Table 2

Barriers and facilitators to the delivery of infectious disease interventions in conflict settings

General themesExamples
Constrained accessDifficulty accessing target populations due to ongoing conflict, insecurity and armed insurgency. This includes bans on health services and attacks on health workers by antigovernment groups or armed militia.
A challenging physical environment, for example: rainy seasons, winter weather or long distances.
Community buy-inLack of community support and political hesitancy to embrace health campaigns from foreign agencies.
Mistrust and misinformation from local community members, particularly around the administration of polio vaccines.
Poor infrastructureDestruction of health infrastructure and a lack of transit centres along borders, causing limited access to facilities for care provision.
Displaced persons who established living quarters in crowded areas with scarce sanitation and poor water supply, further facilitating an environment for the spread of highly infectious diseases like measles and poliovirus.
LogisticsLogistical problems with supply chain, specifically with the storage and shipment of vaccines to various vaccination sites.
Resource constraints and rising costs due to the high demand of services, resulting in a shortage of diagnostic tools, drugs and equipment.
Human resourcesOngoing violence in conflict countries induced an exodus of thousands of doctors and nurses, seriously threatening the already strained health system.
Major turnovers of international staff, a shortage of trained health workers and the presence of inexperienced teams during the early phases of an intervention contributed to delays in service delivery.
StigmaChallenges noted with introducing HIV care into areas with minimal HIV knowledge; concerns that people diagnosed as HIV-positive could face serious negative consequences (eg, abandonment, physical violence, discrimination).
Language barriers with care providers, and a fear of stigmatisation for receiving services for other taboo illnesses.
Mobile populationsHigh patient mobility was challenging for ensuring the continuity of care, particularly for HIV and TB treatment.
Frequent movements of conflict-affected populations also accounted for lower than expected screening members and limited vaccination coverage during immunisation efforts.
Social mobilisationForming strong partnerships with local community leaders (eg, elders, civic and religious figures) who leveraged their influence to negotiate access and promote community uptake of health interventions.
Swift coordination with Ministry of Health or other partners in developing comprehensive operational plans to allocate resources quickly and efficiently.
Employing strategies to provide knowledge to population; guided by promotion efforts (eg, radio broadcasting, precampaign focus-group interviews, etc)
Capacity buildingProviding skills training to enrich and strengthen the role of CHWs and other national staff who are most familiar with the context; particularly useful for behavioural change/education and screening interventions.
Optimising the use of pre-existing resources, facilities and tools with limited resources.
Safeguards and resource provisionEnsuring sufficient and working equipment for communication and feedback (eg, telephone/internet connection, camera, copier machine and computers). As well as obtaining sufficient resources and long-term commitment from aid agencies.
Regular monitoring of the security situation and adapting contingency plans; allowing patients/staff coming from distant locations to stay near project sites.
Operational mobilityFlexibility to move ‘temporary fixed posts’ (ie, mobile clinics, health posts), frequently in response to caregivers’ demand to bring interventions (specifically vaccines) closer to their homes.
Working within closed camps or areas with restricted movement of populations helped to ensure intervention coverage and the continuity of care.
Reliable surveillanceInstituting sustainable and reliable infectious disease surveillance helped to guide health planning for refugee populations.
Detailed mapping of population settlements and their movements, aided in identifying communities with the largest target populations.
Negotiating ceasefiresNegotiating cease-fire or tranquillity days between warring factions, particularly for national immunisation days, allowing health workers to vaccinate children in areas with ongoing conflict.
  • CHWs, community health workers.