Health in the Fragile States – Supporting Health System Development


Fragile states’ population constitutes 1/6th of the global population. As the World Health Organization (2005) highlights, over a third of fragile states, citizens are malnourished, and 1/3rd of the global AIDS infected population comes from fragile states. In addition, in all global maternal deaths, 1/3rd takes place in fragile states, and fragile states account for deaths that contribute to most deaths around the globe.

These key health challenges exacerbate a lack of competency in health systems, in reference to meeting the health needs of fragile states’ populations. Skolnik (2011) indicates that the key barrier towards health system development in fragile states is the inability to understand the health system challenges in reference to the conceptualization of health in fragile states, and the needs and issues that fragile nations experience concerning health and development.

Primarily, Zivetz (2006) notes that the commonest approach used to counter the shortcomings in the fragile state health care system is the humanitarian relief approach that advances neither state legitimacy nor health system development. This only offers a temporary measure, which does not improve the health programs designs or interventions available thus questioning whether the approach, humanitarian effort, ought to be the only key strategy.

With this in mind, this essay seeks to explore the recent concepts of fragile states, and the needs and issues they experience with respect to health development. This will inform us whether humanitarian aid should be the sole strategy, and help create a roadmap (drawn from successful health systems) for efforts required to support fragile states’ health systems to increase health gains and harness fragile states’ health system development. Cumulatively, this will mitigate key health challenges that fragile states’ populations experience over their counterparts in non-fragile states.

The conceptualisation of Fragile States

Humanitarian relief responds to humanitarian crises, and seeks to alleviate the immediate suffering brought by crises. Although humanitarian relief provides health sector in fragile states with assistance, most of the aid is temporary, thus resulting to relapse of the health system.

In reference to this, the concepts of fragile states reveal that health circumstances surrounding fragile cannot be dealt with humanitarian relief as a sole strategy. Levin & Dollar (2005) conceptualise fragile states in terms of legitimacy, the capacity of the government capacity in providing basic security and core services, and effectiveness in reference to the provision of basic security and core services.

The relationship between these two aspects is eminent; government’s unwillingness or incapacity to address basic needs, including health results to ineffectiveness or fragility in reference to providing citizens with essential needs. Evidently, most post-conflict states experience this state of fragility. In such states, fragility may exacerbate due to chronic underperformance, stagnation, and government collapse resulting from conflict.

Institutions that meet citizens’ basic needs such as health institutions become nonfunctional thus fraying the social structure. Mechanisms that respond to, community needs, natural disasters and disease outbreaks become non-existent. As Levin & Dollar (2005) show, restructuring mechanisms that respond to such circumstances require long-term, not short-term strategies such as humanitarian relief that are temporary.

Chauvet & Collier (2004) argue that legitimacy and effectiveness are narrow-minded perceptions that imply fragility is a result of these two factors only. Therefore, they conceptualise fragile states in reference to common characteristics shared by fragile states. Fragile states experience conflicts that lead to destruction of assets, lives, livelihood and property.

In such states, conflicts and instability diminish trust, a fundamental aspect for unity and progress. Restoring trust in the entire society requires long-term strategies that enable the population to heal, not short-term strategies such as humanitarian relief that deal with immediate issues and move to other humanitarian crises upon alleviating the health issues at hand.

Still Palmer, Strong, Wali & Sondorp (2006) show that one-sided perceptions cannot conceptualise fragility. Hence, they culminate the concepts discussed above into a typology, single concept in reference to the forms that fragile states exacerbate. These include states that are deteriorating, collapsing, and recovering from conflicts in both post conflict situations and early stages of recovery.

This manifests four fragile states’ conditions; early recovery, arrested development, deterioration and post conflict. This brings the realization that conflict may not necessarily cause fragility; some states are fragile due to underperformance or stagnation. The complexity of stagnation or underperformance, which may range from political interference to lack of resources require well-outlined long-term strategies. In this case, humanitarian relief may only offer temporary solutions to alleviate stagnation, but not long-term solutions.

Obviously, it is unlikely that all fragile states may exhibit all concepts discussed. This is mainly because the concepts have broad definitions, fragility, legitimacy, effectiveness and common characteristics, which do not recognise the need to be context-specific; focus on the sensitivity of the outstanding fragile situation present in a specific state. In this regard, Newbrander, Yoder & Debevoise (2007) conceptualise a state’s fragility in reference to key structural elements that constitute a state; security, accountability, financing, stewardship, essential service delivery and resource management. As a result, it is easy to identify specific fragility components and maintain neutrality while analysing a state’s fragility.

Needs and Issues that Fragile States Experience in Respect to Health and Development

Humanitarian relief mainly deals with immediate health issues in the health system. However, health systems experience issues that need long-term approaches thus nullifying the credibility of humanitarian relief as a sole factor in mitigating issues that fragile states’ health systems experience.

In respect to health and development, fragile states exacerbate different issues that need long-term strategies. Because of the possible circumstances discussed in the concepts above such as government collapse, fragile states’ health systems become dysfunctional; lack sufficient infrastructure, facilities, drugs and supplies. However, Loevinsohn & Harding (2005) note that this may not be the only reason as government underperformance may also contribute to dysfunctional health systems. Manifestly, fragile states lack stringent health sector monitoring mechanisms or policy directions.

This mainly happens because of lack of systems to establish health policies. In the absence of such systems, health systems have no clear direction. The government transfers the task of providing health services to third parties. For the private care providers, this results to misuse of autonomy; offering services, which do not correspond to people’s health needs, and offering non-standardised training to health practitioners. In other fragile states, policy implementation is non-existent. This implies that there is no implementation of existing policies, hence no health sector’s oversight.

