What are the best approaches to strengthening health systems in fragile states? This report from the Health and Fragile States Network surveys current health strategies in an attempt to test the feasibility of health system strengthening in fragile contexts and to shed light on emerging ‘good practices’ and challenges for health issues in these environments. Its findings suggest that while there is great diversity in the approaches taken to strengthen health systems, successful interventions share common elements of community integration, partnership, and long time horizons.
Poor national health systems are considered to be a major constraint in improving health, resulting in increased efforts by the global health community to strengthen national systems. Strengthening health systems in fragile states, however, is often challenging given the limited resources available, problems of governance, and the difficulties of organising and delivering health care in these often conflict-affected settings. Despite these difficulties, the reality that fragile states have a high burden of ill health and are currently off-track to meet the health millennium development goals (MDGs) has sharpened the international community’s focus on health systems in fragile contexts.
Health system strengthening (HSS) initiatives in fragile states aim not only to support the achievement of the health MDGs and national health targets, but also to ensure that the delivery of national health services takes place in an equitable, accountable and sustainable manner, despite the very difficult, often conflict-affected, contexts. The approaches used by donors and international actors to achieve these objectives are diverse and, in many cases, creatively adapted to the specific context. However, in surveying these approaches and strategies, several common themes emerge as being essential for successful interventions:
- Community involvement is embraced as a key to ensure sustainability and security of services.
- There is no simple, single approach that will work. Programmes tend to consist of multiple elements, not only focusing on service delivery but also addressing causes of low service utilisation, investing in staff, improving community awareness and participation, and harnessing local capacity to achieve sustainability.
- Many programmes have gone beyond stand-alone, vertical services provision, and seek to achieve integration with existing services and systems.
- Most initiatives do not work on short timelines. Sustainable successes seem to have been achieved when investments were made over the longer term.
- Most approaches attempt to build a diversity of partnerships, working with everyone from the community to overseas academic institutions.
- Financial support is important. Small seed grants to support local initiatives can have significant long-term impacts.
In spite of the creativity and diversity observed in HSS approaches, doubts persist as to the feasibility of strengthening health systems in fragile state contexts. Challenges remain in negotiating the unique governance constraints imposed by fragile states and in understanding how these constraints impact health outcomes:
- Greater efforts are needed in measuring and evaluating progress and impact in order to quantify success that can currently only be observed qualitatively.
- Current interventions demonstrate the relevance of HSS models to fragile states, but developing health systems that have good coverage and are both affordable and responsive is still a major challenge.
