Capacity
Building
in
Fragile
States




By
Josephine
Garnem



Health
Systems
in
Fragile
States




There
is
no
official
international
list
of
fragile
states,
even
though
there
is
a
consensus
on
some
clear‐cut

examples,
 such
 as
 Zimbabwe,
 Somalia,
 and
 the
 Democratic
 Republic
 of
 Congo
 (DRC).
 However,
 the

Development
 Assistance
 Committee
 (DAC),
 the
 principal
 body
 of
 the
 Organization
 for
 Economic
 Co‐
operation
 and
 Development’s
 (OECD)
 for
 dealing
 with
 cooperation
 in
 developing
 countries,
 defines

fragile
 states
 as
 countries
 suffering
 from
 deficits
 in
 governance
 that
 thereby
 make
 conditions
 for

development
difficult.



[Text
box
–
Fragile
states
account
for
more
than
40
percent
of
child
deaths
and
15
percent
of
the
world’s

population.]



In
 fragile
 states,
 governments
 lack
 either
 the
 will
 or
 capacity
 (or
 both)
 to
 deliver
 services
 effectively.


Access
to
primary
health
care
remains
an
elusive
goal
in
fragile
states.


Donors
find
it
especially
difficult

to
 work
 in
 fragile
 states
 due
 to
 weak
 government
 capacity,
 low
 levels
 of
 human
 resource
 skills,
 and

uncertainties
over
the
transitions
from
emergency
to
developmental
assistance
programs.



Fragile
states
represent
a
particular
challenge
for
donors
and
NGOs.

A
shocking
example
of
this
is
that

fragile
states
produce
more
than
40
percent
of
child
deaths
worldwide
while
accounting
for
15
percent

of
 the
 world’s
 population.
 
 Fragile
 states
 also
 differ
 due
 to
 issues
 of
 staff
 security
 and
 the
 relative

potential
 for
 building
 up
 sustainable
 health
 systems
 dependent
 on
 the
 particular
 political
 context.
 
 A

current
example
of
this
would
be
that
Liberia
and
South
Sudan
seem
more
promising
than
the
Central

African
Republic
(CAR)
or
Darfur.





Because
 of
 all
 of
 the
 difficulties,
 one
 of
 the
 core
 principles
 of
 donating
 to
 fragile
 states
 is
 to
 stay

engaged,
 even
 through
 the
 toughest
 of
 circumstances.
 
 This
 is
 because
 it
 is
 not
 possible
 to
 invest
 in

health
worker
capacity
without
consistent
engagement.



Most
 least‐developed
 countries
 (LDCs)
 have
 woefully
 inadequate
 healthcare
 workforce
 and
 system

capacity.

Fragile
states
have
additional
burdens
of
political
instability
and
decayed
health
infrastructure.


Due
 these
 factors
 in
 fragile
 states,
 international
 NGOs
 are
 called
 upon
 to
 transition
 from
 service

provider
to
capacity
builder.



In
regards
to
building
up
health
systems,
in
terms
of
capacity
building
and
human
resources,
there
are

no
shortcuts
to
the
establishment
of
effective
health
programs
within
a
national
health
framework.

The

transition
 from
 fragility
 to
 effectively
 functioning
 health
 system
 takes
 many
 years.
 
 While
 there
 are

current
donor
and
government
commitments
through
the
Global
Health
Workforce
Alliance
to
address

health
 capacity
 over
 a
 decade
 long
 timeframe,
 in
 fragile
 states,
 it
 may
 well
 take
 a
 decade
 or
 more
 to

reach
what
is
a
‘starting
point’
for
others.



This
 means
 that
 a
 transition
 approach‐‐‐moving
 from
 fragility
 to
 a
 strong
 foundation
 in
 the
 health

sector‐‐‐‐requires
 accepting
 that
 changes
 are
 different
 from
 either
 emergencies
 or
 ‘normal’

development
processes.





This
does
not
mean
delaying
investment
in
health
worker
capacity
or
in
building
up
health
systems.

For

example,
 the
 roles
 of
 Ministries
 of
 Health
 may
 include
 a
 range
 of
 tasks,
 such
 as
 regulation,
 policy

framework,
 financing,
 allocation
 of
 resource
 priorities,
 managing
 contracts,
 and
 monitoring
 and

evaluation.

In
practice,
Ministries
of
Healthin
fragile
states
may
be
able
to
perform
only
a
few
of
these

functions
without
external
staffing
support.



Approaches
 to
 improving
 health
 capacity
 do
 not
 work
 at
 a
 single
 level.
 
