such as in Somalia. The way in which institutions and societal systems respond to tensions and challenges varies and is difficult to predict. Thailand was able to resist the economic crisis that hit South East Asia in 1998, but Indonesia was severely affected. Albania was overwhelmed by the collapse of the pyramid schemes. The Caucasus and Balkan countries are struggling to stabilise their new institutional frameworks. Obviously, a country with marked social inequalities, food, job, economic, environmental and human-rights insecurity, and an inefficient or corrupt public sector is more vulnerable and more likely to see tensions - be they of economic, political, religious or ethnic nature - explode into violent conflict. Nevertheless, it is difficult to pinpoint a deterministic causality: not all inequalities necessary lead to violence, while in the former Yugoslavia the presence of a functioning state did not avoid the conflict. The impact of economic crises is far from predictable. In the recent Asian financial crisis, the political, social, and health outcomes have varied among those countries affected. The crisis led to a change in political leadership in Thailand, the fall of a president in Indonesia, which led to greater democracy, but minimal political changes in other countries. The events that led to the independence of East Timor can be traced directly to the onset of the financial crisis in Indonesia. Negative economic growth occurred in Indonesia, Thailand, Korea, and the Philippines; however, the economy grew in Laos due to expansion of the agricultural sector. Health budgets decreased in most countries, except Indonesia; however, actual health expenditure decreased in Indonesia partly due to the effects of decentralisation and inadequate skilled manpower at the district level. In general, urban populations suffered greatly compared with rural dwellers. On the other hand, various countries have passed through economic crises, political transition, and even armed conflicts without the same health consequences or serious changes in health and disease dynamics. Sri Lanka is one such example of a country experiencing prolonged armed conflict that has been able to maintain essentially free basic health services and to prevent deterioration in national health indicators, except - and this is the important exception - within the zone of conflict itself. Other cases may include Nigeria, which passed through a long constitutional and economic crisis punctuated by civil strife in the Ogoni minority area, or Mexico, that suffered a severe economic crisis without major political instability, but it is nevertheless affected by a "low-intensity" civil war in Chiapas. At the global level, many countries find themselves along a spectrum of increasing vulnerability and instability, as the high-risk situations of Indonesia and Myanmar illustrate, passing through Colombia, to the extreme case of Angola, now entering its 25th (some would say 40th) year of complex emergency. Countries that have experienced pressures such as those cited above could be characterised as “disrupted states”. Whatever the primary cause of this disruption, it

appears obvious that effective solutions to prevent further deterioration towards a “failed state” can only be within the political arena. Nonetheless, instability, crisis and complex emergencies have an undeniable impact upon public health. In Burundi, the annual under-5 mortality rate has increased from 108 per1000 in 1992 to 190 per1000 in 1998. And public health is also policies and politics. Public health professionals have the responsibility to contribute to wider efforts, exploring mechanisms to strengthen the resilience of health systems. In addition, efforts should focus on preparing for situations where the health status of vulnerable communities, namely the majority of the population in many settings, is made worse or when entire societies become vulnerable because of collapsing governance. 2. Worst case outcomes The term "Complex Emergencies" is widely used when referring to these conflicts. Some prefer the names "Complex Humanitarian Emergencies" or "Complex Political Emergencies", whether they want to highlight the humanitarian manifestations of the emergency or its causes, that are essentially political. One problem in using such terms is that they are often used to avoid confronting the real cause and features of the crisis. For instance, speaking of complex emergency for the events of 1994 in Rwanda seems inadequate. The international response was first unable to avoid the genocide and then ended up being blamed for supporting the perpetrators . From an epidemiological point of view, one can recognise causal sequences linking economic crisis, political instability, and complex emergencies - with no other qualification- as defined by the US Centers for Disease Control in Atlanta as:"… situations featuring armed conflict, population displacement and food insecurity with increases in acute malnutrition prevalence and crude mortality rates ". Most emergency health workers agree that mortality is a sensitive and specific measure of the level of a public health emergency. WHO publications (RAP) indicate a daily crude mortality of 1/10,000 as the cut-off value for emergency warning. When previous rates are well known, a noticeable increase in mortality (doubling) is sometimes used. Nevertheless, recent events in Kosovo qualified as a "complex emergency " in the minds of most people but did not feature increases in mortality rates. At this point, one could ask whether all complex emergencies are also immediately "Health Emergencies". Do health workers always need to be at the forefront of relief efforts? Wouldn't resources be better applied beforehand, to increase the resilience of health systems in vulnerable countries, enabling them to deliver health care in spite of violent conflict? The taxpayer assumes that funding for humanitarian agencies is related to the needs of the beneficiaries. With no clear criteria to evaluate efficiency and cost-effectiveness of emergency interventions, funding of agencies and thus their own survival largely depends on field visibility (i.e. coverage by the media) and the image this creates vis-à-vis potential donors. In essence, this meeting should be focused on mitigation of the effects of a public health emergency that has its causal roots in political and economic turmoil and civil conflict. Public health can be effective only in as much as the security of victims or armed conflict is guaranteed (Perrin, 1998). But, in practical terms, the objective of health workers is to prevent excess morbidity and mortality, and in order to achieve this in the acute emergency phase, they must often grant priority to non-medical action.

Security, protection and the provision of shelter, food, water, sanitation may be of more immediate benefit than providing health care. This does not imply that health workers should take on those tasks themselves. Their role lies in triggering action from other sectors, based on the priority needs identified through the first rapid assessment and subsequent surveillance and monitoring. If the need for medical care is less prominent, priority should go to the real requirements of the population. In many instances, inter-sectoral coordination may be more important than stockpiles for epidemic control, and the timing of interventions is of crucial importance 3. Detection Nonetheless, effective early warning systems, namely those that assist in decision-making, remain largely inadequate. The quest for advanced humanitarian intelligence has stimulated a variety of initiatives: from the sets of indicators elaborated by DHA in the early '90s, passing through the UNICEF experience with vulnerability analysis, to the various frameworks promoted by OCHA/IASC. Nonetheless, the memory of the announced tragedy of Rwanda was still with most of us when it was revived by the events in East Timor. There has been much reflection on the value of health information in this direction, last but not least by EHA through HINAP and Health as a Bridge for Peace, and by USAID/CERTI. Still, one week of intense media coverage appears to carry much more weight than years of careful recording of worsening infant mortality rates. Moreover, the question remains regarding the control of those services that generate the health data (and their analysis and dissemination) in a politically tense situation. Humanitarian agencies should be unbiased advocates of the health and human rights of the population they serve. But UN agencies face a difficult plight. At country level, they have the national government as their counterpart. If the government becomes involved in a conflict, it becomes difficult for one country office to distance itself enough to provide impartial assistance to those in need. Special arrangements have to be set in place, and this takes precious time. At the same time, donors may be demanding a swift response in line with their own political interests and/or with the expectations of their taxpayers. These reflections are especially important for WHO. As a UN Specialised Agency accountable to its Governing Bodies, i.e. ultimately its member countries, WHO has to reconcile its unique responsibility in the Health sector, the Humanitarian Imperative and the mandate to develop the capacities and enhance or preserve the self-reliance of its primary constituents. 4. Governance There is a self-evident relationship between the responses to public health emergencies and the strengths and weaknesses of societal and government structures and their capacity to guarantee continued basic services. From this perspective, it seems important to link health interventions to principles of good governance: § Improving economic management to maximise and fairly distribute the benefits of

economic productivity; § Strengthening public sector management for more effective, equitable, and

efficient delivery of health and related services; § Promoting effective and equitable legal systems and strengthening the rule of law;

and

§ Strengthening civil representation and participation to enable better scrutiny of policies and practices.

(Partly based on “Governance”, Bruce Davis, in Focus, Australian Agency for International Development, July 1999) Given the relationship between social tensions, increased civil violence, and the evolution of complex emergencies, health initiatives also need to be viewed along a spectrum defining their possible contribution to peace and/or conflict from: § simply not contributing to the conflict (“.. all health initiatives in … existing or

likely armed conflict should be scrutinised … to assess the chances that they will cause or intensify conflict.” (Anderson, The project Do No Harm)

to: § actively promoting peace building through dialogue and collaboration on non-

controversial issues (Zagaria and Arcadu, Health as a Bridge for Peace, the Angola case study, WHO/EHA 1998)

From a public health point of view, these two sets of concerns can be reconciled by (a) recognising that any continuum of care requires physical, economic and functional access to health services - inter-alia , stability; and (b) accepting that health professionals have a responsibility to contribute to equity and justice within a society. In the 19th century, it was realised that better housing and living conditions could improve the health and, therefore, the productivity of factory workers. Economic and humanitarian arguments were used to convince industrialists to implement the recommendations of health professionals, and a more equitable society brought about an improvement in general health indicators. On merely technical grounds, only public health programmes that consider the inequalities present in a society can address the needs of the entire population. Governments have duties and responsibilities toward all, not just a majority –or, worse, a minority- of its citizens.

5. Health system adaptability

In most developing countries, even in non-emergency contexts, external assistance represents a large share of health expenditures. Major programmes, such as polio eradication and the expanded programme on immunisation, control of malaria, tuberculosis and AIDS, and the integrated management of childhood illness, simply would not be possible without this support. Additionally, social insurance programs, if they exist at all, have often achieved very low coverage. The difficulty of raising taxes has led to a search for alternative sources of funding; namely, community financing and patient charges. In an economic or political crisis, the barriers may become further complicated. In Indonesia, the response in the health sector of the government and major donors to the 1997 financial crisis was to broaden the social safety net, including the distribution of free health care cards. However, in 1998, health service utilisation actually decreased due to management problems in district health services, slow disbursement of funds, shortages of essential medical supplies, and civil strife and insecurity in a number of provinces. If political instability develops further into open conflict, militarization tends to compete with social expenditure and issues of funding – from government or private sources – can be at the very root of the political crisis. External assistance to the health sector is usually maintained, but it may also end up being constrained by political considerations, or simply by the difficulty of coordinating a suddenly swollen number of external partners.

While it seems unlikely that a state would increase funding to the health sector when a complex emergency looms, it might be possible under such circumstances to reallocate resources within the social sector budgets. Alternatively, pre-emptive external assistance could be channelled to preserve essential services and ensure equitable access to services that are essential for survival. Most Asian countries affected by the financial crisis have actually decreased expenditure on disease prevention and health promotion and concentrated resources in curative services. Indeed, as Amartya Sen has pointed out, the observed increase in life expectancy in the UK during the two World Wars was most likely the result of improved equity of access to food and basic health services (A.Sen: Mortality as an indicator of economic success and failure; The Economic Journal, 108, Jan. p.1-25). Governments should be encouraged to design health systems that can withstand crises. This form of health preparedness planning could also contribute to prevention. Placing social services high on the political agenda can help maintain social cohesion, national unity and stability, keeping militarization in check. WHO has a clear role in assisting member countries to assess the vulnerability of the health sector and to set priorities for “essential packages”, i.e. health service interventions that society decides should be provided to everyone in the specific context of each country’s health system (Tarimo, 1997). Various approaches have been developed for assessing the essential needs for health care, the simplest being measures of mortality and morbidity. The Rapid Appraisal approach (Rifkin, 1992) focuses on the community’s own view of needs, and thus is not confined to only health or health care, encompassing broader aspects of social need. In a context of on-going or impending crisis, one could consider using also the WHO Rapid Health Assessment Protocols, or a combination of the two. Once needs are identified, choices must be made between competing priorities. Ideally, this should be done through cost-benefit or cost-utility analysis. In practice, decisions on health interventions most often develop from the interplay of competing interest groups, or to implement one political ideology, and meeting health needs becomes a second order objective (Walt, 1994). This is even more likely to happen in situations of political and social crisis. Whatever the content of the essential packages, they will have to be considered and readjusted following - or, ideally, foreseeing - the dynamics of the crisis. Namely, its impact upon the health needs, the most vulnerable groups, the intervening actors, the state of resources and support systems, the evolution of the overall national policy framework. Here again WHO has a role to play in inter-facing between the country's health sector and the many international partners, coordinating and complementing interventions for health development and preparedness, health relief and post-crisis stabilisation and recovery. Although health sector reform efforts are laudable, some aspects have actually complicated the responses to economic and political crises. Decentralisation, for example, in Indonesia and the Philippines, has led to problems in maintaining peripheral health services because district health services have lacked the necessary management skills and experience. 6. Relevant Action Looking at programme opportunities and constraints in more detail, an initial question touches on how to work with governments on preparedness for situations where their own authority might be at stake. This implies identifying what can and should be discussed with an endangered government, or, for that matter, with a community that

perceives itself as excluded or persecuted. Some institutional reflections may be useful at this point:

⇒ How realistically can a government be called upon to prepare for its own demise, or to request technical cooperation for such a contingency?

⇒ The first requirement for an early warning indicator to be of any value is that all those concerned are ready and feel free to discuss it.

⇒ By definition, excluded minorities are the most vulnerable groups in any country and society.

⇒ Structural adjustment programmes and constitutional changes may contribute to instability and tensions, but they do facilitate the devolution of health services to local authorities (Bjorkman, 1999) and can strengthen local health systems.

⇒ Potential health partners in non-governmental sectors may be parties to the conflict or at least sympathetic to one or other factions.

⇒ How far can WHO go in the search of a compromise between the humanitarian imperative and its fundamental goal of capacity building with and for member countries?

Moreover, technical arguments should be developed along four lines of questioning:

i. The robustness of health systems to prevent the adverse health effects of a complex emergency situation, including the definition of a minimum package of PHC services. This includes a) the assets existing at the various levels of the health system that different

partners can identify as worth protecting vis-à-vis social and economic instability.

b) the partnerships other than MOHs that can be more acceptable and more

effective - in political, institutional and operational terms - in situations where governments’ legitimacy is at stake.

ii. The interventions that are most effective to protect the public health, namely, to

prevent excess mortality/morbidity in complex emergency situations. These may address nutrition and water, include child vaccination and diarrhoeal disease or other control programmes, and possibly the management of violent injuries, but they must also:

a) be suited to the country and acceptable to external donors in spite of the

enhanced instability;

b) ensure the best balance between basic survival needs and long-term health services readjustments under the circumstances;

c) build on - and preserve- the capacities of the affected population, which may

imply greater focus on participatory assessment and health education/ promotion, rather than curative/preventive campaigns.

d) strengthen and/or maintain equity of access to services.

iii. The methods of delivery that best suit certain situations, keeping in mind the need for cost-effectiveness, governance and the health bridge for peace framework.

iv. The tools and methods that best suit planning in situations of high instability and

uncertainty:

a) definitely, planning methods that involve the widest range of stakeholders seem to be most appropriate when dialogue may be an objective in itself, but can logical frameworks accommodate all the contingency options that are needed, or do we have to introduce simulation reflections, scenario planning or other "futures" exercises?

b) The War Torn Societies Project has demonstrated the value of participatory action-research in post-conflict scenarios: can it apply to pre-conflict situations too?

c) which timeframe is more realistic and/or cost-effective in such situations?

7. Relevant WHO initiatives All the points mentioned above are reflected in various on-going EHA initiatives: Health Bridge for Peace, Communicating Best Practices, Research in Emergencies, Health Transition from Relief to Reconstruction, the Health Intelligence Network for Advanced Planning and the Horn of Africa Initiative. They also touch the fields of interest of its closest institutional partners within the Cluster of Sustainable Development and Healthy Environments (SDE): Nutrition, Poverty Reduction and Protection of Healthy Environments. They are reflected in major WHO regional initiatives, e.g. AFRO's effort to build regional capacities for preparedness and the International Consensus Forum on Health and Human Security in Conflict and Transition Settings in Africa of April 1999. AFRO and EMRO's contributed together with experts' advice to a strategy for Management of Health Issues in Emergency Situations in Africa at the 6th Conference of African Ministers of Health organised by the Organisation of African Unity. SEARO is strongly committed to regional training on Health as a Bridge for Peace and is playing an important role in risk monitoring in Indonesia. The same concerns are reflected in major WHO's projects such as Roll Back Malaria, Polio eradication and Making Pregnancy Safer, that include specific strategies for operations in complex emergencies, and the World Report on Violence. Finally, by themselves and by the situations that they aim at addressing, they are relevant to WHO in the definition of its Corporate Strategy. 8. Ongoing Process This consultation may be considered as the first step in a process of study, discussion, research and pilot initiatives. It should help outline a conceptual framework for health, where different concerns can be accommodated and different activities optimised. We hope to contribute options for a re-appraisal of WHO’s modus operandi in situations of enhanced risk or actual complex emergencies, at country and regional levels. We also expect to promote synergies between the Organization's institutional and technical functions, and the planning and operational frameworks as proposed by

the UN Inter-Agency Standing Committee. In both perspectives, this initiative is essential for WHO's core constituents, its member countries. What we can envisage at this stage is a first phase of country-level studies and planning, followed by another of test-implementation and evaluation. The studies will be conducted through technical service agreements at country level. The reports will be brought to a follow-up meeting, where some countries could be selected to test/evaluate an integrated country programme for/in unstable situations. This would then be conducted through the WHO country offices, to be strengthened accordingly with human and material resources, at least for a first pilot phase of 18 months. This consultation should also help us agree to criteria defining an impending crisis and methods to study and monitor relevant indicators, and how to use them to develop technical capacities for a basic package of health services and public health interventions for countries in crisis. Ideally, such package should satisfy the following criteria: a) to be able to withstand any deterioration in the crisis, b) support the principles of good governance, c) contribute to conflict management, and d) optimise the entire range of expertise of WHO and its partners. We hope that this consultation will achieve the following outcomes: • Consensus on key issues to be covered and/or a list of headings the for the

country case studies ; • Commitment for the follow-up from partners within and outside WHO; • A list of vulnerable countries to be considered for further case studies; • Information on country-based institutions who may conduct the studies and agreed

criteria for their involvement; • The essentials of a plan of work for the next 12 months; • A list of points and appropriate mechanisms for further reflection.

Expected outputs of consultation

• Issues to be covered in country case studies • List of countries for further studies • Possible partner institutions; criteria for selection • Points for further reflection • Statements of interest from partners • Plan of work for 12 months

World Health Organization Department of Emergency and Humanitarian Action _____________________________________________________________________

Consultation

PLANNING AHEAD FOR THE HEALTH IMPACT OF COMPLEX EMERGENCIES Geneva, 13-14 December 1999

List of participants UNITED NATIONS AGENCIES : Ms Rita Bhatia, Senior Nutrionist United Nations Office of the High Commissioner for Refugees (UNHCR) P.O. Box 2500 1211 Geneva 2, Switzerland Tel.: (41) 22 739 8308 Fax: (41) 22 739 7366 E-mail: bhatia@unhcr.ch Ms Kate Burns , Senior Epidemiologist United Nations Office of the High Commissioner for Refugees (UNHCR) P.O. Box 2500 1211 Geneva 2, Switzerland Tel.: (41) 22 739 8003 Fax: (41) 22 739 7366 E-mail burns@unhcr.ch Mr Piero Calvi-Parisetti, Chief Liaison Unit Office for the Coordination of Humanitarian Affairs (OCHA) Palais des Nations 1211 Geneva 10, Switzerland Tel.: (41) 22 917 1209 Fax: (41) 22 917 0020 E-mail calvi-parisetti@un.org Mr Larry De Boice, Deputy Director Emergency Response Division, Geneva Operations United Nations Development Programme (UNDP) Chemin des Anémones 11-13 1219 Châtelaine, Switzerland Tel.: (41) 22 917 1234 Fax: (41) 22 917 8060 E-mail ldeboice@undp.org Dr K. Olavi Elo, Director Country Planning Joint United Nations Programme on HIV/AIDs (UNAIDS) 20, avenue Appia CH-1211 Geneva 27, Switzerland Tel.: (41) 22 791 4446 Fax: (41) 22 791 4162 E-mail eloo@unaids.org

Mr Themba N. Masuku, Director, Liaison Office Geneva Food and Agriculture Organization (FAO) Palais des Nations 1211 Geneva 10, Switzerland Tel.: (41) 22 917 3691 Fax: (41) 22 917 0065 E-mail tmasuku@unog.ch Ms Lisa A. Mbele-Mbong, Program Officer WSP Transition Programme Palais des Nations 1211 Geneva 10 Switzerland Tel.: (41) 22 917 8593 Fax: (41) 22 917 8039 E-mail: mbelembong@unrisd.org Mr Agostino Paganini, Advisor for Health Programmes in Emergencies United Nations Children's Fund (UNICEF) 3 United Nations Plaza New York, NY 100 17 USA Tel.: (1) 212 326 7000 Fax: (1) 212 887 74 65 E-mail: apaganini@unicef.org Dr Daniel Pierotti, Senior Adviser Emergency Relief Operations United Nations Population Fund (UNFPA) Palais des Nations 1211 Genève 10 Tel.: (41) 22 917 8314 Fax: (41) 22 917 8049 E-mail: unfpaero@undp.org Ms Cathy Sabety, Programme Specialist Emergency Response Division, Geneva Operations United Nations Development Programme (UNDP) Chemin des Anémones 11-13 1219 Châtelaine, Switzerland Tel.: (41) 22 917 1234 Fax: (41) 22 917 8060 E-mail cahty.sabety@undp.org INTERGOVERNEMENTAL AND NON-GOVERNMENTAL ORGANIZATIONS Mr Richard Brennan, Director Health Unit International Rescue Committee (IRC) 122 East 42nd Street, 12th floor New York, NY 10168-1289, USA Tel.: (1) 212 551 3019 Fax: (1) 212 551 3185 E-mail rbrennan@intrescom.org Professor Frederick M. Burkle, Jr. , Director Center of Excellence in Disaster Management and Humanitarian Assistance Professor, University of Hawaii School of Medicine Tripler Regional Medical Center 1 Jarrett Road (MCPA-DM) TAMC Honolulu HI 96859-5000, USA Tel.: (1) 808 433 7035

Fax: (1) 808 433 1757 E-mail: skip@website.tamc.amedd.army.mil Dr Manuel Carballo, Coordinator International Centre for Migration and Health (ICMH) 11, route du Nant d’Avril 1214 Vernier, Switzerland Tel.: (41) 22 783 1080 Fax: (41) 22 783 1087 E-mail: ICMH@worldcom.ch Dr Bruce Eshaya-Chauvin, Head, Health & Relief Division International Committee of the Red Cross (ICRC) 20 avenue de la Paix 1202 Genève, Switzerland Tel.: (41) 22 730 2252 Fax: (41) 22 733 9674 E-mail: beshaya.gva@icrc.org Dr Brian Gushulak, Director, Medical Services International Organization for Migration (IOM) Case postale 71 1211 Genève 19 Suisse Tel.: (41) 22 717 9358 Fax: (41) 22 798 6150 E-mail: gushulak@iom.int Mr Steve Hansh, Research Coordinator International Humanitarian Affairs Congressional Hunger Center (CHC) 229 1/2 Pennsylvania Avenue, S.E. Washington D.C. 20009 Tel.: (1) 202 547 7022 Fax: (1) 202 547 7575 E-mail: sh@intr.net Dr Bruce Laurence, Medical Director Medical Emergency Relief International (MERLIN) 14 David Mews, Porter Street London W1M 1HW United Kingdom Tel.: (44) 171 487 2505 Fax: (44) 171 487 4042 E-mail: laurence@merlin.org.uk Dr Dominique Legros, Director Epicentre 8, rue Saint Sabin 75544 Paris cedex 11 France Tel.: (44) 171 487 2505 Fax: (44) 171 487 4042 E-mail: dlegros@epicentre.msf.org Dr Gerald Martone, Director Emergency Preparedness Response Program International Rescue Committee (IRC) 122 East 42nd Street, 12th Floor New York, NY 101-68-1289 USA Tel.: (1) 212 551 3061 Fax: (1) 212 551 3184 E-mail gerald@intrescom.org

