News & Commentary

01 November 2017

The World Development Report 2017 and health systems in fragile and conflicted affected states

By Stephen Commins, Associate Director for Global Public Affairs and Lecturer in Urban Planning at the Luskin School of Public Affairs at UCLA. Stephen's recent work has focused on fragile states, disasters, and basic service delivery. He was previously Senior Human Development Specialist in the World Bank’s Human Development Network and was a consultant on the WDR 2017.

The World Development Report 2017 (Governance and the Law) (WDR17) set out to provide a framework for addressing governance failures. But what more is needed to ensure governance enables health systems to operate better in fragile and conflict affected states?

The Report frames governance as a dynamic process between three constitutive elements: formal state institutions, the way those state institutions operate on the ground (i.e. how they solved society’s problems, how they provide incentives for people to cooperate with each other as well as with the state) and the power structure and norms (i.e. the interest in social norms echoes the approach of World Development Report 2015, ‘Mind, Behavior and Society’).

It focuses on the ability of the state to make credible commitment and promote cooperation and collective action for achieving growth, equity and security. This approach contrasts with a normative approach, i.e. the “you should” genre. Experience shows that poor countries can make a lot of development progress with highly imperfect institutions (function versus form). Part of the central goal of the WDR17 was to understand the historical drivers for institutional reforms that establish and grow ‘checks and balances’ institutions.

Governance does not exist in a vacuum

The Report recognized that there are issues that are deeply rooted in the history of each society and state, not only the concept of fragile states, but also the citizens’ experience of the failure of services, such as health, and the breakdown of trust and social cohesion. This breakdown makes trust, transparency and participation difficult concepts to convey or implement.

In reflecting on the Report’s approach to governance as a dynamic process, it led me to wonder if governance should be thought of as a verb, that is, it is management of a collection of moving pieces. Considering fragility as never static, the provision of health services and the rebuilding of health systems takes place within dynamics of change. In each location, governance is always evolving.

Addressing health needs, both short-term and medium term, means recognizing that governance involves the interplay of the bureaucratic, political and tradition. The interplay of actors and institutions in terms of health and fragility means that we need to consider HOW things are done, and not just WHAT is done.

It isn’t necessarily what you do but how you do it

The WDR17 highlighted the importance of looking at function rather than form. Donors have a long history of focusing on form, but for health services in fragile and conflict-affected states (FCAS), perhaps we need to give more attention to starting with the current functioning of the health ‘system’, however hydra-headed and multi-faceted it may be.

Some key questions to consider could be:

  • What is the reality of attempts at institution-building in FCAS, including role of donors?

  • What practical lessons can be drawn from different experiences?

  • What does function rather than form mean in practice?

  • How can donors play a more effective role?

One way to ground the WDR17 insights for service delivery is to connect it with the six-year project undertaken through the Overseas Development Institute, the Secure Livelihoods Research Consortium. This project generated some basic lessons in how to implement good governance change in FCAS and if we apply this to health systems in FCAS there are some clear lessons:

  • From the start, top-down health reforms should be supported by bottom-up, citizen-inclusive efforts to build transparency and accountability. Some of these processes may need to be exploratory and done in preparation for more formal accountability work, but without it, health reforms may fail.

  • Top-down technical reforms may be essential to basic state building in FCAS, but the health service delivery processes that are needed to support them, are best be built from the bottom up.

  • In many FCAS, resource allocation lies at the root of the conflict. Until questions of allocation are addressed between competing groups, trust with the state or between communities will be elusive.

  • Without some health service delivery benefit, people are likely to lose faith in more technical reform processes. Central government technical reforms (which appear distant or distinct from service delivery), should therefore be linked with changes, both nationally and locally, that are more likely to result in health service delivery improvements.


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