Global health in fragile states: A status report

In South Sudan, one in every five children will not live to see their fifth birthday. This is the grim picture that Dr. John Rumunu, director of the USAID funded Sudan Health Transformation Project (SHTP II) paints as he explains the reality of health care in the region.

“Only 25-30 percent of the population has access to health services, which are fragmented,” explains Rumunu. “It is a daunting situation. The health indicators are very grim.”

The soon-to-be-formed South Sudan is deemed a fragile state —a term used to describe a broad range of failing, failed and recovering states. There, like in many fragile states, the challenges for quality healthcare are often markedly differently than in other developing countries. 

“These states are the place that almost a third of the under-five deaths are estimated to take place,” said Diana Silimperi, the Vice President of Management Sciences for Health’s Center for Health Services. Management Sciences for Health (MSH) is a nonprofit that helps build sustainable health systems in developing countries. South Sudan's SHTP II is managed by MSH.  

However, because of the precarious political situation in these countries, in order to prevent a health emergency in the long run, there is an immediate need to invest in health care systems. This includes training health workers in the community, working with the ministries of health, implementing strong leadership, and increasing access to medical facilities and quality health care. 

This is far from simple, and requires a two-pronged approach. According to the first Quadrennial Diplomacy and Development review (QDDR), a kind of blue print for U.S. international assistance and diplomacy that was released earlier this year, “development experts must balance the short term needs of communities at risk with the prerequisites of long-term sustainable development.” 

First, health workers must respond to the acute need of citizens, providing the emergency assistance that is needed in a region that has seen two civil wars, and millions of internally displaced persons (IDPs). Along with that, the ministry of health must work to build sustainable health systems and facilities so that a long-term system of health care will exist for generations to come. Rumunu explains that finding the balance for a country like Sudan is extremely difficult. With renewed violence in the Abyei region, an increase in internally displaced persons, and a large returnee population, the challenges to accessing health care in South Sudan have increased. 

Rumunu’s predicament in South Sudan isn’t unusual. Balancing the need for emergency health care and sustainable, quality health care is tricky in other fragile states as well. 

“I think one thing that shows that very clearly is Haiti and the cholera outbreak,” said Donald Steinberg, Deputy Administrator of USAID. “We have very substantial multi-hundred million dollar programs in building sustainable [health] systems in Haiti.” 

Though many of these programs were underway last fall, their resources had to be reallocated during the cholera outbreak. 

“We have conflict between wanting to show immediate results, show stability, and show commitment, and at the same time, these may not be the projects where we get the biggest bang for the buck in the health area specifically,” said Steinberg. 

However, “bang for the buck” may not matter when all sides of the story are weighed. In Southern Sudan, Afghanistan, Haiti, there have been years of suffering, and access to health care is a social justice issue, argues Silimperi. 

“People deserve basic health care, basic health services,” she said. “It’s a fundamental human right.”