 It
 is
 necessary
 to
 invest
 in

community
health
workers,
mid‐level
professionals,
and
government
officials.

It
also
means
recognizing

that
 capacity
 building
 is
 more
 than
 training
 ‐
 it
 requires
 ongoing
 mentoring
 and
 regular
 programs
 in

professional
 development
 and
 in‐service
 training.
 
 It
 also
 requires
 attention
 to
 strengthening
 the

Ministry
of
Health.



Such
cases
as
Afghanistan,
Timor,
Mozambique,
and
Cambodia
point
to
the
benefits
of
prioritizing
the

early
development
of
a
national
health
employment
scheme.
Three
criteria
for
such
a
scheme
stand
out:

(1)
it
reflects
the
larger
vision
for
the
society;
(2)
it
is
budget‐based;
(3)
it
is
realistic
in
terms
of
capacity

and
capacity
building
options.
Some
of
the
lessons
also
include
the
need
to
address
the
organizational

cultures
 of
 ministries,
 as
 some
 offices
 may
 have
 resistance
 to
 contracting
 with
 qualified
 service

providers.




In
the
health
sector,
because
of
the
particularly
broad
and
complex
mix
of
NGOs,
the
strengthening
of

the
 public
 sector
 requires
 a
 different
 set
 of
 approaches
 than
 in
 education,
 for
 example.
 The
 key
 in

building
 competent
 and
 accountable
 public
 health
 institutions
 resides
 in
 ensuring
 that
 the
 state
 can

have
broad
and
effective
oversight
of
the
health
sector.
In
health
more
than
other
sectors,
the
peculiar

‘new
public
management’
role
of
the
state
is
notable,
as
some
NGOs
should
be
connected
formally
to

the
 different
 levels
 of
 governmental
 health
 systems.
 The
 key
 point
 then
 is
 that
 in
 most
 fragile
 states,

there
will
be
a
continuing
dynamic
between
reducing
immediate
vulnerability,
achieving
specific
health

outcomes,
 building
 a
 more
 lasting
 and
 equitable
 health
 system,
 and
 building
 the
 capacity
 of
 health

providers.



Implementing
an
Integrated
Approach



International
Medical
Corps
typically
initiates
services
in
a
complex
humanitarian
emergency
setting
or

in
the
aftermath
of
a
disaster
and
then
designs
its
programs
to
provide
support
services
and
training
to

local
communities
and
health
institutions.

In
so
doing,
it
recognizes
the
phases
of
relief,
recovery,
and

development
 and
 their
 transitions
 are
 not
 discretely
 consecutive
 but
 often
 overlap,
 depending
 on
 the

specific
 regional
 or
 country
 context
 –
 something
 not
 regularly
 recognized
 by
 donors.
 
 International

Medical
 Corps’
 integrated
 approach
 brings
 together
 two
 different
 linkages:
 
 (a)
 between
 different

phases
of
programs;
and
(b)
between
different
levels
of
health
worker
capacity
and
health
systems,
such

as
community
health
workers,
mid‐level
health
workers,
local
community
based
partners,
and
Ministries

of
Health.



While
 International
 Medical
 Corps
 is
 widely
 recognized
 internationally
 as
 a
 significant
 force
 in

emergency
 relief
 to
 societies
 in
 conflict,
 its
 commitment
 to
 grassroots
 development
 in
 transitional

societies
and
in
contexts
of
post‐conflict
reconstruction
is
seldom
recognized.



Frequently,
 Village
 Health
 Committees
 (VHCs)
 represent
 the
 link
 between
 health
 care
 services
 and

beneficiaries
 upon
 which
 International
 Medical
 Corps
 builds.
 These
 VHCs
 and
 other
 civil
 society

organizations
are
vital
to
building
a
ground‐up
understanding
of
and
demand
for
democratic
processes

and
 good
 governance.
 International
 Medical
 Corps
 seeks
 to
 establish
 or
 reinforce
 VHCs
 in
 every

transitional
 context
 in
 which
 it
 works,
 like
 Liberia,
 Sierra
 Leone,
 Kenya,
 Uganda,
 and
 Burundi.
 
 In

Somalia,
 where
 International
 Medical
 Corps
 has
 worked
 since
 1992,
 the
 VHCs
 are
 essentially
 the
 sole

functioning
 health
 care
 system
 –
 based
 around
 reproductive,
 maternal,
 and
 primary
 health
 care

programs.
 They
 exist
 within
 a
 wider
 network
 of
 Village
 Development
 Organizations
 (VDOs),
 which
 cut

across
 multiple
 sectors,
 including
 education,
 animal
 husbandry,
 and
 water
 and
 sanitation,
 and
 can
 be

linked
to
alternative
livelihoods
programs.



