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Progress in achieving the Millennium Development Goals (MDGs) requires that more attention be paid to the situation of countries in which often, but not exclusively, as a result of prolonged conflict, governments cannot, or will not provide the stewardship needed. This note from The High Level Forum (HLF) on the Health MDGs proposes a broad framework to be applied by all those working to improve health outcomes whether they are groups within the country concerned or outside actors. It is intended as a precursor to the development of more comprehensive guidance.

The authors argue that whatever the specific national circumstances, interventions in fragile states will have two objectives: addressing basic health needs and building more lasting institutions. The key point then is that in most fragile states, there will be a continuing dynamic between reducing immediate vulnerability, achieving specific health outcomes, building a more lasting and equitable health system, and building the capacity of civil society. The importance of knowing the context and understanding the incentives facing all parties is highlighted and it is argued that a careful analysis of institutional capacity is particularly important. Specific issues for discussion at the HLF are identified in the last section.

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