Fragile Settings Research Articles

Managing Innovation for Sustainable Health:rethinking training of health officials in fragile states

Abstract There is great urgency for action to achieve the Sustainable Development Goals, especially in fragile settings, which face acute and complex challenges. Yet, the public sector may be limited in its capacity to address these appropriately, with devastating effects on the health of people and environment now and in the future. The challenges to sustainable health require professionals who are trained relevant competences. In 2020, Karolinska Institutet, Sweden, and Makerere University, Uganda, developed the Centre of Excellence for Sustainable Health under which a new partnership was established with Benadir University, Somalia, Kinshasa School of Public Health, the Democratic Republic of Congo, and Tinkr, Norway to develop training on innovation for sustainable health. The aim of “Managing Innovation for Sustainable Health” (MISH) is to strengthen the capacity to contribute to achieving sustainable health through innovation in the public sector. It targets managers in Somalia, DRC and Uganda from the public and private sector, academia, and civil society. It is one year long, part-time and delivered online with one study trip. It features three modules covering Agenda 2030 and Sustainable Health; Multisectoral Collaboration and Implementation Science; and Innovation and Innovation Management. Integration of participants’ learnings into their professional role, mutual learning between participants, and an emphasis on applicability, all underpin the learning strategies of the program. Quality is monitored through expectation surveys, baseline mid and final impact assessments, module and final program evaluations. MISH has trained about 50 managers, 85% of which say that the training was useful. All partners are represented in both operational and strategic organizational bodies of the program. Our model shows what is possible through collaborative online international learning delivered by partnerships defined by teamwork, trust, and a dedication to true impact. Key messages • There is great urgency for action to achieve sustainable health especially in fragile settings. • There is momentum for higher education to leverage the opportunities of the covid-19 to rethink learning for the global challenges.

Selling "independent foreign policy" amid the US–China rivalry: populism and Philippine foreign policy under the Duterte government

This paper examines Philippine foreign policy under the Duterte government (2016–2022). During this period, Philippine foreign policy is widely acknowledged to have undergone dramatic shifts, with the government making friendly overtures towards China at the cost of its traditional alliance with the US. From a foreign policy analysis perspective, this paper explicitly focuses on the role of political leadership in guiding national foreign policy. This paper argues that the Duterte government made strategic use of political marketing in promoting its populist foreign policy. Thus, political marketing is used as an analytical lens with which to examine much of the rhetoric and behaviour of the Duterte government, particularly in regard to its response to the US–China rivalry. By engaging in this supposedly diplomatic game, the Duterte government tried to sell its foreign policy promises and outcomes as products even when its rhetoric was at times disconnected from its actual performance. Overall, this paper develops an alternative perspective from which to add to our understanding of the role of populist foreign policy initiatives in a fragile democratic setting.

Lessons from Compliance to Covid-19 Infection Prevention and Control Measures Among Health Care Workers in Somalia: Making a Case to Improve Preparedness and Readiness for National Health Security in a Fragile Setting

Lessons from Compliance to Covid-19 Infection Prevention and Control Measures Among Health Care Workers in Somalia: Making a Case to Improve Preparedness and Readiness for National Health Security in a Fragile Setting

(Gendered) resilience in community-based natural resource management in fragile and conflict-affected settings

(Gendered) resilience in community-based natural resource management in fragile and conflict-affected settings

Cancer burden and preparedness in fragile settings

More than a fifth of the world's population live in fragile settings, yet there is a paucity of health-related data on populations in this setting, and what data that do exist are often focused on infectious diseases rather than non-communicable diseases including cancer. In their Article in The Lancet Global Health, Isabel Mosquera and colleagues1 calculated cancer incidence and mortality on the basis of data from population-based cancer registries for 31 countries that had scored 90 or more on the Fragile States Index for at least 10 years.

