Health systems are the result of decisions on how resources are raised and spent, which groups in
society are involved in the process of decision-making, or which needs and interests are responded
to, and the incentives this creates for those delivering services. These decisions are shaped by the
interests and convictions of those in power and depend on how they exercise this power. This puts
governance at the centre stage of health systems research. Until recently however, health governance
research was dominated by normative and ‘technicist’ approaches that focused on technical
dimensions of health administration following the good governance paradigm and had limited
empirical validation. Many low-income, fragile settings present a complex context for which
frameworks based on an understanding of centralised and coherent health systems do not easily fit.
This calls for approaches that allow for a more contextualised understanding of governance with an
explicit focus on the way political, social and economic interactions in the health system are shaped
by humanly devised constraints, also known as institutions. The primary aim of this thesis is to explore
governance of the health system in Tajikistan with such a neo-institutionalist perspective, drawing on
political economy analysis, principal-agent theory, collective action theory and the concept of social capital.
Tajikistan is a low income, post-Soviet and post-conflict setting with features of neo-patrimonialism and state fragility. The combination of a Soviet legacy, including a large public health infrastructure, fragile state capacity, a precarious power balance, partly stemming from a recent experience with conflict, and limited public resources available for health presents deep challenges to health service delivery. Little is known about what political factors have been inhibiting the
introduction of health system reforms, and what these entail at the local level. The relationship between key governance
actors and the role of political-economic interests, social norms and the wider political-economic context in the health governance process, including at district and community levels, have received less attention in scholarly debate. This includes attention to what citizen engagement in the area of health, and local governance structures at the community level actually entail in practice.
The research presented in this thesis draws on literature review and qualitative research conducted
in Tajikistan at central policy level, district level and among communities and health workers. The
thesis first of all sets out to develop an understanding of useful concepts to explore the governance of basic services in neo-patrimonial systems of governance in general; Secondly, it identifies the main governance constraints to the introduction and implementation of the Basic Benefit Package reforms
and associated health management changes, by analysing the interactions of the main stakeholders with the political and socioeconomic context in relation to the technical dimensions of the reform.
Third, it offers an analysis of meso-level accountability in the health system in terms of principal-agent
relationships as a key process in district-level health governance; and lastly it explores how social capital facilitates the engagement with external development agents and local health governance
actors, and fosters collective action around village organisations and community-based health funds.
With explicit attention to the political economy in which health policy changes and the interventions from development agencies take place, and the interconnectedness of central, local and community level
governance the research highlights the role of particular interests, resource-seeking motivations and entrenched power relations in shaping the health system. It shows how these result in and are
affected by unclear mandates, policy incoherence and informal accountability mechanisms. The findings furthermore emphasise the precarious position that health workers as frontline bureaucrats
in the system, and citizens find themselves in, in relation to government. Building on this, the study has provided new insight into important mechanisms that underpin the mixed results in engaging
citizens through community-based health insurance for greater financial protection. Ultimately these insights serve to underline the relevance of contextualising health programmes and addressing the
(informal) resource distribution mechanisms, power dynamics and collective action challenges that are so important in shaping health systems governance.