The Role of Leadership, Management and Governance in Building Health Systems in Fragile States

By Alain Joyal, MBA, CPA 

Why do we do what we do?

The international community has compelling humanitarian, political, security, and economic reasons to become engaged in fragile states. The USAID-funded Leadership, Management and Governance (LMG) project consortium of partners are engaged in fragile states because people in these countries are disproportionally affected by major health problems.

According to OECD’s Development Co-operation Directorate, “States are fragile when state structures lack political will and/or capacity to provide the basic functions needed for poverty reduction, development, and to safeguard the security and human rights of their populations.” Support to leaders, managers, and those involved in governance in the health sector to address these critical gaps can help strengthen health systems, improve health services, and significantly reduce mortality and morbidity rates of most vulnerable populations, within fragile states and beyond.

Supporting the health sector  through improved leadership, management, and governance practices can also help strengthen civil society and contribute to restoring legitimacy to national governance mechanisms at all levels—all conditions essential to improved stability and to the goal of achieving sustainable health system with effective delivery of health services for those most in need.

As we will describe in this article, inspired leadership, sound management and transparent governance (L+M+G) are key ingredients to the successful rebuilding of health system in fragile states  from initial relief and emergency response to the development of country-owned health systems and processes. It is critical that this be well understood and embraced by all international and local stakeholders involved in developing health systems within the context of fragile states.

Defining the Situation

Post-conflict or fragile state situations may be caused by a political transition, a natural disaster, or a deteriorating governance environment where there are also frequent violations of human rights. Some situations see gradual improvements while others become prolonged crises or end up in an impasse.

Fragile states are also characterized by weak policies, institutions, and governance. In fragile situations, institutions essential to meeting people’s basic needs such as primary health care services are heavily dysfunctional (or entirely nonfunctional) and as a result are not adequately serving significant portions of their population.

It is not surprising then that 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 toward achieving the United Nations Millennium Development Goals (MDGs). The burden of disease and the mortality levels experienced by the populations of fragile states are extraordinarily high.

Today the OECD Development Assistance Committee (DAC) monitors 45 countries currently considered to be fragile states; these represent about one-sixth of the world population.

Six out of ten people living under the poverty line live in a low- or middle-income fragile state, and a child living in a fragile state is twice as likely to be undernourished as a child living in a developing country that is not considered a fragile state.  While 47% of the population in developing countries live in a fragile state or in a country recovering from fragility and conflict, 70% of infant deaths occur in these difficult settings.

Most fragile states will simply not meet the MDGs by 2015, and the lack of progress is most acute in fragile states.

L+M+G in Fragile States

The deficiencies of the health system in fragile states can be characterized in a number of ways and will vary, depending on local circumstances. Typical problems include the lack of health system infrastructure, personnel, equipment, supplies, and drugs, and a health delivery system that is in disarray or dysfunctional.

More often than not there is no system for setting direction and establishing policy, nor the ability to enforce policies that do exist. In addition, the health system operates without adequate information, and few functional management systems are in place since management and leadership capacity is lacking.

Consequently, in determining what interventions and assistance can be provided to the fragile state, the real challenge is the requirement to address these interlinked problems concurrently while finding the right balance between relief interventions and longer-term system and capacity development concerns.

In order to face this overarching challenge, overcome numerous and complex obstacles, and achieve the desired results, L+M+G are necessary at all levels and at every stage (relief, rehabilitation, reconstruction, and development) to transition the health system from operating in an emergency mode (addressing immediate concerns) to developing a sustainable system (addressing both immediate and long-term concerns).

The framework below outlines how applying four leading, managing, and governing practices together within a health context can lead to improved health systems and concrete health results in all health systems; they are also vital to improving health conditions in fragile states.

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The following are illustrative situations in which key L+M+G practices are used by those who lead, manage, and govern in the health sector, including in fragile states:

  • Balancing immediate life-saving concerns with longer term health sector development while the health system and the State apparatus in general is dysfunctional is a real challenge. Initially, there is no process or system for establishing policies and enforcing their implementation. Strong leadership and governance are required at that stage in order to set a clear vision that is widely owned across all concerned international and national actors (set shared direction and engage stakeholders).
  • Because local resources are inadequate, donors should be ready to assist in providing resources and remain engaged in the long-term to support the building of sustainable development initiatives (mobilize). They play a critical role in providing for technical assistance, initial support to recurrent costs, capital investments, and training of health workers (focus, inspire and implement).
  • In the earliest stages of support, the state legitimacy and effectiveness in delivering core functions of government, including basic health services, is weak and often compromised (accountability and stewardship of resources). The active implication of the international community on the ground is critical to achieving rapid health results in priority areas such as immunization and disease responsiveness so that a constructive tone is set among stakeholders and the population.
  • Effective engagement with fragile states depends on donor coordination (align) and an understanding of health challenges (scan and evaluate) to inform the design of health programs and the selection of interventions (plan and organize). Planning and organization require considering options related to the selection of services to be delivered, the organization of services, their distribution to beneficiaries, and their financing.
  • The Ministry of Health may need to be reorganized in order to meet the requirements of the new vision of the health sector (set shared directionalign/mobilize, and organize). This may include decentralization of functions and responsibilities that were formerly centralized, and this in line with the broader political context of national government plans for provinces or states and the degree of autonomy they will eventually have, including their degree of control over financial and human resources (stewardship).