The Gendered Experience of Close to Community Providers during COVID-19 Response in Fragile Settings: A Multi-Country Analysis

Many countries, and particularly those including fragile contexts, have a shortage of formal health workers and are increasingly looking to close-to-community (CTC) providers to fill the gap. The experiences of CTC providers are shaped by context-embedded gender roles and relations. This qualitative research study in Lebanon, Nepal, Myanmar and Sierra Leone explored the gendered experiences of CTC providers during the COVID-19 pandemic in fragile settings. We used document review, in-depth interviews or focus group discussions with CTC providers, and key informant interviews with local stakeholders to generate in-depth and contextual information. The COVID-19-associated lockdowns and school closures brought additional stresses, with a gendered division of labour acutely felt by women CTC providers. Their work is poorly or not remunerated and is seen as risky. CTC providers are embedded within their communities with a strong willingness to serve. However, they experienced fractures in community trust and were sometimes viewed as a COVID-19 risk. During COVID-19, CTC providers experienced additional responsibilities on top of their routine work and family commitments, shaped by gender, and were not always receiving the support required. Understanding their experience through a gender lens is critical to developing equitable and inclusive approaches to support the COVID-19 response and future crises.

A Comparative Analysis on the Social Determinants of COVID-19 Vaccination Coverage in Fragile and Conflict Affected Settings and Non-fragile and Conflict Affected Settings.

The coronavirus disease 2019 (COVID-19) pandemic has coerced various resources of all the countries. While the high-income nations redirected financial and human resources to understand specific determinants of vaccination coverage, fragile and conflict-affected setting (FCS) nations were waiting for global bodies to cater to their ever-growing need for vaccines and other lifesaving drugs. This study aimed to determine various factors influencing vaccine coverage in the FCS context. World Bank's classification of FCS states was the primary source for country classification. The study utilized data from various other open sources. The study models cross-country inequities in COVID-19 vaccine coverage and we have employed multi-variate log-linear regressions to understand the relationship between COVID-19 vaccine coverage and cross-country macro-level determinants. The analysis was conducted on two samples, non-FCS Countries and the FCS countries. Socio-economic determinants such as gross domestic product (GDP) per capita, socioeconomic resilience; health system determinants such as density of human resources, government spending on health expenditure; and political determinants such as effective government, more power to regional governments, political stability and absence of violence play a pivotal role in vaccine coverage. We also found that FCS countries with a higher share of people strongly believing in the vaccine effectiveness have a positive association with COVID-19 vaccine coverage. The study confirmed that political factors, government effectiveness and political stability are also important determinants of vaccine coverage. The result further draws attention to few policy implications such as promoting future research to explore the linkages between the perceived equality before the law and individual liberty and its effect on vaccination coverage in the FCS.

Building power-ful health systems: the impacts of electrification on health outcomes in LMICs

ABSTRACT Critical disparities threaten health care in developing countries and hinder progress towards global development commitments. Almost a billion people and thousands of public services are not yet connected to electricity – a majority in sub-Saharan Africa. In economically fragile settings, clinics and health services struggle to gain and maintain their access to the most basic energy infrastructure. Less than 30% of health facilities in LMICs report access to reliable energy sources, truncating health outcomes and endangering patients in critical conditions. While ‘universal health coverage’ and ‘sustainable energy for all’ are two distinct SDGs with their respective targets, this review challenges their disconnect and inspects their interdependence in LMICs. To evaluate the impact of electrification on healthcare facilities in LMICs, this systematic review analysed relevant publications up to March 2021, using MEDLINE, Embase, Scopus, CENTRAL, clinicaltrials.gov and CINAHL. Outcomes captured were in accordance with the WHO HHFA modules. A total of 5083 studies were identified, 12 fulfilled the inclusion criteria of this review – most were from Africa, with the exception of two studies from India and one from Fiji. Electrification was associated with improvements in the quality of antenatal care services, vaccination rates, emergency capabilities and primary health services; with many facilities reporting high-quality, reliable and continuous oxygen supplies, refrigeration and enhanced medical supply chains. Renewable energy sources were considered in six of the included studies, most highlighting their suitability for rural health facilities. Notably, solar-powered oxygen delivery systems reduced childhood mortality and length of hospital stay. Unavailable and unreliable electricity is a bottleneck to health service delivery in LMICs. Electrification was associated with increased service availability, readiness and quality of care – especially for women, children and those under critical care. This study indicates that stable and clean electrification allows new heights in achieving SDG 3 and SDG7 in LMICs.

