Aid Effectiveness, Health Sector Investment, and Conflict Prevention in Sub-Saharan Africa's Fragile States: A Comparative Assessment

The relationship between official development assistance to the health sector, health outcome improvements, State legitimacy building, conflict prevention in sub-Saharan Africa's fragile and conflict-affected States, is one of the most policy-relevant but analytically under-explored questions which face the developing countries globally. Does health Official Development Assistance (ODA) to fragile States, build the State legitimacy which reduces armed group recruitment vulnerability, or does it substitute for domestic health investment in ways that undermine, rather than strengthen institutional capacity and State-citizen trust? This paper examines the aid effectiveness, health investment, conflict prevention nexus across six sub-Saharan African country cases, and it draws on the Organisation for Economic Cooperation and Development's Development Assistance Committee (OECD-DAC) Creditor Reporting System data, on health ODA (2018 to 2022), World Bank World Development Indicators government health expenditure data (2022), the World Health Organisation's Universal Health Coverage (WHO-UHC) Service Coverage Index (2021), the Mo Ibrahim Foundation's Ibrahim Index of African Governance (IIAG) Overall Governance scores (2023 data year), and the Armed Conflict Location and Event Data Project's (ACLED) Conflict Severity Index (2022). Rwanda provides the most compelling positive case as the study finds a pattern that is consistent with health ODA supporting State legitimacy and favourable governance outcomes, when it is channelled through government systems which are aligned with a country's health priorities, and are designed to build domestic institutional capacity, rather than to substitute it. It further finds that Somalia and Northeast Nigeria illustrate the cautionary cases, in which large volumes of health ODA which are channelled through parallel systems of non-governmental organizations, are associated with weaker domestic health governance capacity in this comparative sample, and may be associated with reduced State legitimacy by linking health services with international actors rather than government. The paper argues for a fundamental reorientation of health ODA in fragile States toward government-aligned, conflict-sensitive, capacity-building approaches, that explicitly measure and pursue security dividends alongside health outcomes.