State-building agenda and health

There is an increasing emphasis on state-building when working in fragile states. State-building can be defined as activities that strengthen organisational and institutional capacity (for example to make and enforce policies, ensure the implementation of state-sponsored programmes), ensure state legitimacy, enhance access and allocation of resources and strengthen political processes to manage expectations (the social compact between state and its citizens).

Key to state-building endeavors is building governance structures and processes that address inequities and inequalities, and promote accountability. Delivery of basic services, including health, is seen to be one way of promoting the social contract between society and state, and therefore enhancing governance and ultimately state-building. However, the dynamics of this interaction are not well understood.

One hypothesis is that rebuilding health systems strengthens the social contract between state and society and contributes to state-building. Building health systems contributes to wider state-building by helping to strengthen state capacity and signaling the increased willingness of the state to act on behalf of citizens in a responsive and accountable manner. This generates enhanced support for the state in return (legitimacy) and a stronger social compact between state and society. Furthermore, the planning, management and delivery of health services contributes to capacity beyond the health sector.

Preliminary evidence suggests that health sector strengthening can contribute to state building in the health sector. It can help build legitimacy and capacity, and put health on the state-building agenda. However, the impact of health sector interventions on wider state-building is unclear. There may be more scope for wider state-building and strengthening the state-society compact through decentralised and ‘bottom up’ approaches, though this needs to be verified. Caution is thus urged in using development aid for health for discrete state stabilisation programmes.