'There is scope for incorporating resilience approaches into large-scale health interventions in fragile states.'
The COVID-19 pandemic reminds us of our mutual dependencies and long-standing commitments to help the world's most vulnerable people in the most fragile places. Now is the time for our humanitarian and development models and methods to catch up.
Against the backdrop of a global pandemic, and with only 10 short years to accelerate progress towards the Sustainable Development Goals (SDGs), it is imperative we push to make health systems fit for purpose in the hardest places.
There has been some movement in this direction. Yet, even with increased donor financing and technical support in the decade leading up to the 2030 SDG deadline, what has become increasingly clear is that the conventional approach to strengthening health systems is wholly inadequate to deal with the urgent needs of fragile states.
Even as the richest nations grapple with the debilitating effects of COVID-19, the chair of the Organisation for Economic Co-operation and Development's major donors group has cautioned against leaving the world's fragile states behind. As previous crises have waned, so too has international engagement. For example, in the wake of the 2013-2016 Ebola outbreak in West Africa, funding for humanitarian aid to the affected countries dropped 77 percent and there were no donor "nexus" commitments to support the ongoing strengthening of health systems in these fragile countries.
Without a long game on how to strengthen health systems in the hardest places, countries around the world will remain vulnerable to the current pandemic and future crises. Donors will also forfeit their pledge to "leave no one behind" in meeting the SDGs - putting millions of children and vulnerable communities at risk.
We must take action across the humanitarian, peace, and development nexus to move in five new directions to build more resilient health systems within especially fragile states.
Focus on multi-dimensional risks
The daunting challenge for health systems in fragile states is how to both provide ongoing health services and cope with multi-dimensional risks.
The World Health Organisation's "building blocks" have been the gold standard for strengthening health systems - helping to visualise and guide interventions in the areas of leadership, drug supply chains, human resources, service delivery, information systems, and financing. What's missing is a focus on identifying and managing complex risks and crises that disrupt health systems, including epidemics (or pandemics), conflict, disasters, climate change, and rapid urbanisation.
This focus is critical for fragile contexts, which by definition have higher risks and lower coping capacities at the state, system, and community levels.
For instance, although disease surveillance systems in fragile contexts are paradoxically better than in many less fragile countries, most hone in only on a specific disease. There is an urgent need to detect risks from multiple known and unknown diseases, including from crowd-sourcing and other non-traditional sources. Moreover, health systems must maintain functionality in the face of shocks and stress from conflict, disaster, and demographic pressures.
Resilient health systems are constructed with an awareness of how complex, overlapping risks will affect vulnerable groups and system performance, and are then able to focus on how to mobilise diverse coping capacities. The OECD's resilience systems analysis provides valuable guidance on mapping complex risks and diverse capacities.
The Democratic Republic of Congo demonstrates the need for a resilient approach. While its health system has focused on responding to Ebola, cases of measles rose to the point where the illness is now at the level of a national outbreak just as COVID-19 cases are also emerging. More broadly, the DRC is also dealing with protracted conflict, heavy debt burdens, food insecurity, flash floods, and displaced populations.
Boost social capital
Fostering resilience is not simply an exercise in technical support and funding. Political economies with entrenched patterns of clientelism, state capture, and marginalisation often leave vulnerable groups without access to social protections and basic services.
Efforts must be made to boost social capital - the norms and networks of cooperation that are the biggest deficit in fragile states and, which mounting evidence has shown, are the driver of resilience. Social capital can help increase community trust, perceived value, accountability, and agency in health systems - the demand side of the equation - which is key for success.
In the face of complex, interacting risks, fragile health systems must stitch together diverse capacities, drawing on skills across public institutions, the private sector, civil society, communities, and international partners.
These groups should help support three discrete functions:
- absorptive capacities to prepare, prevent, and withstand immediate shocks (often the role of communities and frontline responders);
- adaptive capacities to learn from past crises and improve communications, collective action, and coping mechanisms (often a collaborative effort across groups); and
- transformative capacities to reform features of the formal and informal system in ways that build surge capacities, failsafe mechanisms, multi-level decision-making and mutual accountability between government, the private sector, civil society and external partners.
Foster adaptive approaches
Most development interventions are based on preconceived solutions, metrics, and timelines that cannot change despite new insights, faulty theories of change, or operational disruptions from shocks or stress. This approach is doomed to fail in fragile contexts, given their high contextual complexity and recurring crises. Adaptive learning was the key variable in containing Ebola, according to recent analysis. Reformers must commit to more problem-driven and adaptive approaches to unpack complex political, economic, and social problems in fragile health systems and continually iterate solutions for improved resilience and service delivery. USAID, for instance, is pioneering efforts to incorporate complexity-aware theories of change and adaptive management into global programming to strengthen resilient health systems in fragile settings.
Build scalable solutions
While adaptive approaches are indispensable, they are often seen as labour intensive and hard to scale up. A major barrier to (adaptive) scaling is a misconception that it is a secondary process that follows a winning pilot project or breakthrough innovation. Scaling is most effective as an organising framework for collective action with a large scope, not for replicating small projects.
Afghanistan's basic package of health services is a successful case of outcomes-based scaling, which combined the political authorisation and programmatic oversight of the Ministry of Health with pooled donor funds and the diverse capacities of communities and implementing partners such as World Vision. The initiative met the country's 2015 Millennium Development Goal of halving infant and maternal mortality. Because the initiative was outcomes-based, partners were able to use different tactics, innovations, and programme models to adapt to rural, urban, conflicted, and disaster-prone areas. We argue there is scope for incorporating resilience approaches into large-scale health interventions in fragile states. Similarly, Ethiopia's national productive safety net demonstrates how livelihoods support and community health insurance can be layered together to promote wide-scale resilience.
Promote collective action at the country level
Resilience in the health sector relies on support from contributing sectors, including security, infrastructure, social protection, telecommunications, and the economy. Given the significant role that donor funding plays in supporting fragile health systems and other key sectors, development cooperation must be strengthened at the country level. Recent commitments by the World Bank, the UN, and the G20 to strengthen country platforms in diverse fragile states provide a critical opportunity to promote shared priorities and mutual accountability between governments, donors, implementing partners, and civil society to advance a resilience agenda across the humanitarian, peace, and development nexus. These platforms can also help to coordinate national efforts for a resilient health system with regional and multilateral platforms for global health security, pandemic response, and beyond. These cannot be top-down efforts, but must co-create and adapt solutions with communities, business, and local government to achieve resilient health outcomes.
The aid community's shift from a mindset that narrowly addresses fragility to one that helps build multidimensional resilience will take time and is not assured. Although the health sector has only recently begun to embrace a resilience paradigm, its leadership, resources, and expertise are essential to accelerating this shift.