Papers by Jean-Benoît Falisse
Community governance, the direct (co-)management of public services by community members, is a po... more Community governance, the direct (co-)management of public services by community members, is a popular approach to improve the quality of, and access to, healthcare servicesincluding in so-called 'fragile' states. The effectiveness of such approach is, however, debated, and scholars and practitioners have emphasised the need to properly reflect on the contextual features that may influence social accountability interventions. We study a randomised intervention during which community-elected health facility committee members were trained on their roles and rights in the co-management of primary healthcare facilities. 328 publicly-funded health facilities of Burundi and Sud Kivu in DR Congo were followed over a period of one year. In Kivu, but not in Burundi, the intervention strengthened the position of the committee vis-à-vis the health facility nurses and affected the management of the facility. HFC members mostly focused on improving the elements most accessible to them: hiring staff and engaging in basic construction and maintenance work. Using survey data and interviews, we argue that part of the discrepancy in results between the two contexts can be explained by differences in health facilities' management (whether they primarily depend on a local church or more distant authorities) as well as different local histories of relationship to public service providers. The former affects the room available for change, while the latter affects the relevance of the citizens' committee as an acceptable way to interact with healthcare providers. No effect was found on the perceived quality of and access to services, and the committees, even when strengthened, appear disconnected from the citizens. The findings are an invitation to rethink the conditions under which bottom-up accountability mechanisms such as citizens committees can be effective in 'fragile' settings.
Journal of Peace Research, 2021
Access to justice is often described as key for building and consolidating peace and enhancing so... more Access to justice is often described as key for building and consolidating peace and enhancing socio-economic development in fragile and post-conflict states. Since the 2000s, legal empowerment has been one of the most popular approaches to improve such access, and a growing literature has presented mixed evidence of mixed quality of its outcomes. We evaluate and discuss the impact of a locally provisioned legal aid program on justice-seekers’ use of dispute resolution fora, legal agency, and trust in judicial institutions. The program was implemented between 2011 and 2014 in 26 municipalities of rural Burundi. We consider its effects on 486 beneficiaries using various propensity score-matching methods and data on non-beneficiaries from two distinct control groups (n = 3,267). Forty-eight interviews with key informants help discuss judicial practices. We find that the program increased the use of courts but not trust in the judiciary. It had no significant impact on the use of alternative dispute resolution mechanisms. Qualitative and quantitative evidence suggest that justice-seekers’ perception of the treatment they received in courts, also known as ‘procedural justice’, shaped their perception of accessing justice. Qualitative evidence also points to a possible ‘watchdog effect’: in some cases, the presence of a legal advisor may have pushed judges to better comply with procedures. While legal aid programs can improve access to courts, it does not necessarily mean an erosion of judicial ‘forum shopping’ or that trust in state institutions is reinforced and rights fully realized.
European Journal of Development Research, 2021
Mainstream development policies often promote citizens committees to oversee basic social service... more Mainstream development policies often promote citizens committees to oversee basic social services. Such committees require influence over, and legitimacy among, service providers and citizens to perform their roles, which local elites can help or hinder. Using a mixed-methods approach, we analyse the situation in 251 health facility committees in Burundi, part of which benefited from interventions designed to bolster their relationship with local leaders. Interviews and focus groups reveal that leaders’ support is essential for committees to access citizens and work with nurses, but the failure of the interventions show it is hard to nurture. The local socio-political elites (politicians, faith leaders) bypass and ignore the committees. In a ‘fragile’ context such as Burundi’s, the lack of political elite capture attempt suggests a largely vacuous committee system. The committees remain a façade participatory institution. Understanding and engaging with local everyday local politics is crucial for committee-based development approaches.
