1. Population.

Twelve systematic reviews explored the significance of cultural norms, community engagement, and collaboration with various community groups in overcoming barriers, improving health outcomes, supporting healthcare providers, enhancing access to healthcare, and promoting health in FCAS. The evidence concentrates in conflict-affected and humanitarian settings predominantly concerning displaced populations and post-conflict contexts in LMICs.

The cultural norms of patients have played a role in shaping healthcare services and overcoming cultural and religious barriers is needed to ensure effective care [34–37]. Engaging the community in HSS initiatives, particularly in post-disaster recovery has been instrumental. Enhancing health outcomes, in relation to mental health, as exemplified by armed conflict settings suffering from the Ebola virus disease outbreak and its aftermath, required involving relatives with community health workers in closely monitoring individuals experiencing psychological distress [38]. Engaging refugee healthcare workers and recruiting them in facilities serving refugee and displaced populations was also crucial in supporting the workforce in post-conflict humanitarian settings [40, 41]. Training the community, particularly displaced populations such as refugees and asylum-seekers, was found to address healthcare gaps, and promote health by training others and distributing health information [35, 37, 40, 41]. Health promotion activities organised and provided through community groups, including churches, also reduced stigma and created a more welcoming atmosphere in healthcare facilities [42]. In addition, involving the community in selecting candidates for community health workers training increased their acceptance and facilitated their work on deployment [43].

Community cohesion and pooled resources played a crucial role in mitigating the impacts of crises [34]. Collaboration between the community and health system was also essential in providing a safe environment for healthcare workers [39]. Communities also have provided financial support in situations where the government was unable to pay healthcare workers’ salaries [39] in addition to facilitating access to healthcare services by organising patient transportation [42]. Involvement of community volunteers, and intensive community engagement activities improved trust and uptake of healthcare interventions such as immunisation in protracted crises settings [44]. Community-driven multistakeholder programmes were found to be effective in facilitating increased access to healthcare services and improving community healthcare initiatives. Community-nominated volunteers played a significant role in designing specific healthcare services and health promotion activities. Hence, involving traditional community leaders and empowering the community as service users to propose their own solutions was emphasised as a means to enhance healthcare delivery, ensure cultural appropriateness, and overcome resistance [42]. Faith-based organisations, including churches, also played an influential role in reaching out to migrant healthcare workers and mobilising them to return to their home countries to strengthen the post-conflict health systems in their respective countries [45]. Furthermore, communities have played a role in mobilising political will for quality healthcare services [34].

Overall, the evidence suggests that it is important to address cultural and religious barriers; and foster collaboration and support as to promote culturally appropriate healthcare and enhance community engagement through individuals and organised community groups. Empowering, and involving refugees and displaced populations in the health system also contribute to promoting health, narrowing the health workforce gaps and improve healthcare utilisation. This suggests the importance of coproduction and proactive engagement of the community in strengthening the health system.

2. Governance.

Twelve systematic reviews highlighted the challenges in health system governance and coordination in various FCAS including acute and long-standing humanitarian disaster and post-disaster settings, as well as in countries rebuilding their health system long after armed conflict. They explored various barriers, and facilitators of health system governance; and aspects of leadership and financing were most evidenced.

The study by Lokot et al. [40] identified the challenges in health system governance and coordination in settings with refugees, displaced and non-displaced conflict-affected populations. These challenges included unclear responsibilities of different actors, mistrust among stakeholders and within vertical programme delivery, tension, and lack of harmonised health response; as well as lack of and restrictive healthcare policies, implementation problems, lack of expertise and capacity, and limited legal guidance. Financial barriers were frequently cited in the reviews. They included fragmented structures such as the lack of inclusive finance systems, inefficient resource allocation, and a lack of clarity on financial needs [40]. Additionally, having a disorganised structure of service delivery and limited infrastructure, including health facilities, water supply and other utilities were also identified as challenges in various fragile and humanitarian settings [39]. Government agencies were not trusted due to perceived lack of accountability, unethical practices such as reporting non-existent needs to obtain funding and prioritising cost-effectiveness over meeting medical needs; transparency-related barriers, such as employment issues, were also identified [40]. Post-conflict, weak governance and financial support were reported to influence decisions regarding transfer or deployment of human resources. Existing job descriptions became irrelevant, leading to the drafting of new job descriptions by NGOs and aid agencies to meet immediate service needs which made it difficult to manage performance of healthcare workers and the increasing number of job descriptions without central coordination [46]. In settings with conflict-affected populations, multiple humanitarian actors existed, although poorly coordinated, with fragmented and non-uniform coordinating hubs, and third parties conducting monitoring and evaluation [40]. There was evidence that NGOs fill government gaps; however, donors were found to be central to both the problems and solutions as their interests may dominate funding, decision-making, and policymaking [40, 47].

