Operationalising health in the humanitarian–development–peace nexus (HDPN) in Africa: a new framework for building resilience in countries with fragile, conflict and violence-affected settings

Abstract

Humanitarian needs are escalating globally, with around 300 million people requiring assistance—over half in Africa. These crises are increasingly driven by conflict, climate-related disasters and emergencies and economic instability, all severely impacting public health and disrupting health systems. A new approach is essential to address root causes of humanitarian crises and develop durable solutions. In response to this need, the WHO developed a framework for health in the humanitarian–development–peace nexus (HDPN) in Africa. This framework was informed by literature reviews and consultations with key stakeholders across UN and wider humanitarian sector (including the African Union bodies, WHO offices and relevant non-governmental organisations). The framework presents a structured method for countries to integrate health across the HDPN, emphasising policy alignment, the need for sustainable financing, strong monitoring systems and adaptable governance. It defines clear roles for WHO, the African Union Commission, regional economic communities and authorities in countries as applicable. Key areas for operationalising the framework include health sector development planning, budgeting, financing, intersectoral coordination, services delivery and monitoring and evaluation. It also recommends integrated strategic actions focusing on health across humanitarian, development and peacebuilding efforts, emphasising synergy and co-benefits from this nexus approach. With a growing number of countries facing humanitarian crises, fragility and conflict, urgent implementation of this framework is vital to build resilience and improve health outcomes across Africa and beyond.

SUMMARY BOX.

• Humanitarian requirements are escalating globally, with approximately 300 million people currently in need of assistance, most of them in Africa. Crises are increasingly driven by conflict, climate-related disasters and economic instability, with major impacts on health. The humanitarian–peace–development nexus (HDPN) approach aims at facilitating better utilisation of resources to address crises and their root causes, through cross-disciplinary and interdisciplinary empowerment and participation of stakeholders across humanitarian, development and peace sectors. Despite broad institutional and high-level strategic support, the HDPN approach has only been partially operationalised.

• Here, we present a new focused framework that provides comprehensive guidance for operationalising health in the HDPN in countries with fragile conflict and violence (FCV) contexts in Africa and beyond. The framework is flexible and adaptable to diverse contexts, proposes targeted and measurable interventions and emphasises integrating and prioritising health across humanitarian, development and peacebuilding efforts, with the collective outcomes of promoting health security, achieving universal health coverage and the right of access to health for all.

• The framework for health in HDPN in Africa addresses a critical gap and is the first of its kind to guide policy and planning. Its application will accelerate translation of policy into practice/action and will in turn generate experience and evidence for various stakeholders in implementing the nexus approach within countries in need. Finally, it will facilitate cross-country learning and application of global goods to inform the change and improvement in countries with FCV settings and other public health emergencies.

Introduction

Africa is registering socioeconomic advancement; however, these gains are threatened by protracted conflict, population displacements, climate change and natural disasters, all compounded by fragile political institutions.¹ These events are impeding achievement of the African Union (AU) agenda 2063 and the 2030 United Nations (UN) Sustainable Development Goals (SDGs).^{2 3} Moreover, these shock events are undermining the sovereignty and territorial integrity of affected countries with cross-border implications, with more than half of the 300 million people globally currently requiring humanitarian assistance in Africa.^{4 5}

The prevailing situation calls for concerted efforts by African countries and relevant global stakeholders to deliver effective humanitarian responses and solutions. At the 15th extraordinary AU humanitarian summit and pledging conference in 2022, African leaders committed to addressing the humanitarian challenges through identifying durable and sustainable solutions and endorsed the Malabo declaration.⁶ To translate this into action, a 10-year post-Malabo plan of action, 2022–2032, was developed to guide Africa with a strategy to deal with its future humanitarian challenges and reinforce the continent’s capability to predict, prevent, protect against, respond to and build resilience in combating humanitarian challenges.⁷ The latter stipulates the milestones, targets and outcomes for eight priority interventions, including to apply the humanitarian–peace–development nexus (HDPN); develop measures and strategies to tackle forced displacement from disasters; strengthen strategies integrating health security to combat epidemics and pandemics and build resilient health systems for universal health coverage; devise strategies to address post-conflict reconstruction and development; and mobilise resources for sustainable and timely humanitarian action.⁷