BMJ Global Health, 2021
This paper provides evidence that the COVID-19-related mortality rate of national government mini... more This paper provides evidence that the COVID-19-related mortality rate of national government ministers and heads of state has been substantially higher than that of people with a similar sex and age profile in the general population, a trend that is driven by African cases (17 out of 24 reported deaths worldwide, as of 6 February 2021). Ministers' work frequently puts them in close contact with diverse groups, and therefore at higher risk of contracting SARS-CoV-2, but this is not specific to Africa. This paper discusses five non-mutually exclusive hypotheses for the Africa-specific trend, involving comorbidity, poorly resourced healthcare and possible restrictions in accessing out-of-country health facilities, the underreporting of cases, and, later, the disproportionate impact of the so-called 'South African' variant (501Y.V2). The paper then turns its attention to the public health and political implications of the trend. While governments have measures in place to cope with the sudden loss of top officials, the COVID-19-related deaths have been associated with substantial changes in public health policy in cases where the response to the pandemic had initially been contested or minimal. Ministerial deaths may also result in a reconfiguration of political leadership, but we do not expect a wave of younger and more gender representative replacements. Rather, we speculate that a disconnect may emerge between the top leadership and the public, with junior ministers filling the void and in so doing putting themselves more at risk of infection. Opposition politicians may also be at significant risk of contracting SARS-CoV-2.
Urban Forum
This paper explores the role of savings groups in resilience to urban climate-related disasters. ... more This paper explores the role of savings groups in resilience to urban climate-related disasters. Savings groups are a rapidly growing phenomenon in Africa. They are decentralized, non-institutional groups that provide millions of people excluded from the formal banking sector with a trusted, accessible, and relatively simple source of microfinance. Yet there is little work on the impacts of savings groups on resilience to disasters. In this paper, we use a combination of quantitative and qualitative evidence from Dar es Salaam (Tanzania) to shed new light on the role that savings groups play in helping households cope with climate-related shocks. Drawing on new data, we show that approximately one-quarter of households have at least one member in a group, and that these households recover from flood events faster than those who do not. We further argue that the structure of savings groups allows for considerable group oversight, reducing the high costs of monitoring and sanctioning that often undermine cooperative engagement in urban areas. This makes the savings group model a uniquely flexible form of financing that is well adapted to helping households cope with shocks such as repeated flooding. In addition to this, we posit that they may provide a foundation for community initiatives focusing on preventative action.
Social Science & Medicine, 2020
Health Facility Committees (HFCs) made of elected community members are often presented as key fo... more Health Facility Committees (HFCs) made of elected community members are often presented as key for improving the delivery of services in primary health-care facilities. They are expected to help Health Facility (HF) staff make decisions that best serve the interests of the population. More recently, Performance-Based Financing (PBF) advocates have also put the HFC at the core of health reform, expecting it to hold HF staff into account for the HF performances and development. In Burundi, a country where PBF is implemented nationwide, a randomised control trial was implemented in 251 health facilities where the HFC had been largely inactive in recent years.A random sample of 168 HFCs was trained on their roles and rights, witha subset also given information about the performance of their HF (using PBF indicators) and the PBF approach in general. The interventions, taking place in2011-2013, madethe HFCs better organised but largely failed to generate any effect on HF management and service delivery. Nested qualitative analysis reveals important tensions between nurses and HFC members that often prevent further change at the HF. In the HFs that received both the training and information interventions, this tension appeared exacerbated: the turnover of chief nurses was significantly higheras the HFCsexerted pressure to remove them. This situationwas more likely to happen if the HFC had already received training before the interventions, thereby suggesting that repeated training empowers committees. Overall, the results provide rare rigorous evidence on HFCs, suggesting that more attention needs to be paid to the socio-economic and cultural contexts in which they operate. They also invite to caution when discussing the role of HFCs as a possible watchdog in PBF schemes.
Development Policy Review, 2020
Motivation: Higher education is regarded as a key instrument to enhance socioeconomic mobility an... more Motivation: Higher education is regarded as a key instrument to enhance socioeconomic mobility and reduce inequalities. Recent literature reviews have examined inequalities in the higher education systems of high-income countries, but less is known about the situation in low-and middle-income countries, where higher education is expanding fast. Purpose: The article reviews the academic literature on higher education in low-and middle-income countries using a research framework inspired by social justice and capability approaches. It considers the financial, socio-cultural, human, and political resource domains on which people draw, and how they relate to access, participation, and outcomes in higher education. Methods: A literature search for studies explicitly discussing in-country inequalities in higher education revealed 22 publications. Substantial knowledge gaps remain, especially regarding the political (and decision-making) side of inequalities; the ideologies and philosophies underpinning higher education systems; and the linkages between resource domains, both micro and macro. Findings: The review highlights key elements for policy-makers and researchers: (1) the financial lens alone is insufficient to understand and tackle inequalities, since these are also shaped by human and other non-financial factors; (2) socio-cultural constructs are central in explaining unequal outcomes; and (3) inequalities develop throughout one's life and need to be considered during, but also before and after higher education. The scope of inequalities is wide, and the literature offers a few ideas for short-term fixes such as part-time and online education. Policy implications: Inclusive policy frameworks for higher education should include explicit goals related to (in)equality, which are best measured in terms of the extent to which certain actions or choices are feasible for all. Policies in these frameworks, we argue, should go beyond providing financial support, and 1 .