Community‐based
 approaches
 to
 health
 care
 also
 provide
 International
 Medical
 Corps
 with
 a
 primary

point
of
access
to
the
state
at
the
district
and
regional
health
levels
where
support
can
also
be
provided,

such
 as
 to
 district
 health
 officers,
 clinical
 staff.
 
 
 In
 many
 such
 cases,
 national
 staff
 are
 trained
 and

deployed,
 using
 incentives
 where
 necessary
 while
 a
 variety
 of
 technical,
 financial,
 and
 operational

support
is
provided
to
the
state
systems.

 




Community‐driven
 development
 programs
 can
 strengthen
 local
 organizations
 and
 build
 social
 capital,

like
community
action
groups,
district
health
boards,
and
water
user
groups.

Social
funds
can
be
used
to

give
 communities
 and
 user
 groups
 a
 voice
 in
 project
 planning,
 budgeting,
 and
 supervision,
 while

boosting
capacity
for
self‐governance
at
the
base.




Participant
 communities
 are
 involved
 in
 prioritizing
 longer‐term
 activities
 through
 participatory
 needs

assessments
 prior
 to
 program
 implementation.
 
 Where
 integrated
 activities
 recover
 livelihoods
 and

secure
 disposable
 incomes,
 International
 Medical
 Corps
 has
 successfully
 established
 cost‐recovery

mechanisms
 and
 community
 financing
 schemes
 to
 assist
 communities
 to
 access
 health
 services
 when

International
Medical
Corps
exits
the
community.



International
 Medical
 Corps’
 participatory
 approach
 to
 community‐based
 primary
 health
 care
 seeks
 to

build
 capacity
 in
 poor
 rural
 communities
 to
 provide
 sustainable
 health
 delivery
 through
 community

mobilization
 for
 training
 and
 job
 creation,
 as
 well
 as
 by
 linking
 district,
 regional,
 and
 national
 health

authorities
in
health
policy
forums.





For
 example,
 by
 employing
 a
 community‐based
 strategy
 that
 focused
 on
 improvements
 to
 both
 the

supply
 and
 demand
 sides
 of
 the
 health
 care
 system
 in
 Azerbaijan,
 International
 Medical
 Corps

successfully
closed
the
gap
between
a
fragile
state’s
available
support
for
the
health
sector
and
the
local

health
care
needs
of
low‐income
families.




The
 project’s
 participatory
 approach
 to
 its
 planning
 and
 implementation
 stages
 with
 community

stakeholders
 –
 including
 Community
 Action
 Groups
 and
 Community
 Health
 Management
 Committees

established
 by
 International
 Medical
 Corps
 ‐‐
 gives
 the
 entire
 program
 a
 potential
 for
 replication

anywhere
in
the
world
where
there
is
a
need
for
improved
health
care
infrastructure
in
the
context
of

limited
economic
resources
and
a
dearth
of
health
care
financing
opportunities.





By
 delivering
 training
 to
 local
 providers,
 mobilizing
 communities,
 and
 strengthening
 local
 institutions

within
 this
 framework
 for
 capacity
 building,
 International
 Medical
 Corps
 is
 able
 to
 significantly

strengthen
the
health
sector
and
increase
access
to
quality
health
services.



Partnering
With
the
Ministry
of
Health



International
Medical
Corps
has
found
that
interactions
with
the
Ministry
of
Health
at
a
national
level

are
as
vital
as
those
at
the
local
level
in
bringing
about
change.





By
 collaborating
 closely
 with
 the
 Ministries
 of
 Health
 in
 Sri
 Lanka,
 Indonesia,
 Lebanon,
 Pakistan,
 and

Sierra
Leone
at
both
regional
and
central
levels
to
influence
practice
and
policy,
International
Medical

Corps
 reinforced
 its
 mental
 health
 training
 activities
 for
 health
 providers
 at
 the
 local
 level.
 
 With
 the

resulting
 local
 activities,
 amendments
 to
 national
 policies
 to
 include
 mental
 health
 into
 basic
 primary

health
 packages,
 and
 additions
 to
 medical
 and
 nursing
 school
 curricula,
 International
 Medical
 Corps’

training
 programs
 successfully
 served
 to
 create
 enduring
 mental
 health
 service
 delivery
 within
 the

primary
care
framework.