Mr Momodou Mboge, Health Advisor Emergency Department, OXFAM GB Public Health Team OXFAM 274 Bandbury Road Oxford, OX2 8JJ United Kingdom Tel.: (44) 0186 531 2257 Fax: (44) 0186 531 2224 E-mail: mmboge@oxfam.org.uk Professor Marcel Merlin, Director Centre Européen de Santé Humanitaire (CESH) Faculté de Médecine Laënnec Rue Guillaume Paradin 69372 Lyon Cedex 08 France Tel.: (33) 478 785 707 Fax: (33) 478 785 709 E-mail: ceshl@laennec.univ-lyon.fr Mr Graham Miller, Multilateral Liaison CARE International 1, rue Gauthier 1201 Geneva Switzerland Tel.: (41) 22 731 3369 Fax: (41) 22 738 9268 E-mail caregva@iprolink.ch Mr Benoît Miribel, Director Bioforce Développement 44, Boulevard Lénine 69694 Vénissieux France Tel.: (33) 472 893 141 Fax: (33) 478 702712 E-mail: direction@bioforce.asso.fr Dr Michael F. O’Leary , Health Economist/Anthropologist Consultant of Maxwell Stamp plc. London 25 Keats Close, Horsham, West Sussex RH12 5PL, UK Tel.: (44) 403 242 397 Fax: (44) 403 269 324 E-mail mol@gloabalnet.co.uk Dr Pierre Perrin, Chief Medical Officer International Committee of the Red Cross (ICRC) 20 avenue de la Paix 1202 Genève, Switzerland Tel.: (41) 22 730 2810 Fax: (41) 22 733 2057 E-mail pperrin@icrc.org Dr Jean Rigal, Technical Support Director Médecins Sans Frontières (MSF) 8, rue Saint Sabin 75544 Paris cedex 11 France Tel.: (33) 140 219 929 Fax: (33) 148 066 868 E-mail: jrigal@paris.msf.org

Dr Hakan Sandbladh, Director Health Services International Federation of Red Crescent and Red Crescent Societies (IFRC) CP 372 1211 Geneva 19, Switzerland Tel.: (41) 22 733 0395 Fax: (41) 22 730 4222 E-mail sandblad@ifrc.org Dr Michel Thailhades Relief Health Services International Federation of Red Crescent and Red Crescent Societies (IFRC) CP 372 1211 Geneva 19, Switzerland Tel.: (41) 22 733 0395 Fax: (41) 22 730 4222 E-mail tailhade@ifrc.org Mr Robbie Thomson Senior Officer, Refugees Disaster Response International Federation of Red Crescent and Red Crescent Societies (IFRC) CP 372 1211 Geneva 19, Switzerland Tel.: (41) 22 733 0395 Fax: (41) 22 730 4222 E-mail thomson@ifrc.org Ms Alice Tligui, Director International Health Exchange (IHE) 8-10 Dryden Street London WC2E 9NA, UK Tel.: (44) 171 620 3533 Fax: (44) 171 620 2277 E-mail info@ihe.org.uk Mr Willem van de Put, Director HealthNet International Singel 540 1017 AZ Amsterdam The Netherlands Tel.: (31) 20 420 1115 Fax: (31) 20 420 1503 Willem@hni.nl Ms Margareta Wahlstrom, Disaster, Relief and Operations Coordination International Federation of Red Crescent and Red Crescent Societies (IFRC) CP 372 1211 Geneva 19, Switzerland Tel.: (41) 22 733 0395 Fax: (41) 22 730 4222 E-mail wahlstro@ifrc.org Dr Peter Walker, Director, Disaster Policy Department International Federation of Red Crescent and Red Crescent Societies (IFRC) CP 372 1211 Geneva 19, Switzerland Tel.: (41) 22 733 0395

Fax: (41) 22 730 4222 Walker@ifrc.org Dr Dawit Zawde, President African Humanitarian Action (AHA) African Avenue, P.O. Box 6398 Addis Ababa Ethiopia Tel.: (251) 1 511 224/513 541 Fax: (251) 1 513 851 E-mail: ah.dz@telecom.net.et ACADEMIC INSTITUTIONS Dr Abdullhi M. Ahmed, Coordinator International Centre for Health Management (ICHM) Istituto Superiore di Sanità (ISS) Viale Regina Elena, 299 00161 Roma Italy Tel: (39) 06 493 872 93 Fax: (39) 06 493 872 95 E-mail ahmed@iss.it Ms Gabriella Arcadu, Programme Officer International Training Programme for Conflict Management Scuola Superiore Sant'Anna Via G. Carducci 40 56127 Pisa, Italy Tel.: (39) 50 883 204 Fax: (39) 50 883 356 E-mail: garcadu@sssup.it Magdalena Bjerneld, University Teacher, Consultant Unit for International Maternal and Child Health (IMCH) Uppsala University Dag Hammarskjölds väg 21 752 37 Uppsala Sweden Tel: (46) 18 665 936 Fax: (46 )18 508 013 Email: magdalena.bjerneld@ich.uu.se Professor Barbara Carrai, Executive Director International Training Programme for Conflict Management Scuola Superiore Sant’Anna Via G. Carducci 40 56127 Pisa Italy Tel.: (39) 50 883 204 Fax: (39) 50 883 356 E-mail bcarrai@sssup.it Professor Andrea De Guttry, Director International Training Programme for Conflict Management Scuola Superiore Sant'Anna Via G. Carducci 40 56127 Pisa Italy Tel.: (39) 50 883 111 Fax: (39) 50 883 225 E-mail: deguttry@sssup.it

Dr Patricia M. Diskett, Programme Officer Disaster Management Centre Cranfield University, R.M.C.S Shrivenham Swindon SN6 8LA, Wiltshire United Kingdom Tel.: (44) 1793 785 287 Fax: (44) 1793 785 883 E-mail: p.m.diskett@rmcs.cranfield.ac.uk Professor Ranieri Guerra, Director /SAC Istituto Superiore di Sanita Viale Regina Elena, 299 00161 Roma Italia Tel.: (39) 6 4990 3430 Fax: (44) 6 4938 7073 E-mail: guerra@iss.it Professor Debaraty Guha-Sapir, Director Centre for Research on the Epidemiology of Disasters (CRED) School of Public Health, Faculty of Medicine Université catholique de Louvain 30-34 Clos Chapelle-aux-Champs Brussels 1200 Belgium Tel.: (32) 2 764 3327 Fax: (32) 2 764 3441 E-mail: sapir@epid.ucl.ac.be Dr Nancy B. Mock, Associate Professor International Health and Development Tulane University School of Public Health and Tropical Medicine 1440 Canal Street, Suite 2200 New Orleans, Louisiana 70112-2737 USA Tel: 1-504-587-7318 Fax: 1-504-584 3653 Email: mock@mailhost.tcs.tulane.edu Ms Monika Pearson, Nutritionist Nutrition Unit, Uppsala University Dag Hammarskjölds väg 21 752 37 Uppsala, Sweden Tel: (46) 18 471 2220 Fax: (46 )18 508 013 E-mail: monika.lowgren-pearson@nutrition.uu.se Professor Leif Hambraeus , Professor in Human Nutrition Department of Medical Sciences, Nutrition Unit Uppsala University Dag Hammarskjölds väg 21 Uppsala 732 37, Sweden Tel.: (46) 18 471 2211 Fax: (46) 18 559 505 E-mail: leif.hambraeus@medsci.uu.se Dr Jennifer Leaning, Senior Research Fellow Harvard Center for Population and Development Studies 9 Bow Street Cambridge MA 02138, USA Tel.: (1) 617 495 3699 Fax: (1) 617 495 5418 E-mail: jleaning@tiac.net

Mr Les Moseley, Director Coventry Centre for Disaster Management Coventry University Priory Street Coventry CV1 5FB United Kingdom Tel: (44) 1203 838 898 Fax: (44) 1203 838 950 E-mail: cbx067@coventry.ac.uk Dr Ronald J. Waldman, Professor of Clinical Public Health Columbia University, School of Public Health Center for Population and Family Health 60 Haven Avenue, B-3 New York NY 10032, USA Tel.: (1) 212 304 5219 Fax: (1) 212 305 7024 E-mail: rw178@columbia.edu Dr Anthony Zwi, Head, Health Policy Unit London School of Hygiene and Tropical Medicine Keppel Street London WC1E 7HT United Kingdom Tel: (44) 207 927 2374 Fax: (44) 207 637 5391 E-mail: anthony.zwi@lshtm.ac.uk REPRESENTED COUNTRIES Mr Pavlov Anatolv, Counsellor Permanent Mission of the Russian Federation to the United Nations Office and other International Organizations in Geneva 1211 Genève 20, Switzerland Tel: (41) 22 733 18 70 Fax: (41) 22 734 40 44 Ms Veomayouri Baccam, Second Secretary Permanent Missions of the United States to the United Nations Office and other International Organizations 1292 Chambésy Switzerland Tel.: (41) 22 749 4214 Fax: (41) 22 749 4671 E-mail veomayoury.baccam@ties.itu.int Mr Paulo Barcia, Counsellor Permanent Mission of Portugal to the United Nations Office and other International Organizations in Geneva Case postale 51 1211 Genève 20, Switzerland Tel: (41) 22 918 0200 Fax: (41) 22 918 0228 E-mail: mission.portugal@ties.itu.int Mr Klaus Botzet, Counsellor Permanent Mission of Germany to the United Nations Office and other International Organizations at Geneva Case postale 171 1211 Geneva 19, Switzerland Tel.: (41) 22 730 1248 Fax: (41) 22 734 3048

Dr Brenton Burkholder Chief, International Emergency and Refugee Health Branch CDC/NCEH/Mailstop F-48 4770 Buford Highway Atlanta, GA 30341 USA Tel: (1) 770 488 3519 Fax: (1) 770 488 7829 E-mail btb0@cdc.gov Mr Jose Consarnau, Counsellor Permanent Mission of Spain to the United Nations Office and other International Organizations at Geneva Case postale 201 1211 Genève 20 Switzerland Tel: (41) 22 731 22 30 Fax: (41) 22 731 53 70 E-mail: mission.spain@ties.itu.int Ms Leslie B. Curtin, Director Office of Population and Nutrition U.S: Agency for International Development (USAID) USAID/Indonesia JI Medan, Merdeka Selatan No.3 Jakarta 10110 Indonesia Tel.: (62) 21 344 2211 Fax: (62) 21 380 6694 E-mail lcurtin@usaid.gov Dr Meena Dawar Canadian International Development Agency (CIDA) 200 Promenade du Portage, Hull Quebec, KIA OG4 Canada Tel.: (1) 819 994 7091 Fax: (1) 819 999 9049 E-mail meena-dawar@acdi-cida.gc.ca Mr Flavio Del Ponte , Senior Medical Advisor Humanitarian Aid – Swiss Disaster Relief Swiss Department of Foreign Affairs Tel.: (41) 22 731 6204 Fax: (41) E-mail flavio.delponte@deza.admin.ch Mr Björn Ekman, Program Officer Health Division Swedish International Development Cooperation Agency (Sida) 105 25 Stockholm Sweden Tel.: (46) 8 698 5100 Fax: (46) 8 698 5643 E-mail: bjorn.ekman@sida.se Dr George Havens Emergency Public Health Officer OFDA Health Unit, BHR US Agency for International Development (USAID) Ronald Reagan Building Washington DC 20523, USA Tel.: (1) 202 7124 81

Fax: (1) 202 216 3707 E-mail ghavens@usaid.gov Mr Helle Ekmann Jensen,, Counsellor Permanent Mission of Denmark to the United Nations Office And other International Organizations at Geneva Case postale 435 1235 Geneva 19, Switzerland Tel: (41) 22 918 00 43 Fax: (41) 22 918 00 66 E-mail heljen@gvach.um.dk Dr Etsuko Kita Bureau of Medical Cooperation, International Medical Center of Japan Ministry of Health 1-21-1 Toyama, Shin-Juke Tokyo 162-86 55, Japan Tel: () Fax: () E-mail etkita@it.imcj.go.jp Mr Kerry Kutch, Counsellor (Development), AUSAID Permanent Mission of Australia to the United Nations Office and other International Organizations at Geneva Case postale 172 1211 Geneva 19, Switzerland Tel: (41) 22 799 9108 Fax: (41) 22 799 9190 E-mail kerry.kutch@dfat.gov.au Mr Knut Langeland, Counsellor Permanent Mission of Norway to the United Nations Office and to other International Organizations at Geneva Case postale 274 1211 Genève 19 Switzerland Tel.: (41) 22 918 0400 Fax: (41) 22 918 0410 Mrs Louise Lavigne , Counsellor Humanitarian Affairs Permanent Mission of Canada to the United Nations Office And other International Organizations at Geneva Avenue de l’Ariana 5 1202 Geneva, Switzerland Tel.: (41) 22 919 9255 Fax: (41) 22 919 9295 Ms Betsy Lippman, Refugee Officer Permanent Missions of the United States to the United Nations Office and other International Organizations 1292 Chambésy, Switzerland Tel.: (41) 22 749 4442 Fax: (41) 22 749 4671 E-mail lippman@state.gov Mr Peter Lundberg, Programme Officer Division for Humanitarian Assistance Swedish International Development Cooperation Agency (Sida) 105 25 Stockholm, Sweden Tel.: (46) 8 698 5774 Fax: (46) 8 698 5613 E-mail: peter.lundberq@sida.se

Ms M. Lundemo, Adviser Permanent Mission of Norway to the United Nations Office and to other International Organizations at Geneva Case postale 274 1211 Genève 19, Switzerland Tel.: (41) 22 918 0400 Fax: (41) 22 918 0410 Dr W.H. Lyerly Senior Advisor for Crisis Mitigation, Transition and Recovery Crisis Mitigation and Recovery Division, AFR/SD/CMR U.S: Agency for International Development (USAID) Ronald Reagan Building, Suite 4.06 Washington DC 20523 Tel.: (1) 202 712 5541 Fax: (1) 202 216 3466 E-mail wlyerly@aol.com Ms Natalia Quintavalle, First Counsellor Permanent Mission of Italia to the United Nations Office and other International Organizations in Geneva Chemin de l’Impératrice 10 1292 Chambésy, Suisse Tel.: (41) 22 918 0820 Fax: (41) 22 734 6702 Mr Advic Sanela, Second Secretary Permanent Mission of Bosnia and Herzegovina to the United Nations Office and Specialized Agencies in Switzerland, 22 bis rue Lamartine 1203 Genève, Switzerland Tel.: (41) 22 345 8858 Fax: (41) 22 345 8889 Ms Linda Vogel, Health Attaché Permanent Missions of the United States to the United Nations Office and other International Organizations 1292 Chambésy, Switzerland Tel.: (41) 22 749 4627 Fax: (41) 22 7494717 E-mail: linda.vogel@ties.itu.int Ms Pamela H. Wolf, Senior Technical Officer Office of Population Health and Nutrition U.S: Agency for International Development (USAID) USAID/Indonesia JI Medan, Merdeka Selatan No.3 Jakarta 10110, Indonesia Tel.: (62) 21 344 2211 Fax: (62) 21 380 6694 E-mail pamelawolf@usaid.gov Mr Akito Yokomaku, First Secretary Permanent Mission of Japan to the United Nations Office and other International Organizations at Geneva Chemin des Fins 3 CP 337, 1211 Geneva 19, Switzerland Tel.: (41) 22 717 3107 Fax: (41) 22 717 3811 E-mail akito.yokomaku@mofa.go.jp

WHO PARTICIPANTS Headquarters: Dr C.Djeddah, DPR/PVI Dr N.H. Al-Gasseer, OSD/EIP Dr C.M. Garcia Moreno Esteva, EIP/GPE Dr A. Goubarev, OSD/EIP Dr P.D. Hartigan, Director, HSC/HPR

Mr J. A. Hueb, WSH/PHE Dr C. Romer, DPR/PVI Dr B. Saraceno, Director MNH/HSC Ms P.K. Singh, EXD/SDE

Ms M. Skold, HSD/SDE Mr L. Tillfors, ECP/EGB Hedwig Deconinck, Training officer WHO/EHTP Dr M. Toole, Consultant REGIONAL OFFICES : AFRO: Dr Ait Chellouche , EHA Dr I. Sow, EHA Responsible Officer AMRO/PAHO Dr C. De Ville de Goyet, EHA Dr C. Guerra de Macedo , Dr Jean-Luc Poncelet, Emergency Preparedness Adviser EMRO Dr A. Gebreel, EHA EURO: Dr Richard Alderslade, Regional Adviser Partnerships in Health and Emergency Assistance Dr Fatime Arenliu-Qosaj, National Professional Officer Public Health based at WHO Kosovo Dr Rusudan Klimiashvili, WHO Liaison Officer, Georgia Dr Luigi Migliorini, Head WHO Humanitarian Mission to Albania based in Tirana Dr Jan Theunissen, Coordinator Humanitarian Assistance and Emergency Preparedness SEARO Dr Johanna Larusdottir, EHA Dr Peter Hybsier WHO Representative, Sri Lanka Dr E.K. Rodrigo, WHO Temporary Adviser Consultant Psychiatrist/Senior Lecturer Department of Psychiatry, Faculty of Medicine University of Peradeniya Sri Lanka Dr Eigil Sorensen Consultant EHA/DPRK Department of Emergency and Humanitarian Action (EHA) Dr X. Leus, Director Dr M. Connolly, communicable disease Control in refugee and displaced population Dr D. Deboutte, EHC Dr E. Kossenko, EHP Dr K. Shibib, EHP Dr Y. Tegegn, EHP Dr M. Thieren, EHP Dr J.-P. Menu, T.C. Senior Adviser EHA and T.C. EHP Dr A. Loretti, T.C. a.i. EHC/EHA

World Health Organization Department of Emergency and Humanitarian Action _____________________________________________________________________

Consultation

PLANNING AHEAD FOR THE HEALTH IMPACT OF COMPLEX EMERGENCIES Geneva, 13-14 December 1999, Excecutive Board Room

Provisional Programme

Day 1 - 13 December 1999 8:30 Registration 9:30 Official opening by Dr G. Harlem Brundtland, Director-General of WHO Plenary presentation:

The evolving nature of complex emergencies: health, risk and vulnerability

(Dr Ronald Waldman, Columbia University)

Discussion 10:50 Coffee break

Plenary presentation of two preliminary Case Studies: Algeria (Dr Danielle Deboutte, WHO/EHA)

Indonesia (Dr Michael Toole, Macfarlane Burnett Centre)

Discussion, organization of working groups 12:30 Lunch Afternoon 14:30 Group Discussions

Reviewing the case study methods Identifying vulnerable countries for further case studies Setting criteria for identifying partners to conduct the studies Outlining process for follow-up at 6, 12, 24 months

16:00 Coffee break Feedback from Groups

General discussion 18:30 Reception

Day 2 – 14 December 1999 Morning 9:00 EHA synthesis of first day proceedings Plenary presentations: Community and institutional preparedness and resilience of health

systems (Dr Anthony Zwi, LSHTM)

Essential services packages: tools for the mitigation of complex emergencies (Dr Agostino Paganini, UNICEF)

Discussion

10:45 Coffee break Plenary presentations:

Health, governance and conflict management (Dr Carlyle Guerra De Macedo, Director Emeritus, PAHO/AMRO)

An overview of early warning mechanisms and United Nations' Framework for

Coordination ( Dr. Piero Calvi-Parisetti, OCHA)

Discussion

12:30 Lunch Afternoon 14:30 Group discussions, on separate themes

Essential package of health services to mitigate effects of complex emergencies

Strengthening institutions in vulnerable countries Integrating health sector reform and provision of essential health

services Coordination mechanisms for preparedness planning and mitigation

Feedback from Groups 1 and 2 16:00 Coffee break Feedback from Groups 3 and 4

General Discussion EHA Synthesis and Follow-up Plans

18:00 End of meeting

Planning Ahead for the Health Impact of Complex Emergencies.