Health Policy and Planning, 2018
This study contributes to the health policy debateon medical systems integrationby describi... more This study contributes to the health policy debateon medical systems integrationby describing and analysingthe interactions betweenhealth-careusers, indigenous healers, and the country’s biomedical public health system, in the so far rarely documented case of post-conflict Burundi.We adopt amixed-methods approach combining (i)data from an existing survey on access to health-care,with 6,690 individuals,and (ii) original interviews and focus groups conducted in 2014 with 121respondents,includingindigenoushealers, biomedical staff, and health-careusers.The findings revealpluralisticpatternsof health-careseeking behaviour,which arenot primarily based on economic convenienceor level of education.Indigenous healers’ diagnosis is shown to revolve around the concept of ‘enemy’and the need forprotection against it. We suggest ways in which this category may intersect with the widespread experience of trauma following the civil conflict. Finally, we find that, while biomedical staff displaysambivalent attitudestowards healers,cross-referrals occasionally takeplace between healers and health-centres.Thesefindingsare interpretedin light of the debate on health systems integration inSub-Saharan Africa. In particular, we discusspolicy options regarding healers’ accreditation, technical training,management of cross-referrals as well as of herb-drug interactions; and we emphasisehealers’ psychological support role in helping communities deal with trauma. In this respect, weargue that the experience of conflict,and the experiences and conceptualisations of mental and physical illness,needto be taken into account whendevising appropriate public or international health policy responses
Tropical Medicine and Infectious Disease, 2019
While academic literature has paid careful attention to the technological efforts-drugs, tests, a... more While academic literature has paid careful attention to the technological efforts-drugs, tests, and tools for vector control-deployed to eliminate Gambiense Human African Trypanosomiasis (HAT), the human resources and health systems dimensions of elimination are less documented. This paper analyses the perspectives and experiences of frontline nurses, technicians, and coordinators who work for the HAT programme in the former province of Bandundu in the Democratic Republic of the Congo, at the epidemic's very heart. The research is based on 21 semi-structured interviews conducted with frontline workers in February 2018. The results highlight distinctive HAT careers as well as social elevation through specialised work. Frontline workers are concerned about changes in active screening strategies and the continued existence of the vector, which lead them to question the possibility of imminent elimination. Managers seem to anticipate a post-HAT situation and prepare for the employment of their staff; most workers see their future relatively confidently, as re-allocated to non-vertical units. The findings suggest concrete pathways for improving the effectiveness of elimination efforts: improving active screening through renewed engagements with local leaders, conceptualising horizontal integration in terms of human resources mobility, and investing more in detection and treatment activities (besides innovation).
Social Media andPolitics in Africa: Democracy, Censorship and Security, 2019
Politique Africaine, 2019
Performance-based Financing (PBF) has travelled extensively in Africa. The analysisof interviews ... more Performance-based Financing (PBF) has travelled extensively in Africa. The analysisof interviews with key actors and grey literature shows that its implementation in Burundi corresponds to a strategic usage, as a tool for achieving a policy of selective free health-care. It also reinforces a technocratic elite within the Ministry of Health. Grasping such political and strategic reterritorialisation is key to comprehend global health travelling models.