Governance improvements, particularly political commitment and enhanced leadership were reported to improve health system performance in various fragile and conflict-affected settings. This included people-centred governance approaches which improved stakeholder engagement, accountability, setting a shared strategic direction, and stewarding resources responsibly [34, 39, 40, 42]. Additionally, there was evidence that decentralisation supported health system reforms in conflict-affected contexts [40, 48]. Management and directive coordination, such as the United Nations Humanitarian Cluster Approach, 4Ws, the Sphere project, the 5×5 model and the model of information coordination improved coordination amongst humanitarian healthcare organisations; however, providing specific guidance on which model to use was found to be challenging [40, 49, 50]. The cluster system contributed to improving access to healthcare services and other inputs, such as drug availability, workforce, and the level of healthcare services by improving the coordination amongst different health organisations particularly in acute humanitarian crisis [49]. The non-health humanitarian clusters also contributed to improving health outcomes in displaced populations [35]. Additionally, prior networks and infrastructure built through previous work, including governance structures and outreach capabilities were reported to be crucial to strengthening community health service programmes such as vaccination, especially in less secure areas. Cross-border governance and coordination initiatives among different countries governments have also been implemented to reduce the risk of vaccine-preventable diseases transmissions [44]. In conflict-affected settings, structural reforms in adopting service delivery, using information from various sources and databases for sharing and policymaking; as well as having prior systems and plans in place to manage the changing needs and emergency preparedness with strong support from the central level facilitated resource deployment at the local level [40].

Health financing strategies such as community-based health insurance, performance-based financing, coordinated donor funding, and fees retention policy for local health facilities assisted with health system reforms and services in an ongoing and near post-disaster situations, as well as long-term health system reforms [44, 48]. ‘Cash transfers’, that is forms of payment by formal or informal institutions to people, were also applied by governments and humanitarian agencies/NGOs with the purpose of reducing economic hardships and poverty, increasing households’ access to basic food, improving food security, or preventing acute malnutrition [51]. Hence, creating a reliable and cost-effective financial monitoring system, together with better coordination within and across organisations, and donors, was recommended to strengthen the system of managing the outpouring resources of aid in various humanitarian settings [50]. ‘Performance-based financing’, which means payments and incentives provided directly to healthcare workers or facilities, had a positive effect on healthcare interventions [44]. Performance-based financing has been more common in FCAS contexts and more commonly adopted earlier in the recovery period [34, 47]. It has been shown that, conditions of fragility may favour its rapid emergence; and the key factors that drove the adoption included the strong influence of external actors; greater openness to institutional reforms; lack or lower level of trust within the public system and between government and donors; widespread corruption; lack of accountability and fiduciary concerns; as well as the perceived lack of capacity of the government to manage external funds which all tend to favour more contractual approaches [47]. Although the situation of de facto decentralisation also drove the adoption of performance-based financing, the lack of formal or appropriate decentralisation processes has been shown to have hindered progress as external influence solely was not enough to sustain the project. Therefore, it has been suggested that performance-based financing may be more likely to be sustained in countries where it is introduced as part of a wider set of health system and health financing reforms. Hence, it has been recommended as a tool to reinforce the overall governance of a health system [47]. Furthermore, evidence suggests the importance of countries owning their health finance, in order to minimise the negative influences of external donors on the provision of healthcare and strengthen the health system in the long run [48].

