Fragile States

Fragile States (including Afghanistan, Democratic Republic of Congo, Haiti, Liberia and South Sudan)

{Photo credit: Warren Zelman}Photo credit: Warren Zelman

There are no magic bullets in life. For fixing a healthcare system, though, there is one approach that comes close: results-based financing. Management Sciences for Health (MSH) pioneered results-based financing in Haiti in 1999, and has been adapting and improving it ever since in sub-Saharan Africa, Latin America, and South-East Asia, including in fragile states.

In my 20-plus years in global health, I’ve seen what happens without results-based financing: A major donor sends millions of dollars’ worth of equipment and supplies to a developing country—and the quality of health services delivered doesn’t improve—or worse, it declines. Why?

Health providers are human, like all of us—sensitive to incentives, motivation, and demotivation. Say a hospital improves and now is well stocked: the community realizes this and the utilization rate doubles. Suddenly, a nurse may be facing 40 patients a day instead of 20, but without any added pay or assistance. It’s only natural he or she might work less under the crushing workload.

{Photo credit: Rui Pires}Photo credit: Rui Pires

Are you interested in health systems strengthening for the Sustainable Development Goals (SDGs), epidemics prevention, and global health security? Join MSH at these events during the 69th World Health Assembly in Geneva. Can't join us in person? Join the conversation online with hashtag . On Twitter, follow , , , and .

 {Photo credit: Associated Press/Aurelie Marrier d’Unienvil}Women celebrate as their country is declared Ebola free in the city of Freetown, Sierra Leone, Saturday, Nov. 7, 2015.Photo credit: Associated Press/Aurelie Marrier d’Unienvil

When 18-year-old Ianka Barbosa was 7 months pregnant, an ultrasound showed the baby had an abnormally small head, a dreaded sign of microcephaly due to Zika infection.  Upon hearing the news, Ianka’s husband fled. In her poor neighborhood of Campina Grande, Brazil, Ianka soon became a young mother alone.

As Ianka’s baby Sophia grows, she may never walk, or talk. She could develop seizures before she reaches six months.  By the end of the year there may be a staggering 3,000 Sophias in Brazil – mostly in the poorest places.

Epidemics erase the gains women have achieved.

The world has suffered a series of “Zikas”—virtually unknown diseases that seemed to come from nowhere and explode with devastating consequences for families and entire countries – before Zika, Ebola, SARS, AIDS, and others.

Epidemics don’t just leave behind a death toll.  They can demolish the gains women have made in maternal, newborn, child, adolescent, and reproductive health—gains that have been propelled by women’s rights and empowerment. 

SCMS supported local partners in 25 countries to build country ownership of supply chain management. Read more about SCMS’s impact in its report: 10 Years of Supporting PEPFAR through Stronger Public Health Supply Chains

By Sherif Mowafy

[Chantal, an HIV-positive woman, waits for her monthly supply of antiretroviral medication at the Hôpital Immaculée Conception in Haiti.] {Photo credit: Jean Jacques Augustin, SCMS}Chantal, an HIV-positive woman, waits for her monthly supply of antiretroviral medication at the Hôpital Immaculée Conception in Haiti.Photo credit: Jean Jacques Augustin, SCMSAs the warm Haitian sun comes up, Chantal leaves her four children behind to get her HIV treatment, traveling for three hours in the back of a crowded jeep.

She bumps over unpaved roads to her monthly visit for antiretrovirals, one that she has been doing routinely for several years to keep her disease at bay.

Her children don’t know that she is HIV positive, and she doesn’t want to tell them. She makes this long trip over rough and ragged terrain to preserve her privacy and escape the possibility of stigma, still prevalent in Haitian society.

 {Photo credit: Rebecca Weaver/MSH}A community health worker in Democratic Republic of the Congo.Photo credit: Rebecca Weaver/MSH

This Global Health Impact issue highlights community health and community health workers, and presents a glimpse of MSH's work at the community level, in partnership with national ministries of health, civil society organizations, the private sector, and more.

The community is the center of the health system in developing countries.

