In many conflict‑affected countries, the collapse of health systems leaves communities without the basic conditions needed for human dignity to flourish, a crucial concern for Catholic theological ethics. This reflection explores how medical non-government organizations (NGOs) contribute to peacebuilding and development in such contexts, drawing on the post‑war experiences of Mozambique and Timor‑Leste. While humanitarian organisations often provide essential care where states cannot, their presence also raises ethical questions about dependency, power, and the long‑term shaping of local institutions. Using the World Health Organization’s Health as a Bridge for Peace framework as a starting point, this piece examines how health interventions can either reinforce or undermine the foundations of just and lasting peace. The case studies show that NGOs can help rebuild trust, restore essential services, and strengthen local capacity. Yet they can also unintentionally fragment systems or displace local leadership. These tensions invite deeper moral reflection grounded in Catholic social teaching: solidarity as a call to stand with vulnerable communities, subsidiarity as a reminder to reinforce local agency, and the common good. Ultimately, the ethical challenge is not simply whether NGOs should act, but how they can do so in ways that honour local agency, avoid reproducing inequalities, and contribute to the conditions in which peace can take root. The experiences of Mozambique and Timor‑Leste suggest that health programmes, when grounded in genuine partnership, can become a form of peacebuilding that aligns with a vision of human flourishing at the heart of Catholic social thought.
NGOs, Health and Peace
I reflect on international relief and development NGOs that provide immediate health-related services in the context of war-torn countries as well as long-term development of health systems within the framework of peacebuilding. In so doing, I will address interventions that raise ethical questions about neutrality, equity, and system impact. At stake is a deeper ethical question: how can health interventions in war‑torn societies honour human dignity without overshadowing local agency?
The World Health Organisation (WHO) has been developing policy frameworks for the attainment of peace through the provision of medical services. According to the WHO (1981), “The role of physicians and other health workers in the preservation and promotion of peace is the most significant factor for the attainment of health for all” (World Health Assembly, 1981: Resolution 34.38). In 1998, WHO adopted Health as a Bridge for Peace (HBP) as its multidimensional paradigm to support health workers in fostering peace; strategies encompass immediate health relief and the development of health infrastructures to contribute to peacebuilding initiatives, but also raise questions about how medical actors navigate the boundaries between humanitarian care and political influence.
For Catholic social teaching and WHO, peace is not merely the absence of violence. Attention is therefore devoted to “structural” peacebuilding because it is aimed at the creation of the conditions for a peaceful environment where life can flourish by safeguarding dignity and the fundamental needs of people living in that context (Ricigliano, 2003). International non-government organizations (INGOs) working within the HBP framework indeed provide relief services for all people, regardless of the conflicting party to which they belong, and focus upon the broader restoration of health services, hence contributing to peacebuilding and development (ibid.).
Crucially, “integrated” programming differs from “conflict-sensitive” planning. The former explicitly addresses the underlying causes of conflicts while fostering post-conflict development (Bayne and Vaux, 2013). The article therefore evaluates the ethical role of medical INGOs against their effectiveness in working within an integrated approach to peacebuilding and development in fragile political environments.
Case Study One: Mozambique
Conflicts can have significant impacts upon health services. Mozambique suffered damages over 80% of its health facilities (Rubenstein, 2009). Following its independence from Portugal on 25 June 1975, the civil war deeply affected national socio-economic infrastructures, especially impacting human development (Shiyan Chao and Kees Kostermans 1999). In terms of international health interventions, on the one hand, medical INGOs fostered peacebuilding by delivering services to formerly restricted areas to defuse military control and ease political tensions. By addressing underlying iniquities in health service delivery, medical INGOs initially focused on rural and impoverished communities (Vaux and Visman, 2005).
Furthermore, international health workers succeeded in gaining access to areas under the influence of RENAMO, a Mozambican political party and militant group. In these areas, the health workers tackled military control over the movement of people, through service provisions across both lines of conflict and especially through their demobilisation programmes which sought to provide primary health care services to former combatants and their families (WHO). For instance, Africare focused upon the strengthening of community-based and home-based treatment of AIDS, HIV, family nutrition and provision of health services with the aim of empowering local communities from both sides of the conflict (Africare, 2020). Other INGOs decided to offer medical training to people from RENAMO areas to foster local empowerment and to encourage the integration of rebel communities within a broader framework of common administration (Vaux and Visman, 2005). Cross-party provision of primary health care thus endeavoured to strengthen structural peacebuilding activities by addressing the underlying roots conflict within the social sector and by providing feasible reintegration programmes for former combatants.
