MIHR Fragility Model Brief March 2024

Fragile settings are characterized by the worst health indicators and weakest health systems globally, with women and children being among the most vulnerable. Despite the recognition of fragility's impact on health, researchers have observed notable gaps in research and tools linking health and fragility. A health-sensitive conceptual model of fragility has been developed to address this gap. This model is designed to improve understanding of fragility and its impact on health, and to inform health programming in fragile settings. The model is based on a comprehensive and systematic literature review, a comparative analysis of leading fragility and risk measurement frameworks, and consultations with key stakeholders. The model defines fragility as a multidimensional concept that encompasses various factors, including political, security, economic, societal, and environmental dimensions. The health dimension is a critical sixth dimension that is considered in isolation and in interaction with other dimensions. Understanding fragility requires analyzing each component and the relationships between them, as well as considering the state-society relationship and the social contract. The model identifies several key characteristics of fragility, including the presence of shocks, stresses, and stressors, as well as the vulnerability of a context to manage and mitigate these threats. Fragility is not synonymous with crises, but rather informs the vulnerability of a context. The model also highlights the importance of considering the interactions between different factors, known as fragility dynamics, which can have a significant impact on healthcare, health systems, and health outcomes. The health-sensitive conceptual model of fragility is intended to inform health programming in fragile settings, including program design, monitoring, evaluation, and learning (MEL) approaches, conflict sensitivity, and exit strategies. The model is particularly relevant to USAID and USAID partner audiences, and is designed to support health actors in developing a contextual understanding of fragility and its impact on health. The model has been applied to MIHR's Fragility, Crisis Sensitivity, and Complexity (F2C) Assessments for several countries, including South Sudan, Tanzania, Mali, Burkina Faso, and the Democratic Republic of the Congo. These tests informed selected revisions to health-sensitive fragility factors, and highlighted the importance of considering the interactions between different factors in understanding fragility. Overall, the health-sensitive conceptual model of fragility provides a critical foundation for understanding the complex relationships between health and fragility in fragile settings. By considering the multidimensional nature of fragility and the interactions between different factors, the model can inform health programming and support the development of more effective and sustainable health interventions in fragile settings.