Hints for Groupwork

Day 1: 13 December 1999 (Group 1) Review the case study methods Topic presentations: Algeria (DD), Indonesia (MT) Topics from the background paper: "..........mortality is a sensitive measure of the level of emergency. WHO publications (RHAP) indicate a daily crude mortality of 1/10,000 as the cut-off value for emergency warning. When previous rates are well known, a noticeable increase in mortality (doubling) is sometimes used. Recent events in Kosovo, though, qualify as a "Complex Emergency " in the mind of most, but did not feature increases in mortality rates." ".... "decision-producing" - early warning systems remain wanting. The quest for advanced humanitarian intelligence has stimulated a variety of initiatives... Nonetheless, the memory of the announced tragedy of Rwanda was still with most of us when it was revived by the events in East Timor.... one week of intense media coverage appears to carry much more weight than years of careful recording of worsening infant mortality rates. And the question remains open about whom controls the services that generate the health data (and their analysis and dissemination) in a politically tense situation. Humanitarian agencies should be unbiased advocates of the health and human rights of the population they serve. But UN agencies face a difficult plight. At country level, they have the national government as their counterpart. If the government becomes involved in a conflict, it becomes difficult for one country office to distance itself enough to provide impartial assistance to those in need. Special arrangements have to be set in place, and this takes precious time. At the same time, donors may be demanding a swift response in line with their own political interests and/or with the expectations of their taxpayers." " Various approaches have been developed for assessing the essential needs for health care, the simplest being measures of mortality and morbidity. The Rapid Appraisal approach (Rifkin, 1992) focuses on the community’s own view of needs, and thus is not constrained to only health or health care, encompassing broader aspects of social need. In a context of on-going or impending crisis, one could consider using also the WHO Rapid Health Assessment Protocols, or a combination of the two." ⇒ "How realistically can a government be called to prepare for its own demise, or to request

technical cooperation for such a contingency? ⇒ The first requirement for an early warning indicator to be of any value is that all those concerned

are ready and feel free to discuss it. ⇒ By definition, excluded minorities are the most vulnerable groups in any country and society." " This consultation should also help us agree to criteria defining an impending crisis and methods to study and monitor relevant indicators, and how to use them to develop technical capacities for a basic package of health services and public health interventions for countries in crisis"

Other topics Outputs • Consensus on key issues to be covered • A list of headings for the country case studies • Commitment for the follow-up from partners within and outside WHO Day 1: 13 December 1999 (Group 2) Identify vulnerable countries for further case studies Topic presentation The evolving nature of complex emergencies: health, risk and vulnerability( RW) Topics from the background paper "...... Estimates based on data of May 1999 from the UN Office for the Coordination of Humanitarian Affairs (OCHA), suggest that as many as 73 countries, with a total population of almost 1800 million people are passing through differing degrees of instability. Globalization demands high levels of ............ competitiveness. It risks marginalising entire regions... and exacts high social costs from countries undergoing economic and political transformation, as suggested by the steep reduction in life expectancy observed in Russia between 1992 and 1997, or by the case of the Democratic People's Republic of Korea, where the annual crude death rate increased from 6.8 per 1000 in the early '90s to 9.3 per1000 in 1998. The rapid changes ........include and interact with the redefinition of the role of the State. These include the crisis of the welfare system in industrialized countries, the collapse of states, and the explosion of violent conflicts in contexts of greater vulnerability, where changes can speed up and precipitate long-dormant tensions. (World Bank). Least developed countries see their capacity for health service delivery severely compromised or completely collapsed, such as in Somalia. The way institutions and societal systems respond to tensions and challenges varies and is difficult to predict. Thailand was able to resist the economic crisis that hit South East Asia in 1998, but Indonesia was severely affected. Albania was overwhelmed by the collapse of the pyramid schemes. The Caucasus and Balkan countries are struggling to stabilise their new institutional frameworks. Obviously, a country with marked social inequalities, food, job, economic, environmental and human-rights insecurity, and an inefficient or corrupt public sector is more vulnerable and more likely to see tensions - be they of economic, political, religious or ethnic nature - explode into violent conflict. Nevertheless, it is difficult to pinpoint a deterministic causality: not all inequalities necessary lead to violence, while in the former Yugoslavia the presence of a functioning state did not avoid the conflict. ......... various countries have passed through economic crises, political transition and even armed conflicts without the same health consequences or serious changes in health and disease dynamics. Sri Lanka is one such example.........that has been able to maintain essentially free basic health services and to prevent deterioration in national health indicators, except - and this is the important exception - within the zone of conflict itself. Other cases may include Nigeria, which passed through a long constitutional and economic crisis punctuated by civil strife in the Ogoni minority area, or Mexico, that suffered a severe economic crisis without major political instability, but it is nevertheless affected by a "low-intensity" civil war in Chiapas. ........ many countries find themselves along a spectrum of increasing vulnerability and instability, as the high-risk situations of Colombia, Indonesia and Myanmar illustrate, to the extreme case of Angola............. Whatever the prime cause of a crisis, it appears obvious that effective solutions to prevent further deterioration towards a “failed state” can only be within the political arena. Nonetheless, instability, crisis and complex emergencies have an undeniable impact upon public health. In Burundi, the annual under-5 mortality rate has increased from 108 per1000 in 1992 to 190 per1000 in 1998.

Other topics Outputs

• A list of vulnerable countries to be considered for further case studies; • Commitment for the follow-up from partners within and outside WHO

Day 1: 13 December 1999 ( Group 3) Set criteria for identifying in-country partners who will conduct the studies Topic presentation Algeria (DD), Indonesia (MT) Topics from the background paper " The quest for advanced humanitarian intelligence has stimulated a variety of initiatives: from the sets of indicators elaborated by DHA in the early '90s, passing through the UNICEF experience with vulnerability analysis, to the various frameworks promoted by OCHA/IASC... EHA through HINAP and Health as a Bridge for Peace, and by USAID/CERTI. .... the question remains open about whom controls the services that generate the health data (and their analysis and dissemination) in a politically tense situation. Humanitarian agencies should be unbiased advocates of the health and human rights of the population they serve. But UN agencies face a difficult plight. At country level, they have the national government as their counterpart. If the government becomes involved in a conflict, it becomes difficult for one country office to distance itself enough to provide impartial assistance to those in need." "These reflections are especially important for WHO. As a UN Specialised Agency accountable to its Governing Bodies, I.e. ultimately its member countries, WHO has to reconcile its unique responsibility in the Health sector, the Humanitarian Imperative and the mandate to develop the capacities and enhance or preserve the self-reliance of its primary constituents." " There is a self-evident relationship between complex emergencies and the strengths and weaknesses of societal and government structures ........in this perspective, it seems important to link health interventions to principles of good governance: § ...................... § Strengthening public sector management for more effective, equitable, and efficient delivery of

health and related services; § ....................... § Strengthening civil representation and participation to enable better scrutiny of policies and

practices. (B.Davis) Given the relationship between social tensions, the increasing of violence and the eruption of complex emergencies, health initiatives need also to be viewed along a spectrum defining their possible contribution to peace and/or conflict: § from simply not contributing to the conflict ......... § to actively promoting peace building through dialogue and collaboration on non-controversial

issues.." " The studies will be conducted through technical service agreements at country level. The reports will be brought to a follow-up meeting, where some countries could be selected to test/evaluate an integrated country Programme for/in unstable situations. This would then be conducted through the WHO country offices, to be strengthened accordingly with human and material resources, at least for a first pilot phase of 18 months" " Potential health partners in non-governmental sectors may be parties to the conflict" .

" The War Torn Societies Project has demonstrated the value of participatory action-research in post-conflict scenarios: can it apply to pre-conflict situations too? " Others Outputs • Information on country-based institutions who may conduct the studies • Agreed criteria for their involvement; • Commitment for the follow-up from partners within and outside WHO Day 1: 13 December 1999 ( Group 4) Outline the process for follow-up at 6, 12, 24 months Topic presentation Opening speech (GHB) Topics from the background paper " As the leading global public health agency, WHO.........seeks to identify options for acting to mitigate the impact of evolving economic and political crises on the health of populations. These options need to be explored firmly within the context of the Organization’s mandate, structure, and member state expectations. WHO does not have an international mandate to directly address the root political causes of conflict; however, it has an obligation to respond to identified risk factors for the deterioration of population health in any given setting. Briefly, this requires an early recognition of a vulnerable population, an analysis of the direct and indirect health consequences of economic and political instability, and the identification of critical health programs that need the support of the international community." "All the points mentioned above are reflected in various on-going EHA initiatives..... They also touch the fields of interest of its closest institutional partners within the Cluster of Sustainable Development and Healthy Environments (SDE): Nutrition, Poverty Reduction and Protection of Healthy Environments. They are reflected in major WHO regional initiatives.......The same concerns are reflected in major WHO's projects such as Roll Back Malaria, Polio eradication and Making Pregnancy Safe......, and the World Report on Violence. Finally, by themselves and by the situations that they aim at addressing, they are relevant to WHO in the definition of its Corporate Strategy" " This consultation can be considered as the first step in a process of study, discussion, research and pilot initiatives. It should help outline a conceptual framework for health, where different concerns can be accommodated and different activities optimised." "We hope to contribute options for a re-appraisal of WHO’s modus operandi in situations of enhanced risk or actual complex emergencies, at country and regional levels. We also expect to promote synergies between the Organization's institutional and technical functions, and the planning and operational frameworks as proposed by the UN Inter-Agency Standing Committee. In both perspectives, this initiative is essential for WHO's core constituents, its member countries." " What we can envisage at this stage is a first phase of country-level studies and planning, followed by another of test-implementation and evaluation. The studies will be conducted through technical service agreements at country level. The reports will be brought to a follow-up meeting, where some countries could be selected to test/evaluate an integrated country programme for/in unstable situations. This would then be conducted through the WHO country offices, to be strengthened accordingly with human and material resources, at least for a first pilot phase of 18 months"

Other topics Outputs • The essentials of a plan of work for the next 12 months • A list of points and appropriate mechanisms for further reflection • Commitment for the follow-up from partners within and outside WHO Day 2 :14 December 1999 ( Group 1) Essential package of health services to mitigate effects of complex emergencies Topic presentations Essential services packages: tools for the mitigation of complex emergencies (AP) Health, governance and conflict management (CGM) Topics from the background paper "... it seems important to link health interventions to principles of good governance: § Improving economic management to maximise and fairly distribute the benefits of economic

productivity; § Strengthening public sector management ....... § Promoting effective and equitable legal systems and strengthening the rule of law; and § Strengthening civil representation and participation...........(B.Davis) .... health initiatives need also to be viewed along a spectrum defining their possible contribution to peace and/or conflict: § from simply not contributing to the conflict ... (Anderson) § to actively promoting peace building through dialogue and collaboration.. (Zagaria and Arcadu)" " WHO has a clear role in assisting member countries to assess the vulnerability of the health sector and to set priorities for “essential packages”, I.e. health service interventions that society decides should be provided to everyone in the specific context of each country’s health system (Tarimo). Various approaches have been developed for assessing the essential needs for health care, the simplest being measures of mortality and morbidity. The Rapid Appraisal approach (Rifkin,) focuses on the community’s own view of needs, and thus is not constrained to only health or health care..... In a context of on-going or impending crisis, one could consider using also the WHO Rapid Health Assessment Protocols, or a combination of the two." " Whatever the content of the essential packages, they will have to be considered and readjusted following - or, ideally, foreseeing - the dynamics of the crisis: its impact upon the health needs, the most vulnerable groups, the intervening actors, the state of resources and support systems, the evolution of the overall national policy framework. ...... for health development and preparedness, health relief and post-crisis stabilisation and recovery.. " " The interventions that are most effective to protect public health, or prevent excess mortality/morbidity in complex emergency situations. These may address nutrition and water, include child vaccination and diarrhoeal disease or other control programme, and possibly the management of violent injuries, but they must also e) be suited to the country and acceptable to external donors in spite of the enhanced instability; f) ensure the best balance between basic survival needs and long-term health services

readjustments.... g) build on - and preserve- the capacities of the affected population, which may imply greater focus

on participatory assessment and health education/ promotion, rather than curative/preventive campaigns.

" The methods of delivery that best suit certain situations, keeping in mind the need for cost-effectiveness, governance and the health bridge for peace framework" " Ideally, such package should satisfy the following criteria: a) to be able to withstand any deterioration in the crisis, b) support the principles of good governance, c) contribute to conflict management, and d) optimise the entire range of expertise of WHO and its partners". Other topics Outputs • Strategic and programmatic options for mitigation, preparedness and response

vis-à-vis the health and nutrition consequences of complex emergencies. • Commitment for the follow-up from partners within and outside WHO Day 2 :14 December 1999 (Group 2) Strengthening institutions in vulnerable countries Topic presentation Community and institutional preparedness and resilience of health systems (AZ) Health, governance and conflict management (CGM) Topics from the background paper " Public health professionals have the responsibility to contribute to the wider effort, exploring mechanisms to strengthen the resilience of health systems. ...efforts should focus on preparing for situations where the health status of vulnerable communitie...is made worse or when entire societies become vulnerable because of collapsing governance" "There is a self-evident relationship between complex emergencies and the strengths and weaknesses of societal and government structures and their capacity to guarantee basic services also during a crisis. In this perspective, it seems important to link health interventions to principles of good governance........... Given the relationship between social tensions, the increasing of violence and the eruption of complex emergencies, health initiatives need also to be viewed along a spectrum defining their possible contribution to peace and/or conflict......" " From a Public Health point of view, these two sets of concerns can be reconciled by a) recognising that any continuum of care requires physical, economic and functional access to health services -I.e. inter-alia, stability, and b) accepting that health professionals have a responsibility to contribute to equity and justice within a society............On merely technical grounds, only public health programmes that consider the inequalities present in a society can address the needs of the entire population. Governments have duties and responsibilities toward all, not just a majority –or, worse, a minority- of its citizens. " In most developing countries, ............external assistance represents a large share of health expenditures. Major programmes, such as polio eradication ......, simply would not be possible without this support. Additionally, social insurance has often very low coverage, if any at all. The difficulty of raising taxes has led to look for alternative sources of funding; namely, community financing and patient charges. In an emergency, all of these funding systems are challenged. In as complex emergencies, the hurdle may get further complicated: militarization tends to compete with social expenditure and issues of funding..... can be at the very root of the political controversy. External assistance to the health sector is usually maintained, but it may end up being also constrained by political considerations, or simply by the difficulty of coordinating a suddenly swollen number of external partners. While it seems unlikely that a state would increase funding to the health sector when a complex emergency looms, it might be possible.... to reallocate the social sectors’ budget, or channel pre-

emptive external assistance, to preserve essential services and ensure equitable access to what is essential for survival". Governments should .... design health systems that can withstand crises. ... Placing social services high on the political agenda can help maintain social cohesion, national unity and stability, keeping militarization in check. WHO has a clear role in assisting member countries to assess the vulnerability of the health sector and to set priorities for “essential packages”, I.e. health service interventions that ....should be provided to everyone in the specific context of each country’s health system (Tarimo, 1997)." " The robustness of health systems ... includes c) the assets existing at the various levels....... that different partners can identify as worth protecting

........ d) ...partnerships other than MOHs...........in situations where governments’ legitimacy is at stake." " The methods of delivery that best suit certain situations................" Other topics Outputs § Strategic and programmatic options for mitigation, preparedness and response

vis-à-vis the health and nutrition consequences of complex emergencies. § Commitment for the follow-up from partners within and outside WHO Day 2 :14 December 1999 (Group 3) Integrating health sector reform and provision of essential health services Topic presentation Algeria case study (DD) Indonesia case study (MT) Community and institutional preparedness and resilience of health systems (AZ) Topics in the background paper "........one could ask whether all complex emergencies are also immediately "Health Emergencies". Do health workers always be on the forefront of relief ? Wouldn't resources be better applied beforehand, to increase the resilience of health systems in vulnerable countries, enabling them to deliver health care in spite of violent conflict?. Public health can be effective only in as much the security of victims or armed conflict is guaranteed (Perrin, 1998). But, in the eyes of beneficiaries and partners, the primary role of health workers is to prevent excess morbidity and mortality..........Security, protection and shelter, food, water, sanitation may be of more immediate benefit than providing health care. This does not imply that health workers should take on those tasks themselves. Their role lies in triggering action from other sectors, based on the priority needs identified through the first rapid assessment. If the need for medical care is less prominent, priority should go to the true requirements of the population. ..." " Public health professionals have the responsibility to contribute to the wider effort, exploring mechanisms to strengthen the resilience of health systems. In addition, efforts should focus on preparing for situations where the health status of vulnerable communities, namely the majority of the population in many settings, is made worse or when entire societies become vulnerable because of collapsing governance" ⇒ " By definition, excluded minorities are the most vulnerable groups in any country and society.

⇒ Structural adjustment programmes and constitutional changes may contribute to instability and tensions, but they do facilitate the devolution of health services to local authorities (Bjorkman, 1999) and can strengthen local health systems."

" The methods of delivery that best suit certain situations, keeping in mind the need for cost-effectiveness, governance and the health bridge for peace framework" Other topics Outputs § Strategic and programmatic options for mitigation, preparedness and response

vis-à-vis the health and nutrition consequences of complex emergencies. § Commitment for the follow-up from partners within and outside WHO Day 2 :14 December 1999 (Group 4) Coordination mechanisms for preparedness planning and mitigation Topic presentation Early warning mechanisms and UN Framework for Coordination ( PCP) Topics in the background paper: "Various approaches have been developed for assessing the essential needs for health care, the simplest being measures of mortality and morbidity. The Rapid Appraisal approach (Rifkin, 1992) focuses on the community’s own view of needs, and thus is not constrained to only health or health care, encompassing broader aspects of social need. In a context of on-going or impending crisis, one could consider using also the WHO Rapid Health Assessment Protocols, or a combination of the two. ....choices must be made between competing priorities. Ideally, this should be done through cost-benefit or cost-utility analysis. In practice, decisions on health interventions most often develop from the interplay of competing interest groups... (Walt, 1994). This is even more likely to happen in situations of political and social crisis. ...essential packages... will have to be considered and readjusted following - or, ideally, foreseeing - the dynamics of the crisis......... WHO has a role to play in inter-facing between the country's health sector and the many international partners, coordinating and complementing interventions for health development and preparedness, health relief and post-crisis stabilisation and recovery." ".... a first question touches on how to work with governments on preparedness for situations where their own authority might be at stake. This implies identifying what can and should be discussed with an endangered government, or, for that matter, with a community that perceives itself as excluded or persecuted..... ⇒ How realistically can a government be called to prepare for its own demise, or to request technical

cooperation for such a contingency? ⇒ The first requirement for an early warning indicator... is that all.....are ready and feel free to

discuss it."..... ⇒ Potential health partners in non-governmental sectors may be parties to the conflict. ⇒ How far can WHO go in the search of a compromise between the humanitarian imperative and its

fundamental goal of capacity building with and for member countries?" "The partnerships other than MOHs that can be more acceptable and more effective - in political, institutional and operational terms - in situations where governments’ legitimacy is at stake." " The tools and methods that best suit planning in situations of high instability and uncertainty: d) ..planning methods that involve the widest range of stakeholders seem to be most appropriate

when dialogue may be an objective in itself; but can logical frameworks accommodate all the contingency options that are needed..........?

e) The War Torn Societies Project has demonstrated the value of participatory action-research in post-conflict scenarios: can it apply to pre-conflict situations too?

f) which timeframe is more realistic and/or cost-effective in such situations? " "All the points mentioned above are reflected in various on-going EHA initiatives..... They also touch the fields of interest of its closest institutional partners within the Cluster of Sustainable Development and Healthy Environments (SDE): Nutrition, Poverty Reduction and Protection of Healthy Environments. They are reflected in major WHO regional initiatives...(and).... in major WHO's projects such as Roll Back Malaria, Polio eradication and Making Pregnancy Safer.... ... by themselves and by the situations that they aim at addressing, they are relevant to WHO in the definition of its Corporate Strategy" Other topics Outputs § Strategic and programmatic options for mitigation, preparedness and response

vis-à-vis the health and nutrition consequences of complex emergencies. § Commitment for the follow-up from partners within and outside WHO

Statement of Dr Gro Harlem Brundtland

Director-General World Health Organization

Planning Ahead for the Health Impact of Complex Emergencies Geneva, 13 December 1999 Dear Colleagues and Guests, Welcome to this consultation on Planning Ahead for the Health Impact of Complex Emergencies. Recently, I attended the launch of the UN Consolidated Inter-Agency appeal (CAP) for the year 2000. There, I underlined that Health is the cornerstone of humanitarian assistance, its ultimate objective and the true yardstick against which one can evaluate the needs for, and the overall performance of humanitarian assistance. The same message applies today, but I am here to invite you to put greater emphasis on what Health can contribute to prevention and preparedness for humanitarian emergencies. WHO has embarked in a process of reflection on health priorities in response to humanitarian emergencies. Today we want to look at what we can do for those countries that are on the brink of acute crisis and for those emerging from them. We feel that these are the contexts where WHO can really make a difference. There is consensus that, in order to facilitate stabilisation and recovery, humanitarian aid must be accompanied by investment in building civil society. WHO fully endorses this view. We also feel that investing in civil society, in vulnerability reduction and preparedness through Health before crises explode, may help defuse them. Placing health and social services high on the political and economic agenda can help maintain social cohesion, national unity and stability and ultimately reduce the need for humanitarian assistance. We see poor countries undergo periodical disasters along apparently immutable patterns. Economic downturns combine with natural disasters and trigger off emergencies in those countries that lack the capacity to cope with them. International consensus is growing that the distinction between natural disasters and human-induced emergencies is artificial and that there are no "Natural" Disasters. There are natural hazards, which can impact upon human vulnerabilities that are mostly determined by human causes. In this sense, all emergencies can be said to have political causes: either by commission or by omission. These reflections are important for the way WHO is carrying out its work and mandates. WHO has an often unique, long-term presence in almost two hundred countries, local partnerships and knowledge of the context where disasters take place

and of their impact on the people's health. We cannot ignore phenomena of this magnitude. It cannot ignore the mortality and morbidity associated with complex emergencies. It cannot ignore the risk of many countries losing costly and scarce health assets and opportunities for development. Nor, as a UN Specialized Agency accountable to our Member States, can WHO ignore the global trends. International funding declines faster for areas where political solutions continue to fail or that donors do not consider of strategic importance. Unfortunately, these very areas are often those where the needs are the greatest. In 1998, 93% of the UN appeal for Kosovo was funded, but only 41% of the one for Africa's Great Lakes, down from 84% in 1997. As humanitarian aid tends to concentrate in countries that are closer to the donors' doorstep, ways must be found to strengthen resilience and capacities in other more distant, vulnerable countries. These thoughts are not new to WHO, and have materialised in a number of global and regional programmes and initiatives. Recently, the Directors for Programme Management from all WHO Regions agreed on the need for the Organization to face the growing number of man-made and natural disasters. They pointed to the vulnerability of the poor, to the need for consensus, stronger leadership and greater capacities within WHO for mitigation and preparedness. Man-made disasters and other humanitarian emergencies will be one key theme of the 10th General Programme of Work that will be presented to the World Health assembly in May 2000. WHO's ultimate goal is to increase the self-reliance of its Member States. This consultation will look at the country level, where emergencies originate, and where WHO offices are tasked to deliver the Organization's technical cooperation. We need options on how WHO can best bring its corporate expertise to strengthen local health systems. WHO wants them to be more resilient during a crisis, prepared to absorb humanitarian assistance without being overwhelmed by it and capable to more towards recovery, once the crisis is over, without repeating the old mistakes. We have important experts in the field of emergencies. But we can always do better and let us not shy away from close scrutiny of our own performance. Our ability to work effectively at country level is a key measure of our work. There is still room for improving our performances and we should be open to new ideas and new ways of working. We need your opinion on which countries should be given priority attention, in terms of need and opportunities for action. You have to define what health systems may require in order to withstand a crisis and what are the essentials that these systems should be able to deliver in spite of the circumstances. We also need your advice on what can be identified as a health system and on who can be the relevant partners in situations of social disarray. We have to search together for the "common goods" that can catalyse dialogue and collaboration in spite of mistrust. We have to see how an ideal country framework for analysis and action could interface with the international systems for development assistance and humanitarian aid. Finally, we will need to consider how all this would impinge upon WHO's current modus operandi and what should be the next steps of the process.

Our vision in this area of work is of a world where communities can understand their vulnerability and prepare for the unexpected and where, when the unexpected happens, impac t of health is minimal. WHO has the obligation to assist its Member States to develop health systems that can withstand crises. We have to see together whether we have the capacities for this, and, if not, identify how to develop and apply them. Thank you. Have a fruitful meeting.

