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

The conceptual framework (Figure 1) starts with state-building as an end-point. It was not a focus to probe the concept of state-building in itself; however, it has to be recognized that this is a disputed concept. Fukuyama [8] defines state-building as the creation of new government institutions and the strengthening of existing ones. He argues that in building states it is important to consider the scope and the strength of the state. The scope of the state refers to the different areas in which the government is able to produce policies and define interventions while its strength is the ability to enforce these policies or to implement these interventions successfully [9]. This is the broad approach used in this paper.

While state-building is often presented as a neutral concept, others have pointed to the inherently political nature of the project and to the fact that building of states can mean reinforcement of oppressive regimes. This includes the role that HRH (the subject of our study) may play in this process. There is a great wealth of historical literature on how colonial medicine and health services, through the medical workforce, contributed to establishing unfair and coercive states [10,11]. Lyons [12] gives a particularly compelling example with the case of “sleeping sickness” prevention in 1900–1940 Congo, which facilitated the building of the colonial state. This example, which echoes other cases around the world, highlights the fact that strengthened human resources in health can also become, through the health system they service, accomplices of the building of oppressive states (to which they bring legitimacy).

Other critics have taken issue not so much with the overall goal of state-building as with its realism, with externally driven, short-term programmes unlikely to create the robust institutions needed to “build” a state [13]. They argue that there is limited evidence of the efficacy of state-building and that indeed it may be counterproductive, undermining the very social legitimacy it is intended to support [14,15]. This point is echoed in empirical work by economists on modern state-building (especially in relationship to aid) that underlines the need for both iterative and localized solutions to institution- and capacity-building [16] and the fact that the “the macroeconomic framework [that aid and donors bring in is] in general much too complex for the available human resources” [17].

However, it should be noted that this critique is aimed at external interventions, and in this paper, we take the concept at its broadest, to include and indeed focus on internally driven processes.

Our framework identifies three core areas which are hypothesized to contribute to state-building, which are (1) capacity and willingness to provide core services to the population, (2) legitimacy, and (3) providing security and stability. These are broadly supported within the political sciences and economics literature [18]. In particular, Brinkerhoff [19] argues that “governance reconstruction” in failed states and post-conflict societies is articulated around three dimensions:

As the OECD argument on the linkage between effectiveness and legitimacy shows, these three dimensions seem necessarily closely linked. This constitutes the base of the “whole-of-government” approach that the OECD and many donors are increasingly adopting in their intervention in post-conflict and fragile settings, integrating defence, diplomatic and development agencies [21-23]. The donors’ literature generally identifies the same [24] or similar three dimensions of state-building; the World Development Report 2011, for example, stresses the ability to provide security, justice and jobs [25], while the Department for International Development (DFID) focuses on political settlement and processes, core functions and expected functions [26].

Other authors (see, for example, [27]) make a slightly different analysis of state-building, differentiating between constitutive and outputs domains. Constitutive domains include political settlement and regime, security, rule of law, administrative governance; while output domains include service delivery (health, education, utilities, etc.), justice system and processes and economic governance. Similarly, Haider [7] makes an interesting distinction between tangible and intangible aspects of state-building. The first group includes actions such as demobilizing soldiers, restoring infrastructure, building institutions and providing services, while the second includes promoting positive state–society and intra-society relations; restoring/generating trust in government, public institutions and among citizens; and fostering socio-political cohesion.

Based on this review of the theoretical literature on state-building, we identify two possible pathways through which the legitimacy of a state may be increased with reference to HRH:

In a sense, these pathways could be seen as pertaining, respectively, to the tangible and the intangible aspects of state-building described above.

HRH development clearly intersects with state-building via a wider web of human, institutional and economic development. State-building per se is a relatively recent concern for economists, who have, however, been interested in the role of institutions and human capital in economic growth and development for a longer time [28]. There is a well-established literature on the role of what economists call human capital, often narrowly understood as (formal/school) education, in generating economic growth through innovation and gains in productivity [29-31]. Economic surplus and growth are, in turn, perceived as fundamental elements for the emergence of states, which are deemed as resting on the protection of productive economic interests (especially security) in exchange for taxation [32]. Contrary to post-war growth theories [33], recent neo-classical growth theories argue that human rather than physical capital is the lead engine of growth [34].