The determinants of the quality of clinical management among diabetic and hypertensive patients in a context of fragility: A cross-sectional survey from Lebanon.

IntroductionThe management of NCDs is a growing challenge in low- and middle-income settings with the increasing prevalence and the associated demands that such conditions make on health systems. Fragile settings both exacerbate the risk of NCDs and undermine systems capacity. Lebanon is a setting where strategies to address rising NCDs burden have faced particularly acute contextual challenges.MethodsWe conducted a cross-sectional survey with patients accessing non-communicable disease across 11 primary care centers within the Greater Beirut and Beqaa areas. Response were received from 1,700 patients. We generated a Clinical Management Index Score as a measure of quality of care, and scores related to a range of socio-demographic characteristics and other context specific variables.ResultsSignificantly higher clinical management index scores (better quality of care) were associated with patients living in the semi-urban/rural context of Beqaa (compared to Greater Beirut), having health insurance coverage, aged above 60, having high levels of educational attainment, and making partial or full payment for their treatment. Relatively lower index scores (poorer quality of care) were associated with Syrian nationality (compared to Lebanese) and with patients suffering from diabetes or hypertension (compared to comorbid patients).ConclusionThe study identified a wide margin for improving quality of NCDs care in fragile contexts with particular gaps identified in referral to ophthalmology, accessing all prescribed medication and receiving counseling for smoking cessation. Additionally, findings indicate a number of predictors of comparatively poor quality of care that warrant attention, notably with regard to Syrian nationality/legal status, lack of health coverage, seeking free health provision and lower educational attachment. Although these are all relevant risk factors, the findings call on donor agencies, NGOs and provider institutions to design targeted programs and activities that especially ensure equitable delivery of services to diabetic and hypertensive patients with compounded vulnerability as a result of a number of these factors.

Does inter-border conflict influence the views of task sharing among community health volunteers in Nigeria? A qualitative study

BackgroundVolunteer community health workers are increasingly being engaged in Nigeria, through the World Health Organization’s task sharing strategy. This strategy aims to address gaps in human resources for health, including inequitable distribution of health workers. Recent conflicts in rural and fragile border communities in northcentral Nigeria create challenges for volunteer community health workers to meet their community's increasing health needs. This study aimed to explore the perception of volunteers involved in task sharing to understand factors affecting performance and delivery in such contexts.MethodsThis was a qualitative study conducted in fragile border communities in north central Nigeria. Eighteen audio recorded, semi-structured interviews with volunteers and supervisors were performed. Their perceptions on how task sharing and allocation of tasks affect performance and delivery were elucidated. The transactional social framework was applied during the thematic analysis process to generate an explanatory account of the research data, which was analysed using NVivo software.ResultsPromotive and preventive tasks were shared among the predominantly agrarian respondents. There was a structured task allocation process that linked the community with the health system and mainly cordial relationships were in place. However, there were barriers related to ethnoreligious crises and current conflict, timing of task allocations, gender inequities in volunteerism, shortage of commodities, inadequate incentives, dwindling community support and negative attitudes of some volunteers.ConclusionThe perception of task sharing was mainly positive, despite the challenges, especially the current conflict. In this fragile context, reconsideration of non-seasonal task allocations within improved community-driven selection and security systems should be encouraged. Supportive supervision and providing adequate and timely renumeration will also be beneficial in this fragile setting.

