title: State-building and human resources for health in fragile and conflict-affected states: exploring the linkages.
abstract: BACKGROUND
  Human resources for health are self-evidently critical to running a health service and system. There is, however, a wider set of social issues which is more rarely considered. One area which is hinted at in literature, particularly on fragile and conflict-affected states, but rarely examined in detail, is the contribution which health staff may or do play in relation to the wider state-building processes. This article aims to explore that relationship, developing a conceptual framework to understand what linkages might exist and looking for empirical evidence in the literature to support, refute or adapt those linkages.
  
  
  METHODS
  An open call for contributions to the article was launched through an online community. The group then developed a conceptual framework and explored a variety of literatures (political, economic, historical, public administration, conflict and health-related) to find theoretical and empirical evidence related to the linkages outlined in the framework. Three country case reports were also developed for Afghanistan, Burundi and Timor-Leste, using secondary sources and the knowledge of the group.
  
  
  RESULTS
  We find that the empirical evidence for most of the linkages is not strong, which is not surprising, given the complexity of the relationships. Nevertheless, some of the posited relationships are plausible, especially between development of health cadres and a strengthened public administration, which in the long run underlies a number of state-building features. The reintegration of factional health staff post-conflict is also plausibly linked to reconciliation and peace-building. The role of medical staff as part of national elites may also be important.
  
  
  CONCLUSIONS
  The concept of state-building itself is highly contested, with a rich vein of scepticism about the wisdom or feasibility of this as an external project. While recognizing the inherently political nature of these processes, systems and sub-systems, it remains the case that state-building does occur over time, driven by a combination of internal and external forces and that understanding the role played in it by the health system and health staff, particularly after conflicts and in fragile settings, is an area worth further investigation. This review and framework contribute to that debate.
authors.affiliation: ReBUILD Programme, Institute for International Health and Development, Queen Margaret University, Edinburgh, UK. switter@qmu.ac.uk.
authors.forename: Sophie
authors.initials: S
authors.lastname: Witter
authors.affiliation: Department of International Development & St Antony's College, University of Oxford, Oxford, UK. jean-benoit.falisse@qeh.ox.ac.uk.
authors.forename: Jean-Benoit
authors.initials: JB
authors.lastname: Falisse
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine & ReBUILD Programme, London, UK. maria.bertone@lshtm.ac.uk.
authors.forename: Maria Paola
authors.initials: MP
authors.lastname: Bertone
authors.affiliation: Liverpool School of Tropical Medicine, Liverpool, UK. Alvaro.Alonsogarbayo@lstmed.ac.uk.
authors.forename: Alvaro
authors.initials: A
authors.lastname: Alonso-Garbayo
authors.affiliation: Faculdade de Medicina e Ciências da Saúde, Universidade Nacional Timor Lorosa'e, Dili, Timor-Leste. joaosmartins@hotmail.com.
authors.forename: João S
authors.initials: JS
authors.lastname: Martins
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine (LSHTM) & Health Economics and Financing Directorate, Ministry of Public Health, Kabul, Afghanistan. ahmad.salehi@lshtm.ac.uk.
authors.forename: Ahmad Shah
authors.initials: AS
authors.lastname: Salehi
authors.affiliation: The School of Population Health, University of Queensland, Brisbane, Australia. enricopavignani@hotmail.com.
authors.forename: Enrico
authors.initials: E
authors.lastname: Pavignani
authors.affiliation: Liverpool School of Tropical Medicine, Liverpool, UK. tim.martineau@lstmed.ac.uk.
authors.forename: Tim
authors.initials: T
authors.lastname: Martineau
mesh_terms: D000346:Afghanistan; D000068337:Armed Conflicts; D002063:Burundi; D003695:Delivery of Health Care; D003906:Developing Countries; D006076:Government; D006078:Government Programs; D006282:Health Personnel; D006296:Health Services; D006801:Humans; D012922:Social Change; D012940:Social Problems; D049648:Timor-Leste; D000078329:Workforce