Have Donors Again Lost Focus on Health in Fragile States?

By Stephen Commins, Associate Director of Global Public Affairs @ UCLA Luskin,  Faculty Cluster Leader of Global Environment and Resources, Lecturer in Urban Planning

Getty Images News | Pascal Parrot


Despite a decade of research and various efforts at investing in connecting fragile states programming with health systems strengthening, the reality is that most donors have lost focus on HSS in FCAS. The imperative of bureaucratic pressures as well as legislative demands for ‘results’ tends to produce short term approaches, and frequently issues of prolonged crises and state fragility are less pressing then humanitarian emergencies. Thus, it is difficult for donors to show results in fragile states and perhaps this is why they appear to have lost interest or focus on the long term issues of health in FCAS.

Donor approaches to health in fragile states have developed both through donor programs and a more deliberate and intentional process amongst donor agencies concerned about the effectiveness of their aid programs.

Some of the initial work was undertaken by the Task Force on Low Income Countries Under Stress which provided guidance on the Bank’s work in fragile states. The High Level Forum on Health published a study in 2004 that sought to identify the particular health gaps in fragile states. DFID began working on ‘difficult partners’ through a number of key papers and studies that included assessing how to work with ‘difficult partners’ and to identify different types of aid instruments.

The World Bank’s World Development Report 2004 included a section on service delivery in fragile states. Within the OECD/DAC, the Fragile States Group initiated several studies on services in fragile states. The overall Service Delivery process led to several sectoral publications as well as a synthesis paper, and connections with the Good Practices in Fragile States DAC process.

More recently, in Busan, a group of 19 fragile states (also known as the g7+) called for a new approach to development assistance. This new approach—the New Deal—establishes new guidelines for relations between donors and fragile states and underscores the link between development and peacebuilding and statebuilding goals.

Despite all of these endeavors, in practice, donors consistently underestimate the time required to build and sustain systems for quality education, health and WASH. Perhaps this is why they appear to have lost interest or focus on the long term issues of health in FCAS.

Long term, broad based goals are required, rather than projectising aid without contextual perspective.

The lessons from the past fifteen years of research and experience in the areas of health, fragility and governance point to the need to:

• analyze systematically the relationship between service provision and local government accountability and capacity
• understand how different service provision modalities can have either negative or positive effects both on human development outcomes and government capacity
• assess of non-state provision, even when it is effective in achieving its explicit goals (saving lives, alleviating human suffering and/or supporting long term development), may undermine longer term goals of accountability and voice.
• determine the better programming options that reduce the negative impacts of the short route of service provision.
• consider how health programs can support and build up local voice and capacities that can be mobilized for accountability in both the short and long route over time.

Donors will consistently be tempted and under pressure to find ‘quick fixes, magic bullets and perfect solutions’ (Enrico Pavignani)

To regain a focus on working in protracted crises, donors need to be realistic, tough minded and candid in dealing with the deeply embedded political, economic, social and ‘identity’ relations that shape the context for work in each country.

In each country, assessing the various relationships and capacities, the balance of services in the short term with medium to long term governance goals—this is an art, not a science.


Slider credit: Flickr/ Rainforest Flow
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