PlOS one, 2018
Performance-based financing (PBF) schemes have been expanding rapidly across low and middle incom... more Performance-based financing (PBF) schemes have been expanding rapidly across low and middle income countries in the past decade, with considerable external financing from multilateral , bilateral and global health initiatives. Many of these countries have been fragile and conflict-affected (FCAS), but while the influence of context is acknowledged to be important to the operation of PBF, there has been little examination of how it affects adoption and implementation of PBF. This article lays out initial hypotheses about how FCAS contexts may influence the adoption, adaption, implementation and health system effects of PBF. These are then interrogated through a review of available grey and published literature (140 documents in total, covering 23 PBF schemes). We find that PBF has been more common in FCAS contexts, which were also more commonly early adopters. Very little explanation of the rationale for its adoption, in particular in relation with the contextual features, is given in programme documents. However, there are a number of factors which could explain this, including the greater role of external actors and donors, a greater openness to institutional reform, and lower levels of trust within the public system and between government and donors, all of which favour more contractual approaches. These suggest that rather than emerging despite fragility, conditions of fragility may favour the rapid emergence of PBF. We also document few emerging adaptations of PBF to humanitarian settings and limited evidence of health system effects which may be contextually driven, but these require more in-depth analysis. Another area meriting more study is the political economy of PBF and its diffusion across contexts.
Arts and International Affairs, 2019
Background
Human resources for health are self-evidently critical to running a health service a... more Background
Human 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.
Methods
An 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.
Findings
We 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.
Conclusions
The 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.
This paper explores the effects of anti-corruption sensitisation messages on bribe-taking and pub... more This paper explores the effects of anti-corruption sensitisation messages on bribe-taking and public service delivery. In a novel lab-in-the-field experiment in Burundi, 527 public servants were asked to allocate rationed vouchers between anonymous citizens; some of these citizens attempted to bribe the public servants to obtain more vouchers than entitled. Two groups of public servants were randomly exposed to similar short messages that called to either the idea of good governance or professional values of integrity. Public servants exposed to the professional identity message behaved in a more equitable manner than those not exposed to any message. We hypothesise that reflecting upon professional values increases moral costs and prompts fairer service delivery. Bribe-taking was not impacted by the messages and bribe-taking and service delivery appear to be distinct dimensions, correlated to different variables. The experiment provides new insights into the design of public service improvement and anti-corruption strategies.
Journal of Refugee Studies
In the 2000s, the government of Burundi and the United Nations created vil- lages to permanently ... more In the 2000s, the government of Burundi and the United Nations created vil- lages to permanently reintegrate over 5,000 uprooted families. Most of these ‘Peace Villages’ soon became areas of socio-economic instability. The dominant narrative blames inefficient aid coordination, while returnees deplore their mar- ginalization in the process and in local communities. The idea of villages epitomizing ‘development’, economic interests in building villages and the rhet- oric of Burundi as a successful peace-building story may explain why villagiza- tion kept being presented as a solution. Above all, the problem is conceptual: the Peace Villages programmes (i) mixed up the causes and consequences of sustainable economic development and reintegration and (ii) recognized land as identity-giving but mistakenly assumed that it would also provide for the livelihood of the returnees. Durable solutions for uprooted returnees need to allow them agency in their own reintegration process, capitalize on their socio- economic skills, and engage with local communities and development initiatives.
Health Policy and Planning
Background: Performance-based financing (PBF) is an increasingly adopted strategy in low- and mid... more Background: Performance-based financing (PBF) is an increasingly adopted strategy in low- and middle-income countries. PBF pilot projects started in Burundi in 2006, at the same time when a national policy removed user fees for pregnant women and children below 5 years old.
Methods: PBF was gradually extended to the 17 provinces of the country. This roll-out and data from the national health information system are exploited to assess the impact of PBF on the use of health-care services.
Results: PBF is associated with an increase in the number of anti-tetanus vaccination of pregnant women (around þ20 percentage points in target population, P<0.10). Non-robust positive effects are also found on institutional deliveries and prenatal consultations. Changes in outpatient visits, postnatal visits and children vaccinations are not significantly correlated with PBF. It is also found that more qualified nurses headed to PBF-supported provinces. The limited quality of the data and the restricted size of the sample have to be taken into account when interpreting these results. Health facility-level figures from PBF-supported provinces show that most indicators but those relative to preventive care are growing through time.
Discussion: The dataset does not include indicators of the quality of care and does not allow to assess whether changes associated with PBF are resource-driven or due to the incentive mechanism itself. The results are largely consistent with other impact evaluations conducted in Burundi and Rwanda. The fact that PBF is mostly associated with positive changes in the use of services that became free suggests an important interaction effect between the two strategies. A possible explan- ation is that the removal of user fees increases accessibility to health care and acts on the demand side while PBF gives medical staffs incentives for improving the provision of services. More empirical research is needed to understand the sustainability of (the incentive mechanism of) PBF and the interaction between PBF and other health policies.
