External Actors and the Provision of Public Health Services in Somalia

Abstract

Concentrating on the health sector, this article argues that the provision of collective goods through external actors depends on the level of state capacity and the complexity of the service that external actors intend to provide. It shows that external actors can contribute most effectively to collective good provision when the service is simple, and that simple services can even be provided under conditions of failed statehood. Effectively delivering complex services requires greater levels of state capacity. The article also indicates that legitimacy is a key factor to explain variance in health service delivery. To demonstrate this, the article assesses health projects in Somalia. It shows that simple services—malaria prevention and tuberculosis control—are provided effectively in all three Somali regions, including the war‐torn South‐Central region. In contrast, the HIV/AIDS project only achieved substantial results in Somaliland, the only region with a comparatively higher level of state capacity, and failed in the South‐Central region and Puntland.

External Actors, State‐Building, and Service Provision in Areas of Limited Statehood: Introduction

“…The second part of the special issue concentrates on efforts by external actors to directly contribute to the provision of collective goods and services, such as access to clean water, sanitation, and nutritious food (Beisheim et al. 2014), public security (Hönke and Thauer 2014), and public health (Schäferhoff as well as Hönke and Thauer 2014).…”

“…To avoid circular reasoning with regard to our dependent variable, we consider output legitimacy with regard to two processes: Local domestic actors and communities might consider international actors as legitimate in anticipation of their performance or because they trust their knowledge and moral authority. Over time, a virtuous cycle might evolve in which the initial performance of external actors meets the expectations of local communities which then increases the formers’ legitimacy and, hence, their effectiveness (see articles by Beisheim et al. 2014; Matanock 2014; Schäferhoff 2014). …”

“…Highly institutionalized arrangements between external and domestic actors or—in some cases—provided solely by the external actors, can compensate for extremely limited state capacity and, thus, substitute for weak state capacity. At the same time, if there is at least some state capacity in areas of limited statehood, this can also help to foster successful service provision (see Schäferhoff 2014 on the quasi‐state Somaliland).…”

“…2014). HIV/AIDS treatment in Puntland and Southeast Somalia had no chance of success because engaging with the disease at all was regarded as illegitimate by key political actors and the population (Schäferhoff 2014).…”

Coping with Complexity: Internal Audit and Complex Governance

“…Wilson's analysis, quoted at length above, specifically points to the complexity and variable nature of governmental tasks, a concern resurfacing, for instance, in more recent research on the variable success rates of policies (Schäferhoff, 2014) and on task-diversity in governance (Van Thiel, 2012). The sheer number and variety of governmental tasks have steeply increased since Wilson's time.…”