The humanitarian, development and peace nexus (HDPN) in Africa: the urgent need for a coherent framework for health (2024)

Summary box

• The humanitarian development and peace nexus (HDPN) has in the recent decade emerged as a novel paradigm to bridge gaps between humanitarian, development and peace building actors.

• The approach recognises that crises often occur in contexts of fragility, conflict and violence, requiring integrated and coordinated responses addressing immediate needs, rebuilding the system, and preventing and mitigating the impacts of future crises.

• The HDPN is garnering global attention from donors, governments and international organisations. However, its adoption in Africa from policy to planning and practice is limited, yet the continent has a high number of protracted crises and fragility, affecting country economies and population health.

• This commentary aims to ignite and galvanise vital dialogue and collaboration among key global and continental stakeholders, including the African Union (AU) Member States, WHO, Africa CDC, AU-Health, Humanitarian Affairs and Social Development, AU-Political Affairs, Peace and Security and major funders including humanitarian partners about the urgent need to strategically position health within the HDPN in Africa. It presents the rationale for a coherent HDPN framework in Africa that strategically positions health as an integral component of the HDPN. It highlights the transformative HDPN approach in enhancing health security and fostering resilient health systems in Africa.

• We contend that the efforts of humanitarian, development and peace building actors should be integrated and well coordinated to leverage scarce resources for the responses to the immediate and continuing health needs, drive rebuilding of the health system and to tackle the underlying drivers to prevent and mitigate the impacts of future crises in contexts of fragility, conflict and vulnerability.

Background

The humanitarian context in Africa is evolving in complexity and scale due to wars and conflicts, compounded by weak political institutions, fiscal constraints and pre-existing root causes, including weak health systems, emerging and re-emerging infectious diseases and population displacement within and between borders.1 A Danish Refugee Council global population displacement forecast for 2023, projects that population displacement is set to increase by another 5.4 million, with sub-Saharan Africa witnessing the biggest increase in new displacements over the next 2 years.2 The level of vulnerability of displaced populations has further been exacerbated during the COVID-19 pandemic as a result of reduced funding for humanitarian operations leading to food ration cuts for refugee populations in several countries, which has negatively affected refugees’ food security, nutrition and protection situation.3 The continent’s changing demographics with high population growth, increasing economic inequality, rising levels of education with unemployment/underemployment, and increased vulnerability to global threats, amplifies the risks of future crises.4 Disasters and extreme weather events, such as flooding and drought, are among the major causes of and contributors to humanitarian crises in Africa.5

In 2022, the 10 most under-reported humanitarian crises were all in Africa, according to the aid organisation CARE.6 To ensure, we act on all crises proportionately, all stakeholders—the United Nations, donors, the media, politicians, the private sector, civil society and non-governmental organisations (NGOs) alike need to be engaged. The nature of humanitarian responses is also changing due to demands from local experts and the need to allow affected communities to speak for themselves.6 Several NGOs are changing their approaches to support this way of working and donors are increasingly mindful of the need to listen to the people in crisis regions so that they tailor donor assistance more effectively to the critical needs of affected populations. The latter is also due to the realities that, in war/conflict borne humanitarian crises, the authority of the national government is often compromised, territories are controlled by a non-state armed group or by an occupying force and thus inaccessible under the coverage of routine social and essential health services.7

The 2022 African Union (AU) extraordinary humanitarian summit declaration in Malabo, Equatorial Guinea, is explicit in recognising that Africa cannot achieve meaningful social economic transformation and integration without tackling the root causes of, and finding durable solutions to humanitarian crises.8 Similarly, countries will not be able to achieve the Sustainable Development Goals (SDGs) and universal health coverage (UHC) by 2030, nor health security nor successfully implement national development plans and national health sector plans when they remain under instabilities and frequent emergencies. This further underscores that national, regional and global health security is intrinsically linked with equitable access to health services. If access to essential services remains low for large sections of the population, surveillance and response networks will not function optimally, increasing within and between country vulnerability, further exacerbating continuing crises.

Since the world humanitarian summit in 2016 in Istanbul, Turkey, the concept of the humanitarian development and peace nexus (HDPN) has been emphasised as the required programming paradigm to bridge the gap between the traditionally separate sectors of humanitarian aid, development and peace building—a necessity to address the root causes and drivers of conflict and instability, which is particularly needed in prevailing contexts in Africa9 (figure 1, adapted from Howe10).

The HDPN approach recognises that crises often occur in and are interrelated to pre-existing contexts of fragility, conflict and vulnerability, and therefore, require integrated and coordinated responses that address both the immediate needs of affected populations and the underlying drivers of crises.11 The HDPN concept recognises the need to contextualise humanitarian action and that facilitating recovery and longer term resilience to shocks is equally essential as crisis response.12 13 The HDPN also seeks to facilitate greater engagement with affected communities and aligns with the localisation agenda, rather than seeing humanitarianism as a separate entity to recovery efforts.14 Now considered a pre-eminent paradigm, the HDPN approach is gaining increasing attention from donors, governments and aid organisations, including in Africa, where protracted crises and fragile contexts are prevalent.15 The utilisation of HDPN can allow an orderly transition from humanitarian response to recovery and can guide assets and infrastructure to be maintained for their continued functions and services. Moreover, it can also guide practical solutions in political institutions, ownership and governance to oversee the transitions and averting a gap between humanitarian response, investment and the development agenda.

