Building Health Systems in Fragile States

Building Health Systems in Fragile States

Fragile states such as Afghanistan, the Democratic Republic of Congo, Haiti, Liberia, and Southern Sudan have among the worst health statistics – especially for women and children.  For political, economic, security and other reasons they can be extremely challenging work environments. Despite this, I have been deeply inspired to see what local health leaders have achieved when they have created strong partnerships among government, donors,  non-governmental organizations and where possible the private sector.  The charismatic former minister of health from Afghanistan, the  medical director of an urban clinic in northern Haiti, and the director of Torit hospital in Southern Sudan stand out as examples of local leadership in action under circumstances that would immobilize many of us.

In fragile states, constraints on governments often prevent them from simultaneously building their stewardship role and immediately expanding service delivery. Supporting the Ministry of Health to establish a basic package of health services, train local organizations to implement those services, and provide incentives (such as through performance-based financing) is critical to success. Additionally, the goal should be to move from many plans and actors across districts to one health plan with committed partners. 

In Haiti, improved health outcomes  resulted from a pragmatic approach developed by a four-way partnership between the Government of Haiti, the United States Government, a network of Haitian and international non-governmental organizations (Sante Pour le Developpement et la Stabilite d’Haiti, SDSH), and MSH. We continue to use this approach to strengthening the health system as we work with our partners in Haiti to respond to the cholera outbreak.  

In Afghanistan, MSH has successfully partnered with the Ministry of Public Health, service delivery NGOs, and donors to improve local capacity. MSH supports seven health projects in Afghanistan, each one leveraging the other to strengthen the health system and provide quality care to Afghans.

In 13 provinces covering 52% of the population, with US Agency for International Development support, MSH and its partners have trained health care leaders and community health workers; integrated health services; increased the detection and treatment of disease; expanded access to medicines, clean water, and health information; and improved the performance of grants.

MSH has helped the Ministry of Public Health and other partners to achieve important results: 25,000 community health workers are now employed; more than two-thirds of the population now has access to basic health services; nearly 60% of pregnant women now receive prenatal care; deaths of children under the age of five have declined by one-third; health facilities now maintain adequate stocks of medicines; use of modern contraception has increased from 5% to more than 40%; and, tuberculosis detection rose from 24% to more than 70% – nearly 90% of detected cases are treated.

Principles of effective donor engagement in fragile states should include: supporting direct service delivery for both health impact and local credibility; promoting transparency and accountability; providing long term expert presence on the ground, not just short term consultancies; encouraging local innovation and avoiding barriers to local initiatives; a commitment to long-term financing; and using mechanisms such as performance-based financing to increase program effectiveness and efficiency.

Jonathan D. Quick, MD, MPH is President and Chief Executive Officer of MSH. Dr. Quick has worked in international health since 1978, he is a family physician and public health management specialist.


Dr.Prakash Sanchetee
Need urgent focus on lot of fragile states facing current health problems, integrating system day to day,coordination among regional people & all other partners.Expert team from top to grass root level & follow up. I want to be a part of team to do community work with good training program,workshop & deliver expertise to community. Dr.Prakash Sanchetee MBBS,DMCW,DPH,PGDHH,PGDHA. Address--A/120,Lake Garden,Kolkata,India. Email
Jon Eliot Rohde
Jono - nice comment and good examples. It is obvious that the US has failed Haiti in the most basic needs - water. Any scope to put pressure on, now nearly 10 months after the quake? the Afghan success is something that seems never cited in the press - the improvement in health is nothing short of dramatic - most of it can be traced to MSH and partners work. FP rising from 5% to 40 % is probably unprecedented, as well as the fall in child mortality.. Congrats.
Dr Maduabuchi J...
Hello Dr Quick, It is very interesting to read your blog and to be informed on the level progress to support vulnerable people in fragile states. The situations in these countries are so appalling and of concern to many of us. Imagine that the Haiti cholera epidemic could happen and kill many people after longtime predictions following the earthquake. It is good the Governement of Haiti gave MSH support and the opportunity to help. How are we sure it not because their desperate situation. I have said this because of the attitude of some state governments in Africa. I am from Enugu State Nigeria, and was just told yesterday of how some government officials frustrated the efforts of donor agencies to assist cholera vistims in some communities. Tens died of Cholera. More efforts should be geared towards strenghtening NGOs to care for the needy and sick people in rural communities. More power to your elbows.

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