In fragile states, particularly those that have experienced extended periods of conflict, health systems have typically been seriously eroded and damaged. Health infrastructure is destroyed, or is not functional. This policy brief by USAID’s Health Systems 20/20 Project focuses on the transition from emergency assistance and relief to strengthening the health system for the long term, and the role of non governmental organisations and how they can help fragile states to rehabilitate their health systems. The author illustrates how there is general agreement on the broad features of state fragility, but as a category it contains significant variation. Thus, transition strategies and interventions need to be contextualised for particular country situations.
The author shows how experience in many fragile states has led to the identification of several critical issues that affect the possibilities for successful transitioning, from responding to immediate health needs to ultimately supporting health system strengthening. The brief explains how decisions taken early in rehabilitation efforts influence subsequent possibilities and options. It also discusses how donor procedures and funding mechanisms create roadblocks for sustainability-enhancing investments. Specific activities are discussed which transitional programming needs to take into account. These include the need to rebuild sustainable public health system capacity and the importance of identifying and capitalising on existing sources of capacity. The author concludes that without attention to health system strengthening, fragile states cannot move beyond dependence upon external resources and expertise to sustain improvements in health outcomes.