Health systems in fragile and conflict-affected states face significant challenges including limited availability of services, supplies, funding, infrastructure, and trained workers. Weaknesses are exacerbated in these settings and can indicate state fragility when service coverage is below average for countries with similar incomes or access is inequitable. To reduce fragility, health systems strengthening interventions in these contexts must meet population needs, build sustainable local capacity, enhance state legitimacy, and reinforce state authority.

1. better systems, better health
Health Systems Strengthening in Fragile
and Conflict-affected States: Introduction
Better Health Systems: Strategies that Work
Presentation Series at the Global Health Council
Derick W. Brinkerhoff
February 7, 2012
Abt Associates Inc.
In collaboration with:
I Aga Khan Foundation I Bitrán y Asociados
I BRAC University I Broad Branch Associates
I Deloitte Consulting, LLP I Forum One Communications
I RTI International I Training Resources Group
I Tulane University’s School of Public Health

2. Health Systems in FCS: A “Snapshot”
 Limited availability of services
 Limited drug/medical supplies
 Weak/no funding of salaries and recurrent costs
 Few and inadequately trained health workers
 Poor/destroyed infrastructure
 Donor/NGO-dominated planning and service delivery
 Weak/no government policy and regulatory capacity

3. Service Delivery and FCS
 Poor countries in general suffer from service delivery and
institutional weaknesses, including health services
 These weaknesses are indicators of state fragility when:
 A country’s service provision/coverage is significantly below
average performance for countries with similar income levels
 Service provision/coverage is inequitably distributed and
exclusionary

4. Absolute Service Delivery Failure
Thresholds
Service delivery indicator Average Standard State fragility thresholds
(poor deviation
countries)
At risk Failed
Child mortality rate 111.2 66.7 >177.9 >244.6
(per 1000 live births)
Primary school enrollment rate 72.1 21.1 <51.0 <29.9
(% of cohort)
Provision of improved water 69.8 17.2 <52.6 <35.4
(% of population)

5. Fragility Rankings
Country Authority Service Delivery Legitimacy
Afghanistan Failing n/a
Democratic Republic Failing Failing At risk
of the Congo
Liberia At risk Failing

6. Health Interventions in FCS

7. To Contribute to Reducing Fragility…
 HSS needs to
 Meet the health needs of
affected populations
 Build capacity of health
system to function
effectively and
sustainably
 Enhance state legitimacy
 Reinforce state authority

8. better systems, better health
Thank you
www.HealthSystems2020.org
Abt Associates Inc.
In collaboration with:
I Aga Khan Foundation I Bitrán y Asociados
I BRAC University I Broad Branch Associates
I Deloitte Consulting, LLP I Forum One Communications
I RTI International I Training Resources Group
I Tulane University’s School of Public Health