About the Report

Because of the uncertainties and questions about health 

development in fragile and conflict-affected states, home to 

one-sixth of the world’s population, including whether and how 

it can advance state legitimacy or security, the United States 

Institute of Peace convened a two-day conference in June 

2011—“Postconflict and Fragile States: Challenges for the Next 

Decade”—that brought together policymakers, organizations 

engaged in health development, ministries of health, human 

rights experts, academic researchers, and advocates to consider 

the questions and recommend a way forward. This special 

report is a product of that conference. 

About the Authors

Rohini Jonnalagadda Haar is a physician who has engaged 

in clinical services, program development, and public health 

research in numerous countries with a variety of organizations. 

Leonard Rubenstein is a senior scholar at the Center for Public 

Health and Human Rights at the Johns Hopkins Bloomberg 

School of Public Health.

2301 Constitution Ave., NW • Washington, DC 20037 • 202.457.1700 • fax 202.429.6063

Special Report 301 January 2012

© 2012 by the United States Institute of Peace. 

All rights reserved.

Contents

Introduction 2

War, Fragility, and Health 2

Health, State-Building, Stability, and Governance 5

Health Reconstruction 7

Health Investments in Fragile and 

Conflict-Affected States 10

Conclusions and Policy Recommendations 11

Rohini Jonnalagadda Haar and Leonard S. Rubenstein

Health in Postconflict 

and Fragile States

Summary

•	 The populations of states experiencing severe instability or unable to meet the basic functions of governance—referred to as fragile states—as well as those embroiled in conflict 

make up one-sixth of the world’s population and suffer from far poorer health than their 

counterparts in other states at comparable stages of development. 

•	 During many armed conflicts, health facilities and health workers come under attack, and 

infrastructure is often destroyed, inducing health workers to leave and undermining management capacity, thus further depleting health system competence to meet basic needs.

•	 Evidence is emerging that effective and equitable health services may be a central contributor to state legitimacy. 

•	 All too often, health interventions in fragile and conflict-affected states are limited to 

humanitarian relief, which does not advance either health systems development or state 

legitimacy.

•	 Two decades of experience in development of health systems in fragile and conflict-affected 

states have shown a need to address weaknesses in policy, leadership, management capacity, human resources for health, supplies, service delivery, and data collection and evaluation through World Health Organization’s (WHO) building blocks for health services. 

•	 The military’s record of engagement in civilian health systems development is poor, and its 

efforts to use health interventions to promote stability have not proven fruitful. Its most 

appropriate role in civilian health in fragile and conflict-affected states is to provide or 

support health services in highly insecure areas.

•	 Donors have not made health systems development in such states a priority in global health 

programs. Investments are often seen as politically or financially risky, and as having lower 

potential payoffs. Given the poor health indicators in these states, however, health development in fragile and conflict-affected states should be a higher priority.

•	 Donors need to confront directly whether the goal of health development is stabilization 

or population health. 

United States Institute of Peace www.usip.org

SPECIAL REPORT
2 

•	 Research is warranted on the relationships between health and armed conflict and between 

health development and state building. 

Introduction

The role of health in development and aid policy in conflict-affected and fragile states remains 

a conundrum. Evidence is increasing that conflict and fragility have a devastating impact on 

health. At the same time, knowledge on how to construct effective and sustainable health 

systems in these states through local leadership and donor commitment is expanding. Yet, 

except in countries of strategic or political interest to donors, such as Afghanistan, Iraq, or 

the Balkans, the level of donor investment in these states remains low even as global health 

spending has dramatically increased. Moreover, the policy animating these investments is 

murky, a mixture of health goals and political objectives relating to stabilization and counterterrorism. Whether health investments can and should advance those political goals remains 

highly contested. At the same time, the conventional distinction between emergency health 

interventions and humanitarian relief on the one hand and health development on the other, 

although reflected in funding streams, often makes little sense on the ground. Conflict and 

fragility tend to be protracted, but health systems development can often proceed even before 

peace and stability are established. Further, fragility or conflict, and its attendant impacts on 

health, may well affect one or more regions of the country rather than its entirety.

War, Fragility, and Health

No consensus has yet been reached on a definition of a fragile or postconflict state. Generally, though, a fragile state is considered “unable to perform basic functions [such as] 

maintaining security, enabling economic development, and ensuring the essential needs 

of the population are met.”1 They are “characterized by weak policies, institutions, and 

governance.”2 These states are not just poor or corrupt; they are understood as incapable 

of accomplishing basic functions including providing effective core services such as education, transportation, state financing and administration, justice, and health. Some states 

experience fragility as a result of a political crisis while others are fragile for decades and 

intermittently erupt into violent conflict. Conflict-affected states are easier to identify, 

though organizations that track conflicts use varied definitions of conflict based on indicators such as number of casualties or extent of fighting. The distinction between conflict 

and postconflict status is imprecise because some conflicts become chronic, and displaced 

persons and refugees remain in camps or otherwise without permanent settlement for 

decades. In other states, a formal end to a conflict is replaced by high levels of continuing 

violence and instability, sometimes including renewal of war. An estimated one-sixth of the 

world’s population live in fragile or conflict-affected states.3

Health Indicators in Fragile and Postconflict States 

However defined, states characterized as fragile or conflict-affected tend to have far worse 

population health indicators than states at comparable levels of development and show 

less progress on achieving the Millennium Development Goals. Vulnerable groups—which 

include women, children, refugees, the elderly, and the mentally ill—in such states are 

generally affected the most. Poor indicators are likely a product of inadequate governance 

and service development, disruptions of health and determinants of health like clean water 

and sanitation, destruction of infrastructure, flight of health workers, or a combination of 

these and other factors. 

The views expressed in this report do not necessarily 

reflect the views of the United States Institute of Peace, 

which does not advocate specific policy positions.

To request permission to photocopy or reprint materials, 

e-mail: permissions@usip.org

About the Institute

The United States Institute of Peace is an independent, 

nonpartisan institution established and funded by Congress. 

Its goals are to help prevent and resolve violent conflicts, 

promote postconflict peacebuilding, and increase conflict 

management tools, capacity, and intellectual capital worldwide. The Institute does this by empowering others with 

knowledge, skills, and resources, as well as by its direct 

involvement in conflict zones around the globe.

