The “empty void” is a crowded space: health service provision at the margins of fragile and conflict affected states

Abstract

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.

Current state of pharmacovigilance in the Arab and Eastern Mediterranean region: results of a 2015 survey

“…The pattern of health systems focusing efforts on national healthcare treatment needs rather than on prevention and public health is well documented . In the contexts of Palestine, Lebanon, Somalia and Afghanistan, reliance on international aid and political instability further hamper efforts at mobilizing for health reform policies such as pharmacovigilance . International aid is by nature prone to politically motivated shifts which may not reflect the unique needs of the population.…”

“…[11] In the contexts of Palestine, Lebanon, Somalia and Afghanistan, reliance on international aid and political instability further hamper efforts at mobilizing for health reform policies such as pharmacovigilance. [12,13] International aid is by nature prone to politically motivated shifts which may not reflect the unique needs of the population. A lack of coordination and accountability between disparate providers and agencies leads to duplicative and fragmented efforts.…”

An Emerging, Post-Neoliberal Power: The Practice of Brazilian South-South Cooperation in Haiti

“…Multiple scholars (see Carment, Prest & Yagadeesen, 2010;Hill, Pavignani, Michael, Murru & Beesly, 2014;Nay, 2013), even those who think the fragile state concept still has analytical merit, argue that it has been used without precision, applied to what are very different challenges, such as civil conflict versus poor socio-economic conditions. For example, Carment, Prest and Yagadeesen (2010) note that failed states are only one way in which the more general term fragile state can be broken down; they also add: weak states, collapsed states, difficult partners, difficult environments, and Low…”

“…By identifying the roots of failed states, interventions like those to promote democracy sought to built up the state through technocratic fixes, such as by improving the judiciary (Burron & Silvius, 2013). Similarly, when understood as a lack of capacity to deliver public goods, then interventions are premised on the assumption that they can help the state to regain this capacity (Hill et al, 2014). (Nay, 2013).…”

“…My view is thus an extension of Baranyi's (2012) challenge to consider the historical constitution of Haiti's state fragility by acknowledging the importance of external actors. Hill et al (2014) further add that a more adequate analysis of fragility would involve seeing beyond the state as a void, and recognizing how binaries, such as public/private or formal/informal, are inadequate for examining service provision in similar contexts.…”