However, institutional economics and especially the influential work of Acemoglu and Robinson [35] tend not to put human capital at the centre of (state) development. “Good institutions”, which equates to inclusive ones, matter much more than human capital and are also not necessarily the product of higher human capital, argue for instance Acemoglu et al. in [36]. Similarly, economic historians such as Khan [37] challenge the mainstream understanding of human capital, showing that in the building of Western European states ad hoc “commonplace skills and entrepreneurial abilities to resolve perceived problems” matter much more than formal and deep technical knowledge.

Most theoretical and applied economists nonetheless agree on the idea that support of human capital development is one of the state’s key functions [38,39]. They assume that strengthened human capital has positive impacts on markets and growth, although this impact may not always be visible in the short run. The latter, as well as “weak constraints on the ruling group” and “political instability”, lead theorists [38,40] to argue that weak states have very little incentives for investing in human capital and may develop human resources (and other investments) “outside of state structures”.

On their side, historians advance the nature of the political and professional elite as an explanatory factor for state-building. Looking at the cases of Brazil and Chile, de Carvalho [41] shows that a common ethos among the elite as well as social and ideological homogeneity favoured the consolidation of effective political power and the building of these states outside of Spanish and Portuguese rule. However, this homogeneity can quickly lead to a dead end as power is not being redistributed. This is also the point of Waldner [42], who looks at successful development stories in the 20th century and identifies broad coalitions of the existing human resources as necessary for sustainable development. The importance of the civil servants’ ethos and ideology in the building of the state is highlighted by many other authors, including Anderson [43] who works on early modern Germany. It is more generally reflected in the distinction between nation- and state-building (the latter is stripped of the ideological dimension).

This leads to the case of the “illiberal state-building” of Angola, where the elite is invoking, among others, the lack of human resources to justify a different state-building “in defiance of liberal peace precepts on civil liberties, the rule of law, the expansion of economic freedoms and poverty alleviation” [44]. De Oliveira, in company with most historians and economists, is doubtful of the real commitment of predatory elites to human resource development.

The connection between the civil service and the citizens is identified by historians, such as Olowu [45], as a key factor for effective state-building as it should enable adequate goods, services and efficient markets. Looking at the argument the other way round, he highlights that “the disconnection between the state and society is one of the fundamental causes of the crisis of the African state and its civil service systems”.

In FCAS, governments struggle to mobilize, manage and distribute health resources. Often, health care is delivered either through public health services or by contracting out to third parties (e.g. NGOs). For example, in post-conflict Sierra Leone, health services were provided through public facilities [46], while in Afghanistan [47] and initially in Timor-Leste [48] NGOs were contracted to provide health services to the population (see Tables 1 and 2). Sometimes, particularly during the early stages f post-conflict, NGOs deliver services in areas where security is still volatile while government covers urban and more secure areas. This is, for example, the case of South Sudan where NGOs were reported to deliver 84% of health care services, while government took responsibility for the other 16% [49].

While delivering services through third parties is suggested to undermine a government’s legitimacy by some authors [50], others maintain that whether there is a loss of legitimacy or not depends on the role that the state plays on coordinating the work of NGOs or other private providers. In Afghanistan, the MoPH developed national health workforce policies including HR management systems. However, as capacity for health service delivery is still limited, the MoPH signed contracts with NGOs allocated to provinces, and NGOs are bound by a formal contract to deliver a Basic Package of Health Services (BPHS) at the provincial level [51]. This shows some control over the NGOs’ work by the MoPH [2]. A similar strategy was used in Cambodia [52]. In both cases, the state retains its stewardship role and is seen as responsible for the provision of services; therefore, its legitimacy should not be affected. In Timor-Leste, the European Union shifted from funding NGOs directly to funding them via the government, allowing the Ministry of Health (MoH) to sign contracts with NGOs detailing a list of services that they had to deliver at the district level [53]. As security improved and the transitional government was in place, in 2001, the government took over the management of health services and staff from NGOs, while requesting NGOs to continue providing technical and logistical support. How much each different strategy (e.g. direct public provision or commissioning/contracting out) contributes to improve the legitimacy of the emerging government is again difficult to ascertain, and there is no empirical evidence of the linkage of the type of service provision with state legitimacy.

