War and Peace: The Health and Health System Consequences of Conflict in Colombia

Lead Research Organisation: University of York
Department Name: Centre for Health Economics

Abstract

Internal armed conflicts have become more common and more physically destructive since the mid-20th century. Although these conflicts constitute a global problem, poorer countries have been disproportionately affected, with devastating consequences for health and development. Beyond the direct health effects of people being killed or maimed, population health is affected indirectly through destruction of economic assets, damage or lack of access to public health infrastructure and large population displacements.

The overarching goal of our project is to investigate the consequences of long-term internal conflict for population health, the health system and post-conflict health policymaking through an in-depth study of the past and current experience of conflict and peace agreement in Colombia. Since 1958 an estimated 220,000 people have died in Colombia due to the civil conflict and more than six million (13% of the population) have been forcibly displaced. A peace accord between rebel forces and the Colombian government was agreed in December 2016 and has ended hostilities, creating a unique window of opportunity to conduct research of immediate policy relevance. Our project will provide much needed evidence on under-researched issues such as the consequences of conflict for health service organisation and delivery, and the impact on often overlooked populations including internally displaced families and the poorest groups.

These questions will be answered through a mixed-methods research programme involving two linked work packages. The quantitative package will rely on survey data collected by the team and data already available, analysed using state-of-the-art techniques. The qualitative and historic analyses will employ focus groups with residents of selected municipalities, interviews with national and local government officials and civil society representatives, and examination of publicly available official documents and historic administrative datasets, generating a uniquely rich portrait of the consequences of civil conflicts for the health system. The conclusions drawn from all these analyses will provide the basis for specific, evidence-based health policy recommendations by the research team.

The principal elements that will ensure this project has practical impact are its distinctive timeliness for health policymaking, constant stakeholder engagement and methodological rigour. Close engagement with Colombian and international policymakers, aligned with the breadth and depth of our analyses, will inform the extent of generalisation of health system policy implications to other developing countries, particularly where sustained conflicts with resulting population displacements are currently ongoing or have recently concluded. Potential beneficiaries of our research include populations affected by conflict violence, health policymakers and the broad academic community.

Technical Summary

We will investigate the consequences of long-term internal conflict for health and the health system, and for post-conflict health policymaking, through an in-depth study of the Colombian experience of conflict and peace agreement. A peace accord between rebels and the Colombian government was agreed in December 2016, which creates a unique window of opportunity to conduct research of immediate policy relevance for Colombia and other conflict-afflicted countries. Key knowledge gaps exist about the dynamics of health and health systems during and after conflict. Our project will fill gaps in several areas and respond to the information needs expressed by Colombian policymakers, using a broader array of data than available for previous studies in Colombia and elsewhere.

Our research will be undertaken through two linked work packages, guided by a suitable theoretical system framework. The quantitative package will rely mainly on two secondary datasets complemented by primary data we will collect with a new household survey, analysed using innovative econometric modelling. This work will uncover the consequences of conflict on child and adult health outcomes; variation of impacts across population groups; and the main mechanisms for impacts related both to individual demand for and system supply of health services. The qualitative and historic package will employ focus groups with conflict-affected communities, interviews with key stakeholders, and examination of policy documents and historic data sources. This package will further scrutinise channels behind the quantitative findings; examine how health policymakers have responded to the conflict consequences; identify key post-accord challenges for the Colombian health system; and identify possible strategies for responding to these. The results from these two work packages will be linked to specific, practical policy options within the Colombian context, informed by constant dialogue with national stakeholders.

Planned Impact

The principal elements that will ensure this project has impact are its distinctive timeliness for health policymaking, constant stakeholder engagement and methodological rigour. Many stakeholder groups will benefit, including Colombian and international policymakers, citizens and the academic community across a wide range of disciplines. The ultimate beneficiaries of redirections in health service organisation and delivery that favour more effective responses to current health needs, informed by our research, will be millions of Colombian citizens whose health and general welfare have been affected by the conflict directly or indirectly.

Our work will use a wealth of data and state-of-the-art methods to provide a robust, exceptionally rich account of the consequences of protracted internal conflicts for population health and the health system. It will derive policy recommendations based on rigorous evidence in a context where a fresh peace accord is likely to highlight the need - and create institutional scope - for health system adjustments. Topics such as identifying priority health needs, population groups, services and effective delivery mechanisms for the fledgling post-conflict period are high on the Colombian government agenda. We have already developed strong links with key stakeholders in the Colombian context and will continue to engage them in the project from start to finish. We have secured the appointment of two senior staff contact points within the Colombian Ministry of Health (MoH) to give feedback on research direction and assist with other study aspects, to maximise the practical usefulness of our research. Meeting activities during the project with MoH and sub-national health officials, health professionals, NGOs and civil society representatives will enhance influence on policy change.