Despite this necessity, however, coherent approaches for comprehensive implementation of HDPN within health programming in Africa have remained largely lacking. In May 2023, the WHO Liaison Office to the AU and the United Nations Economic Commission for Africa and the AU department for Political Affairs, Peace and Security (AU-PAPS) held bilateral discussions with the theme ‘strategic positioning of health in the humanitarian, development and peace nexus’. The emerging consensus from these deliberations was the strategic importance of the AU organs (PAPS and the commission for Health, Humanitarian Affairs and Social Development-HHS) and WHO (all levels) to design mechanisms that will facilitate the advancement of the WHO Global Health Peace initiative (GHPI),16 as well as, enable the wider adoption of the HDPN approach.

Why is a coherent HDPN framework for health in Africa needed now?

First, a coherent HDPN framework for health in Africa is anchored on the main outcomes of the extraordinary AU summit that was articulated in the Malabo declaration of 2022. In the Malabo declaration, African heads of state and government expressed concern over the growing challenges of humanitarian crises on the continent and identified eight priorities to address them.8 The eight priorities are: (1) strengthening the AU institutional frameworks, mechanisms, tools and humanitarian diplomacy; (2) developing measures and strategies to tackle forced displacement from disasters and climate change; (3) establishing measures to address the growing food and nutrition insecurity on the continent; (4) strengthening integrated strategies for health security and building resilient health systems to combat epidemics and pandemics and deliver UHC; (5) strengthening the role of young people, the youth and the diaspora in humanitarian action; (6) advancing the humanitarian-peace-development nexus; (7) formulating strategies for postconflict reconstruction and development and finally (8) mobilising resources for sustainable and timely humanitarian action. As such the political will exists to elevate HDPN to its right place as a fundamental part for health systems development in all relevant AU member states.8

Second, a coherent HDPN framework for health in Africa jointly led by WHO and the AU will contribute to strengthening intercluster collaboration within WHO, as well as collaboration between WHO, donors and the AU organs (Africa Centres for Disease Prevention and Control (Africa CDC), HHS and PAPS) to promote the GHPI and contribute to the achievement of the WHO’s triple billion targets.16 17 The triple billion targets are a WHO initiative to improve the health of billions of people by 2025. As the foundation of WHO’s 13th General Programme of Work (GPW13), the triple billion function both as a measurement and policy strategy.17 They are an integral part of the GPW13’s results framework, a tool designed to measure and improve impact on health at the country level. Additionally, measurement of these targets has been consciously aligned with those of the SDGs, to reduce country burden in data collection and streamline efforts to accelerate progress towards achieving key targets. Importantly, the triple billions focus on the execution and delivery of significant improvements in the health of the world’s population through evidence-based interventions, strengthened health information systems, and support for transformational public health policy (figure 2, adapted from WHO17).

Third, the framework will promote primary healthcare (PHC) and the delivery of essential public health functions, underscoring the role of PHC and district health management in the provision of public health services, including emergency preparedness and response as key to building resilience in fragile and conflict-affected settings.18 19

Finally, the utilisation of the HDPN approach can allow an orderly transition from humanitarian response to recovery and can guide assets and infrastructure to be maintained for their continued functions and for the continuity of essential services to the affected and local communities. Moreover, it can also guide practical solutions for political institutions, governance and accountability to oversee the transitions by averting a gap between humanitarian response and the investment/development agenda.

Our methodological approach for developing a coherent HDPN framework for health in Africa

In view of the above, WHO in collaboration with the relevant AU organs has embarked on developing a coherent framework for HDPN for health in Africa that is grounded in evidence and reflects the context, needs and priorities of the continent. The approach to develop the HDPN framework will entail: (a) a review and analysis of the relevant literature, policies and programming on HDPN in Africa and globally; (b) consultations with key informants and other stakeholders, including the AUC, regional health and economic communities, Member States, WHO-all clusters and other UN organisations such as UN OCHA, civil society organisations, academia and other relevant actors; (c) online surveys, virtual and in-person interviews/meetings, and focus group discussions with key stakeholders to identify needs, strengths, weaknesses/challenges, opportunities and threats for advancing the HDPN in Africa; (d) developing a draft HDPN framework for health in Africa that outlines the vision, mission, goals, guiding principles, objectives and operationalisation mechanisms, based on the findings of the literature review and stakeholder consultations; (e) presenting the draft framework and recommendations to the WHO, the AU and other stakeholders for feedback and final validation and (f) finalisation of the framework based on feedback and inputs from the WHO, the AU and other relevant stakeholders.

Conclusion

The WHO and the AU have jointly initiated the critical process to develop a coherent HDPN framework for health in Africa. Such a framework is urgently needed to guide policy, planning and programming by all relevant AU Member States, the WHO and the AU secretariats, partners, the regional health and economic communities, donors, and international organisations. We believe the methodological approach we have adopted will result in an evidence-led framework, capable of making HDPN approaches a reality in Africa. Importantly, an inclusive stakeholder consultation process will help to identify needs, challenges and opportunities for HDPN for health in Africa, and will increase buy-in of the framework. A coherent framework will serve as the basis for the operationalisation of the HDPN in the health sectors of all relevant AU Member States. Further, it will enable integrated governance setup for responding to crises, orderly transition to recovery and support the creation of practical political solutions with shared accountability.

Finally, the dividends for health are likely to be multiple, including stabilisation and recovery to build resilient health systems to achieve health security; UHC; cobenefitting other SDGs; leveraging nationally owned response resources; assurance to investors and donors for legacy impact and catalysing country journeys to self-reliance. It is out of necessity that the efforts of humanitarian, development, and peace building actors should be integrated and well coordinated to leverage scarce resources for the responses to the immediate health needs, rebuilding the health system and tackling the underlying drivers to prevent and mitigate the impacts of future crises in contexts of fragility, conflict and vulnerability. We, therefore, call on all relevant stakeholders, especially the Member States to actively participate in the development process and subsequently to domesticate and implement the HDPN framework for health in Africa.

Data availability statement

All data used are available in public domain.

Ethics statements

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