Abstract
BackgroundHuman resources for health are self-evidently critical to running a health service and system. There is, however, a wider set of social issues which is more rarely considered. One area which is hinted at in literature, particularly on fragile and conflict-affected states, but rarely examined in detail, is the contribution which health staff may or do play in relation to the wider state-building processes. This article aims to explore that relationship, developing a conceptual framework to understand what linkages might exist and looking for empirical evidence in the literature to support, refute or adapt those linkages.MethodsAn open call for contributions to the article was launched through an online community. The group then developed a conceptual framework and explored a variety of literatures (political, economic, historical, public administration, conflict and health-related) to find theoretical and empirical evidence related to the linkages outlined in the framework. Three country case reports were also developed for Afghanistan, Burundi and Timor-Leste, using secondary sources and the knowledge of the group.FindingsWe find that the empirical evidence for most of the linkages is not strong, which is not surprising, given the complexity of the relationships. Nevertheless, some of the posited relationships are plausible, especially between development of health cadres and a strengthened public administration, which in the long run underlies a number of state-building features. The reintegration of factional health staff post-conflict is also plausibly linked to reconciliation and peace-building. The role of medical staff as part of national elites may also be important.ConclusionsThe concept of state-building itself is highly contested, with a rich vein of scepticism about the wisdom or feasibility of this as an external project. While recognizing the inherently political nature of these processes, systems and sub-systems, it remains the case that state-building does occur over time, driven by a combination of internal and external forces and that understanding the role played in it by the health system and health staff, particularly after conflicts and in fragile settings, is an area worth further investigation. This review and framework contribute to that debate.
Highlights
Human resources for health are self- critical to running a health service and system, and there has been a small but growing literature on the returns to investing in human resources for health (HRH) from the point of view of health and associated economics gains [1]
While recognizing the inherently political nature of these processes, systems and sub-systems, it remains the case that state-building does occur over time, driven by a combination of internal and external forces and that understanding the role played in it by the health system and health staff, after conflicts and in fragile settings, is an area worth further investigation
We draw on wider literature on the links between state-building and human, institutional and economic development and examine evidence for different mechanisms which might link HRH development with state-building, drawing from fragile and conflict-affected settings (FCAS), where the notion of state-building is most applicable
Summary
Human resources for health are self- critical to running a health service and system, and there has been a small but growing literature on the returns to investing in human resources for health (HRH) from the point of view of health and associated economics gains [1]. This article aims to explore that relationship, developing a conceptual framework to understand what linkages might exist and looking for empirical evidence in the literature to support, refute or adapt those linkages This is of importance as the state-building rationale is explicit or implicit in many of the investment models of development agencies [3], including for investments in HRH, and merits better understanding in itself. We draw on wider literature on the links between state-building and human, institutional and economic development and examine evidence for different mechanisms which might link HRH development with state-building, drawing from fragile and conflict-affected settings (FCAS), where the notion of state-building is most applicable. Lack of a policy framework, inequalities in health service provision across the country, low capacity of public and private sectors, differences in the quality of the services, the absence of infrastructure, lack of coordination and shortage of health human resources were some of the main challenges [74]
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