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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. 1

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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’. 4In 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.

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Consideration of these domains will critically inform health interventions in contexts of fragility.