After the initial emergency stage, the international community’s contribution may remain significant but its focus must shift toward the development of the national health sector institutions and their governance, as well as the strengthening of the capacity of health managers and workers to manage and lead.

As soon as practically possible, capacity building in L+M+G must be integrated and progressively amplified in the support provided to the sector to ensure that health leaders are acting wisely, and making the best possible decisions regarding people’s health.

Top Principles for Effective Engagement and Work in Fragile States

Through the country programs carried out by the LMG project, international actors like USAID, Management Sciences for Health (MSH), and the other LMG consortium partners can affect outcomes in fragile states health sector, and the adoption of principles based on proven best practices and lessons learned can help maximize the positive impact of their engagement, and minimize unintentional harm.

To that effect, MSH (the lead consortium partner on the LMG project) proposes a set of 10 top principles for working in fragile states based upon over 40 years of accumulated experience in strengthening health systems worldwide.

MSH’s Working Principles for Health Development Initiatives in Fragile States

1.    Use a two-pronged approach: strengthen government, policymaking, and coordination functions; and rebuild existing health care at the service delivery level.

2.    Develop active and well-coordinated partnerships to mobilize resources and get the job done. In fragile states, effective partnerships are particularly valuable given the challenges that must be overcome.

3.    Build leadership, management and governance capacity at national and local levels. Effective leadership and management in fragile situations are absolutely critical to building sustainable health systems owned by the country health managers and workers.

4.    Empower country-level ownership of decision-making. It is essential that government decision-makers feel ownership of whatever policies are decided and implemented. This may slow down the pace of change but those programs are more likely to last and achieve their purposes.

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5.    Build sustainable health workforces—especially women. In fragile states, there is often a lack of skilled workers, and women are more likely to stay on the job, which may have a greater impact on maternal and child survival.

6.    Balance immediate needs with long-term sustainability. Working in fragile states requires a balancing act in working with colleagues and counterparts toward long-term sustainable solutions while addressing emergency relief.

7.    Incorporate a public health perspective and evidence-informed decisions to prioritize interventions. In fragile situations priority settings may be extremely challenging to decision makers. Selecting and focusing first on three to four high impact public health interventions will contribute most at addressing vulnerable population urgent needs and restoring the health system legitimacy. Helping government officers facing complex choices to collect, use and report public health information is a vital way to facilitate rational allocation of limited resources.

8.    Focus interventions at the household level. Most deaths occur at home in the least developed fragile states, and life-saving interventions can be undertaken by members of the family or household to good effects.

9.    Utilize inexpensive, locally-based, high-impact health services. Often the simple, locally-based and cheaper solutions can have the most impact.

10.  Train community-based health workers selected among well-established and regarded members of the served community such as shop owners, teachers, artisans, women, and other peer leaders, etc. Giving basic training on appropriate medications for different conditions to these community-based individuals can have a significant impact, especially where more formal health services have not yet been re-established.

Within these principles, MSH stresses the importance of building leadership, management, and governance capacity at national and local levels.  Time and again, we have witnessed that in fragile situations, even in the midst of chaos and confusion, most senior health managers we have worked with and supported are striving to improve the health of their people, and time spent on building their leadership and management capacity is time well spent.

Helping to build a sustainable health workforce in which women play a central role and are empowered to move into health leadership positions is another top principle for successful health system strengthening, and achieving greater impact in reducing maternal and child mortality in fragile states.

When it comes to development in fragile states, including in the health sector, the OECD has also defined 10 principles intended to guide national and international stakeholders engaged in fragile states.Within these principles, importance is given to designing interventions and promoting approaches that avoid inadvertently creating societal division and worsening corruption and abuse. Stakeholders are to promote transparency and accountability at each step and phase along the way out of fragile situations.

Our Work

A durable exit from poverty and insecurity for the world’s most fragile states will need to be driven by each country’s own leadership, in being responsive to their citizen’s needs, including health related needs. The long-term vision for international engagement in fragile states is to help all those involved to  build effective, legitimate, and resilient health systems and institutions capable of engaging productively with the population to promote sustained health improvement and overall development. No progress toward stability can last without effective ownership, sustained commitments, and focused efforts on the part of the country’s leaders and managers at all levels—from the national level down to the community level—within a health system. Inspired leadership, sound management and transparent governance are key ingredients at each stage toward the realization of this vision.

