By Luc Van Leemput, Evelyn Depoortere, Jan Boeynaems (ITM)

The 2nd Global Symposium on Health Systems Research took place in Beijing, China, from 31 October to 3 November 2012. Contrary to the first Symposium organized inMontreux, Switzerland(2010), this time “Fragile States” made it to the symposium programme. Indeed, three sessions on the specific challenge of health systems research in fragile states were included; in Montreux there were none. We attended two of them – unfortunately we were not able to attend the satellite session of Wednesday 31 October, chaired by Steven Solter on “UHC in Fragile States, the role of Community Health Workers”. In this blog, we will discuss the two sessions we participated in. Overall, the content of both did not meet our (exaggerated?) expectations.


A morning session on Friday 2 November on “Health Systems in Post-Conflict States” was  organized by representatives of Re-BUILD, a consortium funded by DFID (2011-2017) that aims to strengthen policy and practice in countries recovering from conflict. The afternoon of the same day, Steven Solter chaired a session on “Health systems functioning in fragile states”. In both sessions, presentations of country case studies were combined with presentations on overarching challenges of doing health systems research in fragile states.


Country case studies were presented on Uganda, Sierra Leone, Cambodia (two), and Irak. A case study on Afghanistan was cancelled because the representative had not received his China visa in time (sounds familiarJ). The choice of countries is probably the best example that “fragile states” and “post conflict states” can be very diverse and that there is an urgent need to better define them, an issue that was regularly raised during the sessions. Unfortunately, because the Re-BUILD consortium has just started its work, few research results could be presented – the focus was more on research “in the making”. The most interesting account came from Freddie Ssengoba from Makerere university, who studies the dynamics in changing aid relationships and inter-agency networks in health districts inUganda. He stressed the importance of good leadership at local level. Country presentations on Sierra Leone and Cambodia were much less convincing. For the former, a research plan was introduced but had yet to be launched. Preliminary results of research in Cambodia on health financing were controversial to say the least, claiming that the introduction of user fees to access health services after the end of the conflict had shown no significant impact on household and catastrophic health expenditure. A second presentation on Cambodia zoomed in on the recent implementation of a nation-wide electronic Health Information System, which seems to rather increase inefficiencies so far. On Irak the point was made that a primary public health care system is now generally available and that important investments in basic health care infrastructure (like rural health services) can be observed. However, the quality of services remains unacceptably low, primarily so in rural areas. A further shift from public to private services is expected to continue if the prevailing problem of regular stock-outs of essential drugs in the public system cannot be tackled.


In general, it was not really clear how the above research dealt with the specific challenges of fragile states. The different case studies remained rather descriptive, hardly any data was provided.


As for the overarching challenges of doing health systems research in fragile countries, Tim Martineau made the point that more longitudinal studies are needed to better assess how policies introduced at a given moment in time impact long term development. Sally Theobald made a plea for the use of context-specific gender indicators in fragile states in order to construct a gender equitable health system in post-conflict settings. Both remained rather vague on how to practically move forward. At the end of the second session, Egbert Sondorp made a plea to advocate for a thematic working group on “Fragile States” within Health Systems Global, the new society launched at the Symposium. Time was dedicated to brainstorm on the possible focus of such a working group, the results of which were promised to be integrated in a short proposal to be submitted to the newly elected Board of the Society.


We are crossing fingers that the working group will materialize, and according to the latest news that indeed seems to be happening. Based on the Symposium presentations and discussions, there clearly seems increasing consensus that Health Systems are complex adaptive systems posing particular challenges for research and policy. This is even more so in fragile and failed states. While research in the latter may be challenging, it is not impossible. However, adapted and innovative approaches are needed. We would argue that it is essential to better define and understand the concept of fragility, and in particular to distinguish the different stages and sub-categories it covers. Such differentiation is of importance given its direct operational impact. At the same time, we need to be careful not to get stuck in too rigid a framework that doesn’t recognise the fluidity of these different stages or categories. Probably the key principle when dealing with fragile states is flexibility, based on strong local context analysis.

In any case, after the election of Freddie Ssengoba, member of the Re-BUILD consortium, in the Board of the Health Systems Global Society, we certainly hope that health systems research in fragile states will be recognised as a challenge on its own, and are ready for a dynamic exchange!

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One Response to Health Systems Research and the particular challenge of Fragile States

  1. We too were encouraged to see some representation of health systems in fragile states at the 2012 Symposium, but we need to see more action in this area. There needs to be an explicit focus on populations in the most need if we are to achieve universal health coverage, read more about this view in ReBUILD Researcher, Sally Theobald’s blog

    In response to “crossing fingers that the working group will materialize” we have good news, indeed we are set to make this happen! We are part of a group that was formed at the Symposium in Beijing. This group has registered its interest with the secretariat and is submitting a two-page proposal for the establishment of a fragile states health systems research, working group. Further news will be coming soon on the ReBUILD website website

    It is true to say that ReBUILD is in the making and the findings we presented at the Symposium were provisional. The finding reported from the analysis of Cambodian data, that user fees did not have a detectable impact on household expenditure or utilisation when they were introduced in the 1990s is, on the face of it, surprising and perhaps controversial. Perhaps it is less so, in the light of the explanation advanced that significant informal charges pre-dated formal ones, and may to some degree have been replaced by formal ones. Of course, this requires further investigation which we are undertaking.

    But that does not mean that we cannot start the post conflict agenda movement, building critical networks and shedding some much needed light on this previously neglected area of research.

    On that note we would like to thank you for the blog about the ReBUILD panel and hope that you will support us in keeping this conversation going. We also join you in celebrating the good news for ReBUILD’s Freddie Ssengooba, who was elected to the Board of the Health Systems Global Society, who is well equipped to lead the dynamic exchange on research in fragile states.

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