Emergent health services in failed states: Can we build capacity but include the informal sector?

1. Emergent health services in failed states: Can we build capacity but include the informal sector? Peter S Hill, Associate Professor, Global Health Systems School of Population Health

2. The research • The provision of health services in failed states • Danida funded research • Core team specialising in post-conflict states: • Enrico Pavignani • Marcos Michael • Maurizzio Murri • Peter Hill • Team supplemented for specific cases

3. The case studies • Afghanistan: historically resistant to state building, clan based, unstable • Central African Republic: ‘l’état phantôme’ limited post colonial state development • Democratic Republic of the Congo: ‘The Congo does not exist’ – challenges of a state with diverse peripheries and no core

4. The Case Studies • Haïti: a state in perpetual ensekurite – earthquakes, cyclones, disease outbreaks, political instability: ‘routinized ruptures’ • Palestine: the ‘state-in-waiting’, paralysed by internal factions and international politics • Somalia: the economy with no apparent recognition of a state, nor of borders

5. Emergent themes • The limits of state governance and services • Unique contributions of context, history, culture • The non-linear relationships between development assistance and systems capacity • The extraordinary activity of non-state actors • Proliferation of atypical facilities and services • Redundant, duplicated, unbalanced services

6. The limits of the state • CAR: ‘l’état se termine à PK12’: essentially little state infrastructure beyond Bangui • Haïti: MSPP has direct control of only 15% of sectoral health facilities. 60-80% managed by NGOs, faith-based organizations. Decentralised responsibilities to the Départements but limited resources. 47% of population have no access to health services.

7. The limits of the state • DR Congo: ‘the state is so present, but so useless’ (Trefon, 2009). • Government health expenditure lowest in Africa, Kinshasa dominates periphery • Uneven distribution of funding • Administration fed from user fees • Afghanistan: contracting-out promoted since 2002, but provides only 20% of services

8. Context, history and culture • Haïti: exceptional history of independence, but crippling reparations. Bossale-Créole tensions replicated colonial tensions, and may explain resistance to economic drivers. • Palestine: factional chaos, Israeli conflict, international assistance has resulted in rich complex uncoordinated services, but ideally adapted to unpredictable impact of conflict.

9. Context, history and culture • Afghanistan: significant attrition of services under Taliban; current state services delegated through contracting to NGOs; ambiguous military presence in health sector • Somalia: strong merchant culture with extensive Somali ethnic presence in both Kenya and Ethiopia; active links to diaspora: Nairobi, Toronto, Dubai

10. Development assistance & capacity • Haïti: ‘inverse relationship between assistance and state building’ due to urgency of disaster response, overwhelming resources, limits of state authority, mal-distributed investment. • Palestine: highest per capita development assistance, MoH ineffective in governance and stewardship, diverse service networks locally and internationally. Strong factional divisions.

11. Development assistance & capacity • Somalia: Market approach makes it difficult to quantify extent of development assistance. Entrepreneurial private sector ‘capacity’ clearly evident, but little public health service delivery – polio campaign an exception. • Afghanistan: massive investment in state-building but limited control, or central governance of service provision

12. Extraordinary activity of non-state actors • Haïti: ‘100%’ access to traditional medicine. Strong NGO, FBO presence, often with direct international links. Direct, largely unregulated importation/sale of drugs. Diaspora provided health services. Few private Doctors. • Afghanistan: Despite Contracting-out, extensive growth of non-regulated private sector with high out-of-pocket expenditure.

13. Extraordinary activity of non-state actors • Somalia: emergence of for-profit facilities (eg 6 Faculties of Medicine) in absence of state provision; regional pharmaceutical markets; cross border health seeking • DR Congo: historical FBO dominance, but significant increase in private facilities, esp in cities (75% in Lubumbashi). 30 private medical faculties cf 3 government.

14. Emergent services • Palestine: factional divisions, multiple sources of funding (Islamic charities important) result in multiple unregulated, uncoordinated services – but often perversely appropriate (eg midwives). • Somalia: unexpected services in telemedicine, with network of international consultations and local prescribing and supervision. Cross border access into Kenya, but also internationally.

15. Emergent services • Haïti: Fly in/fly out clinics, often FBO. Strong international links for some centres. Diaspora provided health services mean unplanned provision of specialised care. • DR Congo: emergence of private, ‘intermediate’ facilities, lacking full capacity. Cost-driven multiplication of pharmaceutical procurement and supply.

16. Where to from here? • These are ‘wicked’ environments. • Returns on state unpredictable and non-linear. • The informal sector rarely addressed, but occupies large proportion of service provision. • Issues of quality, equity, coordination, accountability, inexperience in this sector. • Requires deep local knowledge and networks, responsive, flexible approaches – but high risk.