Board of Directors

J. Robinson West (Chair), Chairman, PFC Energy •

George E. Moose (Vice Chairman), Adjunct Professor of 

Practice, The George Washington University • Judy Ansley,

Former Assistant to the President and Deputy National Security Adviser under President George W. Bush • Eric Edelman,

Hertog Distinguished Practitioner in Residence, Johns Hopkins 

School of Advanced International Studies • Kerry Kennedy, 

President, Robert F. Kennedy Center for Justice and Human 

Rights • Ikram U. Khan, President, Quality Care Consultants, 

LLC • Stephen D. Krasner, Graham H. Stuart Professor 

of International Relations, Stanford University • John A. 

Lancaster, Former Executive Director of the National Council 

on Independent Living • Jeremy A. Rabkin, Professor, 

George Mason School of Law • Judy Van Rest, Executive Vice 

President, International Republican Institute • Nancy Zirkin,

Executive Vice President, Leadership Conference on Civil Rights

Members Ex Officio

Michael H. Posner, Assistant Secretary of State for 

Democracy, Human Rights, and Labor • James N. Miller, 

Principal Deputy Under Secretary of Defense for Policy •

Ann E. Rondeau, Vice Admiral, U.S. Navy; President, 

National Defense University • Richard H. Solomon, 

President, United States Institute of Peace (nonvoting) 
 3

In considering the impact of armed conflict on health, it is often difficult to identify 

exact causes of death and ill health, because indicators depend on a host of factors that 

include the size, intensity, and chronicity of the conflict, the state of existing infrastructure, and the extent of destruction of infrastructure, among others. Many of the reports 

of the relationship between armed conflict and health are based on small observational or 

survey-based studies and often do not include correlations with levels of fighting or other 

relevant factors. It can be said with some confidence, though, that in most conflicts the 

greatest impacts on civilian morbidity and mortality are indirect, and nonviolent deaths 

far outnumber violent ones.4 A study reviewing World Health survey data estimated that 

378,000 nonviolent war-related deaths occurred annually from 1985 to 1994 (a range of 

156,000 to 614,000).5 In Darfur, 87 percent of excess civilian deaths between 2003 and 

2008 were nonviolent.6 

These deaths are typically a result of increases in infectious disease from destruction of 

infrastructure, decline of preventive measures like vaccinations and access to clean water, 

and shortages of medication and supplies for treatment. The poorest countries, with low 

baseline health service capacity, and even more decreased capacity after a conflict, have 

the highest ratios of noncombat-related deaths.7

Some analysts have challenged the assertion that significantly increased civilian deaths 

are associated with armed conflict. The 2010 Human Security Report argues that “nationwide mortality rates actually fall during most wars” primarily because local conflicts do 

not dramatically alter the general trend in improvement of health indicators worldwide. It 

states that “of the 52 countries that experienced war in the period from 1970 to 2008, only 

8 countries (or 15 percent) experienced any increase in the under-five mortality ratios during wartime.”8 More recent studies, however, question this analysis. They show that health 

impacts of armed conflict tend to be concentrated in particular regions or be a product of 

targeting identifiable demographic groups that national level studies may not reveal. In a 

background paper to its 2011 World Development Report, World Bank analysts showed that 

though conflict can dramatically affect the health of populations directly involved in the 

violence, the entire country may not suffer equally.9 Their comparison of mortality rates 

between provincial regions and the nation as a whole within conflict settings reveals that 

provincial data is often dramatically different from national aggregates. Particularly in 

conflicts that are more locally focused, targeted groups within populations may be more 

significantly affected than the population as a whole.10 Another critique of the Human 

Security Report approach is that under-five mortality may not be an appropriate indicator 

of the impact of conflict on health because it shows long-term trends, and may decline or 

increase in the months and years after a conflict rather than during it. 

Moreover, even if declining in conflict regions, in sub-Saharan Africa more than 60 percent of under-five deaths occur in areas of chronically unstable governance, and of these 

almost two-thirds are preventable. The data also indicate that the highest potential for 

excess deaths among children is in low-level conflicts in poor countries.

Finally, national statistics may be misleading, given the nature of statistical reporting 

systems and the disruptions caused by conflicts. Because national reporting may select 

for populations in more secure environments where assessments are easier, proportionally 

fewer conflict-affected populations may be surveyed.11 Regional surveys in Kenya, Congo, 

Somalia, and Ethiopia, for instance, show that some areas are less surveyed than others, 

creating black holes that could skew national data. Additionally, generalizations from available country statistics may not fully assess breakdown in health-care delivery, in particular 

isolated populations such as internally displaced persons and refugees, who usually have 

worse health status and may live in camps outside the reach of demographic country data. 

Comparing data with expected outcomes, as the Global Burden of Disease Project has done, 

In most conflicts the greatest 

impacts on civilian morbidity 

and mortality are indirect, 

and nonviolent deaths far 

outnumber violent ones.

Because national reporting 

may select for populations 

in more secure environments 

where assessments are easier, 

proportionally fewer conflictaffected populations may 

be surveyed.
4 

and to neighboring areas, might reveal more about health impacts than passive demographic health survey data.12

Increased morbidity is also significantly associated with conflict, though here, too, the 

relationships are complex. Mental health impacts of war are often severe.13 For other conditions, especially in chronic, low-level conflicts, morbidity may not follow expected patterns. 

A study in Nepal has shown that of nineteen Millennium Development health indicators, 

sixteen actually improved during the time of the Maoist insurgency from 1996 to 2006. One 

factor that could have influenced this finding is that the Maoists attempted to support the 

communities where they operated; another is that indicators were among the worst in Asia 

at the time the insurgency started.14

More sophisticated methods of determining the precise relationship of fragility, conflict, 

and health, including assessments within regions, are needed. What existing studies demonstrate, though, is that these relationships are hardly incidental, and the public health 

community is obligated to collaborate on information collection and sharing to better 

understand the health terrain of modern fragile states. 

