Database at a Glance: Private-Sector Care in Fragile States

Fragile states are home to over one-third of the world’s poor people and experience an unusually high incidence of disease. Worldwide, these countries account for more than a third of maternal deaths, more than half of the deaths of children under age five, and over a third of the deaths from HIV/AIDS.

When compared to other developing countries, fragile states face particular difficulty in ensuring that their citizens have access to quality healthcare because the institutions that ensure people’s basic needs – including healthcare – are often nonfunctional due to conflict, insufficient infrastructure, and lack of resources.

The public sector in fragile states has struggled to meet citizens’ basic health needs, and in many places the private sector has worked to fill the gap. We were curious to learn about how private-sector healthcare operates in fragile states and analyzed data from the CHMI program database to investigate related trends. We were particularly interested in what the CHMI database tells us about the types of care that programs in fragile states provide and the unique methods that the private sector employs to deliver care in fragile states.

This blog post uses the World Bank’s list of fragile states from FY13. The World Bank categorizes countries as fragile when they experience (1) weak governance, (2) weak policies, and (3) weak institutions as indicated by a score of less than 3 on the Country Policies and Institutional Performance Assessment (CPIA) index.

The CHMI database contains information about 75 healthcare programs that operate in fragile states (see map below). Of those, 62 programs operate in one fragile state, and 13 programs that operate in two or more fragile states. The three countries that have the largest number of CHMI program profiles are Haiti (12), Nepal (12), and South Sudan (9).

For all graphics in this blog post, please click on the image to see an interactive version.

In terms of legal status, the vast majority of programs (67%, or 50 programs) are private, not-for-profit entities. Roughly 11% of the programs are Public-Private Partnerships, and 8% are private, for-profit initiatives. The rest of the programs (13%) are run either by corporations, the government, an unspecified private-sector organization, or an unspecified entity. Donors were the primary funding source for 65% of programs, including most of the private, not-for-profit programs.

The majority of programs – 84%  focus on providing some kind of basic health service, such as general primary care (25%), HIV/AIDS care (36%), maternal and child healthcare (28%), family planning and reproductive healthcare (24%), malaria care (13%), and/or tuberculosis care (5%). (Note that some programs focus on providing multiple types of care.) 

This fits with what USAID’s Providing Health Services in Fragile States report notes, which is that the priority of many health programs and service providers in fragile states is to address the most basic and pressing health problems.

Fragile states experience a notably high burden of disease and mortality in large part because the local institutions that usually provide basic healthcare are non-functioning. Donors and healthcare programs try to fill this gap by providing basic health services.

Fitting this trend, 16% of programs in the CHMI database that operate in fragile states provide secondary or more specialized services that don’t focus on basic, immediate needs. Only 5% of programs have a specific focus on eye care, 1% focus on care for chronic diseases, and zero programs focus on mental health or rehabilitative care.

CHMI identified a number of emerging practices in fragile states, including:

Training healthcare workers to provide community-based care

  • In many fragile states, traveling long distances is impossible due to conflict and/or lack of infrastructure. Tiyatien Health trains village health workers in Liberia to deliver primary healthcare in communities that were previously deemed unreachable.
  • The Patan Academy of Health Sciences (PAHS) is a medical school in Katmandu, Nepal that addresses healthcare gaps in rural areas by providing subsidized medical training to students in exchange for an agreement that graduates will serve in rural, underserved areas of Nepal for two to four years after graduation.

Adapting pharmacies and products to enable the provision of quality medicine in isolated communities

  • Healthy Entrepreneurs Pharmacy-In-A-Box is a pharmacy franchise that adapted their core franchise model, which is geared towards urban areas, to accommodate the unique needs of rural communities. Pharmacy-In-A-Box is a small pharmacy that consists of approximately 25 essential generic medicines that are tailored to the specific health needs and infrastructure realities of each rural community. Healthy Entrepreneurs operates in five countries, including the fragile states of Burundi, the Democratic Republic of the Congo, and Haiti.
  • In South Sudan, the Maternal, Newborn, and Child Survival Initiative (MNCSI) trains frontline health workers to use a specialized midwives kit that contains basic sterile supplies that can aid in delivery, particularly in communities that are remote and far from health clinics or hospitals.

