Working with Non-State Providers in Post-Conflict & Fragile States

This is an independent report commissioned and funded by the Research and Evidence Division in the Department for International Development. This material has been funded by UK aid from the UK Government; however, the views expressed do not necessarily reflect the UK Government’s official policies.

The state may be more or less directly involved in catering for the health needs of its citizens as follows:

  • Full provision of healthcare by the state including delivery of services to the citizenry
  • Partial provision of healthcare mainly by the state, blended with competition and choice of health services from non-state providers
  • Partial provision via contracting non-state providers to deliver certain aspects of healthcare and support inputs to what the state is providing
  • Complete healthcare provision by a non-state sector within agreed standards, regulations and policy frameworks or because the state is completely unable (failed state).

The scope of primary health services provided by the non-state sector includes preventive (e.g. promoting use of and distributing mosquito nets; nutritional counselling) or curative (e.g. providing treatment for common illnesses) or restorative (e.g. rehabilitative services such as physiotherapy); and can include traditional (e.g. traditional birth attendance) or modern (e.g. skilled birth attendance in health facilities) practices.

This review identifies existing evidence on strategies for how governments of post-conflict and fragile states can effectively engage non-state providers, with a view to strengthening health systems and improving health outcomes. We sought to answer the following research questions:

  • How effective are different approaches of engaging with non-state providers in improving the delivery of primary healthcare in fragile, conflict or post–conflict settings?
  • What is the impact of non-state actors’ delivery of primary healthcare in fragile, conflict or post-conflict settings?

This review identifies both what the available evidence can tell us, and what gaps there are in the evidence base. This summary provides an overview of the key evidence synthesized in the systematic review. The evidence is deeply contextual and this brief provides a broad overview. It is not designed to provide advice on which interventions are more or less appropriate in particular contexts but summarizes what is known about the effects of interventions.


High quality evidence from post-conflict and fragile states supports working with non-state providers in primary healthcare service delivery in the following ways:

  • Community empowerment (involving communities in taking the lead in planning, implementing and or monitoring health services) – to increase service quality, use and satisfaction; and to reduce neonatal and child mortality, but not stillbirth; and to reduce morbidity
  • Community health insurance – to increase utilization of modern health services and reduce catastrophic expenditure
  • Pay for performance – to improve satisfaction and quality of care (although low quality evidence raises concerns about how this is achieved)
  • Training traditional birth attendants (TBA) – to reduce perinatal and infant mortality

Moderate quality evidence supports:

  • Contracting out to non-state actors – to increase service use
  • Social franchising – to improve the availability, use and cost-effectiveness of primary care services
  • Community empowerment – as a cost-effective strategy that strengthens the coverage and capacity of health that facilitates and enables communities to deliver primary care services
  • Accreditation and regulation – to improve the quality of service delivery, and raise satisfaction levels with health services
  • Training traditional birth attendants – to increase capacity for TBAs to provide antenatal, postnatal and other primary healthcare services

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