Electronic Thesis and Dissertation Repository

Thesis Format



Doctor of Philosophy


Epidemiology and Biostatistics


Thind, A


Globally, health systems face destabilization amidst conflicts and natural disasters, adversely affecting populations' well-being. Understanding domains of health system fragility remains a gap in literature, hampering effective mitigation. In protracted conflict, Afghanistan's health system offers a crucial case for studying health system fragility. This research aimed to bridge gaps in comprehending health system fragility, with research questions:

1. What is the conceptual understanding of the fragility of health systems and its relationship with resilience, and how can it be applied in Afghanistan?

2. Did the introduction of female health workers to support Maternal, Neonatal, and Child Health service delivery by Afghan Red Crescent Society's Mobile Health Teams lead to a change in service delivery outcomes?


Grounded Delphi Methodology was used to conceptualize health system fragility in Afghanistan. Quantitative approach used Interrupted Time Series analysis, validating findings through qualitative content analysis.

Key Findings

Fragility of health systems is driven by several factors, outlined through a seven-domain framework. Afghanistan's health system is primarily fragile due to its reactive and uncertain nature. Mitigating factors contributing to these fragility domains reduce fragility, as evidenced by the improved delivery of postnatal care services by Afghanistan Red Crescent Mobile Health Team following introduction of midwives, particularly in most insecure provinces.


Health system fragility is complex, context-dependent, intricately related to resilience of systems. Context-driven interventions show promise in improving health system fragility. Further exploration of the conceptual framework on fragility through real-world cases can enhance our understanding of health system fragility factors and mitigation efforts.

Summary for Lay Audience

This study looks at what makes health systems weak or 'fragile' and how that understanding can be applied to real-world situations. Most studies looking at the fragility of health systems in the past focused on the weakness resulting from the overall situation in which the health system was operating (contextual fragility), or they focused on what makes health systems recover after a disaster (resilience). We wanted to understand the different areas that weaken health systems and how they bounce back, focusing on Afghanistan.

We chose Afghanistan because it has had lots of conflicts, and its government has been working to improve healthcare. The Afghanistan Red Crescent (ARCS) worked with the Ministry of Public Health to help women and children in hard-to-reach places using mobile health teams. They also added more female healthcare workers in a sensitive way to improve services.

We had two main questions: First, we asked what makes healthcare systems fragile and how it relates to resilience, using Afghanistan as an example. Second, we checked if having more female healthcare workers in Afghanistan helped women and children.

To find answers, we talked to experts and used data from ARCS. We discovered seven areas linked to the fragility of health systems. In Afghanistan, the healthcare system often could not respond quickly and did not always know how to provide the best care, which made it weak. Adding more female healthcare workers, like midwives, improved some services for women, especially in areas with more conflict. We can use the information from this study to look at other situations where health systems can be weak and apply the findings from our study to find more practical solutions.