In summary, the evidence suggests that health system governance in FCAS faces significant challenges including unclear responsibilities, mistrust, financial barriers, and inadequate infrastructure. It underscores the importance of effective governance improvements, political commitment and leadership to enhance health system performance. These suggest the need for comprehensive and people-centric governance strategies, effective coordination mechanisms, and appropriate financing models. Additionally, the findings emphasise the significance of country ownership in health financing to minimise external influences and strengthen overall health system governance for sustained success.

3. Platforms.

Ten systematic reviews highlighted the challenges and barriers of access and healthcare service platforms in crises situations, and the impact on vulnerable populations. Various care models and strategies to strengthen the health service platforms in different context of FCAS were reviewed.

Providing adequate healthcare services in crises settings presented several challenges due to contextual constraints and feasibility opportunities; and higher rates of healthcare service interruption were observed immediately post-disaster [37, 41]. Active conflicts and concerns with security and safety of patients and healthcare workers had strong influence on the choice of health service platforms [44]. They also became significant barriers to healthcare provision; for instance, community-based services and night-time work became overly unsafe [39]. Apart from this, multiple factors hindered access to healthcare, particularly affecting vulnerable populations such as people from minority groups. These factors included the nature and burden of specific diseases, especially NCDs, as well as non-functioning facilities, inadequate staffing, distance to the nearest healthcare facility, and an influx of refugees or returnees, also recently, the COVID-19 lockdowns [37, 52]. Limited access to healthcare has commonly been noted during active conflicts, influxes of displaced populations, and pandemic related restrictions. Besides, availability of medicines is a crucial aspect of access to healthcare, with public facilities generally performing poorer compared with camp-based primary healthcare services or private healthcare providers in settings with displaced populations [52]. The findings also highlighted significant variations in access rates across different areas and times, even within the same country, supporting the suggestion on the need of understanding local circumstances when designing healthcare models [38, 52]. Additionally, several barriers, including financial, logistical, organisational, and sociocultural factors, as well as the context of security, hindered implementation or success of new interventions [37]. The stage of humanitarian crisis was also found to be a critical factor in determining the feasibility of different healthcare models as for instance, disaster situations, particularly ongoing or recent conflicts impact people’s healthcare seeking behaviour [52].

Significant variations of healthcare models were found in humanitarian settings. Some NCD interventions were integrated into primary healthcare systems, while others were implemented as vertical or single interventions [37]. The most frequently described model in settings with displaced populations in Iraq involved a joint response by camp-based or parallel structures and the formal national health system [52]. Ruby et al. [54] documented the utilisation of traditional treatments for arthritis in refugee settings, noting improved health outcomes when compared to Western medicine. Establishing a strong relationship between modern mental healthcare and traditional or religious healers have also been found to be beneficial [38]. Furthermore, coordination with traditional healthcare providers, and even recruiting them into the health system supporting regular healthcare providers has reported to improve access to healthcare in humanitarian settings [39].

Strategies to strengthen vaccination delivery in protracted humanitarian settings commonly included utilising multiple service delivery pathways such as fixed-sites, mobile teams, and mass-vaccination sites. Central coordination led by the Ministry of Health, in collaboration with agencies and NGOs, was found to facilitate on-the-ground preparedness and delivery of immunisations before disease outbreak [44]. Lassi et al. [36] included the use of community-based maternal and neonatal health services, which involved training community health workers, conducting awareness workshops, and empowering the community through communication and education. Accordingly, outreach services, involving trained physicians and community health workers, were employed to raise community awareness, transfer skills to the district health team, overcome religious and cultural barriers, and motivate health facilities in conflict-affected areas [36]. Community health worker interventions have been reported to improve access to healthcare, notably in psychosocial support, and reproductive and maternal health services, post-conflict [53]. Building the capacity of local community health workers and involving them in health promotion initiatives were reported as key in ensuring the continuity of essential healthcare services [42]. Trained mobile healthcare workers also provided basic emergency obstetric and new-born care along with a full range of family planning services in humanitarian settings [41]. According to Ismail et al. [44], the use of mobile health teams improved vaccination coverage in humanitarian crisis. They also emphasised the importance of strengthening public-private partnerships by integrating private providers into routine delivery of immunisation. However, Asgary et al. [37] argued that, establishing new clinics, training healthcare workers, and supporting stationary clinics are more effective in addressing NCDs than relying solely on mobile clinics. Yet, mobile clinics established immediately after disasters were more inclined to address acute injuries, whereas pre-existing stationary clinics were more likely to assist patients seeking NCDs care in the same timeframe [37].

