Governance and the role of the state in fragile settings: broadening the health systems (governance) frame
The South Sudanese food crisis is caused by protracted conflict and insecurity, which has a knock-on effect on food production and distribution. The cholera outbreak in Yemen due to the complete breakdown of sanitation as a result of the civil war, is exacerbated by malnutrition and massive internal displacement. The use of rape is an instrument of war by armed groups in the sectarian violence in the Central African Republic. Corruption in the Democratic Republic of Congo has led to a loss of national income and the resulting blow to state coffers in dire need of resources to fund public goods such as health and education.
These examples are all related to state collapse and/or a failure in the state’s organisation of public service delivery and public accountability, resulting in a downward spiral of government distrust and loss of state legitimacy.
Governments in fragile settings are challenged both from within and without, by armed and rebel groups with transnational operations and a reach that extends beyond state capabilities. The government fails to protect the population, and does not deliver on its mandate, from which it derives its legitimacy.
In these settings, a myriad of non-state actors come in to organise and deliver health services: international non-governmental organisations (NGOs) and humanitarian actors, but also increasingly, local non-state actors find a way to ‘make do’ and produce what De Herdt et al. called ‘real’ governance. It is actually this hodgepodge of actors who are active in the full range of social service delivery, financial support, infrastructure and agricultural rehabilitation, and educational and health sectors, who we need to take into account when we talk about health policy processes and outcomes in these fragile settings.
In the cases cited above, a few of the consequences are: malnutrition and poor health outcomes for children; an infectious disease outbreak and risk to global health security; compromised sexual, reproductive and mental health; and a lack of financing for the health system. These examples, just a handful of the many out there, illustrate the fact that state failure and a failure in adequate coordination between actors in fragile settings has repercussions for health, healthcare and access to health services.
Yet, in the global health community, there is a tendency to limit the frame of health systems strengthening or health systems governance interventions to governance within the health system alone. In many cases this goes even further, with governance becoming synonymous with government, and interventions becoming focused only on the public health system. The private sector is overlooked and the outer sphere is ignored.
Unfortunately, this is not the way it works in complex, open systems - health governance cannot be so easily delineated from the broader governance context. The ‘ring-fencing’ of health system interventions and governance and accountability interventions risks blinding us to the actual governance problems out there, and some of the (imperfect) solutions. It seems we (professionals, academics, policymakers, governments, donors and other stakeholders alike) are so busy trying to find a quick fix and get things to function correctly, that we forget that health systems do not work in isolation.
Sometimes 'good enough' governance is good enough
We know that “good governance has an influence on health via its positive impact on income and the quality of the health care sector.” We also know that a population’s health is shaped by structural factors or social and political determinants of health. These factors, which include “economic policies and systems, development agendas, social norms, social policies and political systems,” and their mechanisms of action, are put forward in the conceptual framework developed by Solar & Irwin, 2010 as part of the Commission on Social Determinants of Health (CSDH).
It is obvious then, that the quality of governance, the political system, rule of law, the level of corruption, transparency and accountability all have an impact on health. This is of particular importance in fragile states where public goods such as education, infrastructure etc. are non-existent, insecurity prevails, corruption is widespread, and there is a complete breakdown of trust in government and institutions. Here, ‘good enough’ governance in any one of the sectors outside of health, will have an impact on actions within the health sector.
In situations like the ones described in the first paragraph, health systems strengthening interventions can prove futile or even counterproductive, as was the case in South Sudan, where Nuer people refused food and vaccination from NGOs because of their distrust of the Government and the organisations linked to it.
We have to be modest, as members of the global health community, of what we can achieve in fragile settings, and which activities to prioritise, in collaboration with other actors and sectors. If the context conditions are not in place for interventions to succeed, as a community, we must have the courage to take a step back, stop non-urgent interventions and focus only on the most pressing needs.
In place of those other more long-term interventions, the focus can be shifted to cross-sector collaboration in order to solve bottlenecks - for instance through the mobilisation of immediately available resources such as manpower etc. - and put in place the (non-health) measures that will promote the chances of success for health sector interventions.
We, members of the global health community, need to remind ourselves of the existence of the overall governance context in which health interventions are framed and the importance of governance in other non-health sectors. So, what does this mean in reality?
Firstly, we must break down silos and engage in intersectoral action with other humanitarian and development actors. The fact that there are no facilitators, or ‘meta-governors’ as it were, with a legitimate mandate to coordinate such action makes this a challenge, particularly when new actors to the sector are brought into the picture.
However, functioning and productive intersectoral partnerships are achievable, if all the actors within a country or setting agree to put aside their organisational agendas and philosophies, work towards a common goal, in a concerted manner in horizontal and vertical networks, and pool funds where possible.
Secondly, we must appropriate the Health in All Policies (HiAP) maxim, and adapt the philosophy behind the idea for use in fragile settings. This means that we must work more with non-health sector humanitarian and development actors to ensure that health is given systematic consideration before any policy and intervention is made and/or implemented.
It is a pragmatic approach that is usually overlooked in fragile settings because the focus is usually on security. However, during the emergency period, all the (non-health) actors who step in and provide some sort of governance in the absence of the state, do make decisions and implement policies and interventions which can have an impact on health.
This is even more flagrant during the reconstruction phase, where it is a case of ‘every man for himself’ in all the different sectors. It is easier to make health central when everything is being built or rebuilt from scratch, rather than to add it as an afterthought. It also makes it difficult for future governments to dismantle programmes if they are part and parcel of the national fabric (for example, the NHS in the UK).
We must, therefore, advocate a bottom up, joint sense-making approach from the get go, with all the stakeholders who are involved in state building, so that health will be central to all the decisions that are being made.
Thirdly, we must recognise the fact that ‘good enough’ governance in every domain would have more of an impact on health outcomes than ‘excellent’ governance in just the health sector; and this is particularly relevant in fragile contexts.
Finally, and perhaps most crucial of all, the global health community must learn to walk the tightrope between being bold and vocal about challenging bad governance. We must be pragmatic about the actor that has the capacity to deliver, as well as the concrete results that can be obtained in fragile contexts and emergency situations with partners present on the ground when action needs to be taken.
Clara Affun-Adegbulu, Kristof Decoster, Sara Van Belle and Willem van de Put from ITM Antwerp