Beyond fragility: a story about modern health systems and the struggle to keep aid relevant. The case of Somalia

Thematic article

Beyond fragility: a story about modern health systems and the struggle to keep aid relevant. The case of Somalia

Switzerland's Horn of Africa regional programme (RPHoA) supports health interventions in Ethiopia and Somalia since 2014¹. Although still a newborn, this programme has built up significant insight and some practical experience while attempting to navigate in what are commonly known as "fragile contexts" or "complex operating environments", where Somalia is usually considered a rather extreme case scenario. The objective of this brief is to share a few highlights of this experience as a wishful contribution to a progressive and very much needed change of discourse.

In the learning process, one enlightening realisation of SDC has been that the term of "complex operating environments" is ironically more illustrative of the difficulties faced by the very structure and mind-set of the positivist Western world in dealing with unorthodox-looking mechanisms, than of the reality of the context itself. At the same time, this denomination feeds the rationale for an increasingly demanding compliance framework imposed on traditional bilateral donors and partners to counteract the uncertainty, informality, and unpredictability that usually characterize such environment.

One of the devastating aspects of a fragile context is its partially or totally dysfunctional (or collapsed) formal health system and related overwhelmingly poor population's health indicators. Yet one could argue that ineffective health systems are not circumscribed to fragile contexts², and that extremely poor health indicators can also be found in contexts that are not officially³ labelled as fragile. So what is so threatening about disrupted health systems beside their common inefficiency and disheartening impact on human lives that creates the global urge for a growing volume of research, discussions and attempts to suggest new (creative, "out of the box") recipes for meaningful engagement in such contexts? This article argues that what might be at stake is the functioning of the aid industry in its current form, the latter seeing its own failures reflected in the "resistance to improve" of contexts like Somalia. From the author's point of view, the starting point revolves around a shift in perspectives, without which innovation is hardly stimulated.

The problem of definitions
For the classical aid industry rationalization (through definitions) and simplification (through standardization) of complex realities is an often non-admitted prerequisite to effective programming. However, there is nothing more defiant of definitions and standardization, than a disrupted health system like the Somali one, to the extent that it challenges the very idea of a health system as understood in linear-thinking, pyramidal societies with a recognized State. Inevitably, any attempt to label it involves favouring one perspective over many others. The classical way to describe a health system starts from characterizing its governance patterns from the perspective of its ultimate duty bearer, the State. A very useful and comprehensive example of this is provided by the typology of distressed health systems suggested by Pavignani and Colombo⁴. Simplistically said, since Somalia is a "failed state", it would be counterintuitive to qualify the health system managed by such a State as anything else, but disrupted, distressed or collapsed. A more accurate and nuanced description of the Somali health system can be found in type 2 case (second from the top) of table 13.1 (see below), where the fragility of the system is given by its beheaded nature (this is how "absent, disinterested and resourceless" practically translates in Somalia).

This perspective fits like a glove the inherently paternalistic model of Western aid as it reinforces the idea of a void that needs to be (re)filled and, thereby, supports naturally interventionist (often well intentioned) approaches. These usually aspire at bringing the system back to its old self or, ideally, at making it better, although often forgetting to analyse the "lost" system (i.e. the "baseline") in the first place.

SDC lived experience in Somalia does not show anything substantially wrong with this, except that such practice fails to take into account two important sets of factors:

At the conceptual level, facts such as (1) the evolutionary nature of health systems, (2) the society's resilience capacity to refill its own voids, (3) the underlying ancestral governance mechanisms of the Somali population that resist Weberian state structures since decades, (4) the extraterritorial and highly nomadic nature of Somali bonding (manifested in networking patterns of pastoralists across borders or the diaspora, for example), and (5) the pressure of global political and economic interests finding their haven on a territory, where regulations and control are minimal or inexistent

At a more practical level, the very absence of a recognized government on a territory deprives traditional ODA actors, like SDC, with the one interlocutor/structure necessary for public aid to be efficiently operationalized into further health system building efforts.

Thus along with the growing awareness of this crippled perspective, SDC has developed a different analysis, namely that Somalia (and probably many other "fragile" contexts) counts not with one, but with a plethora of parallel health systems. On the one hand the formal, but unpredictable, chaotic and somehow artificially held together State-led system that plays by international standards and agendas (UHC and alike) acts as interface with the traditional aid industry⁵. On the other hand a much bigger mostly informal patchwork of fairly cryptic, organically developing and diverse networks and initiatives (returning diaspora, direct foreign investments, drug store businesses, faith-based charities, community-based solidarity groups, random private donors projects, professional corporations, academia-based networks, etc.) that operate in parallel according to an "open market" logic (with competition as the main drive, and not necessarily equity).

The leading position occupied by the latter in people's health seeking behaviour despite the rather wild and unregulated commoditized version of healthcare that they promote within one of the poorest populations in the world is an inevitable recognition, though difficult to admit. SDC and its traditional partners could rather easily avoid worrying about anything beside the formal system and focus on "complementarity of roles", if only the plurality of systems would not work according to a principle of communicating vessels, where all the typical boundaries between public and private, State and non-State, formal and informal, individual and collective benefit are blurred. Individuals (including government officials) adapt to this by naturally shifting sides or wearing multiple hats as needs and opportunities arise. One has the choice to adopt a conservative stand and read the complexity of this environment as a nuisance in the "system" or a threat to effective programming and to a set of theoretically sound working instruments (CSPM assessment tools, risk analysis matrices and logframes). SDC, on the contrary, is in the process of learning to shift perspectives and complement the vision of a failed State with one of a vibrant, resilient and young society imposing on the aid industry a unique governance model. From this angle, the existence of a plurality of systems becomes an important asset, a basket filled with locally relevant and accepted initiatives that only wait to be disclosed and tapped into (not changed, distorted or replaced with compliant blueprints). But by whom?