The Evolution of Complex Emergencies and The Future Role of WHO

Dr Ronald Waldman

Joseph L. Mailman School of Public Health of Columbia University Good morning. The objective of this meeting, as we have heard and read in the background document, is to help WHO to develop a strategy by which it can contribute to preparedness planning and to the mitigation of the health effects of complex emergencies in those countries that are determined to be most vulnerable. I admit, at the start, that this is one of the most difficult talks I have ever agreed to prepare. It is difficult on a number of levels: for one thing, you are a very diverse group. People involved in policy and politics; technical experts, who develop the guidelines and who contribute the science, to the extent that it exists; and operational people, who tend to criticize both of the other groups, but whose principal job is not to criticise, but to make sure that the right kind of work gets done in the right kind of way in the most difficult of circumstances. On another level of difficulty, although we are here to talk primarily about public health issues, it will be difficult, no, impossible, in fact, undesirable to focus only on public health – complex emergencies are complex in that the force intersectoral considerations. Not that this isn’t good, but it is difficult. We already know that complex emergencies have their roots in political, economic, social and environmental soils, and to try to stick to the theme of health will be very challenging. It will also be hard to talk only of preparedness – most of us in this room, I would guess, have been primarily involved in response, an area in which we have accumulated experience, even collected and analyzed data, and about which some clear directions for public health workers have emerged. I don’t think the same can be said about either preparedness or mitigation to the same extent and, in fact, one of the main messages of my remarks, and hopefully of the meeting, will be to collect, analyze, and act on relevant and accurate data to a far greater extent than what is currently the case. Finally, this talk is difficult because I will be talking about something we do not like to discuss – there is something profoundly disappointing about contemplating the failure of societies. And when we talk about complex emergencies, whatever definition we use (and I will come back to the question of definitions, if only to dispense with it as quickly as possible), whatever definition we use, we are talking about the inability of governments to take care of their constituencies. For those of us who work to protect and promote the public health, it is most unpleasant to consider that in our day and age, on our watch, we are witnessing – no, we are participating in, the loss of gains which had previously been made, and even made impressively in some places. But, worst of all, it is extremely unsettling to have to consider the problems we will be discussing for the next two days without being able to present a clear solution, one that could safely and effectively and uniformly be applied wherever and whenever it might be needed. The problems are profound – already an estimated 40-50 million people have been forcibly uprooted from their homes. Most of them have settled in inhospitable terrains, their lives temporarily and all too often permanently disrupted. Those affected by the complex emergencies which are the focus of this meeting have lost their jobs and livelihoods, their children’s education has ground to a halt, rates of morbidity and mortality are far in excess of what they have known, and they have lost

the ability to direct their own lives. And this situation reigns around the world – a few years ago it would have been difficult for any of my students to answer the question, what do these countries have in common: Burundi, Indonesia, Russia, Sierra Leone, Mexico. But now it has become clear: all are or have recently been involved in situations of low- or high-intensity conflict which has resulted in governmental instability at national and/or local level and has had a significantly negative impact on the health of their populations. So, the problem is clear. It is the solution that remains murky at best, unreachable at worst. It really makes one envy the immunization people and their vaccines. We don’t even use the same language – we are not talking about prevention here, but rather preparedness and mitigation. If an ounce of prevention is worth a pound of cure, how much is an ounce of mitigation worth? But before I paint too dark a picture, I better say that I, for one, firmly and steadfastly believe that vast improvements can be made. We are, or should be, in spite of ourselves, all optimists at heart, and we couldn’t wake up and go to work in the morning if we did not have the confidence that through our collective efforts we could find answers to even the most complicated of problems. But to solve the problems, we need to understand the constraints and, although a discussion of some of those constraints and how to overcome them will be at the heart of my remarks and the focus of the meeting, I’d first like to review briefly the cost of our failures and how the nature of the consequences of complex emergencies has evolved. SLIDE 1(definition): What we call complex emergencies today have, of course, been occurring for centuries. This is one of many definitions which was developed at a particular point in time, but it has already become outdated. I suggest that, at least for the purposes of this meeting, we not dwell on the finer points of one or the other relatively valid definitions, but that focus on situations where the public health systems have either broken down or are in danger of imminent collapse - 'complex public health emergencies', if you will. Many of you know that, when confronted with a request to define what constituted pornographic literature, a prominent United States Supreme Court justice replied “I can’t define it, but I know it when I see it”. I suspect that many of us might answer the same way regarding complex emergencies. Whether we call them ‘political’, ‘economic’, ‘humanitarian’, or whether we attach any other modifier, the impact on the affected population is the same: disruption, upro oting, danger. SLIDE 2 (number of people affected): Similarly, although the number of people affected in these ways by complex emergencies may fluctuate over time, SLIDE 3 (countries involved): and the number of countries involved in complex emergencies may grow or shrink, it remains clear that, as Robert Kaplan described in his famous 1994 article in the Atlantic Monthly entitled The Coming Anarchy, the elements that are coming together to bring about complex emergencies, including scarcity, crime, overpopulation, tribalism, disease, and misguided governance, will be with us for some time – the problem is likely to grow before it goes away, if it ever will. It sort of makes one long for the old days when all we had was simple famine, drought and pestilence. So we should study what we know about what happens in emergencies in order to learn why we need to be better prepared and better able to mitigate their effects. Unfortunately, because of the lack of data, we are only able to talk very intelligently about a relative few over the emergencies that have elicited major international responses over the past two decades. SLIDE 4 (Crude death rates): Although the ‘modern era’ of complex emergencies and, with it, the rise of humanitarian relief as we know it today, may be said to have begun with the Biafra secessionist war some thirty years ago, crude death rates, defined here as all deaths in the total population per month, began to be reported with

some regularity during the Cambodian crisis of the late 1970s. These are aggregate numbers from a variety of refugee situations, with crude mortality, generally from the early stages of the international relief effort (but, it should be noted, not necessarily from the early stages of the complex emergency). Comparison with baseline is complicated, of course by the fact that the baseline data is national, not local, and sources of the data are difficult to ascertain. But clear and important differences are consistently seen, with mortality in refugees ranging from about 7 to 25 times what might be expected. SLIDE 5 (child mortality in Sudan): When crude mortality is substantially increased over a prolonged period of time, it is usually the children who are most affected. Data regarding other age segments of the population have not been routinely collected, but there have been suggestions that, in situations of particularly intense and prolonged conflict, mortality in young men may be high enough to affect overall rates. Most would agree that the pattern shown here from Sudan and here (SLIDE 6) from Northern Iraq, are representative. SLIDE 7 (4 mortality experiences): Here we see the mortality experience of four different population as a function of how long their camp has been in existence. Again, it is important to remember that we only pick up the mortality experience of these populations from the time we come in contact with them, not from the start of the emergency. We do not know what has happened to the left of the graph, (the time that is the subject of this meeting), that is, before they fled from their homes and during their period of transit, although we frequently can guess. But we should be careful because we do have the horrible experience of refugees in Hartisheik A camp in eastern Ethiopia, where mortality increased steadily during the first nine months of the international relief effort, while the refugees were totally dependent on external aid. SLIDE 8 (Goma, with different denominators): The intensity of the mortality experience in Goma is well-known, but should always be explicitly reviewed. Of all the disturbing numbers on this slide, including the CMR and the proportion of the population that perished in less than one month’s time, one of the most disturbing is the discrepancy between these denominators. Not being able to establish the size of a population even of a population at risk of dying, renders life difficult for both epidemiologists and health service providers, yet this uncertainty is serious in all complex emergencies. SLIDE 8a--- In Goma, the numerator was easier to determine - bodies were picked up from the side of the road, since burial was almost impossible because of the volcanic nature of the soil. SLIDE 9 (Goma, bodies reported vs. bodies counted): The discrepancy between the number of deaths reported through the health system and the numbers of bodies counted is always worth pointing out and is a sober reminder for those delivering health services in emergencies that they need to work as far out in the community as early as possible, and not rely on the establishment of clinics to have an early impact. We are all familiar with some of the correlates of mortality in emergency settings. Malnutrition figures prominently among them. As you know, it had traditionally been thought that only the severely malnourished died. Now we know (primarily through the work of Pelletier and his colleagues at Cornell), that even mild and moderate malnutrition are substantial risk factor, at least for children. Food security, of course, is a key factor to address in considering emergency preparedness. It is the vulnerability of populations to interruptions in their food supply which contributes

greatly to the levels of mortality I have been showing. Much more can and should be done to guarantee to all people regular safe access to food and this should be done before a crisis develops, not in response to one. SLIDE 10,11,12 (causes of death series): Certain Interventions are eminently feasible and effective, when one is ready for them. Measles is a case in point in these slides, and measles vaccination has now become a recognized, almost reflex action of relief agencies. One can see in these slides that measles has essentially disappeared as a major cause of death in complex emergencies, although a large outbreak did occur in the eastern part of the Democratic Republic of the Congo earlier this year, claiming the lives of 1400 children. Ensuring high levels of vaccination coverage prior to an emergency would be a much more efficient way of influencing mortality. Strengthening other health activities in a pre-emptive fashion would also be useful. David Werner and David Saunders, in their publication entitled “Questioning the Solution” suggest that if the Rwandan population had been better prepared to prevent and treat dehydration on their own, instead of relying on government health services for the distribution of oral rehydration sachets, that mortality from the cholera epidemic in Goma in July 1994 could have been substantially reduced. SLIDE 13: Impact of War in Bosnia But the effect of emergencies has been evolving. We should, I feel, re-consider the importance of mortality as an indicator of an emergency, or as a trigger for response. I am not sure that I agree that mortality is still a very sensitive indicator of emergencies, as is suggested in the background paper. The prevalence of psychosocial problems in large populations who have had their societies uprooted, their homes destroyed, their families ripped apart cannot be demoted in importance because it does not result in higher than expected mortality rates. SLIDE 14: SGBV Crimes against women and other vulnerable people are not to be ignored, treated as secondary issues, and certainly not tolerated just because they do not result in mortality. SLIDE 15: Human rights abuses in Kosovo. The widespread and repeated violations of basic human rights witnessed over and over during the past few years of political chaos which has reigned in parts of our world requires study, intervention, and redress as surely as do the epidemics of measles and cholera with which we, as health professionals, sometimes feel more comfortable. The two most current emergencies to which international relief agencies are currently responding, those in Kosovo and E. Timor, are not at all associated with elevated mortality rates. Complex emergencies and the forced migration which accompanies them, in many ways can be said to take the lives of the living as well. So, I think that this very brief review of mortality and morbidity as the consequences of complex emergencies is compelling and amply justifies this meeting. The bottom line is that, as public health officials, we cannot allow situations such as the ones I’ve presented to occur. There is a growing sentiment, and a resentment in fact, in the humanitarian community that, despite the best of intentions, emergency relief is no more than a bandaid applied to wounds that just do not seem to heal. And, even worse, emergency relief, unless it is carefully and soundly applied, may in fact, in some cases, be working to the detriment of sustained development. Unfortunately, humanitarian response has been seen by some donors as a convenient and highly visible way to re-channel funding previously earmarked for development of the health sector.

So, then, I have tried to establish that prevention is better than cure, something we already knew. What can WHO do to promote emergency preparedness to mitigate the effects of complex emergencies in a world which we know has become confusing. I mentioned Kaplan’s argument that the future holds chaos; against that, and especially in light of recent event, we need to consider the inevitable, and in many ways beneficial, trend toward globalization, a trend that includes free trade, which many developing countries see as being potentially beneficial to their populations. These trends seem to lead in opposite directions, breakdown and societal anarchy on the one hand, stronger economies and accelerated development on the other. Frankly, the world right now doesn’t seem to make a lot of sense. One can only suspect that both lines will play out and that the often-mentioned disparity between the haves and the have-nots will continue to grow. As it does, one becomes quickly confronted with the question of constituency – who should the United Nations in general, and WHO in particular, seek to serve. It is naïve to thing that the needs of the population are always served by the State, yet the United Nations, and some have suggested WHO even more than the other specialized agencies, seems to be particularly loyal to its Member States. In his opening speech to this year’s session of the General Assembly, the Secretary-General of the United Nations declared that “state sovereignty, in its most basic sense, is being redefined…” He went on to say that we must be willing “to think anew about how the United Nations responds to the humanitarian crises affecting so much of the world…” And that is what we are supposed to do here for the next two ways – to think about how WHO and other organizations can adapt to changing conditions to bolster the health status of all people in order to minimize the health impact of complex emergencies. What WHO can do is not novel – what needs to be re-thought are the ways by which it can get its work done. I believe that WHO is perfectly well suited to do four specific things to help reduce the risk of poor health outcomes in countries where the risk of a complex emergency is greatest: First, it should develop, or I should say, continue to develop and to assist others who are in the process of developing, functional and relevant surveillance systems. WHO should play a leading role in conceptualizing the indicators that would be the best predictors of poor health outcomes in emergencies, it should test those indicators, and it should follow them in a number of selected countries to validate their usefulness. Early warning systems and emergency preparedness programs such as USAID’s CERTI and WHO’s Health as a Bridge for Peace and HINAP may not be sufficient, but they and others like them are unquestionably necessary. To date, these programs have been by and large inadequate or unheeded. Secondly, WHO should do what it traditionally does in other areas – serve as a technical guide to those working in humanitarian response. It should see itself as responsible for the setting of standards of performance and of accountability. Intervenors, be they from the public or NGO sector, be they state, NGO, or external, should adhere to clear guidelines. There are many examples of WHO having done just this in other fields, but humanitarian work has been distinctly marked by the lack of professional norms and standards. Mention should be made of the SPHERE Project and of the promise it holds for at least partially rectifying this situation. Thirdly, WHO must make a concerted effort to have its developmental policies and programs strengthened in ALL areas and in ALL population groups of emergency-prone countries. In attempting to do so, it may be confronted with the issue of sovereignty that was mentioned above – unlike the case with peaceful development, conflict-prone societies frequently deny access to health services and programs to large numbers of its population. Relief has frequently meant addressing the needs of those who have suffered from intentional aggression and violations of human rights. According to the Secretary-General, there is nothing in the UN Charter that

“precludes a recognition that there are rights beyond borders” – the right to health should be offered to all, regardless of where they live, regardless of who governs them. A good example of where disparities in health status and access to health programs may well contribute to conflict and emergency is in the state of Chiapas in southern Mexico. There, infant mortality is almost 50% higher than the national average, the prevalence of stunting is more than double the national average, and Chiapas ranks last among the states of Mexico for deaths from diarrhoea, from tuberculosis, and from all communicable diseases. Conflict has broken out once already in recent years, and the political situation remains quite unstable. Yet, humanitarian groups seeking to work there on developmental programs, and specifically on health programs, to redress this situation have had many obstacles placed in their way by government authorities. What should WHO’s role be in a situation like this? I believe that that is what we are going to be discussing during the course of this meeting. 4. Finally, WHO needs to promote research in the area of preparedness and mitigation. It is one thing to talk about the need for data, quite another to know which data are needed. What are the kinds of information to which policy makers will respond? When danger is imminent, what are the most compelling ways to use that data to effectively plead the case of those who are most likely to suffer? WHO has considerable expertise in this area and it should use that expertise in the field of complex emergencies as well. So, WHO has frequently proven its ability to establish surveillance systems, to promulgate norms and standards, and to assist the implementation of development programs in the health sector and to promote and use the findings of relevant research. But it may not be perfectly well-suited to do these things in the case of incipient emergencies unless it adapts to today's circumstances. In order to be effective in today’s world, WHO will have to become more proactive in its pursuit of equity in the health sector as a means of preventing disaster. One other thing, and perhaps the most important thing, that WHO ought to do, in my opinion, which it has not done optimally in the past, is to become a strong and forceful and effective advocate of the people whose lives it is seeking to improve. Early warning systems are not enough – they can be an excuse to say that something is being done while, in fact, a blind eye is being turned away. What we need even more than early warning is early action. May be this meeting can help advise about which actions would be most appropriate. Similarly, the simple promulgation of norms and standards in not enough. SLIDE 17: This is the black deck of the slave ship Wildfire – slave ships transported over 600 people from Africa to Europe on decks that were separated by 18 inches. To one observer, a slave-deck was “so covered with blood and mucus that it resembled a slaughter house.” Or, in a way, maybe a tortured precursor of the early stages of some of today’s refugee camps. Is this such a wildly extreme example? Is it so far removed from the degree of human rights abuses that have been so well documented in Sierra Leone, in Kosovo, and in East Timor? Without meaning to be overly cynical, let me suggest that if WHO had existed during the time of the slave trade, it would not have been acceptable for it to develop and disseminate standards for the minimum amount of space to accorded to each slave. And today, it is not enough to go about doing one’s business without a strong moral commitment and a clear-cut strategy for seeing that those standards will be respected and adhered to not only to their letter, but in their spirit as well.

Finally, on this point, let me stress that WHO does not and should not have to bear the burden by itself. Nothing I have mentioned, including the advocacy role, needs to be done alone and in fact nothing should be. WHO would have no trouble finding willing and able partners. The clout of a supportive United Nations agency would do wonders for the effectiveness of the NGO community, for example, if that support were tangible and dependable. WHO should recognize that humanitarian community sometimes feels that it has been let down by an overly bureaucratic, slow to respond, and unsympathetic agency. Partnerships with NGOs, with the commercial private sector, with other elements of the public sector, and perhaps most importantly with representatives of the affected communities, will be necessary if the health impact of impending emergencies is to be mitigated. In closing, it is clear that I have been true to my word - I have not been able to restrict myself to speaking, in technical terms, of public health issues. Many of the issues with which we are involved are of a political nature. All of us, WHO included, must take stands on the issues which confront us, stands which are based on the best available data and which we must promote in order to justify our own actions and to influence and guide the actions of others. We must do so strongly and effectively in order to better serve the millions of people whose lives are at risk of being hopelessly disrupted or unnecessarily lost. Thank you.

Lessons from Algeria By Dr D. Deboutte

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•• UUrrbbaann ddwweelllleerrss:: 5533%%

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• Cardio-vascular (24.5)

• Trauma and poisoning (12%)

• Symptoms (12%)

• Tumours (10.5%)

• Endocrine disorders (7.5%)

• Respiratory system (7%)

• Genito-urinary system (7%)

• CNS and sensory organs (4%)

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• enterically transmitted conditions : 40/100,000 (1997) down to 32 in 1998

• drop in typhoid fever and viral hepatitis

• dysentery: 9.75/100,000 (1997) 10.8/100,000 (1998); compare to 7.25 in 1990 and 5.57/100,000 in 1991

7. NNuuttrriittiioonn

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• Iodine deficiency : 25.9% (mild), 15% (moderate) 7.2% (severe) (1995)

•• Vitamin A deficiency is not considered to be a public health problem, but vitamin D deficiency continues to occur.

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•• proportion of budget spent on salaries 86% (1994) reduced to 59% in 1999

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The Impact of the Financial Crisis and Recent Political Changes on the Health

Sector in Indonesia Presentation of Dr M. Toole

Mike Toole, Alison Rodger, Brad Otto

Macfarlane Burnet Centre for Medical Research Melbourne, Australia

December 1999

Based on a study commissioned by the Australian Agency for International Development

Table of Contents ABBREVIATIONS SUMMARY Indicators of the Effects of the Crisis Responses to the Crisis I. BACKGROUND Political Factors Health Indicators Table 1: Comparative health indicators in SE Asia (1998) Figure 1: Rice Production and imports 1990 to 1999 (Indonesia) II. SOCIAL IMPACT OF ECONOMIC CRISIS Table 2: Household per Capita Expenditures: 1997, 1998 & Changes - rupiah per month ('000) III. INDICATORS OF THE EFFECTS OF THE CRISIS ON THE HEALTH SECTOR HEALTH FINANCING International Comparisons

Recent Trends in Indonesia Health Sector Funding Table 3: Health budget allocation as a share of total public expenditure (in billion rupiah) Table 4: Actual central government and aid expenditure (realisation) compared to allocation in million rupiah Specific Impact of the Crisis on Expenditure on Health Table 5: Functional breakdown of central Government and external aid funds, 1994/5 & 1997/8 in million rupiah IMPACT OF ECONOMIC CRISIS ON COVERAGE AND UTILISATION OF HEALTH SERVICES Utilisation of health services and private expenditure on health Table 6: IFLS2+Use of health services, particularly public health services And SUSENAS data on contact rates Table 7: Impact on the use of health services Immunisation Coverage Table 8: Immunisation uptake for children less than 3 years of age Family Planning Services MCH Services IMPACT OF ECONOMIC CRISIS ON HEALTH OUTCOMES Countrywide Trends General Indicators of Health and Nutrition Table 11: Indicators of health and nutritional status derived from the IFLS 2 + data Nutrition Surveillance System Tuberculosis (TB) STDs HIV/AIDS Impact in Areas of Civil Strife IV. Response to the Crisis

INDONESIAN GOVERNMENT RESPONSE The Social Safety Net (SSN) Nutritional SSN initiatives Other SSN health initiatives The Impact of Decentralisation EXTERNAL ASSISTANCE World Bank Asian Development Bank UNICEF World Food Programme Table 12: Summary of Donor Activity in response to the crisis (excepting World Bank and ADB) Non Governmental and Community Based Organisations V. POTENTIAL AREAS FOR DONOR FOCUS REFERENCES Appendix 1: Key Health Indicators in Indonesia Pre Crisis Appendix 2: Surveys and Data Sources Helen Keller International UNICEF 100 Villages Survey Poverty Analysis and Monitoring Unit Kecamantan Rapid Poverty Survey The Indonesia Family Life Survey UNDP On-The-Ground Monitoring Survey SUSENAS BKKBN Central Bureau of Planning (BAPPENAS) Ministry of Health Kecamantan Crisis Impact Survey

Abbreviations ACF Action contre la Faim ADB Asian Development Bank AIDS Acquired Immune Deficiency Virus BAPPENAS National Planning Bureau BCG Bacille Calmette-Guerin vaccine BKKBN National Family Planning Board BLN Foreign Aid BPS Central Statistics Bureau CHD Centre for Health Data, Ministry of Health DEPKES Ministry of Health Dinas Provincial government health department FP family planning GDP gross domestic product GOI Government of Indonesia HBV hepatitis B vaccine HIV Human immunodeficiency virus HKI Helen Keller International HNSDP Health and Nutrition Sector Development Program HSFP Health Sector Financing Project ICRC International Committee of the Red Cross IFLS2 Indonesia Family Life Survey, Round 2 IMRs infant mortality rate(s) INPRES Presidential instruction (infrastructure and drugs allocations) IUD intrauterine device JICA Japanese International Cooperation Agency JKB Jakarta-based NGO JPKM community health insurance scheme Kanwil provincial office of the Ministry of Health Kartu Sehat Health card which provides free of charge health services for the poor Kasehatan Health MCH maternal and child health MDM Medicins du Monde MMR maternal mortality ratio MoH Ministry of Health MSF Médecins sans Frontières NGO(s) non-government organisation NTB West Nusa Tenggara province NTT East Nusa Tenggara province OCP oral contraceptive pill PMI Indonesia Red Cross PMTAS School Snack Program Posyandu Community Integrated Health Services Post Puskesmas Health centre RI Republic of Indonesia Rp Rupiah Rumah sakit hospital SKRT Households Health Survey SMERU Social Monitoring and Emergency Response Unit (World Bank

supported officer to study effects of economic crisis) SPSDP Social Protection Sector Development Program SSN Social Safety Net

STD sexually transmitted diseases Surat miskin certificate letter of poor SUSENAS National Socio -Economic Census TB tuberculosis TBA (dukun) traditional birth attendant UN United Nations UNDP United Nations Development Program UNFPA United Nations Family Planning Agency UNICEF United Nations Children’s Fund UNSFIR United Nations Support Facility for Indonesian Recovery USD United States dollar WFP World Food Program WHO World Health Organization

Summary This paper examines the health effects primarily of the financial crisis in Indonesia. The political changes that followed the onset of the crisis are described and reference is made to particular geographic areas where political, ethnic, or religious violence has occurred. Since East Timor is no longer part of Indonesian, the health situation in that former province post-referendum is not examined in depth. Few reliable data were found on the health effects of conflicts in West Kalimantan, Aceh, Ambon, and Irian Jaya. The economic crisis in Indonesia commenced in the latter half of 1997 and was probably more complex than in other East Asian countries due to the political and social dimensions which complicated economic difficulties and the responses. One of the first effects of the economic crisis was that the currency depreciated strikingly – from Rp 2,000 per USD to more than 10,000 per USD within 6 months. Companies and factories closed down and unemployment rose. The crisis was further compounded by El Niño, which caused a severe drought in the eastern part of the country and extensive fires in other areas.

