Fragile States Critical to Fight Against AIDS

By Samantha Ritter | June 20, 2013

A health worker explains HIV medications to a patient in the Democratic Republic of the Congo.

James Pursey/EGPAF

On June 7th, Management Sciences for Health (MSH), a global health nonprofit organization, hosted a briefing on Capitol Hill to discuss the critical role of community health workers in fragile states – countries currently embroiled in conflict, emerging from conflict, or unable to sustain and deliver services to a vast majority of their population. Two of the countries in which the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) works, Côte d’Ivoire and the Democratic Republic of the Congo, are currently considered to be fragile states, and others have only recently stabilized. 

Moderated by Dr. Steve Solter of MSH, the distinguished panel featured Haiti’s Minister of Health, the United States Agency for International Development (USAID), the International Medical Corps, and MSH Rwanda. Panelists shared their experiences of working in fragile states and the challenges of building a health workforce in settings with extremely limited resources.

Community health workers are often the only point of contact with the health care system for millions of people in fragile settings, and are charged with providing preventive and curative care across the health spectrum. Developing these workforces is difficult enough in stable countries, but in fragile states – where they are needed the most – it is especially challenging. Some fragile states, such as South Sudan, the Democratic Republic of the Congo, and Liberia, were left without any health care systems after decades of civil war. Other countries, like Haiti, were decimated by natural disasters. The panelists discussed how creating strong teams of community health workers is essential to improving maternal and child survival rates, increasing life expectancy, and preventing HIV infections.

In Haiti, community health workers form the backbone of a health system shattered by the 2010 earthquake. Despite the weak health care system, life expectancy has increased from 48 years in 1982 to 62 years in 2012, and the HIV prevalence decreased from 6.6 percent in 2003 to 1.9 percent also in 2012.

Ethiopia’s political and financial support for the development of a community health cadre (known as the health extension worker program) significantly increased the ratio of health care workers to the overall population and improved access to care for Ethiopians across the country.

Afghanistan, devastated by three decades of war, had a maternal mortality rate in 2005 that was nearly double that the Democratic Republic of the Congo, the country with the world’s worst rate in 2013.  After the country revitalized midwifery education to ensure women delivered in the presence of a skilled birth attendant, the maternal mortality rate dropped by more than 70 percent in just five years. In fact, the midwife program was so successful that the country is not even ranked in Save the Children’s current rankings of the worst thirty places to be a mother.

Rwanda was the final country discussed by the panel. Considered to be a failed state after the 1994 genocide, it was left with only 120 doctors for a population of 9 million people. Those in charge of rebuilding adopted task-shifting – training less specialized health workers to do traditionally higher level tasks as a strategy to deal with an insufficient number of health workers. Some of the tasks included providing antiretroviral therapy for HIV/AIDS, performing caesarean section, delivering antibiotics, and offering family planning services. They also piloted the use of an innovative performance-based financing approach that motivates the underpaid health workforce by providing facilities with more money if they have better health outcomes. Community health workers have been a critical piece of EGPAF’s work in Rwanda, as they counsel mothers to improve maternal, infant and young child nutrition. Rwanda remains an extremely poor country, but it has reduced deaths from HIV/AIDS, malaria, and tuberculosis by 80 percent in the past decade through community-based healthcare.  

Overall, the panelists’ experiences demonstrate the feasibility of providing effective, quality health care, even in the most challenging settings. Moreover, they underscore the importance of frontline health workers in achieving global health targets. These programs were successful because the package of services provided by health workers fit the needs of the community, maximizing resources and saving lives.

It’s important to note that frontline health workers are as critical in stable states as they are in fragile states. To support these efforts, the Elizabeth Glaser Pediatric AIDS Foundation recently became a member of the Frontline Health Workers Coalition to bolster support for the doctors, nurses, pharmacists, community educators, and others that are so central to our work to eliminate pediatric AIDS. Further investment in building the health workforce should be central to global and national health and international development frameworks in fragile and stable states alike.

Samantha Ritter is Public Policy Associate for the Foundation, based in Washington, D.C.