Providing specialized HIV/AIDS education to consumers and providers

  • The Omiling HIV-AIDS Project promotes HIV/AIDS awareness and testing in the Omiling countryside of South Sudan, which experiences some of the highest HIV/AIDS rates in the country. Omiling has a high proportion of women who were raped during Sudan’s civil war and subsequently became infected with HIV/AIDS. This program trains women to educate remote communities about HIV/AIDS and provides support groups to HIV-positive women to help them cope with the emotional aftermath of rape and the social stigma attached to HIV/AIDS.
  • In East and Central Africa, development has led truckers to take common routes through the region; prostitutes are prevalent at truck stops, and sexual practices have contributed to the spread of HIV/AIDS. The SafeTStop program operated by Regional Outreach Addressing AIDS through Development Strategies (ROADS) runs recreational and resource centers that offer confidential HIV testing and counseling, and a place to relax for truck drivers and other transient workers along trucking routes. SafeTStop operates in 8 countries, including the fragile states of Burundi and South Sudan.

Building the capacity of local government institutions and facilitating Public-Private Partnerships (PPPs)

  • Though many private-sector programs in fragile states operate largely independently from local government institutions, some programs are working to strengthen the government’s ability to address health needs. In Nepal, Nyaya Health runs a hospital and mobile medical services in Accham district. They partner with local government officials to rebuild the public sector health system by constructing local healthcare infrastructure and training local healthcare workers.
  • In Afghanistan, the Afghanistan Health Policy Project run by the Futures Group strengthens the Ministry of Public Health’s capacity to design, negotiate, and manage hospital PPPs.

Pakistan is not considered to be a fragile state based on the World Bank’s classification system, but we wanted to include mention of it here because it is often considered to be a fragile state in other classification systems (such as the OECD’s 2013 list of fragile states) and CHMI profiles quite a few programs that operate in Pakistan.

Of the 37 CHMI-profiled programs in Pakistan, 54% focus on primary care, and 32% (the second largest group of programs) focus on secondary/tertiary care. A total of 9 programs, or 24% of all of the Pakistan programs, provide both primary and secondary care services. This is interesting, as it fits with the notion that states that experience less fragility and conflict (such as Pakistan, according to the World Bank classification system) have more capacity to provide secondary/tertiary care services because basic health needs are already being met. Akhuwat Health is one example of a program that provides both primary and secondary care services through its mobile clinic in Punjab.

Another innovation that we’ve noticed in Pakistan is the use of online or phone-based health information services to reach providers and consumers with healthcare information. SRHMatters, run by Marie Stopes Society Pakistan, is an online counseling service that provides sexual and reproductive health information to Pakistani youth. HealthLine Pakistan provides health information to semi-literate community healthcare workers to enable them to better serve their communities. 

We know that the private sector plays an important role in delivering healthcare to the poor in fragile states, but what we don’t yet know is which types of models are the most effective at providing healthcare and meeting health needs. As our database grows and we gather more data about programs that operate in fragile states, we will continue to look for trends in private-sector healthcare with an eye towards what types of models show the most promise to effectively deliver healthcare and meet the health needs of the poor in fragile states.


Caveat to these preliminary conclusions: CHMI’s data collection methodology and relationships with partner organizations in specific countries may result in data collection biases. Furthermore, CHMI uses the health focus area tags, such as “general primary care” and “HIV/AIDS”, only for programs that have a particular focus on that type of care. We acknowledge that many programs provide some more specialized care as part of their general primary and other health care services. CHMI cannot attest to the efficacy or impact of individual models.

Photo (top) of a Healthy Entrepreneurs franchise pharmacy by Healthy Entrepreneurs