Strengthening public health systems can help foster good governance, encourage reform, and improve stability in fragile settings, said Emmanuel d'Harcourt of the International Rescue Committee (IRC), at the fourth meeting in the Environmental Change and Security Program's Health, Population, and Fragility series. Harcourt was joined by fellow IRC colleague Lizanne McBride and Columbia University Professor Ronald Waldman to discuss best practices for conducting health work in fragile or post-conflict countries, as well as the potential impact of health systems on stability and security in rebuilding states.

The Value of Health Systems

Fragile governments often suffer from common problems—such as weak human resources, low absorptive capacity, and a lack of information on which to base effective policies—that impede their ability to implement critical public services like health care. Additionally, Waldman said, new governments often struggle to meet the demands of citizens who expect public services to resume after conflict ends. Failure to meet these expectations could allow conflict to reemerge: "There is a relatively limited window of opportunity available to convince people that they should make an emotional, a political, and a real investment in those fragile governments that take form following a tenuous peace accord, as is the case in the Democratic Republic of Congo (DRC), south Sudan, and Afghanistan."

Investing in health systems, Waldman said, presents a promising entry point to address these problems and strengthen the relationship between government and citizens.

In the DRC, for example, health systems are the strongest "relic" and one of the only sectors that continues to function well. Health systems are thus one of the avenues through which the public can demand—and receive—services from the transitional government. This process not only encourages citizens to invest in the new government, but can also lay the foundation of democracy and good governance. "We ought to recognize that it's an obligation of the health system not only to improve the health status of the population, but to work in such a way that it fosters better comprehensive governance."

From Service Delivery to Building Systems

In the past, donors have focused on the delivery of essential health services, principally due to the "unspoken argument" that larger health systems could not be implemented successfully in fragile settings, noted d'Harcourt. However, recent studies conducted by the IRC in Rwanda and southern Sudan challenged this assertion, concluding that fragile governments can administer effective health programs. In Rwanda, for example, government-supported health programs helped reduce the child mortality rate by 25 percent between 2000 and 2005. According to d'Harcourt, this reduction is evidence that health systems can be implemented in fragile environments: "You can put in systems. Why not do it in health? It is concrete, the population definitely supports it, and it's not that expensive."

But keep expectations realistic, Waldman warned: if governments had difficulty delivering health services prior to a conflict, there is no reason to believe a new government will have more success in this area. "Some things don't change," he said. He also stressed that investing in health systems will not be a stabilizing force unless governments have enough funding to implement programs on a national scale. Several international studies pointed out that donor investment in the health sector remains inadequate, prompting Waldman to conclude that unless funding levels are increased, health systems will not help stabilize fragile environments.

The IRC's new Institutional Program Framework aims to incorporate capacity building as a principal component of the organization's operations. Recognizing the need to build systems is a major shift in thinking, noted McBride, who stressed that stabilization in fragile settings requires strengthening governance at all levels, particularly at the community level. "It's insufficient to just meet basic needs and build institutions. If we don't do it in such a way that brings communities back together with their institutions, which is what conflict has destroyed…we won't be successful," she said. One significant challenge facing IRC is developing ways to measure progress on building institutions and social cohesion. While these indicators tend to be the hardest to define in a fragile or conflict setting, McBride nevertheless maintained that they can be developed by drawing on the vast amounts of information collected by the development sector on institution building.

Recommendations for USAID

Missions have a better chance of succeeding if all actors involved contribute and coordinate on national-scale system-building projects, said d'Harcourt. USAID is in a unique position to facilitate cooperation among local and international NGOs, host country officials, and beneficiaries operating in fragile settings. He argued that if USAID accepts the role of central coordinator, rather than operating alone in the field or implementing a single program, the organization will "function better" in post-conflict and fragile settings. D'Harcourt also urged the Office of U.S. Foreign Disaster Assistance (OFDA) to only issue long-term funding grants, arguing that short-term grants force programs to alter their strategic frameworks too frequently. In addition, he called for increased monitoring of costs and results of OFDA grants.

McBride stressed the need for USAID to support the development of sophisticated evaluation and data collection methods in the service delivery sector. Field donors still fail to understand the value of these methods and instead prioritize "peace dividends," she noted. McBride also called on USAID to demand that NGOs, including the IRC, base reports and proposals on more comprehensive data when operating in fragile environments. She emphasized that the IRC's efforts to collect data in fragile settings would be greatly assisted through close collaboration with USAID: "We have to work as partners."

Drafted by Ken Crist.