“How do our interventions provide an opportunity to really work at some of the core drivers of instability or lack of resilience?” said Larry Cooley from Management Systems International at a recent Wilson Center event on scaling up reproductive, maternal, newborn, child, and adolescent health interventions.

In fragile settings—countries in conflict or crisis—scaling up healthcare is increasingly complex, yet incredibly urgent. Maternal mortality in fragile states is almost quadruple that of other low- and middle-income countries, and infant mortality is double. And 60 percent of the countries with the highest maternal and neonatal mortality rates are classified as fragile, conflict, and violence impacted by the World Bank.

Understanding the context in fragile states is key, said Cooley. “Governments and markets”—the two main platforms for scaling up health interventions—“are both compromised.” Interventions and programs are often politicized along battle lines.

Countries experiencing conflict or instability often cannot rely on public financing, and international support is inconsistent. “Resources tend to flow in very quickly around a crisis,” said Cooley, “and they flow out equally quickly.” Consequently, financing organizations such as the Global Financing Facility (GFF) invest in non-governmental organizations and humanitarian aid programs to secure stable ground.

“Always—even within fragile systems—there are people and points of strength that can be built upon,” said Laura Ghiron, vice president of Partners in Expanding Health Quality and Access. “For example, there are those who know the limitations of the system,” said Ghiron, “but are trying…to work around them.”

Most importantly, scaling up in fragile settings requires a heavy focus on the system, and not the details of the intervention in and of itself. “We need to be giving appropriate attention to the system that is going to have to deliver that intervention,” said Dr. Stephen Hodgins, associate professor for Global Health at the University of Alberta and editor-in-chief of Global Health: Science and Practice.

“Sometimes the interventions that we are introducing make relatively heavy demands,” said Dr. Hodgins, “and we need to make a determination whether that is realistic given the system that we actually have to work with.”

At the end of the day, scaling up interventions should be doing no harm, said Cooley, and should be seen as “a chance to really advance some of the building blocks of peace and stability.”