Working With Non-state Providers in Post-conflict and Fragile States in Primary Healthcare Service Delivery

Abstract

Home to at least a third of the world’s poor with the worst health indicators, post-conflict and fragile states are lagging in their efforts to achieve the Millennium Development Goals (Alliance 2008). Health services are predominantly non-state in most low-income countries, including those that have relatively effective governance, and the poorest strata of the population are more likely to use non-state providers (Palmer 2006, OECD 2006). An important area of focus for the review is to identify the role of the national government in regulating, coordinating and information sharing among public and nonstate providers, in settings where lack of regulation and organisation of health service provision are common characteristics of the health sector (Moran & Batley 2004). One of the primary reasons for supporting health service delivery in fragile states is that it is an entry point for triggering broader governance reforms (Berry et al. 2004). As such, the effectiveness of different modes of engagement and the scope of the desired outcomes are important research questions. A central theme in the literature is the dynamics between the immediate need to reduce vulnerability and achieve specific health outcomes versus longer term objectives of building sustainable health systems that promote equitable access to health. There is thus is a need for a review to address both the immediate and long term outcomes associated with health service delivery programs in fragile states (High Level Forum 2005). Despite the wealth of challenges, from poor health to extreme poverty and destroyed infrastructure, early strategic investment in the health sector during transition and postconflict periods can provide opportunities to re-align systems and introduce new service delivery models (High level Forum 2005). Effective government capacity-building to engage in essential tasks of leadership, planning, and oversight of a system based on primary care can lead to long-term returns in terms of the equity, efficiency, and effectiveness of the services provided (Macrae et al. 1996). It can also contribute to enhanced legitimacy of the state, known as the “peace dividend (Jones et al. 2006, Waldman 2006). While some researchers contend that there is too little empirical evidence of this effect to date (Rubenstein 2009), it is critical to thoroughly assess whether working with non-state actors has improved both health system capacity and health outcomes, and to examine where gaps in evidence remain.