In line with the Malabo declaration and the action plan, in May 2023, the WHO liaison office to the AU and the United Nations Economic Commission for Africa (UNECA) and the AU Commission for Political Affairs, Peace and Security (AUC-PAPS) held bilateral discussions with the theme ‘Strategic positioning of health in the humanitarian, development and peace nexus’. There was consensus that AUC-PAPS, the AU Commission for Health, Humanitarian Affairs and Social Development and WHO (Regional Office for Africa, Regional Office for the Eastern Mediterranean Region and Headquarters) should collaborate in advancing the WHO Global Health and Peace initiative.⁸ Subsequently, the WHO embarked on developing an evidence-based framework for health in the HDPN to serve as a guide for African countries and beyond.

The humanitarian–development–peace nexus and policy impetus

The HDPN, ‘New Way of Working’, aims at encouraging humanitarian and development actors to work closely together. The HDPN approach moves beyond traditional stand-alone efforts, promoting synergistic engagement of all actors and enabling coordinated, simultaneous implementation of humanitarian, development and peacebuilding actions. It emerged from the 2016 world humanitarian summit,⁹ as a comprehensive approach for collaboration across the humanitarian and development sectors.¹⁰ Later, ‘sustaining peace’ was integrated into the approach, completing the triad of the new paradigm.¹¹ The HDPN approach is therefore intrinsically linked with the aspirations of the AU agenda 2063 and the ‘Silencing the Guns’ initiative.¹¹

Moreover, the HDPN provides a robust structure for the effective and integrated operationalisation of key frameworks such as the common African position on humanitarian effectiveness,¹² the Sendai framework for disaster risk reduction,¹³ the 2001 Abuja declaration on HIV/AIDS, tuberculosis and other infectious diseases,¹⁴ the 2015 AU humanitarian policy framework,¹⁵ including its envisioned African humanitarian agency and the 2023 Lusaka agenda on the future of global health initiatives.¹⁶

Implementing the HDPN facilitates directions set by the AU, including the Aswan Forum for Sustainable Peace and Development,¹⁷ the Tangier declaration on promoting the peace, security and development nexus in Africa,¹⁸ and the Malabo declaration.⁶ These initiatives underscore the significance of a unified approach to the HDPN, offering strategic benefits for its scaling up with health as a priority.

Current status of operationalisation of the HDPN approach

Despite broad institutional and high-level strategic drives, the HDPN approach has only been partially operationalised.^{19 20} Barriers to its full implementation include conceptual difficulties in applying the approach and limitations in capacity within the sectors to change from siloed approaches. Furthermore, inadequate political support for change, along with competition and cultural differences between humanitarian and development actors, has hindered progress. The increasing unpredictability and complexity of emergencies in Africa, in fragile conflict and violence (FCV) settings where circumstances can change rapidly, have made operationalisation of the HDPN challenging.²¹ These are also attributed to the lack of control of the situation by national authorities, proactive planning with dedicated shared resources and collective political accountability to support orderly transition from the humanitarian response to national development process. The scope of humanitarian assistance can also be limited in terms of duration and objectives, while national programmes are constrained to take over, thereby often leaving a gap. Although health has been discussed in the HDPN literature, there is little evidence for its systematic consideration across the nexus to date.^{10 22} While a range of individual initiatives have adopted nexus-style approaches,²³ and some ad hoc country level application,²⁴ health has remained peripheral or implemented largely within traditional silos rather than embedded across all the three pillars. Linked to this, is a lack of data and reports of the impact and benefits of the full operationalisation of the HDPN approach. Globally, the progressive operationalisation of the HDPN has been considered in a wide-ranging agenda from recovery to longer-term development and peacebuilding, embedded into emergency response.²⁵

