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This paper looks at some of the roles of non-state providers (NSPs) in providing health services in fragile states that are coming out of conflict, and the relationships of NSPs with state agencies. The authors argue that the most significant issue for both NSPs and donors in fragile states is the challenge of delivering services effectively while also strengthening the capacity of public institutions, where feasible, so that the state will have both the capacity for service delivery (even if not direct provision) and the willingness to be accountable to its citizens. This can be described as the ‘two-track problem’: balancing the urgent need for services with the long-term process of building effective and accountable public institutions.

To illustrate the above ‘two-track problem’, the authors present two examples of the role of health NSPs. These are contracting out basic health provision in Afghanistan, and financing health provision via the Multi-Donor Trust Fund in Southern Sudan.

The key findings of this paper are:

• relations between states and non-state providers in fragile states occur within specific complex political and economic contexts.
• donor approaches to specific fragile states shape the flow and priorities of aid resources. 
• in the health sector, fragile states have dramatically poor health outcomes, with higher mortality and morbidity rates than other low-income, relatively stable states.
  

To address the balance between state and NSP roles in fragile states, the authors conclude that in assessing the connections between health services and the roles of the state in fragile states, some of the key issues include: dynamics of the political settlement, approaches to connecting health services to health-system strengthening, donor aid instruments and, pre-existing and evolving roles of NSPs.

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