_{Participants of a training organised by the STEP III project in Ethiopia. Copyright: GIZ}

People caught up in conflict and fragility are in desperate need of functioning health services. In such situations, development partners need to provide support with a dual perspective: meeting immediate needs while also building sustainable systems.

‘In fragile and conflict affected states, there is a mandate – indeed a critical need – to keep delivering basic services to the population as well as to support the development of more sustainable structures, often in the context of quite dysfunctional systems. The art of a good project is to deal with the resulting trade-offs.’ So says consultant Dr Eva Tezcan, who has been supporting Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) to identify lessons learned in German-supported capacity development projects in the health sectors of the Democratic Republic of Congo, Ethiopia, Iraq, Libya, Syria and Yemen.

This article draws on her findings, as well as on more recent interviews with the teams of German-supported projects in Afghanistan, Ethiopia and Libya.

Fragility is a central challenge for development cooperation

Fragile and conflict-affected states are home to more than 1.5 billion people, and cover a wide range of different contexts and situations, united in being highly volatile, and having reduced institutional capacities and limited ability to provide basic services to their populations. A large majority of these countries also experience conflict and the effects of active armed violence (Bousquet 2022).

In 2022, some three-quarters (73 percent) of people living in extreme poverty lived in fragile contexts, and the number of countries around the world classified as fragile and conflict-affected continues to grow, linked to rising trends in climate-related crises and food insecurity, political instability and persistent gender inequalities.

Maintaining functional health systems is critical for building people’s resilience to repeated, often multiple crises. Developing the capacities of healthcare providers and administrators to provide good quality care is an essential component of health systems strengthening in all countries, but is particularly important in fragile contexts. Their complexity and volatility, however, pose a central challenge for development cooperation (BMZ 2019).

Managing complex dilemmas

In fragile contexts, health workforce development projects are faced with complex dilemmas; time and again, they are required to balance the competing priorities of ensuring immediate access to quality health services, while providing support for longer term institution building and health systems strengthening.

The 2015 report ‘Capacity Development in Situations of Conflict and Fragility’, commissioned by GIZ, identifies six such capacity development dilemmas, which cannot be solved in the short-term with an either/or choice, but require continuous balancing and carefully weighed trade-offs. Below, we explore some of the key dilemmas for the health sector, drawing on examples from Afghanistan, Ethiopia, and Libya.

Working with external development partners versus strengthening public institutions

In settings requiring humanitarian assistance, there is often some urgency to re-establish basic services to meet people’s immediate needs. In the absence of a functioning state, development partners may rely on international non-government organisations (NGOs) or private contractors to deliver results, capitalising on their presence on the ground and the speed of their response. When working through external partners, it is important not to bypass local solutions or to overwhelm the capacities of local partners with the scale of the support provided.

When the German-supported ‘Improving Primary Health Care Provision’ project in Libya started, a combination of violent armed conflict and the COVID-19 pandemic posed acute challenges for the project team for working directly with Libyan health professionals and with communities to support access to care. In agreement with the Libyan ministry of health, the project therefore worked through the humanitarian NGO International Medical Corps (IMC), which is experienced in providing on-the-job training, essential equipment and medicines in fragile contexts.

As countries transition from receiving humanitarian assistance to engaging in transitional and development cooperation approaches, their needs evolve accordingly and building capacities of national experts must take priority, as explained by Randa Shinkada, technical advisor for the project in Libya.

We now work with national experts to provide capacity development inputs. They know the culture and the communities well and we are developing their skills, which is more sustainable and more effective than bringing in external experts.

Randa Shinkada, Improving Primary Health Care Provision, Libya

Despite the still-challenging context in Libya, the project is determined to strengthen health institutions by enhancing management competencies at facility, district and national levels.

Using external expertise versus strengthening local capacities

Christian Möller, Head of the Training of Health Professionals component of the German-supported ‘Sustainable Training and Education Programme (STEP) III’ project in Ethiopia, explained that there are also non-humanitarian contexts where the use of external partners for capacity development may be a suitable – if temporary – strategy, such as when there is a need to start quickly and hit the ground running.

When we set out, our implementing partner JHPIEGO provided a good solution for us, and they were also already advanced with digital learning in Ethiopia which convinced many people to participate in e-learning.

Christian Möller, STEP III, Ethiopia

The STEP III project is now focusing on balancing short-term inputs with long-term institutional strengthening by, for example, building the skills of local staff to develop training curricula for biomedical technicians and nurses, and developing the capacities of medical staff so they can take on more senior management roles within the Ethiopian health system.

Matthew Rodieck is an advisor for the German-supported project ‘Promoting Technical and Vocational Education and Training (TVET) in Afghanistan’, which has a health component that is working to build the competencies of midwives. Drawing on many years of experience, Matthew underlines the importance of going beyond technical skills to empower local staff and boost their confidence so they feel able to speak up and participate actively in discussions with their international counterparts.

Short-term inputs versus longer-term strengthening of health systems and institutions

In fragile and conflict situations, health workforce capacity development interventions often focus on training health staff and technicians at their workplace or in training facilities. While these shorter-term inputs are designed to improve the quality of service delivery, development cooperation must not lose sight of the need for more comprehensive structural and institutional health systems strengthening. Short-term interventions should ideally always be implemented with longer-term objectives in mind.

