Health system reforms in five sub-Saharan African countries that experienced major armed conflicts (wars) during 1990-2015: a literature review

Abstract

Background: Sub-Saharan Africa (SSA) has had more major armed conflicts (wars) in the past two decades - including 13 wars during 1990-2015 - than any other part of the world, and this has had an adverse effect on health systems in the region.

Objective: To understand the best health system practices in five SSA countries that experienced wars during 1990-2015, and yet managed to achieve a maternal mortality reduction - equal to or greater than 50% during the same period - according to the Maternal Mortality Estimation Inter-Agency Group (MMEIG). Maternal mortality is a death of a woman during pregnancy, or within 42 days after childbirth - measured as maternal mortality ratio (MMR) per 100,000 live births.

Design: We conducted a selective literature review based on a framework that drew upon the World Health Organisation's (WHO) six health system building blocks. We searched seven databases, Google Scholar as well as conducting a manual search of sources in articles' reference lists - restricting our search to articles published in English. We searched for terms related to maternal healthcare, the WHO six health system building blocks, and names of the five countries.

Results: Our study showed three general health system reforms across all five countries that could explain MMR reduction: health systems decentralisation, the innovation related to the WHO workforce health system building block such as training of community healthcare workers, and governments-financing reforms.

Conclusion: Restoring health systems after disasters is an urgent concern, especially in countries that have experienced wars. Our findings provide insight from five war-affected SSA countries which could inform policy. However, since few studies have been conducted concerning this topic, our findings require further research to inform policy, and to help countries rebuild and maintain their health systems resilience.

Keywords: Angola; Eritrea; Ethiopia; Mozambique; Rwanda; armed conflict; community healthcare workers; decentralisation; fragile states; health-financing system; war.

Figure 1.

Factors affecting access to maternal health services in war affected sub-Saharan African countries, 1990–2015. Adapted from the WHO six health system blocks (2010).

Figure 2.

Studies inclusion criteria for the literature search and the number and type of papers included.

Figure 3.

Maternal mortality decline in five sub-Saharan African countries affected by war during 1990–2015 (from the most significant decline in 2014). Data source: The 2015 Maternal Mortality Estimation Inter-Agency Group (MMEIG).

Figure 4.

Total health expenditure in five "war-affected" countries compared to the median sub-Saharan region (most countries had no data prior to 1995). Data source: WHO