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Record number 523441
Title Networked health sector governance and state-building legitimacy in conflict-affected fragile states : the variable impact of non-state provision of public health services in eastern Democratic Republic of Congo
Author(s) Aembe, Bwimana
Source University. Promotor(en): Thea Hilhorst, co-promotor(en): D. Dijkzeul; Murhega Mashanda Job. - Wageningen : Wageningen University - ISBN 9789463431606 - 231
Department(s) Sociology of Development and Change
Publication type Dissertation, internally prepared
Publication year 2017
Keyword(s) governance - health - congo democratic republic - central government - local area networks - non-governmental organizations - conflict - gezondheid - democratische republiek kongo - rijksoverheid - lokale netwerken - niet-gouvernementele organisaties
Categories Conflicts

State fragility in the Democratic Republic of Congo (DRC) has impacted the state’s ability to provide public services, as well as and the population’s experiences and perceptions of the state. For public health and for social welfare more broadly, the contributions of the state are weak and contingent on the involvement of non-state service providers (NSPs). The population has become dependent on non-state actors for the provision of basic social services, and NSPs are especially important in public health, where their engagement accounts for the survival of the sector. The state and NSPs interact through networked governance, where relevant actors are involved in a network through resource interdependency, cooperation, collaboration and even competition to achieve social goals (Klijn, 2004). Networked governance processes in the DRC public health sector take place at three structural levels: national, provincial and operational. Networked governance serves as an institutionalised public model for health sector management through these three levels.

A great deal of previous work has studied the link between legitimacy and state service delivery, but there has been little investigation of the link between basic service provision by NSPs and state legitimacy in fragile states. This study explored how the networked governance of the health sector contributes to state-building processes and to state legitimacy in the DRC, also examining how the image of the state is shaped by NSP service provision. The study focused on state-building outcomes related to effective public health governance, the strengthening of system management and health service provision through state–non-state interactions. The study also explored state legitimacy and the population’s experiences and perceptions of the state, in a context where the delivery of public health services is mediated by non-state actors.

The research was guided by the following key question:

How does the networked governance of health services, involving state and non-state actors through multi-stakeholder interactions, affect state-building and legitimacy in the fragile setting of eastern Democratic Republic of Congo?

Networked Governance in the Management of the DRC’s Health Sector

Non-state stakeholders have been actively involved in the delivery of basic public services throughout the history of the DRC (Pearson, 2011; Seay, 2013; Waldman, 2006). Some scholars have argued that strong inputs from NSPs, supported by international funding, gives the DRC’s health sector its ‘current resilient’ outlook (Pearson, 2011: 12; Seay, 2013). Although these inputs have not been homogeneous across provinces or health zones (HZs) within provinces (Pavignani, Michael, Murru, Beesley & Hill, 2013; Pearson, 2011), their aggregate contribution accounts for the persistence of the sector in terms of policy making and enforcement, health system management and service delivery.

NSPs can be categorised as national or international, and as traditional or situational partners. Faith-based organisations (FBOs) are classified as national and as traditional partners of the state. International actors recognised as traditional health policy partners mostly include bilateral and multilateral institutions that have long supported state-building in the DRC. In contrast, most international NGOs are situational partners whose emergence was spurred by state fragility and the humanitarian consequences of wars. In collaboration with the Ministry of Health (MoH), traditional international partners contribute to the process of national policy making and system strengthening. Situational partners are mostly engaged in unintegrated projects and humanitarian interventions focusing on circumstantial situations of social vulnerability. Through their frequent use of different policies and stand-alone projects, these organisations have involuntarily contributed to a decentralised and rather fragmented system. Traditional partners such as FBOs and international donor organisations play a crucial role in the networked governance of the health sector and in public health care delivery.

Networked Governance and State Legitimacy in the DRC’s Fragile Health Sector

The DRC has a long history of state fragility and deficiencies in performing the functions of modern states. NSPs operate like surrogate state service providers, and both the state and NSPs are engaged in the process of health care provision through networked governance.

In this study’s examination of state legitimacy, ‘a state is more legitimate the more it is treated by its citizens as rightfully holding and exercising political power’ (Gilley, 2006). A lack of legitimacy is a major contributor to state fragility, because it undermines state authority (Unsworth, 2010). In most cases, declines in service delivery have been found to reduce the population’s support of the state and its leadership (OECD/DAC, 2008). However, little is known about how this works in fragile settings characterised by institutional multiplicity, so how NSP interventions contribute to state legitimacy was treated as an open question in this study.

Actor-oriented Interactions in the Networked Governance of the DRC’s Health Sector

Networked governance arrangements in the DRC’s health sector have the characteristics of a social arena, which is ‘typical of actor-oriented interactions’ (Hilhorst & Jansen, 2010). As symbolic locations, arenas are neither geographical entities nor organisational systems; rather, they describe the political actions of all of the social actors involved in a specific issue (Kitschelt 1980 in Renn, 1993).

