This study shows that those familiar with and directly involved in HSR in FCAS face many challenges in gaining support for and in conducting and applying high-quality research. Using an online survey and documenting a discussion group allowed the authors to consolidate and synthesise the experiences of researchers, funders and implementers from a wide range of countries, including many FCAS.
Contextualising health systems research in FCAS
Results from this study should be contextualised against the background of some broader issues affecting HSR in general and HSR in FCAS specifically. First, HSR is a relatively young field  that urgently requires development  in order to maximise its contribution to policy and practice. Developing the field is challenging because HSR includes a wide range of complex and interconnected systems and issues (as illustrated by the six WHO building blocks) and is conducted by researchers offering a multitude of diverse disciplinary perspectives [32, 33]. Thus, systematic progression of HSR will take intense effort and coordination across disciplines. Second, the principles for engagement of aid in FCAS increasingly emphasise state building as the central objective . As a result, HSR in FCAS may be critiqued primarily on its contribution to state building rather than on its contribution purely to health outcomes . For this reason, HSR may need to formulate its research more often in relation to fragility, not just being research that happens to be conducted in a fragile state. Finally, the fragile states literature  increasingly calls for highly contextualised, flexible approaches for aid in general and for health sector development in particular. This focus demands a highly contextualised and specific evidence base, which may limit research generalisability.
While this study did not specifically collect data on how to address the challenges commonly confronted when conducting HSR in FCAS, some practical recommendations arise from the data.
Need for more sustained support
Health systems strengthening, a lengthy and complex process, should become the primary focus after the transition from humanitarian relief to sustainable development . Evidence suggests that, in addition to improving health outcomes, health systems strengthening may play a significant role in state building by contributing to the reinforcement of government legitimacy [38, 39]. However, because the role of health systems strengthening in influencing health outcomes and state stability in FCAS is insufficiently understood, HSR in FCAS warrants significant and long-term investment.
This study shows that there is currently insufficient institutional support for HSR in FCAS. More funding for HSR in FCAS is required in order to overcome the lack of evidence regarding which health systems strengthening approaches are effective and which are not [40, 41]. Specifically, there is a lack of financial support for and commitment to longitudinal research. Strong longitudinal research is essential to demonstrate the impact of health systems characteristics and strengthening initiatives on health outcomes. More long-term funding would also enable more substantial and nuanced capacity building, and relationship development. Current examples include the ReBUILD Consortium (funded by the United Kingdom’s Department for International Development), which is an international research partnership exploring approaches to health systems development in post-conflict settings  and RECAP-SL (funded by the European & Developing Countries Clinical Trials Partnership) that aims to build HSR capacity in Sierra Leone. Seed funding grants may prove useful for testing the feasibility of high-risk research in FCAS.
Institutional support extends beyond financial support in enabling researchers to conduct research even in extremely challenging environments. While HSR in FCAS often entails security considerations beyond those normally confronted by research institutions, overly constrictive travel bans or restrictions imposed by institutions, such as universities, limit the development of contextual knowledge, relationships and the research process. We must understand the nature and effects of fragility in order to strengthen health systems within it. Meaningful support for the research process even in light of the pervasive challenges is critical to high-quality HSR in FCAS.
Need for research capacity building
This study shows that investment in research capacity building within FCAS is essential to meet the challenges related to implementation of high-quality research in these complex environments. The study further reinforces the notion that capacity building should not be limited to individual research personnel but should extend to essential research organisations and functions such as universities and ethical review boards . Professional development and retention of skilled people is particularly challenging in fragile situations, where factors that push people out of their environment, such as active conflict, extreme lack of resources and poor leadership, are extremely strong. However, these factors lose intensity in post-conflict situations, thus enabling policies aimed at building and retaining skilled workers to become more relevant . Capacity building undertaken during times of relative stability can enable research to continue during times of instability.
Capacity building is necessary not only because research-related knowledge and skills may be limited as a consequence of disrupted or destroyed education systems, but also because access to FCAS is commonly constrained. In-country authorities or researchers’ universities or employers might impose travel bans or restrictions. The security context may be too poor to allow travel. Such constraints may limit research to more stable areas, leading to sampling bias. Capacity building addresses this challenge by enabling researchers based in less stable areas to conduct their research. For example, during the Ebola epidemic, the United Kingdom-based ReBUILD Consortium researchers were unable to travel to Sierra Leone. However, due to capacity-building efforts aimed to empower researchers to work more autonomously since the programme’s inception, the United Kingdom-based team was able to provide their support remotely while the Sierra Leone-based team successfully carried out the research . Encouraging any researchers to continue work during conflict requires assessing risks and benefits. Reflection upon the necessity and feasibility of the research is recommended . That said, enabling researchers who live in FCAS to conduct research even in the midst of fragility offers great potential for timely research that truly captures the context in fragile environments.
Need for relationship and trust building
In addition to a need for capacity building within FCAS, this study also shows a need for relationship building among stakeholders, including local communities, government authorities and international researchers. Often overlooked, relationship building is essential to address challenges that arise from a lack of trust in the research process. A growing body of literature suggests that strengthening trust is not just important in research relationships, but is also critical to other societal relationships that are part of health system strengthening after conflict . Our study shows that HSR in FCAS would particularly benefit from increased investment in relationships among local and international research team members as well as between researchers and research participants.
Interestingly, local implementers in this study more commonly raised trust issues than international implementers, donors or academics. Local implementers may more easily recognise this as an issue because management structures within international organisations often empower international staff more than local staff. Local staff may thus feel wary of international stakeholders. Tensions between local and international stakeholders are common in fragile states. In the context of service delivery, tensions between local government and international organisations have been well documented [37, 47]. One could assume that similar tensions exist in the context of research. Research capacity building may redress power imbalances between local and international stakeholders, and improved communication between both parties may increase mutual understanding and trust.