On the other hand, international health workers addressed post-conflict development of Mozambiquan capacities for the restoration of health services in the post-GPA context (Vaux and Visman, 2005). For instance, Save the Children’s Maternal, New-born and Child Health (MNCH) programme in Mozambique envisaged tackling the main causes of preventable deaths by offering professional and technical support to Mozambique’s Ministry of Health, by investing into the rehabilitation of health infrastructures across the country and by providing local training to enhance community-based empowerment (Save the Children, 2020). Moreover, Médecins sans Frontiers [Doctors without Borders] have been working in the Tete province of Mozambique for almost twenty years to provide HIV care, including antiretroviral (ARV) community treatments and supply mechanisms of medicines to fight HIV and Tuberculosis (TB). To foster Mozambique’s independence from international organisations and donors, MSF have transferred their HIV projects to the national Ministry of Health (MSF, 2018: 63).
Furthermore, INGOs allowed the Ministry of Health to initiate the Health Sector Recovery Programme in 1995 for the rehabilitation of local and national primary care infrastructures. With an initial cost of US$ 355 million for a period of six years, the programme was sponsored by government funding for only 33%, whilst the remaining 67% stemmed from international aid, including a US$ 100 million investment by the World Bank (Shiyan Chao and Kees Kostermans 1999). Although significant progress was made with regard to the implementation of the programme, an enormous amount of external aid was not delivered through governmental channels, but rather through health-related INGOs which, on their part, prevented donors from endorsing political forces that constituted parties in the conflict (Lanjouw et al., 1999 and WHO, 2005). Medical INGOs can have a positive impact in both the long-term development and the strengthening of peacebuilding in the country.
In spite of this, the Mozambiquan National Health Service (NHS) was dependent upon international investments for 90% of its capital spending by 1999 (Vaux and Visman, 2005). It can thus be argued that Mozambique’s dependence on external donors might have hindered its negotiation capacity before the World Bank and the IMF (ibid.). Additionally, the vast heterogeneity of INGOs operating in Mozambique has been criticised for hampering the national health system and the local ownership of healthcare provisions, as well as for negatively impacting upon social inequalities, instead of solving them (Alonso and Brugha, 2006). In his country-based study, Pfeiffer (2003) revealed that local health workers were attracted by international medical organisations due to salaries against which Mozambique’s NHS could not compete; as a result, many local health practitioners sought employment in INGOs and consequently left their country, hence impoverishing the national health infrastructure and increasing Mozambique’s dependence on external assistance (ibid.). Therefore, the increase of international organisations might have eventuated in the fragmentation of healthcare services, instead of in their enhancement, highlighting the ethical risk of undermining local systems while trying to strengthen them.
Notwithstanding the relevance of arguments stressing the negative ethical impacts stemming from the involvement of medical INGOs, it is crucial to highlight the overall benefits deriving from their work in post-war contexts like Mozambique. Access to health services in rural areas have tripled between 1994 and 1996 (Vaux and Visman, 2005). Additionally, from an initial record of infant mortality of 17,5%, it decreased to 7% by 2011 (Adedokun, 2005). Alongside the contribution of medical INGOs to peacebuilding and development, INGOs and NGOs successfully collaborated to support Provincial Health Authorities for the coordination of medical activities (Rodriguez-Garcia et al., 2001).
By contrast, negative experiences as the ones indicated above should reinforce INGOs’ ethical commitment to “learn by doing” and thus encourage the continuous assessment and adjustment of their policy cycle in post-conflict contexts. Local and international NGOs should focus more on tackling the underlying causes of war rather than solely providing immediate relief. Medical INGOs’ successes in restoring Mozambique’s health system can therefore be considered an important case of integrated programming aimed at the overall consolidation of peace.
Case Study Two: East Timor (later Timor-Leste)
Now known as the Democratic Republic of Timor-Leste, the country has been affected by different outbreaks of violence and conflict. Increasing international pressure allowed East Timorese people to hold an independence referendum on 30thAugust 1999, which resulted in 78.5% of the voting electorate (98% of the population) in favour of independence (Alonso and Brugha, 2006). The outcome was met by a further outbreak of violence led by militia and the Indonesian army in September 1999. Consequently, 70% of state infrastructures and 35% of health facilities were destroyed, whilst 40% of health resources were severely damaged (Silva and Ball, 2006). The UN Security Council decided to deploy multinational forces for the restoration of peace and instituted the United Nations Transitional Administration for East Timor (UNTAET) (UNSCR 1272/99). The new Constitution entered into force in March 2002, and East Timor (Timor-Leste) gained its independence on 20th May 2002.