Indicators of the Effects of the Crisis Indonesia’s health expenditure is relatively low as a percentage of public spending. Rising Government spending on health was observed until 1996/7. During 1997/98 total expenditure on health fell, despite a 34% increase in foreign aid input in real terms. Declining budgetary support has particularly affected the most peripheral health services (the village-based posyandu) which have traditionally focused on prevention and health promotion activities. The cost of essential drugs (including contraceptives) has risen substantially. Overall, the crisis has a strong urban bias. Using the BPS official poverty line definition of poverty, it is estimated that the proportion of the population in (absolute) poverty increased from 11% to around 14% (less than predicted). The main effects can be summarised as follows: • The impact of the crisis has been serious, but much less severe than that predicted. • The impact has been very uneven; Java has been hard hit even in rural areas; large

parts of Sumatra, Sulawesi, and Maluku, have experienced minimal negative effects; and other areas show negative impact, but it is unclear whether problems are economic crisis-related or result from drought (East Timor, NTT, NTB) and fires (East Kalimantan).

• Pre-crisis economic status has not been a good predictor of actual impact. Information on the crisis on health in Indonesia is scattered and largely anecdotal; however, the effects are likely to be in the following areas: • Nutritional status, especially on the very young, reproductive age women and the

elderly • Availability of drugs and other medical supplies • Rise in some communicable diseases, e.g. STDs, TB, diarrhoeal diseases • Switching by users to cheaper forms of health care provision

• Delays in or failure to take up medical treatment As the crisis developed, it was predicted that there would be a general shift from private sector health facilities to the subsidised public sector. Instead, it appears that use of both public and private sector facilities has been falling steadily and being replaced by higher rates of self-treatment. However, utilisation rates--which were never high in Indonesia--appear to have been falling since at least 1995. A decline of about two percentage points has been observed in the use of public services by adults

between 1997 and 1998 and a decrease of 6% was also found in the overall use of health care among children. Decreased use was seen in both urban and rural areas. Childhood immunisation had been nearly universal pre crisis in Indonesia according to official figures. Reports suggest that thus far decreasing rates of participation by children in the posyandu program have not produced significant declines in immunisation coverage. A decline in Vitamin A coverage has been observed. There has been little change in the prevalence of contraceptive use or in the method mix between 1997 and 1998 although prices of services at both public and private providers have risen considerably with the exception of the oral contraceptive pill (OCP). There has also been a reported increase of the use of IUDs. Reliance for MCH services appears to be on less expensive services and there has been almost 5 fold increase, (from 1.6% to 7.1%), in family members delivering babies. BPS figures on changes in the consumer price index between early 1996 and August 1998 show an overall price increase for services and drugs of 61%. Some antibiotics doubled in price, as did chloroquine. Health and nutrition indicators from national surveys demonstrate the complexity of investigating health effects using routine data. Overall, these data are not inconsistent with the evidence of a complex and heterogeneous crisis, with pockets of serious health effects. The percentage of persons experiencing severe health problems has increased substantially from 12.8% in 1997 to 14.6% in 1998 with urban areas more affected than rural. With regards to gender, the data show greater effects on women. The Watching Brief analysis demonstrates that malnutrition among under 5s has decreased overall from 34.9% in 1992 to 29.8% in 1998. Urban rates have remained at around 28%. Overall, this study considers child malnutrition a greater problem in rural areas. The HKI reports show increased prevalence of micronutrient deficiencies (especially vitamin A) and increased wasting among under 5s and women. IFLS2 data show a mixed picture and indicate that haemoglobin levels have actually improved on average between 1997 and 1998 and that children have experienced an increase in weight for height. However, adult Body Mass Index has declined. TB is ranked as the number one infectious disease in Indonesia. DOTS has been adopted as the national policy, but problems existed with the program even pre crisis. The economic crisis may affect availability of treatment and compliance rates. To date there has been no evidence of serious STD public health risks arising from the crisis; however, these may become apparent later. There is an urgent need to improve basic surveillance through sentinel site monitoring and other means of rapid epidemiological assessment. The number of reported cases of HIV reported to date is lower than earlier estimates, but there is an increasing trend and the potential for epidemic spread exists both due to sexual transmission and also IDU (there are an estimated 100,000 users of illicit drugs in Jakarta alone). Reliable reports indicate that the number of sex workers in West Timor and their average number of daily clients have significantly increased since the exodus of the anti-independence militia from East Timor in September. Responses to the Crisis The major response to the crisis by the Indonesian Government (GOI) was expansion and restructuring of the Social Safety Net (SSN) with support from major donors, in particular the World Bank and the ADB. Approximately 55.5% of the development budget (about Rp 17.3 trillion) was allocated for SSN schemes, implemented through four broad categories. Approximately 11.5% of the SSN allocation is for health. All SSN funds are supposed to be targeted exclusively on poor households. Poor households are issued with health cards (kartu sehat) which can be used to obtain free health services. Services are offered under the following programs: Basic Health

Services, JPKM/Health Card, Health Services for Pregnant women., Food and Nutrition Interventions, Hospital Operational Costs. There is great confusion in the Ministry of Health as to what the impact will be of the proposed district level decentralisation. Central level program managers are at a loss to explain what decentralisation will mean for health program design, management, coordination, or evaluation. There is currently little to no capacity for district level health staff to take on the responsibilities of program management as envisaged in the decentralisation plan. To date, it is unclear what plans there are to develop that capacity. There is currently a discussion to dissolve the provincial level offices of the ministry of health (Kanwil Kesehatan), and have all provincial level activities operate from the Home Affairs Health Services Offices (Dinas Kesehatan Tk I). This possibility adds additional confusion about respective roles of central, provincial, and district health offices in a decentralised environment. The World Bank and the ADB are the two largest international donors contributing to financing the SSN. Assistance is by way of long term loans rather than grants. The loans provide general GOI support, specific support for the social and nutrition sectors, and funds for other designated projects. The UN agencies provided funds and expertise in a number of areas including emergency food assistance (WFP), nutritional support to infants and mothers (UNICEF), subsiding drugs and other supplies (UNDP) and maternal health programs (UNFPA). Support from bilateral donors has ranged from small programs undertaken by NGOs to resources for the SSN. Australia, Japan and the USA provided food aid. Japan has subsided drugs and other essential supplies. Bilateral donors have also funded design and evaluation projects. Recommendations Donors should build on existing programs. Effective program design is crucial and priority should be given to funding services that serve the poor in deprived urban poor areas or remote rural areas. Special attention should be given to ensuring free access by the poor to health services. Crisis responses should not weaken or replace existing structures and should promote community development. Specific responses could include: Minimising the impact on vuln erable groups: Children and pregnant and lactating women are at greatest risk. Targeted supplements may be easier to implement and monitor. Micronutrient supplementation for vulnerable groups is vital, in particular in urban areas. Ensuring supply and ra tional use of drugs: Review of current policy and practice, promotion of rational use of drugs, increased use of generic drugs, and standardised prescribing practices. Logistics systems also need improving. Strengthening health information: There is a major problem of lack of good information on the impact of the crisis. Even prior to the crisis little was known about health seeking behaviour of the poor and causes for their low utilisation of services. Given the urgent need to have an informed basis fo r policy making in health planning and financing, this represents a loss to the planning process. Strengthening of health information systems is an urgent priority, including surveillance focussed on politically vulnerable areas, such as Aceh, Ambon, North Maluku, West Kalimantan, West Timor, and Irian Jaya. Given that Pusat Data is currently working with significant World Bank funding and other donor support and input into surveillance, it would be critical to assess the current status of these efforts before any additional support were to be proposed to the national system. Assistance with improving public health surveillance would be better focussed at developing capacity at peripheral levels (district and province) to

analyse, interpret, and use surveillance data for health program evaluation and planning. With the uncertainties created by the impending decentralisation of health planning to district levels, increasing the skills of program managers at peripheral levels to better use whatever data they have access to would derive the most benefit. HIV/AIDS: There is a need to strengthen and expand HIV/AIDs and STD surveillance. Harm reduction activities should be supported and STD treatment services strengthened at PHC level. Capacity and strengthened roles of NGOs in this area should be supported. Government activities should be supported especially in key areas where budget savings may be attempted by the Government. Ensuring provision of basic health services: In areas where the government is unable to provide adequate coverage, donors should supplement activities and funding requirements. Potential areas where shortfall could occur include immunisation, maternal and child health, family planning services, and tuberculosis treatment and control. Strengthening primary health care services in urban areas: Available data on the effects of the crisis indicate a particularly strong impact on the urban poor. Most previous activities by donors in the health sector have emphasised rural primary health care. There is a need for additional donor support to the development of appropriate and innovative urban primary health care services.

I. Background2 The economic crisis has affected Indonesia since 1997 and was probably more complex than in other East Asian countries due to the political and social dimensions which have complicated current difficulties and the responses. One of the first effects was that the currency depreciated strikingly – from Rp 2,000 per USD to more than 17,000 per USD within 6 months. Companies and factories closed down and unemployment rose – an estimated 8 million people have lost jobs since 1997. The crisis was further compounded by El Niño that caused a severe drought in the eastern part of the country and serious fires in other areas during 1997. This resulted in reduced agricultural production and increased environmental degradation. One result of this was the increased requirement for imported rice (Figure 1) at inflated prices due to the collapse of the rupiah.

Politic al Factors In May 1998, an estimated one million people took to the streets of Jakarta to call for an end to the “New Order” regime of President Soeharto. On May 21, Soeharto resigned and appointed B.J. Habibie as head of a transitional government. In June 1999, relatively peaceful elections took place installing a new Parliament, followed in October by the election of a new President Abdurrahman (Gus Dur) Wahid. In August 1999, the people of the province of East Timor overwhelmingly voted for independence from Indonesia. Widespread violence, destruction, and depopulation followed the vote, perpetrated by anti-independence militia; there is also evidence that elements of the Indonesian military forces may have been involved (International Crisis Group, October 1999). Between 300-400,000 East Timorese were displaced, of whom more than 260,000 were forced into neighbouring West Timor. Health facilities in West Timor were overwhelmed by the influx. The rapid deployment of a multinational force (INTERFET) has created the security conditions to allow the steady return of East Timorese to their homes, including an estimated 90,000 returnees from West Timor (Office of US Foreign Disaster Assistance, November 24, 1999). The northwestern province of Aceh has had a secessionist movement at least since 1974. Between 1989 and 1998 the province was a Military Operational Zone within which the army had sweeping powers. Various crackdowns on dissent have cost numerous lives, including 41 people who died in Beutong in July 1999 (International Crisis Group, October 1999). During this time, popular support for secession has steadily grown and was illustrated by a recent demonstration of hundreds of thousands of people in favour of independence. In January 1999, violence between Christian and Muslim communities on the island of Ambon in Maluku province led to hundreds of deaths and the displacement of between 20,000 and 30,000 people into 48 camps across the islands of the archipelago. A near state of war still exists between the two groups in Ambon and violence flared again in November and spread to other island communities. In June 1999, violence between ethnic Madurese and Melayu in Sambas, West Kalimantan resulted in the displacement of some 30,000 Madurese into camps in Singkawang and Pontianak.

2 The bulk of this report focuses on the documented effects of the financial crisis on the health sector and makes reference, where appropriate, to the impact on health that can be attributed to political events. However, in December 1999, there were few precise data available on changes in health trends in Aceh, Ambon, West Kalimantan, and East Timor beyond a few nutritional surveys and generalities about major health problems.

The eastern province of Irian Jaya has had an active armed resistance group since the 1970s. Conflict between the Free Papua Movement and the Indonesian military has created waves of displaced people, including tens of thousands of refugees into neighbouring Papua-New Guinea. Health Indicators In terms of health status, Indonesia made great progress between the 1960s and 1990s in terms of life expectancy (61 years in 1995) and infant mortality rate [IMR] (50 per 1000 live births in 1995) see Appendix 1. However, it still lags behind its Asian neighbours and much of the progress was recorded prior to this decade. The progress has also not been nationwide, with some districts still recording IMRs of over 100 and others between 25-30. Although Indonesia is entering the epidemiological transition, with the leading cause of death already cardiac disease, the next four leading causes of death remain communicable diseases. Table 1: Comparative health indicators in SE Asia (1998)

Country

IMR

(per 1000

live births)

Life

expectancy

at birth

(years)

MMR

(per 100,000

live births)

<5 mortality

rate (per

1000 live

births)

Fertility

rate (births

per woman)

Indonesia 52 64 390 75 2.8

Malaysia 12 71 34 14 3.4

Philippines 40 67 208 53 3.8

Thailand 35 69 200 42 2.1

Source: Asian Development Bank, in The Health Sector in Indonesia: The Road to Reform. Prepared by PT Hickling Indonesia under a contract from The Canadian International Development Agency. 1999.

Figure 1: Rice production and imports 1990 to 1999 (Indonesia)

Source: Food and Agriculture Organisation (UN Rice market monitor) 1999.

One of the significant shortages experienced during the crisis was that of raw materials for drug production. Due to the lack of confidence in the banking sector the pharmaceutical industry was not able to open letters of credit. About 90% of raw materials for pharmaceuticals were imported and production was severely affected during the crisis. Provinces and district health offices had a reduction in operating budgets resulting in cuts in preventive programs. Government hospitals were faced with increased operating and drug costs. Health was identified by the GOI as one of the national priorities during the crisis and 13 susceptible gro ups have been identified as target populations for assistance – including the poor, new born infants, pregnant women, the elderly, malnourished and people from the eastern part of Indonesia affected by El Niño. The GOI’s response to the crisis was not to expand capital investment on health but, with the support of international donors, to provide services for the poor and elderly, maintain MCH services, and ensure supply of essential drugs. Expansion of the social security safety net formed a major component of the overall response. (SMERU 1998, Ministry of Health Nov 1998, Asian Development Bank Nov 1998, Canadian International Development Agency 1999, BAPPENAS 1998, UNSFIR 1999).

II. Social Impact of Economic Crisis The first reports on the effects of the crisis were alarming. BPS estimated that poverty would increase from 11% of the population (22 million) to 40% (80m). The Minister for Food announced that 17 million were likely to suffer food shortages. The ILO projected an increase in the official poverty rate of 11% to 66% by 1999. It has become clear that the most dramatic projections have not been borne out. (Institute for Health Sector Development/ World Bank. 1999 Overall, the crisis has a strong urban bias where the depreciated rupiah, corporate debt, illiquid banks, exorbitant interest rates, exit of foreign investment and lack of trade finance, have to a large extent paralyzed the formal economy. The preliminary data from the IFLS 2+ household survey in seven provinces shows that average per capita household expenditure had decreased by 24 percent (Table 2). Average household spending in urban areas fell by 34 percent with the median falling by 5 percent. In contrast, rural expenditures fell by much less, with mean expenditure falling 13 percent, but median expenditure falling by only 1.6 percent. Table 2 Household Per Capita Expenditures: 1997,1998 & Changes -

rupiah per month (‘000)

Mean Change in 1998 Percent Change

1997 Mean Median Mean Median

Urban 319 -108 -7 -33.9% -5.0%

Rural 194 -26 -2 -13.4% -1.6%

All respondents 246 -60 -2 -24.4% -1.5%

Source IFLS2

Recent reports from World Bank researchers (Poppele et.al., Sumarto et.al. 1999) attempted to triangulate three key sources. These are the Indonesian Family Life Survey (IFLS2), which tracks household level changes between August/September 1997-8; the 100 villages survey, which tracks household level changes between July 1997 and August 1998; and the Kecamatan Rapid Poverty Assessment, in which expert respondents from 4,000 sub-districts gave qualitative assessments of the impact of the crisis. Using the BPS official poverty line definition of poverty, they estimate the proportion in (absolute) poverty will increase from 11% to around 14%. These studies suggest a major revision of the crisis scenario. The main findings can be summarised as follows: • The impact of the crisis has been severe but much less so than most dire observers

had predicted. • The impact has been very uneven – agricultural exports have boomed in some

areas as a result of the devaluation of the rupiah. Ø Java is hard hit, even in rural areas, Ø Some of the other islands, particularly large parts of Sumatra, Sulawesi, and

Maluku, have experienced minimal negative crisis impact and areas that escaped the drought may actually be booming from export crop earnings (due to the currency depreciation);

Ø Other areas show negative impact, but it is unclear whether problems are economic crisis-related or result from drought (East Timor, NTT, NTB), fires (East Kalimantan), or political instability (East Timor, West Kalimantan, Irian Jaya).

• Pre-crisis economic status is not a good indicator of impact - some poor areas have not been hit particularly, while some well off areas have been very hard hit. Equally, some of the poor are doing even worse

• The crisis has hit the affluent disproportionately harder than the poor, with the newly emergent middle class the “worst” hit. (Institute for Health Sector Development/ World Bank. 1999)

• III. Indicators of the Effects of the Crisis on the Health Sector Health Financing International Comparisons The Indonesian Health sector usually has a relatively low allocation of resources, especially when compared with other Asian countries. The 1990 World Development Report indicates the public and private share of GDP allocated for health in Indonesia was 2.5%, compared to 4.5% in other Asian countries. The World Bank’s Health, Nutrition and Population Sector Strategy Paper (1998) shows similar findings for more recent years, with Indonesia’s health expenditure (particularly public spending on health) remaining relatively low as a per cent of GDP. The IMF’s 1998 annual statistical yearbook indicates that Indonesia’s health expenditure is also relatively low as a percentage of public spending, 2.5% (1996), in comparison with Malaysia (6.3% in 1997), Thailand (8.6% in 1997) and Philippines (3.2% in 1997). Recent Trends in Indonesian Health Sector Funding Despite the relatively low comparative figures for health expenditure, Indonesia’s commitment to the health sector has been rising as a share of all public spending (Health Sector Financing Consultancy Report. Institute for Health Sector Development/The World Bank. 1999). Table 3 shows the allocations for total Government spending and public expenditure on health. These figures are for allocations and include foreign aid. They therefore show intentions rather than actual spending.

Table 3: Health budget allocation as a share of total public expenditure

(in billion rupiah)

Year Health allocation Total public expenditure Percentage

1992/93 1,971.0 59,960.5 3.29 1993/94 2,225.5 66,865.6 3.33 1994/95 2,599.6 74,760.7 3.48 1995/96 2,803.0 82,352.5 3.40 1996/97 3,352.6 90.616.4 3.70 1997/98 4,560.8 100,317.6 4.55

Sources: 1985/6 (Prescott et al), other years (Malik et al, 1997).

Table 4 shows a rise in expenditure in nominal terms in each year, with rising government spending until 1996/7 and the increase in 1997/8 due to the rise in foreign aid . In real terms, total expenditure fell in 1997/8, despite a 34% increase in foreign aid input in real terms.

Table 4: Actual central government and aid expenditure (realisation) compared to allocation in million rupiah

Earmarked Govt. Health Budgets

Foreign Donor Assistance for

Health

Other Govt.

Spending

Year

Allocation Realised Allocation Realised Estimated realisation

Total estimated

realisation in current

prices

Total estimated realisation in real terms in

93/4 prices

Percentage change to previous

year

1994/95 1,354,593 1,648,840 122%

373,271 142,415 38%

492,883 2,284,138 2,114,944

1995/96 1,673,475 1,918,589 115%

397,483 157,046 40%

589,992 2,665,627 2,259,007 +6,8%

1996/97 1,930,745 2,079,683 108%

451,238 154,503 34%

690,741 2,924,927 2,285,099 +1,5%

1997/98 2,453,333 1,933,334 79%

771,529 267,739 35%

814,678 3,015,751 1,816,717 -21%

Source: DEPKES data, compiled by the World Bank Notes: Earmarked Government health budgets are DIK, DIP, INPRES for health, SBBO, & OPRS. Other Government includes estimates for SDO, military & other non-DEPKES health expenditure. There was lower expenditure than allocations in the majority of provinces (except Jakarta, West Java and East Timor), particularly in 1997/8. Reasons for lower than allocated expenditure include: • some under-spending on health service construction, may have been due to delays

in capital expenditure for facility development; this could explain low performance in particular provinces but not general low spending in 1997/8;

• provincial and district governments may be diverting part of the budgets intended for health for other purposes. This assumes the full allocation was released from Ministry of Finance.

• the crisis is presumably the cause of the change in spending patterns in 1997/98, in particular underspending across all foreign aid development funds. There is a combination of factors leading to the slow disbursement of funds; including the devaluation of the Rupiah; administrative arrangements relating to use and disbursement of funds (some dating back prior to 1994/5); and the lack of skilled staff at local district level able to manage or act autonomously. The result is that there is a large cumulative underspend of development funds, and extrapolation to year-end indicates a 32% rate of expenditure against budget. This is lower than in previous years (which spent 34-40% of external aid budgets), although the total amount spent is likely to increase. (Institute for Health Sector Development/World Bank 1999.)

Specific Impact of the Crisis on Expenditure on Health It is not yet clear what the impact of the economic crisis has been on public expenditure on health or provision of services. The crisis has had an impact on the 1998/9 health sector budget, which went through various amendments even after the fiscal year had started, due to cash injections from donor assistance. The aid has been used to counterbalance the consequences of the crisis and devaluation of the rupiah. The nominal health budget was cut by 4%, but with the high levels of

inflation existing in 1998 (increased 8 fold from 1997) this adversely affected the ability of the government to maintain services (UNESCAP 1999) External financing has increased in response to the crisis - as Table 4 shows, the share of foreign aid in central government managed health spending has risen from 6.2% in 1994/5 to 8.9% in 1997/8. The figure for 1998/9 is expected to be much higher because of the increased support received to counteract the impact of the crisis. The allocation of expenditure across different activities is shown in Table 5 , based on analysis of expenditure data from DEPKES for two years - 1994/5 and 1997/8. Data indicates that the largest share is devoted to primary health care, although the share has declined. The decline for PHC is mainly due to the fall in INPRES (health service construction) funding in 1997/8.

