Health systems research in fragile and conflict affected states: a qualitative study of associated challenges

Access constraints

Almost all respondents mentioned access constraints as a significant challenge to conducting research in FCAS. These include access to reliable data, the field and research participants.

Many underscored the difficulty of accessing reliable ‘data’, ‘information’ or ‘evidence’ in FCAS. During a crisis, one contributor explained, “People don’t know the importance [of data] at [the] national level and international level, and also the donors are more focused on providing services”. A participant working in academia in the United States added that institutional memory loss, a consequence of “continual turnover of government and aid agency personnel” challenges access to information. Further, insecurity limits access to the field. One respondent recounted that travel bans limit access to fragile settings and “once in-country, safety concerns can limit the ways in which researchers can move and interact”. Access to research participants is, according to another respondent, challenged by “poor infrastructure and internet access”, which makes it “logistically hard to contact people and arrange interviews”.

Participants emphasised the need for “more innovative ways of data collection” if insecure areas or populations are to be included in research. The constrained access to information, sites and populations might yield a sampling bias. A respondent from Europe working in funding, contributed: “In FCAS it is difficult to reach the target areas/populations for the research. In more cases, research areas are convenience-selected and based on security and ease-of-access rather than for representativeness of the population/country.”

Weak local research capacity

Many respondents highlighted weak local research capacity in FCAS. Research capacity includes both the necessary staffing (numbers, skills and knowledge) and the infrastructure, for instance, ethical review boards, required for conducting high-quality research.

In terms of necessary staffing, many reported limited in-country capacity. An Afghan respondent working in international implementation experienced a “shortage of researchers and data collectors for fielding studies” and “low capacity of the government and non-government institutions to lead and implement research” whilst conducting HSR in FCAS. Consequently, the quality of HSR might be compromised. A respondent from Europe working in international implementation remarked: “Capacity of staff we have found in general to be weaker in conflict affected states. This can affect quality of the research.” Other respondents cited that research infrastructure is often disrupted or missing in FCAS. A respondent from the United States commented that ethical review boards are “either non-existent or complicated”.

Collaboration challenges

Respondents identified collaboration as a key challenge to conducting HSR in FCAS. The main reason mentioned was that many different actors are commonly involved in health systems strengthening efforts in FCAS, including research. One respondent recounted a complex consensus-building process that included a variety of actors aiming to build “one common agenda and support for research”.

Language barriers, both literal and figurative, can make collaboration difficult. In the figurative sense, national researchers voiced a negative perception of the use of the word ‘fragile’ by international researchers. Further, the use of conceptual language sometimes leads to misunderstandings. A respondent from Sierra Leone who worked on local implementation stated: “Beyond the issues of conducting any type of health research, which were certainly present, the understanding of the very concepts of some of the systematic issues was not entirely present. So [these issues were discussed] with ‘buzz words’, but not with real understanding of the meaning, for many of our team counterparts.”

Lack of trust in the research process

A lack of trust in the research process also stymies collaboration. A survey respondent from Sudan working in academia identified “a lack of trust between the researchers, participants, and the local community” as one of the main challenges of conducting HSR in FCAS. The respondent observed the effects of power differentials within the research process, wherein the researcher exercises power by analysing the data provided by participants. Another respondent noted that significant cultural differences resulted in scepticism towards researchers, whom local residents considered “outsiders”.

Further, many respondents stated that political and conflict-related sensitivities made research more difficult in FCAS. One respondent noted that mistrust between communities and state and non-state actors makes qualitative research particularly challenging. Another respondent thought that political and conflict-related sensitivities bias research results and therefore affect research quality. A participant from Europe working in international implementation disclosed: “I interviewed people who had been involved in the health system in South Sudan about health systems strengthening… The main challenges that I encountered were that people still working in South Sudan were often reluctant to speak negatively about the situation as they were worried about repercussions from the government”. Another respondent mentioned mistrust relating to the “flow and use of resources” because, he said, in fragile settings “this often is partly on a cash basis, and diversions of funds are not uncommon”.

Rapidly outdated findings

Participants highlighted that contexts within FCAS, including their health systems, change rapidly. A respondent from Europe working in international implementation underscored this, saying: “The context in a fragile state is much less predictable and constantly changing, meaning that any gains made in the health system and health systems strengthening can be lost overnight, as in the case of South Sudan. This makes research much harder.” He continued by saying that, because the context is constantly changing, it is more difficult “to capture the context at any one particular point in time”. Another respondent noted that, because contexts in FCAS change so rapidly, research findings become out-of-date quickly, which reinforces the reality that research must be “tailored to each specific situation”.

Lack of engagement with research process and results

Respondents viewed the lack of substantial engagement with the research process and its results as key to poor uptake of HSR. A survey respondent working in Afghanistan explained that national governments were often reluctant “to engage in health research while other immediate issues, such as security and maintenance of power, are at hand”. Another factor leading to poor research uptake is lack of “acceptance of results” by policymakers. For example, a respondent from Australia working in academia noted that, in the case of health services utilisation analyses, policymakers often regarded health services clients in FCAS as “unqualified” providers of information upon which to base policy decisions. Respondents cited a lack of clarity regarding “whom to disseminate information for translation to policy and practice to”.

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 [37]. 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 [42] 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 [43]. 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 [44]. 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 [42]. Encouraging any researchers to continue work during conflict requires assessing risks and benefits. Reflection upon the necessity and feasibility of the research is recommended [45]. 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 [46]. 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 [48]. This highlights the need for novel approaches to research and the communication of research results [49]. 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 [50] – 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. [18] 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 [48]. 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 [51], 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 [52]. 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 [53].

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” ([22], 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” ([22], 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.