Rationale for a framework for health in the HDPN in Africa

Recognising health as a driver for socioeconomic development and social cohesion, the objective of applying the HDPN approach to health is to facilitate all parties to work together to ensure continuity of access to essential health services and health protection of communities in all contexts, and to manage the emergency response, development and peacebuilding efforts alongside one another. This requires political commitment of global, continental, regional and national actors to the HDPN approach as essential in FCV contexts. A framework for health in the HDPN will support better positioning of health within existing coordination platforms, response actions and stakeholder mapping. Related activities must be supported by dedicated resources for humanitarian response, emergency preparedness and risk reduction, as well as for longer-term health system strengthening.

The HDPN approach emphasising health can address the high burden of diseases in countries with FCV contexts, where the highest rates of child and maternal mortality are found, and least progress is being made towards achieving Universal Health Coverage (UHC). While the HDPN approach has its biggest role in protracted humanitarian emergencies, its wider critical role is underscored by recent health crises, for example, 2014–2015 West Africa Ebola virus disease outbreak,²⁶ and COVID-19 pandemic,⁸ highlighting the interconnectedness between health and socio-political stability and the need for resilient health systems to achieve UHC and other SDGs.

Public health emergencies, which are often worsened by socioeconomic disparities, weak health systems and conflict, do amplify social and economic divides, reinforcing a cycle of fragility and illness. Inequitable access and poor services reflect existing vulnerabilities but can also lead to further destabilisation and conflict when people feel marginalised and excluded. Climate change further exacerbates health risks by worsening existing conditions such as scarcity in water, food and socioeconomic stress, and often leads to migration and conflict. Importantly, health initiatives can foster dialogue and trust building and can bridge gaps between conflicting groups, acting as facilitators of peace and stability efforts.²⁷

Health in the HDPN reinforces that health priorities and programmes align with the HDPN approach, and that humanitarian, development and peace efforts are simultaneous, prioritised and comprehensively address health issues in a collaborative and coordinated manner, thereby maximising their effectiveness.²⁷ The health sector provides a unique platform for defining collaborative outcomes, working with well-defined, overarching, globally agreed goals.¹⁶ The WHO health system framework also provides a guide for framing the HDPN objectives and can be used to identify domains to target.²⁸ Having agreed objectives arising from identified needs in the joint analysis phase, partners can plan and programme accordingly by identifying their own entry points.²⁹

Participatory approach for developing the framework

The approach used to develop the framework for health in the HDPN involved a consultative process informed by available practices and evidence. First, a scoping review was undertaken comprised of relevant literature, policies and programming on the HDPN. Second, gaps in knowledge identified were used to inform the initial consultations with 39 key informants, including representatives from the AUC (n=12), regional actors including WHO regional and country offices (n=7), regional economic communities (n=2) and health clusters (n=7), relevant UN organisations (n=3), international committee of the red cross (n=1), civil society and peacebuilding organisations (n=5) and academia (n=2). Third, virtual and in-person interviews, meetings and a focus group discussion (Joint Humanitarian Coordination Forum/African Union Commission retreat, February 2024) were used to identify needs, challenges, opportunities and options related to advancing health in the HDPN in Africa. Findings from the literature review, key informant interviews and the focus group discussion underscored the necessity, challenges and opportunities for a dedicated framework on how and where and how to embed health in HDPN. A draft framework was then developed outlining the aims, objectives and operationalisation mechanisms, based on the findings of the literature review and stakeholder consultations. Finally, the draft framework and recommendations were presented to the AUC, WHO and key stakeholders for review and finalisation. Online supplemental annex 1 provides a list of organisations (n=23) involved in various stages of the framework development.