The impact of this research goes beyond valuable contributions to the Colombian setting. Key topics within the UHC agenda (e.g. equitable access to good quality care and health systems resilience), the broader SDG agenda (good health and well-being; peace, justice and strong institutions) and the UK Aid Strategy (strengthening global peace, security and governance in conflict-affected states; promoting global prosperity) will be addressed. The breadth and depth of aspects explored will favour informed generalisation of health system policy implications to other developing countries - particularly where protracted internal conflicts with large-scale internal displacement are currently ongoing or have recently concluded (e.g. Democratic Republic of Congo, Sri Lanka, Ukraine). This impact channel will be facilitated by engagement and dissemination activities with international academic and non-academic networks working on related topics, as well as the setting-up of a steering group of experts, drawn from international development organisations and academia, who will expand the reach of our findings to other countries and regions through their networks.

There will be novel contributions to a number of under-researched questions related to conflict and health. For example, our project will be the first to study systematically the wider effects of conflict on the organisation and public provision of health services, drawing evidence-based conclusions for post-conflict health policy. Our results will be promoted through publication in high-profile journals, including summary findings in Colombian outlets. Impact through capacity building in Colombia will be achieved, among others, by joint design, development and dissemination of the research; exchange of visits between Colombia and UK-based investigators; use of local resources to conduct and manage survey and qualitative data collection; joint data management and sharing; and recruitment of junior researchers in Colombia to be mentored and trained by more experienced researchers, and to learn by doing.

Publications

10 25 50
 
Description ReCSS Interdisciplinary Research Groups Funding Scheme (Rounds 1-2-3): Security, Conflict and Peace (SCoPe) interdisciplinary research network
Amount £6,778 (GBP)
Organisation University of York 
Sector Academic/University
Country United Kingdom
Start 01/2018 
End 07/2020
 
Description York ESRC Festival of Social Science 2019: "Building peace, improving health: an evening with perspectives from Colombia" event
Amount £1,000 (GBP)
Organisation Economic and Social Research Council 
Sector Public
Country United Kingdom
Start 06/2019 
End 12/2020
 
Title CONPAS survey (rounds 1-2) 
Description The research team developed a new household survey, the "Conflicto, Paz y Salud" Survey (CONPAS), which was administered by a local contractor. CONPAS was administered in 29 municipalities of Meta in the second half of 2018 with follow-up in the same period of 2019. Each CONPAS survey round includes information on 1309 households, 4410 household members, among which there are 350 children between the ages of 3 and 5. Our CONPAS survey adds to existing datasets by including, in addition to questions about current (i.e. post-ceasefire) health status, retrospective questions at the individual and household levels on health impairment and resulting care seeking behaviour, access and cost coping strategies, because of conflict-related violence. We also collect information on health status and risk factors in domains that are particularly relevant in conflict settings but are unavailable from existing sources, including disability and alcohol use disorder. Data collection was directed to the heads of the households or to someone 18 years or older in a given household. For questions about children and children's health, the mother or another adult female was asked to provide responses. Information was collected electronically and monitored daily by field supervisors for any inconsistencies. In general, the acceptance of the survey among the population was high, with positive feedback in population centers. 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2019 
Provided To Others? No  
Impact Impact includes providing additional information for decision-making by project partners (e.g. Colombian Ministry of Health and local Meta Secretary of Health). 
 
Title COL conflict timeline 
Description Graphical timeline of the Colombian conflict. Main purposes are to provide a source of consultation for researchers and the general public with an interest in the topic, as well as to serve as visual reference for some of our research analyses. 
Type Of Material Database/Collection of data 
Year Produced 2018 
Provided To Others? Yes  
Impact Impact is forthcoming, for instance, by providing additional information to the general Colombian public about conflict landmarks and their impact on the current socio-political context. 
URL https://goo.gl/smWdJJ
 