Strengthening healthcare providers’ capacity for intra-uterine device and contraceptive implant services in humanitarian and fragile settings: a case study from Nepal

Strengthening healthcare providers’ capacity for intra-uterine device and contraceptive implant services in humanitarian and fragile settings: a case study from Nepal

Effectiveness of case-area targeted interventions including vaccination on the control of epidemic cholera: protocol for a prospective observational study

IntroductionCholera outbreaks in fragile settings are prone to rapid expansion. Case-area targeted interventions (CATIs) have been proposed as a rapid and efficient response strategy to halt or substantially reduce the...

First aid guidelines for fragile contexts: Contextualization & Adaptation

Topic: In situations of remoteness to medical care, disaster or conflict, first aid provision is important but challenging. Education for learners in such contexts needs to be adapted according to resources available. This paper explores the educational approach and adaptations recommended by the 2020 IFRC First Aid, Resuscitation and Education Guidelines and provides a review of them. As a specialist in fragile and harsh contexts, the ICRC has contributed insight which enables the new guidelines to reflect challenges faced by those providing first aid education in peacetime and in war, and in other situations of adversity. Context: First Aid in armed conflicts, disasters and remote settings Adaptation: Educators need to adjust both the first aid skills and the way of teaching to the realities of those providing first aid. In some instances, safety and security of the first aider and the person requiring help should be prioritized over providing care. In remote settings or places where medical assistance is unlikely to be expedient, or in situations where effective first aid might not be possible, the psychological wellbeing of the first aid provider is also important and educators need to prepare their learners for such occurrences. Within the 2020 International First Aid Guidelines, authors tried to reflect the specific circumstances faced by first aiders in fragile settings, aiming to put the learner at the center and adapt the education to their needs and the realities of the resources available to them. Discussion: First aid educators around the world have to understand that guidelines are provided as an evidence-based guiding document which need to be adapted by the educator to the realities faced by the learner. It is their role to give learners the permission and confidence to act as best they can and provide options for delivering alternative care where resources or circumstances are limiting. Conclusions: The specific circumstances of armed conflict, disasters and remote settings will require the first aid educators and first aiders to adapt the scientific evidence of the first aid guidelines to their realities, and in some instances, place safety and security ahead of first aid provision. To increase the likelihood of successful implementation of evidence-based first aid techniques and practice, first aid education must consider aspects of context that promote and/or hinder implementation in these settings. Important, but not yet explicit enough in the new guidelines, is the permission needed to be given to first aid educators to create an authentic, intelligent and humanitarian approach to first aid learning. The goal is to encourage people to be creative and adapt to harsh realities using available resources without being distracted by theories which they cannot apply.

Self-care interventions for sexual and reproductive health in humanitarian and fragile settings: a scoping review

BackgroundSelf-care is the ability of individuals, families, and communities to promote health, prevent disease, maintain health, and manage illness and disability with or without a health care provider. In resource-constrained settings with disrupted sexual and reproductive health (SRH) service coverage and access, SRH self-care could play a critical role. Despite SRH conditions being among the leading causes of mortality and morbidity among women of reproductive age in humanitarian and fragile settings, there are currently no reviews of self-care interventions in these contexts to guide policy and practice.MethodsWe undertook a scoping review to identify the design, implementation, and outcomes of self-care interventions for SRH in humanitarian and fragile settings. We defined settings of interest as locations with appeals for international humanitarian assistance or identified as fragile and conflict-affected situations by the World Bank. SRH self-care interventions were described according to those aligned with the Minimum Initial Services Package for Reproductive Health in Crises. We searched six databases for records using keywords guided by the PRISMA statement. The findings of each included paper were analysed using an a priori framework to identify information concerning effectiveness, acceptability and feasibility of the self-care intervention, places where self-care interventions were accessed and factors relating to the environment that enabled the delivery and uptake of the interventions.ResultsWe identified 25 publications on SRH self-care implemented in humanitarian and fragile settings including ten publications on maternal and newborn health, nine on HIV/STI interventions, two on contraception, two on safe abortion care, one on gender-based violence, and one on health service provider perspectives on multiple interventions. Overall, the findings show that well-supported self-care interventions have the potential to increase access to quality SRH for crisis-affected communities. However, descriptions of interventions, study settings, and factors impacting implementation offer limited insight into how practical considerations for SRH self-care interventions differ in stable, fragile, and crisis-affected settings.ConclusionIt is time to invest in self-care implementation research in humanitarian settings to inform policies and practices that are adapted to the needs of crisis-affected communities and tailored to the specific health system challenges encountered in such contexts.

