Aid coordination has assumed a prominent place on health policy agendas. This paper synthesizes the findings of research undertaken to explore the changing practices of aid coordination across a number of countries. It begins by reviewing the key issues giving rise to increased attention to aid coordination in the health sector. The second section describes, assesses and compares the strengths and weaknesses of the dominant mechanisms or instruments which were found to be employed to coordinate health sector aid in the case studies. From this analysis, four factors become clear. First, in many countries, coordination mechanisms have been introduced as a part of an incremental process of trying out different approaches--there is no one model that stands out at any one time. Secondly, some instruments function largely for consultation, predominantly coordinating inputs, while others are more directive and operational, and are used to manage inputs, processes and outputs. Third, many of the mechanisms have not excelled, although, fourth, it is difficult to judge the effectiveness or impact of aid coordination. It is therefore argued that concern with the effectiveness of aid coordination arrangements must give way to a broader analysis of the processes, outputs and outcomes governing the use of both external and domestic resources, focusing on institutional characteristics, the distribution and nature of influence among the actors, and the interests which they pursue through the aid regime. These factors varied considerably across the countries indicating that aid management is context dependent and subject to continuing changes. Finally, the paper looks at the findings in the light of the introduction of sector-wide approaches.

BackgroundDefinitions of fragile states focus on state willingness and capacity to ensure security and provide essential services, including health. Conventional analyses and subsequent policies that focus on state-delivered essential services miss many developments in severely disrupted healthcare arenas. The research seeks to gain insights about the large sections of the health field left to evolve spontaneously by the absent or diminished state.MethodsThe study examined six diverse case studies: Afghanistan, Central African Republic, Democratic Republic of the Congo, Haïti, Palestine, and Somalia. A comprehensive documentary analysis was complemented by site visits in 2011–2012 and interviews with key informants.ResultsDespite differing histories, countries shared chronic disruption of health services, with limited state service provision, and low community expectations of quality of care. The space left by compromised or absent state-provided services is filled by multiple diverse actors. Health is commoditized, health services are heterogeneous and irregular, with public goods such as immunization and preventive services lagging behind curative ones. Health workers with disparate skills, and atypical health facilities proliferate. Health care absorbs large private expenditures, sustained by households, remittances, charitable and solidarity funding, and constitutes a substantial portion of the country economy. Pharmaceutical markets thrive. Trans-border healthcare provision is prominent in most studied settings, conferring regional and sometimes true globalized characteristics to these arenas.ConclusionsWe identify three distortions in the way the global development community has considered health service provision. The first distortion is the assumption that beyond the reach of state- and donor-sponsored services is a “void”, waiting to be filled. Our analysis suggests that the opposite is the case. The second distortion relates to the inadequacy of the usual binary categories structuring conventional health system analyses, when applied to these contexts. The third distortion reflects the failure of the global development community to recognise—or engage—the emergent networks of health providers. To effectively harness the service provision currently available in this crowded space, development actors need to adapt their current approaches, engage non-state providers, and support local capacity and governance, particularly grassroots social institutions with a public-good orientation.

The bold decision was taken in Afghanistan in 2002 to provide donor-funded public health services by means of contracting-out of predefined health care packages. This study seeks to identify the extent to which progress has been made in public health services provision in the context of broader state-building agendas. The article argues that the provision of public health services was also intended to generate a peace dividend and to legitimize the newly established government. The widely portrayed success of the contracting model is backed up by very high official figures for health service coverage. This contrasts with evidence at household level, which suggests limited utilization of public health services, and perceptions that these offer inferior quality, and a preference for private providers. The dissonance between these findings is striking and confirms that public health care cannot remain immune from powerful market forces, nor from contextual determinants outside the health field.

Drawing on the case studies presented in this issue, from Bangladesh, Cambodia, Mozambique, Zambia and South Africa, and examples from other countries, this paper asks what general conclusions can be drawn about the management of external resources, and specifically what lessons could inform the future implementation of sector-wide approaches (SWAps) in the health sector. Factors constraining the management of aid by ministries of health are grouped under three themes: context and timing, institutional capacities and the interplay of power and influence in negotiations over aid. Two factors, often underplayed, were found to be important in facilitating management of resources: the inter-relationship of formal and informal relationships, and the extent to which incremental changes are tolerated. The main conclusion is that coordination and management of external resources is inherently unstable, involving a changing group of actors, many of whom enjoy considerable autonomy, but who need each other to materialize their often somewhat different goals. Managing aid is not a linear process, but is subject to set-backs and crises, although it can also produce positive spin-offs unexpectedly. It is highly dependent on institutional and systemic issues within both donor and recipient environments. In promoting sector-wide approaches the key will be to recognize context-specific conditions in each country, to find ways of building capacity in ministries of health to develop and own the future vision of the health sector, and to negotiate a realistic package that is explicit in its agreed objectives. The paper ends with identifying crucial actions that will enable ministries of health to take the lead role in developing and implementing SWAps.

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