The document discusses lessons learned in health systems strengthening within fragile contexts, emphasizing strategies for improving maternal and child health outcomes in countries like Afghanistan and South Sudan. It highlights the importance of understanding local health issues, building capacity, and employing both formal and informal health systems. Additionally, it calls for adaptability, local stakeholder engagement, and the use of mobile technologies to enhance service delivery and accountability in challenging environments.

1. Lessons learned from health
systems strengthening in
fragile contexts
Juli Hedrick, MPH, Design and Development Officer
with Dr. Dennis Cherian, BHMS, MPH, MA Senior Director, Health
and Jonathan Papoulidis, Executive Advisor, Fragile States
World Vision

2. Health System Strengthening
Health systems strengthening: (i) the process of identifying and implementing the
changes in policy and practice in a country’s health system, so that the country can
respond better to its health and health system challenges; (ii) any array of
initiatives and strategies that improves one or more of the functions of the health
system and that leads to better health through improvements in access, coverage,
quality, or efficiency. (WHO)
Relief Resiliency and Recovery Development
Information Medical Products Financing Service Delivery
Health Workforce
Leadership and
Governance

3. Fragile States, Fragile Contexts
Broken social contract between state and society, broken institutions, and low resilience to shock
and stress
Fragile States Index: 50 most fragile states on a scored spectrum (World Bank, Fund for Peace)
WV is active in 32, with long term development programs in 17.
Fragile contexts: pockets of fragility that can occur in any state (consider Indonesia, Jordan, Lebanon)
Factors:
• Insecurity: war, conflict, drought, famine, flooding
• Instability: political, economic,
• Vulnerability: geographic or social access, extreme poverty, culture, gender, caste, tribe, religion
One-third of those living on less than one dollar per day currently live in fragile states; two-thirds
will be in fragile states by 2030. (G7+)

5. USAID Child Survival and Health Grants Program
Afghanistan Better Health for Mothers and Children Project
2008-2013
Goal:To achieve sustained improvements in the survival and health of mothers,
newborns and children Partners:The Herat Department of Public Health (DOPH)
Afghanistan Ministry of Public Health (MOPH), Bakhtar Development Network,
USAID Mission, Kabul Dimagi, Inc.
South Sudan Mother and Child HealthTransformation
Project 2010-2014
Goal: To reduce maternal, neonatal, infant and child mortality in Gogrial East and
West counties of Warrap state through three strategic objectives that aim to 1)
increase use of high impact low cost and feasible interventions for better maternal,
neonatal, infant and child health (MNCH) outcomes, 2) strengthen capacity of the
health system to deliver essential health services and 3) build and strengthen local
and national partnerships to sustain improvements in MNCH. Partners: South
Sudan Ministry of Health (all levels)
GogrialWomen’s Network, USAID, Juba Mission

6. Keep the design as simple as possible
• Get a thorough situational analysis of fundamental health issues but
also cultural and gender issues. Identify one or two most vital
barriers to knowledge, behavior, health care seeking, distance, no
provider, etc?
• Access (geographic, religious/ social, etc), quality, coverage. physical
or social. Gender, inequity, mobility. Population dispersion. Caste,
ethnic divisions. View every technical intervention – immunization,
HBLSS, etc. through equity lens.
• Use operations research to dig deeper on other interventions
• Design social interventions in addition to clinical care.
• Simplify the staffing and the budget

7. Build human resources for health
• Assess availability and local capacity. Likely extremely
limited – use short term volunteers, North/South or
South/South collaborations, training programs.
• CHWs bridge the gap between community and facility.
Work with low-level illiterate/ low literate frontline health
workers Communicate visually, tools, counting beads
• Plan for high staff turnover
• Explore the potential of mission hospitals as an extension
of the gov’t health facilities, pairing/ mentoring of staff,
motivation, commitment, areas of growth.

8. Use mobile technologies where possible
• Consistency in programming and reporting
• Allows for continuation in tenuous security situations
• In Afghanistan,WV taught frontline health workers to use
algorithms loaded onto mobile phones for improved maternal
health outcomes
• Not an option in South Sudan – won’t work everywhere

9. Work with the formal health system
• Find the conduit that works: may be technical
vs. political
• Link into or create coordination mechanisms: projects vs. system strengthening
• Use accountability measures: CitizenVoice and Action
In Bangladesh: a network of mother-led savings groups improved health and
nutrition outcomes by advocating for service delivery
In DRC,WV has an MOU with the government to use CVA as the
preferred method of social accountability. Over 500 officials from various
ministries have been trained to use the scorecard.

10. Informal: Community health workers and community health
systems – the best conduit of actual service delivery
Shura in Afghanistan, formerTBAs in South Sudan
Literacy – counting beads, tools
Supervision: provide local support
In an operations research embedded in a child survival grant in
northern South Sudan,WV used a supportive supervision model
to build capacity of illiterate frontline health workers.
Use mobile technologies where possible
consistency in programming and reporting
allows for continuation in tenuous security situations
In Afghanistan,WV taught frontline health workers to use
algorithms loaded onto mobile phones for improved maternal
health outcomes
Work with informal health systems

11. Merge the formal and informal
Joint meetings – rebuild relationships
Reports
High profile project visits
Monitoring and evaluation
Mandates and policies
Input from and reporting to all stakeholders
North/South collaboration

12. Security
• Be adaptable.
• Identify local stakeholders/ organizations, strong decision
makers
• Cultivate local ownership through use of advisory groups
– informed, equipped, aware of local situation. Best
advocates.
In Afghanistan, the shura (local health committee)
In South Sudan, the HHPs

13. ThankYou