Another issue highlighted is inequity in the provision of health services in relation to curative and secondary services. As a result, poor people have minimal public health services options. The issue of operating with insufficient information is also eminent. This is due to lack of current information pertaining paramount health issues such as endemic diseases and the number of health facilities versus the population available. As Meagher (2005) notes, this may be due to insufficient functional management systems or management capacity.

Evidently, the absence of systems diminishes the basis on which to develop budgets, conduct disease surveillance and assess human resources. As a result, government experience increased difficulty when formulating crucial information concerning health care delivery, thus making the provision of current health care information impossible. When it comes to managerial capacity, fragile countries have a shortage in managerial personnel in terms of skills.

Carvalho (2006) argues that this may be due to non-standardised training. However, poor planning, tracking skilled human resources and enrolling more health professionals in educational institutions may also contribute to lack of managerial capacity. These issues need long-term measures, show that humanitarian relief alone cannot counter challenges and harness health system development in fragile states.

Besides the issues discussed, there are several long-term needs in fragile states’ health system that cannot be solely addressed through a single short-term strategy, such as humanitarian relief. Manifestly, from the issues above, there is the need for resources in terms of supplies, trained staff, drugs and finances.

Lack of infrastructure exacerbates the need for infrastructure, equipment and facilities. Absence of current information pertaining paramount health issues highlight the need for information management and planning, while non-standardised training show the need for accountability in the health care system. Less stringent monitoring mechanisms or policy directions show the need for policy-making mechanisms, while health inequity highlight the need for health services equity when it comes to accessing the services.

Shortages in the managerial capacity and insufficient functional management systems show the need for functional management systems and a functioning delivery system. In addition, fragile states show the need for policy mechanisms, and capacity building in health facilities, health human resource and health system management. As discussed below, addressing such needs require a combination of long-term strategies, not a single short-term strategy such as humanitarian relief (Mano, 2007).

Interventions and Lessons Available; roadmap

The first step to counter the health and development needs in the fragile states would be to prioritise the needs and address each accordingly, long-term or short-term depending on the extremity and the state of the need at hand. Since the government is unaware of the health system’s condition and resources, gathering information, assessing health resources will come in handy. As World Health Organisation (2005) shows, this would necessitate humanitarian relief.

However, as the government address urgent, essential health needs, humanitarian relief, that mainly focus on the immediate health needs would no longer be useful, unless the parties involved take a long-term approach.

Evidently, the second solution taken would be policy, plan and strategy development. This would ensure that stringent monitoring mechanisms, policies and strategies are available to prioritise short-term and long-term health needs of the state, and guide the parties involved towards addressing the health needs. As McGillivray (2006) notes, there are clear expectations of donor’s reliability, the length and amount of funding.

This harnesses planning for sustainability purposes and mitigates barriers to health and development. However, this would still not be possible without developing the health sector human resource. Unfortunately, humanitarian relief cannot undertake this role due to the continuum under which it operates, solving immediate problems. As Kaplan (2008) notes, health system management commences with human resource management and long-term strategies that ensure that there is the correct number of professional health workers, proper training, and a mechanism for certifying workers.

This implies that fragile states need to upgrade workers with inadequate training and standardise system requirements due to the different levels and forms of training available. This will mitigate the need for skills, managerial capacity, functional management systems and a functioning delivery system.

When financing health services, governments should ensure that critical health indicators, such as infrastructure, basic package for health services, resources and redevelopment of the health care sector, with the most immense impact are prioritised to counter the need for healthcare resources. For instance, the key causes of mortality and morbidity are preventable or treatable. In this regard, fragile states should ensure steady and affordable supply of drugs. The government should do this when maintaining a balance on preventive and curative services on the entire population to ensure equity.

One of the key lessons learned is from Congo, a fragile state (Waldman, 2006). Both the government and the donors keep withdrawing from the provision of health services due to political reasons, thus affecting the health system development. This shows that humanitarian efforts cannot solely develop health systems in fragile states to full functionality.

Health system parties should demonstrate commitment, long-term approaches. Donors ought to go beyond the humanitarian crisis and eliminate the tendency of donors to shift to other crises upon crises alleviation. This is the only way that governments in fragile states can rebuild health systems to yield positive long-term effects.

As Newbrander, Ickx & Leitch (2003) show, Afghanistan provides an indispensable lesson in reference to the country’s tendency to apply engagement principles required in fragile states health sector. These principles include collecting, analysing health information, instilling flexibility and creativity when designing health plans and programs, and seeking new funding tools to transit from humanitarian stage to development stage. In addition to this, there is the use of technical experts during the implementation stage, monitoring, aligning to ensure coordination with multiple donors and harnessing long-term commitment (Organisation for Economic Co-operation and Development, 2007).

These principles have made Afghanistan address its health system’s shortcomings in reference to expanding health services and providing essential medicines. As a result, Afghanistan has developed a beneficial and successful health system. Likewise, such principles, can result to commitment, expertise and multiple sources of funds that can help fragile countries adhere and execute the solutions outlined effectively, thus resulting to health system development, health benefits.


Cumulatively, it is evident that humanitarian relief cannot solely deal with issues present in the health system development, in fragile states. The fragile states concepts, issues and needs, and solutions and lessons that address health needs show that health in fragile states can only be addressed using long-term approaches, solutions, not short-term approaches.

This does not nullify the fundamentality of humanitarian relief in the health system development. Instead, it shows that humanitarian relief cannot solely be a key strategy that successfully mitigates issues of health system development in fragile states. As shown in the roadmap, the development of a fragile states’ health system require multiple approaches, solutions, including short-term and long-term strategies.


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