Attacks on Health Facilities, Personnel, and Patients

Security of health-care infrastructure and health-care personnel are at high risk from attack, 

interference, or obstruction during armed conflict. These assaults violate international 

law and can undermine the ability of institutions and personnel to carry out their missions, stimulate migration of health workers away from places in need, and limit access of 

populations to critically needed health-care services. Infringements of security can come in 

various forms. At the most basic level, health workers, hospitals, and patients come under 

direct attack, through shelling, bombing, or shooting, and by interference with water supply 

or electricity, or obstruction of access. Facilities may also be taken over by security forces 

or armed groups for military purposes. Health workers are targeted for killing, kidnapping, 

or assault, or subjected by security forces to arrest, detention, and prosecution for having 

provided impartial medical care to combatants or others associated with a side opposed 

to those forces. Ambulances may be denied travel through checkpoints or shot at. Further, 

Red Cross insignia may be misused for unauthorized purposes.15 The assaults not only bring 

about immediate casualties, but deprive a population of a key health resource, such as a 

hospital, clinic, or health worker, over the long term. 

The experience of Liberia during its civil war indicates how hospitals, rather than being safe 

havens for the ill, can become targets. Phebe Hospital, where Dr. Walter Gwenigale, Liberia’s 

current minister of health and social welfare, worked at the time, was attacked and looted in 

September 1994 and again in 2002. Much of the equipment and most of the drugs were looted. 

Staff members were threatened and fled. Although many health workers returned in the years following the end of the civil war, the already sparse staff diminished in size, leading to fewer health 

consultations and less access to treatment for the community. A recent study by the International 

Committee of the Red Cross in sixteen countries revealed 655 violent events against health-care 

personnel and patients, including killing, wounding, and kidnappings, as well as denial of access 

to facilities and destruction of infrastructure, in just two and a half years.16

Research is scant on the specific impacts of assaults on health worker migration and on 

access to health services, but given health worker shortages in fragile states and inadequate 

infrastructure, the losses would be likely to be heavily felt. In Iraq, where health worker 

flight as a result of targeted attacks has been studied, the departures were significant, and 

health services suffer from lack of qualified staff.17

Intimidation of health workers through demands to restrict services to individuals 

associated with a particular faction or group may also impede access to care. In Nepal, the 

Security of health-care 

infrastructure and health-care 

personnel are at high risk 

from attack, interference, or 

obstruction during armed conflict.
 5

government required health-care practitioners to report any patients who were possible 

Maoists; in Kosovo, Kosovar Albanian physicians were arrested and prosecuted for allegedly 

providing health-care services to members of the Kosovo Liberation Army. In so doing, the 

government was attacking the oaths of physicians to provide unbiased and equal care to all. 

These attacks, as clear ethical and human rights violations, require a greater commitment 

from the international community for documentation, prevention, and accountability. 

As U.S. assistant secretary of state for democracy, human rights, and labor Michael 

Posner explained, international humanitarian law requires states to take measures to protect patients and medical personnel. Agencies responsible for reporting on and demanding 

compliance with human rights laws, however, have devoted too few resources and too little 

priority to reporting and use of diplomatic tools to secure compliance with international 

obligations. The need for protection remains urgent. Posner acknowledged that governments and human rights organizations need to do more to use diplomacy to seek compliance and report on and condemn violations. In a step toward enhanced reporting, the U.S. 

Department of State has committed to including incidents of attacks on health personnel, 

facilities, and patients in its annual country reports on human rights practices.18

Health, State Building, Stability, and Governance

Stabilization and peacebuilding in fragile and postconflict states have become major 

features of international policy and foreign assistance. A number of factors contribute to 

this increased attention. First is a high rate of conflict recidivism, given that 31 percent of 

conflicts restart within ten years of concluding.19 Second, conflict has a destructive impact 

on population health and well-being. Third, concerns exist about the potential for local 

conflicts to evolve into regional ones and for poorly governed states to become a breeding 

ground for terrorist groups. One key unanswered question in furthering such policies is the 

role health programs can play in advancing state building and stability.20

In the long term, stronger health systems can improve the health of the population, in 

turn leading to greater productivity and economic growth, less violence, and state stability. 

Evidence indicates that improved health services can increase trust in government and thus 

modestly contribute to reinforcement of the authority and legitimacy of the state through 

developing human capital, providing quality health services, promoting citizen oversight of 

health programs, generating fiscal reform, and creating monitoring mechanisms.21 A study 

by RTI International of Iraqi citizens has shown, however, that the relationship between providing services and trust in the state is not always linear. The researchers found a U-shaped 

correlation between community satisfaction with water services and willingness to pay for 

these services, which can be seen as a proxy for trust in the state. At the lowest end of satisfaction, people are willing to pay almost anything just to get a service, and that willingness 

doesn’t reflect faith in the government; when they are very satisfied, citizens may trust the 

government and also be willing to pay for these services. Between these extremes, when 

some services are provided but are poor quality, citizens are not as willing to pay.22

Different communities and populations also have different expectations of what the 

government should provide. What Iraqis historically have expected from government service 

may be very different from what is expected in Europe or sub-Saharan Africa. Moreover, 

health is often low on the list of people’s priorities when compared with security, jobs, a 

fair justice system, and education; health services are not considered significant for many 

people until they become sick. Furthermore, health services are a necessary but hardly sufficient feature of the government; if the government does not provide other basic services 

such as education, transportation, water, electricity, and justice, it may not be seen as 

legitimate or gain strength despite hefty investments in health. 

If the government does not 

provide other basic services such 

as education, transportation, 

water, electricity, and justice, it 

may not be seen as legitimate 

or gain strength despite hefty 

investments in health. 
6 

The evidence does suggest, however, that equity in services may be a more powerful predictor of confidence in government than the general sufficiency of services. Health services 

are often not equally distributed within countries and are often particularly weak for rural 

or scattered populations.23 These inequities may, in some circumstances, motivate conflict 

among different groups. Service inequalities often predate the conflict and continue after it. 

It is possible that to the extent to which health services become more equitable, they may 

reinforce state legitimacy, and thus can play a role in reducing the likelihood that conflict 

will resume. This question, though, has not been the subject of rigorous study. 

Responding to these inequities is not simply a matter of institutionalizing equity in 

service delivery; it also requires the contribution and collaboration of numerous communities and reinforcement of the authority of the state to perform its role. Both the Guatemala 

Peace Accords of 1996 and the South Sudan Comprehensive Peace Agreement of 2005 had 

language setting out the health and education obligations of the government.24 However, 

in weak states without stable infrastructure, articulating the obligation does not ensure the 

capacity to deliver these services. UN agencies or other nonstate actors may be required to 

help provide services. The specific mechanisms of this assistance can either hinder or help 

state legitimacy. 

