Health governance in fragile states Lessons from early recovery fragile states…. Laurie Zivetz, MPH, PhD

STATE LegitimacyEffectiveness Compact/Policies Health Systems Consumers Marketplace Adapted from World Development Report, World Bank Civil Society/Voice Elements of state building

Assumptions: 1.Effectiveness + legitimacy = governance 2.Development assistance can have greater impact on effectiveness 3.Stewardship begins with a regulatory role

ClientsProviders Humanitarian Agencies State 1. Post conflict humanitarian assistance circumvents the state

2. External resource flows out of sync with absorptive capacity; planning frameworks

3. Emergence of two tracks Relief bureaucracies stay too long, or morph into rebuilding functions Non state actors control disproportionate resources Talent, decisionmaking gravitates to resources

Why do rebuilding efforts rely on non state actors? 1.Accountability and capacity concerns 2.Political considerations

4a. Rebuilding efforts benefit from coordination Coordination and planning Rand, 2006

Compact Voice Services Responsiveness TA $ Trng Providers Information and reporting Clients/Citizens Client power State: Politicians and policymakers TA Trng TA $ / Trng Trng Trng/TA Trng $ / TA TA $ $ KEY: TA=Technical Assistance $=Funding Trng=Training 4b. Fragmentation overwhelms already fragile states

5. Leaving too soon Staying for a long time does not always guarantee success; leaving early assures failure.

Supporting state stewardship in health 1.A common donor framework for planning and action 2.A lead actor 3.Funding mechanisms that support a coherent, state-led approach 4.Donor alignment with government systems 5.Realistic, reliable aid flows

Directives/oversight Resources and reporting Responsiveness/reporting Voice/compact Aid agencies Recipient state Responsiveness/reporting Donor state 6. Standing the model on its head: Reciprocal accountabilities to build governance