Adverse events following introduction of the ChAdOx1 nCoV-19 vaccine in Somalia in 2021: findings from a fragile setting and implications for the future

Vaccination against coronavirus disease 2019 (COVID-19) began in Somalia on 16 March 2021 with the Covishield (ChAdOx1 nCoV-19) vaccine. However, by the end of 2021, only a small percentage of the population had been fully vaccinated. As side effects play an important role in determining public confidence in vaccines and their uptake, this study aimed to examine reported adverse events following immunization (AEFIs) of vaccine recipients. This cross-sectional-survey-based study was conducted between March and October 2021 in Somalia. Vaccine recipients who were eligible to receive the first dose of the Covishield vaccine in the first phase of COVID-19 vaccination were eligible for study inclusion. P<0.05 was considered to indicate significance. Of the 149,985 respondents who had received the first dose of the Covishield vaccine, 378 reported side effects. This represented a reported AEFI rate of 2.5 per 1000 population. Amongst those who reported adverse events, males (2.8 per 1000; P<0.001), respondents aged 35-49 years (3.3 per 1000; P=0.001) and teachers (3.5 per 1000; P=0.000) had higher rates of adverse events compared with females, other age groups and other occupations. Amongst population settlement types, a higher rate of AEFIs was observed amongst refugees (23.9 per 1000; P=0.000) and internally displaced populations (19 per 1000; P=0.000). Nearly half of the vaccine recipients who reported side effects (48%) reported one local symptom, and most symptoms were mild in nature. The probability of having acute and severe side effects was found to be 66% lower among males compared with females [odds ratio (OR) 0.44, 95% confidence interval (CI) 0.26-0.73; P=0.002]. Respondents aged >60 years (OR 1.52, 95% CI 0.64-3.62; P=0.34) were more likely to develop acute and severe AEFIs. None of the study population reported any severe life-threatening symptoms or death. Some variables (sex, profession, age) put recipients at higher odds of acute and severe AEFIs, but the Covishield vaccine generally produced mild side effects in a small proportion of the vaccinated population in Somalia. This study confirms that COVID-19 vaccines are safe, and their benefits clearly outweigh any associated risk.

Assessing innovative approaches for global health capacity building in fragile settings in the MENA region: development of the evaluation of capacity building (eCAP) program

BackgroundGiven the magnitude and frequency of conflicts in the MENA region along with their devastating impact on health responses and outcomes, there exists a strong need to invest in contextualized, innovative, and accessible capacity building approaches to enhance leadership and skills in global health. The MENA region suffers from limited (1) continued educational and career progression opportunities, (2) gender balance, and (3) skill-mix among its health workforce, which require significant attention.Main textThe Global Health Institute at the American University of Beirut incepted the Academy division to develop and implement various global health capacity building (GHCB) initiatives to address those challenges in fragile settings across low-and middle-income countries in the MENA region. These initiatives play a strategic role in this context, especially given their focus on being accessible through employing innovative learning modalities. However, there exists a dearth of evidence-based knowledge on best practices and recommendations to optimize the design, implementation, and evaluation of GHCB in fragile settings in the MENA region. The present paper describes the development of the evaluation of capacity building program (eCAP), implemented under the Academy division, to assess the effectiveness of its initiatives. eCAP is composed of 3 phases: (1) a situational assessment, followed by (2) production of multiple case studies, and finally (3) a meta-assessment leading to model development. The goal of eCAP is not only to inform the Academy’s operations, but also to synthesize produced knowledge into the formation of an evidence-based, scalable, and replicable model for GHCB in fragile settings.ConclusioneCAP is an important initiative for researchers, educators, and practitioners interested in GHCB in fragile settings. Several lessons can be learned from the outcomes it has yielded so far in its first two phases of implementation, ranging from the situational assessment to the production of evaluation case studies, which are expanded on in the manuscript along with pertinent challenges.

