Since 2017, the Research Unit on Health in Situations of Fragility (RUHF) 6 9 has studied aspects of fragility and their impact on population health. Our research focused particularly on non-communicable diseases (NCDs) and mental health. As part of our work, we engaged systemically with policies and interventions required to promote, prevent, control, and manage NCDs and mental health and how these are integrated at the primary healthcare level. These disease categories require continuity of care and long-term investments into health service delivery and capacity and, as such, offer an ideal tracer for studying fragility as it relates to health. We worked across Sierra Leone, Lebanon, Nepal, El Salvador and Nigeria: all contexts with escalating risk in relation to at least one fragility-related dimension of the OECD framework.

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The OECD had applied similar definitions until 2016, when the organisation proposed a more nuanced understanding: Beginning with the formulation of the OECD’s multidimensional framing of fragility, a broader use of the term is emerging, which is of potential utility in the field of global health. The World Bank has seen this binary designation as fundamental to its strategy. Using the Country Policy and Institutional Assessment, the World Bank evaluates performance across domains of economic management, social inclusion, equity and structural policy. Poor performers are included in the ‘fragile situations’ list. 2 Most situations so identified are conflict affected.The concept of fragility has thus evolved. The OECD has continued to publish on the multidimensional nature of fragility with landmark reports every 2 years. 4 A sixth dimension of the framework—human fragility—was added in 2022 in recognition of factors affecting the realisation of people’s well-being and potential. The breadth of this evolving conceptualisation is emphasised in the overview of all reports: ‘fragility is a global phenomenon, felt across multiple dimensions to varying degrees in all contexts’. 4

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Development and global health research have long applied a binary definition of fragility. Within this, countries are either labelled fragile or not. However, the COVID-19 pandemic has thrown this distinction into question. Many settings previously thought of as fragile are now outperforming others. 1Consideration of these domains will critically inform health interventions in contexts of fragility. In the development sphere, the term ‘fragile’ has generally been used as a pejorative label to represent ‘fragile and conflict-affected states’ with chronic governance challenges. This framework identifies two domains that warrant more intense, politically sensitive study: political economy and financing for health services delivery and community engagement in shaping systems for health.

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Adopting the OECD’s fragility definition, our work explored the capacity of the broader systems for health 7 to deliver care in each setting. We considered the capacities of public, private and not for profit, as well as formal and informal, care providers to deliver NCD and mental healthcare, subject to the diverse contextual risks and state, system and community capacities present. We examined how communities sought help and healthcare and perceived care quality of different providers.