MSH's Working Principles for Health Development Initiatives in Fragile States

MSH's Working Principles for Health Development Initiatives in Fragile States

Women and child in Tambura, South Sudan. {Photo credit: MSH.}Photo credit: MSH.

Nearly 50 countries, including Afghanistan, Democratic Republic of the Congo, Haiti, Liberia and South Sudan, are considered a fragile or conflict-affected state -- a state that is in conflict, recovering from conflict or crisis, or a state that has collapsed or has a strong and repressive government. Over nearly 40 years of working in fragile states, Management Sciences for Health (MSH) has identified best practices, lessons learned, and appropriate interventions for a myriad of situations in fragile states.

MSH takes an integrated approach to building high-impact sustainable public health programs that address critical challenges in leadership, health systems management, health service delivery, human resources, and medicines. Wherever our partnerships succeed, the positive impact of good health has a ripple effect, contributing to the building of healthy nations.

MSH works collaboratively with health care policymakers, managers, providers, and the private sector to increase the efficacy, efficiency, and sustainability of health services by improving management systems, promoting access to services, and influencing public policy.

1. Use a two-pronged approach. First, the policymaking and coordination functions that belong uniquely to the government must be strengthened. Second, existing health care at the service delivery level must be rebuilt. In fragile states, it is critical to restore the leadership capacity of the Ministry of Health while also keeping health workers working. Performance-based financial incentives --- even relatively small amounts --- for health workers can keep them active under extremely stressful and difficult conditions.

2. Develop partnerships. Every country needs effective partnerships between government, the private sector, donors, and international organizations to mobilize resources to get the job done. But in fragile states such partnerships are particularly valuable and important given the challenges that must be overcome. In fragile states, a whole of society approach is critical. Governments must lead development initiatives and work in partnership with nongovernmental organizations (NGOs) and the private sector.

3. Build leadership, management and governance capacity at national and local levels. Effective leadership and management are absolutely critical to building health systems, particularly in fragile states. Although these states may be vulnerable to corruption, most senior health managers want to improve the health of their people. Advocacy efforts with these high-level decision-makers can often pay off and make a significant difference. Time spent on leadership and management training, even in the midst of chaos and confusion, is time very well spent.

4. Empower country-level ownership of decision-making. The MSH approach is grounded in the principle that governments must lead development initiatives and they must do so in partnership with local service delivery organizations and the private sector. It is essential that government decision-makers feel ownership of whatever policies are decided and implemented. This may slow down the pace of change or may result in programs that are less than ideal, but those programs are the ones that are likely to last.

5. Build sustainable health workforces -- especially women. In fragile states, there are often a lack of skilled workers who can provide health services. Recruiting, training and supporting health workers, especially women, to provide services at all levels are imperative to a state's recovery. Women are more likely to stay on the job, particularly in villages or urban slums, and may have a greater impact on maternal and child survival.

6. Balance immediate needs with long-term sustainability. Working in fragile states requires a balancing act: working with colleagues and counterparts toward long-term sustainable solutions while addressing emergency relief. The dilemma is often the need to choose between short-term quick fixes that can have an immediate effect on reducing mortality versus longer-term interventions that can be more sustainable and can lead to greater capacity in the future. Both are needed, but balancing the two can be difficult.

7. Prioritize interventions. Health managers in fragile states frequently are trying to do twenty things at the same time, and it’s impossible to do twenty things well. Selecting and focusing on three to four high priority interventions will have the most impact. Often our fragile state colleagues have difficulty choosing priorities because of pressures (personal and political) placed upon them. For example, making the decision to provide a basic package of health services to as many people as possible can be an effective way to reduce mortality.

8. Focus interventions at the household level. Most deaths occur at home in the least developed fragile states. Life-saving interventions often must be undertaken by members of the family or household. When roads are dangerous or impassable, or health facilities are closed or understaffed, villagers need to be prepared with the knowledge of how to take urgent action safely. For example, having a few simple medicines on-hand and knowing how to use them correctly can help deal with common but potentially life-threatening problems. The focus on household interventions can empower people and save lives. For example, most diarrhea deaths in children can be prevented by home-based oral rehydration and simple zinc tablets.

9. Utilize inexpensive, locally-based, high-impact health services. Although large amounts of money and resources can be very helpful, it is often the simple, locally-based and cheaper solutions that can have the most impact. Most under-age-five pneumonia deaths in poor fragile states can be prevented, for example, if trained community case managers can provide appropriate antibiotics shortly after the onset of symptoms.

10. Train community shop owners.  When a child or adult is sick, many people in developing countries will first go to the local general store because it is cheaper, faster, and easier. Even in fragile states which are suffering acute emergencies, community shops in rural areas and urban slums are often open for business. If the shopkeepers are given basic training on appropriate medications for different conditions, they can have significant impact, especially when public and NGO health services have not yet been re-established.

Additional guiding principles of effective donor engagement in fragile states include: (a) promote transparency and accountability; (b) provide long-term expert presence on the ground not short term consultancies; (c) promote local innovation and avoid creating barriers to local initiatives; (d) make a commitment to long-term financing and building; (e) build in flexible financing schemes such as performance or results-based financing; and (f) coordinate with other donors.

We welcome your feedback and comments as we further develop these principles.

Steve Solter, MD, MPH, technical lead, fragile states, and country lead of MSH, contributed to this blog.

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