Weak government institutions can also negatively impact the coordination of international assistance in reconstruction efforts. The end of civil war often brings a surge of financial and technical assistance from foreign governments, NGOs, and IGOs. While this assistance is often a positive event — granting governments access to far more resource than domestically available — and while it is almost always eagerly accepted by post-conflict regimes, the influx of support can come with unintended pitfalls. The sheer number of organizations offering assistance can overwhelm governments. After Kosovo’s war, more than 400 organizations flooded into the country. In 1995, Rwanda’s post-conflict Ministry of Health had to manage 89 NGOs in the health sector alone. The responsibility to oversee and coordinate the myriad of organizations most often falls on the shoulders of the government bureaucracy. Many states would have difficulty effectively managing such a sudden and large increase in responsibilities even during peacetime. After having their capacity reduced by civil war, these institutions often have little chance of successfully managing the relief effort.
Post-conflict governments often face an imbalance of power between themselves and providers of international assistance. Crippled by war, government institutions lack the de facto authority or capacity to work with NGOs and IGOs in the reconstruction process as equals, much less as leaders. This is due in no small part to the large share of reconstruction funds coming from international donors. Near the end of the Mozambique’s civil war, much of the reconstruction funds were managed the European Union and UNHCR, and not by the Mozambican government. The more the government is dependent on the support of international donors for health financing, the more leverage those donors and the NGOs they support have in shaping national health policies. While NGOs have shown to be better equipped to ramp up services quickly than state institutions, a valuable capacity when operating in crisis environments, they are self-interested actors whose interests are not necessarily parallel to those of the government. Ideally, reconstruction funds would be channeled through the Ministry of Health, which would disperse them as part of a unified national strategy for health system reconstruction; however many post-war governments lack the capacity to do so.
When this happens, international donors often select and fund health efforts independent of any central coordinating body. The end result is a proliferation of disorganized health projects funded by international donors and operated by NGOs, each with their own small area of operation and with minimal coordination with any national reconstruction strategy. This “project-based” reconstruction is particularly likely when the regime lacks legitimacy in the eyes of the international community. During the early 1990s, Cambodia’s interim government was seen as lacking political legitimacy, leading many donors to sidestep state institutions and directly fund some seventy NGOs in the health sector, “some with little or no official recognition and no obligation to locally account for how resources were disbursed, this uncontrolled environment was, to take a common phase, a ‘free for all’”. A similar problem is seen in Somalia, where decades of ineffective government institutions created a uncoordinated project-based effort which placed more emphasis on short-term relief than long term health system reconstruction. Nowhere is this problem more apparent than in the statements of one health professional in Bosnia and Herzegovina who described international involvement in his country’s health reconstruction process this way:
The magic word that opened all doors was “project.” In those days, anyone with a modicum of self-respect had to have a project. Rushing to submit their project proposals, the experts would sometimes forget to change the name of the country in the project title and we would suddenly have to decide on a Breast Feeding Campaign in Moldavia or AIDS Prevention in Georgia. But, mistakes happen, no harm done. There were a lot of other projects, such as Doctors’ Associated against the Torture and International Physicians against Nuclear War (although we did not have one), and Role of Nurse in the Sequence of the Rape, and of course – anti-smoking projects. If somebody wanted to help but had no idea what to do, a non-smoking campaign always came in handy. We had at least a hundred anti-smoking actions of all sorts. Millions of dollars were spent, but to no avail. The locals still smoke. It does not matter that at this moment only 30% of the inhabitants of Bosnia and Herzegovina have a safe water supply (Simunovic 2007, 5).
The inability of weak institutions to manage a unified health reconstruction effort has significant detriments to health care delivery: health providers become more fragmented and the population becomes more dependent on health care directly from NGOs. In post-war Uganda this effect was dramatic. The Ugandan health system was bifurcated; the government became responsible for secondary and tertiary care while internationally funded NGOs provided primary care. This type of health care system fragmentation can lead to inefficiencies in the health care delivery. Thus, during post-conflict reconstruction, a critical component is the government’s capacity to integrate the myriad of international assistance efforts into the national health system.
Christopher R. Albon is a political science Ph.D. specializing in armed conflict, public health, human security, and health diplomacy.