Architects’ sketches or builders’ plans for health systems development in fragile and conflict affected states?

By Barbara McPake (Institute for International Health and Development, Queen Margaret University, Edinburgh and Nossal Institute for Global Health, University of Melbourne)

The post-2015 sustainable development goals are emerging. If they are finalised close to the form that is currently proposed, then they represent a significantly increased ambition, with old Millennium Development Goals (MDGs), such as reducing maternal mortality and incidence of HIV, embedded in the larger goal of promoting healthy lifestyles, addressing the social determinants of health and achieving universal health coverage; and entirely new areas of focus including promoting peaceful and inclusive societies. Overall the number of goals will grow from 9 to 17.

Fragile and conflict affected states (FCAS) have been among those that have been left behind in the process of pressing for the achievement of the MDGs to the extent that the 2011 World Development Report on Conflict, Security and Development reported that no low-income FCAS had yet achieved a single MDG. While the statement may be misleading, and more recently the World Bank has reported that 20 FCAS have achieved MDGs, there is no contesting that progress in such countries has been markedly slower. Critics of the MDG approach have argued that it pays insufficient attention to locally defined and owned definitions of progress and development (Sumner and Melamed, 2010) and such a view appears to have inspired the G7+ (a coalition of self-identifying FCAS) Principles for Good International Engagement in Fragile States and Situations which emphasise that: ‘A durable exit from poverty and insecurity for the world’s most fragile states will need to be driven by their own leadership and people.’

The argument that globally devised and packaged policies fail to deliver development and may even undermine it, is not new and was popularized by Robert Chambers in his 1983 text: ‘Rural Develoment: Putting the Last First. Among the critiques is the recognition that such packages are premised on a generic understanding of the problem requiring resolution which is contradicted by the multiplicity of realities that maintain fragility and conflict in FCAS (for example see Baird and Hammer, 2013 on contracting in Cambodia; and Obadare, 2005 on the rejection of polio vaccine by Northern Nigerian states). Barry Munslow, speaking at the ReBuild annual workshop last week compared the global policy package to the ‘architect’s sketch’ which imagines the future aspired to, but has not considered the terrain on which that future needs to be built. In contrast, the ‘builder’s plan’ is developed from a careful analysis of that terrain with detailed provisions for accommodating the specificities emerging from that analysis. If we accept the need for ‘builders’ plans’, from where can they come?

A critical issue is the weakness of local capacity for careful analysis that more often than not characterises countries emerging from conflict. Educated populations tend to have greater opportunity to escape conflict affected situations; and sometimes a higher conflict related mortality among those that fail to do so. In the aftermath of conflict a youthful, poorly educated and inexperienced national bureaucracy and civil society often confronts a well-financed and enlarged, but locally inexperienced and short time horizon focused international aid industry in negotiating the policy agenda. The international aid industry brings blueprints (architects’ sketches) from other contexts while national stakeholders fail either to understand or articulate the disconnects between the sketches and the realities of the terrain; or fail to promote their understanding because such inconvenient truths are readily perceived to be unwelcome and unrewarded.

All this suggests that a critical investment in the transition from fragility and conflict is in a cadre of locally embedded, critical researchers and policy analysts who can develop the confidence to confront the international aid industry with inconvenient truth and find welcoming and rewarding audiences for their messages. Their task is to develop builders’ plans for the rebuilding of institutions. Is there a genuine interest among funding agencies to support this? DFID has funded the ReBUILD consortium (in which I declare a strong interest) with precisely this agenda in supporting the development of local capacity to analyse the terrain of the health system and the opportunities to support locally appropriate health institution building. There are other examples but they are dwarfed by investment in the purveyors of architects’ sketches whose promises of ‘best global practice’ and ‘(globally) evidence based innovation’ offer the allure of steering clear of messy realities. Ultimately, these serve development ends in such contexts poorly.

Baird, I.G. and Hammer, P. (2013) Contracting illness: reassessing international donor-initiated health service experiments in Cambodia’s indigenous periphery, South East Asia Research, 21, 3: 457-73

Chambers, R. (1983) Rural Development: Putting the Last First, Longman

Obadare, E. (2005) A crisis of trust: history, politics, religion and the polio controversy in Northern Nigeria, Patterns of Prejudice, 39. 3, 265-84

Sumner, A and Melamed, C. (2010) Introduction – the MDGs and Beyond: Pro-poor policy in a changing world, IDS Bulletin, 41, 1: 1-6


2 thoughts on “Architects’ sketches or builders’ plans for health systems development in fragile and conflict affected states?

  1. Thanks for this challenge Barbara – one of the significant messages that came out of my engagement with the health sector reforms in Cambodia was the assumptions made on the foundations on which we were building – often planners discounted the enduring (but often suppressed) social and political constructs that would latter challenge the blueprints that had been layed down over them. Sustainable building needs that deep understanding of the sub-strata that underpins construction. Best, peter.


  2. Thanks Peter. The real challenge is the disconnect between those that understand those realities and those that think their packaged solutions need no such understanding. We are dealing in a market for international aid innovation in which understanding context appears to be cheaply valued.


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