Aims and objectives

The aim of the framework is to guide countries with FCV contexts and partners in prioritising and integrating health in the HDPN approach, targeting the collective outcomes of promoting health security, UHC and the SDGs, as well as the WHO’s Global Health and Peace Initiative. It also aims to facilitate harmonisation, complementarity and synergy of the efforts of HDPN partners. Importantly, its application will foster stronger synergies between WHO, the AU and its specialised agencies and relevant humanitarian and health partners. Moreover, the framework seeks to enhance the involvement, ownership and leadership of national governments, and collaboration with communities, civil society and the private sector in applying health in the HDPN.

The objectives of the framework are to (1) guide the operationalisation and prioritisation of health in the HDPN; (2) outline the generic roles and responsibilities of key sectors and stakeholders at continental, regional, national and subnational levels, including the different sectors that should contribute to implementing health in the HDPN approach based on their comparative advantages; and (3) provide recommendations for operationalisation and implementation.³⁰

Target audience and scope

The target audience for the framework is countries in Africa and beyond with FCV contexts and humanitarian response, the AUC and its organs, the regional economic communities, the WHO secretariat, donors and implementing agencies and bilateral and multilateral development partners engaged in the HDPN and health security. Other potential audiences include relevant UN agencies, international nongovernmental organisations and development banks.

The scope covers critical components needed to operationalise health in the HDPN, while acknowledging contextual differences, including presence of an enabling environment and the potential need for phasing interventions due to realities on the ground. The framework further emphasises that health is a human right and the indispensable role of health in catalysing wider recovery, peace, stability and development. While the framework does not explicitly cover aspects such as housing, education, food security and livelihoods, these aspects should be considered proportionately in transitional planning from response to recovery and longer-term stability and development.

Structured approach for countries to integrate health across the HDPN

For the operationalisation of the framework, health in the HDPN is defined as any health-related activities where at least two of the three groups of actors (humanitarian, development, peacebuilding) are working together to provide immediate lifesaving assistance, strengthen and rebuild health systems and institutions, enhance emergency management capacities and address the drivers of emergencies.³⁰

For country level contextualisation, the framework identifies the domains and articulates objectives and actions under all three pillars and national level entries where they will be anchored, translated into actions for change and improvements (figure 1 and table 1). For example, national health sector strategic development planning should reflect leveraging and transitioning of resources from humanitarian response, development and peace partners to support health system recovery, which should in turn build capacity to support ongoing and future health needs in humanitarian contexts and peace building. This would require humanitarian response plans to ensure flexibility to support recovery processes and orderly transition of resources and bridging with developmental planning.

Figure 1. Overview of the framework for health in the humanitarian–development–peace nexus (HDPN). AU, African Union; NGO, Non Governmental Organisation; SDG, Sustainable Development Goal; UN, United Nations.

Table 1. Changes required to transition from status quo to application of the HDPN, with a focus on health.