The road to innovation or simply to modernity?

Somalia health market is proving to be able to flourish without a State at (almost) all… Is this a sign of failure or a sign of modernity (post-modernity⁶)? This article takes the risk of qualifying Western aid instruments for health systems strengthening in Somalia as somehow obsolete⁷ and a contributing factor to a stagnating atmosphere of "déjà vu", mutual mistrust and frustration, and comfortable statu quo for some actors, who actively interfere with ideals of change. For SDC jumping into this arena as a new, and yet equally traditional player represents a triple challenge: political, institutional and technical. All of it further complicated by the open conflict that drastically limits both direct access to beneficiaries and partnership options. Yet further investments in the health of the Somali people are still very much needed...

The good news is that the choice of avenues to engage differently is wide and open for exploration. The more nuanced news is that only a tiny fraction of these opportunities, although promising, are compatible with the nature and "raison d'être" of the type of rather risk-averse support SDC is in a position to offer. RPHoA's to date efforts to operate "creatively" are limited to the use of existing instruments in unconventional ways that usually stretch all PCM tools (mainly the administrative and financial ones) to their limits. The path leading to the ability to do this can be extremely rewarding but, at the same time, it is a hugely overlooked and/or miscalculated planning component of the RPHoA in terms of time and resources consumption. In Somalia, anything is being tested from the use of locally managed small (cash) actions to explore partnerships with unconventional partners (e.g. corporative groups of private service providers), to attempting engagement with existing partners for not strictly conventional mandates (e.g. supporting humanitarian partners' more longer-term in expanding their thematic reach or engaging in the continuum of care), to embedding humanitarian funds (with a limited, but minimally defined budget to be used rather flexibly to absorb sudden shocks, such as epidemics) into classic bilateral cooperation programmes and, finally, to experimenting scenario-based planning and monitoring, thereby challenging the strict use of logframes. While the thinking behind these tests might represent an innovation at a specific institutional level, the practicalities of turning them into an operationalizable intervention remain absolutely conventional and far too much precious time (or at least more than what a context in chronic crisis can afford) is currently spent on adapting reality to established (outdated?) frameworks.

One should not deny that awareness of these shortcomings is per se key to openness for improvement and efforts in this direction are critical in the long run. However, expectations should be carefully managed regarding how fast public international aid can effectively evolve to match the host country's development imperatives (in time for UHC2030?). In highly insecure environments, ODA is more than anywhere else largely motivated by the needs and priorities of donor countries in the first place. This is made particularly evident in Somalia, where an "open market space" has progressively replaced territorial sovereignty and where, consequently, global politics are being played in the most unequivocal manner in every sector. In this spirit of preservation of own interests, mandates or principles, the traditional aid industry gets easily stuck in focusing on the impossible task of controlling naturally unpredictable environments, at odds with effective development objectives in the host country. Under the pressure of a growing number of fragile contexts challenging traditions and the perspective that these places will host most of the world's extreme poor by 2030⁸, change is nevertheless unavoidable, since it is through changes and adaptations that modernity has defined itself over history. The Somalia case suggests that patterns of aid resisting this change could be naturally and silently side-lined. Therefore, we might be at the verge of having to define new roles for ODA, beyond development cooperation.
 
This article is part of the ongoing discussion within SDC and its partners on working in fragile contexts and operationalizing the nexus humanitarian aid/development cooperation. SDC is committed to keep the topic on its agenda so to continually refine its understanding of such contexts. Previous discussions took place during the Global Face 2 Face Health last November in Versoix, with the interview of an expert, Dr. Enrico Pavignani (Suggested Readings) and during a fish bowl session (Sharing promising experiences and main challenges across different fragile contexts).

For more information, please contact: SDC Horn of Africa Regional office, Nairobi, Barbara.profeta@eda.admin.ch
 
NB: The RPHoA is currently elaborating its second phase (2018-2022). The health programme within it is still far too young to provide more detailed, practical, hands-on comments on "what works" and "what doesn't" in Somalia health system's strengthening endeavour.

[1] Switzerland's Horn of Africa regional programme (RPHoA) involves four main actors of the Federal Administration: SDC, Directorate of Political Affairs, Federal Office for Migration and the Department for Human Security. The RPHoA opened in 2012, but health was the last thematic focus to be developed. The regional programme includes Kenya and regional dynamics (migration, food security, governance), but not in health so far. SDC uses different aid instruments for this programme: humanitarian aid, bilateral and multilateral cooperation, deployment of technical staff (secondments).
[2] Highlighted in WHO World Health report 2013: http://apps.who.int/iris/bitstream/10665/85761/2/9789240690837_eng.pdf
[3] By the World Bank Group's List of Fragile Situations, for example: http://www.worldbank.org/en/topic/fragilityconflictviolence/brief/harmonized-list-of-fragile-situations  
[4] Pavignani, E. and Colombo, S. (2016), «Strategizing in distressed health contexts: strategizing national health in the 21st century, chapter 13», WHO, p.20.
[5]Despite no available evidence, the formal health system in Somalia is estimated to provide 18-20% of the healthcare services.
[6] An interesting read around a similar debate: Duffield, M. (1998), "Aid Policy and Post Modern Conflict: A Critical Policy Review", Published as School of Public Policy Discussion Paper No. 19, University of Birmingham, July 1998.
[7] This is not meant to be a laconic conclusion, but rather a realistic assessment of the poor tangible progress achieved by the official health system (this is about the system, not the health outcomes whose accurate measurement remains one of the biggest challenges in the country) compared to the volume of external aid invested during the past 25 years in the form of a sequence of fairly similar low-risk programmes.
[8] http://www.worldbank.org/en/topic/fragilityconflictviolence/overview