The Multilevel Nature of Health Sector Networked Governance Arenas

Health sector governance in the DRC has a pyramidal organisation involving the central (national), intermediate (provincial) and operational (HZ) levels (Bukonda, Chand, Disashi, Lumbala & Mbiye, 2012).

The central level consists of the national MoH, which is expected to play a strategic role, engaging in policy formulation, elaboration of the mechanisms for public policy implementation, sector funding and high-level interactions with non-state stakeholders (i.e. signing framework agreements or specific agreements). The MoH is responsible for general sector policy and system regulation, national programmes and tertiary hospitals (Waldman, 2006). Although policy making is an exclusive function of the MoH (Zinnen, 2012), donors and other development partners inform and support the process through technical and financial assistance.

The intermediate level concerns the management of the provincial health system and the oversight of the operational (HZ) level. The intermediate level organises and provides technical support to the HZ (World Bank, 2005). At this level, state and non-state actors interact to improve the structural system governance and to manage the provision of health services. Through the Comité Provincial de Pilotage Santé, stakeholders work towards harmonising interventions and establishing the model of engagement at the provincial level. Using HZ evidence-based reports, the Comité Provincial de Pilotage Santé defines provincial-level stakeholder priorities in line with the national health policy.

The HZ is the operational unit that integrates primary health care services and the first-referral level. An HZ covers an average population of 110,000 and consists of a central HZ office, an array of health posts and centres, and a general referral hospital (Carlson, Maw & Mafuta, 2009). Because of the lack of government financing over the last decades, HZs and their constituent facilities have operated with considerable autonomy, although MoH structures have retained administrative control, particularly over human resources (Carlson et al., 2009). Many facilities have become in effect privatised, relying on patient fees to pay staff and operating costs. At the HZ level, networked governance of the local health system takes place through the Bureau Central de Zone de Santé (HZ Management Board). In this arena, interactions take place among representatives of the state, non-state actors (where possible) and community-based organisations—especially the community health development committees (Comité de Développement Sanitaires).

Research Methods

This research is part of the Secure Livelihoods Research Consortium, which focuses on state legitimacy, capacity for state-building and livelihood trajectories in conflict-affected situations (Levine, 2014). This study fell under the first two of these themes, with a focus on the population’s experiences, perceptions and expectations regarding state legitimacy and on building effective states that deliver services and social protection. This study began in 2012, with the empirical research starting in August 2013. The fieldwork lasted 19 months, ending in April 2015.

Most of the research was conducted in the province of South Kivu, with complementary data collection in Kinshasa. A case study design was used, with two multi-stakeholder governance arrangements serving as the cases. The first case was performance-based financing (PBF), which is the transfer of money or material goods from a funder to a contracting recipient, on the condition that the recipient will take a measurable action or achieve a predetermined performance goal. The second case was a community-based health insurance (CBHI) programme—Mutuelle de Santé (MUS). The case study of PBF focused on health system governance because of PBF’s pivotal role in the process of building the health system. The CBHI case study explored MUS outcomes related to equity in access to health services, protection from financial risk and the financing of health services. The CBHI case study was based primarily on observations in a rural area (Katana) and a semi-urban area (Uvira).

Focusing on the multilevel networked governance of the DRC’s health sector, this study drew on institutional ethnography, which examines work processes and studies how they are coordinated, typically through examining various texts and discourses (Smith, 2009). Attention was given to discourses, relationship patterns, writings and multi-stakeholder governance arrangements throughout study period.

Six types of participants were interviewed: public health officials and state actors from MoH offices at national and provincial levels (approximately 30 participants); representatives of donor organisations, international NGOs and national NGOs (16 organisations: three donor organisations, six international organisations and seven national NGOs); health service providers throughout the province (20 medical doctors); individuals involved in the management of CBHI/MUS at multiple levels, especially in Katana and Uvira (approximately 68 participants); CBOs (35 people from Comité de Développement de l’Aire de Santé, CODESA); and community members (beneficiaries, clients and citizens), especially in Katana, Bukavu, Uvira and Idjwi (approximately 1,000 participants). For the last category of respondents, community opinions on health services, the state and NSPs were assessed through interviewees’ personal storytelling, semi-structured interviews and focus groups. To assess the baseline situation in the health sector, a content analysis of the four main official policy papers was also conducted.

Main Research Findings

The findings of this research revolved around three main study concerns: 1) the institutional outlook, functioning and state-building outcomes of networked health governance and international intervention models; 2) the review of the two schemes fostering networked governance through multi-stakeholder governance engagement; and 3) the exploration of the impact of NSP interventions on the population’s perceptions and the legitimacy of the state.

