Rebuilding Health Systems in Fragile States through High-Impact Interventions: Lessons Learned

Rebuilding Health Systems in Fragile States through High-Impact Interventions: Lessons Learned

A woman and baby rest at St. Josephs' Health Center -- the only health institution in Abricots, Haiti. {Photo credit: MSH.}Photo credit: MSH.

Suzanna Ile, a 26-year-old woman from South Sudan, lost her first two babies in childbirth. Suzanna did not have a nurse or midwife to tell her that her pelvis was dangerously small for childbirth; nor was there a safe place for a caesarian section even if she had known the risk.

Suzanna’s experience is typical of what women have faced in South Sudan, the newest country in the world. South Sudan is home to 10 million people, spread across an area about the size of France. The people have experienced civil war off and on for five decades --- hardly anyone remembers a time without conflict. In places like the capital city of Juba, the infrastructure has been seriously damaged. The conflicts have devastated the economy and disrupted the education system.

South Sudan has some of the worst health indicators in the world. Health facilities are grossly understaffed as health workers fled the country: only ten percent of staff positions are appropriately filled. There are less than two doctors for every 100,000 people. A woman in South Sudan is five-hundred-times more likely to lose her life giving birth than a woman in Europe. Forty-five percent of children suffer from physical stunting due to malnutrition.

For nearly 40 years, MSH has worked with partners to improve the health of people living in fragile states, such as South Sudan. In recent years, we have worked in nearly a dozen fragile states --- states in conflict, recovering from conflict or crisis; or states that have collapsed --- including Afghanistan, Haiti, Liberia, and Democratic Republic of the Congo.

We have found these to be among the most difficult countries in which we work. At the same time, working in them can be the most satisfying and produce the most impact. Health needs are invariably the greatest in fragile states. After years of suffering, the people deserve health services as a basic human right. And rebuilding in post-conflict or recovery states offers the greatest potential for creating a sustainable local health system.

Though our work in fragile states, we have identified ten principles or best practices for rebuilding health systems for health impact in fragile states. These principles apply in a variety of fragile state settings, including any country that is rebuilding after conflict or crisis.

By rebuilding health systems through high-impact interventions, it is possible to see significant health improvements over time.

Afghanistan provides one of many superb examples of the growing evidence that applying these principles in fragile states can produce a positive and lasting health impact. When the Taliban fell from power in December 2001, Afghanistan was left with a largely dysfunctional health system --- one that had been devastated by decades of war and civil disruption. In large parts of the country there were few, if any, active women health workers; less than half the "hospitals" had both electricity and running water; immunization had fallen to less than 20 percent; access to primary health care was less than 10 percent; and 9 out of 10 women were on their own for labor and delivery with no skilled birth attendant.

Not surprisingly, Afghanistan recorded some of the highest maternal, infant and child mortality rates in the world at that time.

Within five years, in a 13-province area with over 7 million inhabitants (one third of the total Afghan population), thousands of community health workers had been trained, half male, half female; nearly 1,000 community midwives had been trained; over 350 health facilities were actively delivering health services; more than 60 percent of facilities had female health workers; access to primary care had increased to more than 60 percent of the population; and immunization and percent of births attended by trained birth attendants had doubled.

Contrary to conventional wisdom, service quality measures increased along with service delivery statistics. Most impressive, however, was that --- by independent assessment --- infant and child mortality declined by more than 25 percent during this period.

An Afghan midwife in Wardak province takes the blood pressure of her patient. Photo credit: MSH.

How was this stunning increase in service delivery and health impact achieved in such a challenging environment and in such a relatively short period of time?

The answer lies in the application of sound principles for health system development in fragile state settings. A key driver in Afghanistan was an effective partnership among Afghan health leadership with a vision for universal coverage and high-impact health services at the community level; committed development partners such as USAID, The World Bank, and the European Union; capacity-building nongovernmental organizations (NGOs) like MSH and our partners; and capable local and international service-delivery NGOs. Together we applied the principles, including focusing on the community and household level and prioritizing low-cost, high-impact interventions such as immunization and family planning.

Afghanistan overcame gender barriers to health access for women and children through improved local human resources for health. By 2010, community midwifery schools had trained over 2,000 midwives. More than 22,000 community health workers had been trained as part of a policy ensure one male and one female community health worker per village (averaging 100-150 households).

After nearly a decade of steady pursuit of sound health system development principles and strategies, the 2010 Afghan National Mortality Survey revealed remarkable health results. Maternal mortality had fallen by two-thirds, from an estimated 1,600 per 100,000 live births in 2002 to less than 400 in most parts of the country. Infant mortality fell from an estimated 165 deaths per 1,000 live births in 2000, to 129 in 2004/2005, to 77 in the 2010 survey. Likewise, under-five mortality plummeted from 257 per 1000 live births in 2000, to 191 in 2004/5, to a remarkable 97 in 2010. This decrease is equivalent to saving 150,000 infant’s and children’s lives per year.

Too often after a period of intensive intervention, health system improvements plateau --- or worse --- regress. The 2010 survey results from Afghanistan are especially encouraging, because they show a trajectory of continued improvement in health.

In South Sudan, high-impact interventions are also showing positive results. There are increases in the number of trained health workers, midwives, and health facilities, and the volume of health services delivered. These changes have led to a 65 percent increase in malaria prevention intervention in pregnancy and doubling in antenatal care.

MSH has learned that when it comes to fragile states, it is definitely not the case that one size fits all. What worked in Afghanistan may not be realistic for Haiti or South Sudan. We must continue to assess and learn from what has worked, as well as adapt the unique circumstances of a given location.

Suzanna, Modi, and the midwife. South Sudan. Photo credit: MSH

Suzanna was fortunate in her third pregnancy. The midwife from Lokiliri Health Centre identified Suzanna’s third pregnancy as high risk, referred her to the Main Hospital in Juba, and Suzanna took this advice. Her son, Modi, is now a healthy two year old.

There are millions of Suzanna’s and Modi’s in fragile states --- mothers, children, and their families who have suffered through conflict and crisis --- and who deserve a better tomorrow. By beginning with a core set of principles, lessons learned from decades of experience can be applied elsewhere, giving women, children and their families a better chance at health.

Jonathan D. Quick, MD, MPH, is president and chief executive officer of Management Sciences for Health. Dr. Quick has worked in international health since 1978. He is a family physician and public health management specialist.

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