In summary, the evidence suggests that healthcare service platforms face a number of challenges, mainly due to the context and feasibility of interventions in providing adequate healthcare services to vulnerable populations, and access to healthcare being constrained in FCAS. Strengthening healthcare infrastructure, improving access to medicines and supplies, capacity building, and integrating private and traditional healthcare providers in the system can enhance healthcare service delivery. Furthermore, it is crucial to focus on tailored and context-specific healthcare models that consider local circumstances and address specific challenges while planning interventions.

4. Workforce.

Thirteen systematic reviews considered barriers, facilitators, and recommendations to strengthen the health system workforce in FCAS. The challenges of attracting and retaining healthcare workers, and health professional training and education, as well as workforce strengthening in post-conflict health systems were most evidenced.

Conflict-affected settings faced unique challenges in terms of health workforce. During conflicts, national health systems and healthcare workers often become targets, leading to displacement, injuries, or even death because of targeted attacks or collateral damages [39, 45, 46, 55, 56]. In such settings, healthcare workers tend to leave their jobs or country, seeking safety and recognition for their skills elsewhere. Security concerns greatly impact staff retention and job satisfaction, with personal safety being a key factor in the decision to stay or leave [39]. The fear of instability and political challenges also push many to decide to leave their job or their home country and refuse to be deployed in certain areas [55]. Consequently, healthcare workers become concentrated in safer regions, leaving remote and conflict-affected areas underserved [46]. External factors, such as better opportunities and technologies in host countries, also influence migration decisions [46, 55]. Post-conflict, the flight of healthcare workers may persist due to skill mismatches and disrupted healthcare services [46]. Uncertainty about the situation and the potential re-emergence of conflict was found to be strongly associated with healthcare workers decision to migrate or not; also discouraged them from returning to their home countries. Destruction of health facilities and staff residences further complicated redeployment [43, 46, 55]. Intentions to migrate were also driven by challenging work environments, inadequate resources, overwhelming responsibilities, and unmanageable workloads [55]. Furthermore, security concerns posed significant barriers to healthcare provision; community-based services and night-time work became particularly unsafe. Although safety concerns related to security included both physical and psychological issues, the literature mostly focused on the physical aspect [39].

Salaries, incentives, and benefits also played crucial roles in the supply and retention of healthcare workers [39, 46, 55]. It has been observed that, inadequate salaries often force healthcare workers to hold multiple jobs, which inadvertently affects the quality of healthcare they provide [39, 46]. However, governments were typically unable to offer competitive and timely salaries; and salary scales were constrained by the amount of donor financing available [39, 44, 46]. Consequently, NGOs and aid organisations unintentionally contributed to labour market imbalances by attracting public healthcare workers to work for them, with the offer of more attractive employment packages, potentially concentrating the workforce in safer geographic areas depriving the relatively unsafe areas, also reducing the size of workforce available to restore routine public healthcare services [46, 55]. Post-disaster, many NGOs cease to function in full capacity and there may only be limited workforce vacancies due to the weakened economy and health system. The remaining NGOs can also not afford or sustain their workforce, possibly leading to further labour market disequilibrium [55]. Additionally, the growing market for private healthcare in post-conflict settings may challenge the dominance of the public health sector [46].