Tropical Medicine & …, 2012
objective Community participation is often described as a key for primary health care in lowincom... more objective Community participation is often described as a key for primary health care in lowincome countries. Recent performance-based financing (PBF) initiatives have renewed the interest in this strategy by questioning the accountability of those in charge at the health centre (HC) level. We analyse the place of two downward accountability mechanisms in a PBF scheme: health committees elected among the communities and community-based organizations (CBOs) contracted as verifiers of health facilities' performance.
Cahiers d'Histoire du Temps présent, 2009
From the end of the 1970s onwards, the Médecins sans frontières (MSF) movement established itself... more From the end of the 1970s onwards, the Médecins sans frontières (MSF) movement established itself as a major actor in the world of humanitarian aid and cooperation in development. Initially French in origin, the organisation expanded, and a Belgian section was established in 1980. Within a few years, this Belgian section was functioning on a fi nancial, human and technical scale comparable to that of its French parent organisation, and began to develop its own methods of action and organisation.
Through the use of unpublished internal documents and interviews with former leading fi gures in MSF, this article analyses the workings of the machinery of MSF Belgium
during its fi rst years of existence (1980-87). What emerges from behind the clichés which all too often constitute the only available history of non-governmental organisations, is an organisation characterised by a high level of rofessionalism. Motivated by a new – more technical and consciously apolitical – concept of humanitarian aid, MSF Belgium put in place an operational structure which resembled closely that of a classical private business. Relying on high-quality recruitment from the Institute of Tropical Medicine at Antwerp, the organisation developed particular mechanisms (kits, guidelines, training
courses, etc) and forms of expertise, which had in many cases been developed in response to the challenges encountered during its first long-term mission in Chad. As a consequence, MSF Belgium rapidly came to enjoy a reputation for excellence, and its image became a model to be emulated by the wider society, including by institutions.
This enabled it to receive important fi nancial support, notably from the European Development Fund, as well as to develop technical partnerships with universities, nongovernmental
organisations and companies.
In a final section, this article re-examines the crisis of identity and leadership which MSF experienced in the middle of the 1980s, and which led MSF Belgium to reaffirm and reinvent the apolitical character of its discourse and interventions.
Established in 1980, the Belgian section of Doctors Without Borders quickly developed into the bi... more Established in 1980, the Belgian section of Doctors Without Borders quickly developed into the biggest section of the organization. Because of the professional skills of its volunteers and communication policy, it started serving as a model for a new generation of non-governmental organizations driven by expertise rather than ideological beliefs. Around 1985, its apolitical character – seen as fundamental to the effectiveness of any Doctors Without Borders work on the field – was doubly questioned. Internally, the Belgian and French sections of Doctors Without Borders clashed over the newly-established think tank Liberté Sans Frontières. Externally, the organization had to face the political manipulation of humanitarian aid in Ethiopia. As a result, Doctors Without Borders started giving more careful thought to the issue of political engagement. This has remained a major issue ever since. Should Doctors Without Borders publicly report human rights violations they witness on the field, even if this puts at risk the continuation of their assistance? Is ‘silent diplomacy’ possible and effective?
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Papers by Jean-Benoît Falisse
Human 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.
Methods
An 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.
Findings
We 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.
Conclusions
The 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.
Methods: PBF was gradually extended to the 17 provinces of the country. This roll-out and data from the national health information system are exploited to assess the impact of PBF on the use of health-care services.
Results: PBF is associated with an increase in the number of anti-tetanus vaccination of pregnant women (around þ20 percentage points in target population, P<0.10). Non-robust positive effects are also found on institutional deliveries and prenatal consultations. Changes in outpatient visits, postnatal visits and children vaccinations are not significantly correlated with PBF. It is also found that more qualified nurses headed to PBF-supported provinces. The limited quality of the data and the restricted size of the sample have to be taken into account when interpreting these results. Health facility-level figures from PBF-supported provinces show that most indicators but those relative to preventive care are growing through time.
