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Unlocking Progress in Fragile StatesOptimising high-impact maternal and child survival interventions

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UK

Unlocking Progress in Fragile StatesOptimising high-impact maternal and child survival interventions

320 million children are growing up in fragile states – countries affected bychronic poverty, the abuse of human rights, poor governance and conflict.

This report aims to:• raise the profile of the threats to children living in fragile and

conflict-affected states• better understand the constraints and opportunities in these countries• document innovative and effective approaches.

Working in fragile states brings many challenges. But there are opportunitiesfor positive change. While context is clearly crucial, it is nevertheless possibleto draw lessons from countries that are making progress. This discussionpaper identifies and documents approaches that are working in fragile statesprogressing towards achieving the United Nations’ Millennium DevelopmentGoals 4 and 5 – on reducing child and maternal mortality.

The report documents key bottlenecks to optimising high-impact healthinterventions, particularly in the poorest and most vulnerable populations,and recommends ways to ‘unlock progress’. It focuses on the health aspects of child survival rather than on broader social determinants, and draws onavailable literature, key informant interviews and a comparative analysis ofcase studies from Liberia, Nepal, Nigeria, Guinea Bissau and Zimbabwe.

Unlocking Progress in Fragile StatesOptimising high-impact maternal and child survival interventions

Published bySave the Children UK1 St John’s LaneLondon EC1M 4ARUK+44 (0)20 7012 6400savethechildren.org.uk

First published 2010

© The Save the Children Fund 2010

The Save the Children Fund is a charity registered in England and Wales(213890) and Scotland (SC039570). Registered Company No. 178159

This publication is copyright, but may be reproduced by any methodwithout fee or prior permission for teaching purposes, but not forresale. For copying in any other circumstances, prior written permissionmust be obtained from the publisher, and a fee may be payable.

Cover photo: Conneh clinic dispensary, Liberia. (Photo: Anna Kari)

Typeset by Grasshopper Design CompanyPrinted by Page Bros (Norwich) Ltd

Save the Children is the world’s independent children’s rights organisation.We’re outraged that millions of children are still denied proper healthcare, food, education and protection and we’re determined to change that.

This report was written by Regina Keith and Nichola Cadge.

Contents

Acknowledgements iv

Abbreviations and acronyms v

Key facts vi

Executive summary vii

Introduction 1

Progress 4

Health aid architecture 11

Which countries are regressing and why? 5

Health system strengthening 13

Conclusion 19

Recommendations 20

Annex: health indicators for fragile states 21

Bibliography 22

Notes 24

Many thanks to all those who took part in focus group discussions,key informant interviews and answering the short questionnaire.Particular thanks go to Susan Grant and the Save the ChildrenLiberia team, including communities and partners in Bong countyand Monrovia. A special note of gratitude to the HonourableMinister Dr Gwenigale and his team in the Ministry of Health inLiberia for contributing to the study despite other demands ontheir time.

Acknowledgements

v

ART anti-retroviral therapy ARV anti-retroviralBPHS basic package of health services CAR Central African RepublicCHW community health worker CMAM community-based management of acute malnutrition CM community midwife CSO civil society organisationDAC Development Assistance Committee (of the OECD)DFID UK’s Department for International Development DRC Democratic Republic of Congo EU European Union FBO faith-based organisation GAVI Global Alliance for Vaccines and Immunisation HR human resources LICUS low-income countries under stressMDG Millennium Development GoalMNCH maternal newborn and child healthMoH Ministry of Health NGO non-governmental organisation OECD Organisation for Economic Cooperation and DevelopmentORT oral rehydration therapyPBF performance based financing PHC primary health care PMTCT prevention of mother-to-child transmission TBA traditional birth attendant UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organization

Abbreviations and acronyms

vi

• Nearly 320 million children live in fragile or conflict-affected states.

• Although fragile states have only 14% of the world’s population,they represent approximately:– 35% of the world’s poor– 51% of children dying before the age of five– one-third of under-nourished children– 46% of children out of school– 44% of maternal deaths.

• The proportion of people living with HIV is four times greater and the malaria mortality rate 13 times greater in fragile states than in other developing countries.

• Of the World Bank’s LICUS countries, 90% of the 26 countries haverecently been involved in a war or are currently undergoing a crisis.Post-war states have a 40% risk of relapsing in the first ten years.

• More than 2 million children have died over the past decade as a direct result of armed conflict.1

• During a typical five-year war, infant mortality increases by 13%.2

• In 2006, 25 of the 39 serious food emergencies were due to conflict and its aftermath or a combination of conflict and natural hazards.

• In sub-Saharan Africa, the number of undernourished people increased by 37 million between 1991 and 2002, the latest reference period.This increase can largely be attributed to the changes in five war-torncountries, which accounted for 78% of the total increase.

• Fragile states received 43% less aid than their health and poverty indicators demand.3

Key facts

vii

Children born in states considered fragile are morelikely to be malnourished, uneducated and abused,and to lack access to essential requirements for life including water, sanitation, food and healthcare.This report attempts to capture the positiveinterventions that are beginning to show impacteven in these challenging contexts. It captures which interventions are leading to progress, withthe understanding that all countries are unique;hence, context must always be reflected upon whenmaking decisions about health service provision.

Stopping preventable deaths does not requireexpensive and complex healthcare; it needssustained support to deliver simple, cost-effectivesolutions such as exclusive breastfeeding, access toimmunisations and bed nets, and the diagnosis andtreatment of pneumonia, diarrhoea and malaria.Infants that are breastfed are six times more likelyto survive than infants that are not breastfed4 but,on average, only 24% of children in fragile states areexclusively breastfed, while only 12% sleep underinsecticide-treated bed nets (to prevent malaria),only 42% of children seek care when they havepneumonia, and 39% take oral rehydration solutionwhen they have diarrhoea.

Using the 2007 OECD/DAC list of fragile states,six states considered fragile have reduced theirunder-five mortality rates by 50% or more since1990 rates and are on track (or almost on track) for achieving their MDG 4 target: Indonesia, Laos,Eritrea, Comoros, Haiti and Liberia. However, fivefragile states have increased their under-fivemortality rates since 1990, with, variously, continuedconflict, political instability, high HIV impact and lackof focus on child and maternal healthcare. Kenya,Congo, Cameroon, Chad, and the Central AfricanRepublic (CAR) have more health workers and

Executive summary

higher levels of health expenditure than other fragile states, but their child mortality rates haveincreased in recent years.

Liberia focused on improving the number of skilledhealth workers in rural health facilities, whileincreasing political will, resources and coordination.There is growing evidence that delivering servicesfree at the point of access (Liberia, Burundi, Nepal,Sri Lanka and Uganda5) has had a positive impact on service utilisation, health-seeking behaviour andhealth outcomes. Interventions that are integratedinto other programmes can increase coverage forboth interventions.6 Increased focus and resourcesfor measles has led to a dramatic reduction indeaths. Coverage of immunisation averages morethan 66% in fragile states. This attests to the factthat progress can occur in the most difficultsituations. Even countries in open conflict havenegotiated harmony days, or ceasefire agreementsto allow for national immunisation campaigns.

Malnutrition is associated with more than one-third of all child deaths, and in fragile states morethan one-third of the population is malnourished.Increasing the diets of pregnant women – evenslightly – improves their children’s survival rates and development. There is now evidence to showthat few women in fragile states can afford a healthy diet.7 Giving nutrition advice does not lead to changes in diet if women cannot afford it. InAyeyarwaddy division in Myanmar (Burma), aroundhalf the studied families lived on around US$1.08per day, but a healthy diet would cost US$1.15 perday (more than the average day salary).8 Cashtransfers, on the other hand, were shown toimprove nutrition, food security, access to water,and access to health in Niger, Ethiopia, Mexico,Peru and Bolivia.9

Adding micronutrients (such as zinc,Vitamin A,iron, folic acid and iodine) to supplement women’sand children’s diets can also help to reduce child and maternal deaths. The fragile states of Nepal and Indonesia have increased their coverage of Vitamin A by including it in child health days; Nepalhas achieved 93% coverage, and Indonesia 86%.

To reduce the impoverishing nature of ill health and high death rates, more resources need to beinvested in strengthening national health systems,and in developing a long-term vision as well asshort-term strategies. Evidence from Liberia, Nepaland Myanmar (Burma) indicates that developing astrategic framework and national plans and policiesas early in the post-conflict transition phase aspossible helps to increase confidence in thestrategic direction of the health sector.

Overall, Liberia, Sri Lanka and Cambodia, states thathave secured senior political leadership and focusedon developing equitable health policies and buildingresponsive primary healthcare services, have shownthe most progress.10 Afghanistan and Liberia, whichhave chosen to implement only a basic package ofhealthcare due to budget and capacity constraints,have targeted priority diseases like pneumonia,diarrhoea and malaria, and are seeing improvements.While other countries that have spent timedeveloping new health policies and plans, likeNigeria, Sierra Leone and DRC, without ensuringthat key services are maintained, have seen little to no progress in child health outcomes. Anothercritical factor for success was the development ofpro-poor maternal and child health policies with afocus on the removal of user fees at the point ofdelivery to increase access, the importance ofworking with communities, and the centrality ofpolitical will and additional, flexible resources.