In Libya, for example, the registration system for doctors is not functioning, and health information and human resource management systems are weak. It is assumed that there are many ghost workers on the government’s payroll – i.e., health workers who either do not exist or do not work in a public facility. Without reliable information on the numbers and types of health workers and their location, training resources cannot be managed efficiently.

To address this gap, the project collected basic information of all health workers of the supported facilities. The data was communicated back to the respective health facilities and also provided to the local health authorities and the Ministry of Health with the aim of enabling them to improve the targeting and follow-up of in-service training measures. According to Manuela Peters, Project Leader in Libya, the project hopes that such data will one day be incorporated into a national information system for the management of human resources in the health sector.

As a transitional development assistance project, we work at service delivery level and close to the communities, providing management support at local health authority level in cooperation with the Libyan Ministry of Health. We hope that – through our work – we can contribute to emerging strategies of the ministry of health.

Manuela Peters, Improving Primary Health Care Provision, Libya

A purely technical versus a political approach

Although it may be easier to focus on the technical aspects of capacity development, an in-depth understanding of the political economy is particularly important for operating effectively in fragile settings. Derick Brinkerhoff, who put forward the original concept of capacity development dilemmas, wrote, ‘long-term results are contingent upon the murkier, less measurable, and less manageable realm of political and power dynamics’ (Brinkerhoff 2007, p.20).

In Afghanistan, restrictions on women’s movement, and on their education and workforce participation, have reduced access to midwifery care, placing the lives of mothers and their newborns at risk. The TVET project addresses these challenges in several innovative ways. Working through experienced local implementing partner AABRAR (Afghan Amputees for Bicycle Rehabilitation And Recreation), community midwives will learn to use tablets, entering basic data as they work in the community, and subsequently meeting with their supervisors to review and upload the data, and to discuss the treatment of difficult cases. The midwives’ husbands, meanwhile, will be employed as Community Midwifery Assistants and trained to raise awareness of safe delivery practices among the men in the community. This enables the women to travel safely with their husbands.

An emergent versus a planned approach

To be accountable to their constituencies, development partners require results frameworks and indicators to demonstrate the extent to which supported interventions are reaching their objectives. However, working effectively in fragile and conflict-affected contexts requires great management flexibility and a willingness to pivot and to seize opportunities for capacity development as they arise.

This ‘emergent approach’ requires flexible and adaptive monitoring frameworks that are able to measure success in different ways. In Afghanistan, where policies change frequently and restrictions may differ from place to place, TVET Advisor Matthew Rodieck says, ‘we don’t only need a Plan B, but plans C, D and E as well’. Being reliant on local implementing partners means that the options for project monitoring are unpredictable and extremely limited, and this requires working relationships with local counterparts that are built on trust.

In order to report on activities, we need transparent, coherent evidence of what partners are doing and this takes time and must be based on strong working relationships. Indicators must be flexible and we must be realistic in our expectations.

Matthew Rodieck, Promoting TVET in Afghanistan

During the COVID-19 pandemic in Libya, community members highlighted the need for mental health and psychosocial support (MHPSS) interventions. The project recognised this as an entry point for the development of a training programme for primary care doctors, nurses and community health workers in psychosocial first aid and emergency care.

The team was surprised by the high level of demand for these services, given the stigma traditionally attached to mental health conditions in the country. A mayor who was trained in psychological first aid, for instance, stated that he wished he had had these skills to support his daughter when she was released from a kidnapping. In cooperation with the ministry of health, the project therefore invested more resources in this critical area of work. This included the introduction of basic mental health services at health facility level, as well as intensive training to a MHPSS Focal Persons representing each of Libya’s regions.

The importance of capacity development for rebuilding trust at all levels

A lack of trust is a key marker of situations of conflict and fragility – between governments and their citizens where the social contract is failing, between service providers and the communities they serve, and between different segments of the population. Health workforce capacity development can help to rebuild trust between communities and their health facilities in these contexts. Embedding community-based capacity building activities within the overall health service delivery approach has been applied successfully in projects in Iraq, Libya, Syria and Yemen, and is a clear strategy in Afghanistan.

Strengthening community trust in service providers may even have a knock-on effect on the broader political situation. In Libya, with two governments in place in the East and West regions, the Improving Primary Health Care Provision project has worked hard to rebuild the trust between communities and their health centres, as well as between the local and national health authorities that was damaged through the conflict. ‘Our training and workshop events bring together health staff with their technical peers, as well as community-based health workers from the west, south and eastern regions, which are sometimes in conflict with each other’, says Manuela Peters. This provides common ground for discussion and helps participants to gain an understanding of each other’s situations.

Health workforce capacity development in fragile and conflict-affected states is highly challenging and yet can be done

For German Development Cooperation in health, these projects provide ample evidence that it is possible to build local capacities and ownership in challenging contexts, while seeking to strengthen health systems and institutional structures. However, as Eva Tezcan reminds us, ‘operating in fragile settings is really extremely tough. In development contexts, one is informed by best practices, but these practices rarely apply in highly fragile situations, so we need more learning about what works’.

Given the situation the world currently finds itself in, with mounting political tensions and open conflict, exacerbated by the effects of economic and climate crises, it can be expected that more and more German-supported capacity development projects will operate in situations of fragility and conflict. These projects will need to work flexibly and adaptively, and to demonstrate high levels of innovation and resilience as evidenced in Afghanistan, Ethiopia and Libya.

Corinne Grainger,
September 2023