Abstract Health systems rebuilt after armed conflict often record early gains that do not last, yet the dominant technical frameworks, built on stable and politically neutral assumptions, describe what a health system contains at one moment and cannot explain why reconstruction endures in some places and unravels in others. This systematic review searched four electronic databases for peer-reviewed studies published between 2000 and 2025 on health system reconstruction in post-conflict and conflict-affected settings. After independent screening, 31 studies were synthesised through best-fit framework synthesis, guided by an ecological-temporal framework that combines social-ecological systems theory with Braudel’s distinction between immediate, medium-term, and long-term change. The review tested the framework’s central proposition: that gains last where action at one time horizon or spatial level is matched by action at the others. Three processes recurred, with different strengths of evidence: proactive and collaborative stewardship that aligns fragmented aid with national systems; distributive justice through health care, which links health services to food security, livelihoods, and social protection; and trust repair through networked service delivery that sustains reliable frontline care across conflict lines. Each faltered at the hand-over between horizons: a ministry could not take up coordination as donor involvement grew, a coverage programme built on NGO contracts ended after nearly two decades, and health workers left where pay and protection did not follow. The framework did not anticipate that communities as well as donors would build parallel systems, or that health workers’ decisions to stay or leave would decide whether gains carried forward. Most studies observed reconstruction for three years or fewer, so the evidence records little of long-term change. Restoring pre-conflict arrangements is an inadequate goal where those arrangements distributed care unequally across regions and groups. The review sets out actions matched to each time horizon for governments, donors, and humanitarian agencies.
Abstract Sierra Leone is entering a dense period of health sector strategising, with multiple frameworks active across system strengthening, partner coordination, digital transformation, health security, and water, sanitation and hygiene (WASH). Their coexistence raises a critical question: do they reinforce a coherent agenda for resilient, equitable universal health coverage (UHC) or generate fragmentation and implementation burden? We conducted a qualitative health policy analysis combining documentary review of five national strategies, the National Health Sector Strategic Plan (NHSSP) 2026 to 2030, the National Health Compact 2025, the Digital Health Roadmap 2024 to 2026, the National Action Plan for Health Security 2025 to 2029, and the WASH Sector Strategic Plan 2026 to 2035, together with selected Ministry of Health frameworks, and sixteen semi structured key informant interviews. Data were analysed using the Framework Method, guided conceptually by a policy coherence lens spanning strategic priorities, governance, monitoring, financing, and district level implications. The strategies converged around primary health care, equity, service readiness, surveillance, workforce strengthening, WASH, and improved data systems. Coherence was strongest at the level of aspiration and weakest in operational architecture, with three recurrent fault lines: parallel governance structures, fragmented monitoring frameworks, and limited translation of cross cutting ambition into integrated district implementation. Documentary analysis showed misaligned planning horizons, including a Digital Health Roadmap that expires within the first year of the umbrella NHSSP, and indicator sets that define shared priorities differently across documents. Sierra Leone’s policy portfolio is directionally aligned but operationally fragmented. Strengthening coherence will require a clearer strategy hierarchy, a unified results framework, rationalised coordination, embedded digital governance, stronger health, WASH and health security integration, and financing that supports cross programme implementation. Findings derive from a purposive sample and are analytical rather than statistically representative.
Abstract The COVID-19 pandemic severely disrupted routine immunization globally and across Cameroon, causing a surge in “zero-dose” (ZD) children and exacerbating “missed opportunities for vaccination” (MOV). This necessitated accelerated recovery initiatives like the Big Catch-Up (BCU). This study explores BCU’s operationalization, implementation, and sustainability in Cameroon, assessing how vertical funding interacted with national health systems to reach ZD and under-immunized children. Focusing on four districts (urban, conflict-affected, isolated island, and remote rural), we triangulated data from 34 document reviews (e.g. national policies, operational plans, budget frameworks, and Expanded Program on Immunization reports), 37 key informant interviews across all health system levels, and 11 focus group discussions with 86 community stakeholders, including caregivers. Thematic analysis reveals that while BCU remained a campaign-style intervention with parallel reporting structures, its funding acted as a critical accelerator to operationalize Cameroon’s preexisting but under-implemented 2021 National Policy and Guidelines on Catch-up Immunization. However, centralized financial control created top-down pressures that were mitigated through bottom-up co-creation during local micro-planning. Operationally, reducing MOV required a shift from passive screening to active “Catch and Vaccinate” models, necessitating context-specific delivery adaptations in conflict zones and island populations. Despite these operational successes, stakeholders expressed deep concern regarding the long-term institutionalization due to an impending fiscal cliff. The system’s heavy reliance on external donor financing threatens the sustainability of community health workers’ incentives essential for demand generation. Furthermore, while the parallel IASO digital platform enabled real-time geolocation of missed children, it created double-reporting burdens, highlighting the structural challenge of synchronizing campaign tools with the national routine health information system. Ultimately, while recovery funding can successfully catalyze national policies and drive immediate equity gains, sustained resilience requires an urgent transition to domestic financing, the embedding of adaptive service delivery models into routine primary care, and the harmonization of digital tracking systems.