Overall, there needs to be increased accountableleadership and political commitment, supported byincreased volume, quality and predictability of aidand domestic resources and efforts to ensure that resources reach the most poor, vulnerable,marginalised and hardest-to-reach areas. Thetransition period needs to see maintained focus

on service delivery, while developing plans andpolicies for the long term. Strong coordination,harmonisation and alignment between partners has been shown to reap rewards, as in Liberia, butcoordination and alignment is a major weakness in many fragile countries. The active involvement of the community in the planning, implementationand monitoring of health services, can make thedifference between success and failure, and hasplayed a significant role in the delivery of healthservices in countries like Nepal.

A renewed analysis of the scale and contribution of fragile states to maternal and child mortality,given that more progress on all the health MDGshas been witnessed in non fragile states, is urgentlyneeded. Operational research into innovativeapproaches to overcome obstacles to health service delivery and exploring the impact that newpolicies like free healthcare, contracting-out andperformance-based funding have on health servicesin the medium and long term in the context offragile states.

The response to maternal and child mortality infragile states would be greatly strengthened, bemore efficient and have greater impact if there wasmuch greater collaboration between stakeholdersworking on fragile states and those working onmaternal, newborn and child survival.

This report has attempted to capture whichinterventions are leading to progress. However,central to this is the understanding that all countriesare unique, and hence country context and a robustsituation analysis are essential to making decisions,and designing and evaluating appropriate healthsector responses to reducing maternal, neonatal and child mortality. Success is possible, and partnersneed to learn from and build on that success.But women and children can’t wait, and nationalgovernment and the international community musturgently ramp up efforts to accelerate progress in fragile states to have an impact on reducingunnecessary child deaths in the world’s mostvulnerable communities.

viii

UNLOCKING PROGRESS IN FRAGILE STATES

320 million children are growing up in fragile states– countries affected by chronic poverty, the abuse of human rights, poor governance and conflict.Working in fragile states brings many challenges;however, there are opportunities for positivechange. Context is crucial, but it is possible to drawlessons from countries that are making progress.

The purpose of this discussion paper is to identifyand document approaches that are working in thesestates progressing towards achieving MillenniumDevelopment Goals 4 and 5. The report willdocument key bottlenecks to optimising high-impacthealth interventions, particularly in the poorest andmost vulnerable populations, and will recommendways to ‘unlock progress’. The report focuses on the health aspects of child survival rather than on broader social determinants, and draws onavailable literature, key informant interviews and acomparative analysis of case studies from Liberia,Nepal, Nigeria, Guinea Bissau and Zimbabwe. Forthe purposes of this report we have used the 2007DAC list of fragile states.11

Save the Children has 90 years’ experience ofworking in countries that are considered fragile.Programme implementation, policy and advocacy are core parts of Save the Children’s strategy.This report aims to raise the profile of the threatsto children living in fragile and conflict-affectedstates, to better understand the constraints andopportunities in these countries, and to documentinnovative and effective approaches.

What are fragile states?

There is debate concerning the value of definitions.Fragile states are characterised by political instability,corruption, poor governance, low acceptance of therule of law, conflict, degraded infrastructure, pooraccess to basic services, migration of skilled workers,weak economic growth and extreme poverty.The World Bank estimates that while only 9% of the developing world’s population live in fragilestates, these states account for 25% of those living in extreme poverty. From 1990 to 2002, the grossdomestic product (GDP) per capita of fragile stateswas broadly flat, while that of other developingcountries grew at 1.17% a year in real terms.

More recently, the potential spill-over effects fromfragile states have become a key area of concern inthe global health security agenda. These includeconflict, instability, organised crime, migration,human trafficking and epidemic disease outbreaks.

The UK’s Department for InternationalDevelopment (DFID) defines fragile states ascountries that are unable or unwilling to provide the essential services required by its population.12

Save the Children defines fragile states as those thatare unable or unwilling to create the economic,social and political conditions in which the rights of children can be realised.13

Scale of the problem

Fragile states are home to 15% of the world’spopulation,14 yet they account for one third of thoseliving in absolute poverty, a third of maternal deaths,half of child deaths under five, and one-third of

1

Introduction

people living with HIV. Approximately 8.8 millionchildren globally died in 2008 due to preventablecauses such as birth complications, pneumonia,diarrhoea, malaria, HIV and measles.15 Nearly 4 million of these children were in fragile states.16

The ten countries with the highest rates of childdeaths have all emerged from conflict in the lastdecade (see Table 1). Conflict leads to an inability toeffectively respond to the needs of the population.More than 2 million children have died over the pastdecade as a direct result of armed conflict.17 A five-year war can lead to infant mortality increases of13%.18 Many fragile states have been engaged in, orhave been transitioning from, conflict or insecurity.

More than half of these deaths occur in threecountries – Nigeria, DRC and Afghanistan. Thesethree countries also account for 117,000 maternaldeaths each year.Vaccine-preventable diseasesaccount for about 25% of deaths amongst childrenunder five, and nearly half of the children in fragilestates are not fully vaccinated. The malaria mortalityrate is 13 times greater in fragile states than inother developing countries.19 More than one-thirdof all children who die before their fifth birthday aremalnourished. One in three people living in fragilestates are malnourished.20

Fragile states, the right to health and MDGs 4 and 5

The UN Special Rapporteur for the Right to Healthoutlined the right to health as “a right to an effectiveand integrated health system, encompassing healthcare and the underlying determinants of health,which is responsive to national and local prioritiesand accessible to all”.21 Every government in theworld has signed up to at least one internationalhuman rights instrument that recognises the right to health. As such, governments, as the key duty-bearer to citizens, are obligated to respect, protectand fulfil the right to health for their citizens.Progressive realisation of the right to health infragile states poses significant challenges; yet theobligation to take concrete steps does not rest with the government alone. The internationalcommunity is also obliged to support countries intheir attainment of the right to health.

In 2000, global leaders agreed on eight goals tobegin to address growth global inequalities. TheMillennium Development Goals have specifictargets, are time-bound and, importantly, have thecapacity to mobilise domestic and internationalresources, national governments and civil societytowards common causes – and so are potentially

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UNLOCKING PROGRESS IN FRAGILE STATES

Figure 1: causes of under-five deaths

Source: WHO (2009) Child and Adolescent Health and Development: Progress report 2008: highlights WHO Geneva

NCD 4%

Other infectious diseasesand worms 9%

HIV and AIDS 2%

Measles 4%

Malaria 7%

Diarrhoeal causes 16%

ARI 17%

Neonatal deaths 37%

Injuries 4%

Table 1: MDG 4 progress in the fragile states with the highest child mortality rates

Country Under-five Conflict MDG 4 MDG targetmortality rate 1990:2007

1 Sierra Leone 262 1991–2000 290:262 Target 97 (very off track)

2 Afghanistan 257 1978–(ongoing) 258:257 Target 87 (very off track)

3 Chad 209 1988–(ongoing) 201:209 Target 67 (increasing)

4 Guinea Bissau 198 1998–1999 240:198 Target 80 (off track)(ongoing insecurity)

5 Nigeria 189 1967–70; 230:189 Target 77 (off track)riots and coups until 2001

6 Burundi 180 1993–2003 189:180 Target 63 (off track)

7 CAR 172 2003–2007 171:172 Target 58 (increasing)(ongoing)

8 DRC 161 1996–2001 200:161 Target 66 (off track)(ongoing insecurity)

9 Angola 158 1975–2002 258:158 Target 87 (off track)(ongoing)

10 Guinea 150 2007 (unrest); 230:150 Target 78 (off track)2008 coup (bloodless)

a powerful instrument in the fragile states context.Despite progress in the health MDGs in somefragile states, the 2008 Global Monitoring Reportstated that “on current trends, most countries areoff track to meet most of the MDGs, with those infragile situations falling behind most seriously”.22

The World Bank’s Global Monitoring Report in 2007 similarly concluded that “Despite theenormous challenge of poverty in fragile states,progress against the MDGs is possible.”

MDG 4 seeks to reduce child deaths by two-thirdsby 2015 from 1990 levels. Globally, fewer childrenare dying; since 1990 there has been a 27%reduction in child deaths. However, only five fragilestates are on track to reach their MDG 4 target:Comoros, Laos, Indonesia, Haiti and Eritrea. These

countries also have the lowest child mortality ratesamong the OECD/DAC fragile states (the impact ofthe 2010 Haiti earthquake on child mortality rates is not yet known).

The fragile states that have the highest childmortality rates have all undergone conflict orinsecurity in recent years. Four countries have seen their child mortality rise since 1990: Kenya by 24%, Congo 21%, Chad 8% and Central AfricanRepublic 1%. The latter three countries have had ongoing conflict and low levels of politicalcommitment and resources invested into health systems. The case of Kenya in particulardemonstrates how fragile progress can be, and how significant declines can be witnessed in arelatively short space of time.

3

INTRODUCTION

The constraints on effective health service delivery in fragile states are enormous – weak systems, lack of capacity, low staff morale, weak monitoring andevaluation systems, an unregulated and oftenproliferating private sector, and regressive healthfinancing policies. Access barriers are also significant– insecurity, marginalised and under-served areas,financial barriers, lack of information, and gender and cultural constraints. Underlying this are morecomplex root causes – poverty, poor governance,lack of political will, and conflict. There is frequentlya lack of coordination between donor programmesand vertical funds, and a poor alignment of policies and strategies by different agencies and the government.

