Some environments present particular challenges for health service delivery, including active conflict, political instability, limited financing, extreme geography and high rurality. In some cases, all of these challenges exist together.

In such environments, facilities can go months, or even years, without being visited by government teams, severely limiting the delivery of health services. This is the case in several countries in which Acasus works, including Afghanistan, Somalia, and Ethiopia, among others.

However, thanks to the dedication, motivation, and creativity of managers in these countries, several best practices to deliver health services in challenging areas are emerging.

These are detailed below:

• Use data to reset the narrative: 'Security' can become a catch-all excuse for low-performance, limiting conversations on improvements. Collecting and sharing facility-level data helps to focus managers on the ‘actual’ drivers of low performers and removes security as an excuse for inaction.
• Secure early commitment of leaders: Engaging program leaders - e.g., EPI directors - early-on in the reform process helps reset expectations, and champion new narratives around performance. 
• Begin with realistic targets: It is tempting to over-promise in order to provide hope and buy-in. However, it is more impactful to set realistic targets that can be achieved early-on by teams, helping to drive belief and ‘know-how’ in driving (even modest) change. From here, more ambitious targets can be set.
• Embed teams in communities: Innovative provinces hire locally, embedding staff in hard-to-reach areas to ensure access. One province hired local supervisors with existing community relationships in AGE-held areas, while another hired officials who live in mountainous areas often cut off by snow. 
• Celebrate local champions: ‘Local champions’ drive improvements in the most challenging areas. They have deep local knowledge, understand ‘the art of the possible’, and are trusted by communities. Identifying and celebrating these champions, and sharing how they improve performance, helps show that change is possible even in the hardest areas.

The health team taking supplies to a district in Badakhshan from Faizabad (the capital district)

• Share ‘access privileges’ gained by partners or teams: Teams from local partners or programs (e.g., Polio) can often access communities that the government cannot. However, due to coordination challenges, these access privileges are rarely shared across the system. Launching new coordination mechanisms can help leverage these gains across different areas to improve overall service delivery.
• Use new routines to share best-practices and celebrate success: Comparing provincial performance in regular meetings helps to share best practices, celebrate good performers, and drive management-belief that challenges can be resolved. Such routines can also be used to embed new standards and expectations on performance and access, to help sustain improvements.
• Use non-financial incentives: Provincial managers are proud. When their peers are celebrated, it often motivates them to improve. Non-financial incentives (e.g., certificates, league tables, messages from senior officials, participation in knowledge-share calls, etc.) have all helped motivate managers to do more to improve access, through leveraging their pride and competitive spirit.  
• Use local communication channels: sometimes the internet or phone signal is cut off in times of crisis: Being able to leverage informal channels, e.g., radio, newspapers at public markets, churches or mosques, etc., can help disseminate important health messages.
• Walk the talk: Stakeholders in insecure areas are often suspicious of outsiders trying to help. Regular visits and field trips help to build trust, relationships and credibility with communities, while also providing unique insights on challenges and best practices to partners and national teams.

• Be transparent and commit to improvements: When access is granted, it is typically based on an agreement that outputs and insights will be shared and acted on. Several actors have lost access privileges by over-promising and under-delivering, frustrating AGE and local communities.
• Be persistent, but patient: Continued persistence, grit and a belief that improvements are possible are vital. However, it is also critical to know how much to push, when to push, and that ‘big change’ is typically borne out through dozens of ‘small wins’. Patience is essential.