Why post-conflict health gains often do not last: a systematic review of time horizons and scale in health system reconstruction

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.