Providing Healthcare in Armed Conflict: The Case of Mali JANUARY 2019 This issue brief was drafted by Alice Introduction Debarre, Senior Policy Analyst at IPI. It accompanies a policy paper published in 2018 entitled “Hard to In 2012, armed conflict erupted in northern Mali. Today, despite a peace deal Reach: Providing Healthcare in signed in Bamako in 2015, the situation in central and northern Mali remains Armed Conflict,” as well as a second unstable due to fighting among armed groups, fighting between armed groups case study on provision of health - and the Malian armed forces, and criminality. 1 Three foreign military care in Nigeria. These papers aim to operations are currently supporting the government of Mali: the French assist UN agencies, NGOs, member Operation Barkhane, the UN Multidimensional Integrated Stabilization states, and donor agencies in Mission in Mali (MINUSMA), and the European Union missions in the Sahel. providing and supporting the The recent deployment of troops from the G5 Sahel Joint Force adds a fourth provision of adequate health component to an already complicated military landscape. 2 Increasingly, services to conflict-affected popula - humanitarian actors have also been raising the alarm as to the role of climate tions. change in exacerbating conflict in Mali. 3 This issue brief is based on a Conflict and insecurity in northern and central Mali has had dire combination of desk and field research. The author conducted consequences for the health of the civilian population and created numerous twenty-five interviews in Bamako challenges for the provision of health services to those in need. The humani - from April 29, 2018, to May 8, 2018, tarian situation is complex and volatile. There are approximately 5.2 million with representatives from national people in need of humanitarian assistance and over 77,000 internally and international NGOs, UN displaced persons. Food insecurity remains a major concern, with approxi - agencies, and the Malian Ministry of mately 2.5 million people still considered “food insecure” in spite of a decrease Health. in affected populations since 2017. 4 Additionally, 1.8 million people require The views expressed in this publica - humanitarian health assistance. 5 tion represent those of the author This issue brief aims to assist UN agencies, NGOs, member states, and and not necessarily those of the donor agencies in providing and supporting the provision of adequate health International Peace Institute. IPI services to conflict-affected populations in Mali. It maps and explains the welcomes consideration of a wide range of perspectives in the pursuit challenges health actors face, the understanding of which is key to ensuring of a well-informed debate on critical that health policies are adequate. It also looks at the governance structures set policies and issues in international up to operationalize those policies, seeks to identify and analyze gaps in policy affairs. and implementation, and provides recommendations for bridging those gaps. IPI owes a debt of gratitude to its many donors for their generous 1 See, for example, Boubacar Sangaré, “Settling Local Disputes Is Key to Peace in Central Mali,” Institute for Security Studies, November 12, 2018. support. IPI is particularly grateful to 2 See, for example, UN Security Council, Joint Force of the Group of Five for the Sahel—Report of the Secretary the Bill & Melinda Gates Foundation General , UN Doc. S/2018/1006, November 12, 2018; Jennifer G. Cooke, “Understanding the G5 Sahel Joint Force: Fighting Terror, Building Regional Security?” Center for Strategic and International Studies, November 15, 2017; for making this publication possible. Arthur Boutellis, “Shake-up of G5 Sahel Joint Force Starts at Home, in Mali,” IPI Global Observatory , July 27, 2018; and Aïssata Athie, “Coordinated Response Key to G5 Sahel Joint Force Success,” IPI Global Observatory , June 19, 2018. 3 International Committee of the Red Cross, “Mali-Niger: Climate Change and Conflict Make an Explosive Mix in the Sahel,” January 22, 2019. 4 UN OCHA, Humanitarian Bulletin Mali , July–August 2018, available at https://reliefweb.int/report/mali/mali- humanitarian-bulletin-july-august-2018 ; UN OCHA, Humanitarian Bulletin Mali , September–mid-November 2018, available at https://reliefweb.int/report/mali/mali-humanitarian-bulletin-september-mid-november-2018 . 5 Mali Health Cluster, Bulletin du Cluster santé , janvier–juin 2018, available at www.who.int/health-cluster/countries/mali/mali-health-cluster-bulletin-jan-june-2018.pdf . 