Distinguished guests, ladies and gentlemen
Hardly a week goes by when there isn’t some act of politically motivated violence, especially against civilians, intended to instill fear.
The world is indeed facing rising terrorism targeting civilians, with related deaths, injuries and severely affecting the living conditions of millions of people. For instance, the Lake Chad Basin crisis (in north-eastern Nigeria, northern Cameroon, western Chad and southeast Niger) has affected about 17 million people.
International humanitarian laws are increasingly being flouted. In 2016, there were over 300 attacks on healthcare facilities across 20 countries globally, and 979 health workers were injured or killed in attacks. The Geneva Convention prohibits such attacks on healthcare facilities which are regarded as a war crime.
Ladies and gentlemen, war and terrorism directly impact on health, not only of targeted populations. In today’s interconnected world, when interventions - especially immunization campaigns - become difficult or impossible to deliver, global health security is directly threatened.
War and terrorism reduce or deny access to healthcare when health workers and health facilities are targeted and infrastructure is destroyed, leading to loss of civilian lives.
In South Sudan, over half the population (56%) lacks access to functional health facilities, while in the Central African Republic, nearly a quarter of health facilities are totally or partially destroyed.
Healthcare delivery in northern Nigeria has been directly affected by the insecurity. In 2016, nearly two-thirds of the 743 health facilities in Borno State in Nigeria were completely destroyed or damaged.
Many people in Borno State have not had access to routine vaccinations, basic medicines for years, as six local government areas are inaccessible to humanitarian partners.
Some 3.7 million people in Borno State, nearly 60% of whom are children, are at risk of malaria, and an estimated 8500 people are infected weekly. The disease has caused more deaths than all other causes combined, including outbreaks of cholera (total of 4392 suspected cases; 59 deaths; CFR: 1.4%), measles and Hepatitis E.
Health services are compromised: for instance, in the Central African Republic (CAR), only half the laboratories, 11% of the blood banks and 20% of the ARV services are functional, while South Sudan reports frequent stock outs of medicines and other commodities.
Freedom of movement is severely curtailed, making referrals for secondary care such as surgery often impossible – not only for trauma patients, but even, for instance, women needing Caesarians who cannot travel safely.
Maternal mortality in the Central African Republic is the 2nd highest in the world (882/100 000 live births), while in South Sudan, less than 11.5 % of births are assisted by a skilled attendant.
As trauma cases escalate, healthcare workers face mounting pressure, and are themselves affected psychologically, socially and financially. There is high attrition of health workers, many of whom are forced to flee, and training is often suspended.
For instance, in the Central African Republic, training capacity and quality has decreased, with 1 doctor / 22 000 population.
Lack of clean water, sanitation increase the risk of communicable diseases (e.g. cholera), while reduced access to essential medicines and services exacerbates existing health needs (e.g. NCDs, mental health care).
There are currently 2.4 million internally displaced people in South Sudan and CAR. These vulnerable populations often have limited access to humanitarian assistance, contributing to negative coping mechanisms, including survival sex.
War and terrorism, and natural disasters like flood or drought, impact on agricultural production, causing food insecurity, famine and severe acute malnutrition, particularly in children.
In South Sudan, about 6 million people are in emergency/crisis level food insecurity.
Acute malnutrition from food insecurity is rising in Borno State, Nigeria.
Coordination of Aid
Ladies and gentlemen, we learned from the Ebola epidemic in 2015/16 that aid coordination is absolutely critical in an emergency, and is the most appropriate structure for relief coordination. Without coordination, there is logistical chaos, duplication of effort, unnecessary competition between humanitarian actors.
Significant coordination gaps exist:
Often, government leadership falls short in assessing the roles of humanitarian agencies, the effects of the coordination mechanism, and may under crisis accept support without ensuring sustainability and coherence.
In CAR, some partners provided bilateral support without following the existing MoH framework, whereas in South Sudan, healthcare services depend on partners, raising the issue of sustainability.