Table 5: Functional breakdown of central Government and external aid funds, 1994/5 & 1997/8 in million rupiah

Central & foreign aid

expenditure

% of total

1994/5 1997/8 1994/5 1997/8

Primary Health Care 942,984.6 778,102.8 53.2% 35.6% Secondary & Tertiary Hospitals

391,841.5 699,125.4 22.1% 32.0%

Education & Training 111,037.6 183,655.9 6.2% 8.4% Research & Development 10,395.5 27,356.3 0.6% 1.2% Management 237,410.9 499,741.6 13.4% 22.8% Total 1,693,670.2 2,187,982.0 100% 100%

Source: Institute for Health and Development 1999 Key Health Financing Issues in Indonesia. On a per capita basis and taking into account inflation, the level of expenditure per capita has remained roughly constant for hospitals, health education and training and research. The fall in PHC expenditure is marked, but much of the fall is due to decline in a few provinces – particularly fundin g to Jakarta (PHC funding down from 524,345 m Rp in 1994/5 to 208,144 m Rp in 1997/8) – in real terms, a fall by 75%. Irian Jaya, Maluku and NTT also experienced real falls greater than 60% while Aceh saw a large real increase. Many health programs have been discontinued including some programs on preventive health (UNESCAP 1999). In addition the HIV/AIDS budget was cut by 50% in 1998-1999 largely due to the withdrawal of the World Bank HIV/AIDS project. Impact of Economic Crisis on Coverage and Utilisation of Health Services Utilisation of health services and private expenditure on health There is a strong dichotomy in the use of health services in Indonesia. Pukesmas and posyandu are situated at the sub-district or village levels and are used mostly by low income people for health treatment. Public and private hospitals are located mostly in

the cities and are used more by the middle and high income groups. (Asian Development Bank, June 1999) Although only about 18% of Indonesian doctors work exclusively in private practice, it is accepted practice for most government employed doctors to run private clinics in the afternoons and evenings. Most drugs are paid for directly by patients. There is also a significant use of traditional healers and self-treatment accounts for quite a high proportion of illness episodes. (Institute for Health Sector Development/ World Bank. 1999.) Reports of private hospital and clinic use being substituted with the less expensive services provided by Government hospitals and increased use of traditional healers are widespread (UNESCAP 1999). It is also likely that low income groups are switching to traditional healers or letting health problems go untreated (ADB June 1999). In addition, the poorest populations appear likely to cut consumption of health services as the crisis increases the opportunity cost of health care. Any reduction in the use of private health facilities places a further burden on government by increasing use of public facilities. Nearly all public health facilities charge user fees to supplement their revenue. Studies report that more managerial attention is placed on increasing user fees and recovering costs than reducing waste and inefficiency. (UNESCAP 1999) There are no good data sources on health seeking behaviour, but there are now a number of sources of data on health facility utilisation. Data on private expenditures and service use can be obtained from several sources, including the Indonesian Family Life Survey, the Households Health Survey (SKRT) and the National Socio-Economic Census (SUSENAS). SUSENAS is the most general and, for estimating expenditures, the most useful of these. (Institute for Health Sector Development/ World Bank. 1999.) As the crisis developed, it was predicted that there would be a general shift from private sector facilities to the subsidised public sector as the middle class and non-poor felt the squeeze on their incomes (Wilopo 1999). Instead, it appears that use of both public and private sector facilities is falling steadily across the board and being replaced by higher rates of self-treatment. Furthermore, utilisation rates seem to have been falling at least since 1995, when there was a SUSENAS module on health (Table 6). Rates have fallen more overall in public sector facilities than in private ones, but in urban areas, there have been similar declines in both. The early indication is that private expenditure has declined, and now represents roughly 65% of total expenditure. It also suggests that the changes in private spending have been very uneven between provinces, a finding that is consistent with other effects of the crisis. SUSENAS data indicates that there has been a 2.5% decline overall in the use of health facilities since 1997 and that the greatest decline has been in the use of public health facilities (2% drop), compared to private facilities (0.5% drop).

Table 6: IFLS2+ Use of health services, particularly public health services and SUSENAS data on contact rates

IFLS2+

1997 1998 Change

% of Adults using any services 14.4 13.3 -1.1 % of Adults using any public services 7.2 5.4 -1.8 % of children using any services 25.8 19.9 -5.9 % of children using public services 20.3 13.2 -7.1

SUSENAS data

1995 1998 Change Total 14.6 12.1 -2.5 Private 7.0 6.5 -0.5 Public 7.6 5.6 -2.0 Health centres 6.4 4.5 -1.8 Data from the IFLS2 survey broadly support the findings from SUSENAS, ie there has been a decline of about two percentage points in the use of public services by adults between 1997 and 1998. There was a very slight, but non-significant rise in the use of private services and a rise of 75% in the use of traditional practitioners (although the numbers involved are very small). A decrease of 6% was found in the overall use of health care among children (unfortunately, the IFLS survey aggregates all children under 15). This decrease was mainly in relation to visits to the posyandu (integrated health post - village level) rather than the puskesmas (primary health care centre), and raises the question of what services children are missing. The decline in use of the posyandu by children is of concern because it is an important source of preventive care, such as growth monitoring, immunisations and vitamin A. Decreased use was seen in both urban and rural areas. The Rand report (Rand Corporation 1998) analyses IFLS data from 1997 and 1998. For the report the same 1,934 households interviewed during 1997 were re-interviewed during 1998. The results illustrate the relationship between economic resources and the use of health care in Indonesia during the crisis. For adults the proportion using public services has declined from 7.4% in 1997 to 5.6% in 1998. For children the overall use of health services has decreased significantly from 27% to 17%. The study reports that it is children from the poorer and middle income households who are switching out of private providers. In contrast children from higher income households are increasingly relying on private care.

Table 7: Impact on the use of health services Accessibility 1997 1998 % change % use of health services by adults % use of health services by children

14.6 26.9

13.4 16.7

-1.2 -10.2

Source: RAND report 1998

According to some NGOs utilisation of their services by the poor is higher. SUSENAS data suggest that utilisation of all health services (even prior to the crisis) is low compared with other countries at a similar level of economic development. The issue of low utilisation of health services was discussed with a number of Ministry staff and NGOs, and the following explanations were offered: • cost of services and / or transport to the services and difficulty of obtaining surat

miskin or kartu sehat or lack of awareness about eligibility and use of these mechanisms;

• attitude of government health staff – the poor do not feel welcome, rarely get to see a doctor, and are rushed through the clinic

• low level of education • lack of trust in western / modern medicine • limited outreach efforts by government staff - not popular, insufficient incentives

or funding (Institute for Health Sector Development/The World Bank. 1999.) Immunisation Coverage Childhood immunisation had been nearly universal pre crisis according to the WHO Immunisation profile for Indonesia which is based on Government reports to WHO. Coverage rates in 1997 ranged from 62% (HBV), 91% (DPT), to 100% (BCG). However, this view of universal coverage pre-crisis is challenged by the Rand Corporation report based on IFLS2 data. The impact of the crisis is still unclear although common vaccinations for measles, mumps and rubella may have become too costly for poor families and they have stopped buying them, according to some reports (UNESCAP 1999). The RAND report suggests that although coverage was not universal pre crisis, thus far decreasing rates of participation by children in the posyandu program have not produced significant declines in immunisation coverage. There are only two vaccinations for which uptake appears to have changed significantly; polio for which the rate is significantly lower in 1998 than 1997 and HBV for which the rate is significantly higher (Table 8) (Rand Corporation 1998).

Table 8: Immunisation uptake for children less than 3 years of age 1997 1998 Change (%)

BCG 75% 74% -1 Polio 87% 80% -7 DPT 1 70% 72% +2 DPT 2 54% 60% +6 DPT 3 39% 42% +3 HBV 40% 49% +9 Measles 55% 52% -3

Source: IFLS 2 data, RAND report 1999

Family Planning Services UNFPA undertook provision of contraceptives to cover the effects of the crisis (Asian Development Bank, June 1999). The RAND report using IFLS2 examined the impact of the crisis on family planning and found little change in the prevalence of contraceptive use or in the method mix between 1997 and 1998. MCH Services In rural areas the majority of people (55%) still rely on traditional helpers to assist at delivery of infants. In urban areas the reliance is on trained midwives (65%). The role of the doctor is still minor, especially in rural areas (only 4%) and in urban areas (17%). The crisis has made rural people rely more on traditional helpers (increased by 1.1%) and family members (increased by 5.4%), while use of doctors, midwives and paramedics to deliver the baby decreased by 1.7%, 5.3% and 0.3% respectively. The reliance appears to be on less expensive services and the increasing proportion of family members delivering babies has been almost 5 fold from 1.6% to 7.1%. The impact of the crisis is more severe in urban areas. The percentage of doctors and midwives attending deliveries has declined by 3% and 7%, respectively. There has been an increased reliance on traditional helpers and family members by 3% and 7% respectively. This increased reliance on untrained persons is likely to affect pre and postnatal morbidity. (Asian Development Bank Report, June 1999). The Midwives Association has conducted some research on choice of traditional birth attendants and government midwives with the following conclusions: • TBA (dukun) provides comprehensive service. Stays for 40 days as general home

help, performs female circumcision (very widely practised); • Traditional practice is accepted. For example, if a mother or infant dies and a

TBA was involved it is accepted as ‘natural’ but if such deaths occur with the government midwife or at a government centre then the provider is blamed;

• TBA is cheaper than government midwife. (Institute for Health Sector Development/ World Bank, 1999)

During the past decade, the GOI has invested heavily in training village midwives in an attempt to achieve universal coverage (one per village). In 1999, there were consistent reports that the contracts of these midwives (“bidan di desa”) would not be extended; thus, removing a key human resource from the most peripheral level.

Impact of the Crisis on Availability and Costs of Health Care, Drugs and Consumables From April 1998 to July 1998 the Consumer Price Index increased by 25.2%, and the increases in drug prices paid by retailers to distributors between July 1997 and June 1998 ranged between 16% to 69% according to the Ministry of Health (DEPKES). The rupiah devaluation against the US dollar has ranged from 2,450 to over 17,000, and appears to be becoming more settled over the last quarter of 1998 and in late 1999 was around 7,000. It is difficult to estimate exactly how this has affected the price of goods and services to the poor. BPS figures on changes in the consumer price index between early 1996 and August 1998 show an overall price increase for services and drugs of 61%. This compares with rises of between 200-300% for various foodstuffs, over 200% for clothing and 36% for education. Prices of some generic drugs, which are generally more affordable to the poor, rose very steeply between 1997-98. Some antibiotics doubled in price, as did chloroquine. (Institute for Health Sector Development/ World Bank. 1999. Kashiwagi 1999).

Figure 2: Trends in generic drug prices (in rupiah) 1997-1998. (Hull 1998.)

The Ministry of Health reports that only about 20% of drugs and consumables requested by health centres and hospitals were supplied centrally in 1998. They also report changes in usage of antibiotics from relatively expensive to the less expensive (and potentially less effective) and from the penicillin group to other potentially less potent, but cheaper groups. (Kashiwagi, 1999). Private and NGO clinics have borne the greater brunt of the price rises as they do not receive subsidies. While the MoH has received a special subsidy for drugs as well as an increase in funding through SSN, which far outweighs the increased cost of imported medical supplies, private NGOs have been hit hard by rising prices and this has affected their ability to provide services to the poor. Most have not received any new financing either from government or donors. Other medical supplies have also been affected. Shortages of syringes, gloves, medical equipment and laboratory supplies have been reported (Wilopo 1999). However, indications are that the problem may also be logistical rather than just supply. Cost/lack of availability of contraceptives may increase the conception rate and produce a rise in unsafe abortions and maternity related health problems. Doubling of the cost of some contraceptives on the open market has been reported. Wilopo (1999) notes some shifting to cheaper methods, particularly in the case of injectables. There is anecdotal evidence of women switching to the pill as it is cheaper. Method choice at private facilities appears to have changed between 1997 and 1998 with a higher fraction of private providers offering IUDs (27% of facilities in 1997 and 33% in 1998). Prices of services at both public and private providers have risen considerably (Table 9 ) with the exception of the OCP.

0

1000

2000

3000

4000

5000

6000

7000

8000

Paracetamol Antalgin Amoxycillin Cotrimoxazole INH (TB) Depo-provera Saline Infusion

Pric

e (R

upia

h) Apr '97Sep '97Jan '98Jul '98

Table 9: Median prices at family planning services.

Public Private

1997 1998 1997 1998

IUD insertion 1,000 2,000 15,000 20,000

Depo-provera injection 3,500 7,500 5,000 10,000

OCP - microgynon 900 1,000 2000 2,000

OCP - marvelon 900 900 1,500 2,000

Norplant implant 3,500 7,500 10,000 25,000

(Source IPLS2 data: Rand Corporation 1998)

For both public and private providers the frequency of stock outages increased significantly between 1997 and 1998 (Table 10). Table 10: Proportion of facilities reporting stock outages

Public Private 1997 1998 1997 1998

IUD - 5% - 13% Depo-provera injection 11% 46% 6% 20% OCP - microgynon - 40% - 27% OCP - marvelon - 40% - 19% Norplant implant - 20% - 19% Source IPLS data: Rand Corporation 1998

Impact of Economic Crisis on Health Outcomes Countrywide Trends Studies on the impact of the economic crisis on the health sector in areas such as South America demonstrate that whereas mortality and morbidity in the short term were somewhat independent of economic conditions, child malnutrition and infant mortality increased appreciably. (Pan American Health Organisations. 1989) Information on the crisis on health in Indonesia is scattered and largely anecdotal. From existing studies and hypothetical assumptions, the effects are likely to be in the following areas: 1. Nutritional status, especially on the very young, reproductive age women and the elderly 2. Availability of drugs and other medical supplies, due to inflationary pressure 3. Rise in some communicable diseases linked with economic indicators and

deterioration of infrastructure, e.g. STDs, diarrhoeal diseases 4. Effects of increased exposure to less safe working conditions as workers move

from formal to informal sector employment, e.g. rise in accidents 5. Increased domestic and gender violence 6. Switching by users to cheaper forms of health care provision 7. Delays in or failure to take up medical treatment, relinquishing treatment

before completion. To improve monitoring the effects and impact of the crisis several initiatives are already under way including: monitoring of nutritional status of under 5s; recording of

utilisation by kartu sehat holders at Puskesmas level; repeating the nutrition module of SUSENAS annually to monitor nutritional effects of the crisis (funded by the World Bank); and epidemiological monitoring through health facility utilisation. General Indicators of Health and Nutrition Health and nutrition indicators from the IFLS 2+ survey and from SUSENAS ’98 demonstrate the complexity of investigating health effects using routine data. Overall, these data are not inconsistent with the evidence of a complex and heterogeneous crisis, with pockets of serious health effects. There is also clear evidence of a cutback in visit rates to public clinics, but how exactly to interpret that is unclear.

Table 11: Indicators of health and nutritional status derived from the IFLS 2+ data

1997 1998 Change

Nutrition

Low height for age (% of children under 9 with z score <-2)

50.68 45.66 -5.02 (improvement)

Weight for height (% of children under 9 with z score <-1)

35.56 35.20 -0.36 (improvement)

Body mass index of adults (% of population with kg/meter squared<18)

14.05 14.69 0.63 (worsening)

Inadequate Haemoglobin (% with level less than 12 mg/dl)

34.75 30.83 -1.66 (improvement)

Evaluated health status Number of seconds to move from sitting to standing 5 times

7.6 5.9 -1.64 (improvement)

Overall evaluation of health status by nurse

5.94 5.98 0.04 (slight improvement)

Self reported health status % reporting themselves in poor health: adults

13.64 13.83 0.19 (slight worsening)

% reporting their children in poor health 6.96 8.3 1.34 (worsening) % reporting that they had been ill 21.01 21.95 0.92 (slight worsening) % reporting their children had been ill 25.56 24.76 -0.8 (slight

improvement) Source: IFLS data

Table 11 contains a mix of indicators, both health and nutritional. There are some that show improvement, others that are worse, but overall the changes are small in either direction. The data from the 1998 SUSENAS (collected relatively early in the crisis) show some changes in self-reported morbidity. Other data sources, such as the “100 villages” survey and other specific nutritional data show similar complex patterns, with some indicators improving and others worsening, (Kamarcan Village Survey Report). Given the complex and regionally heterogeneous nature of the crisis itself, this is not surprising.

Nutrition This is a controversial area. Nutritional experts remain divided about how to measure changes in nutritional status and how to interpret trends. It is also premature to draw any firm conclusions about impact as data are only just becoming available. In addition, there is a problem of what is the baseline, given the disruption in nutritional monitoring. The main sources of information are the World Bank’s Watching Brief (Jan 1999) using SUSENAS data, the ISFL2+ study and Helen Keller International Nutritional Survey (May 1999) on poor urban areas of Jakarta and Surabaya. The Watching Brief analysis looks at trends from SUSENAS data comparing 1992 and January 1998. Its findings therefore relate to overall changes in levels of child malnutrition between these dates. This is relatively early in the crisis, so it is not the best indicator of crisis impact. It does show a progressive improvement in child nutrition over this period. Malnutrition among under 5s has decreased overall from 34.9% in 1992 to 29.8% in 1998, but malnutrition is still a serious problem particularly for vulnerable groups. The decrease in malnutrition has been almost

entirely registered in rural areas, but from a much higher starting point. Urban rates have remained at around 28%. The documented increase in malnutrition in children aged 6-11 months in both the 1992 and 1998 surveys demonstrates that child -feeding practices remain inadequate. The most vulnerable children live in rural households without access to clean drinking water and in areas of limited infrastructure. Living in areas already identified as “backward” is a strong indicator for poor nutritional status. A strong positive correlation is also found between the educational level of the mother and the nutritional status of the child. This is a more powerful predictor than household economic level. Unemployment is not found to have an impact on nutritional levels. The urban poor are not nutritionally worse off than the rural poor, but their numbers are considerably fewer. Overall, this study considers child malnutrition to be a greater problem in rural areas. The HKI survey is of a sample of 1,100 – 1,200 households that have been monitored at regular points during the crisis. The HKI surveys were of a smaller nature than SUSENAS or IFSLS2, focusing on Jakarta and Jawa Tengah only. January HKI data was published in March/April; however, later rounds are still undergoing analysis. Unlike the Watching Brief analysis, HKI has argued strongly that the crisis is an urban one, as the urban poor have fewer coping mechanisms. Their data show increased prevalence of micronutrient deficiencies (especially vitamin A) and increased wasting among under 5s and women. The key HKI findings included: • The BMI of women of reproductive age has dropped by 0.45kg/m2. • The gap in BMI between social groups has increased. • The prevalence of maternal malnutrition has increased from 15% in 1996 to 18%

in 1998 • Child hood anaemia has increased from 50% to 65% from 1996-98 and maternal

anaemia from 15% to 19% during the same period. • Prevalence of both child hood and maternal night blindness has increased

significantly. • The urban slums are worse off than rural areas. IFLS2 data showed a mixed picture and reports that haemoglobin levels have actually improved on average between 1997 and 1998 and that children have experienced an increase in weight for height. However, Adult Body Mass Index has declined. This sample is small for measuring nutritional impact and is rendered less useful by not separating out data on under 5s from under 15s. Analysis of 1997 and 1998 IFLS data in the same households by the Rand Corporation illustrated that receipt of vitamin A in the six months by children aged less than 3years has declined substantially. In 1997, 55% of the children under 3 years had been given Vitamin A in the previous 6 months. By 1998 the proportion was less than 43%. This probably reflects decreased use of the posyandu by children (from 56.8% in 1997 to 41.3% in 1998) and reductions in availability of vitamin A at health facilities. (Rand Report, 1998) There are a number of reasons why the urban v. rural impact debate is a difficult one. Studies are not comparable, HKI surveys are small, while SUSENAS data provide national coverage. The regional coverage of the IFLS2 is also broader than the HKI surveys. SUSENAS data is highly aggregated and seeks to draw broad conclusions about trends over time. HKI sampled urban slum dwellers, many of whom are not legally registered residents and thus overlooked by government or other official surveys. In that sense, the study provides a picture of child malnutrition as it relates to chronic poverty. It also demonstrates the very variable nature of the picture. In Jakarta, malnutrition rates are 22%, while in DI Aceh, they are 48%. It is difficult to

draw any conclusions from it on the specific impact of the crisis on nutritional status in rural areas. Micro level studies, on the other hand, are able to give a more detailed picture of specific areas and problems. The HKI study shows that relative to where they were before the crisis, the urban poor may be experiencing a decline in nutritional status, which most affects vulnerable population groups – reproductive age women and children under 5. In addition the HKI surveys took place later than the SUSENAS 1998 survey so the timing of data gathering surveys may impact on the results. There is other, more anecdotal information, on the impact of the crisis on food availability in qualitative studies. A number of studies indicate food substitution is being increasingly used to counter the rising price of rice. Some of the substitute foods are actually more nutritious than refined rice, others less so. There are reports of low income families in Jakarta having to double their food expenditure and so cutting out protein foods, and of meals being skipped or low income families having fasting days (Wilopo 1999). Little seems to be known about urban coping mechanisms, such as the extent to which urban households have access to rural food supplies through economic and social networks. (Institute for Health Sector Development/ World Bank. 1999.) Implications of available information to date would seem to be: • Improved monitoring needed for vulnerable groups – children, reproductive age

women, the elderly • Micronutrient/nutritional supplementation for under 5s, pregnant women

Surveillance Systems Systems of monitoring are fairly undeveloped. Most epidemiological surveillance is piecemeal and done through vertical programs (such as diarrhoeal diseases control) or specific donor funded projects. UNICEF is now collaborating with the DEPKES crisis centre to carry out limited epidemiological surveillance, based on data from health facility utilisation, (Institute for Health Sector Development, 1999). Disease surveillance is based on two main systems: SP2TP and SP2RS: • SP2TP - Integrated Puskesmas Recording and Reporting System - national,

centrally-designed comprehensive reporting format for puskesmas • SP2RS - Integrated Puskesmas Recording and Reporting System - national,

centrally-designed comprehensive reporting format for hospitals These are developed and managed out of the General Directorate of Family Health. Data are shared with the Centre for Health Information (Pusat Data) which summarises the data into annual provincial and national health profiles. Pusat Data is also developing pilot computerised surveillance and reporting systems. With World Bank funding, their aim is to computerise all data collection and reporting at the puskesmas and district level.