Throughout sub-Saharan Africa, community health workers, often volunteers, represent the foundation of the health system, addressing priority health areas ranging from maternal and newborn health to family planning and infection prevention. The community health worker (known by different names in different countries) is the fundamental frontline promoter, provider of services and medicines (through integrated community case management), and the one who refers and links beneficiaries with more complex health needs to facilities. Not only do community health workers extend access to health services for the underserved and those living in hard-to-reach or conflict-ridden areas, they help countries accelerate certain health outcomes and achieve the Sustainable Development Goals and related targets for universal health coverage.

 {Photo credit: Katy Doyle/MSH}A health worker in Togo counsels a woman on reproductive health.Photo credit: Katy Doyle/MSH

Many years ago I began my public health career in Ciudad Nezahualcoyotl, then a squatter settlement of 1.8 million people, bordering Mexico City in the State of Mexico. Lack of land and unaffordable rents forced poor migrants, streaming in from the country side in search of employment and a better life in the city, to settle in the surrounding peri-urban areas. This large municipality, with few paved streets, was difficult to navigate in the rainy season. During the dry season, the wind would kick up dust storms that made it hard to see a block ahead. Nezahualcoyotl means hungry coyote in the Nahuatl language  and too many families in Neza, as people sometimes called it, were poor and hungry.

{Photo credit: Brooke Huskey/MSH}Photo credit: Brooke Huskey/MSH

Many child deaths in developing countries are preventable: Children die from treatable conditions, such as pneumonia, diarrhea, and malaria, because families in rural, hard-to-reach, or conflict-ridden areas can’t access or afford the treatments. The Sustainable Development Goals (SDGs), launched in September 2015, set ambitious targets of ending preventable child deaths by 2030 and reducing mortality among children under age five to at least 25 per 1,000 live births.

Integrated community case management (iCCM) has been recognized as a key strategy for increasing access to essential treatments and meeting the objectives for children under five laid out in the SDGs. Integrated community case management entails training volunteer community health workers to serve as the first point of contact for medical treatment in remote areas, enabling them to recognize and treat common childhood illnesses. To be effective, community health workers must operate within a broader pharmaceutical system in which the needs for quality medicines and other health commodities are assured.

 {Photo credit: MSH staff}Amina is one of 3 million children in the Sahel region of sub-Saharan Africa who received seasonal malaria chemoprevention malaria in 2015.Photo credit: MSH staff

Four-year-old Amina is why I work on malaria. I met her in Basse District, The Gambia, last year when I was visiting the team distributing lifesaving malaria treatment to children under five. Words can’t describe the feeling of seeing this young Gambian girl, who had been severely ill with malaria, now beaming with joy, literally running to me for her fourth treatment.

Her mother walked up and described to me how sick Amina had been before MSH and partners began ensuring access to the quality-assured malaria treatments for children under five in the district. Since she first got malaria as an infant, every year during the rainy season (from September through December), Amina would become severely ill with malaria. She couldn’t play with the other kids outside, or go to school. One year, she fell into a coma and was hospitalized. But, in 2015, Amina experienced the opportunity for a healthy life: since September, she had received monthly treatment for malaria, known as seasonal malaria chemoprevention (or SMC). At four years old, Amina knew that this was what stopped her from feeling so ill, and enabled her to feel well.

She ran towards me for her medication, smiling ear to ear.

Unpublished
 {Photo credit: Ghaffar Rabiu}Dr. Zipporah Kpamor, Country Director, MSH Nigeria, is interviewed at the 10th anniversary event.Photo credit: Ghaffar Rabiu

Management Sciences for Health (MSH) celebrated 10 Years of Improving the Health of Women and Children in Nigeria with 250 stakeholders and supporters at a special event in Abuja on March 31, 2016. Distinguished guests included the chairman of the Nigerian House of Representatives, director of the Federal Ministry of Health in Nigeria, high-level representatives from state governments and partner organizations, and more.

After a rousing rendition of “Arise, Oh Compatriots,” the Nigerian national anthem, Country Director, Dr. Zipporah Kpamor, welcomed participants and underscored the intention for the day’s two round-table panel discussions:

In Nigeria, 150 women and 2,300 children die every day from preventable causes. One in five children won’t live to see their fifth birthday. This event can help continue conversations on what we can do to end preventable deaths among women, children, and young people.

Currently, MSH’s partnerships for health system strengthening in Nigeria reach nearly 560,000 people through four projects.

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