Fragile states such as Afghanistan, the Democratic Republic of Congo, Haiti, Liberia, and Southern Sudan have among the worst health statistics – especially for women and children. For political, economic, security and other reasons they can be extremely challenging work environments. Despite this, I have been deeply inspired to see what local health leaders have achieved when they have created strong partnerships among government, donors, non-governmental organizations and where possible the private sector. The charismatic former minister of health from Afghanistan, the medical director of an urban clinic in northern Haiti, and the director of Torit hospital in Southern Sudan stand out as examples of local leadership in action under circumstances that would immobilize many of us.
In fragile states, constraints on governments often prevent them from simultaneously building their stewardship role and immediately expanding service delivery. Supporting the Ministry of Health to establish a basic package of health services, train local organizations to implement those services, and provide incentives (such as through performance-based financing) is critical to success. Additionally, the goal should be to move from many plans and actors across districts to one health plan with committed partners.