Tuberculosis (TB) TB is ranked as the number one infectious disease in Indonesia, with an estimated 450,000 new cases per year and 175,000 deaths. DOTS has been adopted as the national policy but problems exist with the program pre crisis – diagnosis poorly made, treatment schedules not implemented, volunteer supervisors of treatment difficult to find (AusAID 1999). There is also concern about a possible rise in multiple drug resistant TB. The economic crisis may affect compliance rates, with infected individuals not completing courses of treatment. STDs

In relation to STDs, it is known that there are high rates of untreated STD infection in the general female population (around 10% for gonorrhoea and chlamydia). The problem is not therefore solely related to sex workers. Wilopo (1999) suggests that there has been an increase in the numbers of commercial sex workers, possibly corresponding to layoffs in “female” areas of manufacturing industry and other female areas of the economy. The World Bank (1999) study on the gender impact of the regional crisis quotes data from the Jakarta based NGO, JKB, of 50-100 newcomers per month being absorbed into the red light districts in 1998, compared to 20 per month in 1997. Data from a STD clinic in Yogyakarta with a high percentage of sex worker clients show a doubling of visits between January 1998 and September 1998 and an increase in the number of confirmed STD cases (Wilopo 1999). A study of sex workers in Kupang, Ujung Padang, and Bali revealed that 48% reported no change in the number of clients since the economic crisis, 28% reported a decrease, and 24% an increase. Among those who had worked at the same location for more than 12 months, a higher proportion reported an increase in clients. The same survey showed that in the three provinces, the fee paid for sexual services dropped by an average of 18% (32% in Kupang) [Centre for Health Research, University of Indonesia, 1999]. There have been reports of a significant increase in the number of sex workers in Kupang, West Timor, since the exodus of militia from East Timor in October 1999. Each sex worker was reported to be seeing 5-6 clients daily in October compared with 2-3 daily three months earlier (AusAID Indonesia HIV/AIDS & STD Prevention and Care Project report, October 1999). No evidence was found of significant STD public health risks from crisis so far. However, these may become apparent. There is an urgent need to improve basic surveillance through sentinel site monitoring and other means of rapid epidemiological assessment. HIV/AIDS The number of cases reported to date (1,000 reported, 51,000 estimated) is lower than earlier estimates (up to 250,000 by the year 2000) there is an increasing trend and the potential for epidemic spread exists both due to sexual spread and also IDU (there are an estimated 100,000 users of illicit drugs in Jakarta alone). Impact in Areas of Civil Strife East Timor By April 1999, the combination of economic and political factors had already had an impact on health services. In the provincial hospital in Dili, the daily number of outpatients had decreased from approximately 600 one year earlier to 110 and inpatients from 130 to 51 (UN Interagency report, April 1999). In contrast, attendance at church-run health facilities had increased. At the time of this assessment, there were 69 doctors in the province compared with more than 200 in 1998. Following the referendum on independence, supported by 78% of the population, widespread violence by anti-independence militia resulted in the displacement of between 300-400,000 people, most into neighbouring West Timor. In November, more than 90,000 displaced persons returned to East Timor and WHO has established disease surveillance. Malaria and possibly dengue fever, and acute respiratory infections have been the most common conditions reported. The situation is still evolving and it is too soon to make valid comparisons between disease incidence rates pre- and post-crisis. One report indicated that in October malaria accounted for 20-

30% of morbidity in Dili compared with 10% in previous years (HINAP, October 14, 1999). The planting season was due to commence in November and a poor harvest is predicted for 2000 raising food insecurity as a major issue next year. A high number of measles cases have been reported since the returned of the displaced, both in East Timor and among refugees in Darwin, possibly reflecting a low immunisation coverage prior to the violence. West Timor More than 260,000 East Timorese displaced persons were registered by the GOI in November; however, the actual figure may have been higher. Living conditions in camps were poor, with inadequate access to water and sanitation and a high incidence of diarrhoeal diseases (ICRC, November 1999). Malaria and dengue have been reported to be increasing health problems. The increase in both the number of sex workers and the average number of clients per worker following the exodus from East Timor was noted above. West Kalimantan Violence between ethnic Madurese and Melayu in Sambas, West Kalimantan resulted in the displacement of some 30,000 Madurese, in Singkawang and Pontianak. ICRC did three surveys of nutrition in the area around Pontianak, using a QUAC stick. The first survey found 7% of children with severe malnutrition; the second survey found 5.5% with severe malnutrition; and the most recent survey, in August 1999, found 3.16% with severe malnutrition. In July, ACF-F conducted a survey and found that the prevalence of acute malnutrition among children less than 5 years was 14.1%, including 2.3% with severe wasting (RNIS, September 1999). Ambon, Maluku A series of riots and ongoing civil strife began in Ambon in January 1999 resulting in the loss of many hundreds of lives. The strife continues with major disturbances in other islands, including Tual and Tanimbar, into December. At least 20,000 people have been displaced and are scattered throughout the islands of the Moluccas. In May/June 1999, ACF-F found the prevalence of acute malnutrition to be 11.2%, including 0.8% severe wasting.

IV. Responses to the Crisis Indonesian Government Response The Social Safety Net (SSN) Funding the Social Safety Net (SSN) in 1998/1999 was the subject of the most dramatic government budgetary revision ever. The entire portfolio of Rupiah-financed programs, including donor-assisted projects, were reviewed and major reallocations were made in order to increase the SSN budgetary allocations. Approximately 55.5% of the development budget, or about Rp 17.3 trillion was allocated for SSN schemes, implemented through four broad categories (food security, public health and education, employment and income generation, and the promotion of small and medium scale enterprises) in 17 sectors3. Approximately 11.5% of the SSN allocation is for health. An independent SSN monitoring group reviewed the allocations, and reported that in fact, only Rp 9.3 trillion is considered to be pure SSN schemes, with the remaining Rp 8.6 trillion funding supplementary programs, some of which were considered to be of a non-SSN variety. Of the Rp 9.3 trillion, Rp 2.25 trillion (24%) was allocated to health. Donors (bilateral and multilateral) are actively contributing to the SSN, through grants, loans, provision of supplies and equipment. The major contributors are:

ADB (Asian Development Bank) Australia (AusAID)

Canada (CIDA) EU (European Union)

Germany ICRC (International Committee of the Red Cross)

Japan (JICA) New Zealand

OCHA UNDP

UNFPA UNICEF

USA WFP

WHO World Bank

SSN funding has been given for two years in the first instance (1998-2000) for crisis rescue. A further round will run from 1999-2002. This offers a substantial increase in funding, mainly for existing programs and using existing targeting mechanisms. All SSN funds are supposed to be targeted on poor households only. As with other SSN programs, BKKBN (family planning) data provide a basis for estimating numbers of poor households for funding allocation, as well as for identifying individual eligible households. In health, poor households are issued with health cards (kartu sehat) which can be used to obtain free health services. Services are offered under the following programs:

1. Basic Health Services

2. JPKM/Health Card

3. Health Services for Pregnant women.

4. Food and Nutrition Interventions

3Industry, agriculture, forestry, irrigation, manpower, domestic trade, foreign trade, cooperatives and small

and medium enterprises, road infrastructures, energy, regional development, education, social welfare, health, housing/settlement, religious affairs, and law.

5. Hospital Operational Costs

Funding has been allocated directly to health service providers according to estimates of numbers of poor people served as follows: • Rp10,000 per poor family client per year to each Puskesmas. This provides funds

for 1, 3, and 4 above • Rp10,000 per poor family client per year to each district level health authority • Rp10,000 per poor family client per year to hospitals. For food supplementation allocations are based on estimates of numbers of malnourished infants and children, based on Posyandu and Puskesmas data. Nutritional SSN initiatives To reduce the potential of malnutrition, there are three main nutrition activities being implemented as part of SSN : a) Provision of supplementary feeding to children 0 – 24 month of age and

anaemic mothers b) Revitalising the village nutrition centre (“Posyandu”), and c) Revitalising Nutrition Surveillance System. The specific objectives of these activities are to prevent any increase in prevalence of malnutrition due to the crisis; to reduce the prevalence of low birth weight, malnourished children, and micronutrient deficiencies in children and mothers particularly iron, vitamin A and Zinc; and to educate mothers on good infant feeding practices. Using international loans, the government ordered 2.5 million tons of rice and plans to import a further 2.85 million tons before April 1999. The rice will be sold to the poor and other vulnerable groups at a subsidised price. Initially activities were focused on 150 'high risk' districts, but in October 1998, with the economy failing to improve, all districts were included. The program involves a number of government agencies including Ministries of Planning, Health, Agriculture, Family Planning (data on poor households) and Nutrition Research Centre in Bogor. Supplementary Feeding Food supplements - local foods (ADB funded), blended foods (WFP) and locally blended (World Bank) are distributed to malnourished pregnant and lactating women, infants (6-11 months) and children (1-2 years). Prior to SSN there was a limited program of food distribution to school children. For school children, the food aid has been channelled through a special program called: PMTAS (School Snack Program). Other food supplement programs ceased in 1984. Food supplements are distributed to infants through the Posyandu, Bidan di Desa or volunteers (Ibu Asuh). In addition to the usual monthly Posyandu sessions, extra weekly sessions are to held expressly for the distribution of food supplements to needy households. A blended food of soya-rice-maize mixed produced by a domestic food industry has been introduced for supplementary feeding of infant 4 to 12 month of age as a nutrition component of SSN. The soya mixed package of 500 gram is distributed once in a week through village health centres and village nutrition centres (Posyandu). For older children (6 to 24 months) and malnourished-pregnant mothers, SSN provides funds for supplementary food to be locally purchased and cooked at mothers’ home (home made) or at a community kitchen at Posyandu. Specific feeding programs have been established in West Kalimantan and Ambon, with the support of ICRC, ACF, MSF and other NGOs, and in West Timor, with

extensive support of international agencies, including UNHCR, WFP, ICRC, and other NGOs. Revitalisation of Nutrition Surveillance System The early warning system (EWS) of data collection and dissemination covers: • annual data on food production, consumption and prices for identification of

'crisis' districts (kecamatan). • data on poor families (from BKKBN); • data on nutritional status of pregnant and lactating women and children under five

years; • World Bank funding to repeat annually the nutrition component of SUSENAS The objectives are to monitor food availability (and the economic crisis) and to increase capacity of district staff to manage food and nutrition programs. An Early Warning System (EWS) was in place in Indonesia until 1984 when the country became self-sufficient in rice and malnutrition was thought to have been minimised. Under SSN the old system will be revitalised. Once crisis areas are identified Districts are to develop their own programs, in coordination with Bappenas/Bappeda. Other SSN health initiatives Revitalisation of Posyandu Posyandu is a village community organisation run by women volunteers to deliver basic nutritional services, primary health care (immunisation, pre-natal care, and health education), and family planning with technical support from health professionals (midwives and public health nurse) and nutrition professionals. The posyandu has been the backbone of rural health care at village level, especially in remote areas, and by 1995 almost all villages in Indonesia (65,000 villages) at least had one posyandu. Indonesia with UNICEF assistance achieved Universal Child Immunisation including polio through the posyandu. Nutritional services include monthly weighing of children, high-dose vitamin A supplementation , nutrition and health education for mothers, and distribution of iodised-salt and/or iodised capsule to target groups. Unfortunately, at present many posyandu are not functioning and the Government of Indonesia is committed to revitalising the posyandu as a component of the Social Safety Net. Kartu Sehat (health card for the poor) under SSN SSN funding has provided an impetus to the kartu sehat scheme. Although started in 1994 it is recognised by MoH that the scheme was not functioning as envisaged. At most, card holders obtained free services at Puskesmas, but rarely did the services extend to hospitals or to delivery services for pregnant women. Under SSN, it is emphasised that all health services should be provided free of charge. The key difference is that health providers are for the first time to be reimbursed for services provided to poor people. At the same time there is much greater pressure on providers to play an active role in administering the scheme, including identifying poor families, recording details, and issuing cards to them. Health Services for Pregnant women Midwives are to identify and monitor all pregnant women and offer a minimum number of visits (3 pre-natal, delivery, 3 post-natal). All services are to be free for poor households.

It is probably too early to come to any conclusions concerning the success of SSN in health. However, initial impressions are that SSN funding has stimulated efforts to reach the poor and increased incentives to disburse kartu sehat. However, more information is needed on how funds are being used in practice and whether service provision to the poor is cost-effective. This will require independent monitoring of the program. (World Bank Watching Brief Jan 1999, Indonesia Crisis Bulletin 1998, Helen Keller International Oct 1998/May 1999, BAPPENAS 1999, Canadian International Development Agency 1999, Christian Children’s Fund 1999, Jahari A et al 1999, Asian Development Bank. 1999, SMERU, March-April 1999, UNICEF 1998, Institute for Health Sector Development/ World Bank 1999, Asian Development Bank 1998, Ministry of Health 1998, Social Safety Net Technical Guidelines (in Indonesian) 1998.) The Impact of Decentralisation There is great confusion in the Ministry of Health as to what the impact will be of the proposed district level decentralisation. Central level program managers are at a loss to explain what decentralisation will mean for health program design, management, coordination, or evaluation. Some have said they are considering applying for transfers to district level positions as they feel this is where control and resources will be focussed, and they are unsure about the future role of the central level ministry of health. There is currently little to no capacity for district level health staff to take on the responsibilities of program management as envisaged in the decentralisation plan. To date, it is unclear what plans there are to develop that capacity. National level health staff are unable to answer this question. It is extremely difficult to predict how any given model of decentralisation will play itself out in terms of developing locally credible systems of support for the poor. Decentralisation does not, of itself, guarantee greater local ownership. Much depends on the nature of the emerging political settlement and the degree of accountability which can be built into it. There is currently a discussion to dissolve the provincial level offices of the ministry of health (Kanwil Kesehatan), and have all provincial level activities operate from the Home Affairs Health Services Offices (Dinas Kesehatan Tk I). This possibility adds additional confusion about respective roles of central, provincial and district health offices in a decentralised environment. External Assistance World Bank In July 1998, the World Bank extended a $1 billion Policy Reform Support Loan, a portion of which will support the purchase of food and essential drugs and the increased monitoring of health indicators in the coming months and years. The Bank conducted a review of the budget in January 1998, and recommendations were made in the negotiations leading up to the Policy Reform Support Loan. The health team is continuing to monitor the budget and the availability of funds for health expenditures. In response to the crisis, the Bank re-examined its overall strategy in the health sector to address the immediate and medium-term needs of the poor. Projects which provide basic health services to the poor have been given a greater priority. An Early Childhood Development project, planned before the crisis, has been restructured to include $11 million in nutritional supplements to children between 6-24 months of

age, when the most debilitating effects of malnutrition are felt. Projects designed to improve the efficiency and performance of the health sector have also been given greater priority – as government expenditures contract, efficiency gains will help maintain the Government’s long-term investments in health. The World Bank is assisting with loans to ensure adequate supply of food. The Government has ordered 2.5 million tons of rice and plans to import an additional 2.85 million tons before April 1999. The rice will be sold to the poor and other vulnerable groups at a subsidised price. As part of the Policy Reform Support Loan in April 1998, the Government is committed to providing adequate funds for essential drugs, including the vaccines and drugs needed for communicable diseases control. Additional funding is also being provided for drug and vaccine quality control, hospital and health centre laboratory work, and equipment necessary to sustain emergency room services. The World Bank is also improving its monitoring abilities by undertaking a series of rapid assessments of health services, and accelerating the processing and analysis of the health indicators contained in the annual socioeconomic household survey (SUSENAS). (Source: The World Bank web site). Asian Development Bank Since the advent of the crisis the ADB has targeted the health sector in Indonesia with two major loans; the Social Protection Sector Development Program (SPSDP) and the Health And Nutrition Sector Development Program (HNSDP). In contrast to the World Bank the ADP focus is significantly broader in scope. The total potential funding for these two loans alone is estimated at USD600 million. The bank proposes a comprehensive package of initiatives which would form the strategic basis for the reform of the health care system in Indonesia. The ADB proposes to convince the GOI to increase Government spending on health from its current level of 2% to 4% by 2001. (Government of Indonesia 1999, Asian Development Bank 1999).

UNICEF In Indonesia, the Mid Term Review of the country program, which took place in 1998, provided the opportunity to completely revamp the structure of UNICEF’s assistance. The new structure is specifically designed to respond to the crisis. Interventions include a new Rapid Response Complementary Feeding Program that provides low cost complementary food for infants in selected provinces with the aim of revitalising the village health post network and a community self-help approach to the crisis. UNICEF, UNDP and WFP are cooperating on ways to provide emergency assistance to vulnerable groups. Efforts are also underway to expand the scope and coverage of Indonesia's existing community health financing activities, including saving schemes for maternal health and grants for emergency obstetric care. In response to the increase in school drop-outs, UNICEF and the government have launched a national social mobilisation campaign aimed at keeping children in school. UNICEF is also expanding its support to existing government efforts to monitor the effects of the crisis. These include reactivating an early food security monitoring system at district level, refocusing of the100-village sentinel site surveillance and setting up an emergency crisis "hot-line" informatio n system. (UNICEF web site). World Food Programme WFP has extended its emergency operation in Indonesia (EMOP) until June 2000. Excluding the Government's contribution, the total WFP cost is now USD 135.8

million, against the initial requirement of USD 88 million. Originally implemented in rural areas in the eastern part of the country affected by drought, the operation will now expand to urban areas, mainly greater Jakarta, Surabaya, Semarang, Bandung and Yogykarta, where there are over 4 million out of the total 6 million beneficiaries. In the cities, under the new EMOP extension, WFP will provide support to children who will receive a take-home ration. This is meant to encourage their parents to keep them in school, as school attendance will be seen as a way to supplement the family income. WFP food-for-work activities will be implemented in the five cities as well as in rural areas that have either chronic food shortages, a high number of landless farmers or returnees following either civil strife or economic difficulties in the cities. International NGOs including CARE, CRS have been collaborating with the WFP since 1997 to implement emergency food programs under Food for Work schemes in areas affected by drought and forest fires as well as by the economic crisis, including Irian Jaya, NTT, NTB, East Kalimantan and Java. Self-targeting under these schemes appears successful, as only the needy are prepared to work for food. High numbers of women from female supported households are coming forward. Under the current emergency operation, WFP will provide support to the Government's subsidised rice program which will enable families to purchase 20 kilograms of rice a month at subsidised prices. Proceeds will be used to procure rice for activities in other programs. Other activities included in the new EMOP extension are support to orphanages and shelters for street children, distribution of mineral and vitamin enriched blended food to pregnant and nursing mothers and children under five, support to IDPs and victims of religious and ethnic strife. (WFP web site, UNSFIR 1999). Table 12: Summary of Donor Activity in response to the crisis (excepting

World Bank and ADB)4 Agency Activity USD millions United Nation Development fund

Survey of social and economic impact of the crisis Rapid humanitarian assistance Food security Supply of generic drugs

0.38 0.20 0.08 0.13

United Nations Children’s Fund

Complementary feeding (6-24 months) Survey on social changes in 100 villages Back to school campaign

1.08 0.45 0.15

United Nations Population Fund

Emergency assistance Contraceptives needs assessment and supply Reducing maternal mortality

4.0 3.0 2

WHO Policy and strategy development and support for monitoring crisis Specific health interventions Study on restructuring of the pharmaceutical industry

13.7

0.3 0.13

WFP Emergency food assistance 135.8 Bilateral agencies Agency Activity USD millions Australia

• Food aid with support for the World Food Program emergency operation

31.5

4 Excluding aid to East and West Timor related to East Timor conflict

• Emergency medical supplies in response to the drought and the economic crisis. Supply was mainly to the Eastern Provinces of essential drugs and medical supplies.

• Assistance with establishing a Social Monitoring and Early Response Unit (SMERU)

• Community level assistance eg supplementary feeding programs for vulnerable groups such as infants.

• Contribution to a World Bank program to assist the GOI with the SSN.

• Assistance with the Back to School Campaign (in collaboration with UNICEF).

Canada Drought mitigation SSN

4.30 2.57

Denmark Supplementary food assistance 0.007 European Union Health support to victims of drought

Emergency medical assistance Short term food programs Improved drinking water supply

0.83 0.35 0.33 0.04

German Agency for Technical Development

Support to drought victims 0.75

Japan Internal Cooperation Agency

Sector program loan Medical supplies, raw materials for drugs

1200.0 30.0

United States Agency for International Development

Strengthening SSN Emergency food aid Contraceptives Essential medical supplies

45.0 25.0 7.4 4.0

Source: The Canadian International Development Agency (ADB data). 1999.

Non Governmental and Community Based Organisations Non governmental and community organisations in Indonesia have played an important role in the response to the crisis. NGOs have assisted with the JPS Program and also delivered separate initiatives including primary health and nutrition programs and food supplements for the most disadvantaged. NGOs may also play a role in monitoring of the JPS program (Centre for International Economics, 1999). International NGOs have largely, though not exclusively, responded to the health needs of populations directly affected by civil strife, violence, and population displacement in East Timor and West Timor. ICRC and Caritas were the most active in East Timor prior to the referendum; however, all agencies were obliged to leave during the violence that followed. ICRC and Caritas and many other NGOs were able to return once security had been assured by INTERFET. ICRC has also had programs in West Kalimantan and Ambon, as has MSF and ACF. V. Potential Areas for Donor Focus The problems exposed by the financial crisis in Indonesia are largely pre-existing problems. From available data the impact of the crisis has been severe, but much less severe than predicted. In addition, the impact has been very uneven; Java is hard hit even in rural areas, large parts of Sumatra, Sulawesi, and Maluku, have experienced minimal negative crisis impact and other areas show negative impact, but it is unclear whether problems are economic crisis-related or result from drought (NTT, NTB) and

fires (East Kalimantan). Pre-crisis economic status has not been a good indicator of impact. Information on the health effects of political conflict has been scarce. The findings of several nutrition surveys have been disseminated; however, the impact on morbidity and mortality has not been documented apart from the obvious consequences of the violence in terms of deaths and injuries. In East Timor, no longer part of Indonesia, a health surveillance system has been established and is being coordinated by WHO. Information on the crisis on health in Indonesia is scattered and largely anecdotal, however the principal effects appear to be in the following areas: • Reduced nutritional status, especially on the very young, reproductive age women,

and the elderly • Decreased use of health services, especially by children at the posyandu level • Fewer resources available for disease prevention and health promotion programs • Diminished availability of drugs and other medical supplies • Rise in some communicable diseases, e.g. TB, and possibly STDs • Switching by users to cheaper forms of health care provision • Delays in or failure to take up medical treatment Donors should build on existing programs and aim to ensure that programs target the poorest and most vulnerable groups. Effective program design is crucial and must take into account gender issues and be relevant to cultural contexts. Priority should be given to funding services that serve the poor in remote areas or deprived urban poor areas and special attention should be given to ensuring free access of the poor to health services. Crisis responses should not weaken or replace informal support mechanisms and should promote community development. Strengthening of health information systems is an urgent priority, including surveillance focussed on politically vulnerable areas, such as Aceh, Ambon, North Maluku, West Kalimantan, West Timor, and Irian Jaya.