However, Liberia, Laos, Indonesia, Eritrea, Comorosand Haiti are all making progress, and reduced theirunder-five mortality rates by around 50%, and areon target to reach MDG 4. Liberia, for example, hasreduced its child mortality rate from 235 per 1000in 1990 to 111 in 2009.

The context of health system capacity, burden of disease analysis, cultural and social norms, security,and geographic access must be taken into accountwhen planning for, and prioritising the delivery of,interventions to reduce maternal and child mortalityin fragile states. In Asia, action is particularly neededto improve the health of mothers and newborns.In Africa, infectious diseases are responsible foraround 60% of child deaths.

While context is key to designing any health sectorresponse in fragile states, the following case studiesfrom Liberia, Nepal, Guinea Bissau, Nigeria andZimbabwe, and from the child survival and fragile

states literature, attempt to identify some of the key lessons that have facilitated progress and helped to reduce child deaths in fragile states, and theyattempt to identify notable gaps.

Evidence-based interventions

The direct causes of child and maternal mortalityand the package of high-impact, cost-effectiveinterventions have been the subject of extensivestudy. There are 37 key, low-cost, high-impactpromotional, preventive and treatment interventionsand strategies that significantly reduce maternal,neonatal and child deaths. They are deliveredthrough different levels of the household-to-hospitalcontinuum of care. Scaling up these interventionsmust take into account the specific epidemiologicalpriorities of the women and children and addressdemand-side barriers such as cost, distance andtrust. This can only happen when countries develop their plans based on the data collectedfrom functioning health systems, working closely with the communities they serve. Up to 20% ofneonatal deaths and 40% of child deaths could beprevented by scaling up these services.23 Uptake of these interventions in fragile states is less welldocumented and analysed, and the followingattempts to draw out the data and experiences on a few selected interventions.

Sixteen interventions have been shown to preventup to 72% of neonatal deaths with universalcoverage.24 These interventions include, for themother, folic acid supplementation, maternal tetanusvaccination, intermittent preventive treatment toprevent malaria, and safe delivery. For the newborn,

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Progress

5

PROGRESS

Liberia – case study

After 14 years of conflict, Liberia has been makingsteady progress in health and governance. Althoughthe country has maintained relative peace in the last six years, it has been supported by more than10,000 UN peacekeeping personnel. The governmenthas been in place for four years; the next electionsare scheduled for 2011. Up to 64% of the populationcontinue to live below the national poverty line.Unemployment and underemployment remain aserious problem, especially amongst young people.

Today, the under-five mortality rate is 111 per 1,000live births, compared to 235 in 1990. The infantmortality rate has reduced from 139 to 72 per1,000 live births. But access to skilled healthcare isstill mostly limited to those in urban areas. Thereare only 50 doctors in Liberia for 3.5 million people

(one doctor per 70,000 people) – largely due tohigh levels of migration during the war – and mostof these doctors live and work in urban areas.

The most notable areas of progress in child healthservices are increased immunisation coverage,increased use of oral rehydration therapy (ORT) and insecticide-treated bed nets (6% toapproximately 36%), increased access to treatmentfor malaria within 24 hours, and more rapid health-seeking behaviour. The latter is largely attributableto improved security and to the sustained policy of free access to basic health services at the point of delivery, with only 36% of healthexpenditure coming from out-of-pocket.Vitamin Asupplementation has also increased, as has themanagement of severe malnutrition. Improved

continued overleaf

Figure 2: Liberia health service indicators

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governmentexpenditure

to health

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attendance

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RespiratoryInfection

% bed netcoverage(2009)

interventions include newborn resuscitation,prevention and management of hypothermia,immediate and exclusive breastfeeding,‘kangaroo’mother care and community-based management of pneumonia.

Simple changes, like encouraging women to startexclusive breastfeeding within an hour of delivery,have a remarkable beneficial effect on newbornsurvival. Neonatal death in children that werebreastfed within an hour of delivery was only 0.7% per 1,000 compared to 4.2 per 1,000 whenbreastfeeding was started after three days.25

Breastfed children are six times less likely to diebefore the age of five than non-breastfed children.

Despite this, only 24% of children in fragile statesare exclusively breastfed up to six months of age.The low uptake rates and slow rate of scale-up inmany countries is even more surprising given thatthis intervention has low resource requirements,and that support does not require a formal healthsystem and can be encouraged through communitygroups – a significant missed opportunity to impacton neonatal mortality and the survival chances of children.

Cambodia and Eritrea have some of the lowest childmortality rates among fragile states, and report thatmore than 50% of children are exclusively breastfed.Chad and Sierra Leone have some of the highest

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UNLOCKING PROGRESS IN FRAGILE STATES

Liberia – case study continued

water and hygiene practices like hand-washing arealso showing a positive impact in reducing numbersof deaths due to diarrhoea. Accreditation of primaryhealthcare facilities is beginning to demonstrateimpact through improved quality of care and services.

There are various reasons for this positive progressin Liberia. Strong political leadership – with high-level commitment from the Head of State and theMinister of Finance – is demonstrated by increasednational spending on health, which has reached 20%of GDP. Strong Ministry of Health (MoH) leadershiphas promoted partnership and coordination ofdonors, national and international NGOs, faith-based organisations (who are providing 70% ofhealth services, particularly in rural and hard-to-reach areas), and the returning Liberian diaspora.This partnership extended beyond fundingcommitments and implementation. Early andextensive consultation on a series of critical policyissues have led to the development of broadly-owned and agreed policies and plans for a basicpackage of healthcare, decentralisation and thenationally-adapted use of Integrated Management of Newborn and Child Illnesses protocols.

“At first, children used to die too much, they could not go toclinics as you had to pay. Nowservices are free and we cancome to clinics, but they oftenrun out of drugs like malariatreatment, but they always havevaccines and ORT and that is abig improvement.”

Mother of four in rural clinic in Liberia (at a focus group discussion)

However, the management of moderatemalnutrition, exclusive breastfeeding rates and the number of women being delivered by skilledattendants are showing slow progress. A lack ofskilled midwives and weak referral systems arecritical barriers to improving maternal and neonatalmortality, and are now key areas of focus for theMoH and many NGOs.

rates of child mortality among fragile states, and less than 10% of babies are exclusively breastfed.Côte d’Ivoire, Zimbabwe, Chad, Burundi and GuineaBissau all have fewer women breastfeeding todaythan three years ago. In the same period, Haiti,Guinea, The Gambia, Togo, Cameroon, CAR, SierraLeone and Cambodia have all increased the numberof women exclusively breastfeeding. Djibouti andChad have less than 2% of babies being exclusivelybreastfed, while the Côte d’Ivoire has only 4% ofbabies being exclusively breastfed.

All of the OECD fragile states, except Nigeria,Côte d’Ivoire, Kenya and Chad, have increased the number of deliveries supported by a skilledattendant, reflecting increased resources andplanning. However, while some progress has beenseen in fragile states, this is from a relatively lowlevel, and on average still only 47% of women giving birth are supported by skilled attendants,with massive rural urban inequities in access. InAfghanistan and Chad, only 14% of women aresupported by a skilled birth attendant; bothcountries have very high rates of maternal deaths.

To improve maternal health more mothers need to be supported by a skilled attendant, and haveimproved access to emergency obstetric services.However, more investment is required to ensure the availability of skilled staff and that good-quality,emergency obstetric services are available and

accessible to women, and that parallel efforts aremade in reducing barriers to women seeking healthcare.

From 2000–2006, mortality due to measles wasreduced by 68%. The largest reduction – 91% – wasin Africa. In 2006, global routine coverage of measlesvaccine reached 80%, increasing from 72% in 2000.Even in fragile states, the average coverage withmeasles vaccination is more than 66%. Eritrea hasattained 95% coverage rates and has one of thelowest child mortality rates in fragile states. Evencountries in conflict, like DRC and Afghanistan, wereable to accommodate ‘days of harmony’ or gun-freedays, to allow for national vaccination campaigns.This has saved 9.2 million children from dying frommeasles between 2000 and 2006.26 However, thepicture is mixed. Chad, CAR and Somalia have thelowest reported measles coverage, at around 30%.This is a target area for accelerating progress onMDG 4 in these countries.

Pneumonia remains the most common cause ofdeath in children under five, killing more childrenthan HIV, malaria and measles combined. Thepercentage of children under five years withsuspected pneumonia who receive antibiotics isdismally low; only 42% of children in fragile statesseek care when they have pneumonia. Performanceis very mixed – Myanmar (Burma), Cambodia,Cameroon, Haiti and Guinea have all increased their

7

PROGRESS

Figure 3: Percentage of women delivering with a skilled birth attendant

Afghan

istan

Chad

Laos

Haiti

Eritr

ea

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Figure 4: Percentage of cases where care is sought for acute respiratory infections

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coverage of children seeking pneumonia treatment,but Côte d’Ivoire, Burundi, Sierra Leone, Togo,The Gambia, Guinea Bissau, Kenya and Chad havefewer children seeking treatment for pneumoniathan three years ago, demonstrating the fragility ofprogress and the need for sustained investment.