The Leadership, Management and Governance Project has ongoing capacity-building activities in the following fragile states:


The LMG/Afghanistan program works in this post-conflict context that is rebuilding after three decades of war to provide essential support to the Afghan Ministry of Public Health (MOPH) and Ministry of Education (MOE) to strengthen established service delivery systems in order to increase further coverage of populations in need and improve their quality. One of the main goals of LMG/Afghanistan is to strengthen Afghan financial management systems and capacity at the MOPH and MOE to help meet the objective set at the 2010 Kabul International Conference, in which the goal was adopted that 50% of public development assistance allocated to Afghanistan would be handled by the Afghan public sector financial management system. LMG also assists the MOPH on its goal of institutionalizing leadership, management, and governance capacity building of the health work force, in particular through the strengthening the MoPH’s Management and Leadership Development Directorate.

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Côte d’Ivoire

After a coup d’état in 1999 and civil war that broke out in 2002 and again in 2011, LMG/Côte d’Ivoire is helping the country rebuild in very specific way by providing support to the Permanent Secretary of the Global Fund Country Coordinating Mechanism (CCM), a country-level multi-stakeholder partnership responsible for the support and oversight of all grants in the country of the Global Fund to Fight AIDS, Tuberculosis and Malaria. The project has also supported a transparent membership renewal and election process, and revised key governance documents, including bylaws, governance manuals, and the rules for conflicts of interest. Moving forward, LMG/Côte d’Ivoire is providing capacity building assistance to strengthen Global Fund grant implementation, management, and monitoring through continued support to the CCM and Principal Recipients.


Working within a country that has seen bloody coups, uprisings, wide-scale drought, and massive refugee problems, as well as a border war with Eritrea in the late 1990s, LMG/Ethiopia program is working to improve the leadership and management capacity of the Ethiopian health workforce. To meet this objective, LMG/Ethiopia is collaborating with the Federal Ministry of Health, regional health bureaus, zonal and district health offices, training institutions, professional health associations, and civil service organizations to create a process for systematically building leadership, management, and governance competencies of the Ethiopian health workforce. The goal is to strengthen the health system and improve access to—and quality and utilization of—priority health services for Ethiopian citizens.


Working in the context of a country that suffered political turmoil, including a coup d’etat in 2004, followed by a devastating earthquake in 2010, the LMG/Haiti Project is providing technical assistance, capacity development, management, and leadership development to the Haitian Ministry of Health to design and implement a health insurance system based on performance to pay for health services within departmental level networks. These referral networks have been based on the concept of a local unit called the Unité d’Arrondissement de Santé or District Health Unit, which the government has been attempting to promote over the last 15 years in order to decentralize the health system. The LMG team is using health systems strengthening approaches that increase the Government of Haiti’s ability to manage its health services contracting sources, and link the Haitian population to functional referral networks.


An estimated 50,000 people were wounded in 2010 in Libya’s eight-month civil war. Many of the injured combatants and citizens have received surgical and medical care, some of them overseas, and now they require short- and long-term rehabilitation in Libya. At the request of USAID and the Government of Libya, the LMG project has set out to provide technical assistance aimed at enhanced care and support for the war wounded as the country recovers from the civil war. LMG’s support to the Ministry of Social Affairs focuses on building human capacity at the Swani Rehabilitation Center, including strengthening transferable skills that can be used at other rehab centers in Tripoli and around the country. The LMG project will also support the new Ministry of Wounded and Missing (MOWM) with development of the ministry’s strategy and structure to ensure its success, including an assessment of leadership, management and governance strengths and weaknesses, and through prioritized technical assistance that will enable MOWM leaders to address their challenges and ensure that quality services are provided to the war wounded.


In Uganda, a country that has suffered intermittent conflicts and has waged a civil war against the Lord’s Resistance Army, the LMG project has adapted a key data and management information tool called a Dashboard to be used by implementing partners (non-governmental organizations, civil society organizations, and faith-based organizations) that will allow these actors to analyze programmatic and financial health-related data, and go through a continuous performance-improvement process. This dashboard tool has been tested in two Ugandan organizations: Reproductive Health Uganda, and Protecting Families Against HIV/AIDS. The LMG project has also been working in Uganda with the African Centre for Global Health and Social Transformation (ACHEST) to develop its management, leadership, and governance capacities. LMG’s support will enable this important African NGO to fully play its role as the coordinating center for the U.S. Government-funded Medical Education Partnership Initiative (MEPI), a support network of 13 schools of medicine and public health in Africa. The LMG project will also provide technical assistance to the Joint Clinical Research Center (JCRC), a leading African organization in delivering HIV and AIDS care, treatment, and laboratory services.

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