Areas of change and improvement across national, regional and global stakeholders	Status quo in humanitarian, development and peace initiatives	Changes needed to apply the HDPN, with a focus on health
Enabling policy and governance	Humanitarian, development and peace have a linear relationship Reactive and crisis driven, lack of sustained leadership commitment Inadequate coordination between humanitarian, development and peace efforts Humanitarian actions focus on humanitarian partners, with development partners to be carried along during the ‘nexus period’ Dependency on United Nations and other partners for driving health priorities Community engagement as an afterthought Humanitarian assistance and development are separated from ‘peacekeeping’	Simultaneous implementation of humanitarian, development and peace efforts with effective coordination and transition across the three pillars Joint working and health sector meetings between humanitarian and development partners from acute phase of crisis into the protracted stage until full recovery Proactive leadership and sustained political commitment positioning health as central to development and peace Coordination between humanitarian-focused, development-focused and peace-focused stakeholders and initiatives National ownership and stewardship for prioritising health with whole-of-society (including community) engagement Policies and governance structures prioritise building resilience and addressing root causes of health risks, vulnerabilities and inequities
Planning based on joint analysis	Fragmented, sector-specific planning and policies with limited health integration Absence or late planning for transition and recovery with a focus on the health system Peace initiatives missing the role of health	Joint planning and modalities for implementation and collective outcome evaluation established before the crisis occurs Joint analysis and collective outcome setting between health cluster and other clusters Joint and integrated policies and plans reflecting immediate to long-term health priorities as cross-cutting objectives for all relevant sectors and stakeholders, including in health strategy, humanitarian response plan, health service sector development plan, national development plan, planning for SDGs and national action plan for health security Timely planning for transition of resources and capacities from response to strengthening the national health system, including stewardship role of ministry of health Peace negotiations guarantee right of access to improved and equitable health services and safeguarding health infrastructure
Budgeting and financing	Ad hoc, emergency response-focused health funding Inadequate consideration for long-term health sector development in allocation of resources Dependency on external aid, with inadequate clarity on transition to national funding	Data-informed multiyear resource allocation focused on addressing foundational health system gaps while responding to humanitarian needs Leveraging resources from humanitarian response to support health system recovery, strengthening and resilience Development funding also targeting communities living in conflict-affected areas Defined roadmap for transition to recovery and increased domestic funding, reducing dependence on external aid
Integrated services	Inconsistent service delivery and weak monitoring, including fragmented primary healthcare and public health services Limited or superficial local community participation	Improved, integrated services focus on equity and rights, with proportionate prioritisation of all aspects of public health and health determinants addressing root causes of risks, vulnerabilities and inequities Sustained engagement and empowerment of local communities to participate in health services Mental health and psychosocial support recognised as an enabler of, and integrated into, peacebuilding and development efforts
Monitoring and evaluation	Ad hoc, parallel and inadequate health information systems Lack of explicit accountability mechanisms for health in the HDPN	Shared accountability for health across all relevant sectors, considering wider determinants Integrated health information systems that monitor the implementation of health in the HDPN

HDPN, humanitarian–peace–development nexus; SDGs, Sustainable Development Goals.

For budgeting and financing, transitional funding is required to cover bridging financing for health before the decline or cessation of humanitarian support. This will ensure assets mobilised have a proper inventory and accountability for their maintenance and that life-saving assistance to affected populations is sustained with accountability of authorities responsible in the absence of humanitarian partners.

For access to services, the role of primary healthcare in service delivery should be strengthened, including public health services for emergency preparedness and response, disease prevention, health promotion and provision, with community and multisectoral participation. In practice, this entails maintaining health infrastructure, equipment and health workers deployed for humanitarian assistance until national health systems resume their functionality. The health sector should contribute to and remain part of national development and prosperity so that there can be good health systems and services for the population, including those hard to reach and marginalised.

For monitoring and evaluation, it is critical to assess the effectiveness of the nexus approach in enhancing coordination and contributing to collective outcomes across humanitarian, development and peace priorities.

The framework reinforces the need for political will and sustained commitment with coordination of all relevant stakeholders across and between all three pillars of the HDPN (table 1).

Stakeholders’ roles and responsibilities

The concurrence and involvement of all relevant stakeholders is needed to enable full operationalisation of health across the HDPN, thereby preventing gaps, duplication of activities and competition over limited resources. Key stakeholders with roles and responsibilities at supranational, national and subnational level are presented reflective of typical partners’ landscape in FCV contexts in Africa in figure 2 including UN agencies (United Nations Office for the Coordination of Humanitarian Affair (UNOCHA), International Organisation for Migration (IOM), etc) and AU bodies (African Union Humanitarian Agency, etc). However, more detailed and specific roles and responsibilities must be tailored to the context encompassing civil society organisations, faith-based organisations, national and local non governmental organisations (NGOs) and national Red Cross and Red Crescent societies.³⁰

Figure 2. Subnational, national and supra-national stakeholders for health within the humanitarian–peace–development nexus in the African context, with their roles. CSOs, Civil Society Organisations; FBO, Faith Based Organisation; NGO, Non Governmental Organisations; UN, United Nations; UNCT, United Nations Country Team.

