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Amidst all talk about funds, business plans and governance I would like to give you a little update on some of the issues that are currently high on our agenda, and in development in programmes in Burundi, Cambodia, Myanmar, and hopefully South Sudan.
Social determinants of health
Central to the raison d’etre of HNTPO is the relation between health, specific psychosocial problems in fragile states, and the search for interventions that influence one through the other. Social determinants of health need to be addressed in order to strengthen both health of communities and health care delivery systems – and we assume that a population that is actively engaged in building health care delivery systems in turn contributes to rebuilding community structures.
State security versus human security
As I state in almost every presentation there is an important difference between the dominant ‘State Security Agenda’ followed by institutional donors and the ‘Human Security Agenda’ that has been proposed as an antidote. Common ground between the two is the idea that failed states or fragile states need to be repaired – that we need ‘state building’. Within that context there is a lot of talk about concepts that are not always very clear, such as social protection, food security, livelihoods, peace dividend, gendered environmental awareness and so on. Quite often these terms serve as container concepts, such as social protection, that now includes much more than the former legal aspects of UNHCR projects: under social protection many see public service delivery which includes health, education, food security and more.
The important and dangerous misunderstanding is in the word ‘protection’, because it assumes that there is an agent who is protecting people. In earlier times and in more concrete concepts that would be the UNHCR – to protect refugees, or in a wider sense the UN, when they formulated the ‘responsibility to protect (R2P or RtoP) initiative in 2005. Now that has changed again. Protection is equaled to a ‘state’, and the concept is used exactly in those countries where the state is not willing or not able to provide any kind of social protection. That is why an example as the Dutch idea of the 3D approach, where state building is the goal and public service delivery is seen as an instrument towards state building, is so dangerous and misleading.
Service delivery and state-building
The general claim that there is a causal link between service delivery and state-building is frequently made but rarely evidenced – as stated by Rachel Slater and Samuel Carpenter in “Service delivery and state-building: the 46.7 billion dollar question?” http://www.odi.org.uk/opinion/6884-service-delivery-state-building-conflicted-affected-states . One of the issues that came up in a recent conference was this concern about “gaps that remain in the guidance about how to deliver basic services in volatile, low capacity situations, particularly in relation to comparative costs and programme effectiveness”.
If we have a look at these texts, we see how there is an urgent need for alternative study designs, more than the current ‘reviews of reviews’ or the ever-simplifying RCT’s. There is a need to do much more in context studies, in understanding the particulars of specific settings. An attempt is made by the “Secure Livelihoods Research Consortium” in a series that can be found here and I attached one example of these reports – on South Sudan. However, these reports are just a beginning.
Developing the concept
HNTPO should be proud of having done a lot of work in this field already. And we continue in this field. Planning the Burundi project where we integrate community systems strengthening, health care, agricultural intensivation and integrated insurance is a good example of how we investigate the possibilities in fragile situations. Another example is the research that we are starting up in Cambodia.
I hope this update helps people see what we are working on, next to the daily challenges!
Willem van de Put – Extern directeur HealthNet TPO
Achtergrond – Willem studeerde geschiedenis, filosofie en culturele antropologie aan de Universiteit van Amsterdam. Hij specialiseerde zich in medische antropologie en voerde als medisch antropoloog diverse veldopdrachten uit in Nicaragua, Oeganda en Cambodja. In 1995 vertrok hij naar Cambodja, alwaar hij programmadirecteur werd voor de Transcultural Psychosocial Organization (TPO) en een ‘community mental health’ programma opzette. In Cambodja werd hij gekozen als voorzitter van het stuurcomité van MEDICAM, een Cambodjaans platform voor ruim 90 internationale en lokale NGO’s werkzaam op het gebied van gezondheid. In 1997 en 1998 was hij tevens gastdocent voor Medische Antropologie op de Universiteit van Phnom Penh. Toen hij terugkeerde naar Nederland, werd Willem directeur van Healthnet International, dat later fuseerde met TPO tot het huidige HealthNet TPO.