Building
the
Capacity
of
Local
Partners



In
 keeping
 with
 its
 mission
 to
 promote
 self‐reliance,
 International
 Medical
 Corps
 partners
 with
 local

NGOs
 and
 community‐based
 organizations
 and
 builds
 their
 management
 capacity
 to
 provide

appropriate
results‐oriented
programs
in
line
with
best
practice
interventions.



These
 partnerships
 build
 local
 capacity
 by
 creating
 strengths
 that
 offset
 disaster‐related
 vulnerability.


For
 example,
 International
 Medical
 Corps
 provided
 technical
 and
 management
 training
 to
 numerous

Kenyan
organizations
following
the
bombing
of
the
U.S.
Embassy
in
Kenya,
such
as
St.
Johns
Ambulance,

Kenyatta
 National
 Hospital,
 Nairobi
 City
 Council
 Ambulance
 Service
 and
 Fire
 Brigade,
 and
 the

Resuscitation
 Council
 of
 Kenya.
 
 Following
 the
 Tsunami
 in
 Indonesia,
 International
 Medical
 Corps

partnered
 with
 a
 national
 first
 responder
 ‐
 Ambulan
 118
 –
 to
 build
 the
 logistic
 and
 administrative

systems
 that
 would
 allow
 it
 to
 deploy
 resources
 more
 rapidly
 –
 something
 it
 did
 very
 effectively

following
the
earthquake
in
Yogakarta
in
May
2006.





Building
Capacity
in
Fragile
States



Because
 of
 their
 difficult
 context,
 fragile
 states
 require
 considerable
 thought
 and
 planning
 when
 it

comes
to
investing
in
and
implementing
relief
and
development
work.

Engagement
at
all
levels
–
from

government
 health
 workers
 to
 the
 Ministry
 of
 Health
 and
 to
 local
 NGOs
 –
 is
 critical
 and
 a
 long‐term

vision
 as
 to
 how
 these
 activities
 will
 play
 out,
 from
 beginning
 to
 end,
 will
 help
 greatly
 in
 program’s

success.

This
is
partly
because,
in
these
environments,
it
will
likely
take
a
long
time
to
implement
the

project
 according
 to
 international
 standards,
 while
 some
 partners
 may
 not
 have
 the
 capacity
 to
 carry

out
 key
 activities
 and
 meet
 goals
 as
 expected.
 
 Despite
 these
 challenges,
 sustainable
 progress
 can
 be

made
within
these
environments,
particularly
if
the
focus
is
on
providing
immediate
relief
while
enabling

self‐reliance
through
training
and
capacity
building.



[Text
box
‐

Lessons
Learned]

• Work
with
a
long‐term
vision
from
the
beginning
of
the
engagement
in
health
services.

• Engage
the
local
government
healthcare
staff
to
provide
the
information
on
priority
health

topics
and
provide
medical
expertise.

• It
takes
a
long
time
to
build
partner
capacity,
and
to
help
them
to
implement
the
project

according
to
international
standards
and
requirements.


• Not
all
local
partners
have
sufficient
capacity
to
implement
projects
effectively
and
meet
key

goals
within
additional
support
and
mentoring.



International
Medical
Corps

International
 Medical
 Corps
 was
 established
 25
 years
 ago
 by
 volunteer
 doctors
 and
 nurses
 as
 a
 non‐
profit,
 voluntary
 organization.
 Its
 mission
 is
 to
 improve
 the
 quality
 of
 life
 for
 vulnerable
 populations

through
 health
 interventions
 and
 related
 activities
 that
 build
 local
 capacity
 in
 underserved
 areas

worldwide.
 
 International
 Medical
 Corps
 provides
 health
 care
 through
 training
 and
 rehabilitates

devastated
health
care
systems
and
helps
bring
them
back
to
self‐reliance.



About
the
Author



Josephine
Garnem
came
to
International
Medical
Corps
in
1999
when
her
country,
Sierra
Leone,
was
at

civil
 war.
 
 She
 joined
 a
 small
 team
 that
 helped
 build
 and
 sustain
 one
 of
 the
 country’s
 most

successful
health
care
programs,
where
survivors
of
the
conflict
were
offered
basic
health
care

and
 post‐traumatic
 stress
 counseling
 and
 child
 soldiers
 and
 young
 women
 could
 receive

complex
surgical
interventions.

The
program
also
trained
traditional
birth
attendants
in
proper

delivery
methods,
dramatically
reducing
the
mortality
rate
for
children
and
mothers,
and
most

of
the
Ministry
of
Health
nurses,
many
of
whom
are
still
serving
their
communities.

She
now

works
for
International
Medical
Corps
in
Washington,
DC,
managing
all
goods‐in‐kind
donations

for
the
organization.