FRAGILE STATES

STRENGTHENING HEALTH SYSTEMS IN FRAGILE STATES

Stronger health systems. Greater health impact.

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MSH’S TOP 10 PRINCIPLES FOR WORKING IN FRAGILE STATES

management sciences for health WWW.MSH.ORG

Saving lives and improving the health of the world’s poorest and most vulnerable people by closing the gap between knowledge and action in public health.

200 R IVERS EDGE DR IVEMEDFORD, MA 02155UNITED STATESTEL + 1 617 .250 .9500COMMUNIC ATIONS@MSH.ORG

Even during times of conflict there are ways to save lives in fragile states. MSH has developed the following principles as a guide to improving health and health systems in fragile states.

1. Incorporate a public health perspective and evidence-informed decisions to prioritize interventions. Even in situations where political insurgencies threaten lifesaving priorities, appropriate engagement can help guide ministries of health to make decisions using sound public health principles.

2. Balance immediate needs with long-term sustainability. Conditions in fragile states often require difficult choices between quick impact and longer-term, more sustainable interventions that can lead to greater future capacity. The key is to find balance.

3. Use high-impact, inexpensive interventions focused at the household level. Simple interventions, provided at the household level, such as oral rehydration solution and zinc to treat diarrhea, bed nets, and anti-malarial medications save lives.

4. Train community shop owners. Even in the midst of conflict, small shops selling medicines in difficult-to-access areas are often open for business. With basic training, shop owners can have significant impact even when public and NGO services are unavailable.

5. Build sustainable health workforces—especially women. Shortages of skilled health workers create one of the most daunting challenges in fragile states. Recruiting, training, and supporting health workers—especially women—to provide services at all levels is imperative to a state’s recovery.

6. Build leadership, management, and governance capacity. Effective leadership, management, and governance are critical to building sustainable health systems, particularly in fragile states.

7. Empower country-level ownership of decision-making. A government’s inability to deliver services should not lead to external agencies taking control of the health agenda. Inclusion of willing government and civil society organization partners is essential to sustainable solutions.

8. Work with senior health managers. Local knowledge is invaluable for elaborating effective local programs.

9. Performance-based incentives are effective. Well-implemented systems for performance-based incentives can keep health workers in fragile states working toward results even under extremely difficult conditions.

10. Partnerships are essential for success. In fragile states, partnerships among government, the private sector, donors, community organizations, and international organizations are particularly valuable. True country ownership is essential, since governance is usually weak and governments are often perceived as being controlled by well-meaning outsiders.

MSH’S WORK IN FRAGILE STATESThe greatest development challenges of the 21st century are found in fragile states, nations frequently stressed by civil unrest, natural disasters, or war. For 40 years, Management Sciences for Health (MSH) has helped build resilience in fragile states by improving access to and the quality of key health services, including family planning, maternal and child health, immunizations, and child nutrition services at facilities and in communities.

The myriad factors that perpetuate fragility require practical, unique solutions tailored to each country’s complex realities. MSH interventions address significant concerns that occupy the space between relief and development. We are currently managing 68 projects in 23 fragile states as diverse as Afghanistan, Haiti, and the Democratic Republic of the Congo.

WHY FRAGILE STATES?

Fragile states contain the majority of the world’s poor and the number is growing. Approximately 1.5 billion people live in fragile states. These countries have the lowest health indicators and are the furthest behind in meeting the Millennium Development Goals.

23FRAGILE STATES

68ACTIVE PROJECTS

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MSH’S WORK IN FRAGILE STATES

MSH partners with governments and communities to build resilient health systems. In Afghanistan, Nigeria, Democratic Republic of the Congo, and 20 other fragile states, MSH transfers practical skills—such as in leadership, governance, financing, and training local pharmaceutical vendors—that foster the resiliency communities need to survive and even thrive amid crises.

Building community-level resilience is essential to long-term development. Progress toward sustainability should be defined in part by our ability to support local capacity to overcome shocks and chronic stresses. Developing local organizations’ capacity to deliver basic services is essential to assist vulnerable populations in fragile states where governments are not capable of providing quality care. In countries as diverse as Afghanistan, Haiti, and Rwanda, MSH has helped build local capacity while improving services through performance-based financing for health services.

UNIVERSAL HEALTH COVERAGE AND FRAGILE STATES

Universal health coverage will never be attained without reaching into the

desperately underserved areas and among the most vulnerable populations

scattered within and throughout fragile states. MSH believes that health is a

human right and that universal health coverage cannot be achieved without

direct involvement in countries where that right is most threatened.

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BUILDING RESILIENT HEALTH SYSTEMS

GENDER INCLUSION

Transforming gender roles is essential to creating resilience and lasting change. The USAID, PEPFAR-funded Community-Based Support for Orphans and Vulnerable Children (CUBS) project in Nigeria, led by MSH, helped Brigid Egesi, a widow and mother of five, write a business plan and obtain a start-up loan of about $250 from a village savings group. She used the money to rent a building and obtain a pharmacy license and within 12 months she had opened a pharmacy, which serves her community and supports her family.

PRACTICAL SOLUTIONSMSH has developed tools and interventions for performance-based financing, capacity-building for local organizations, leadership and governance, initiatives supporting local drug sellers, and integrated community case management of childhood illnesses, that effectively address the specific needs of fragile states.

It is often the simple, local solutions that can have the most impact. For example, we save many lives just by improving access to common medicines, such as antimalarials, or simple remedies, such as oral rehydration therapy and zinc to treat diarrhea. However, working in fragile states requires a balancing act: partnering with colleagues and counterparts toward long-term sustainable solutions, while also addressing urgent needs. This dilemma often necessitates choosing between short-term interventions with quick impact and long-term solutions that can be more sustainable and have greater overall effect.

§ Either way, practical solutions must be tailor-made. For example, in Democratic Republic of the Congo, MSH, through the USAID-funded Supply Chain Management System (SCMS), helped build productive relationships with local suppliers of antiretroviral medications. By purchasing commodities locally, the project was able to reduce shipping time and costs, while supporting local businesses. In 2014, more than 22,500 Congolese are expected to receive treatment with antiretrovirals supplied by the partnership.

§ In Nigeria, the CUBS project has provided support to over 51,000 orphans and vulnerable children by funding and training local organizations and working with state ministries to establish long-term support. And in Rwanda, MSH has worked side-by-side with the Ministry of Health to redesign the community-based health insurance scheme and develop a national database to manage enrollment. Rwandans pay into the revised system on a sliding scale and the poorest citizens, about 25 percent of the population, now receive care free of charge, creating access to life-saving care for thousands of Rwandans.

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management sciences for health WWW.MSH.ORG

Saving lives and improving the health of the world’s poorest and most vulnerable people by closing the gap between knowledge and action in public health.

200 R IVERS EDGE DR IVEMEDFORD, MA 02155UNITED STATESTEL + 1 617 .250 .9500COMMUNIC ATIONS@MSH.ORG

www.msh.org/regions/fragile-states

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Management Sciences for Health (MSH) works to save lives by closing the gap between knowledge and action

in public health. Since 1971, we have worked with policymakers, health professionals, and communities in

over 150 countries to improve the quality, availability, and affordability of health services.

Go to the people

Live with them

Love them

Learn from them

Start with what they have

Build on what they know.

But of the best leaders

When their task is accomplished

The work is done

The people will all remark

We have done it ourselves.

—Lao Tzu

TAO OF LEADERSHIP