Cost Recovery or Community Recovery? Rehabilitating Local Health Services in the Aftermath of Conflict and War

This thesis addresses the chronic failure of health service provision in conflict-affected
developing countries, with specific ~eference to Somalia. It reviews the main arguments on
how these ·seryices shoul~ be sustained: on the one hand, that these countries lack the
resources to provide essential services and that the solution is' through vastly increased
financial assistance, and the opposing view that aid has consistently failed to produce
improvements in service provision and the solution is for health services to become 'selffinancing'
through the imposition of user-fees. The thesis examines the effe~t~veness of
cost recovery approaches employed by governments particularly in the context of structural
. ,
adjustment and analyses their impact on the health and well-being of people in African
countries in terms of reduced access -to health services,· indebtedness and increased
morbidity. The thesis develops an alternative model for sustaining health services supported
by the National Red Crescent Society in Somalia, which has been field tested in the
Puntland region of Somalia. The new model is based on local empowerment to participate
in the management of the community health service, and adopts financing modalities based
on local coping capacities, seasonal income flows and user involvement in decision making
about' priority services and treatments, and sustaining the service. By empowering people to
identify the broader causes of ill-health and to address these causes within the terms of the
social and political context that determines their health stafus, the approach goes beyond
dealing with the immediate causes of their illness, and supports collective mobilization to
address deeper structural causes of sickness and in·health.