State-building and human resources for health in fragile and conflict-affected states: exploring the linkages

Abstract

BackgroundHuman resources for health are self-evidently critical to running a health service and system. There is, however, a wider set of social issues which is more rarely considered. One area which is hinted at in literature, particularly on fragile and conflict-affected states, but rarely examined in detail, is the contribution which health staff may or do play in relation to the wider state-building processes. This article aims to explore that relationship, developing a conceptual framework to understand what linkages might exist and looking for empirical evidence in the literature to support, refute or adapt those linkages.MethodsAn open call for contributions to the article was launched through an online community. The group then developed a conceptual framework and explored a variety of literatures (political, economic, historical, public administration, conflict and health-related) to find theoretical and empirical evidence related to the linkages outlined in the framework. Three country case reports were also developed for Afghanistan, Burundi and Timor-Leste, using secondary sources and the knowledge of the group.FindingsWe find that the empirical evidence for most of the linkages is not strong, which is not surprising, given the complexity of the relationships. Nevertheless, some of the posited relationships are plausible, especially between development of health cadres and a strengthened public administration, which in the long run underlies a number of state-building features. The reintegration of factional health staff post-conflict is also plausibly linked to reconciliation and peace-building. The role of medical staff as part of national elites may also be important.ConclusionsThe concept of state-building itself is highly contested, with a rich vein of scepticism about the wisdom or feasibility of this as an external project. While recognizing the inherently political nature of these processes, systems and sub-systems, it remains the case that state-building does occur over time, driven by a combination of internal and external forces and that understanding the role played in it by the health system and health staff, particularly after conflicts and in fragile settings, is an area worth further investigation. This review and framework contribute to that debate.

Improving the resilience and workforce of health systems for women’s, children’s, and adolescents’ health

“…Strengthening and building up these capacities are pre-conditions for effective health service delivery, especially in fragile states and contexts with weak governance, where they may also contribute to broader state building efforts. 24 Improving the workforce Optimising the competence and capacity of the health workforce can bring key services, such as contraception, closer to communities and improve coverage of key interventions to reduce maternal, neonatal, and fetal morbidity and mortality from obstetric complications. The "obstetric transition" of sustainable development goal 3.1 requires a health workforce that can provide obstetric and newborn services and access to family planning.…”

Rebuilding research capacity in fragile states: the case of a Somali–Swedish global health initiative

“…The rebuilding of fragile states requires that citizens regain possibilities to take care of their families and live a life free from war and other threats [7], and that they can rely on at least a minimum level of shared responsibilities for basic, social, and health services across ethnic, social, and economic groups [7,8]. …”

“…In forming legitimate and trusted states, freedom from corruption, access to basic health and education facilities as well as security are fundamental [7–9]. Seven of the eight top-ranked fragile states globally are African, with Somalia as the most problematic case [8].…”

“…Seven of these indicators are related to factors for which access to higher education and research at universities can make a difference: group grievance, brain drain, uneven economic development, poverty and economic decline, state legitimacy, public services, and human rights and the rule of law [8]. Few factors are reported to be as important as basic health with access to health services if a state is to gain trust and achieve legitimacy among its citizens [7,9,10]. …”

Leadership Personality and Social Dis-integration in Somalia

“…Therefore, a context of war mongering created by colonial legacy and clannism can be seen as responsible for the collapse of the Somali social fabric. As posited by a large body of literature, the failure and collapse of the Somali state rest on two key factors: A history of bad leadership and a culture characterized by clannism [2,3,4,5,6,7,8,9]. Interestingly, on one hand, recent studies have indicated the transition of Somalia into a post conflict stage, which implies the need for Somalia to go through the post conflict reconstruction stages.…”