2 ISSUE BRIEF It focuses on the coordination of health actors, the Figure 1. Mali’s public healthcare system prioritization of health services, the sustainability of health services and the transition to develop - ment work, context-specificity and localization, and accountability for healthcare providers. The State of Healthcare in Mali Mali has a decentralized health system (see Figure 1). The Ministry of Health heads the development of national health priorities, strategies, and policies, which are then implemented by the National Health Directorate ( Direction nationale de la santé , or DNS). There are three national hospitals, all located in the capital, Bamako. The National Health Directorate also coordinates and controls regional health programs developed by regional health directorates ( directions régionales de la santé , or DRSs). Seven regional hospitals implement these programs and can provide advanced care. Below these hospitals are referral health centers ( centres de santé de reference , or CSRs), which provide care at the district level. Finally, the referral health centers each supervise a number of community health centers ( centres de are also more expensive private healthcare santé communautaires , or CSCs). The community providers in Mali, which the Ministry of Health health centers provide primary healthcare with a licenses and works with to ensure they meet focus on maternity and pediatric care. In bigger national standards. villages, community health workers are often According to a number of interviewees, the present to respond to essential health needs and, if health standards adopted by the government of needed, can refer patients to the community health Mali are in compliance with international centers. 6 The government set up a community standards. Mali has ratified the International health worker program in 2009 to provide health - Health Regulations (IHR) and appointed an IHR care to populations living five kilometers or more focal point. At each level of the Malian healthcare away from the closest community health center. 7 In system, there is a point person for epidemiological some areas, these community health workers also surveillance who reports to the National Health have community relay agents ( relais communau - Directorate. The government is currently working taires ) working in small villages who can detect to put a community-based surveillance system in diseases, provide advice, and refer patients to them. place at the village level. Each level also has a The Ministry of Health has a unit responsible for standing committee for the management of ensuring the security of health personnel in the epidemics and emergencies ( comité permanent de central region. This unit collaborates with the gestion des épidémies et des catastrophes ) that takes Ministry of Security and the Ministry of Defense to stock of existing capacity, support needed, and ensure health personnel are present in the right potential gaps. The government also created a areas and able to do their work adequately. There Department of Emergency Public Health 6 For more on community health in Mali, see Kristen Devlin, Kimberly Farnham Egan, and Tanvi Pandit-Rajani, “Community Health Systems Catalog Country Profile: Mali,” Advancing Partners and Communities, September 2016. 7 Mohammad H. Asadi Lari, “In Mali, Innovation Means Access to Lifesaving Healthcare,” Canadian Red Cross Blog, July 30, 2018. Providing Healthcare in Armed Conflict: The Case of Mali 3 Operations for Epidemics ( Département des reportedly still mostly functional in areas operations d’urgence de santé publique pour les controlled by armed groups, and the Ministry of épidémies ) to detect and lead the response to major Health sends supports to community health public health crises. A 2017 joint external evalua - workers in those areas when possible, although this tion of Mali’s capacity to implement the IHR noted support is impossible to monitor. 14 A Ministry of that the country’s healthcare system had technical Health representative interviewed for the research capacity in areas such as vaccination, surveillance, noted that the ministry is considering extending and notification of epidemics but needed to be the community relay agents to conflict zones, as reinforced across all areas. 8 they have proven to be successful in reaching more 15 Despite progress, notably in decentralizing remote communities. healthcare and developing community health Given the level of need and the poor state of the centers, Mali’s healthcare system remains poor. Malian healthcare system, humanitarian actors Even the national hospitals, the best facilities in the play an important role in the provision of health - country, reportedly suffer from overcrowding, lack care services in the country, both by providing of up-to-date equipment, and insufficient medical direct services and by supporting government supplies. 9 Regional hospitals also lack equipment, health structures.