An Interim Health Authority (IHA) was established in March 2000 to coordinate the work of local and international health workers, showing an ethically stronger model of alignment with national authority. IHA assigned one medical INGO to each district of the country to ensure effective delivery of healthcare to all the areas deteriorated by the conflict; INGOs thus proved to be successful in maximising coverage across the country, in efficiently utilising limited resources and in ensuring capacity-building through the training of local staff (Alonso and Brugha, 2006). Additionally, subsidiary contributions of medical INGOs, centrally coordinated by the IHA, included: the restoration of one health centre for each district and one health department for each sub-district, staffed health posts in rural locations, and mobile clinics for basic healthcare in otherwise isolated areas (ibid.). INGOs’ contributions from October 1999 and February 2000 effectively focused upon the delivery of immediate relief assistance to those affected by the conflict.
An ethical evaluation of INGO involvement in East Timor nevertheless entails considerations of their ability to aid in the form of structural peacebuilding and post-conflict development without hindering the long-term sustainability of peace, as it has been observed in other instances through exacerbation of social iniquities and donor-dependency. Issues surrounding the management and distribution of international aid is often controversial; legitimacy, coherence and sustainability of projects can constitute problems (Macrae, 1997 quoted in Alonso and Brugha, 2006). In East Timor, it was possible to observe an interconnected process of trust and legitimacy for the newly democratically elected institutions, whilst coherence was achieved through the central coordination of activities by national authorities in the form of a “sector-wide approach” (SWAp), as in the case of IHA (Cassels, 1997). International donors and NGOs were only supporting the implementation of governmental policies, thus fostering the ownership of East Timorese people over the stabilisation of their country.
Conclusion
In conclusion, this essay has illustrated the importance of health INGOs to peace and development in contexts of conflict, especially when their activities are designed and implemented within an “integrated” approach to peacebuilding. By reflecting on two case studies, namely Mozambique and East Timor (later Timor-Leste), this article has elucidated the relevance of medical INGOs in human flourishing when they deliver both structural peacebuilding and post-conflict rehabilitation in war-torn countries.
The role of INGOs in peacebuilding and development has been regarded as essential in the immediate aftermath of the conflict, especially in relation to the health sector; however, to avoid ethical issues of dependency on external assistance and long-term destabilisation of services due to competing interests of foreign NGOs (like in Mozambique), the government’s 2002 Health Policy Framework for East Timor (see WHO, 2013) represented a post-crisis “NGO phase-over” strategy to foster local ownership (Mercer et al., 2014). INGOs have provided important support to East Timor’s structural peacebuilding and sector-wide development; their participation to the Ministry of Health’s design and implementation of the “phase-over” further reinforced capacity building and the country’s self-reliance.
Health-related INGOs therefore constitute an important case for the evaluation of NGOs’ ethical contributions to peace and development in contexts of conflict. The conceptualisation and practice of “structural” peacebuilding thus represent an important step in the right direction for the realisation of integrated approaches to peacebuilding and development in conflict-affected countries. Ultimately, the ethics of international health interventions hinge on whether INGOs strengthen or displace local systems: a question that must remain central in all future peacebuilding efforts.
Further Reading
Bayne S., Vaux T. (2013). Integrated development and peacebuilding programming: Design, monitoring and evaluation. London, England: DfID.
Lanjouw S, Macrae J, Zwi A (1999). Rehabilitating health services in Cambodia: the challenge of co-ordination in chronic political emergencies. Health Policy and Planning, 14 (3):229–242.
United Nations Security Council (UNSC) (1999) Resolution 1272 (1999) establishing UNTAET.
Vaux, T. and E. Visman (2005), “Service Delivery in Countries Emerging from Conflict”, Centre for International Co-operation and Security, Department of Peace Studies, University of Bradford, Final Report for DFID, January.
World Health Assembly (1981) Resolution 34.38: The role of physicians and other health workers in the preservation and promotion of peace. Geneva: WHO.
World Health Organization (WHO) (1998) Health as a Bridge for Peace (HBP) framework.