The training and deployment of community health workers (CHWs) is often chosen as a means to ensure service provision in remote areas, which in turn is hypothesized to show willingness of the emerging government to provide services for all, hence contributing to state-building. It is reported that the introduction of teams of CHWs increased access to antiretroviral therapy in remote areas of Mozambique [54]. Similarly, in Afghanistan, CHWs—more than half of whom are women [55]—arguably contributed to strengthen the health system by expanding accessibility to TB and maternal, neonatal and child health (MNCH) services [56]. In Pakistan, the Lady Health Workers programme also reportedly improved access to and utilization of MNCH services [57]. The fact that these CHWs contributed to increased acceptability of health services may have promoted the image of the government as willing to provide services to their constituencies. However, in the case of Pakistan, the popularity of the programme was attributed to the support received from the Prime Minister, who strongly promoted this strategy, which demonstrates the possible two-way links between politics and HRH investments. Whether CHWs are integrated in the national workforce with a specific role or contracted by NGOs and therefore working more independently may influence their impact on state-building.

During early post-conflict interventions, donors and governments often need to show quick results, and priorities may follow externally driven political objectives rather than health needs. Priority is then given to the rehabilitation of the more visible physical infrastructures, such as tertiary hospitals, and peripheral structures that serve people who have less access to health care and often greater health needs are neglected. Similarly, in HRH, priority for rehabilitation of the different cadres may not be guided by equity concerns: the medical workforce is sometimes prioritized above the nursing workforce, despite the fact that nurses are the main providers of basic services, particularly in more deprived areas where the population most in need lives [58]. For example, in Cambodia, nurses and midwives trained before the war were retrained as doctors. This took the experienced HWs of these cadres away from their original professions, causing an over-production of doctors and medical assistants. Moreover, pressures were in place to abandon training of assistant-level nurses and midwives in favour of training diploma nurses, who often then ended up working in the private sector^a.

Periods of post-conflict are often said to open windows of opportunity to improve the efficiency of existing institutions as resistance from politicians and civil servants is often less intense than during periods of stability. In Timor-Leste, an inflated nursing workforce during the Indonesian times was reduced from more than 3 000 to 1 400 after the conflict [53]. In Mozambique, the MoH removed around 2 000 ghost workers from the payroll in the early 2000s [55]. Pavignani and Colombo suggest that the reconstruction process represents a unique opportunity to improve equity in human resources within the health system [59]. The precise timing of this window of opportunity can vary; a study of HRH policy in Sierra Leone found that the window for reform opened not in the immediate post-conflict period, when capacity and authority were still limited, but after some years, when government and donor commitment coalesced around reforms linked to the Free Health Care Initiative [46].

Despite these examples, it has been shown, however, that in many countries affected by conflict the government is often not able to provide health services. Therefore, networks of formal and informal health workers with different backgrounds and skills emerge to provide different services demanded by the population [60], including training [55].

The reintegration of “civil service personnel” of opposing factions may play a relatively important role in reconciliation and peace-building. In a review of the DDR process of Ethiopia, Colletta et al. [61] find that, among all the activities carried out to reintegrate ex-fighters, only HWs have a special status (1 400 ex-combatant health workers were employed by the MoH at the end of the conflict). In Sierra Leone, there are descriptions of how a polio campaign and EPI vaccinations became an entry point for the negotiations with the Revolutionary United Front (RUF) rebels towards the end of the conflict in 2000–2001 for the delivery of health services behind rebel lines. In terms of HRH, “training and implementation of the exercise had a 60% RUF, 40% MOHS personnel” [62] and it was key to involve local (qualified and unqualified) personnel from the communities. The “combat medics” who were providing services for the RUF and for the population behind rebels’ lines had little or no formal qualification. Initially, they were included in the campaigns only for the social mobilization aspects. However, the “combat medics” themselves later demanded to be included as vaccinators and were eventually trained by the District Health Management Team (DHMT). Later on, they were mostly employed to carry out vaccinations in the border areas between Sierra Leone and Guinea which were still unsecure. The collaboration between DHMT/government HWs and RUF combat medics is often stressed as one of the keys of the success of the campaign and the subsequent beginning of MoH provision of health services in the Kailahun district^b. At least in the informant’s experience, deployment of HWs hired and paid by the MoH in all districts, reintegration and training of “HWs” (including the unqualified ones) formerly working with the rebels and local recruitment all played a key role in reinforcing and entrenching the health systems in rebel-affected areas.