Donors can affect the ability of a ministry of health to use health services to advance 

state legitimacy. The most important action, of course, is to provide funding for the equitable development of health services. In doing so, however, they need to reinforce the 

authority and leadership of the host government, which may be the most critical factor in 

developing an effective health system. They can advance legitimacy by helping build the 

capacity of the ministry and refraining from touting their own contributions. For instance, 

donors can pool funds and permit the ministry of health to contract services to nongovernmental organizations. The ministry must develop capacity to develop a plan for services, 

manage the contracts, and ensure financial accountability for the funds.25

Evidence is only anecdotal, however, of the impacts of health programs on stabilization, 

which differs from legitimacy and state building in that it principally concerns establishing 

and maintaining security.26 The theoretical mechanisms by which stability through health 

interventions could occur are complicated by the nuances of each state’s history of conflict 

and ethnic or other composition. Metrics need to be established to measure potential 

impacts of health development on stabilization. The paucity of evidence on the relationship 

between health and stability, however, should not be a basis to refrain from investing in 

health. Instead of looking for tangible stability dividends from those investments, policymakers can take the broader view that health investments are essential to a healthy population, long-term development, and state legitimacy. 

At the same time, efforts to meet immediate humanitarian needs should take the 

impacts NGO actions have on service provisions into account. NGO interventions that are not 

coordinated with national government can have negative effects on state legitimacy and 

be potentially destabilizing. Similarly, failure to include government actors in planning and 

executing humanitarian response to advance health system development can be a missed 

opportunity to build state capacity and legitimacy. In South Sudan, for example, despite 

generous humanitarian relief in the face of only 25 percent of the population’s having access 

to primary health services, the United States has not prioritized health interventions except 

those that have immediate impact, such as malaria control. 

Policymakers have asked whether investing in a particular health program can advance 

stability. This is a political question. The alternative and essential question is whether 

health investments can improve people’s lives and well-being. The answer is clearly yes. At 

the same time, peace and stability promote and protect health, so investments in security 

also have health benefits. 

Equity in services may be a more 

powerful predictor of confidence 

in government than the general 

sufficiency of services.
 7

Health Reconstruction: Lessons Learned and Challenges 

Fragile states vary greatly in history, governance, sources of conflict, and health indicators, 

but by definition lack legitimacy and effective service administration. Because of weaknesses in stewardship, accountability, delivery of essential services, resource management, 

financing, or security, these states are often unable to fulfill a basic function, to organize a 

system of health services.27 The health sector often suffers from weakness in infrastructure, 

health supplies, and adequately trained staff—which may stem from existing inadequacy, 

attacks during conflict, neglect, or all three—as well as deficiencies in resources and administration, data collection, and management. They are also characterized by gross inequities 

in access and quality. Natural disasters that strike these states exacerbate the challenges. 

The health service delivery system, including coordination and oversight of service systems, 

is often in disarray, leaving communities without proper access to medical care, particularly 

outside urban areas. 

In many cases, these deficiencies also mean that the government is not participating 

in medical care, leaving nongovernmental and private actors to operate an uncoordinated 

and poorly directed delivery system that leads to inequitable service delivery (and possibly 

fuels further conflict). Without a coordinating mechanism, many clinics may open in some 

regions but none in others, leaving communities alienated from health services. Similarly, 

without government stewardship of appropriate information collection, the health system 

often operates with little up-to-date information on current health status, epidemics, locations of health facilities, and other important indicators. Finally, in the absence of a capable 

ministry, fragile states often lack the management capacities that allow for developing 

budgets, tracking expenditures, assessing workloads, managing human resources, and carrying out disease surveillance.28

To meet these daunting challenges, reconstruction efforts should be based on the World 

Health Organization’s six health system building blocks—leadership and governance; health 

services; health information; human resources; financing; and access to essential medicines, 

vaccines and technologies—as the core structural components of a state’s health system.29

Moreover, key questions about sequencing must be tailored to the capacity, security situation, and state of health in each state. 

Giorgio Cometto, Gyuri Fritsche, and Egbert Sondorp cite the need for “sustained investment in assessment and planning of recovery activities; building of procurement capacity 

early in the recovery process; support for funding instruments that can disburse resources 

rapidly; and streamlining the governance structures and procedures adopted by health recovery 

financing mechanisms and adapting them to the local context.”30 The process requires strong 

local leadership, as has been demonstrated in Liberia. Donors and those who provide technical 

assistance should work with the national government directly, as well as with NGOs and other 

actors, to build capacity. It is critical to meet short-term health needs of the population even 

as the arduous work of health workforce development, management capacity building, and 

planning take place. Often a balance must be struck between short- and long-term needs. 

The experience of health services development in a wide variety of fragile and conflictaffected states has yielded important lessons in strategies to strengthen national government capacity in key areas of need. Several high-impact interventions have proved useful. 

Developing a plan and strategy for a package of basic health services based on local 

information collection and survey data can be a productive starting point around which to 

align health priorities. Assisting with identifying the needs of the nation and creating this 

package has been a successful basis for future rebuilding in Afghanistan and Liberia.31

In Afghanistan, the World Bank, the EU, and USAID funded the model. Each took responsibility for one of three regions where they provided financial and technical assistance to the 
8 

ministry on capacity building, including contract management regarding services offered by 

NGOs to implement the package. By 2005, a new basic package of health services capable of 

expanding to a broader level of interventions among both rural and urban populations was 

developed. The success of this package and its capability to transition to more ministerial 

leadership is a key lesson in aligning priorities and strengthening government management 

of the health sector. 

The specific model of strengthening basic services will vary depending on health, 

geography, capacity, and political circumstances. In 2002, Afghanistan’s new Ministry of 

Public Health made a vital if controversial decision approving a basic package of health that 

focused on reducing maternal and child mortality rather than a larger package that included 

mental health or disability. Despite pressure for more comprehensive coverage, the need to 

set priorities and to place particular focus on it in rural rather than urban areas was clear. 

In Liberia, rebuilding rural health clinics after the war was considered the priority, including promoting equity between urban and rural areas. In Somalia, where central government 

barely exists, NGOs developed relationships with health “ministries” among the factions to 

promote service development. 

The need to adjust to local circumstances is also illustrated by the role of the ministry of 

health. Although the ministry is generally the key player, in some circumstances its leadership is impossible because of corruption, instability, weakness, or political opposition. In 

bureaucratic and hierarchical ministerial systems, a slow central government can weaken 

health resources in already vulnerable areas. In such circumstances, creating a decentralized model that can communicate effectively with the central government to realize both 

national and local goals should be a priority. 

