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

Abstract

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,

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