Abstract
BackgroundFragility can have a negative effect on health systems and people’s health, and poses considerable challenges for actors implementing health programmes. However, how such programmes, in turn, affect the overall fragility of a context is rarely considered. The Swiss Red Cross has been active in South Sudan and Haiti since 2008 and 2011, respectively, and commissioned a scoping study to shed new light on this issue within the frame of a learning process launched in 2015.MethodsThe study consisted of a document review, qualitative field research undertaken between June and August 2015 in South Sudan and Haiti, and two data triangulation/validation workshops. Semi-structured key informant interviews and focus group discussions included 49 purposively sampled participants who helped build a deeper understanding of what constitutes and drives fragility in the respective countries. Moreover, interviews and focus group discussions served to grasp positive and negative effects that the Swiss Red Cross’s activities may have had on the overall state of fragility in the given contexts.ResultsQualitative data from the two case studies suggest that the community-based health programmes implemented in South Sudan and Haiti may have influenced certain drivers of fragility. While impacts cannot be measured or quantified in the absence of a baseline (the projects were not originally designed to mitigate overall fragility), the study nevertheless reveals entry points for designing programmes that are responsive to the overall fragility context and contain more specific elements for navigating a more sustainable pathway out of fragility. There are, however, multiple challenges, especially considering the complexity of fragile and conflict-affected contexts where a multitude of local and international actors with different goals and strategies interfere in a rapidly changing setting.ConclusionsHealth programmes may not only reach their health objectives but might potentially also contribute towards mitigating overall fragility. However, considerable hurdles remain for aid agencies, especially where scope for action is limited for a single actor and where engagement with state structures is difficult. Thus, cooperation and exchange with other aid and development actors across the spectrum has to be strengthened to increase the coherence of aid policies and interventions of actors both within and across the different aid communities.
Highlights
Fragility can have a negative effect on health systems and people’s health, and poses considerable challenges for actors implementing health programmes
While health actors operating in fragile environments do consider the extreme challenges of working in fragility and try to find solutions to cope with absent or underperforming state actors by adopting bottom-up approaches, they rarely question whether and to what extent community health programmes influence the overall fragility context and whether health programmes should, beyond health objectives, incorporate strategies aimed at reducing overall fragility [8, 9]
Conceptualising and contextualising fragility Based on the interviews conducted, primary drivers of fragility identified for both settings were (1) inability or unwillingness of the state to provide basic services; (2) lack of effective mechanisms to ensure inclusive citizen participation; (3) erosion of social cohesion and community spirit; and (4) high external aid dependency
Summary
Fragility can have a negative effect on health systems and people’s health, and poses considerable challenges for actors implementing health programmes. How such programmes, in turn, affect the overall fragility of a context is rarely considered. While health actors operating in fragile environments do consider the extreme challenges of working in fragility and try to find solutions to cope with absent or underperforming state actors (working around fragility) by adopting bottom-up approaches, they rarely question whether and to what extent community health programmes influence (positively or negatively) the overall fragility context and whether health programmes should, beyond health objectives, incorporate strategies aimed at reducing overall fragility (i.e. working on fragility) [8, 9]
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