Many fragile states are starting from very low levelsof prevention coverage: 17 fragile states have fewerthan 10% of the under-fives sleeping under bed nets, while Sudan and Guinea have less than 0.3% ofchildren sleeping under them. Overall, only 12% ofchildren in fragile states sleep under an insecticide-treated bed net, even though universal coverage of

this intervention is estimated to save the lives of691,000 children a year, second only to exclusivebreastfeeding for the number of lives saved. TheGlobal Malaria Action Plan’s target is 80% coverageof locally appropriate vector-control methods suchas long-lasting insecticidal nets, indoor residualspraying, and, in some settings, other environmentaland biological measures, by the end of 2010.With increased national and international efforts to achieve the target, this could have significantimpacts on the survival chances of children andtheir mothers in fragile states. This is particularlyimportant in DRC and Nigeria, which have thehighest burden of malaria deaths, globally.

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UNLOCKING PROGRESS IN FRAGILE STATES

Figure 5: Percentage of children under five sleeping under a bed net

Chad

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9

PROGRESS

Nepal: the impact of community level interventions and engagement

Nepal has struggled with internal conflict, enormousgeographical access challenges, cultural barriers, andhigh levels of poverty and inequity. Despite thesechallenges Nepal was removed from the fragilestates list in 2007, and has reduced its child deathsfrom 162 per thousand live births in 1990 to 61 in2009. Nepal’s maternal mortality rate was reducedfrom 538 in 1996 to 281 in 2006. Like Liberia, Nepalidentified key priority interventions and policies to ensure quick impact, and concurrently worked on laying down the foundations for a longer-termhealth sector development. Strong politicalcommitment from the government and its partners, supported by extra long-term resources,evidenced-based national plans and policies, healthsystem strengthening and increased communitymobilisation, were all factors in this progress.

Despite increased political commitment, thegovernment still only allocates 8% of its budget to health.

There is compelling evidence that the strengthbehind recent developments in Nepal is highlyconcentrated at the community level. Communityhealth workers have been shown to reduce neonatal deaths in Nepal by 30%.27 In an innovativeprogramme, community health workers in Jumla,Nepal, learnt how to actively seek out, recognise,treat and refer the most serious cases ofpneumonia, with a 59% reduction in pneumoniadeaths and a 28% reduction in child death ratesoverall. Utilisation of the local treatment areasalmost doubled compared with the referral group.28

continued overleaf

Figure 6: Nepal – maternal and child health indicators

100

90

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0% of

governmentexpenditure on health

% skilled birth

attendance

% exclusivelybreastfed

% measlesimmunisation

% care soughtfor acute

respiratoryinfection

% Vitamin Acoverage

10

UNLOCKING PROGRESS IN FRAGILE STATES

Nepal: the impact of community level interventions and engagement continued

Many community-owned efforts have shownviability, even in conflict-affected areas of Nepal.29

The numbers of those seeking care for pneumoniain babies increased from 18% to 43%. The increasedcoverage of interventions and equity plans in Nepalhave led to the reduction in the infant mortality ratefrom 79 in 1996 to 48 in 2006 per 1,000 live births,a significant achievement in a region with the highestamount of neonatal deaths. The coverage of two

doses of vitamin A increased from 85% to 95%. Thenumber of one-year-olds who are fully immunisedincreased from 43% in 1996 to 83% in 2006. Measlescoverage rate increased from 60% to 81% in 2007.As with Liberia, skilled birth attendant figuresremain low – only 19% of women are delivered by a skilled attendant, an increase of just 10% since1990. And only 53% of babies are now exclusivelybreastfed, a reduction of 19% from 1990 figures.

Despite efforts in recent years to improve aideffectiveness, alignment and harmonisation,and to develop more effective instruments for coordinated aid programmes, large gaps remain due to donor politics, inefficient bureaucracies andthe complexities of country context. The financingof the health sector is further complicated by thedisparate global and bilateral funding instruments,and by the complex nature of health services.

Fragility, in its different manifestations, shapes theways in which donors define their policy responses,and how aid is delivered. Working with fragile statesis often difficult and costly, and carries a high risk of failure and reversal of programme gains. In some

cases, donors have decided that aid programmes in fragile states pose intractable dilemmas, and that it is preferable to use aid elsewhere, or useonly humanitarian responses. This results in adisproportionate correlation between the globaldisease burden and health financing.

Developing countries make up 90% of the globalburden of disease, but still constitute only 12% ofthe global health spending.30 Fragile states, from1992–2002, received 43% less aid than would have been appropriate given the extent of theirpoverty. In recent years there is an upward trend –OECD-DAC reported that in 2007 the proportionof total ODA delivered to fragile states had

11

Health aid architecture

Guinea Bissau: the impact of skewed funding

Guinea Bissau has had ongoing fragility sinceindependence. Although the independence struggleended in 1974, political and economic instability has continued and the under-five mortality rate is198 child deaths per 1,000 live births, down from240 in 1990. The maternal mortality rate is 1,110per 100,000 live births. There are only 0.8 healthworkers per 1,000 people, distributed unevenly,with most doctors working in urban settings. Thepresent government budget has allocated only 4% to health (with 10% to education, 70% to securityand 13% to other).

In 2006, government funding made up 11% ofnational health spending, with multilaterals

contributing 56%, global funds 10% and bilateral aid15%. In 2008, the Global Fund to Fight AIDS, TB &Malaria was the largest contributor to the healthsector with a grant of US$44.15 million, of whichUS$13.18 million needed to be spent in the firsttwo years. This was equivalent to the whole nationalhealth spending in 2003 and accounts for 80% of thehealth budget with a focus on HIV. Essential healthsystem strengthening activities are not funded, astraditional donors have reduced support to thehealth sector. Little to no funds were allocated to strengthen the national health system despiteHIV causing less than 5% of the national burden of disease.31

increased to 38.5%. However, this benefited only five countries. The tendency towards aid based on‘good performance’, especially with respect togovernance and the rule of law, has had an impact,with donors setting more demanding terms andconditions for fragile states – for example, askingthat they demonstrate twice as many policy reforms before receiving aid from the World Bankthan stronger performers.

Even when aid is given to fragile states, it tends to be short-term, unpredictable, and poorlysequenced, often failing to mirror national priorities.Uncertainty over funding, for both government andnon-state actors, significantly reduces the capacityto scale-up proven and effective health strategies.

The typical mechanisms for funding fragile states do not take into account the critical – and oftenlengthy – transition from a humanitarian responseto longer-term development. Despite increasingdonor recognition over the past decade that thereis often a gap between the ending of humanitarianassistance and the resumption of long-termdevelopment assistance, difficulties remain. Thefinancial and programmatic ‘bridges’ currently usedby donors for transition remain inadequate. In thehealth sector, the impact of this can endanger gains

made, such as reductions in child mortality and thetraining and retention of health workers, and limitsefforts in building institutional capacity.

Levels of domestic finances for health also remainvery low. Many of the countries with the worstprogress in child and maternal health spend lessthan 5% of their government budgets on health.Nigeria, DRC and Guinea Bissau spend 4%,while Burundi, Burma and Afghanistan all spend 2% or less.

Many fragile states spend less than US$20 perperson per year on health, despite researchindicating that US$34 per person per year isrequired to ensure that a basic package of health is available for all.32 In 2001, all African nationsagreed to allocate 15% of their national budgets to health.

Even where capacity is weak and overall healthexpenditure is low, there are many cost-effectiveinterventions that can have a dramatic impact onchild deaths. As described earlier, there is much that can be done to reduce maternal and childdeaths and start building national capacity andhealth systems.

12

UNLOCKING PROGRESS IN FRAGILE STATES

In recent years, there has been increasing interest in, and analysis of, the ways in which donors,governments and other organisations can deliver aidmore effectively to strengthen healthcare systems infragile states. The challenge is in addressing essentialand priority needs, while also supporting approachesthat will strengthen systems and enable longer-termdevelopment. Recent work has demonstrated thevalue of developing a strategic framework andpolicies for the health sector as early as possible.33

Certainly, the early policy formulation in Liberia andNepal has had significant impact on child mortality.

It is important that Ministries of Health, donors, theUN, and implementing partners recognise the valueand opportunities for health systems strengthening,even in the midst of chronic conflict or naturaldisaster. It is an essential component of earlyrecovery activities. Building resilient health systemsis particularly important in countries prone toconflict, as gains in mortality reduction are fragile,as evidenced by Zimbabwe and Kenya.

Even when it is not possible to engage in healthsystems strengthening at central level, it is possibleto strengthen community healthcare services anddistrict management teams with positive healthoutcomes, which can be built on when centralhealth systems strengthening becomes possible.In Southern Sudan, Somalia and Nigeria, donors fund consortia of NGOs, academics and the privatesector to implement large-scale programmes tostrengthen health systems and increase humanresources. These consortia can bring in senior-levelexpertise, enabling donors to commit long-termresources. These consortia can be expensive, andmanaging partner time can be consuming and costly.

