Health service delivery in early recovery fragile states: lessons from Afghanistan, Cambodia, Mozambique, and Timor Leste

Health service delivery in early recovery fragile states: lessons from Afghanistan, Cambodia, Mozambique, and Timor Leste

Delivering health services in fragile states

The past decade has been marked by a global concern with the number of countries that are unwilling or unable to adequately ensure their people’s security and development needs. This case study explores some key themes in the emerging literature on service delivery in fragile states in light of the health sector experience in four early recovery countries: Afghanistan, Cambodia, Mozambique, and Timor Leste. The analysis considers the various impacts of foreign assistance on state stewardship of the health sector and the programming implications. The investigation starts with state effectiveness and legitimacy. Findings point to the importance of and structural impediments to donor harmonisation in re-establishing health services in a post-conflict context.

The document shows that United Nations (UN) coordination in all four countries was constrained by state avoidance strategies, a spike in aid flows that were out of sync with emerging government capacity, and, in Cambodia and Mozambique, an emphasis on highly visible but largely unsustainable infrastructure projects that were limited by the absence of a planning framework. Harmonisation and alignment of aid systems and accountability requirements were enabled through joint frameworks, common approaches, and trust funds that offered direct budget support that strengthened government systems, accountability, and a common policy framework in Afghanistan and Timor Leste. The authors show how capacity-building efforts have been limited by a restricted focus on skills building rather than power sharing and particularly a lack of control over resources. The document highlights that promising approaches to support state stewardship include: contracting with NGOs in Afghanistan and Cambodia, establishing equity funds in Cambodia and civil service performance-based reform in Afghanistan. There should be sectoral plans under discussion in all countries and significant budget support.

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