Technical Summary: Care Pathways Under Fire

Problem Statement

Achieving universal health coverage requires not only access to services but also Continuity of Care (CoC)—the experience of coherent, consistent care over time—and Care Coordination (CaC)—the organizational processes linking providers and settings. While essential for managing both communicable and non-communicable diseases (NCDs), these principles are severely compromised during armed conflict.

Despite a global rise in armed conflicts (reaching the highest levels since 1946 in 2024), evidence regarding how these conflicts specifically disrupt CoC and CaC remains fragmented. Current literature often focuses on direct mortality or isolated service interruptions, lacking a systematic mapping of the causal pathways that link conflict exposure to the breakdown of care continuity and coordination across the full spectrum of health services. This gap hinders the design of effective preparedness, response, and mitigation policies.

Methodology

This study is a scoping review conducted in accordance with the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis and reported using the PRISMA-ScR extension.

• Data Sources: The review synthesized peer-reviewed literature and grey literature (reports, policy documents, organizational publications) from PubMed MEDLINE, Scopus, Web of Science, Evidence Aid, Research Square, ResearchGate, and the Health Systems in Fragile and Conflict-Affected Settings collection.
• Search Strategy: The search targeted three core concepts: (i) armed conflicts, (ii) continuity of care, and (iii) care coordination. The search was updated through February 17, 2026.
• Eligibility Criteria: Studies were included if they were published between January 1, 2010, and February 17, 2026; available in English, French, Italian, or Spanish; examined the impact of armed conflict on CoC or CaC; and focused on conflict-affected or forcibly displaced populations. Reviews were included; opinion pieces and editorials were excluded.
• Analysis: A total of 74 studies (64 peer-reviewed, 10 grey literature) were included. Data extraction followed the WHO "Continuity and Coordination of care" framework. Findings were synthesized using a combined deductive–inductive approach to cluster drivers, consequences, and mitigation strategies.
• Systems Thinking: An ex-post causal loop diagram (CLD) was developed to visualize the dynamic interactions, interdependencies, and self-reinforcing feedback loops among the identified domains of disruption.

Key Contributions and Results

The review synthesizes evidence from 67 studies (plus grey literature) into five interdependent domains that characterize how armed conflict disrupts care pathways:

1. People

• Healthcare Workers (HCWs): Violence (killings, harassment, abduction), insecurity, and irregular salaries drive attrition and relocation. Shortages lead to overburdened remaining staff, eroding trust-based provider-patient relationships and multidisciplinary collaboration.
• Patients: Insecurity and displacement disrupt therapeutic relationships and treatment adherence. Financial barriers force reliance on self-management or unqualified providers.
• Caregivers/Communities: Displacement shifts care burdens to informal networks, straining families and communities, particularly for dependent patients.

2. Hardware

• Facilities: Direct attacks, looting, and repurposing of health infrastructure (e.g., converting hospitals to military use) reduce capacity. Damage to utilities (power, water) renders facilities non-functional even if structurally intact.
• Drugs and Equipment: Supply chain disruptions, sanctions, and currency collapse cause critical shortages. This leads to treatment interruptions, use of substandard substitutes, and reliance on unregulated markets.

3. Services

• Prevention: Immunization and surveillance campaigns are disrupted by insecurity and infrastructure damage, leading to declines in vaccination coverage and disease monitoring.
• Curative Care: Long-term follow-up for NCDs and chronic infectious diseases (HIV, TB) is severely compromised, resulting in high loss-to-follow-up (LTFU) rates and increased drug resistance.
• Reproductive Health: Access to antenatal, delivery, and postnatal care declines, often forcing women toward riskier alternatives.

4. Linkages

• Referral Systems: Attacks on transport, fuel shortages, and blockades prevent patient transfers. This forces bypassing of primary care, overloading tertiary facilities, and delays in critical interventions.
• Information Systems: Displacement and facility destruction lead to lost medical records. Lack of interoperability and communication blackouts fragment informational continuity.
• Training: Destruction of academic institutions and cancellation of training courses degrade the pipeline of skilled personnel.

5. Governance

• Stewardship: Fragmented leadership, competing actors, and politicization of aid create a "stewardship vacuum." Administrative barriers (permits, registration requirements) further impede access.
• Plans and Protocols: Peacetime protocols often become impractical. The absence of conflict-adapted clinical guidelines forces clinicians into unsafe, non-evidence-based practices.

Causal Loop Dynamics

The authors identified three self-reinforcing cycles (loops) that lock health systems into chronic deterioration:

• R1 (Staff Distress & Capacity): Violence and workload increase distress, accelerating attrition, which further concentrates workload on remaining staff.
• R2 (Training & Capacity): Disrupted training reduces the supply of competent personnel, degrading skills and increasing workload, which further reduces capacity for training.
• R3 (Trust & Utilization): Declining care quality erodes patient trust, reducing care-seeking and follow-up, which further undermines continuity and quality.

Significance and Claims

The paper claims to provide a structured lens for clinicians, policymakers, and humanitarian actors to understand the complex, cascading nature of care disruption in conflict zones. Its primary significance lies in:

1. Systemic Mapping: Moving beyond isolated descriptions of service loss to map the causal pathways and feedback loops that link conflict exposure to the breakdown of CoC and CaC.
2. Operational Insight: Identifying specific leverage points within the five domains (People, Hardware, Services, Linkages, Governance) where interventions can mitigate impacts.
3. Strategic Integration: Arguing that fragmented, domain-specific interventions are insufficient. Effective mitigation requires simultaneous targeting of staff support, training continuity, and patient-facing quality to break the reinforcing cycles of deterioration.
4. Future Directions: Highlighting the need to integrate digital innovation (e.g., telemedicine, AI-assisted triage, drone delivery, portable diagnostics) and conflict-adapted protocols into mitigation strategies. The authors suggest that disaster-risk management frameworks must be adapted to the specific realities of armed conflict, emphasizing pre-positioning, decentralization, and community-anchored delivery.

The authors conclude that safeguarding CoC and CaC requires integrating humanitarian, development, and peace agendas (the Triple Nexus) to build health system resilience capable of withstanding protracted insecurity.