The lack of trust in the relationship between the international researcher and local research participants or communities might exist for similar reasons. However, research brings an additional element that local participants might perceive as a disadvantage, namely that researchers generally hold the power to interpret data collected during the research process. These interpretations may assert considerable influence over policies and programmes that directly affect participants’ lives. Research in FCAS requires adapting communication techniques, especially if the subject matter relates to politics or conflict and how these may impact people’s lives. Social systems and hierarchies are fluid during conflict and previous studies may not adequately inform research in a new setting or time . This highlights the need for novel approaches to research and the communication of research results . In order to build trust and maximise opportunities to apply research results, it is important to communicate results in a timely fashion not only to policymakers but also to communities. Participatory action research – an approach that involves research participants in the process and therefore equalises the power balance in the research relationship  – might be an appropriate solution to address certain research questions.
Need for innovative and flexible approaches
This study reinforces the need for innovative and customised approaches to research design and implementation. Innovation is commonly defined as the use of new ideas or methods. What is novel to one context, however, might not be novel to another. Therefore, the authors suggest that an effective question with which to start is ‘What ideas and methods effectively used to facilitate HSR in non-fragile contexts might be transferable to fragile ones?’ Zwi et al.  suggest that more active participation of refugees and communities in the research process in conflict situations could be promoted.
Researchers and other stakeholders should consider the value of a range of research methods in FCAS. In many cases, descriptive research would be a good starting point. Longitudinal analysis is essential to HSR because it enables analysis of trends and change in personal and organisational behaviour . However, alternative research methods may also yield valuable results. Although longitudinal quantitative methods generally allow statistical testing and prediction modelling, large-scale longitudinal data collection may not be feasible in fluid and insecure environments. Cross-sectional data collection may be more feasible while qualitative methods may be more adaptable and deliver rich, reliable information. Mixed methods research that combines cross-sectional quantitative and qualitative methods may provide well-rounded insight.
The increased availability of information and communication technology, known as eHealth, has shown potential to improve healthcare in developing countries , and could be exploited for research purposes. By using an online survey, this study is an example of the opportunity offered by technology. However, the use of technology in research may introduce bias because of the differing levels of access to it . Marked differences in access to technology exist in FCAS, where most people lack access to even the most basic utilities. Future innovations in research should be designed to include communities and vulnerable people within them. Further, they should be designed in such a way that prevailing health inequities are not exacerbated.
Innovative methods of communicating research results should be pursued. Traditional mechanisms, such as academic journals, may not be accessible to decision-makers in FCAS. Research results may have more impact on policy and practice, from the national level to the household level, if communicated quickly, often and through numerous channels. For example, the Afghan Research and Evaluation Unit, an independent research organisation based in Afghanistan, mobilises these principles in communicating research results .
The study findings highlight that this need for innovation requires flexibility on the part of research stakeholders, including funders and researchers themselves. This is consistent with previous studies on research in conflict situations [22, 54]. As Barakat and Ellis point out in a discussion paper on research in war circumstances, “Where information is hard to come by, one must do everything possible to encourage chance learning” (, p. 153). Giving the example of researchers benefitting from ad-hoc conversations, the authors indicate that such ‘chance learning’ opportunities are “met with little enthusiasm within the realms of rigid research protocol” (, p. 153). Thus, making room for flexibility in terms of funding, design and implementation of HSR allows researchers to respond to changing environments and needs.
This study has several limitations that should be noted when interpreting these findings. First, participation in both the survey and group discussion was based on self-selection. This meant that, although participation required a minimum of experience in HSR in FCAS, this was not corroborated.
Second, there was a lower than expected survey response rate. Survey non-response is a common source of error in survey-based research  and this is reflected here. We have documented potential biases that might have arisen from this. A possible reason for non-response is that, at the time of the survey, the Ebola crisis in West Africa was at its peak. It is likely that many potential respondents were actively engaged in Ebola response initiatives, which could have made our target group less responsive to our survey request. Despite a smaller sample size than anticipated (61 instead of 100), data reached saturation as participants across the sample reported similar challenges.
Third, for feasibility reasons, our survey was only available in English and not in any other languages, which could have prevented some candidates from participating.
Fourth, participation in the online survey was reliant on computer and Internet access and familiarity and therefore could have excluded some potential participants (e.g. those from areas in FCAS with limited Internet connection and/or those with limited computer skills).
Fifth, while men and women were relatively equally represented in the online survey, less balance was achieved in relation to work and geographical background – most survey respondents resided in the United Kingdom and were international implementers or academics and thus their views were over-represented in the results.
Finally, the design of this study was guided by its primary aim of developing a consultative research agenda on HSR in FCAS. Identifying challenges in carrying out research in the context of FCAS was a secondary aim. Consequently, participants were primarily targeted based on their familiarity with HSR and not necessarily on their experience with the obstacles of implementing such research. Additionally, this may have limited the depth of the information provided on challenges involved in conducting HSR in FCAS. Future qualitative research on this topic should consider using data collection methods, such as in-depth interviews, that encourage respondents to provide more detailed information.
The potential biases associated with our sampling methods (purposive snowball sampling) and response rate may limit the generalisability of our findings. We did manage to get a good coverage of country experiences (together, participants had experience working in 56 different fragile and/or conflict-affected countries). While these participants self-defined these as fragile and/or conflict affected, the majority are also listed in popular indices [56, 57].