Health Systems Reconstruction and State-building Study commissioned by the Health & Fragile States Network Authors: Jack Eldon, Governance Specialist Catriona Waddington, Health Specialist Yasmin Hadi, Heath Specialist June 2008

Purpose of the study Explore interactions between health sector activities and state-building in fragile states Develop a conceptual framework about these interactions and conduct a preliminary field test

Methods Desk study Literature review Interviews Case studies: Sierra Leone Nigeria – Enugu and Kaduna States

Three linked definitions State-building - Organisational and institutional capacity - Legitimacy - Political processes to manage expectations - Access to resources Fragile states Health systems strengthening

Health sector activities and issues for state-building Health system building blocks Activity /inactivity in fragile states State building issues raised Service delivery Health workforce Information Medical products Financing Stewardship

HSS: Influences on state-building Balancing short-term and long-term Humanitarian vs development assistance Involvement of government staff Impact of contracting out

Evidence for state-building What is known about the links between the health sector and state-building? Health systems strengthening can contribute to state building in the health sector. Context is key influencer of potential for state-building, but inadequately understood. State-building is a fragile process and can be easily undermined. What is not known? We do not systematically understand the extent of state-building within the health sector – the evidence is generally anecdotal, inconclusive and shaped by sectional interests. There is little if any clear evidence on the relationship between health strengthening, citizen and government expectations and the social compact.

HSS and wider state-building Mixed opinions about health as an entry point Interactions between HSS and state-building may be more a pre-occupation of international community than of governments in fragile states Some capacity spin-offs though probably low potential – health a low-status ministry Probably more impact through decentralised systems and bottom-up approaches

Conceptual framework 1 Some health sector activities contribute to state-building in the health sector by: Strengthening state capacity Signalling state willingness to act positively on behalf of its citizens Creating legitimacy Improving the social compact Improving control over resources

Conceptual framework 2 State-building in the health sector has wider impacts through: Strengthening the capacity of other institutions and sectors Strengthening intergovernmental interactions at different levels of the state Social compact virtuous circle: citizens liking what they see greater legitimacy