Title CONPAS (rounds 1-2) 
Description The research team developed a new household survey, the "Conflicto, Paz y Salud" Survey (CONPAS), which was administered by a local contractor. CONPAS was administered in 29 municipalities of Meta in the second half of 2018 and in the same period of 2019. The resulting CONPAS data includes information on 1309 households, 4410 household members, among which there are 350 children between the ages of 3 and 5. Our CONPAS survey adds to existing datasets by including, in addition to questions about current (i.e. post-ceasefire) health status, retrospective questions at the individual and household levels on health impairment and resulting care seeking behaviour, access and cost coping strategies, because of conflict-related violence. We also collect information on health status and risk factors in domains that are particularly relevant in conflict settings but are unavailable from existing sources, including disability and alcohol use disorder. Data collection was directed to the heads of the households or to someone 18 years or older in a given household. For questions about children and children's health, the mother or another adult female was asked to provide responses. Information was collected electronically and monitored daily by field supervisors for any inconsistencies. In general, the acceptance of the survey among the population was high, with positive feedback in urban and rural areas. 
Type Of Material Database/Collection of data 
Year Produced 2019 
Provided To Others? No  
Impact Impact includes providing additional information for decision-making by project partners (e.g. Colombian Ministry of Health and local Meta Secretary of Health). 
 
Description Javeriana 
Organisation Pontifical Xavierian University
Country Colombia 
Sector Academic/University 
PI Contribution The CHE-York PI has provided leadership for the development of a proposal for further funding in partnership with Xavierian U staff; specific expertise on health economics
Collaborator Contribution The Xavierian team has contributed expertise for co-development of a new proposal for funding; specific expertise in psychiatry, qualitative methods and the Colombian health system; and knowledge and access to data.
Impact Multi-disciplinary collaboration: public health; health systems research; health economics; psychiatry The first output has been development and submission of application for the NIHR Global Health Professorship call 2nd round (outline stage, outcome pending, main applicant Rodrigo Moreno-Serra - CHE), for which Xavierian staff would co-lead work on the effectiveness of mental health interventions in Villavicencio, Meta.
Start Year 2018
 
Description MoH Colombia 
Organisation Government of Colombia
Department Ministry of Health and Social Protection Colombia
Country Colombia 
Sector Public 
PI Contribution The CHE-York team has contributed by adapting some of the research activities to pay attention more closely to the knowledge needs of the local ministry of health; contributing specific expertise on health economics to refine derived research questions; and adding a new data source (household survey on health and conflict, conducted in one Colombian province) as source of information for local decision-making.
Collaborator Contribution The Ministry has appointed two senior staff contact points to give feedback on research direction and assist with other study aspects, to maximise the practical usefulness of our research.
Impact Multi-disciplinary collaboration: public policy; qualitative research; health economics; health system research. Outputs so far include one senior Colombian Ministry of Health official attending a public engagement event related to the project in York (November 2019), as an invited panel member.
Start Year 2018
 
Description SoH Meta 
Organisation Government of Colombia
Department Meta Health Secretary
Country Colombia 
Sector Public 
PI Contribution The CHE-York team has contributed by adapting some of the research activities to pay attention more closely to the knowledge needs of the local secretary of health; contributing specific expertise on health economics to refine derived research questions; and adding a new data source (household survey on health and conflict, conducted in the Meta province) as source of information for local decision-making.
Collaborator Contribution The Secretary has held three meetings with the research team and facilitated another meeting with representatives of local government agencies interested in aspects of the health consequences of the conflict, including by providing the venue and contacting attendees.
Impact Multi-disciplinary collaboration: public policy; qualitative research; health economics; health system research. Outputs so far include a series of technical meetings convened by the Meta government with the research team to discuss preliminary research findings and ongoing data collection.
Start Year 2018
 
Description U Nacional COL 
Organisation National University of Colombia
Country Colombia 
Sector Academic/University 
PI Contribution The CHE-York team has contributed by providing expertise on health economics for joint research on topics related to the project with one UNAL staff, Dr Giancarlo Buitrago; granting Dr Buitrago a CHE Research Fellowship for a visit to CHE during June-July 2019 to work on joint papers, covering travel expenses and accommodation for the period, thus contributing with mentoring of a mid-career researcher from Colombia.
Collaborator Contribution Dr Buitrago brings expertise in medicine and health econometrics, knowledge of relevant datasets and co-leadership in papers derived from this partnership.
Impact Multi-disciplinary collaboration: medicine, health economics Outputs so far include a succesful application to CHE internal funding by Dr Buitrago (CHE Research Fellowship), and a presentation of a joint academic working paper at an academic seminar (University of Sao Paulo, Brazil, September 2019) and invited workshop (Macquarie University, Australia, November 2019).
Start Year 2018
 
