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Key Text Health System Reconstruction: Can it Contribute to State-building?

Author: Jack Eldon, Catriona Waddington
Date: 2008
Size: 58 pages (456 KB)

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Summary

Can rebuilding health systems in fragile states strengthen the social contract and contribute to wider state-building? This study commissioned by the Health and Fragile States Network, which included fieldwork in Nigeria and Sierra Leone, finds that health sector strengthening can contribute to state-building in the health sector, but that its impact on wider state-building remains unclear. There may be more scope for wider state-building and the strengthening of the state-society compact through decentralised and 'bottom up' approaches. Context is the key influencer of potential for state-building, but is often inadequately understood.

While there is considerable evidence of the impact of fragility on health outcomes, there has been little research into the relationship between health and state-building in fragile states. This is surprising as experience suggests that responding to social expectations such as demands for improved services can be central to state survival.

Health sector strengthening can help build legitimacy and capacity within the health sector and put health on the state-building agenda. It is unclear, however, whether the benefits of strengthening the health system extend beyond the health sector to broader state-building. The following issues affect whether activities contribute to state-building within the health sector:

Balancing short-term impact with long-term capacity building: Work in fragile states tends to lack focus on developing capacity in procurement, health information and policy-making.
State involvement in health activities: Many health sector activities in fragile states are contracted out to NGOs. While this does not preclude state-building, pressures for a ‘quick fix’ can mean the state being by-passed.
Stewardship: This refers to governance in the health sector, including leadership, strategic policy, oversight, regulation and accountability. Stewardship tends to be weak in fragile states and there are only a few examples of successful attempts to improve it.
Visible services and state legitimacy: Health service visibility can enhance credibility and legitimacy in the health sector. But visible services provided by NGOs, whose primary accountability is to donors, can undermine legitimacy. Quality in service provision is equally important for state credibility.
Control of resources: Funding mechanisms for health in fragile states rarely strengthen state systems. Budget support can contribute to health sector strengthening if governance and financial management are also strengthened.

Further research is needed to address the considerable gaps in knowledge and understanding of the relationship between health and state-building. This should extend to the interactions between health and state-building in different situations, such as conflict-affected states and transition situations. Implications of the study also include the following:

Greater understanding of the impact of context on state capacity, political will and state legitimacy is needed.
Some donors still need to recognise that state-building is not a linear process, a sequence of steps that if managed well will deliver stronger states.
Systematic study is required to investigate the potential contribution of decentralised approaches to wider state-building. Evidence from the field is mixed but does broadly support the view that decentralised services – including health – can lead to increased citizen involvement and a greater willingness to hold local politicians to account. This in turn can promote state responsiveness and help build confidence in public service provision at the local level.

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Source: Eldon J., and Waddington, C., 2008, 'Health System Reconstruction: Can it Contribute to State-building?', Health and Fragile States Network, London
Author: HLSP Institute, http://www.hlspinstitute.org
Organisation: Health and Fragile States Network, http://www.healthandfragilestates.org/