In Afghanistan donors contracted out services with the Ministry managing NGOs to strengthenprovincial services and a basic package of healthcare.The contracting-out of services was very effective;however, some regions were unable to find strongnational civil society partners, resulting in stagnationof progress once the initial contract had expired.Liberia has recently embarked on a process ofcontracting NGOs, using pooled donor funds tosupport the management and the strengthening of health systems through performance-basedevaluation. The government has established jointsupervision and planning systems with quarterlyreviews and an annual meeting to develop annualplans and priorities. Crucial progress has seenagreement with the donors to support one plan, onestrategy and one monitoring and evaluation system.

“One of our challenges is thatmost of the health services inrural areas have been done byCSOs simply because we do not have the capacity to roll outservices in those regions. If welost that capacity, that would bea big gap. That is where GAVI canbe helpful to us, in supportingthe ongoing work of CSOs”

Her Excellency Ellen Johnson Sirleaf,President the Republic of Liberia.34

13

Health system strengthening

14

UNLOCKING PROGRESS IN FRAGILE STATES

Zimbabwe: a reversal of gains

Zimbabwe is now a collapsed economy where food shortages are commonplace and poverty andunemployment are endemic. In 2007, its populationwas around 13.2 million with an estimated 6 millionliving in exile as political and economic migrants.83% of the population is reported to be living below US$2 a day. At 36 years, the life expectancyfor women is the lowest of any country outside of a conflict zone. Maternal mortality is estimated at 880 maternal deaths for every 100,000 live births,despite 83% of women being delivered by skilledbirth attendants, indicating a highly vulnerablepopulation. High rates of HIV and malnutrition,and a lack of quality maternal health services,are thought to be to blame. Child mortality isestimated at 90 deaths per 1,000 live births,which is considered to be an underestimate due to the rising levels of malnutrition and HIV.

The political situation in Zimbabwe has impactedupon donor funding for social programmes inZimbabwe. None of the key bilateral donorsprovide direct budget support to the government,although material support is provided forhumanitarian reasons. The government allocates 9% of its budget to health (around US$14 perperson per year). Chronic malnutrition affects athird of all children in Zimbabwe. In 2005 more than 2,000 Zimbabwean35 nurses registered to workin the UK, while only 400 nurses are trained eachyear in Zimbabwe. Migration has resulted in 56% ofall doctor posts, 32% of nursing posts and 92% ofpharmacist posts being vacant in 2005. Of 2,500public health nurse vacancies, there were only 291 nurses available, leaving 88% of vacanciesunfilled in December 2006.36

Tanzania: learning from non-fragile states

In Tanzania, earmarking Maternal Newborn & ChildHealth interventions in district budgets led to adecrease in child mortality.37 The Tanzania EssentialHealth Interventions Project was established withthe principles of Alma Ata and primary healthcare(focusing on equity and participation through amulti-sectoral approach).The programme increasedfunding in two districts by US$1 per person per

year, and focused on using Integrated Managementof Childhood Illnesses to deliver key interventions.The programme also strengthened the managementcapacity of the district health medical team. Aburden-of-disease profile tool was developed tolook at intervention packages, not just diseasemanagement. Child deaths dropped by 40% in fiveyears (from 166.8 to 75.4 per 1,000 live births).38

Human resources for health

Availability of skilled birth attendants is limited by the very low levels of health workers in fragilestates; more than half of the fragile states run theirhealth systems with less than one health worker per 1,000 population,39 below the WHO-estimatedminimum of 2.5 health workers per 1,000 populationneeded to reach 80% of the population withessential interventions. Identifying innovativeapproaches to more equitable distribution of healthworkers, and in retaining them in rural areas,remains a priority.

Health workers are the crucial resource of healthsystems. Strategies need to be developed to trainand retain more of them, particularly in rural andhard-to-reach areas. Short-term solutions caninclude better human resource distribution,developing competency-based continuing educationprogrammes, improving supervision, and involvinghealth staff in analysis and decision-making processes.Retention strategies must be simple, clear andrealistic, and must reflect the health workers’ needsand priorities. Equity and transparency are crucial toboth the health worker and the communities thatthey serve. Strategies should include financial andnon-financial incentives.40

15

HEALTH SYSTEM STRENGTHENING

Competency-based 18-month community midwife training

In Afghanistan and Liberia a new communitymidwife cadre is being rolled out. Midwives arefrom, and are selected by, the local community andmust have completed nine years of basic education,and be literate. NGOs follow competency-basedtraining guidelines to ensure all midwives achieve a competent standard of care. Although the

programme is relatively new in Liberia, inAfghanistan it has increased the number of skilledhealth workers from 39% in 2004 to 76% in 2008 in its provinces, and has increased the number ofwomen supported by a skilled attendant from 6% in 2003 to 19.9% in 2006.

Figure 7: Density of health workers per 1,000 people

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ndi

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ambia La

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CAR

Increasing salaries is a critical part of the equationand, as the biggest recurrent cost in healthexpenditure, has to be planned in a coherent way, with support given by donors in the short tomedium term. However, increasing health salaries is not without difficulties and is likely to impact on other public sector workers, and needs to bepart of a broader public sector pay policy. Liberia’sstrategy to increase salaries has helped to improvemorale and retain health workers, and has increasedthe number of young people being sponsored totrain as health workers. However similar efforts to increase health salaries in Sierra Leone haveincreased tensions among public sector workers.

Improving communication and referral systems

Community midwives, health workers, traditionalbirth attendants (TBAs) and communitydevelopment workers in Liberia and Sierra Leone all agree that progress in maternal health referralshas been due to two main factors: free ambulances,and access to direct communication with clinics and hospitals through the use of mobile phones.Some NGOs distribute phones, with a set numberof credits, while others give TBAs cards so they canborrow a phone if they need to call. In Sierra Leone,radios had a similar impact; however, some clinicswere unable to maximise the impact of the radios as the officer in charge kept the radio locked intheir office and was rarely at the post due to travel and training. One innovative example of thesuccessful use of rural empowerment occurred inLiberia. Community midwives were given the use of a mobile phone (by a supporting NGO) to callfor the ambulance to come and collect women tobe referred. In each village, the community midwifemarked with a big cross painted black the point inthe village where the mobile phone worked. When a woman needed to be referred they would sendsomeone to the cross with the village mobilephone. For every referral the community midwifewould be given a new card.

In Sierra Leone there has also been a positiveresponse to the free ambulance and radios. However,

due to the high cost of hospital in-patient care,few women would take up the offer of the referralunless the referral ambulance drove them to thehospital in a neighbouring district that was run by an NGO and offered free healthcare.

Improving nutrition at scale

Vitamin A supplements can help prevent 23% ofchild deaths.41 The fragile states of Nepal andIndonesia have increased their coverage ofVitamin A by including it in child health days;Nepal has achieved 97% coverage and Indonesiamore than 70%. In 2001 alone, this accounted for 35,000 lives saved of children under five in Indonesia.

As evidenced by the exclusive breastfeeding rates discussed earlier, there is a pressing need to get nutrition onto the list of political priorities,and to keep it there, and to implement programmesthat work, such as interventions to address andprevent undernutrition. Mothers need balancedenergy protein supplementation, iron folate andiodised salt. Interventions to improve under-nutrition in neonates, infants and children includeexclusive breastfeeding, vitamin A, zinc (both as a supplement and for use in management ofdiarrhoea), iron fortification and supplementation,the treatment of severe and moderate acutemalnutrition, and improved complementary feeding practices.

Indirect interventions are equally important, andcontribute to:• improved quality and quantity of diet and

nutrition outcomes• conditional cash transfer programmes• access to clean, safe water and sanitation• food subsidies• women’s and girls’ education• rural infrastructure such as roads, clinics,

schools and markets• measures to improve agricultural productivity

and irrigation schemes.

16

UNLOCKING PROGRESS IN FRAGILE STATES

All of the above can improve the availability of foodand the nutrition levels in women and children. It isimportant to stop investing in programmes that arenot working. There is little evidence that growthmonitoring, preschool feeding programmes, food forwork, or microcredit schemes address malnutritionin the under-fives or mothers. Resources supportingthese programmes could be spent more effectivelyinvesting in what is known to work.42

Civil society, voice and accountability

Accountability mechanisms are vital in buildingfunctioning systems, trust and good governance inhealth. It is possible to build the capacity of localgovernment and build community capacity toparticipate in national accountability in even themost difficult of environments.

17

HEALTH SYSTEM STRENGTHENING

Case study – Afghanistan: A community-centred approach to improving child health

In order to address its high maternal, infant andunder-five mortality rates, Afghanistan has setmother and child health as a priority for its BasicPackage of Health Services (BPHS). From 2004 to 2006, Save the Children UK supported theimplementation of BPHS in Jawzjan Province under the REACH programme (Rural Expansion of Afghanistan’s Community-based Healthcare).The purpose of the programme was to establish an equitable, accessible, quality healthcare deliverysystem through expanding the delivery system,improving the quality and increasing local efficiencyand sustainability. In addition, the organisationworked closely with the communities, healthfacilities and Ministry of Public Health to enablethem, through training and involvement, to establishand sustain systems for supporting child survival.

