In rich and poor countries alike, a core challenge is building the state’s capability for policy implementation. Delivering high-quality public health and health care – affordably, reliably, at scale, for all – exemplifies this challenge, since doing so requires deftly integrating refined technical skills (surgery), broad logistics management (supply chains, facilities maintenance), adaptive problem solving (curative care) and resolving ideological differences (who pays? who provides?), even as the prevailing health problems themselves only become more diverse, complex and expensive as countries become more prosperous.
The current state of state capability in developing countries, however, is demonstrably alarming, with the strains and demands only likely to intensify in the coming decades. Prevailing ‘best practice’ strategies for building implementation capability – copying and scaling putative successes from abroad – are too often part of the problem, while individual training (‘capacity building’) and technological upgrades (e.g., new management information systems) remain necessary but deeply insufficient. An alternative approach is outlined, one centered on building implementation capability by working iteratively to solve problems nominated and prioritized by local actors.