Fragile states are home to 15% of the world’s population. People living there are more likely to suffer ill health and die prematurely: half of all child deaths and a third of all maternal deaths occur in fragile states. If the international community is serious about addressing the Millennium Development Goals, there has to be progress in those countries .

Managing the complexities of an effective health system is particularly challenging in fragile states, where the capacity to use increased donor funds effectively - the absorptive capacity - tends to be constrained by many “in country” factors (political, macroeconomic, infrastructure and capacity), as well as by certain donor practices.

What can donors do?
When donor funds ran out, this Ugandan hospital could no longer afford to maintain its ambulances
How can donors engage effectively with the health sector in fragile states? What are the principles and approaches that will help to address absorptive capacity constraints, and support long term development of health systems? A paper by the HLSP Institute highlights the key issues and offers ideas and suggestions for donor engagement.

First, context is crucial. This should dictate the appropriate instrument and the steps that need to be taken. And whatever approach is developed, donors should avoid undermining those systems already in place and must not overwhelm existing capacity or divert it from more important functions. Second, donors’ priorities must be clear. The design of a programme should depend on whether the donor aims to improve health outcomes, strengthen the health system, or catalyse broader societal change.

Within all the components of the health system (stewardship, financing, resource management and service delivery) there is a range of interventions that donors can choose to support. As well as choosing to support a specific function, donors can work on these areas entirely with or outside government, or in an “intermediate” way.

The paper Absorptive capacity of health systems in fragile states examines the range of approaches that are available to donors, together with the specific issues associated with supporting each of various components of the health systems.