References ACIL Australia Pty. Indonesia - Provision of Emergency Medical Supplies Project - Overall Delivery Plan. September 1998. AusAID (Australian Agency for International Development). Indonesia Health sector Review (Draft). Report of the Technical Advisory Group. August 1998 Asian Development Bank. Health and Nutrition Sector Development Program. Asian Development Bank Project design paper. 1998 Asian Development Bank. Assessing the Social Impact of the Financial Crisis in Asia. Ernesto M Pernia and James C Knowles. Economic and Development Resource Center. EDRC Briefing Notes, number 6, November 1998. Asian Development Bank. Asian Development Outlook 1999. 19 April 1999. Asian Development Bank. The Social impact of the Economic Crisis in Indonesia. June 1999 BAPPENAS. Social Safety Net. Health Sector Allocation, FY 1998-1999. BAPPENAS. Indonesia’s Monetary Crisis: Strategic Actions for Minimising the Health Impact. Triono Soedoro, MD PhD, Bureau Chief, Bureau for Social Welfare, Health, and Nutrition. 1998 Canadian International Development Agency. The Health Sector in Indonesia: The Road to Reform . Prepared by PT Hickling Indonesia under a contract from The Canadian International Development Agency. April 1999. Centre for Health Research, University of Indonesia, in conjunction with the AusAID-funded Indonesia HIV/AIDS and STD Prevention and Care Project and the Coordinating Ministry of People’s Welfare and Poverty Alleviation. STD and HIV/AIDS Behavioural Surveillance Survey, in Bali, Kupang, and Ujung Padang. 1999. Center for Economic Social Studies. Study on the Impact of Economic Turmoil and Social Safety Net in Jabotabek and its Surrounding Suburbs Area. Mangara Tambunan and Edi Priyono,. Presented at Bappenas-JICA Interim Discussion on the Survey Finding on the Impact of the Economic Crisis, Jakarta, March 3, 1999. Christian Children’s Fund. Dampak Krisis Pada Status Gizi Anak Balita di Proyek-Proyek Kerja Sama Christian Children’s Fund - Indonesia. (The Impact of the Crisis on Nutritional Status of Children Under 5 in Christian Children’s Fund - Indonesia project areas). Tri Budiardjo, National Director, CCF Indonesia. Jakarta, 25 May 1999. Feridhanusetyawan, Tubagus Social Impact of the Indonesian Economic Crisis. The Indonesian Quarterly, Vol XXVI/1998, No 4. Ford Foundation, ASEM Trust Fund and World Bank. The Social Impact of the Crisis in Indonesia: Results from a Nationwide Kecamatan (Subdistrict) Survey. Prepared by Sudarno Sumarto, Anna Wetterberg, and Lant Pritchett. 1998 Helen Keller International Special Report. Nutrition and Health -related Issues resulting from Indonesia’s Crisis. Summary and Recommendations. Martin Bloem, Roy Tjiong, Federico Graciano, Mayang Sari, Saskia de Pee. October 1998. Helen Keller International. Indonesia’s Crisis: A Comparison of its Impact on Nutrition and Health of the Urban and the Rural Population. Based on results of the HKI/GOI Nutrition Surveillance System., Indonesia, and Center for Health Research and Development. May 1999. Helen Keller International, Alarming rise of iron deficiency anaemia may herald “Lost Generation” Indonesia Crisis Bulletin. Year 1, Issue 3, October (a) 1998. Helen Keller International. Have 30 years of nutritional improvement in Southeast Asia disappeared in one year of the crisis? Indonesia Crisis Bulletin. Year 1, Issue 4, October (b) 1998.

Helen Keller International. The importance of accurate anthropometric assessment and defining the ‘lost generation’ Indonesia Crisis Bulletin, , Year 1, Issue 5, March 1999. Hull T.H, PhD, Director, Graduate Studies in Demography, The Australia National University. Health and Crises: Beyond the Metaphor. Keynote speech presented at the Fourth Asia Pacific Social Science and Medicine Conference, Yogyakarta, Indonesia. 7-11 December 1998. International Crisis Group. Indonesia’s Shaky Transition. October 10, 1999. www.crisisweb.org Institute for Health Sector Development, London. Financed by the World Bank. Health Sector Financing Consultancy Report. March 1999. (Bureau of Planning, MOH provided only the annexes. Full report not available).

Annexes: Annex 1: An Overview of the Indonesian Health Sector Annex 2: Key Health Financing Issues in Indonesia Annex 3: The Health Insurance Market Annex 4: Issues in improving access to health care by the poor Annex 5: Financing health care for the poor - recent lessons Annex 6: A Revenue Model - Illustrating Financing Options for JPKM

Jahari A, Sandjaja, Herman S, Idrus Jus’at and Fasli Jalal. The Hidden Problem - Nutritional Status of Underfives in Indonesia During The Period of 1989 to 1998 (an Analysis on Anthropometric Indicators of Protein Energy Malnutrition Based on SUSENAS Data) Presented at Pre-Workshop on Food and Nutrition, May 10-12, 1999 – LIPI, Jakarta. Kashiwagi E and Dr Amal C Sjaf, Health Research Center, University of Indonesia. The Impact of Economic Crisis on Hospital and Health Center Management in Indonesia Especially on Drug Supply and Use. Presented at Bappenas-JICA Interim Discussion on the Survey Finding on the Impact of the Economic Crisis, Jakarta, March 3, 1999. Macfarlane Burnet Centre for Medical Research. Healthy Mothers Healthy Babies Project Review of Maternal and Child Health Information Systems, Recommendations, and Plan for Implementation of HIS Support Activities. March 1999 Ministry of Education and Culture. Impact of the Economic Crisis in Basic Education - A Study in Ten Rural Districts in Indonesia. Office of Research and Development, Indonesia. Report No. 01-0599. Supported by MOEC, UNICEF, UNESCO, and UNDP. Jakarta, May 1999. Ministry of Health, Bureau of Planning. Strategy for Minimising the Health Impact of Indonesia’s Monetary Crisis. Ministry of Health, Republic of Indonesia. Prepared by the MOH Bureau of Planning with the technical assistance of the World Health Organisation Representative’s Office in Indonesia. Sep 1998 Ministry of Health, Republic of Indonesia. Program Jaring Perlindungan Sosial Bidang Kesehatan (JPS-BK), Pedoman Pelaksanaan, edisi revisi Oktober 98. (Social Safety Net - Health Sector, Operational Guidelines, revised edition) October 1998. Ministry of Health, Bureau of Planning. Jakarta, Indonesia Progress Report: Managing Health Impact of the Economic Crisis, Indonesia. November 1998. Ministry of Health. Some Notes on Basic Information, Accomplishments and Lessons Learned from the Implementation of the Health Social Safety Net Program in Indonesia. Azrul Anwar, Director General of Family Health, Indonesia. Presented at the MOH/WHO Donor Meeting on the Impact of the Economic Crisis on Health, Jakarta, 12 January 1999. National Development Planning Agency (BAPPENAS). The Social Safety Net in Indonesia’s Social and Economic Crisis. Herman Haeruman Js. Deputy Chairman for Regional Development Affairs, Republic of Indonesia, 1999.

Pan American Health Organisations (Executive Committee) Health and Development, Repercussion of the Economic Crisis. 1989 Rand Corporation. Health, Family Planning and Well-being in Indonesia during an Economic Crisis: Final Report. Results of analysis of data collected in the Indonesia Family Life Survey conducted Elizabeth Frankenberg, Kathleen Beegle, Bondan Sikoki, Duncan Thomas.. December 1998. SMERU (World Bank Social Monitoring & Early Response) Social Impacts of the Indonesian Crisis: New Data and Policy Implications. Prepared by Jessica Poppele (EACIQ), Sudarno Sumarto (SMERU) and Lant Pritchett (EACIF). 1998 SMERU (World Bank Social Monitoring & Early Response) Results of a SMERU Rapid Field Appraisal Mission: Implementation of BULOG’s Operasi Pasar Khusus (OPK) in Five Provinces. A Special Report from the Social Monitoring & Early Response Unit (SMERU). A project of the World Bank Indonesia, with support from AusAID, the ASEM Trust Fund, and the US Agency for International Development. December 18, 1998. SMERU (World Bank Social Monitoring & Early Response) Newsletter, The Impact of the Crisis on the Health & Nutritional Status of the Poor March-April 1999. Soekirman, SKM, MPS-ID, PhD, Professor of Nutrition, Division of Community Nutrition and Family Life, Faculty of Agriculture, Bogor Agricultural University (IPB), Bogor, Indonesia. Food, Nutrition and Economic Crisis : An In donesian Perspective. Presented at UNESCAP. The Social Impact of the Economic Crisis. 1999. UNSFIR (United Nations Support Facility for Indonesian Recovery) The Social Implications of the Indonesian Economic Crisis: Perceptions and Policy. Discussion Paper No 1. April 16, 1999. Wilopo P. Country Assistance Strategy up-date on the health sector. World Bank 1999 World Bank Watching Brief. Indonesia: Undernutrition in Young Children. Faadia Saadah, Hugh Waters, Peter Heywood. January 1999. World Bank. UNICEF & the Asian Crisis. The Social Crisis in East Asia - Poverty Net. Social Safety Net Technical Guidelines (in Indonesian):

Puskesmas Health Services (PT-1) Midwifery Services and Hospital Referral (PT-2) Supplemental Feeding with Local Food Sources (PT-3) Supplemental Feeding with Blended Food (PT-4) Food and Nutrition Alert System (PT-5) Community Health Insurance within Social Safety Net (PT-6)

Appendix 1: Key Health Indicators in Indonesia Pre Crisis

1986 1995

Health Expenditure

Health as % of GDP 2.5 1.65

Govt. health expenditures as % of total health

expenditure 1.26 2.0

Recurrent govt. health expenditure as % of total health

expenditure 73.8 65.3

% of recurrent health expenditure devoted to salaries 43.6 57.3

International aid for health as % of total health

expenditures 33.7 20.3

Physical infrastructure

Health centres 5,174 7,076

Auxiliary health centres 12,550 20,353

Mobile health centres 5,623 (1992) 6,207

Public general hospitals 829 1,062

Total hospital beds 63,643 94,966

Health Services

Physicians per 10,000 pop 0.6 1.63

Midwives per 10,000 pop 0.19 2.62

Nurses per 10,000 pop 1.6 5.0

Pharmacists per 10,000 pop 0.1 0.3

% access to health services N/A 43%

% access to essential drugs 33% 50%

% of deliveries attended by health personnel <20% 46.59%

Immunisation coverage 90.3% (1992) 88.6%

Demographic Trends

Life expectancy at birth 58 63.5

Infant mortality rate (per 1,000 live births) 71 55

Under five mortality rate (per 1,000 live births) 111 81

Adult literacy rate (male) 87.8 91.3

Health and Nutrition

% new-borns at least 2500g 86% (1985) 89%

Vitamin A deficiency 1.2% 0.3%

% anaemia in children < 5 55.5 % (1992) 40.5%

Child malnutrition 54.&% 36.1%

Iodine deficiency (West Java) 13.2% (1990) 3.1% (1996)

Derived from WHO Health for All 2000, World Bank 1997. Presented in PT

Hickling Indonesia under a contract from The Canadian International Development

Agency. April 1999.

Appendix 2: Surveys and Data Sources Helen Keller International Helen Keller International's Survey Results on the Nutritional Impact of the Crisis provides a detailed analysis of nutrition, health, and other household and individual data collected through a range of HKI project interventions in Kalimantan, Sulawesi, and Java, with specific analyses on the impact of the crisis on health and nutritional status of women and children based on baseline data collected before the crisis began. UNICEF 100 Villages Survey UNICEF and BAPPENAS (with LIPI and BPS) are running an expansion of the 1994 and 1997 UNICEF 100 Villages Survey (Sentinel Sites), which was conceived as a network of 100 villages to serve as an early warning system on social development problems. Originally intended to focus on mother and child development issues, the instruments for this survey have been extended to a whole range of indicators that were collected this summer. Analysis will be undertaken in October and November, with results available in December 1998. Poverty Analysis and Monitoring Unit Within BAPPENAS, the World Bank-financed Kecamatan Development Project houses a Poverty Analysis and Monitoring Unit, with responsibilities to target the KDP program and evaluate the impact of the KDP on the assisted areas. This unit will provide a stable home for the maintenance and analysis of data sets generated through a range of World Bank activities to monitor the crisis, in cooperation with the BAPPENAS data warehousing exercise. Kecamatan Rapid Poverty Survey The Kecamatan Rapid Poverty Survey, is a qualitative impact assessment survey with 100% coverage (reaching all 4,000 kecamatans in Indonesia) which uses simple scaling by local-level officials (teachers, agricultural extension agents, and health workers) to assess various dimensions of the cris is in every kecamatan. Analytical results should be available in November 1998. The Indonesia Family Life Survey The Indonesia Family Life Survey (IFLS2+) is a panel (longitudinal) survey of 1,500 households being implemented by RAND and the Lembaga Demografi at University of Indonesia. Jointly financed by the World Bank and USAID, this is the third round of the survey (pre-crisis data generated a representative baseline, and re-interview rates were 92% in round 2) that will re-visit a set of urban and rural households visited previously to examine the impact of the crisis on those households, including questions on labor market, social capital, gender, geographical shifts, and access to poverty programs. Full analysis and data reports are due in December 1998 or January 1999. UNDP On-The-Ground Monitoring Survey BAPPENAS and the UNDP are collaborating to collect and coordinate data sources on a wide range of social indicators; they will implement and analyse data from an UNDP on-the-ground monitoring survey" in late 1998 with localised coverage on:

food security, social protection, employment creation, small and medium enterprises. This effort by BAPPENAS also includes development of a "data warehouse" for crisis-related datasets. SUSENAS SUSENAS is the primary GOI monitoring and targeting tool for all national programs, with a 220,000-household nationally representative core sample, supplemented by a 50,000-household sample for specialised questions. SUSENAS is done annually as a nationally representative survey with a core and modules. It covers different topics on a three year cycle. These are housing, education, health, crime and socio -cultural issues. 1998 was health and education, so data can be compared with 1995. General opinio n seems to be that it is about as reliable as anything available – it triangulates reasonably well with IFLS and with trends noted in other small scale surveys. It is limited by being expenditure and consumption based, but the lowest deciles probably do correspond to the poorest in the population. Because of extreme budget shortfalls at BPS, the World Bank and AusAID have agreed to provide one-time technical assistance support to maintain the quality and rigor of this year's analysis; including improved sampling, additional disaggregation, and accelerated analysis.. BKKBN BKKBN is one of the most widely quoted sources of population data and poverty banding and is used generally in the absence of alternatives. It is also being used for targeting in some SSN programs. It is currently the only source for lists of all households in Indonesia. The census, carried out every 10 years, does not include household names, while the Ministry of Home Affairs, responsible for registration of vital statistics, has incomplete data as it depends on voluntary registration.

Central Bureau of Planning (BAPPENAS) Although it is not a data collection agency, BAPPENAS works closely with BPS to resource its own data needs. It carries out secondary analysis of sources, particularly using SUSENAS and BKKBN. BAPPENAS has developed its own working definitions and ways of identifying poverty, mainly as a result of its involvement since 1995 in the IDT, VIP and recently the KDP. As a result, it has experimented with using different combinations of variables and sources of data. Ministry of Health EWS data is being collected under SSN, using a method similar to that used in an earlier EWS project with Cornell University, which was halted in 1984 when Indonesia officially achieved self-sufficiency in rice, and claimed that malnutrition was no longer a serious problem. Consequently EWS data were no longer collected and there is a gap in EWS data sets. Kecamatan Crisis Impact Survey The nationwide Kecamatan Crisis Impact Survey was a subjective, expert respondent survey of three government officials in each of Indonesia’s 4025 kecamatans. In each sub-district three respondents with kecamatan-wide responsibilities were chosen and asked a standard set of questions about changes taking place in the kecamatan. The questions asked about the degree of different kinds of impacts (migration, access

to health and education, food availability, etc.), the frequency of different types of coping strategies, and the most severe effects in each area. All questions were designed to measure proportional change in indicators relative to the same time in 1997, to eliminate seasonal changes.

Community and Institutional Preparedness Presentation of Dr A. Zwi

Available in Hardcopy.

Health Services Presentation of Dr A. Paganini

• Can save lives • Can reduce suffering • Can promote dialogue and reconciliation • But can also create conflict

ESSENTIAL PACKAGE • Composition • Standards • Delivery modality

BAMAKO INITIATIVE • Community co-financing and co-management of services • From user to shareholder

FROM ONE SOMALIA TO MANY ENTITIES • Zones of Recovery • Zones of Transition • Zones of Crisis

FROM BAMAKO TO MOGADISHU • Opportunity for Health Reform • Involving the Private Sector and Civil Society • Keep adapting to the situation

SUGGESTED TOPICS FOR FUTURE DISCUSSION • Tailor the approach • Maximize leadership among the beneficiaries • Bad decisions at the beginning • Seize the opportunity for reform • Invest in local health systems before the crisis

Let's rise to the challenges!

Health, Governance and Conflict Presentation of Dr C.G. De Macedo

Available in Hardcopy.

United Nations Framework for Coordination Early Warning Mechanism

Presentation of Dr P. Calvi Parisetti

Available in Hardcopy.

Planning Ahead for the Health Impact of Complex Emergencies

Concluding Comments Dr X. Leus, Director EHA

For WHO, it is important to take stock, particularly as to how it plays its role for Health in Emergencies. Not only does this remain vague and not particularly well understood, internally as well externally, there is also a sense of competing demands and priorities, where the Organization can truly make a difference. In the Director General’s vision, we see a world where communities understand their vulnerability and prepare so that when the unexpected happens the impact on health is minimal. She asked this Group to define strategies and programme options for strengthening the national and international capacity to cope with complex emergencies. The value of the conceptual framework presented here is well documented in the discussion, and an urgent task now is to finalize this, and integrate the different concepts presented in the plenary sessions. This Consultation also raised a list of issues for further debate and action. There is and always will be a strong tension between action and research, but documentation and advocacy have an essential role to play. We will reflect also on how to keep this discussion going, possibly by using electronic means. A second key question is how to translate this discussion in WHO Technical Cooperation activities, including the necessary review of these activities for their possible contribution to health vulnerability in the wake of complex emergencies. Developing country and beneficiaries’ participation seems essential in this dialogue, and the continuing dearth of funding for such approaches and important development is regretted. For WHO, the mission of the Department of Emergency and Humanitarian Action is, through a concerted effort across the entire Organization, to increase the capacity and self-reliance of countries in the prevention of disasters, preparation for emergencies, mitigation of their health consequences, and the creation of a synergy between emergency action and sustainable development.

WHO is a mechanism to bring the international community together in its effort to prepare to better cope with complex emergencies. EHA wants to be the “conscience” for such efforts, both internally as well externally. To continue with action/research, including the necessary programming at country level, to identify best public health practices and to share experiences, close collaboration with WHO Technical Departments, Regional Offices and WHO Representative offices, is the key, for which EHA will provide leadership and concentrate its efforts.

As we fully realise change is in people and, as Dr De Macedo told us, the only thing that would be unacceptable for WHO now is inaction. You are called to bring about this change and strengthen WHO’s leadership for the international health community, in this key health challenge. I want to commend the excellent work of the different resource persons and organisers of the Conference, thank all the participants and state the hope that you have learned from each other as much as WHO/EHA has learnt from you.

Taxonomy of countries suggested for further studies

At risk

Yemen Pakistan Zambia

Crisis impending

Iraq N. Sudan Russia Nigeria Serbia Colombia Mexico

In crisis

Kosovo Liberia Somalia Tadjikistan Sudan Afghanistan Sierra Leone DR Congo Ethiopia

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Formats for country studies and national partners

Developing a standard format for country studies a) Background information (health profile plus factors considered necessary for good governance by the UN) ♦ Country profile: geographic, demographic and socio-economic factors ♦ Health indicators, morbidity / mortality patterns ♦ Promotion of rule of law, an impartial police force and an independent judiciary ♦ Respect for human rights and tolerance of minority and opposition groups ♦ Transparent political process and meaningful elections ♦ Commitment to eradicate corruption ♦ A military that is subject to strict civilian control ♦ A free press and strong civil society institutions b) Impact of crisis on health and other sectors ♦ Indicators of impact ♦ Health sector financing, provision. availability of trained health care workers, level and payment of salaries facilities, drugs and access particularly too vulnerable communities. ♦ Existence of disaster planning and emergency service delivery ♦ State of government , private, NGO sector and their ability to respond ( previous responses to crisis may be available) ♦ External assistance and presence of international organizations and their relationship with the government and other sectors Country based partner institutions who will conduct the studies ♦ Ministry of Health ♦ Medical Associations ♦ Other relevant ministries ( I.e. those concerned with lifeline systems and other social services) ♦ Non governmental organizations ♦ Military! ? Ministry of Defense ♦ Human Rights groups ♦ Religious / traditional organizations ♦ Private sector ♦ Local / community organizations ♦ WHO and other UN agencies ♦ Other international organizations PM: the WHO Handbook for Emergency Field Operations lists the national and international partners with guidelines for selection of such partners and subsequent coordination between these partners

Afterthoughts from the rapporteur of the Consultation, Dr Rodrigo

In his 1999 Annual Report "Preventing war and disaster: A growing global disaster, the UN Secretary General Mr Kofi A. Annan, describing the humanitarian challenge facing the international community stated that we must strengthen our capacity to bring relief to victims of disaster while at the same time devise strategies to prevent emergencies from arising in the first place. 90 % of all disaster victims live in developing countries and this trend is likely to continue unless adequate steps are taken. The response of the international community is sometimes inconsistent and that more often than not skewed. According to Mr.Annan, this inconsistency can partly be blamed on the sensational media exposure. Mr.Annan goes on to state that the international response must be based solely on human need and resources should not be allocated on the basis of politics, geography and media coverage. This emphasizes the need for accurate information which will generate more sensible perceptions of disasters. A request to become more prepared to cope with disasters from the developing countries particularly will lack credibility unless the international community looks more objectively at the availability of resources. In the early part of the century the ratio of resources held in the developed world in relation to the developing world was 3 to 1. This ration has now increased to a phenomenal 700 to 1. The one single strategy which must occur hand in hand with the relief response must be a more genuine, sincere and concerted transfer of resources. In the absence of such a move our efforts will continue to be relief operations followed by more relief operations. Dr Gro Harlem Brundtland’s observation poor countries undergo periodical disasters along apparently immutable patterns resulting from economic downturns coupled with disasters trigger off emergencies echoes this view. She goes on to state that all emergencies can be said to have political causes: either by commission or by omission. As she states we can not and must not ignore phenomena of this magnitude. The absolute poverty described by Robert McNamara, the former President of the World Bank, is life at the very margin of existence. The absolute poor are severely deprived human beings struggling to survive in a set of squalid and degraded circumstances almost beyond the power of our sophisticated and privileged circumstances to conceive some facts about poverty: Summary Proceedings of the 1976 Annual Meeting of the World Bank/IFC/IDA). It is sad to observe that nearly a quarter of century later the poverty situation has gone from bad to worse. For countries, particularly in Africa, situations of such human deprivation are nothing short of disasters. An adequate transfer of resources from the developed country to the developing countries is a prerequisite to developing preparedness in such countries. The minimum suggested by the UN ( 0.7 % of the GNP ) has been met by only a handful of affluent countries. Not to do so would be unethical as countless lives are lost and will be lost in addition to the heavy morbidity and human suffering brought on by the disaster of poverty, exacerbated too frequently by other emergencies. The international decade for natural disaster reduction has suggested the strategy of a safer world in the twenty first century: risk and disaster reduction for the new millennium. We should say a world more prepared to be safe.