Another vital priority in most fragile states is to develop human resources in health, 

where severe shortages generally exist even apart from the impact of war. The first requirement is having enough trained health workers to appropriately treat and manage the health 

needs of the population. Standardizing skills and certifications pose challenges in locations 

where many health workers may not have had access to adequate training and technologies. 

Educating nurses, technologists, and physicians is a long-term (and expensive) necessity, 

and many states have expanded the role of community health workers as one way to alleviate urgent shortages. In Southern Sudan, where human resources for health have been all 

but nonexistent, and many areas are so vast and remote as to be impossible to reach regularly, the strategy to improve health worker shortages includes a leadership training program 

combined with service expansion. Acquiring a steady supply of essential medications and 

equipment is also vital for health workers to adequately manage patients. 

For all of these priorities, identifying costs and aligning with donors and government 

resources to ensure the availability of long-term funding is vital for the health system to 

recover and rebuild. Although coordinating donors and managing national programming 

in the context of local autonomy in creating health schemes will be difficult for nascent 

governments and stakeholders, creating a sustainable investment strategy is the lynchpin 

of health system reconstruction. 

Promoting transparency, participation, respect for human rights, and accountability 

from all parties is a final priority for all fragile states to improve their health systems 

system. In Liberia, President Ellen Sirleaf Johnson has made accountability a priority 

for the government, as well as for donors and private organizations. By taking on this 

responsibility, the government has shown that it can successfully and transparently manage finances and has also become the principal recipient of major aid contributions. 

Participation must take place at all levels, from community engagement in planning and 

oversight to involvement of women in leadership in service design and implementation, 

consistent with the principles of UN Security Council Resolution 1325 and its successors. 

Identifying costs and aligning 

with donors and government 

resources to ensure the 

availability of long-term 

funding is vital for the health 

system to recover and rebuild.
 9

In particular, integrating women into planning as well as training must be a priority to 

address the chronic discrimination against women and subordination of their health needs 

that exists in many fragile states. Taking that approach can both change social and power 

relationships and improve health. In Afghanistan, where women have been at the forefront of health services development, the first basic package of health services focused 

on child and maternal health. Despite massive illiteracy among women, the ministry and 

partners were able to train women to provide birth control to an otherwise inaccessible 

population. Despite their volunteer status, with motivation and need, the attrition rate 

of these community health workers has been low. 

The challenges of supporting health systems development in postconflict and fragile 

states are especially severe when corruption, political repression, lack of willingness to lead, 

or severe instability are present. In these circumstances, health services must be developed 

through local officials, NGOs, and civil society. There are some models on which to build. In 

Somalia, in response to the lack of a legitimate governing presence, NGOs have been taking 

the lead in the development of the health system. With the assistance of the Global Fund 

to fight AIDS, Tuberculosis, and Malaria, for example, World Vision International and other 

NGOs have been able to increase capacity despite the lack of a stable government ministry 

to ally with. Working with all factions, the groups have spent more than eight years supporting sixty-four tuberculosis (TB) management units and detecting more than 38,000 TB 

cases. By training health workers, improving health facilities and laboratories, and building 

a national TB strategy in the country, they have identified gaps and begun to fill them. 

This capacity building has potential to contribute to a sustainable health system backed 

by a legitimate government in the future. Ignoring health in badly governed states like 

Zimbabwe, where the regime allowed what had been a strongly functioning health system 

to deteriorate, only leads to crisis and further suffering.

Military involvement in civilian health systems development in conflict-affected and 

postconflict states remains problematic. As Ambassador Donald Steinberg, deputy director 

of USAID, pointed out, it is highly unlikely that future armed conflicts will resemble Afghanistan or Iraq, and therefore reliance on lessons from Afghanistan and Iraq may not be productive. It is worth noting, however, that little evidence suggests that health interventions 

as part of counterinsurgency strategy have achieved either strategic or sustainable civilian 

health benefits, especially compared with the initiatives of the Ministry of Public Health and 

its donors.32 The reasons have to do with the incompatibility of military approaches to the 

task with the principles of health systems development, for example, short time frames for 

action, lack of connection between long-term goals and programs, lack of follow-up, and 

use of metrics for success based on money spent. 

In regions beyond Iraq and Afghanistan, the military is involved in providing civilian 

health programs toward “winning hearts and minds” where the United States has a strategic goal of countering extremism. In such instances, concerns arise about the impact of 

unstable and inequitable funding decisions that can result in confusion and resentment 

by recipients about the purposes of the aid. Addressing the question of the role of the 

military in civilian health development programs, which has arisen frequently over the 

past decade, will be vital to the continuing discussions of health in fragile and conflictaffected states. 

Ultimately, working with unstable, fragile, and postconflict states poses a number of 

challenges that require experience and thoughtful planning. By prioritizing the principles 

of improving management capacity, developing long-term commitments, promoting transparency and accountability, and using information systems to create a set of priorities to 

align around, fragile states can begin to recover from their devastated infrastructure, poor 

administration, and weak legitimacy. 

Little evidence suggests that 

health interventions as part 

of counterinsurgency strategy 

have achieved either strategic 

or sustainable civilian health 

benefits.
10 

Health Investments in Fragile and Conflict-Affected States

Global health assistance has rapidly expanded in recent years to more than $20 billion 

globally. Health investments in fragile and conflict-affected states have not received a proportionate share of global health resources based on population needs, with the exception 

of Afghanistan and Iraq, where U.S. and European donors have major strategic and military 

interests.33 Of the thirty-four countries and regions the President’s Emergency Plan for 

AIDS Relief (PEPFAR) program serves, fewer than five fall under most definitions of fragile 

or postconflict states.34 Indeed, the relationship between the under-five mortality rate in 

African states, which are highest in badly governed states, and the level of development 

assistance to those states is inverse. 

Several factors have influenced the aid strategies of donors for fragile states where they 

lack strategic interests. Donors may consider investment in fragile states to be politically 

and financially risky. They may further perceive that aid in these states has less payoff 

than aid to states with more stable governance. Indeed, countries with better policies and 

better institutions may be able to more effectively use aid for community health. However, 

this approach leaves fragile states under aided and “receiving less aid per capita than their 

poverty, populations, and CPIA scores would justify.”35 Currently, evidence suggests that 

these factors cause aid in fragile states to be twice as unpredictable compared with other 

low-income countries, potentially damaging growth and service delivery. 