The humanitarian relief system is often characterized by competition for resources and visibility. Unfortunately, health interventions and health sector coordination do not attract the same financial support compared to other sectors (e.g. food, sanitation).
In Nigeria, in 2017 only a third (33%) of requested funding has been received by WHO and health partners, and less than a quarter (23.9%) for CAR, according to OCHA.
When accountability to donors trumps accountability to affected populations, resources are wasted, and efforts are duplicated due to failure to coordinate and plan based on needs assessment.
Proper aid coordination usually leads to predictable leadership; improved effectiveness of the humanitarian response and enhanced partnerships; and increased accountability.
In 2012, the World Health Assembly adopted a resolution (65.2) reaffirming the central role of health in humanitarian response and strongly endorsed WHO’s role as the Health Cluster lead agency.
Inclusive, equal partnerships among humanitarian actors help to avoid gaps in coordinating resources, knowledge and assets, and are stronger when NGOs have preexisting relationships with UN agencies.
Flexible funding through mechanisms such as pooled funds in countries under transparent management of humanitarian stakeholders, such as the UN Regional Coordinator, will help to allocate funds equitably according to needs, and ensure funding for health.
Increased accountability and transparency ensures that humanitarian aid can build resilience and address the root causes of vulnerability, including more sustainable health services.
WHO’s role in Coordinating Aid
In health emergencies including war and terrorism, WHO is responsible for fostering cooperation between government and partners in conflict affected countries, for coordinating the health cluster (by conducting rapid assessments, developing strategies and plans, and monitoring the health situation), and we have a distinct role in interfacing with security mechanisms.
In north-east Nigeria, WHO is coordinating 22 health sector partners supporting about 90 health facilities each month, facilitating care to over 3 million people this year. We also coordinate surveillance workers, diagnostic and laboratory capacities, contact tracers.
Our coordination has made a difference: our five sub-offices in the field in CAR, and in Borno State (Maiduguri, Nigeria) are helping to ensure disease surveillance, outbreak responses and guidance to health partners for life saving interventions.
WHO’s global health security reforms have made the Organization fit for purpose to address global health threats. In the African Region, our new WHO Health Emergencies Programme last year coordinated the deployment of over 2500 experts, and supported the health response to reach over 6-million refugees and internally displaced people.
WHO’s top responsibility is to support efforts of national health authorities to strengthen their core responsibilities, including to the International Health Regulations of 2005.
In Nigeria, for instance, WHO is supporting the Borno state government to establish an all-hazard Emergency Operation Centre, and has set up 169 Early Warning Alert and Response System sites in Borno State to enable identification of the highest causes of morbidity and mortality and plan appropriate responses.
To reduce childhood deaths and increase healthcare access in this insecure area, we trained and certified nearly 100 community response persons to treat children with malaria, pneumonia, diarrhoea or malnutrition, reaching over 800 communities.
We commissioned a modelling exercise to estimate malaria cases and deaths in Borno, which found that with the right joint actions, up to 10 000 deaths could be prevented.
WHO and partners have stepped up surveillance of malaria, increased access to care, sprayed and distributed bednets, and are currently administering malaria drugs monthly to children under 5 during the peak season to ensure they are cleared of parasites and protected temporarily to reduce the death toll in the next 6 months.
Stronger health systems which offer universal health coverage are the best defence against health insecurity.
In South Sudan, WHO has contributed to a new National Health Policy (2016-2026) to guide efforts to improve health systems for attaining Universal Health Coverage. Our coordination role has led to the revitalization of the health cluster coordination at all levels.
Helping countries to recover from disaster and conflict is key to building resilient, responsive health systems.
In CAR, WHO helped to develop a health transition plan to restore the country’s health services while responding to urgent health service needs. This plan contains a partner mechanism for channeling resources to national priorities.
Finally, WHO and its partners are establishing a system for collecting data on attacks on health workers, health facilities, transport and patients in complex emergencies. Documentation is essential to identify violations, create protection and muster the political will to resolve conflict as quickly and peaceably as possible for health and security for all.