Timing for implementation

Operationalising health in the HDPN implementation should be done proactively as integral to implementing the HDPN approach and across all stages of a crisis, with emphasis on joint planning, joint implementation, joint monitoring using agreed standard tools and collective outcomes for evaluation. This will promote complementarity, partnership and synergy, which represent a shift towards inclusive management of humanitarian, development and peacebuilding actors to build back better systems and structures. Health considerations should be proactively factored in to the nexus approach as a policy requirement in humanitarian assistance so that resources from response can be sustained and orderly transitioned into recovery and development. With time, development and peace-building initiatives also require prioritisation of health with additional resources.

Creating strong conflict-sensitive health strategies in Africa

The framework for health in the HDPN in Africa developed by the WHO is complementary to other approaches and strategies for promoting, providing and protecting the health and well-being of populations, especially those in FCV and peace building settings.⁸ Integrating health across the HDPN and its contextualisation with existing national policy, planning and developmental process will indeed increase localisation, enhance and facilitate the maintenance and equitable access to essential health services, protect communities, reduce exclusion and promote peace building. Such a holistic approach, if pursued properly, will promote health security, build health system resilience for the achievement of UHC and other SDGs,³¹ and will accelerate longer-term recovery of health systems.^{32 33}

Post COVID-19 pandemic, there is a renewed understanding of the centrality of health and well-being to social and economic development of countries. Although the health-related SDGs are off track,^{34 35} new capacities and commitments can be harnessed to revitalise action to equip the health systems of countries to meet the expectations of their populations and address the emerging and re-emerging challenges. The framework for health in the HDPN draws on lessons learnt from past and recent emergencies in Africa and globally. Moreover, it takes into consideration recent health-related political commitment of the AU,^{6 7} the UN General Assembly, the World Health Assembly and WHO regional committees for Africa and the Eastern Mediterranean,36,39 and the SDGs’ principle to leave no one behind.⁴⁰

Finally, integration of promoting, providing and protecting health across the HDPN offers an important pathway for its effective and sustainable operationalisation in general. However, to ensure collective outcomes, it is imperative that humanitarian response, development and peace building actors and programmes address the root causes of crises with complementarity, collaboration and consistency. Peace is key to sustainable development, and the framework can serve as means to achieving progress towards SDG16 (promoting peaceful and inclusive societies, providing access to justice for all and building effective, accountable and inclusive institutions at all levels).⁴¹

Conclusion

This dedicated health in the HDPN framework presents an opportunity for the key stakeholders, that is, the AU and its responsible humanitarian agency and Africa Centres for Disease Control and Prevention (Africa CDC), WHO and African nations, in collaboration with on-ground humanitarian and development partners (eg, UNOCHA, United Nation High Commissioner for Refugees (UNHCR), International Committee of the Red Cross (ICRC), IOM, United Nations Development Programme (UNDP), UNECA, African Development Bank (AfDB), World Bank), to develop integrated and context-specific institutional strategies leading to improved outcomes through the implementation of the HDPN approach.

By ensuring coordinated and integrated health interventions across humanitarian, development and peacebuilding efforts, countries can establish a foundation for long-term health system resilience and social cohesion while addressing immediate crisis needs.

Given widespread fiscal constraint, it is imperative on all relevant stakeholders at global, regional, as well as national and subnational levels to implement the HDPN focusing on health. This will facilitate harmonisation of policies and facilitate concerted actions to enhance countries’ abilities to develop robust health strategies sensitive to conflict dynamics and conducive to peace. It is only through such approaches that we can create strong, conflict-sensitive health strategies that contribute to economic stability, peace and development.

The author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.