As national resources for health decline, so dependence on international resources to finance the capital and recurrent costs is increasing. This dependence, combined with an increasing emphasis on policy-based, as opposed to project-based, lending and grant-making has been accompanied by greater involvement of international actors in the formation of national health policy. This paper explores the process of health policy development in Uganda and examines how major donors are influencing and conflicting with national policy-making bodies. Focusing on two examples of user fees and drugs policies, it argues that while the content of international prescriptions to strengthen the health system may not be bad in itself, the process by which they are applied potentially threatens national sovereignty and weakens mechanisms for ensuring accountability. It concludes by proposing that in order to increase the sustainability of policy reforms, much greater emphasis should be placed on strengthening national capacity for policy analysis and research, building up policy networks and enhancing the quality of information available to the public concerning key policy changes.

No abstract

The end of the Cold War brought with it opportunities to resolve a number of conflicts around the world, including those in Angola, Cambodia, El Salvador and Mozambique. International political efforts to negotiate peace in these countries were accompanied by significant aid programmes ostensibly designed to redress the worst effects of conflict and to contribute to the consolidation of peace. Such periods of political transition, and associated aid inflows, constitute an opportunity to improve health services in countries whose health indicators have been among the worst in the world and where access to basic health services is significantly diminished by war. This paper analyzes the particular constraints to effective coordination of health sector aid in situations of 'post'-conflict transition. These include: the uncertain legitimacy and competence of state structures; donor choice of implementing channels; and actions by national and international political actors which served to undermine coordination mechanisms in order to further their respective agendas. These obstacles hindered efforts by health professionals to establish an effective coordination regime, for example, through NGO mapping and the establishment of aid coordinating committees at national and provincial levels. These technical measures were unable to address the basic constitutional question of who had the authority to determine the distribution of scarce resources during a period of transition in political authority. The peculiar difficulties of establishing effective coordination mechanisms are important to address if the long-term effectiveness of rehabilitation aid is to be enhanced.

The concept of the 'relief-to-development continuum' has been the subject of renewed interest in recent years. Concerned by the rise in relief budgets over the past decade and the absolute fall in development aid resources, support has been growing for the concept of developmental relief. In the context of complex political emergencies, it has been argued further that as effective development aid can reduce vulnerability to the impact of natural hazards, so it might also be used to contribute to a process of conflict prevention. In this way, the concept of the relief-development continuum has become entwined with broader discussions about the contribution of official development assistance management. Drawing on a Review of Operation Lifeline Sudan (OLS), this paper cautions against uncritical application of the concept of the continuum in complex political emergencies and rehabilitation in particular, in the current Sudanese context. It argues that in order to move legitimately from relief aid programming to development aid programming, three fundamental conditions must be in place: first, a minimum level of security, respect for human rights and humanitarian access. Second, empirical evidence from the field needs to demonstrate that the emergency is over. Finally, moving from relief to development aid programming is contingent on donor governments accepting the legitimacy of national governmental structures and of the rebel movements. In other words, for donor governments, moving along the continuum is in significant part determined by foreign policy considerations, not only technical ones. Consideration needs to be given to the actual and perceived legitimation of the different movements that a move to rehabilitation might be seen to imply. The paper argues that none of these conditions had been satisfied in Sudan by mid-1997. Instead of a process of normalisation paving the way to long-term development, the current situation in Sudan is better described as a chronic political emergency. In such a context, uncritical pursuit of developmental strategies may negatively affect the welfare of conflict-affected populations.

Famine is conventionally portrayed as a natural disaster expressed in terms of food scarcity and culminating in starvation. This view has attracted criticism in recent years as the political, legal and social dimensions of famine have become more clearly understood. This paper draws upon these criticisms to understand the particular conditions of famine creation in conflict situations. Following an examination of six contemporary African famines, it is suggested that the use of food as a weapon of war by omission, commission and provision has contributed to the creation of famine in recent decades. Despite the optimism for peace engendered by the demise of the Cold War, the momentum for conflict would seem to be sustained by internal factors, including economic and environmental decline, political instability and ethnic rivalry. Within these conflicts, the strategic importance of food is likely to remain central. This study highlights the need to link concerns with food security and public health to those of development, human rights and international relations.