Institute of Development Studies

Where Governments cannot or will not deliver: Health Service Provision in Fragile States

10 July 2009 – Guy Collender and Tom Barker

Mogadishu's hospitals are overflowing with patients wounded in the latest spate of fighting in the Somali capital. Doctors at Keysaney Hospital are treating twice the number of people they should be and are preparing to care for the injured in tents if the fighting continues.

In the province of South Kivu in the Democratic Republic of Congo (DRC), rape cases have risen dramatically in recent months. In Zimbabwe, World Health Organization (WHO) statistics show that nearly 4,300 people have died from cholera in since August 2008. These unfolding health emergencies are realities in Somalia, DRC and Zimbabwe, and more research and policy advice is now being generated surrounding such fragile states because of the severity of the health challenges they face.

Fragile states, defined by DFID as those “where the government cannot or will not deliver its basic functions to the majority of its people, including the poor”, have some of the worst health indicators and the weakest health services. Services are disproportionately under-funded and funding is more volatile than in other developing countries. Providing health care and rebuilding health services in such countries is a complex and painstaking undertaking for national and local governments, civil society organisations and donor agencies.

Documenting approaches to health service delivery

To help address this challenge, the Health and Fragile States Network was created in October 2007 to foster dialogue and debate; inform and influence policy; and identify, stimulate and conduct research. The Network, together with the IDS Health and Development Information Team and Eldis recently published a Health and Fragile States dossier on the Eldis web platform that describes the difficulties faced by fragile states and the strategies to overcome them. The dossier, funded by DFID, was launched in June 2009 at IDS and the London International Development Centre (LIDC).

The dossier charts two approaches to health service delivery in fragile states:
the humanitarian approach, which focuses on meeting the immediate health needs of a population; and the health systems strengthening approach, which focuses on building the government's capacity as the steward of the health system. In conflict settings, health services are primarily provided through non-governmental organisations (NGOs), faith-based organisations and the private sector. In post-conflict Afghanistan, contracting out the delivery of a basic package of health services to NGOs has led to a rapid expansion of health service delivery.

Achieving better health outcomes

Aid and donor agencies have historically concentrated on humanitarian interventions, but this is changing as they realise the importance of strengthening health systems and long-term interventions. For instance, Médecins Sans Frontières pays increasing attention to reproductive health and mental health, as well as maintaining its primary focus on nutrition and the control of infectious diseases. Multilateral bodies and donors have responded with a series of initiatives to improve health care provision, including the WHO’s Framework for Action in 2007.

However, the creation of strong health systems is not an end in itself – it is a means to achieve better health outcomes. Effective and equitable health systems are not only required for achieving the Millennium Development Goals, but strengthening health systems is essential if the current increase in aid for health is to be well spent and sustained in the future.

HDI plans to continue working with the Health and Fragile States Network to develop the dossier as a high quality knowledge resource, and as a vehicle to stimulate the policy and research agenda around how to best finance, organise and deliver health services in fragile environments.

This piece is adapted from an article by Guy Collender (LIDC) entitled ‘Strengthening the focus’, which appears in Public Service Review: International Development, Issue 14, 23rd June 2009

Tom Barker is Acting Manager of the IDS Health and Development Information Team and id21 Health Editor

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