A Pragmatic Call to Integrate and Regulate Non-State Actors in Fragile Health Systems.

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.