Every health programme strives for sustainable health outcomes but without building strong health systems developing countries will remain in a perpetual cycle of emergency relief and reliance on external support.
This is especially pertinent for the 50 or so states classified as fragile and post-conflict, in which a quarter of the world's seven billion people reside. These collapsed low-income countries, typically characterised by weak governance and limited institutional capacity for development, have some of the worst health statistics in the world.
Half of all child deaths before the age of five and a third of maternal deaths take place in fragile states (World Bank poverty analysis, 2010) and a lack of financial resources, skilled workers, commodities and infrastructure often against a backdrop of conflict and political unrest are largely to blame.
Tackling seriously eroded or nascent health institutions and making the transition from emergency humanitarian relief to the sustainable rehabilitation of health systems is a crucial and ongoing challenge for governments and development partners.
Starting off with emergency relief
Non-governmental organisations and local faith-based organisations play a crucial role in the early stages of recovery. Many are already well-established and involved in the delivery of health services in the absence of national health systems. Even after crises have been stabilised, NGOs often work alongside health ministries to restore and establish basic health services.
In war-torn Afghanistan, more than two thirds of the population can now access basic health services. NGOs, the Afghan Ministry of Public Health and donors have collaborated to train health leaders, increase the detection and treatment of disease and expand access to medicines, clean water and health information for the majority of the population.
Building government capacity and credibility
Governments and development partners face many challenges in the transition from providing urgent post-recovery support to establishing sustainable health systems and institutions.
An influx of international aid can result in disjointed efforts with immediate NGO support failing to align with longer-term health system capacity building. Reliance by donors and governments on external organisations does little to build indigenous capacity and may even contribute to a loss of capacity in cases when health professionals are lured away from the public health system.
The most successful projects provide immediate access to health services, while also building government legitimacy in the eyes of the population. An accountable, responsive and effective public health system is crucial to demonstrate the credibility of the government, particularly in neglected rural locations.
Through effective financial management, robust human resource strategies, policy-making and long-term operational capacity building, governments can ensure they play a central role in the delivery of health services and building a well-functioning health system.
The most successful donor programmes align their activities with national priorities. They work within the context of national health strategies and policies and they capitalise on existing sources of capacity by transferring expertise from NGOs to the public health system.
Country role models pave the way
A number of projects in fragile states are successfully demonstrating how health systems strengthening plans can be combined with providing immediate relief.
In post-conflict Liberia, the government sought technical assistance to enable it to improve its financial management and oversight of the national health system. Through pooled-funding from multiple donors the government introduced a national health plan, which provided funding for NGOs and FBOs to deliver services while ensuring their work aligned with government goals. Health services reached 82% of the population by 2010, cases of malaria dropped to less than 32% and the under-five mortality numbers were halved.
South Sudan has one of the worst maternal mortality rates in the world, and just 40% of the country's 10 million people live within five kilometres of a health facility. A DfID-led £120m health pooled fund, modelled on the Liberia project, is seeking to address these critical health challenges. Through managing the fund, we at Crown Agents are helping to improve community governance and ownership across the majority of states to provide health services and strengthen health systems.
NGOs and FBOs are progressively transferring the ownership of the health system to the government and we are overseeing the quality of those services with an emphasis on planning and management of fiduciary risk. We are also building capacity within the Ministry of Health to encourage government leadership, management capacity and to improve health information systems.
Achieving health outcomes are undoubtedly the main objectives of any health sector intervention but as these projects collectively demonstrate, without attention to health system strengthening, fragile states are at risk of remaining dependent on external aid and expertise. Government ownership of health systems promotes citizen engagement and builds legitimacy, achieving sustainable benefits for the health sector and beyond.
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