Bruno Meessen (ITM, Antwerp) reflects on a recent conference in Amsterdam on health systems strengthening in fragile states.


On October 11th, I attended a one-day expert meeting organized by Medicus Mundi International at the Royal Tropical Institute (KIT) of Amsterdam to discuss the theme ‘Health Systems Strengthening and Conflict Transformation in Fragile States’. Cordaid hosted the meeting. Since this issue is attracting growing attention, events like this may point to the fact that health related NGOs and academics working in fragile states have started to take ownership of the New Deal for Engagement in Fragile States, which was presented and endorsed by a number of governments and multilateral donors at the Fourth High-Level Forum on Aid Effectiveness in Busan, South-Korea. Or perhaps the continental European actors are trying to catch up with UK dynamism, as evidenced by DFID’s current research efforts in this domain?


Our readers are probably more familiar with the concept of health systems strengthening than with ‘fragile states’. Until now, there is not yet an agreed definition of ‘fragile states’ (for an introduction to the topic, see here), and the concept usually focuses more on capacity than on history. In comparison, related terms  like ‘post-conflict states’ or ‘failed states’  describe countries rebounding from civil war or in complete chaos. The OECD DAC characterizes ‘fragile states’ as states that are ‘unable to meet their population’s expectations or manage changes in expectations and capacity through the political process’. . Somalia is an obvious example, but the governments of Burundi, Chad, Haiti or RDC have also identified their countries as a fragile state (I don’t understand why Togo endorsed the New Deal – if anyone has an explanation, please fill me in).


The conference theme was clearly interesting: can strategies be developed that not only strengthen health systems, but also contribute to reducing tensions in fragile states, or – in other words – is it possible to catch two birds with one stone? Key note speaker Rachel Slater from ODI argued there is little evidence so far to support the view that by strengthening health systems (for example, through aid projects) one also contributes to state legitimacy, and thus to state-building (she also shared her doubts on the relevance of systematic reviews for such questions, but this is part of another debate).

As anticipated, all participants agreed about the need to first clarify some concepts (e.g. what do we mean by a ‘state’, a ‘fragile state’, or ‘health systems strengthening’?), which means that scholars in the field have their conceptual work cut out. Alternatively, it could indicate that people like me, who are relatively unfamiliar with the fragile states literature, should get acquainted with it sooner rather than later.


In addition, the discussion also revealed the need to clarify one’s normative assumptions, as it is about prescribing what the state should look like. In this sort of debate, one easily ends up promoting one’s own normative framework. To give but one example: the Taliban probably holds a different view on what the Afghan state should look like than, let’s say, a belligerent NATO country like the Netherlands – although the Dutch might obviously object to being labeled ‘belligerent’. Whose view then is the ‘best’ one, – and, maybe more importantly, whose stance the most legitimate? I consequently don’t see how normative choices can be avoided in this kind of debate, and believe that it is paramount to first specify these choices.


The causal link between health systems strengthening and state consolidation in a specific country is also less obvious than one might think. Several (ex-)humanitarian workers in the audience reminded us, for example, of the problems with ‘instrumentalization’ of health interventions by military forces in order to improve their image in the population – or, winning the ‘hearts and minds’ of the people, as they prefer to call it… (as in Afghanistan). It typically creates confusion to the point that insurgent forces might consider truly independent humanitarian actors as adversaries, and constitutes a well-known example whereby efforts for conflict resolution and improving population health may clash.


However, there are also situations where strengthening the health system may indeed increase the resilience of a state. Interesting examples of this can be found in countries like Rwanda or Morocco (granted, none of these is a fragile state by definition, although the Arab Spring could still prove me wrong for the latter), in which governments undertake massive efforts towards achieving universal health coverage. By displaying strong leadership and putting in substantial financial resources, such governments might genuinely see universal health coverage as the way to go – but they clearly also aim to consolidate their democratic legitimacy, and prevent social tensions as a spin-off. You can’t blame them.


Being a Performance-Based Financing (PBF) expert, I took part in a parallel session on PBF schemes in fragile states with a few other experts. The session’s focus on fragile states made sense: check the 2012 failed states index (a slightly different concept, as mentioned before), and you will notice that the list of failed states resembles the list of countries with an ongoing PBF experience. Obviously, it is fairly unreasonable to expect any health care financing scheme to make a difference in terms of solving longstanding conflicts. We, however, managed to identify some areas where PBF could have an impact on the situation. For instance, we learned that Cordaid is currently exploring how to apply pay-for-performance schemes in South Kivu to support the provision of typical State functions, such as police and justice.


Not surprisingly, one of the main conclusions of this meeting was that more research is needed, and this definitely encompasses more and better frameworks. Frameworks may help us to identify issues to address; to highlight normative choices; understand links, processes, and steps (and perhaps first, to formulate hypotheses). Frameworks also help us to identify the way forward for operational and policy actors; and, last but not least… they help us realize that our intervention addresses only one determinant, one link, one outcome…


For sure, health actors need to remain very, very humble in fragile states.

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2 Responses to Health systems strengthening and conflict transformation in fragile states: catching two birds with one stone?

  1. Ridde Valéry says:

    But why separate theory and evidence ? If I understand evidence as empirical evidence, so theory is build from evidence and evidence is studying thanks to theory.. For me, more theory AND more evidence are needed about HSR, theory is not existing without evidence and evidence without theory is not enough, like free health care without drugs is not free or PBF without evidence is just a concept or how to implement knowledge transfer without evidence ? 😉
    Valéry Ridde

  2. Wim Van Damme says:

    when “more evidence / more research is needed” comes up; I often think of Gerry Bloom’s one-liner: “more theory is needed, not more evidence.” Seem applicable to this debate too.
    greetings from Beijing; where this might come up in the Global Symposium on Health Systems Research too: What is the balance between “new thinking; new concepts; new theories are needed” & “more evidence is needed”…. (and many other things, obviously).

    Wim Van Damme

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