Emerging experience indicates, however, that well-measured aid to fragile states can be 

considerably more effective in improving growth than aid to other low-income countries. 

Because fragile states may be particularly impoverished and lacking resources, with appropriate safeguards their initial ability to absorb aid and use it effectively could be higher than 

more stable countries. Aid practice, however, has not characteristically followed this model. 

Instead, aid is often disbursed for humanitarian emergencies during a conflict and tends to 

diminish dramatically when the conflict winds down. This approach often results in a transitional funding gap between humanitarian aid allocation immediately following a crisis and 

development funding that comes only years later.36 The funding gap can jeopardize service 

provision as well as the ability to develop stable and sustainable health services. 

Moreover, there is a mismatch between organization of health assistance and programs. 

The traditional distinction between humanitarian and development aid is often unresponsive 

to real needs. Some humanitarian crises extend for years, and emergency assistance can span 

decades, using resources to meet immediate needs but ignoring opportunities to build systems and address problems of governance in health. In Southern Sudan, humanitarian health 

assistance continued for twenty years but emphasis on development was minimal. The notion 

that such aid should not concern itself with development of a functioning health system makes 

little sense. Although donors are beginning to look for ways for humanitarian assistance to 

stimulate or reinforce longer-term development, by and large the two streams of funding have 

different goals, different legal requirements, and different measures of effectiveness. And 

though short-term results in humanitarian aid are understandably central, donors also resist 

making painful trade-offs between meeting short-term relief demands and promoting longerterm benefits. Decisions almost always lean toward short-term needs, even in circumstances 

where more lives could be saved in the longer term by concentrating on development. 

Development strategies with humanitarian aid are possible. In the Democratic Republic 

of Congo, the humanitarian aid effort lacked a stable national government to work with. 

Instead, a fragmented but functional health zone system ran regional health systems. 

Health professionals were present, but too few of them. By working directly with local health 

zones and their local government administrators, humanitarian programs were able to function for an extended period as development programming expanded. 

Some humanitarian crises 

extend for years, and emergency 

assistance can span decades, using 

resources to meet immediate needs 

but ignoring opportunities to build 

systems and address problems of 

governance in health.
 11

Donors are also often understandably concerned with the repercussions of providing 

development assistance to corrupt or repressive states. It is vital to resolve these tensions. 

The answer to donor concerns is not to avoid health development assistance to fragile and 

conflict-affected states, but to develop mechanisms that can address corruption and lack of 

capacity. Weak civil administration, in particular, can devastate optimistic plans for government participation in aid, leading to fragmented and disorganized aid allocation and planning strategies as donors rely more heavily on nongovernmental organizations to provide 

services. Early research has suggested that an initial focus on technical and administrative 

assistance in a government committed to reform can assist greatly in long-term governance 

capacity.37 Intensive technical support in Afghanistan, for example, has enabled its Ministry of Public Health to manage funds without the level of corruption that plagues other 

ministries, and to develop the technical competence to manage contracts with reasonable 

effectiveness. Where repression exists, it may be necessary to find alternative mechanisms 

for financing, participation and accountability. 

Financing mechanisms themselves can be used to improve governing capacity while providing greater authority to governments. Liberia’s experience in creating its national health 

plan and basic package of health services and administering donor contributions through a 

pool fund is instructive. The fund was created in 2008 in response to both the uncoordinated 

efforts of multiple donors, which had led to severe geographic inequities, and the desire of 

the government to exert greater control over development even though it lacked sophisticated 

administrative capacity.38 The pool fund enabled donors to support government-established 

health service priorities and normalize health worker staffing and salaries among numerous 

providers, yet be assured of financial accountability. In the years since the pool fund was 

established, Liberia has successfully established a rigorous facility accreditation process that, 

combined with major donor investment, has improved the number of functioning government 

health facilities from 36 percent in 2006 to 82 percent in 2008. 

Conclusions and Policy Recommendations

Health investments can contribute to state building and legitimacy, though the degree to 

which they do so remains uncertain; whether health can advance stability is unknown. The 

knowledge base must be expanded. If donors choose to make stability rather than human 

needs a priority, they should support research to learn whether and how health interventions can contribute to stability. The research is essential for wise and productive investments especially if stabilization and security are deemed objectives of health assistance.

Research is also needed to better understand the health consequences of armed conflict, 

including the extent of morbidity and mortality and factors that influence them. These 

potentially include contextual factors—such as intensity, chronicity, geography, regional 

patterns, preconflict state of health services, history, and culture—that may affect the 

extent of morbidity and mortality in fragile states and particular armed conflicts.

Knowledge must also be developed to inform strategies that afford greater protection 

to and preservation of health functions during armed conflict. Greater understanding is 

needed about the motives of perpetrators, incentives and training that might influence 

their decision making, and successful prevention strategies. The impacts of assaults—including effects on morbidity, mortality, systems capacity and health worker migration (from 

attacks, from threats, and from more general insecurity)—deserve scholarly attention. Data 

on attacks on health-care facilities, personnel, and patients must be collected comprehensively; studies on reasons for and impacts of assaults must be initiated; and evaluations of 

prevention programs must be undertaken.

Financing mechanisms can be used 

to improve governing capacity 

while providing greater authority 

to governments. Liberia’s . . . 

pool fund is instructive.
12 

Finally, research is also required to better understand how to assist fragile states in 

building effective health systems. This includes more robust exploration of the experience 

of, and lessons that can be derived from, health systems development in fragile and conflictaffected states, including at the subnational level and in badly governed states. In addition, 

at least four key questions have received too little attention. The first is how to structure 

aid programs in poorly governed states so as to develop health systems without supporting 

corrupt or repressive governments. The second is how to restructure humanitarian aid programs so that long-term emergency funding supports health systems development. The third 

is how to meet short-term health needs while developing a coherent system. The fourth is 

whether decentralization is an effective strategy either in addressing local grievances or 

compensating for a weak state. Agencies responsible for disaster response should conduct 

a thorough review of how humanitarian aid programs can contribute to development of 

health systems, especially in protracted or chronic conflicts. Evaluations should assess both 

structuring a transition from relief to development and integrating systems development 

into emergency programs.

