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Fragile States: Boosting Community Systems for an Effective Health Response

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Consider for a moment some of the countries currently making the news and the challenges that lie ahead in rebuilding infrastructures and services disrupted by internal conflict, chronic violence and protracted crisis: the Central African Republic, Somalia, South Sudan, Afghanistan...

The populations in these states are among the most vulnerable globally. Conflict and chronic poverty often reinforce each other leading to a vicious downward spiral.

However, conflict is not the only reason for state fragility. Fragility encompasses multiple dimensions - political, security, justice, economic, social and environmental. Fragile and transitional situations comprise a broad spectrum of contexts - from the one-party state of North Korea to war-torn Syria and relatively stable Bosnia and Herzegovina. Close to half of fragile states - 23 of 51 - are middle-income states and economies, and many of them are rich in natural resources.

In fragile states, health systems are weak or quick to collapse as health workers are forced to flee or are not sufficient, and supplies and equipment run out. Preventable diseases increase alongside malnutrition and, even where health services do exist, people are too afraid either to risk the journey to a clinic or have lost trust in them.

Strengthening the health response in fragile states is a humanitarian imperative and an entry point to help the transition from fragility towards more resilient states.

Local organizations play a crucial role in the early stages of recovery and after. Communities and the community health workforce, including volunteers, can hold health service providers to account and contribute extra hands to promote good health, prevent disease, provide care and support and reach out to vulnerable community members, particularly in the context of HIV, tuberculosis and malaria and fragile situations where health professionals are scarce.

In Somalia, for example, internal conflict spanning more than two decades has resulted in the disintegration of the country's infrastructure and significantly weakened the government's capacity to respond to the basic needs of the population. The strong cooperation between the Somali Red Crescent Society and the local health authorities has enabled hard to reach communities to access healthcare. Evidence shows that the organization has a proven track record in delivering health services to remote communities through its trained health volunteers and personnel network, in areas that cannot be accessed otherwise. For example, its immunization coverage among other services is higher than the national average.

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Community organisations have a unique ability to interact with affected communities to understand and respond quickly to their broader health needs. In some contexts, community systems operate outside of mainstream health systems in order to reach people who are marginalised or stigmatised. The communities and community health workforce bring local expertise, on-the-ground agility and established networks which are responsive to changing circumstances that fragility brings. When duly supported and protected, community health workers and volunteers can contribute to sustaining primary healthcare services in fragile states.

The Alliance for Community Health Initiatives (ACHI) is a national organisation working in South Sudan to provide services and build the capacities of other local organisations including government structures to respond to health problems. ACHI has been able to increase access to services for vulnerable populations in eight out of ten states in the country, and last year reached more than 130,000 beneficiaries, including groups most at risk of HIV, people living with HIV, women, children and young people, as well as supported coordination among local NGOs.

Innovative approaches to respond to health must include local community participation and assure sustainable funding, including an emphasis on human resources for health. While many fragile states are supported through international humanitarian agencies, there has been limited success to date in initiating locally-led responses to HIV and other health-related challenges and building long-term capacity.

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We need to work to link the community health workforce, including local organisations, networks - for example of people living with HIV - and community volunteers with national health systems. Involving health professionals in regular national and local disaster preparedness training and systems will ensure that they are fully equipped to respond to the needs of communities in crisis.

Some of the challenges experienced by communities are linked to security concerns and lack of predictable and sustainable funding. Donors need to be able to react quicker and provide more immediate and flexible funding channels to enable local organizations and others to carry out a better coordinated response.

Just some of the many reasons why the International HIV/AIDS Alliance and the International Federation of the Red Cross and Red Crescent Societies (IFRC) have agreed a new partnership to work together to improve health outcomes in fragile states, including meeting the needs of those living with HIV.

Supporting health and community systems in fragile states is key to promoting equitable access to health services. The road to recovery is always long in any post conflict scenario and community involvement with health service delivery is an important first step towards re-engagement with the state and a return to an effective civil society.


Join us in the conversation on 19 May, 6-8pm (CEST), as the discussion on the community health workforce in fragile states gains momentum at the side event of the 67th World Health Assembly. Follow the hashtags #FragileStates and #WHA67.