1. Emergent health services in failed states: Can we build capacity but include the informal sector? Peter S Hill, Associate Professor, Global Health Systems School of Population Health

2. The research The provision of health services in failed states Danida funded research Core team specialising in post-conflict states: –Enrico Pavignani –Marcos Michael –Maurizzio Murri –Peter Hill Team supplemented for specific cases

3. The case studies Afghanistan: historically resistant to state building, clan based, unstable Central African Republic: ‘l’état phantôme’ limited post colonial state development Democratic Republic of the Congo: ‘The Congo does not exist’ – challenges of a state with diverse peripheries and no core

4. The Case Studies Haïti: a state in perpetual ensekurite – earthquakes, cyclones, disease outbreaks, political instability: ‘routinized ruptures’ Palestine: the ‘state-in-waiting’, paralysed by internal factions and international politics Somalia: the economy with no apparent recognition of a state, nor of borders

5. Emergent themes The limits of state governance and services Unique contributions of context, history, culture The non-linear relationships between development assistance and systems capacity The extraordinary activity of non-state actors Proliferation of atypical facilities and services Redundant, duplicated, unbalanced services

6. The limits of the state CAR: ‘l’état se termine à PK12’: essentially little state infrastructure beyond Bangui Haïti: MSPP has direct control of only 15% of sectoral health facilities. 60-80% managed by NGOs, faith-based organizations. Decentralised responsibilities to the Départements but limited resources. 47% of population have no access to health services.

7. The limits of the state DR Congo: ‘the state is so present, but so useless’ (Trefon, 2009). –Government health expenditure lowest in Africa, Kinshasa dominates periphery –Uneven distribution of funding –Administration fed from user fees Afghanistan: contracting-out promoted since 2002, but provides only 20% of services

8. Context, history and culture Haïti: exceptional history of independence, but crippling reparations. Bossale-Créole tensions replicated colonial tensions, and may explain resistance to economic drivers. Palestine: factional chaos, Israeli conflict, international assistance has resulted in rich complex uncoordinated services, but ideally adapted to unpredictable impact of conflict.

9. Context, history and culture Afghanistan: significant attrition of services under Taliban; current state services delegated through contracting to NGOs; ambiguous military presence in health sector Somalia: strong merchant culture with extensive Somali ethnic presence in both Kenya and Ethiopia; active links to diaspora: Nairobi, Toronto, Dubai

10. Development assistance & capacity Haïti: ‘inverse relationship between assistance and state building’ due to urgency of disaster response, overwhelming resources, limits of state authority, mal-distributed investment. Palestine: highest per capita development assistance, MoH ineffective in governance and stewardship, diverse service networks locally and internationally. Strong factional divisions.

11. Development assistance & capacity Somalia: Market approach makes it difficult to quantify extent of development assistance. Entrepreneurial private sector ‘capacity’ clearly evident, but little public health service delivery – polio campaign an exception. Afghanistan: massive investment in state- building but limited control, or central governance of service provision

12. Extraordinary activity of non-state actors Haïti: ‘100%’ access to traditional medicine. Strong NGO, FBO presence, often with direct international links. Direct, largely unregulated importation/sale of drugs. Diaspora provided health services. Few private Doctors. Afghanistan: Despite Contracting-out, extensive growth of non-regulated private sector with high out-of-pocket expenditure.

13. Extraordinary activity of non-state actors Somalia: emergence of for-profit facilities (eg 6 Faculties of Medicine) in absence of state provision; regional pharmaceutical markets; cross border health seeking DR Congo: historical FBO dominance, but significant increase in private facilities, esp in cities (75% in Lubumbashi). 30 private medical faculties cf 3 government.

14. Emergent services Palestine: factional divisions, multiple sources of funding (Islamic charities important) result in multiple unregulated, uncoordinated services – but often perversely appropriate (eg midwives). Somalia: unexpected services in telemedicine, with network of international consultations and local prescribing and supervision. Cross border access into Kenya, but also internationally.

15. Emergent services Haïti: Fly in/fly out clinics, often FBO. Strong international links for some centres. Diaspora provided health services mean unplanned provision of specialised care. DR Congo: emergence of private, ‘intermediate’ facilities, lacking full capacity. Cost-driven multiplication of pharmaceutical procurement and supply.

16. Where to from here? These are ‘wicked’ environments. Returns on state unpredictable and non-linear. The informal sector rarely addressed, but occupies large proportion of service provision. Issues of quality, equity, coordination, accountability, inexperience in this sector. Requires deep local knowledge and networks, responsive, flexible approaches – but high risk.