Engaging vulnerable people in health interventions in fragile settings

Around 1.8 billion people - nearly a quarter of the world’s population - live in fragile and conflict-affected settings (OECD, 2025), where they face some of the highest and most inequitable burdens of preventable disease and mortality, with deep disparities across gender, displacement status, and socioeconomic status. (Diaconu et al., 2020; Abubakar et al., 2018)

Development agencies and humanitarian actors active in fragile settings increasingly advocate or use stakeholder engagement in their programmes. It is being hailed by scholars as a foundational principle of effective and equitable health system intervention. (George et al., 2015; Falisse et al., 2023; Morales-Garzón et al., 2023) Stakeholder engagement entails the meaningful inclusion of all relevant actors - governments, service providers, civil society, and communities - in the design, implementation, and evaluation of research and interventions. It seeks to bridge power asymmetries, strengthen mutual accountability, and promote shared ownership of interventions to enhance health outcomes. Importantly, engagement is not limited to consultation; it requires ongoing dialogue, joint decision-making, and recognition of diverse forms of knowledge. At its core lies the participation of affected communities, whose lived experience provides essential insight into what works and why - yet their involvement too often remains superficial or even exploitative. (Razavi et al., 2020; Lokot & Wake, 2021)

Yet, despite broad consensus on the importance of engagement, there is limited empirical evidence on the minimal conditions that enable meaningful, equitable, and sustainable engagement of affected communities in fragile health systems. (Loewenson et al., 2023; McCaffrey et al., 2025)

In this doctoral study, I address this gap by examining how, why, under what conditions, and with what effects vulnerable populations are being involved in engagement processes in health interventions in fragile contexts. By applying a realist approach, I aim to identify the structural and relational factors that enable meaningful engagement, generating evidence to inform more legitimate, equitable, health (system) interventions.