Despite these unanswered questions, there is now enough knowledge about mechanisms 

and the impacts of postconflict health reconstruction to justify a shift in priorities in global 

health funding. Those who live in conflict-affected and fragile states can and should receive 

their fair share of funding under major multilateral and bilateral funding programs. Indeed, 

questions about whether and how investments in health promote legitimacy and stability 

are to some extent distractions. That health systems development can contribute significantly to the preservation of life and well-being of people in such states is reason enough 

to invest resources there. Global health funding programs should afford greater priority to 

fragile and conflict-affected states based on their highly disproportionate morbidity and 

mortality for their stage of development, especially among children, and the recognized 

connection between an effective service system and long-term state legitimacy.

The existence of corrupt, ineffective, or repressive governance—although it poses serious challenges—should not be an absolute barrier to supporting health systems development. In such situations, policies and programs need to be developed to support alternative 

means of health systems development. Withholding proven health and systems interventions is unacceptable.

In all fragile and conflict-affected states, programs should follow general principles of 

systems development, preferably through leadership by the ministry of health. Adhering to 

standards of equity and nondiscrimination is essential, and respect for human rights principles regarding process will increase legitimacy and quality. The latter includes engagement 

of women in the planning and oversight process and community participation in governance, oversight, and accountability for health services. Women should also be included in 

programs to train community health workers to provide lifesaving interventions, particularly 

for infants and young children.

The role of the military in advancing health in fragile and conflict-affected states 

requires close attention. The military can play a major role in disaster relief, support for 

military health systems, disease surveillance and research, and provision of emergency 

health services in highly insecure areas. It should not, however, be assigned responsibilities 

to contribute to civilian health systems development, nor to use health as a short-term 

stability intervention. When the military carries out other health activities, it should be 

aware of the potential linkages and tensions between the assistance it might provide and 

strengthening health systems.
 13

Acknowledgments

The USIP conference on which this report draws—“Health in Postconflict and Fragile States: 

Challenges for the Next Decade”—was held in collaboration with and with the support of 

the International Medical Corps, the Johns Hopkins Bloomberg School of Public Health, John 

Snow, Inc., the Mailman School of Public Health at Columbia University, Management Sciences for Health, RTI International, the Stanford Center for Children in Crisis, and World Vision. 

The conference benefitted from the participation of Liberian minister of public health and 

social welfare Walter Gwenigale, USAID deputy director Donald Steinberg, and U.S. assistant 

secretary of state for democracy, human rights, and labor Michael Posner. 
14 

Notes

1. OECD/DAC, “Principles for Good International Engagement in Fragile States and Situations” (Paris: Organisation 

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org/dataoecd/61/45/38368714.pdf.

2. Soniya Carvalho, Engaging with Fragile States: An IEG Review of World Bank Support to Low Income Countries Under 

Stress (Washington, D.C.: International Bank for Reconstruction and Development/The World Bank, 2006). 

3. OECD/DAC, “Ensuring Fragile States are Not Left Behind” (Paris: Organisation for Economic Co-operation and 

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4. Hazam A. Ghobarah, Paul Huth, and Bruce Russert, “Civil Wars Kill and Maim People—Long After the Shooting 

Stops,” American Political Science Review 97, no. 2 (2003): 189–202; Benjamin Coghlan, Richard Brennan, Pascal 

Ngoy, David Dofara, Brad Otto, Mark Clements, and Tony Stewart, “Mortality in the Democratic Republic of Congo: 

A Nationwide Survey,” The Lancet 367, no. 9504 (2006): 44–51; Olivier Degomme and Debarati Guha-Sapir, 

“Patterns of Mortality Rates in Darfur Conflict,” The Lancet 375, no. 9711 (2010): 294–300; Les Roberts, Riyadh 

Lafta, Richard Garfield, Jamal Khudhairi, and Gilbert Burnham, “Mortality Before and After the 2003 Invasion of 

Iraq: Cluster Sample Survey,” The Lancet 364, no. 9448 (2004): 1857–864.

5. Ziad Obermeyer, Christopher Murray, and Emmanuela Gakidou, “Fifty Years of Violent War Deaths from Vietnam to 

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1482–486.

6. Degomme and Guha-Sapir, “Patterns of Mortality Rates in Darfur Conflict.”

7. Richard Garfield, “The Epidemiology of War,” in War and Public Health, eds. B. Levy and V. W. Sidel (Washington, 

D.C.: American Public Health Association, 2008).

8. Human Security Report Project, Human Security Report 2009/2010: The Causes of Peace and the Shrinking 

Costs of War (Vancouver: Human Security Report Project, 2010), http://www.hsrgroup.org/human-securityreports/20092010/text.aspx.

9. Debarati Guha-Sapir and Olivia D’Aoust, “Demographic and Health Consequences of Civil Conflict” (Washington, 

D.C.: World Bank, World Development Report 2001 Background Paper, October 2010), http://www-wds.worldbank.

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20300WP0Demog0BOX0361475B00PUBLIC0.pdf. 

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GBD_2005_study/en.

13. Srinivasa Murthy and Rashmi Lakshminarayana, “Mental Health Consequences of War: A Brief Review of Research 

Findings,” World Psychiatry 5, no. 1 (2006): 25–30; Derek Summerfield, “War and Mental Health: A Brief Overview,” 

British Medical Journal 321, no. 7255 (2000): 232–35; Stanley Krippner and Teresa McIntyre, The Psychological 

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15. Leonard S. Rubenstein and Melanie D. Bittle, “Responsibility for Protection of Medical Workers and Facilities in 

Armed Conflict,” The Lancet 375, no. 9711 (2010): 329–40.

16. International Committee of the Red Cross, “Health Care in Danger” (report, July 2010), http://www.icrc.org/eng/

assets/files/reports/4073-002-16-country-study.pdf.

17. Gilbert Burnham, Sana Malik, Ammar S. Dhari Al-Shibli, Ali Rasheed Mahjoub, Alya’a Qays Baqer, Zainab Qays 

Baqer, Faraj Al Qaraghuli, and Shannon Doocy, “Understanding the Impact of Conflict on Health Services in Iraq: 

Information from 401 Iraqi Refugee Doctors in Jordan,” International Journal of Health Planning and Management 

June 2, 2011, doi: 10.1002/hpm.1091.

