Table 2 Research agenda on health systems in fragile and conflict-affected states (FCAS)

Transition & sustainability

• Balance and sequence of emergency and systems strengthening • Sustainability • Reforming a post-conflict health system

• How to get the right balance between emergency service delivery and long-term systems strengthening? • How to sequence HSS in order to get enough initial stability and success to continue the long rebuilding process? • Do we need to do things differently in responding to immediate situations so that we are also supporting longer-term capacity and sustained improvements? • Is there an optimal path to sustainability of health financing after a conflict or crisis? • How to create a policy space to enable effective health system reforms after conflict?

Resilience & fragility

• Consensus on definition of ‘resilience’ • Creating resilient health systems • Relationship between health system strengthening (HSS) and fragility

• What does resilience mean in relation to health systems? How can it be measured? • How have countries survived shocks and conflicts (and if not, why not)? How can we build on these post-conflict? • What are the different types of shocks and what do these imply for coping strategies? • How to build strong local health systems? • What are the linkages with wider state-building? And what are the components and contextual factors of successful examples?

Equity & gender

• Equity issues and fragility • Relationship between more inclusive health service delivery and reduction of tension • Gender perspective and inclusion of marginalised ‘voices’

• How to integrate health equity analyses in health systems research in FCAS? Could the PROGRESS acronym (Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital) used for analysis of disadvantaged groups in clinical trials or something similar be used or developed? • Have inclusive policies in coverage of health services contributed to lessened tensions? And if so, how? • Does targeting health programmes for women and children, and employing more women in health programmes, have any effect on lessening conflict? • How best to promote the voice of citizens in FCAS? • What methodological approaches help local people to express and exercise their views effectively?

Accessibility

• Conflict-related factors to healthcare access • Referral systems and emergency care access

• What are the key factors that influence accessibility of public services in FCAS? And to what extent are these specific to health? • What is the effectiveness of the different types of healthcare providers (public, NGO, faith-based) in these transition contexts? And how can these parallel providers best be resourced so that they contribute to the building up of a public health system? • How to improve referral systems and emergency care access to health facilities in places with limited road accessibility and non-functioning ambulance systems?

Capacity building

• Health system capacity building, particularly health workforce and leadership • Capacity building of local researchers and information systems

• How best to build capacity of the overall health system? • How to strengthen country leadership in understanding and implementing HSS? • Is it effective to invest in future leaders or is this something we cannot control? And, if effective, where should we be investing (e.g. diaspora, academics, politicians) to ensure there will be future leaders? • How best to work through and support local people, organisations and systems for research in insecure areas? • What methodological approaches build the capacity of local people to engage in research?

Actors & accountability

• Roles of various actors in states with weak governance • Accountability mechanisms for national and local government and international actors

• What role does the private sector play in providing health services in FCAS? And how can private provision be regulated to ensure that it promotes (rather than reduces) health equity? • What are the power relationships underlying different processes of accountability? (e.g. between donors or international NGOs and government, central government and local authority, different levels of the state and citizens) • How can international actors (UN, international NGOs, donors) be more effectively held accountable for their HSS activities? • What incentives help actors to be more accountable? And what are the consequences of the failure of accountability?

Community

• Community involvement and empowerment • Community readiness to participate in HSS • Roles of community-based providers

• What are the best approaches to bring community actors into full partnership with national health systems in order to strengthen the linkages between both systems: community system and health system? • What are the determinants of community readiness? And how can the level of community readiness best be increased in order for a community to participate in HSS? • What is the sustainability and quality of services provided by volunteer, versus paid, community health workers? • How to support community-based programming (CBP) beyond the conflict period? And what are successful and scalable models of CBP in post-conflict and fragile states?

Healthcare delivery

• Innovative approaches to service provision and best service delivery models • Quality of care and impact of quality improvement on HSS

• What healthcare delivery models work best in these contexts? Is this the ‘basic package of health services’ contracting model or any other model? And what kind of actors can best implement such models and deliver the best results? • How can quality and performance of healthcare providers best be measured in these contexts? • How can fragile states learn from stable low- and middle-income countries that have achieved improvements in quality of care in their health systems?

Health workforce

• Human resources for health management • Education and training of health workforce

• What kind of external support is most effective in supporting health managers in acute crisis? And how can you provide support that does not undermine the health workforce in these situations? • How best to build an appropriate health workforce post-conflict? • How can we move beyond the current in-service training focus and develop cadres of staff in conflict or crisis contexts rather than waiting for post-crisis situations?

Health financing

• Best finance practices in relation to aid and the political economy of aid • Results-based financing • Universal health coverage

• How much donor aid is enough or too much to instigate and maintain HSS while enabling country leadership? • How are funds channelled in FCAS? Are there any available successful models? • What are the specific opportunities and challenges of results-based financing in these contexts? • How does a vision for universal health coverage influence subsequent health system performance? • What funding schemes are being used? And are there any important mechanisms that are under-documented (e.g. Revolving Drug Funds or community financing)?