In nearly all conflicts, more people are killed through disease and malnutrition than from fighting itself. One billion people now live in fragile states – countries recovering from conflict or at risk of sliding into conflict or chaos. These states contain a third of people living on under $1 a day, a third of people living with HIV, and a third of all maternal deaths. One in three people is also undernourished. The Millennium Development Goals cannot be achieved without more progress in fragile states.
During conflict, health systems are quick to collapse as health workers flee, and supplies and equipment run out. By the end of the civil war in Liberia, for example, there were less than 15 doctors left in the country. Preventable diseases increase alongside malnutrition, and even where health services do exist people are too afraid to risk the journey to the clinic. In the Democratic Republic of Congo, maternal mortality has doubled during the recent conflict. Over half of deaths in children under five are in fragile states.
Conflict and civil strife also cause huge numbers of people to flee violence. This massive migration can spread disease from one region to another, even across borders, and those who flee often end up in conditions that make them even more vulnerable to disease.
What are the challenges?
Countries recovering from conflict face huge challenges – rebuilding the fabric of communities that are essential for effective health services, rebuilding damaged infrastructure, coping with the mental health burden created by violence and fear, shortages of essential skilled workers, and integrating former enemies into society.
But on top of these difficulties, fragile states also receive relatively less aid than other low-income countries – over 40% less by some estimates – and this aid is usually unpredictable and badly coordinated. Many donors have decided that because of the difficulties and risks of working in fragile states, they will do nothing instead.
Can countries recover?
But despite all these problems, there have been some successes. Since the conflict ended in Mozambique in 1992, there has been relative stability and an increase in prosperity and better health. Even in countries still regarded as fragile, there are some examples of progress, such as Nepal where services have been delivered to vulnerable people in spite of acute instability.
Health Poverty Action says:
- International donors need to provide more long-term support to fragile states to help them rebuild health infrastructure from a very low point. Without this long term funding, planning and progress is very difficult.
- There are often few skilled workers left in fragile states. Providing support to train people to provide health and other essential services needs to be a priority in fragile states.