Despite the challenges, available evidence suggests that some healthcare workers chose to remain in conflict-affected settings or return from migration due to personal connections, community support, intrinsic motivations, and favourable working conditions [45, 55]. At times, policymakers have introduced programmes to reintegrate returned healthcare workers; however, it appears that, logistical, and financial barriers, legal status, and certification posed significant challenges to their reintegration [45]. In some areas, the returning healthcare workers had a better chance of employment due to the better education they may have gained; however, there is evidence that feelings of emotional resentment from, or even being threatened by those who did not leave; and working through this situation had been challenging [45]. Moreover, their return contributed to an oversaturated health labour market encouraging students and more recent graduates to migrate abroad, and furtherly impact the remaining healthcare workers [45, 55, 56]. On the other hand, expatriates have been recruited to provide short-term solutions [46, 48]. However, their recruitment resulted in high turnover, discrepancies in skills and qualifications, resentment over control and salary differences, and limited opportunities for local healthcare workers. Additionally, the expatriates also failed to transfer skills to the national staff, and potentially hinder those willing to return to their countries in the long run [46].

A lack of training and education opportunities has been reported as a common push factor for healthcare workers, and a number of other factors impacted education and training [45, 55]. Conflict and war posed significant challenges in providing and maintaining education for healthcare professionals because of disruptions in access to educational resources and infrastructure, as well as threats to the physical and psychological well-being of staff and students [56, 57]. Teaching institutions also faced limitations in their training capacities due to the loss of teachers and a lack of skilled trainers [39, 43, 55, 56]. The quality of ad hoc or emergency on-the-job training provided by NGOs and local providers to fill the gap has also been criticised for its poor quality and limited impact [40, 46]. In response to these challenges, some governments have sent individuals to other countries for training, with the expectation that, they will return to serve in the national public health sector [45]. Deployment of locally trained new graduates to rural and underserved areas as a post-graduation requirement was also implemented in conflict-affected sub-Saharan African countries [48]. During times of war, interventions, such as the reduction of training duration, have been implemented. Many countries have also adjusted their curricula to align with the situation, incorporating the management of war casualties, trauma care, infectious diseases, and mental health. Additionally, higher-level training programmes have been adapted to meet military requirements, specifically addressing areas such as surgery and anaesthesia care [56].

Moreover, task shifting and training community health workers in general or specific areas of healthcare, have been implemented as strategies to address shortages of trained and qualified healthcare workers in various fragile contexts [43, 46, 48, 53, 55]. However, cultural norms, social situations and security concerns have hindered recruitment and deployment/transfer of the newly qualified healthcare workers in some geographic areas, and female healthcare workers, in particular, faced additional challenges; they were discouraged from working in unstable areas, as they faced higher risks [46, 58]. Hence, retaining female healthcare workers has been difficult, mainly in the least-developed areas with limited road connections [43, 55]. Furthermore, some conservative communities also did not believe that young unmarried women should become healthcare workers [39]. Besides, women and girls had limited access to education, especially in rural areas, and candidate eligibility to community health workers training has been problematic [43]. Yet females are shown to play a vital role; in some conflict-affected areas, only the presence of a female community health workers was associated with increased skilled birth attendance and higher family planning use [41] and female healthcare workers tend to remain in their local areas and continue to work through conflict more frequently [55].

In relation to standardising training and education programmes, a lack of consensus among the national stakeholders regarding their value and future posed a significant obstacle, which was often underestimated by governments [55, 56]. The absence of clear definitions of the roles and responsibilities among the key governmental stakeholders also impeded the healthcare workers education and training [43]. Curriculum development, and the selection of students and faculty were subjected to interference from the governmental bodies, the military, and medical organisations [43, 56]. Furthermore, governments occasionally redirected funds allocated for education and public health initiatives towards military funding or even prohibited education and research initiatives altogether. Inadequate educational accreditation, coupled with the absence of a regulatory system and licensing examination, hindered the assessment of graduates’ competency [43]. In conflict-affected settings, training standards and quality assurance were compromised due to the unregulated privatisation of training providers, resulting in an oversupply of graduates who anticipated employment in the public sector [46]. The absence of national standards and quality assurance in education and training institutions had serious implications for the quality of healthcare workers produced. The recommendations to address these issues included enhancing national standards and organising medical bodies to ensure the maintenance of adequate and uniform standards [56]. Additionally, it was proposed to establish educational accreditation linked to clear performance objectives [43] and to establish strategic partnerships with international institutions to provide relevant opportunities for accreditation [55].

