This paper surveys examples of interaction between the health sector and wider state-building in fragile states. It focuses on the sub-national level where citizens and service-providers interact. It concludes that health sector interventions can and should play an important part in the process of state-building, but that further research is needed to build up a body of evidence to prove impact.
State-building is becoming the key framing agenda for donor foreign policy and investments in fragile states. This is a highly country-specific and primarily internal process between citizens and the political elite. States will not become capable and accountable unless citizens are engaged in demand-side processes such as resource mobilisation and allocation, and in monitoring the performance of service-providers and state authorities.
Fragile states without apparent conflict or current natural disaster may still have unacceptably high levels of violence, sexual violence and maternal and infant mortality. The health sector has a prominent role to play in engaging with wider state-building processes that will contribute to greater state resilience. This role includes:
- Developing human capital: Investing in a good-quality healthcare workforce is a prerequisite to health system strengthening and also has state-building properties
- Promoting international technical standards of good-quality healthcare: There is a technical imperative for health services to be provided to the highest standard, adopting flexible models of service delivery where necessary
- Promoting citizen voice and participation: Enhanced citizen engagement and appropriate healthcare system design can contribute to reducing inequities, marginalisation and discrimination, and contribute to stability
- Monitoring abuses and unacceptable rates of mortality and morbidity: The health sector plays an underdeveloped role in monitoring levels of disease, death and violence in fragile situations
- Encouraging diversified resource mobilisation for sustainable service provision and inclusive access: The health sector can assert the need for increased taxation and more citizen mechanisms for monitoring public funds.
Health sector interventions always affect the interaction between citizen, service provider and policymaker. International partners should aim to reinforce, and not undermine, state resilience through these interventions. Well-designed interventions can build up sub-national capacity and support democratic processes by:
- Beginning state-building early, during rather than after crises, by degrees, and using flexible, context-specific strategies
- Engaging citizens in identifying causes of ill health (including looking at causes of violence) and in healthcare delivery to create demand for a stronger social contract
- Highlighting healthcare standards and the right to health as aspirational targets
- Identifying how more coherent programming and better governance can bring improved health status and can create more robust systems to reduce inequalities, destitution and fragility
- Making long-term investments in training and the deployment of health workers to build sustainability in the health sector and to nurture leadership at regional and national levels.