The project took a systematic approach to ensurethat all stakeholders, especially at community level,had a good understanding of the BPHS, and of child rights. Emphasis was put on the importance of community participation and representation ofwomen and children in the health committees.Communities were fully involved in the selection

of community health workers (CHWs), servicedelivery components and village health committeemembers. Once the health committees wereestablished, members undertook two days ofleadership training, including in child rights and child protection, to prepare them for their roles.Additionally, child rights and child protection issueswere covered in all training of health facility staffand CHWs.

An end-of-project evaluation in 2006 found that the integration of topics on children’s rights into allthe training had generated awareness and initiatedchanges in the attitude and practices of staff andcommunity members regarding children and theirissues. Health services were more mother-and-child-friendly – for example, health staff and CHWsreported changes in their own attitudes andbehaviour towards children at home and in theworkplace. Children were given priority forconsultations, and health workers talked morekindly to children during examination immunisationsand other treatments. The evaluation found thatchildren’s participation in health committees waspossible in conservative communities, provided that

continued overleaf

Another innovation with very high impact is the use of women’s support groups in rural Nepal.Female community health volunteers were trainedto support two women’s meetings every month.In addition, mid-level health workers and assistantnurse midwives were appointed to run sub-healthposts and health posts at the community level. Thisincreased the proportion of skilled professionalsattending births from 9% in 1996 to 19% in 2006.One pilot area measured a reduction in neonatalmortality from 36.9% to 26.2% per 1,000 live births.Involving communities stimulates demand for health services and encourages strengthening of health systems.43

A recent article by Zulfiqar Bhutta et al concluded:“The exact mechanisms through which communitysupport groups lead to peri-natal survival are

complex and not well understood. These may affecta range of issues such as women’s empowerment,increased awareness, and development of socialcapital affecting household and family care-seekingpractices.”44

In Nigeria, Save the Children worked closely withgovernors, religious leaders and community elders(including women) to increase community trust in the health services, especially immunisations.Immunisation coverage is rising, and trust in healthservices is increasing as more people use the health services. Coverage has increased from 0% insome states to nearly 20% coverage in two years.Community leaders are also involved in developingthe state health strategies, work plans and priorities.More work is required to overcome gender, culturaland language barriers.

18

UNLOCKING PROGRESS IN FRAGILE STATES

Case study – Afghanistan: A community-centred approach to improving child health continued

parents were consulted and well informed of thepurpose and nature of their children’s involvement.

The policy of ensuring representation of childrenand women on health committees challengedtraditional views of women and children in society,and gave them more voice. A total of 134 childrenbecame members of health committees (120 boysand 14 girls). This provided them with theopportunity to understand the availability of healthservices and to raise their views and concernsabout the health services. Additional leadershiptraining was given to the health committees, andprovided the children with opportunities to learnabout health services and how they could have a stake in monitoring and decision-making.Committee members began to listen to childrenand consider their views. The child rights training

raised awareness among influential village elders and encouraged them to promote children’sparticipation in a context where children traditionallyhad little voice. Health committees and village elderswere found to be actively supporting health facilitiesand taking an interest in the quality of servicesavailable for children and women. In addition to an increased awareness of child rights and childprotection at all levels, the risks of morbidity andmortality for children and their mothers werereduced as a result of improved access to qualityhealthcare at health facilities. Specific policies, suchas exemptions from the payment of registration feesfor under-fives, facilitated access to care. Althoughthis community-centred approach to improving childrights seems to bear fruit, child rights awareness inAfghanistan still has a long way to go.

High-impact, cost-effective interventions that candramatically reduce child and maternal deaths arewell-known, yet the characteristics of fragility incertain states have led to a near or total collapse of health systems and the services that shoulddeliver them – particularly for poor, vulnerable and marginalised groups. Those working in fragilestates face technical, financial and logistic obstacles.However, as this report has shown, progress is possible.

Some lessons are obvious: political commitment isessential; donors need to continue to support NGOsand community-based organisations to maintainservices, while also supporting the governments todevelop strategic plans and policies. Resources needto be more predictable and long term, and focus onhealth systems and key MNCH interventions.

The active involvement and management of servicesby the community is a key part of a successful healthsystem, and is essential for progress, to rebuild trustand social capital, and in promoting accountability.

Human resources are essential, and more supportneeds to be directed towards training and supportingcommunity health workers to provide a link betweenthe health services and the communities. Skilled birthattendants have been proven to reduce maternal andneonatal deaths and this should be developed as a‘quick win’ in fragile states.

It must be recognised that unless health services are free at the point of access in fragile states, theywill not reach the poorest and most vulnerablewomen and children. There is now global consensusthat user fees delay health-seeking, and donors

and governments should support plans to removethem, and meet the increased demand for servicesthat follows.

Increased financial investment in research, innovativeapproaches and dissemination are required ifsuccessful solutions to the myriad of challenges tomaternal, newborn and child survival and healthcareprovision in fragile states are to be found. Sharingbest practice and learning from different contexts is essential.

Finally, the response to maternal and child mortalityin fragile states would be greatly strengthened, bemore efficient and have greater impact if there wasmuch greater collaboration between stakeholdersworking on fragile states and those working onmaternal, newborn and child survival.

This report has attempted to capture whichinterventions are leading to progress. However,central to this is the understanding that all countriesare unique, and hence country context and a robustsituation analysis are to essential making decisionsand designing and evaluating appropriate healthsector responses to reduce maternal, neonatal and child mortality.

Success and progress is possible in fragile states.Partners need to learn from and build on thatsuccess. However, women and children cannot wait,and national governments and the internationalcommunity must urgently ramp up efforts toaccelerate progress in fragile states to have an impacton reducing unnecessary newborn, child and maternaldeaths in the world’s most vulnerable communities.

19

Conclusions

1. Increase accountable leadership andpolitical commitment a. Health plans should prioritise MNCH plans

and budgets, with quantitative and qualitativeindicators to measure demand-side progress.

b. Strategic plans and policies with realistic time-bound targets can help build the managementcapacity and re-establish trust in the healthsector by communicating the shared vision

c. Donors must align their planning andbudgeting processes with the nationalprocesses as early as possible.

2. Increase the volume and quality of healthaid to fragile statesa. More aid, better targeted at country and

district priorities, allocated according to need and mortality.

b. Increased transparency and increasedaccountability to communities for the waythat aid is delivered and used.

c. Increased commitment to harmonisation,alignment and coordination.

d. Predictable recurrent resources.e. More transparency is required to hold

donors accountable more effectively.

3. Address short-term needs and long-termsustainabilitya. Government and donors must increase

support to the scale up of proven cost-effective maternal, newborn and child survivalinterventions in fragile states.

b. Ministries of health, donors, the UN, andimplementing partners must recognise thevalue and opportunities for health systemsstrengthening and early identification of policy formulation priorities.

c. Essential health services should be free at the point of use and out-of-pocket feesreplaced by reliable aid and equitabledomestic resources.

d. The integrated management of maternal,neonatal and child health interventions should be updated to include PMTCT,ORT with zinc, community management ofillnesses, guidelines for working with thecommunity, and postnatal care and follow up.

4. Fund and support active communityengagement in planning and deliverya. Increase the involvement of communities,

especially women and children and healthworkers in health policy and system planning,and ensure downward accountability of health staff and decision-makers.

b. Develop a strategy to rebuild trust and social cohesion and resource programmes to address social development and genderinequities.

c. Ensure that policy changes and entitlementsare communicated to all through nationalcommunication plans and strategies.

5. Increased investment in research andinnovative approachesa. Further research and analysis on the exact

scale and nature of maternal, neonatal andchild mortality in fragile states.

b. Further research is needed to develop, testand evaluate effective tools and strategies forhealth services delivery, including contractingin and out, and community-based managementof childhood illness in fragile states.

c. Research is needed on health policyformation, identification and tackling ofbottlenecks in fragile states.

d. Operational research on strategies andinnovative approaches to address the human resource challenges in fragile states.

e. Research is required on effective equitablehealth financing strategies to replace therationing and exclusion of the poor to health services through user fees.