In summary, FCAS, particularly in the context of conflict suffer from challenges such safety and security, living and working conditions, limited education and training, and education quality assurance and standardisation of healthcare workers. Prioritising the safety and security of healthcare workers, providing competitive salaries and incentives, equitable distribution of healthcare workers, and investment in training and education programmes are considered important to attract, motivate, and retain healthcare workers. Rebuilding healthcare infrastructure, improving working conditions, and ensuring access to resources help retaining healthcare workers and support the quality of healthcare services. Additionally, standardisation, accreditation, and strategic partnerships can help ensuring the quality and effectiveness of health professional education and training that produce competent professionals.

5. Tools.

Eleven systematic reviews discussed both the hardware and software aspects of health system tools focusing on the gaps in physical resources and supervision, as well as interventions and eHealth tools to address the challenges in various contexts of FCAS.

The study conducted by Jordan et al. [34] highlighted physical resources necessary for a functioning health system, such as medicines and other supplies, often served as healthcare quality indicators and they were lacking in humanitarian settings. Inadequacy of equipment, supplies, and infrastructure in clinical settings and training institutions, coupled with insufficient supportive supervision adversely affected the quality of health professional education in conflict-affected settings, and contributed to attrition of healthcare workers [46, 55, 56, 58]. Abujaber et al. [58] reported that supportive supervision played a crucial role in identifying areas requiring development and capacity building in humanitarian emergencies. This led to improved service delivery and performance, particularly among lay healthcare workers. However, healthcare facilities, particularly in rural areas, frequently lacked strict monitoring and supervision systems impacting the services such as by delaying the delivery of materials [43]. Significant gaps in supervision also included supervision by non-clinical personnel, and irregularity or absence of supervision, mainly due to problems with security. Often in FCAS, supervision was also regarded as a means to collect medical records data and provide administrative feedback, rather than offering support to healthcare workers [39]. Besides, the number of capable managers and supervisors was severely limited in crisis situations [43, 46]. Nevertheless, remote supervision was found to yield similar results as in-person supervision [58]. According to Roome et al. [46], these issues were seldom prioritised in long-term training and capacity building strategies, and opportunities to enhance management skills during post-conflict reconstruction were overlooked. Consequently, untrained, under-resourced, and unsupported managers were entrusted with addressing workforce problems while simultaneously coping with the aftermath of conflict. Hence, implementing policies and interventions, such as short-term training, practical tools in a short course format, didactic training, on-site projects, mentoring, and securing high-level support has been suggested to ensure active participation [46].

Conflict-affected areas were characterised by poor-quality data, and inconsistent data collection [40]. Inefficient or inexperienced bodies contributed to incomplete, flawed, or manipulated human resources data, further delaying health system reforms [46]. However, eHealth tools, such as mobile applications were used as interventions for information management, including health records and data in active conflict settings [59]. Information and communication technologies also played a supportive role in health and medical care during disaster responses [49] also aided cash transfer programmes [60]. Compared to traditional paper-based methods, mHealth demonstrated improved data quality and timeliness in epidemic monitoring, prediction of population movement and infectious disease outbreaks, as well as effective monitoring of symptoms through patient care devices, remote vital sign monitors, and SMS messaging [60]. Besides, telehealth interventions in inaccessible areas significantly decreased the risk of death or loss to follow up. Additionally, eHealth interventions which often emerged as a response to changing security contexts in conflict-affected settings supported healthcare professionals’ education, also addressed specific training challenges [56, 59, 60]. Bowsher et al. [59], however, highlighted disparities in the availability and development of eHealth tools, with eHealth initiatives predominantly originating from volunteer organisations on an ad hoc basis, lacking systematic protocols for design and service delivery.

In summary, FCAS suffer from a lack of health system tools, including physical resources, supervision, and data management. Supportive supervision, when undertaken appropriately, is critical to deliver quality healthcare services. Interventions such as short-term training of managers and supervisors, practical tools, mentoring, and high-level support are helpful. Utilising eHealth interventions using standard protocols, systematic design, and delivery improve data management, quality, and timeliness. It also supports education and training in FCAS.