Abstract Tuberculosis (TB) preventive therapy (TPT) is one of three key interventions for reducing TB in South Africa, but uptake and completion rates remain low. In South Africa, the current TPT options include isoniazid and rifapentine or isoniazid and rifampicin. Evidence and lessons learned from programmatic uses of isoniazid preventive therapy (IPT) could provide operational advice to enhance the implementation of new TPT regimens. We conducted 28 in-depth provider interviews (IDIs) to elicit experiences of and preferences for the different TPT regimens between 04/2022 and 12/2022 in the City of Johannesburg, Gauteng and Greater Tzaneen sub-district, Mopani district, Limpopo Provinces. We used purposive sampling to recruit doctors (n = 7), pharmacists (n = 8), and nurses (n = 13) in high and low volume TB and/or HIV facilities. IDIs were recorded for quality, transcription, and translation purposes. Data analysis was conducted using a thematic approach in NVivo 11. We present provider preferences and perspectives for TPT uptake. The most important attributes relating to preferences for TPT regimens attributes among healthcare providers included medication safety, efficacy, and low pill burden. Despite valid preferences for different regimens, healthcare service providers had varied experiences around factors that influence the uptake of the different TPT regimens they offered at their facilities. Many providers indicated that patient booking errors, missing patient records, staff shortages, long queues, medication side effects, and limited understanding of the benefits of TPT were reasons for poor patient TPT uptake and adherence. Limited knowledge was attributed to a lack of educational materials and insufficient staff–patient engagement time. Providers noted that increased clinician awareness and patient counselling contribute to a higher rate of TPT prescriptions, as well as improved patient uptake and adherence. Thus, counselling, staff training, side effect management, and improved file documentation are key factors for TPT uptake.
Abstract Climate change poses disproportionate threats to human health in sub-Saharan Africa (SSA), yet comprehensive evidence on implemented interventions remains under-researched. Understanding the scope and characteristics of existing climate-health interventions is essential for informing policy priorities and action in the region. We conducted a scoping review following Arksey and O'Malley’s framework and preferred reporting items for systematic reviews and meta-analyses extension for scoping review reporting guidelines. We systematically searched Google Scholar, PubMed, Web of Science, and Scopus for peer-reviewed empirical studies on climate-health interventions in SSA, with no date restrictions. Two reviewers independently screened 3009 records. A total of 36 studies reporting 350 interventions were included. The majority of the studies (83.3%) focused exclusively on adaptation, while a smaller proportion (16.7%) combined both adaptation and mitigation strategies. Four overarching intervention categories were identified inductively from the included studies, each comprising distinct but conceptually related sub-categories: health systems strengthening and governance; disease surveillance, monitoring, and early warning; environmental health and infrastructure; and community resilience and social well-being. Vector-borne diseases, particularly malaria, constituted the primary health focus, while heat-related illnesses, occupational health, and mental health received limited attention. Studies mostly reported interventions in West Africa, East Africa, Southern Africa, and multi-regional settings, with Central Africa receiving limited attention. The evidence is predominantly rural-focused (n = 18; 50%), with urban-focused studies accounting for 10 studies (27.8%) and mixed urban–rural settings for the remaining 8 (22.2%). Notably, no dedicated study investigated interventions specifically targeting coastal areas. People-centred interventions predominated over nature-based solutions. Key evidence gaps included cross-sectional study designs limiting causal inference, insufficient cost-effectiveness evaluations, limited integration of indigenous knowledge, and inadequate attention to gender-specific and occupational vulnerabilities. Policy efforts must go beyond disease-specific responses towards integrated strategies addressing multiple climate-health pathways while prioritizing under-represented regions and mitigation opportunities to build comprehensive, equitable climate resilience across the region.