20

Recommendations

21

Country Health Indicators

U5 Maternal Health Stunting Access to Access to Mortality Mortality workers (%U5) water sanitationRate Rate per 10,000 [UNICEF

2009]

Sierra Leone 262 2,100 0.5 40% 57% 39%

Afghanistan 257 1,800 0.4 54% 39% 34%

Chad 209 1,500 0.5 41% 42% 9%

Guinea Bissau 198 1,100 0.8 41% 59% 35%

Nigeria 189 1,100 2 38% 48% 44%

Burundi 180 1,100 0.2 53% 79% 36%

CAR 172 980 5 38% 75% 27%

DRC 161 1,100 0.6 38% 46% 30%

Angola 158 1,400 1.4 45% 53% 31%

Guinea 150 910 0.8 35% 50% 18%

Cameroon 148 1,000 1.8 66% 51%

Somalia 142 1,400 0.2 38% 29% 26%

Djibouti 127 650 0.6 33% 73% 82%

Côte d’Ivoire 127 810 0.7 34% 84% 37%

Congo 125 740 1.2 26% 58% 27%

Kenya 121 560 1.3 30% 61% 43%

Liberia 111 1,200 0.3 39% 61% 27%

The Gambia 109 690 1.4 22% 82% 53%

Sudan 109 450 1.1 43% 70% 34%

Burma 103 380 1.4 32% 78% 77%

Togo 100 510 0.4 24% 59% 35%

Timor Leste 97 510 54% 62% 41%

Cambodia 91 540 1 37% 41% 17%

Zimbabwe 90 880 0.9 29% 81% 53%

Haiti 76 670 0.4 24% 54% 30%

Lao 70 660 1.6 40% 51% 30%

Eritrea 70 450 0.6 38% 60% 9%

Comoros 66 400 44% 85% 35%

Uzbekistan 41 24 15% 88% 96%

Vanuatu 34 68

Indonesia 31 420 1 nd 77% 55%

Annex: health indicators for fragile states

Bryce Jennifer et al (2008) Maternal and child undernutrition:effective action at national level Maternal and child undernutritionseries 4 The Lancet Vol. 371 pages 510–526 Feb 9th 2008

Bustreo F et al (2005) Improving child health in post conflictcountries – can the World Bank contribute? World Bank

Campell Oona, Graham Wendy (2006) Maternal Survival: strategiesfor reducing maternal mortality: getting on with what works LancetOctober 7th 2006 Vol. 368:1284–99

CMH (2001) Report from the Commission on Macroeconomicsand Health

Countdown Working Group (2008) Assessment of the health systemand policy environment as a critical complement to tracking theintervention coverage for maternal, newborn and child health Lancet Vol. 371 April 12th 2008 pg.1284/1293

Countdown (2008a) Countdown to 2015 for maternal newbornand child survival: the 2008 report on tracking coverage ofinterventions The Lancet volume 371 April 12th 2008 pgs 1247–57

Countdown (2008b) Countdown to 2015: Maternal newborn and ChildSurvival Countdown to 2015 team supported by the Partnership forMaternal Neonatal and Child Health WHO and UNICEF

Gary L Darmstadt et al (2005) Evidenced based, cost effectiveinterventions: how many newborn babies can we save? The Lancetaccessed: http://image.thelancet.com/extras/05art1217web.pdf

Da Vanzo et al (2007) Effects of Interpregnancy Interval and outcomeof the preceding pregnancy on pregnancy outcomes in MatlabBangladesh British Journal of Obstetrics and Gynaecology 2007

Dawson P et al (2008) From research to national expansion: 20years’ experience of community based management of childhoodpneumonia in Nepal Bulletin of the WHO 2008, 86

DFID (2005) Why do we need to work more effectively in fragile states?DFID UK

DFID (2007) Drivers of Fragility? What Makes States fragile? PRDEWorking Paper No.7

DFID (2008) Aid Effectiveness report accessed throughwww.dfid.gov.uk/pubs/files/aid-effectiveness.pdf

DFID (2009) Maternal Health Factsheet accessed throughwww.dfid.gov.uk

Dherani S et al (2008) Indoor air pollution from unprocessed solidfuel use and pneumonia risk in children aged under five years:systematic review and met analysis. Bulletin of the WHO 2008,86:390–398

English Mike et al (2009) An intervention to improve paediatric andnewborn care in Kenyan district hospitals: understanding the contextImplementation Science 2009:4:42 July 23rd 2009

Global Monitoring Report (2007) Millennium Development Goals:Confronting the challenges of Gender Equality and Fragile States

Godal, Dr. Tore et al (2009) Leading by example – protecting the mostvulnerable during the economic crisis: The Global Campaign for theHealth Millennium Goals Published by the office of the PrimeMinister of Norway Oslo June 2009 page 6

HLF (2004) Achieving the Health Millennium Development Goals inFragile States Abuja Dec. 2004

Hoeffler A and Reynal-Querol M (2003) Measuring the costs ofconflict Oxford University

ICM (2006) Prevention of Post-Partum Haemorrhage: shared action onsafer motherhood Journal of the International Confederation ofMidwives

IDC (2008) Maternal Mortality Inquiry report InternationalDevelopment Committee UK

IDRC (2008) Fixing the Health Systems – InternationalDevelopment Research Centre – wwwidrc.ca/en/ev-64760-201-1-DO_Topic.htlm

Ioniate G (2009) Analysis of GFATM and other financial inputs into thehealth sector in Guinea–Bissau Feb 27th 2009 UNAIDS

IHP (2008) International Health Partnership and related initiatives(IHP+) Progress report Prepared for the 61st WHA Geneva

James C, Morris S, Keith R, Taylor A (2005) Impact of child mortalityof removing user fees: a simulation model British Medical Journal331:747–749

Keith R, Shackleton P (2007) Paying with their lives Save the Children UK

Keith R (2009) Unpublished note from field research completed inAugust 2009

Koblinsky Marge et al (2006) Maternal Survival 3: going to scale withprofessional care Lancet October 14th 2006 Vol 368:1377–1386

Lockhart C (2005) From Aid Effectiveness to DevelopmentEffectiveness: Strategy and Policy Coherence in Fragile States, BackgroundPaper of the Senior Level Forum on Development Effectiveness in Fragile States: Overseas Development Institute

McGillivary M (2006) Aid Allocation and Fragile States Discussionpaper No. 2006/0. UN University

Madhi SA et al (2008) Vaccines to prevent pneumonia and improvechild survival Bulletin of the WHO 2008, 86:365–372

Mahandhar DS et al (2004) Effects of a participatory interventionwith women’s groups on both outcomes in Nepal: cluster-randomised control trial The Lancet 2004 364:970–979

Merlin (2007) Reducing the Burden: of maternal mortality inAfghanistan: Merlin’s community midwifery education programmes in Takhar June 2007 Merlin UK

Moreno-Torres M and Anderson M (2004), Fragile States: DefiningDifficult Environments for Poverty Reduction: PRDE Working Paper 1,DFID

Nabarro D (2004) The ultimate challenge: sustaining life in fragile statesPower point presentation for the High Level Forum Abuja –December 2–3rd 2004 WHO

Newbrander W (2006) Providing health services in Fragile States,prepared for the sub team for health services service delivery workstream DAC Fragile States group

22

Bibliography

23

REFERENCES

OECD/DAC (2005) Senior Level Forum on Development Effectivenessin Fragile States

OECD (2006) Fact sheet: Ensuring Fragile States are not Left Behind:accessed from http://www.oecd.org/dac/fragilestates

OECD/DAC (2006) Monitoring Resource Flow to Fragile States, 2006Report: Fragile States Group

OECD (2007) Principles for Good International Engagement in FragileStates & Situations: accessed at http://www.oecd.org/ fragilestates

OECD (2008) Measuring aid in Health developed in October 2008by OECD accessed through: www.oecd.org/dac/stats/heath

OECD/DAC (2009) Ensuring fragile states are not left behindSummary Brief March 2009 International network on conflict andfragility

Ooms Gorik and Van Damme Wim (2009) Impossible to wean whenmore aid is needed WHO Bulletin Vol. 86 November 11 2008accessed from the internet on March 11th 2009 www.who.int/bulletin/volumes/86/11/08-059485/en/index.htm

Pearson Mark (2009) Achieving the MDGs: at what cost? Technicalapproach paper HLSP Institute Feb 2009 London UK

Powell C and Cook G (2005) Fragile states from policy to practiceUSAID USA

Ransom K, Poletti T, Bornemisza O and Sordorp E (2007) Promotinghealth equity in conflict affected fragile states Conflict and HealthProgramme LSHTM for WHO Social Determinants of HealthAnalysis

Rietveld C, Waldman R (2006) Health in fragile states: country casestudy: Southern Sudan Basics for USAID July 2006 USA

Rosato Mickey et al (2008) Alma Ata: Rebirth and Revision 5:Community participation: lessons for maternal newborn and child healthLancet September 13th 2008 Volume: 372:962–71

Roth DE et al (2008) Acute lower respiratory tract infections inchildhood: opportunities for reducing the global burden throughnutritional interventions Bulletin of the WHO 2008, 86:356–364

Salama P, Spiegal P, Talley L and Waldman R (2004) Lessons learnedfrom complex emergencies over past decade, www.thelancet.com Vol. 364 November 13, 2004

Save the Children UK (2005) The cost of coping with illness in Eastand Central Africa Save the Children

Save the Children UK (2007a) Treading a delicate path: NGOs infragile states: Zimbabwe case study Save the Children UK

Save the Children (2007b) Treading a delicate path: NGOs in fragilestates: synthesis report Save the Children UK

Save the Children UK (2008) Submission to UK IDC Committee on maternal health accessed April 2008 athttp://www.publications.parliament.uk/pa/cn20078/cmselect/cmintdev/ukhealth

Save the Children (2008) The cost of a healthy diet SC UK

Save the Children UK (2009a) Lasting benefits the role of cashtransfers in tackling child mortality Save the Children

Save the Children UK (2009b) Submission to the HLTF onInnovative International Financing for Health Systems

Save the Children UK (2009c) Health in Fragile States: Policy BriefSave the Children UK

Taylor L (2005) Absorptive capacity of health systems in fragile statesHLSP working paper

UNICEF (2005) Final report to CIDA on the Accelerating ChildSurvival and development Programme in West and Central Africa

UNICEF (2009) The State of the World’s Children 2009: maternal andnewborn health: where we stand

UNFPA (2008) No woman should die giving life: facts and figuresaccessed through www.unfpa.org/safemotherhood briefing for thehigh level even on the Millennium Development Goals, UN NYSeptember 25th 2008