Discussion: The dataset does not include indicators of the quality of care and does not allow to assess whether changes associated with PBF are resource-driven or due to the incentive mechanism itself. The results are largely consistent with other impact evaluations conducted in Burundi and Rwanda. The fact that PBF is mostly associated with positive changes in the use of services that became free suggests an important interaction effect between the two strategies. A possible explan- ation is that the removal of user fees increases accessibility to health care and acts on the demand side while PBF gives medical staffs incentives for improving the provision of services. More empirical research is needed to understand the sustainability of (the incentive mechanism of) PBF and the interaction between PBF and other health policies.
Through the use of unpublished internal documents and interviews with former leading fi gures in MSF, this article analyses the workings of the machinery of MSF Belgium
during its fi rst years of existence (1980-87). What emerges from behind the clichés which all too often constitute the only available history of non-governmental organisations, is an organisation characterised by a high level of rofessionalism. Motivated by a new – more technical and consciously apolitical – concept of humanitarian aid, MSF Belgium put in place an operational structure which resembled closely that of a classical private business. Relying on high-quality recruitment from the Institute of Tropical Medicine at Antwerp, the organisation developed particular mechanisms (kits, guidelines, training
courses, etc) and forms of expertise, which had in many cases been developed in response to the challenges encountered during its first long-term mission in Chad. As a consequence, MSF Belgium rapidly came to enjoy a reputation for excellence, and its image became a model to be emulated by the wider society, including by institutions.
This enabled it to receive important fi nancial support, notably from the European Development Fund, as well as to develop technical partnerships with universities, nongovernmental
organisations and companies.
In a final section, this article re-examines the crisis of identity and leadership which MSF experienced in the middle of the 1980s, and which led MSF Belgium to reaffirm and reinvent the apolitical character of its discourse and interventions.
Human 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.
Methods
An 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.
Findings
We 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.
Conclusions
The 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.
Methods: PBF was gradually extended to the 17 provinces of the country. This roll-out and data from the national health information system are exploited to assess the impact of PBF on the use of health-care services.
Results: PBF is associated with an increase in the number of anti-tetanus vaccination of pregnant women (around þ20 percentage points in target population, P<0.10). Non-robust positive effects are also found on institutional deliveries and prenatal consultations. Changes in outpatient visits, postnatal visits and children vaccinations are not significantly correlated with PBF. It is also found that more qualified nurses headed to PBF-supported provinces. The limited quality of the data and the restricted size of the sample have to be taken into account when interpreting these results. Health facility-level figures from PBF-supported provinces show that most indicators but those relative to preventive care are growing through time.
Discussion: The dataset does not include indicators of the quality of care and does not allow to assess whether changes associated with PBF are resource-driven or due to the incentive mechanism itself. The results are largely consistent with other impact evaluations conducted in Burundi and Rwanda. The fact that PBF is mostly associated with positive changes in the use of services that became free suggests an important interaction effect between the two strategies. A possible explan- ation is that the removal of user fees increases accessibility to health care and acts on the demand side while PBF gives medical staffs incentives for improving the provision of services. More empirical research is needed to understand the sustainability of (the incentive mechanism of) PBF and the interaction between PBF and other health policies.
Through the use of unpublished internal documents and interviews with former leading fi gures in MSF, this article analyses the workings of the machinery of MSF Belgium
during its fi rst years of existence (1980-87). What emerges from behind the clichés which all too often constitute the only available history of non-governmental organisations, is an organisation characterised by a high level of rofessionalism. Motivated by a new – more technical and consciously apolitical – concept of humanitarian aid, MSF Belgium put in place an operational structure which resembled closely that of a classical private business. Relying on high-quality recruitment from the Institute of Tropical Medicine at Antwerp, the organisation developed particular mechanisms (kits, guidelines, training
courses, etc) and forms of expertise, which had in many cases been developed in response to the challenges encountered during its first long-term mission in Chad. As a consequence, MSF Belgium rapidly came to enjoy a reputation for excellence, and its image became a model to be emulated by the wider society, including by institutions.
This enabled it to receive important fi nancial support, notably from the European Development Fund, as well as to develop technical partnerships with universities, nongovernmental
organisations and companies.
In a final section, this article re-examines the crisis of identity and leadership which MSF experienced in the middle of the 1980s, and which led MSF Belgium to reaffirm and reinvent the apolitical character of its discourse and interventions.