18. U.S. Department of State, “Human Rights Reports,” http://www.state.gov/g/drl/rls/hrrpt. 

19. Betty Bigombe, Paul Collier, and Nicholas Sambanis, “Policies for Building Post-Conflict Peace,” Journal of African 

Economies 9, no. 3 (2000): 323–48; Paul Collier, Breaking the Conflict Trap: Civil War and Development Policy 

(Washington, D.C.: World Bank, 2003).

20. David E. Bloom and David Canning, “The Health and Wealth of Nations,” Science 287, no. 5456 (2000): 1207–

209.

21. Margaret E. Kruk, Lynn P. Freedman, Grace A. Anglin, and Ronald J. Waldman, “Rebuilding Health Systems to 

Improve Health and Promote Statebuilding in Postconflict Countries: A Theoretical Framework and Research 

Agenda,” Social Science Medicine 70 (2010): 89–97; Nigel Pearson, “The Role of the Health Sector in Wider StateBuilding,” (London: Save the Children UK for Health and Fragile States Network, 2010).

22. Derick Brinkerhoff, Anna Wetterberg, and Stephen Dunn, “Service Delivery and Legitimacy in Fragile and Conflictaffected States: Evidence from Water Services in Iraq” (paper presented at International Research Society for 

Public Management, Annual Conference, Dublin, April 11–13, 2011). 

23. Frances Stewart, “Conflict and the Millennium Development Goals,” Journal of Human Development 4, no. 3 

(2011): 325–51.

24. Conciliation Resources, “Guatemala: Agreement on a Firm and Lasting Peace” (UN ref. no. A/51/796-S/1997/114, 

Annex II, December 29, 1996), http://www.c-r.org/our-work/accord/guatemala/firm-lasting-peace.php; InterGovernmental Authority on Development Peace Process, “The Comprehensive Peace Agreement between the 

Government of The Republic of The Sudan and the Sudan People’s Liberation Movement/Sudan People’s Liberation 

Army” (Naivasha, Kenya, December 31, 2004).

25. Natasha Palmer, Lesley Strong, Abdul Wali, and Egbert Sondorp,“Contracting Out Health Services in Fragile 

States,” British Medical Journal 332, no. 7543 (2006): 718–21.

26. Pearson, “Role of the Health Sector.” 
 15

27. William Newbrander, “Rebuilding Health Systems and Providing Health Services in Fragile States” (MSH occasional 

paper 7, Cambridge, Mass.: Management Sciences for Health, 2007); William Newbrander, Ronald Waldman, and 

Megan Shepherd–Banigan, “Rebuilding and Strengthening Health Systems and Providing Basic Health Services 

in Fragile States,” Disasters 35, no. 4 (2011): 639–60. http://onlinelibrary.wiley.com.ezproxy.cul.columbia.edu/

doi/10.1111/j.1467-7717.2011.01235.x/abstract.

28. Newbrander, “Rebuilding Health Systems”; Newbrander, Waldman, and Sheperd-Banigan, “Rebuilding and 

Strengthening Health Systems.”

29. World Health Organization. Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and 

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MBHSS_2010_full_web.pdf. 

30. Giorgio Cometto, Gyuri Fritsche, and Egbert Sondorp, “Health Sector Recovery in Early Post-Conflict Environments: 

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Business: Strengthening Health Systems to Improve Health Outcomes: WHO’s Framework for Action (Geneva: WHO 

Press, 2007), http://www.who.int/healthsystems/strategy/everybodys_business.pdf. 

31. Jacob Hughes, Amanda Glassman, and Walter T. Gwenigale, “Liberia Health Pool Fund: Transitioning from 

Emergency Support to Health System Development” (discussion, Center for Global Development, June 13, 2011); 

Newbrander, Waldman, Shepherd-Banigan, “Rebuilding and Strengthening Health Systems.” 

32. Leonard S. Rubenstein, “Post-Conflict Health Reconstruction: Search for a Policy,” Disasters 35, no. 4 (2011): 680–

700, doi: 10.1111/j.1467-7717.2011.01237. The military is, however, able to reach some isolated populations in 

highly insecure areas who have no access to other sources of health care, though the services are not expected 

to be part of a long-term development strategy. 

33. David McCoy, Sudeep Chand, and Devi Sridhar, “Global Health Funding: How Much, Where It Comes from and 

Where It Goes,” Health Policy and Planning 24, no. 6 (2009): 407–17; Mark McGillivray, “Aid Allocation and Fragile 

States” (WIDER discussion paper 2006/01, Helsinki: United Nations University, World Institute for Development 

Economics Research, 2006), http://www.wider.unu.edu/stc/repec/pdfs/rp2006/dp2006-01.pdf. Todd J. Moss, 

Scott Standley, and David Roodman, “The Global War on Terror and U.S. Development Assistance: USAID 

Allocation by Country, 1998–2005” (CGD working paper 62, Washington, D.C: Center for Global Development, 

2005), http://papers.ssrn.com/sol3/papers.cfm?abstract_id=800708.

34. “The United States President’s Emergency Plan for AIDS Relief,” http://www.pepfar.gov/countries. 

35. McGillivray, “Aid Allocation and Fragile States.” 

36. Ann Canavan, Petra Vergeer, Olga Bornemisza, and Jacob Hughes, Post-Conflict Health Sectors: The Myth and 

Reality of Transitional Funding Gaps (Amsterdam: KIT Publishers, 2008). 

37. Paul Collier and Anke Hoeffler, “Aid, Policy and Growth in Postconflict Societies,” European Economic Review 48, 

no. 6 (2004): 1125–45.

38. Hughes, Glassman, and Gwenigale, “Liberia Health Pool Fund.” 
Of Related Interest

•	 Pandemics and Peace by William J. Long (USIP Press, 2011)

•	 Pandemic Preemption by William J. Long (Special Report, June 2010)

•	 Health Initiatives and Counterinsurgency Strategy in Afghanistan by Leonard S. Rubenstein 

(Peace Brief, March 2010)

•	 The Health Sector and Gender-Based Violence in a Time of War by Anjalee Kohli, Kathleen 

Kuenhast, and Leonard S. Rubenstein (Peace Brief, April 2010)

United States 

Institute of Peace

2301 Constitution Ave., NW

Washington, DC 20037

www.usip.org

An online edition of this and related 

reports can be found on our Web site 

(www.usip.org), together with additional 

information on the subject.