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

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.

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.

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.