Balladelli et al. [63] suggest that investment in addressing integration of military health workers requires substantial political and financial efforts but that it is greatly justified. In Angola, more than 1 500 UNITA health workers were reintegrated in the national health service workforce after the conflict. The positive experience was then extended to around 7 500 civilian health workers who worked in areas dominated by UNITA during the conflict [63]. In Mozambique, reintegration of HRHs who worked in areas dominated by RENAMO within the new health system helped in dissipating tensions and contributed to the “good image” of the emerging government [59]. However, there is no empirical evidence about the causal relation or the contribution of the reintegration on improving the legitimacy of the new government or its overall contribution to state-building. It is also to be noted that 20 years after the conflict in Mozambique the divide between the government and the rebels is still wide, and the civil service remains loyal to the ruling party. There are other examples where this integration did not take place. The ratio of Hutu senior government officials per Hutu population in the Rwandan civil service 15 years after the conflict was 1 per 500 000 Hutus while the proportion of Tutsi senior public servants was 1 per 70 000 Tutsis [64].

Although humanitarian workers are important actors in post-conflict settings, it is hard to measure the impact of their interventions on state-building in fragile areas. The role of NGOs often goes beyond the mere delivery of services; it also includes other elements such as the witnessing of human rights abuses by health professionals [65]. There are many positive examples of these interventions, such as humanitarian ceasefires for immunization campaigns in El Salvador or transport of medical supplies in Uganda and Sudan [66]. The provision of health care can be a common ground for collaboration between health professionals from opponent parties, which in turn can contribute to community reconciliation. Continuity in the delivery of health services during relapses of violence after conflict may be perceived positively by a population already traumatized by the recent conflict. In Timor-Leste, the behaviour of the health workforce during the relapse of violence in 2006, which continued providing services despite the turmoil, was reported to have provided a sense of resilience and continuity within the chaos [67]. This particular case demonstrated that health workers were impartial during the conflict and were able to fulfil their professional ethics in times of instability, but this may be an exceptional case rather than the norm.

In the framework proposed, we also identified a series of enabling factors and potential challenges which could strengthen or hinder the linkages between HRH and state-building processes, and we explored the related literature, although not systematically. Many of the concerns (indeed, more challenges than enablers emerge) come from donor-oriented literature. It focuses on lessons for external partners, including the long-term approach which is needed to support successful bureaucratic reforms, a time span which does not fit with the length of typical projects [68]. The need to trade-off short-term goals (re-establishing service delivery) against long-term ones (capacity-building) is also highlighted by a number of authors, such as Fukuyama [8]. Timor-Leste, however, in reconstructing the civil service after the conflict, prioritized capacity-building on general and financial management as a means to strengthen policy implementation. In the early stages of the health sector rehabilitation, priority was given to train mid-level managers (e.g. DHMTs) in order to ensure an efficient management of the newly recruited civil service [53]. As a result, responsibility for health services management was swiftly transferred from international NGOs to government at a relatively early stage in the reconstruction process with no impact on the positive trend of health service delivery output indicators [48]. Another important lesson is that reforming human resource management and development practices is an inherently political process—a fact that donors ignore at their peril [68]. The need for leadership development, adequate remuneration [69], harmonization with wider public administration reforms and developing capacity to manage relationships with non-state actors are also emphasized.