Strengthening the focus

Tuesday, June 23, 2009

Guy Collender, of the London International Development Centre, discusses the challenges of improving health in fragile states

Mogadishu's hospitals are overflowing with patients wounded in the latest spate of fighting in the Somali capital. Doctors at Keysaney Hospital are treating twice the number of people they should be and are prepared to care for the injured in tents if the fighting continues (IRIN 2009a). Another article posted by the Integrated Regional Information Networks (IRIN), part of the UN Office for the Coordination of Humanitarian Affairs, charts how rape cases have risen dramatically in recent months in the province of South Kivu, Democratic Republic of Congo (DRC) (IRIN 2009b). And World Health Organization (WHO) statistics show that nearly 4,300 people have died from cholera in Zimbabwe since August 2008 (WHO 2009). These unfolding health emergencies are realities in Somalia, DRC and Zimbabwe, and more research and policy advice is now being generated surrounding such fragile states because of the severity of their commonplace healthcare problems.

'Fragile state' is a broad term, which encompasses different types of ineffective rule. The UK Department for International Development (DFID) defines a 'fragile state' as 'where the government cannot or will not deliver its basic functions to the majority of its people, including the poor.' This includes:
• Collapsed states (eg. Somalia);
• States in conflict or recovering from conflict (eg. Afghanistan, Sudan, Nepal, DRC and Angola);
• States where governments are strong but are not committed to poverty reduction (eg. Burma and Zimbabwe);
• Gradually improving states (with occasional setbacks) (eg. Ethiopia and Yemen);
• States where development has stopped or is in decline (eg. Cote d'Ivoire).

The World Bank estimates that one billion people live in fragile or conflict-affected countries, and these states account for almost 40% of child deaths (World Bank 2008). It classed 34 countries as fragile states in 2007, and last year, Robert Zoellick, President of the World Bank, said that fragile states are the "toughest development challenge of our era" (ibid). Addressing the entrenched problems in fragile states is widely seen as a priority as the price of neglecting fragile states is higher than the cost of working with them, especially if war can be prevented. Chalmers (2004) has calculated that every £1 spent on conflict prevention saves the international community £4 in the long term. Furthermore, monitoring and reporting mechanisms are poor in fragile states, and this adds to the complexity of designing and implementing effective interventions.

In particular, fragile states have some of the worst health indicators and the weakest health services in the world. Services are disproportionately under-funded and funding is more volatile than in other developing countries. Providing healthcare and rebuilding health services in such countries is a complex and painstaking undertaking for national and local governments, civil society organisations and donor agencies. To help address this challenge, the Health and Fragile States Network was created in October 2007 to:
• Foster dialogue and debate
• Inform and influence policy
• Identify, stimulate and conduct research

The Network's Steering Committee includes representatives from DFID, the European Commission, Save the Children UK, the World Bank and the WHO, and its Secretariat is based at the London School of Hygiene and Tropical Medicine (LSHTM). The Network, together with the Health and Development Information Team and Eldis (both at the Institute of Development Studies, Sussex) recently published 'Health and Fragile States' – an online dossier describing the difficulties faced by fragile states and the strategies to overcome them. The report, funded by DFID, was launched on 2nd June at IDS – a leading global organisation for research teaching and communications on international development – and was discussed on 18th June at the London International Development Centre (LIDC) – a collaborative project which brings together social and natural scientists to facilitate original interdisciplinary research and training to tackle complex problems in international development.

The dossier begins by explaining why it is imperative to focus on fragile states, as populations in such countries 'suffer a significantly higher burden of disease and mortality'. It quotes DFID figures showing that fragile states are home to only 14% of the world's population, yet contain one-third of the world's maternal and under-five mortality, and a third of those living with HIV/AIDS in developing countries. DFID also estimates that the malarial death rate is nearly 13 times higher in fragile states than elsewhere in the developing world. Moreover, a large proportion of these populations live in rural areas with poor infrastructure (transport, water and sanitation) and high levels of illiteracy. These factors, according to the dossier, pose 'additional challenges' to delivering health services where poverty levels are also high, with families often living on less than $1 per person per day. Other obstacles to improving health services in fragile states include 'weak leadership', 'poor governance', ineffective regulation and oversight (a particular problem for acquiring reliable drugs and vaccines in sufficient quantities and at a reasonable cost), and the migration of the health workforce to the cities or out of the country.

The authors of the report continue by charting the two approaches to health service delivery in fragile states:
the humanitarian approach, which focuses on meeting the immediate health needs of a population; and the health systems strengthening approach, which focuses on building the government's capacity as the steward of the health system. They explain how, especially in conflict settings, health services are primarily provided through non-governmental organisations (NGOs), faith-based organisations and the private sector. In post-conflict Afghanistan, contracting out the delivery of a basic package of health services to NGOs has led to a rapid expansion of health service delivery.

The report also highlights how aid and donor agencies have historically concentrated on humanitarian inter­ventions, but this is changing as they realise the importance of strengthening health systems and long-term interventions. For instance, Médecins Sans Frontières pays increasing attention to reproductive health and mental health, as well as maintaining its primary focus on nutrition and the control of infectious diseases. Multilateral bodies and donors have responded with a series of initiatives to improve healthcare provision. In 2007, the WHO developed a Framework for Action comprising six health system building blocks:
• Good health service delivery;
• A well-performing health workforce;
• A well-functioning health information system;
• Equitable access to essential medical products, vaccines and technologies;
• A good health financing system;
• Leadership and governance to ensure the existence of strategic policy frameworks.

A consideration of these points will help to plan and set priorities when strengthening health systems. The Develop­ment Assistance Committee (DAC) of the Organisation for Economic Co-operation and Development (OECD) has also set out its guidance by drawing up 10 'Principles for Good International Engagement in Fragile States'. These include:
• Focusing on state-building as the central objective;
• Prioritising prevention;
• Acting fast, but staying engaged long enough to give success a chance;
• Avoiding pockets of exclusion.

The dossier supports such a focus on strengthening health systems and its position is unequivocal. Its authors (Olga Bornemisza, Egbert Sondorp, Annemarie ter Veen, all from the London School of Hygiene and Tropical Medicine; Nichola Cadge, Save the Children UK; Fiona Campbell, Merlin; and Steve Commins, IMC/UCLA ) state in the report: 'The creation of strong health systems is not an end in itself – it is a means to achieve better health outcomes. Effective and equitable health systems are not only required for achieving the Millennium Development Goals, but strengthening health systems is essential if the current increase in aid for health is to be well spent and sustained in the future.'