article · Health Systems & Reform
Healthcare in fragile states frequently depends on private providers and non-governmental organisations, yet short-term donor funding has resulted in fragmented systems and reduced state capacity. This fragmentation stems from political economy drivers such as donor risk aversion, earmarked funds, and upward accountability requirements. To address this, national governments should transition toward becoming stewards of pluralistic health systems rather than acting solely as primary providers. This involves formally integrating non-state actors through licensing, contracting, shared regulatory standards, and independent verification. Aligning donor practices requires joint financing governance and standardised reporting metrics. Evidence from fragile environments shows that structured contracting and regulation can enhance healthcare access and public oversight. Where state capacity or legitimacy is limited, flexible stewardship approaches, including regional, hybrid, or independently monitored arrangements, can be implemented to coordinate mixed delivery models effectively.
In regions affected by conflict or instability, relying on uncoordinated charities and private clinics leads to uneven and unreliable medical care. Transforming governments into regulators and coordinators rather than sole providers ensures that external donor funding and private services work together efficiently, expanding public access to essential healthcare while building long-term local governance capacity.
The abstract outlines policy and governance frameworks rather than a direct commercial product. It indicates applications for policy makers, development funders, and health administrators seeking to design procurement, contracting, and independent verification systems. These governance models represent applied policy approaches tested in real-world settings such as post-conflict and fragile states, though the abstract does not indicate any direct pathway for commercial product development.
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In fragile states, healthcare delivery relies on non-state actors like NGOs and private providers. Short-term donor funding has created fragmented services and weak state capacity. However, donor-driven fragmentation is not only a technical coordination problem; it is also a political economy problem shaped by earmarking, attribution pressures, fiduciary risk aversion, donor-controlled contracts, and upward accountability to funders. We propose shifting from state-as-provider to state-as-steward, not as a choice between two mutually exclusive roles, but as a move toward pluralistic health-system stewardship in which the state may continue to provide some services while stewarding a mixed delivery system. This means integrating the "shadow health system" of non-state services into national health systems through licensing, contracting, and monitoring providers, while unified standards support coordination. Pooled or jointly governed financing, independent verification, shared reporting metrics, and community accountability are needed to align donor incentives with national priorities. Evidence from Afghanistan, Cambodia, Liberia, and other fragile settings demonstrates that contracting and regulation can improve access and oversight. Where governments lack legitimacy, territorial control, or impartiality, stewardship should be adapted through subnational, regional, hybrid, or independently verified mechanisms. Effective stewardship therefore requires rebalancing power, financing, risk, metrics, reporting, and accountability among donors, ministries, non-state actors, and communities.
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DOI: 10.1080/23288604.2026.2708910
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