Bourdeaux Margaret, Kerry Vanessa, Haggenmiller Christian, Nickel Karlheinz
Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA USA.
Harvard Medical School, Department of Global Health and Social Medicine, 641 Huntington Avenue, Boston, MA 02115 USA ; Associate Director of Partnerships and Global Initiatives, Center for Global Health, Massachusetts General Hospital, 100 Cambridge Street, 15th floor, Boston, MA 02114 USA.
Confl Health. 2015 Apr 13;9:14. doi: 10.1186/s13031-015-0040-y. eCollection 2015.
Destruction of health systems in fragile and conflict-affected states increases civilian mortality. Despite the size, scope, scale and political influence of international security forces intervening in fragile states, little attention has been paid to array of ways they may impact health systems beyond their effects on short-term humanitarian health aid delivery.
Using case studies we published on international security forces' impacts on health systems in Haiti, Kosovo, Afghanistan and Libya, we conducted a comparative analysis that examined three questions: What aspects, or building blocks, of health systems did security forces impact across the cases and what was the nature of these impacts? What forums or mechanisms did international security forces use to interact with health system actors? What policies facilitated or hindered security forces from supporting health systems?
We found international security forces impacted health system governance, information systems and indigenous health delivery organizations. Positive impacts included bolstering the authority, transparency and capability of health system leadership. Negative impacts included undermining the impartial nature of indigenous health institutions by using health projects to achieve security objectives. Interactions between security and health actors were primarily ad hoc, often to the detriment of health system support efforts. When international security forces were engaged in health system support activities, the most helpful communication and consultative mechanisms to manage their involvement were ones that could address a wide array of problems, were nimble enough to accommodate rapidly changing circumstances, leveraged the power of personal relationships, and were able to address the tensions that arose between security and health system supporting strategies. Policy barriers to international security organizations participating in health system support included lack of mandate, conflicts between security strategies and health system preservation, and lack of interoperability between security and indigenous health organizations with respect to logistics and sharing information.
The cases demonstrate both the opportunities and risks of international security organizations involvement in health sector protection, recovery and reconstruction. We discuss two potential approaches to engaging these organizations in health system support that may increase the chances of realizing these opportunities while mitigating risks.
脆弱和受冲突影响国家的卫生系统遭到破坏会增加平民死亡率。尽管国际安全部队在脆弱国家进行干预的规模、范围、程度和政治影响力较大，但对于它们可能影响卫生系统的一系列方式，除了对短期人道主义卫生援助交付的影响之外，却很少有人关注。
利用我们发表的关于国际安全部队对海地、科索沃、阿富汗和利比亚卫生系统影响的案例研究，我们进行了一项比较分析，研究了三个问题：在这些案例中，安全部队对卫生系统的哪些方面或组成部分产生了影响，这些影响的性质是什么？国际安全部队通过哪些论坛或机制与卫生系统行为体互动？哪些政策促进或阻碍了安全部队对卫生系统的支持？
我们发现国际安全部队对卫生系统治理、信息系统和本土卫生服务组织产生了影响。积极影响包括增强卫生系统领导的权威、透明度和能力。负面影响包括利用卫生项目实现安全目标，从而破坏本土卫生机构的公正性。安全行为体与卫生行为体之间的互动主要是临时的，往往不利于卫生系统的支持工作。当国际安全部队参与卫生系统支持活动时，管理其参与的最有效的沟通和协商机制是那些能够解决广泛问题、灵活适应迅速变化的情况、利用人际关系的力量并能够解决安全战略与卫生系统支持战略之间产生的紧张关系的机制。国际安全组织参与卫生系统支持的政策障碍包括缺乏授权、安全战略与卫生系统维护之间的冲突，以及安全组织与本土卫生组织在后勤和信息共享方面缺乏互操作性。
这些案例展示了国际安全组织参与卫生部门保护、恢复和重建的机遇与风险。我们讨论了让这些组织参与卫生系统支持的两种潜在方法，这可能会增加实现这些机遇同时降低风险的机会。