USAID (2002) USAID Child Survival and health Programs Progressreport: Report to Congress

Waldman R (2006a) Health in Fragile States: Country Case Study: DRCJune 2006 USAID BASICS Arlington Virginia USA

Waldman R (2006b) Health programming in post conflict Fragile StatesJune 2006 BASICS USAID Arlington Virginia USA

World Bank (2007) Fragile States: List of fragile states (2007)accessed through www.web.orldbank.org/wbsite/external/extabutus/IDA/0,,contentMDK:213899974-pagePK:51236175-pipk:437394-thesitepk:73154,00html

WHO (1991) Maternal Mortality: a global fact book WHO Geneva

WHO (2000) Managing the complications of pregnancy and childbirth:a guide for doctors and midwives WHO Geneva

WHO (2003) High level forum on health 2003 – Backgrounddocument accessed from www.who.int/hdp/aid/hlf_resources-pdf

WHO (2004a) Making pregnancy safer: the critical role of the skilledattendant. A joint statement by WHO, ICM and FIGO, World HealthOrganisation, Geneva 2004. Accessed through www.who.int/making_pregancy safer/documents/92415916692/en/index.html

WHO (2004b) High level forum on the Health MDGs: achieving thehealth MDGs in fragile states World Health Organisation – AbujaDecember 2004

WHO (2005) World Health Report: Making every mother and childcount WHO Geneva

WHO (2006) World Health Report: Working together for health WHOGeneva

WHO (2009) Child and Adolescent Health and Development:Progress report 2008: highlights WHO Geneva

WHO & GHWA (2007) Scaling up, saving lives: Task force for scalingup education and training for health workers Global Health WorkforceAlliance WHO Geneva

WHO UNICEF (2008) Development of a global action plan for theprevention and control of Pneumonia (GAPP) Report of an informalconsultation

Women Deliver (2008) Invest in women, it pays accessed on March3rd 2009 www.womendeliver.org/facts/maternal.htm

Yates Rob (2009) Universal healthcare and the removal of user fees,Lancet Vol. 373 Issue 9680 pp. 2078–81

You Det al (2009) “Levels and trends in under five mortality, 190-2008” The Lancet published online on the 10th of September 2009

Zivetz L (2006) Health Service Delivery in Early Recovery Fragile States:Lessons from Afghanistan, Cambodia, Mozambique, and Timor LesteUSAID and BASICS, Washington DC

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Key facts1 Bustreo F et al (2005) Improving child health in post conflictcountries – can the World Bank contribute? World Bank2 Hoeffler A and M Reynal-Querol (2003) Measuring the costs ofconflict Oxford University 3 McGillivary M (2006) Aid Allocation and Fragile States Discussionpaper No. 2006/0 UN University

Executive summary4 USAID (2002) USAID Child Survival and health ProgramsProgress report: Report to Congress5 Yates R (2009) Universal healthcare and the removal of user fees,Lancet Vol. 373 Issue 9680 pp. 2078–816 Henry Perry and Paul Freeman et al (2009) How effective iscommunity based primary health care in improving the health ofchildren? Community based PHC Working Group, InternationalHealth Section American Public Health Association July 7th 20097 Save the Children UK (2008) The minimum cost of a healthy diet8 Save the Children UK (2008) The minimum cost of a healthy diet 9 Save the Children UK (2009) How cash transfers can improve the nutrition of the world’s poorest children: evaluation of a pilot safety net programme in south Niger access throughhttp://www.savethechildren.org.uk/en/54_7871.htm and Save theChildren UK (2007) The minimum cost of a healthy diet10 PMNCH (2008) Successful leadership: country actions formaternal, newborn and child health PMNCH

Introduction11 This is compiled based on the World Bank’s Country Policy and Institutional assessment (CPA) World Bank (2007) FragileStates: List of fragile states (2007) accessed throughwww.web.worldbank.org/wbsite/external/extabutus/IDA/0,,contentMDK:213899974-pagePK:51236175-pipk:437394-thesitepk:73154,00html12 DFID (2005) Why do we need to work more effectively in fragilestates? DFID UK 13 Save the Children UK (2009) Health in Fragile States: Policy Briefpage 114 Newbrander W (2006) Providing health services in Fragile States,prepared for the sub team for health services service delivery workstream DAC Fragile States group15 You Det al (2009) “Levels and trends in under five mortality, 190-2008” The Lancet published online on the 10th of September 200916 Countdown (2008) Countdown to 2015: 2008 report (adding thenumber of child deaths from country profiles for the OECD/DACfragile states selected for focus in this report)17 Bustreo F et al (2005) Improving child health in post conflictcountries – can the World Bank contribute? World Bank18 Hoeffler A and M Reynal-Querol (2003) Measuring the costs ofconflict Oxford University 19 Save the Children UK (2009) Health in Fragile States: Policy Brief 20 HLF (2004) Achieving the Health Millennium Development Goalsin Fragile States Abuja Dec. 2004

Fragile states, the right to health and MDGs 4 and 521 Hunt, Paul (2006) Speech to UN General Assembly22 World Bank 2008 Global Monitoring Report, p. xi

Progress23 Zulfiqar A Bhutta et al (2008) Alma Ata: rebirth and revision 6:Interventions to address maternal newborn and child survival: whatdifference can integrated PHC strategies make? The Lancet Vol. 372September 13th 2008 pages 972–98924 Gary L Darmstadt et al (2005) Evidenced based, cost effectiveinterventions: how many newborn babies can we save? The Lancet 25 USAID (2007) Scaling up High Impact FP/MNCH best practices inthe Asia/Near east region Technical meeting Bangkok ThailandSeptember 3–8 200726 WHO (2008) Global Immunisation Strategy Report to 61stWHA Secretariat paper A61/10 Agenda item 11.7 WHO 27 UNICEF (2009) State of the World’s Children28 Dawson P et al ( 2008) From research to national expansion:20 years experience of community based management of childhoodpneumonia in Nepal Bulletin of the WHO 2008, 8629 World Bank (2009) Country Profile: Nepal

Health aid architecture30 IHP (2008) International Health Partnership and related initiatives(IHP+) Progress report Prepared for the 61st WHA Geneva31 Ioniata G (2009) Analysis of GFATM and other financial inputs intothe health sector in Guinea–Bissau Feb 27th 2009 UNAIDS32 CMH (2001) Report from the Commission on Macroeconomicsand Health

Health system strengthening33 Zivetz L (2006) Health Service Delivery in Early Recovery FragileStates: Lessons from Afghanistan, Cambodia, Mozambique, and TimorLeste USAID and BASICS, Washington DC34 GAVI Alliance (2008) GAVI Alliance Progress Report 2008 GAVIGeneva page 5235 Save the Children and Medact (2005) Whose Charity CountsAfrica’s aid to the NHS36 Save the Children (2007) Treading a delicate path: NGOs infragile states Save the Children UK pg 537 UNICEF (2009) State of the World’s Children38 IDRC (2008) Fixing the Health Systems – InternationalDevelopment Research Centre – wwwidrc.ca/en/ev-64760-201-1-DO_Topic.htlm 39 WHO recommends 2.5 health workers for every 1000population (WHO 2006 WHR)40 Weller Bridget (2008) Guidelines: incentives for health professionalsdeveloped for the Global Health Workforce Alliance and Save theChildren UK (2006) One million more 41 USAID (2002) USAID Child Survival and health ProgramsProgress report: Report to Congress42 Jennifer Bryce et al (2008) Maternal and child under nutrition:effective action at national level Maternal and child under nutritionseries 4 The Lancet Vol. 371 pages 510–526 Feb 9th 200843 Mahandhar DS et al (2004) Effects of a participatory intervention with women’s groups on both outcomes in Nepal:cluster-randomised control trial The Lancet 2004 364:970–97944 Zulfiqar A Bhutta et al (2008) – see note 23; Waldman R (2006)Health Programming in Post Conflict Fragile States, BASICS USAIDArlington Virginia USA

Notes

savethechildren.org.uk

Unlocking Progress in Fragile StatesOptimising high-impact maternal and child survival interventions

UK

UK

Unlocking Progress in Fragile StatesOptimising high-impact maternal and child survival interventions

320 million children are growing up in fragile states – countries affected bychronic poverty, the abuse of human rights, poor governance and conflict.

This report aims to:• raise the profile of the threats to children living in fragile and

conflict-affected states• better understand the constraints and opportunities in these countries• document innovative and effective approaches.

Working in fragile states brings many challenges. But there are opportunitiesfor positive change. While context is clearly crucial, it is nevertheless possibleto draw lessons from countries that are making progress. This discussionpaper identifies and documents approaches that are working in fragile statesprogressing towards achieving the United Nations’ Millennium DevelopmentGoals 4 and 5 – on reducing child and maternal mortality.

The report documents key bottlenecks to optimising high-impact healthinterventions, particularly in the poorest and most vulnerable populations,and recommends ways to ‘unlock progress’. It focuses on the health aspects of child survival rather than on broader social determinants, and draws onavailable literature, key informant interviews and a comparative analysis ofcase studies from Liberia, Nepal, Nigeria, Guinea Bissau and Zimbabwe.