Institutional Functioning and State-building Outcomes of Networked Health Governance and International Intervention Models

Networked health sector governance and state-building outcomes (chapter 2). Longstanding patterns of interaction exist between state and non-state actors seeking to improve public health in the DRC. In many cases, private actors have stepped in to fill the void created by the lack of state health care provision. The findings demonstrate that state–non-state interactions in the DRC’s health sector create a burgeoning form of multilevel networked governance and that these interactions play a role in explaining the persistence of the health sector despite the weakness of the state. It is difficult to assess the real influence of these interactions on state-building in a context of critical fragility, where coordination and alignment are problematic. The findings also indicate that several factors—specifically, the fragmented nature of interventions conducted by the majority of international NGOs, imbalanced power relations during negotiations with development partners and weaknesses in governance—impede the construction of a coherent, resilient and sustainable health system in the DRC. Generally, the findings indicate that networked governance through interactions between the state and non-state providers may contribute to state-building.

State fragility discourse and the challenge of policy coalition-building for interventions programming and stakeholder engagement models (Chapter 3)

State fragility is a discourse without a policy coalition in the DRC’s health sector governance network. The government and donors/international NGOs have not yet harmonised their perceptions of fragility. These key stakeholders have also not reached a common understanding on intervention policy, and there is a clash between opposing institutional logics in the processes of policy making and intervention programming. The contentious nature of the concept of fragile statehood has hampered the construction of a policy coalition for health sector interventions. Donors rationalise the persistence of emergency-based interventions by emphasising fragile statehood, whereas state officials assert political statehood and argue for a paradigm shift towards a higher degree of state control. The lack of consensus around state fragility has influenced perceptions of the state and international NGOs/donors in their engagement with health interventions programming in the DRC. Government officials in the DRC see fragile statehood as a stigmatising concept that contributes to difficulties with getting international NGOs to comply with the Paris Declaration on Aid Effectiveness. However, representatives of the state and donor organisations agree that, because public health sector funding is lacking, donors’ financial contributions ensure the sector’s survival.

Multi-stakeholder Health System Arrangements: Strengthening Networked Health Governance and Community Health Coverage

International organisations and donors have supported schemes, such as PBF and CBHI/MUS, which have impacted the networked governance and system-building in the local health sector, as well as improving health care delivery.

PBF and strengthening public health governance (Chapter 4)

This study examined the effectiveness of PBF in three areas of health system governance: structural governance from a capacity-building perspective, health service provision management and demand-side empowerment for effective accountability. In general, the study found that PBF positively impacted the process of health system-building in these three areas. Although much is still lacking, health governance and the provision of services have improved, and patient-centred care and social accountability have strengthened the provider–patient relationship. The research found positive outcomes for incentive-based contracting and output-based financing. However, donors, state officials and other stakeholders doubt the sustainability of these approaches, and PBF faces obstacles associated with state fragility. In addition to structural threats and uncertain sustainability, transforming transactional motivation into transformational change is a challenge. Ultimately, the research found out that PBF supports health sector-based state-building, but it cannot repair a collapsed state.

CBHI and community health coverage (Chapter 5)

The MUS CBHI scheme began operating just after the wars in South Kivu. The research findings indicate that MUS schemes lead to improvements in access and social protection only for a portion of the population. Similar findings for outcomes related to resource mobilisation and the financial sustainability of the health sector point to continued management challenges facing MUS schemes. These challenges are compounded by state fragility. To contribute effectively to universal health coverage, the state should reinforce its stewardship presence in strengthening MUS.

NSPs and Local Perceptions of the State (Chapter 6)

Service provision—especially health care delivery—serves as a public sphere and an arena for interactions and multi-stakeholder processes. The findings indicated that the population’s perceptions of the state reflect a breach of social contract, because the state has failed to live up to the population’s needs and expectations. The presence of NSPs may have negative effects on the population’s perceptions of the state, because NSPs’ performance establishes their benevolent image while solidifying a negative image of the state. However, the state-building legitimacy outcomes of NSPs’ engagement in this context are contingent on how the services are delivered: When NSPs engage with the state on the ground, people also see the state in action. People then assign credit not only to the NSPs, but also to the state, which is important for state-building and legitimacy. There is no direct correlation between service provision by NSPs and the positive image of the state; what positively impacts the image of the state is its visibility on the ground.

Overall, this study explored state-building outcomes resulting from networked health sector governance in a war-affected context with an empirically weak state. In this context, the public health provision inputs of NSPs are crucial for the population’s welfare. The findings indicate that NSP engagement contributes strongly to public health provision and the management of the health system. However, state fragility has a negative impact on networked health governance and donor-supported interventions. Bids to respond to population vulnerability and humanitarian needs should include state-building engagement, as state fragility hampers the success and undermines the sustainability of any rational intervention carried out by non-state actors.

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