Fragile States

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

That point was made often by the Honorable Dr. Walter T. Gwenigale, Minister of Health and Social Welfare of the Republic of Liberia (also widely known as Dr. G in Liberia) at a conference, co-sponsored by MSH on June 9 and 10 at the US Institute of Peace. The event, Health in Post-Conflict and Fragile States: Challenges for the Next Decade was organized by Leonard Rubenstein, Chair of the USIP Health and Peacebuilding Working Group, and Stephen Commins, of International Medical Corps.

The two-day discussion explored the unique characteristics of health service delivery in fragile and conflict-affected states, making the point that “yes, it can be done,” but there is still a long way to go to get it right and find the balance between short-term interventions and long-term development. Speakers shared lessons learned in reconstructing health systems, especially in Afghanistan and Southern Sudan. They also took a look at human rights, governance, and vulnerable populations, particularly women. Dr. Gwenigale and Deputy Administrator of USAID, Ambassador Donald K. Steinberg provided keynotes.

Serafina Sabino, a Medical Assistant in Wau, South Sudan (© Dr. Edward Luka)

Thousands of civilians fled from Abyei following the crisis in May, when northern forces took control over the town. The United Nations Office for Humanitarian Affairs (UNOCHA) reports 50,600 people displaced from Abyei town are verified and registered and estimates the full number to be about 84,000 people. Most of the Internally displaced persons (IDPs) fled to nearby Northern Bahr el Ghazal and Warrap States, where many humanitarian agencies are providing assistance in high displacement areas like Agok, Turalei, and Wunrock. However, many IDPs are arriving in Wau town, several hundred kilometers south of Abyei.

The Ministry of Public Health’s (MOPH) Pharmaceutical Enterprises operates 53 pharmacy stores located near government hospitals nationwide, managed by 118 pharmacists. With 1 million US dollars in capital, pharmaceuticals are purchased, stored, and then distributed to the Afghan people through these government-owned pharmacies.

Dr. Mirza Mohammed Ayoobi, the Deputy Director of Pharmaceutical Enterprises says, “Majority of our government-employed pharmacists have over 15 years of experience, but have not kept pace with the changing landscape of pharmacy practice. They need training on medication counseling, rational use, and good dispensing practices.”

In response, the Strengthening Pharmaceutical Systems Program-Afghanistan team organized and facilitated the first of a series of training programs to upgrade the pharmacist’s knowledge and skills on dispensing and rational use of medicines.

After a training program, MSH interviewed Mr. Mohammad Hasham, a pharmacist in Khairkhana, about the importance and value of this training course.

South Sudan is recovering from five decades of civil war. A lack of infrastructure, human resources, and ongoing violence has ravished the country’s health services. MSH is helping the new Ministry of Health manage the transition to a national health system in the midst of renewed fighting in Abyei and as masses of people, anticipating the formation of the world’s newest country on July 9, 2011, re-enter South Sudan.

Listen to USAID Deputy Administrator Donald Steinberg and MSH Chief of Party John Rumunu (South Sudan) and MSH Center for Health Services Vice President Diana Silimperi talk about health systems in fragile states.

This teleconference is in conjunction with the health and fragile states conference at US Institute of Peace happening June 9 and 10, co-sponsored by MSH.

Management Sciences for Health (MSH) Press Teleconference on Fragile States and Health, June 8.

It is 5:30 a.m. on a Thursday morning in the town of Mwene-Ditu, located in the Eastern Kasaï Province of the Democratic Republic of Congo. The skies are still dark as the crieur, the town crier, makes his rounds, calling out to the community that today is the start of the three-day national vaccination campaign against polio.

As the local residents begin their day, health workers are finalizing preparations for the massive door-to-door effort to immunize children under age five years old from this crippling disease. One such worker is Evariste Kalonji, a community mobilization specialist with the Integrated Health Project.

When the Taliban were chased from power in Afghanistan in December 2001, the health system was in shambles---devastated by years of war and neglect. Access to primary care was below 10% and immunization rates had fallen below 20% throughout the country. Less than half the hospitals had both electricity and running water.  Medicines and medical supplies were scarce and the quality was often unreliable. There were essentially no female health workers active in most of the Afghanistan---a country in which cultural sensitivities mean female providers are essential for women’s health. Nine out of 10 women were on their own for labor and delivery, with no trained birth attendant. Not surprisingly, maternal, child, and infant mortality were among the highest in the world.

Blog post updated Dec. 27, 2011.

Taj Bibi learns how to use zinc and oral rehydration salts to treat her child. Photo credit: BASICS/Afghanistan, MSH.

Taj Bibi sits nursing her 5-month-old baby in the kitchen of her home in the village of Sartal in Takhar province in Afghanistan’s north. The room is dark; the only natural light comes from the doorway to the dusty courtyard outside. The sound of her children playing echoes across the small family compound.

Bibi’s first two children died -- one of them from severe diarrhea -- because the family could not afford to take them to the doctor. “Now, if our children get diarrhea or any other illness, I take them to the community health worker,” she said.

Community health workers (CHWs) are the building blocks of the Afghan health system, bringing basic health services to villages across the country.

Providing immunizations to children in Afghanistan.

Many children in Afghanistan can be spared of communicable diseases that can make them ill and even cause death, if they receive routine vaccinations. But in a country of more than 25 million people in a country the size of Texas, where over 80% of the population lives in rural areas, immunizing every child against measles, diphtheria, pertusis (whooping cough), tetanus, and polio is very challenging.

Large scale immunization campaigns have proved helpful, but have been unable to significantly increase and maintain high immunization rates throughout the country.

The US Agency for International Development’s BASICS project (Basic Support for Institutionalizing Child Survival), with support from MSH, is working with the Afghan Ministry of Public Health (MoPH) and UNICEF to demonstrate in nine districts how an expanded program on immunization (EPI) micro-planning can successfully increase the number of immunized children.

The community midwife sitting with Suzanna Ile and her son, Modi, in South Sudan. {Photo credit: MSH.}Photo credit: MSH.

Blog post updated Dec. 27, 2011.

Suzanna Ile is a 26-year old woman from Lokiliri Payam in South Sudan. Suzanna lost her first two babies in child birth. During her third pregnancy, a community midwife at Lokiliri Primary Healthcare Centre -- a health facility supported by the US Agency for International Development (USAID) through the MSH-led Sudan Health Transformation Project (SHTP II) -- recognized Suzanna’s contracted pelvis and identified her high risk pregnancy.

Without access to emergency services and a health facility capable of performing a Caesarean section, the midwife knew Suzanna would likely lose her third child as well. A contracted pelvis often results in obstructed labor, fistulas, postpartum hemorrhage, or the death of the infant and mother. The midwife discussed with Suzanna alternative delivery options during an antenatal care visit.

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