This is a guest blog by Steve Commins from Thematic Working Group on Health Systems in Fragile and Conflict-Affected States.

Despite fifteen years of donor efforts to define and address fragile and conflict affected states, the global aid system remains inconsistent in its approach to situations of conflict – veering from rapid (and solely) humanitarian, short term responses, to more nuanced investments in longer term tactics and support for health systems. A new set of papers provides evidence on the particularities of local fragility and the innovative ways that health systems can be strengthened even in settings in crisis. 

The papers in a special issue for, Conflict and Health, provide new reference points to literature on health in fragile states.  This has developed both through academic research; donor evaluations from the World Bank, DFID, OECD/DAC; and a more deliberate and intentional process amongst donor agencies concerned about the effectiveness of their aid programs.

State fragility affects essential services in important ways. Fragility undermines state and nonstate organizations involved in the provision of health care and disrupts service delivery systems.

Even in the most fragile of settings, the right to the ‘highest attainable standard of health’ should stand as unassailable. However, in fragile states, health needs are generally far greater and health indicators considerably worse. In these settings special attention needs to be paid to groups who face particular challenges in relation to health such as women, children, migrants and internally displaced people.

Politics and health

The papers we’ve published on Iraq and Afghanistan are a sharp reminder that health services and systems in fragile and conflict-affected states are highly political. This includes the politics of ‘state building’ or ‘state services’ within the country; organizational politics in the aid system; and the domestic politics of the states providing aid.  This is a key element of addressing health needs in fragile states. However, all too frequently, aid is cloaked within humanitarian systems in ways that reduces scrutiny of the context of fragility.

These tensions exist despite significant efforts by donors to map out the nature of state fragility and better approaches to delivering services and restoring systems, including health.

State failure and the shaping of international policy

Donor and academic interest in fragile states has emerged from the challenge of ‘state failure’, the failure of humanitarian programs in complex emergencies, and internal debates within donor agencies over aid effectiveness.

The tragedies of Somalia, Bosnia and Rwanda, and the inability of aid agencies to effectively operate in these complex emergencies, is part of the puzzle of ‘state fragility’.  Another element of this puzzle is the recognition that rewarding ‘good’ governance means reducing development assistance for states that frequently had the worst health and education indicators.

It has taken a decade to reach greater understanding about the potentials and pitfalls of service delivery in these complex environments. Starting with the World Bank’s Low Income Countries Under Stress report, to DFID’s growing research on working effectively in fragile states, through to OECD/DAC work on services and fragility. Running parallel to this work, but not adequately integrated, is the humanitarian reform agenda that led to the cluster system and other important improvements in the emergency response system globally.

Moving forward to improve health in fragile settings

Despite laudable and frequently well designed efforts, donor time frames and aid instruments are a muddle of institutional priorities that are frequently unaligned with realities on the ground. This muddle frustrates many efforts at improving donor response.

Furthermore, after a number of years of productive work in the early 2000s, donors have lost momentum with regard to addressing health in fragile contexts. Many donors have failed to continue to refine their analyses and their aid instruments.

Donors should focus on the day-to-day practices of official policy making. Too often they focus on the aid that they provide rather than  on projecting good governance and resilience. What use is there in developing a governance capacity building project in isolation from a national political discourse on what type of governance the public favors?

Similarly, donor agencies need to foster more transparency about their internal decision making, priority setting, and how politics (both internal and governmental) shape their investments, their commitments and their strategies for address health needs in fragile states.

New learning

A benefit of the papers in the new special issue is that they illustrate that even in exceptionally difficult circumstances, innovation is possible and improvements can be made in health delivery and in health systems in general.  A second benefit is that they provide insights into: practical ways to address local fragility; how donors could be more effective in protracted crises; ways of giving greater attention to community capacity; and encouragement on the value of moving beyond the stop/start structure of aid modalities.