title: A cross-case comparative analysis of international security forces' impacts on health systems in conflict-affected and fragile states.
abstract: BACKGROUND
  Destruction of health systems in fragile and conflict-affected states increases civilian mortality. Despite the size, scope, scale and political influence of international security forces intervening in fragile states, little attention has been paid to array of ways they may impact health systems beyond their effects on short-term humanitarian health aid delivery.
  
  
  METHODS
  Using case studies we published on international security forces' impacts on health systems in Haiti, Kosovo, Afghanistan and Libya, we conducted a comparative analysis that examined three questions: What aspects, or building blocks, of health systems did security forces impact across the cases and what was the nature of these impacts? What forums or mechanisms did international security forces use to interact with health system actors? What policies facilitated or hindered security forces from supporting health systems?
  
  
  RESULTS
  We found international security forces impacted health system governance, information systems and indigenous health delivery organizations. Positive impacts included bolstering the authority, transparency and capability of health system leadership. Negative impacts included undermining the impartial nature of indigenous health institutions by using health projects to achieve security objectives. Interactions between security and health actors were primarily ad hoc, often to the detriment of health system support efforts. When international security forces were engaged in health system support activities, the most helpful communication and consultative mechanisms to manage their involvement were ones that could address a wide array of problems, were nimble enough to accommodate rapidly changing circumstances, leveraged the power of personal relationships, and were able to address the tensions that arose between security and health system supporting strategies. Policy barriers to international security organizations participating in health system support included lack of mandate, conflicts between security strategies and health system preservation, and lack of interoperability between security and indigenous health organizations with respect to logistics and sharing information.
  
  
  CONCLUSIONS
  The cases demonstrate both the opportunities and risks of international security organizations involvement in health sector protection, recovery and reconstruction. We discuss two potential approaches to engaging these organizations in health system support that may increase the chances of realizing these opportunities while mitigating risks.
authors: Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA USA.
authors: Margaret
authors: M
authors: Bourdeaux
authors: Harvard Medical School, Department of Global Health and Social Medicine, 641 Huntington Avenue, Boston, MA 02115 USA ; Associate Director of Partnerships and Global Initiatives, Center for Global Health, Massachusetts General Hospital, 100 Cambridge Street, 15th floor, Boston, MA 02114 USA.
authors: Vanessa
authors: V
authors: Kerry
authors: Avenida Tenente Martins, Monsanto, 1500-589, Lisboa, Portugal.
authors: Christian
authors: C
authors: Haggenmiller
authors: Independent Research & Consultancy, Rua de Angola 92, 2765-193 Estoril, Portugal.
authors: Karlheinz
authors: K
authors: Nickel
keywords: Civil-military interaction; Fragile situations; Fragile states; Health system reconstruction; Health system strengthening; Health systems; Security forces; Stabilization