Description Uniandes 
Organisation University of the Andes
Country Colombia 
Sector Academic/University 
PI Contribution The CHE-York team has contributed by providing co-leadership/management of this project; specific expertise on health economics; and mentoring of junior Uniandes researchers involved in data collection.
Collaborator Contribution The Uniandes team has contributed co-leadership/management of the project; specific expertise in qualitative methods and the Colombian health system; and knowledge and access to data.
Impact Multi-disciplinary collaboration: public health; health systems research; health economics; political science; psychiatry Outputs so far include presentation of research outputs at UK (x1) and Colombian (x3) conferences; dissemination of project in the Colombian media; collection of two rounds of primary data through our new household survey in Colombia (CONPAS).
Start Year 2017
 
Description El espectador 2018 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact El Espectador (Colombia): Interviewed about the start of the project "War and Peace: the Health and Health System Consequences of Conflict in Colombia". In "Nace proyecto para estudiar impacto de la guerra en el sistema de salud colombiano", 15 June 2018.
Year(s) Of Engagement Activity 2018
URL https://www.elespectador.com/noticias/judicial/nace-proyecto-para-estudiar-impacto-de-la-guerra-en-e...
 
Description MH Day German 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Since 1999, local health authorities in the Meta Departamento have been raising awareness and holding training activities to celebrate the World Mental Health Day. Dr German Casas (Uniandes) introduced our War and Peace project and its mental health research during a half-day workshop to mark the November 2018 celebrations, held in Villavicencio. A total of 657 people attended, including the presence of the Departamento's Governor and Health Secretary, Villavicencio's Health Secretary and Mental Health coordinators. The audience was mostly comprised of Health and Mental Heath workers of Villavicencio and other Municipalities, local NGOs, Education authorities, teachers, heath promoters and volunteers. Various members of the audience (policymakers and practitioners) expressed interest in the project's results and encouraged future research involving mental heath in the post-conflict Colombian context, especially on suicidal behaviour and substance abuse, also expressing a desire to collaborate and support current and future research.
Year(s) Of Engagement Activity 2018
 
Description Mesa trabajo Meta 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Technical workshop to discuss the project and potential areas of contribution to decision-making by Colombian Meta officials, firstly through the primary data collection exercise taking place in the region. The workshop took place on 19 July 2018 and was facilitated by the Meta government, which convened 6 representatives of local government agencies to give their input to the research team. This has led to requests for further interaction as the research project progresses.
Year(s) Of Engagement Activity 2018
 
Description Nina seminar @ inception 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Prof Nina Caspersen (research team member, Politics, York) presented a seminar hosted by Uniandes (13 June 2018) on "International experiences with peace agreements and their implementation" and discussed potential lessons for the Colombian case. Around 60 people attended including a Q&A session afterwards, the seminar was advertised in a local TV channel the day before.
Year(s) Of Engagement Activity 2018
 
Description Oscar/Cata in York 2019 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact Prof Oscar Bernal and Dr Catalina Gonzalez (research team members, Universidad de los Andes, Colombia) presented a seminar/webinar hosted by the SCoPe network/University of York (20 March 2018) on "Is Colombia marching to a post conflict era?" and discussed preliminary qualitative results from our join project "War and Peace". Around 30 people attended including a Q&A session afterwards. The full session was recorded and has been made available at the Centre for Health Economics' website.
Year(s) Of Engagement Activity 2019
URL https://www.york.ac.uk/che/news/news-2019/scope-seminar/
 
Description Presentation SoH Meta May2019 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Technical workshop to discuss the project and present preliminary results arising from the survey conducted in Meta. The workshop was facilitated by the Meta government and Secretary of Health; their representatives (6 in total) also gave their input to the research team. This has led to requests for further interaction as the research project
progresses.
Year(s) Of Engagement Activity 2019
 
Description York-ESRC FoSS event 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact We organised an evening public engagement event under the York-ESRC Festival of the Social Science, titled "Building peace, improving health: an evening event with perspectives from Colombia". The event took place on 6th November 2019 and involved three main activities: (i) interactive audiovisual displays featuring York research (e.g. talking-head interviews with community members in conflict-affected areas of Colombia; timeline of the conflict); (ii) a panel discussion with York academics, fellow project researchers from the University of Los Andes, a plastic artist working on the Colombian conflict, the Guardian newspaper correspondent in Colombia, and a senior policy-maker from the Colombian Ministry of Health; and (iii) open discussion session between the panelists and audience. Between 30-40 people attended the event which sparked good discussion and interaction with the discussants and project's materials.
Year(s) Of Engagement Activity 2019
URL https://www.york.ac.uk/che/news/news-2019/building-peace-improving-health/
 
Description Youtube video IGDC 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Youtube video produced by the University of York's Interdisciplinary Global Development Centre to showcase our "War and Peace" project. 64 views so far.
Year(s) Of Engagement Activity 2018
URL https://youtu.be/nYOi06FeKdM