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The “Appalling” Reality of Health in Fragile States

The urgency and political complexity of improving health in fragile states was discussed at LIDC  during the launch of a new online resource exploring the topic. Speakers from academia, government and the charity sector referred to the Health and Fragile States Dossier as they analysed the immense problems of working in difficult contexts. They suggested strategies to improve health and also challenged assumptions about state-building and peace-building at the event on 18 June.
Weak health systems
Egbert Sondorp, Senior Lecturer in Public Health and Humanitarian Aid at the London School of Hygiene and Tropical Medicine (LSHTM) and one of the contributors to the dossier, outlined the “appalling” health in “fragile states” – a term describing countries where governments  cannot or will not deliver basic functions to the majority of their people, including the poor. He highlighted the weakness of health systems in these countries and how they are lagging far behind regarding the Millennium Development Goals (MDGs), immunisation rates and access to drinking water.

Sondorp explained how NGOs often deliver health services in fragile states, but not according to an overarching government plan. He also emphasised the lack of funding, its volatility and its grossly uneven distribution: in 2006 half of Overseas Development Assistance (ODA) benefited only five out of 38 fragile states. His suggestions included keeping health on the agenda during today’s global financial crisis and he warned that the cost of not engaging in fragile states is higher in the long term. He outlined the contents of the dossier, which appears on the Eldis website, explains why fragile states are a priority and charts recent initiatives to improve health systems.
Politics matters
Natasha Mesko, of the Politics and State Team at the UK Department for International Development (DFID), focussed on the importance of politics as she discussed service delivery, legitimacy and the interaction between state and society. She spoke of the connections between state-building and peace-building – linkages which will be described in the upcoming 2009 White Paper on International Development.  She added there is “no substitution for peace” in fragile states.  Her talk warned of national elites liaising with their local counterparts rather than with the poor, and the strength of perceptions in developing countries regarding aid.  Considerations she raised included minding the gap between humanitarian relief and the onset of development aid, supporting human resources and infrastructure and knowing the target population. By 2010, Mesko said, 60 per cent of DFID’s bilateral aid will be for fragile states.
Challenging assumptions
Dr Jonathan Goodhand, Senior Lecturer in Development Practice at the School of Oriental and African Studies (SOAS)
questioned many of the assumptions regarding fragile states. He stressed the need to differentiate between different types of fragility, such as the reality in Afghanistan and Sri Lanka. Goodhand also contested the assumed reciprocity of state-building and peace-building by saying state-building is a “highly conflictual process.” Likewise, he challenged the common idea that fragile states and conflict are internal/domestic problems with external/international solutions. Goodhand said: “International actors may actually be a destabilising factor. Domestic rulers such as Karzai (President of Afghanistan) face a dual legitimacy problem in the sense that they have to simultaneously manage accountability pressures from international and domestic constituencies." He also warned that contemporary state-builders may need to develop new skills and capacities in order to intervene effectively, and, compared to their imperial forbears, their understanding of the local context may be relatively shallow.
Collender, G. (2009) 'Strengthening the Focus', Public Service Review: International Development 14


Health and Fragile States Network, HDI and Eldis (2009) Health and Fragile States Dossier

Health and Fragile States Network