"Mendstate"--and the "end state" problem

I have been asked why I called this blog "Mendstate". One of the problems of the US effort in Afghanistan and Iraq (and way beyond) is an inability for all the various actors to agree on what the military calls an end state. What are the conditions that, when reached, will define a suitable "end state"? And, in the health sector, what is the role of health/medicine in attaining that end state? (Hence I derived the play on words "mendstate"--mend, end, and state....you get it, I'm sure.)

The Health and Fragile States Network (link on sidebar to right) has a series of documents posted from a Feb 2009 conference on health and security, one of which is a USAID document called "Health Programming in Post-Conflict Fragile States" that I find really fascinating. (Here's where you can find this document posted: http://www.basics.org/documents/Health_Programming_in_Post_Conflict_States_Waldman_Final.pdf) What's so fascinating about this document is the relatively cold way in which the authors delineate the argument that the goal of "health programming" in fragile states is not to make people healthy in the traditional sense. The goal of the programming is to create good governance and good government (which is created via legitimacy... see my earlier posts on legitimacy).

So, the first point the paper makes is that morbidity and mortality in post-conflict or during-conflict states is caused by violence, and therefore programs designed to create "health" (or, reduce morbidity and mortality) should therefore reduce violence:

...if the principal objective is to improve the population’s
health, perhaps disease control programs as they are usually conceived should not be
the health sector’s highest priority, at least in a context where conflict is
occurring or where the likelihood of a return to conflict is appreciable.
Instead, programs that aim to bring about a lasting ceasefire or that
contribute to the consolidation of an ongoing peace process are more
important in the immediate, highly fragile, post-conflict setting. (pg 2)

Nothing new, but a nice clear point to start the discussion.

The next point made is actually a two-fer: 1) that USAID's fragile states' strategy, therefore, is one which seeks to reduce instability by bolstering good governance and governments; and 2) that there is not enough emphasis placed on building civil society as well as governments. To do this there are two objectives, according to the paper, which should be pursued simultaneously: 1) a humanitarian objective of health care delivery, poverty reduction, education and so forth; and 2) political processes which accommodate dissent (this is my way of summarizing the suggestion in the document...it doesn't precisely address this point of accommodating dissent).

In summary, then, the USAID Fragile States Strategy has four priorities: enhance stability; improve security; encourage reform throughout areas of
governance; and develop institutional capacity. The question to be asked
(but not necessarily answered) in this paper is: what is health
programming’s role in addressing these priorities? (pg 3)

The authors then describe the trade offs between building legitimacy (which they suggest might come first, even at the expense of effectiveness, or what I termed 'performance' in my "legitimacy part II" post). Showing good intent, the authors propose, could be more important in developing political stability (and therefore reducing violence with a hoped-for commensurate reduction in morbidity and mortality) than actually putting effective "medical treatment" practices on the ground.

Next they tackle the problem of "equitability" which is a humanitarian assistance mantra that mandates that health care should be delivered equitably between all factions, regardless of race, creed, ethnicity, gender and so forth. Using a rather frank description of the Sudan as an example, the authors discuss how providing health care to the "haves" (vice the "have-nots") can contribute to peace-building and ultimately lower morbidity and mortality, as opposed to direct care to everyone equitably which in some cases may contribute to politically-driven violence, increasing morbidity and mortality.

Then a discussion follows about donor behavior, and the rift between relief and development donations and practices. The conclusion:

...others all suggest that a minimum of $15 per capita per year is required to implement a Basic Package of Health Services. While this amount is
frequently available to fund services provided through emergency and humanitarian assistance mechanisms, it is strangely true that once an emergency is deemed to have subsided, health sector funding is often reduced, while funding is increased to develop other aspects of state functions, such as elections, justice, and other infrastructure areas. It should go without saying that without adequate funding, no form of health sector programming will be successful at bringing about important changes in population health status, nor will the health sector be able to make a significant contribution to improving either the legitimacy of a new government or its effectiveness. (pg9)

And buried a bit earlier in the document, the authors make their point, I think, when they write:

As mentioned above, the focus has been on how to implement the same programs in different circumstances, rather than to look at how the circumstances
might determine the nature and design of the programs. Vaccinating 80 percent
of children is one thing, but achieving high vaccination levels in a way that
explicitly enhances the legitimacy (first) and effectiveness (later) of
government may mean settling for lower levels of achievement, at least in
some areas, paying greater attention to ensuring involvement of diverse
elements of civil society, establishing routine vaccination at local health
clinics, and so forth. Of course, it may also be the case, but hopefully not,
that vaccination programs are not as early a priority as they currently are.
How to make health system rehabilitation contribute to the attainment of
political objectives is challenging and context-specific. Clearly, though,
implanting programs designed for very different
settings is likely to be problematic, and donors need to keep their objectives clearly in mind. (pg 7)

What amazes me about this document is that it just simply ends. I'm not sure that these very important points are fully appreciated, socialized and rationalized throughout USAID, since I don't work there. But they absolutely do fit neatly in with counter insurgency strategy, and my previous questions about whether the rest of the government (USAID and the DoS) are fighting a counter insurgencies or doing business as usual (and sometimes in opposition to the counter insurgency) become slightly more salient suddenly.

I think the principles of development and counter-insurgency can converge at the point of recognizing the political origins (which are culturally derived) of problems and solutions. Here we can find room for debate and discussion as to how to describe objectives and end states, and we need to focus on developing clear thought about effecting change.