Fragile and conflict-affected states (FCAS) face persistent challenges that undermine their ability to plan, finance and deliver essential services. Political instability, recurrent emergencies and fragmented external assistance (aid) weaken national institutions and constrain progress toward development targets like universal health coverage (UHC). Effective Development Cooperation (EDC) principles—ownership, alignment, harmonization, managing for results and mutual accountability—were introduced globally to address shortcomings of aid, yet evidence on their functioning and effects in FCAS remains limited. This thesis examined how these principles operate in practice, how they interact with health system governance, and whether they contribute to progress on health goals. Sudan, a long-standing FCAS characterized by shifting political regimes, contested legitimacy, and a highly aid-dependent health sector, served as the primary empirical case.
A mixed-methods research design was applied across four sub-studies. Three qualitative sub-studies explored the evolution of health sector partnerships in Sudan, drawing on semi-structured interviews conducted in 2015 and 2021/22 with government officials, donors, development banks, UN agencies, international NGOs and civil society organizations. These were complemented with document review and observations of coordination meetings. The fourth sub-study applied a quantitative comparative analysis across 17 aid-recipient FCAS to examine whether specific EDC principles were associated with advancing UHC.
The findings revealed shifting patterns of partnership behavior shaped profoundly by political context. In Sudan, periods of authoritarian rule constrained alignment and partners’ willingness to use national systems, while the post-2019 transitional government created a window of opportunity for advancing collaboration due to increased transparency and greater alignment with national priorities. However, unfortunate political reversals, notably the 2021 coup, rapidly dismantled progress, triggering withdrawal of donor support and re-crumbling of coordination. While earlier the civil society organizations were marginalized by donors and other global partners, and manipulated by the authoritarian regime, they were soon aspired – by the global partners – to assume a prominent implementation role when relation with the state was cut after the coup.
Adopting the Humanitarian–Development Nexus (HDN) was sought as a policy solution to ensure development in the midst of recurrent emergencies and humanitarians’ presence, but it had its own challenges. While widely praised, its operationalization was hindered by conceptual ambiguity, tensions between humanitarian and development actors, and unresolved debates about system utilization. A persistent dilemma materialized between strengthening national systems and using them. Humanitarian agencies often maintained parallel mechanisms for procurement, financial management and information systems, citing weak national capacity and the exigencies of crisis response. Development partners and government increasingly advocated a “use to strengthen” approach, emphasizing that durable improvements require channelling assistance through national systems. Over time, some partners, including several UN agencies and international NGOs, shifted toward more active system-strengthening and selective utilization, supported by joint technical assistance and piloting of harmonized approaches.
The cross-country analysis of FCAS demonstrated two principles—alignment with national priorities and joint technical assistance—were individually sufficient to attain UHC in several FCAS. The findings illustrates that multiple pathways can lead to improved outcomes, and that targeted, coordinated support to core governance functions can yield development even amid fragility.
The thesis concludes that EDC has the potential to influence governance and accelerate health system gains in FCAS, yet its effectiveness is highly contingent on political dynamics and functioning coordination platforms. Progress depends on inclusive national ownership, coherent and flexible technical assistance, and gradual yet deliberate movement toward use of national systems. Empowering civil society, maintaining coordination fora, and strengthening monitoring and the accountability mechanisms are essential to sustain gains, particularly in FCAS volatile environments. Findings highlight that although EDC cannot resolve structural fragility, it can create reinforcing pathways that transform fragmented aid into more coherent systems support when global and national actors engage with political realities while upholding principled cooperation.