A mixed methods study to assess the impact of COVID-19 on maternal, newborn, child health and nutrition in fragile and conflict-affected settings

BackgroundThe impacts of COVID-19 are unprecedented globally. The pandemic is reversing decades of progress in maternal, newborn, child health and nutrition (MNCHN), especially fragile and conflict-affected settings (FCAS) whose populations were already facing challenges in accessing basic health and nutrition services. This study aimed to investigate the collateral impact of COVID-19 on funding, services and MNCHN outcomes in FCAS, as well as adaptations used in the field to continue activities.MethodsA scoping review of peer-reviewed and grey literature published between 1st March 2020–31st January 2021 was conducted. We analysed 103 publications using a narrative synthesis approach. 39 remote semi-structured key informant interviews with humanitarian actors and donor staff within 12 FCAS were conducted between October 2020 and February 2021. Thematic analysis was undertaken independently by two researchers on interview transcripts and supporting documents provided by key informants, and triangulated with literature review findings.ResultsFunding for MNCHN has been reduced or suspended with increase in cost of continuing the same activities, and diversion of MNCHN funding to COVID-19 activities. Disruption in supply and demand of interventions was reported across different settings which, despite data evidence still being missing, points towards likely increased maternal and child morbidity and mortality. Some positive adaptations including use of technology and decentralisation of services have been reported, however overall adaptation strategies have been insufficient to equitably meet additional challenges posed by the pandemic, and have not been evaluated for their effectiveness.ConclusionsCOVID-19 is further exacerbating negative women’s and children’s health outcomes in FCAS. Increased funding is urgently required to re-establish MNCHN activities which have been deprioritised or halted. Improved planning to sustain routine health services and enable surge planning for emergencies with focus on the community/service users throughout adaptations is vital for improved MNCHN outcomes in FCAS.

Local approaches to climate-sensitive peacebuilding: lessons from Afghanistan

Since the early 2010s, academic and policy debates about the interlinkages between climate and security have expanded and deepened. Climate is now widely acknowledged to magnify security risks especially in conflict or post-conflict contexts. This relationship is viewed as complex, dynamic and indirect, involving a wide range of intermediate variables. However, this discussion – and hence, related policy efforts – have tended to occur at highly aggregate levels of analysis, especially national, regional and global ones. Instead, this paper addresses climate-sensitive peacebuilding at the local level. What does local climate-sensitive peacebuilding look like on the ground? What are the promising areas for research and policy responses in fragile and conflict-affected settings? After offering a broad overview of climate-sensitive peacebuilding, we focus on the case of Afghanistan, drawing on specific examples that were in place prior to the 2021 return to power of the Taliban. We find that the traditional Western approach in the country – top-down, focused on hard security rather than human security and highly state-centric – tends to ignore the impacts of climate change. In addition, the dominant security paradigm overlooks the potential of local peacebuilding initiatives that address adaptation and resilience. We argue that climate-sensitive peacebuilding offers a bottom-up alternative to addressing the intersection of these risks in conflict-affected settings.

Methodological and Ethical Implications of Using Remote Data Collection Tools to Measure Sexual and Reproductive Health and Gender-Based Violence Outcomes among Women and Girls in Humanitarian and Fragile Settings: A Mixed Methods Systematic Review of Peer-Reviewed Research

Purpose: This systematic review investigates the methodological and ethical implications of using remote data collection tools to measure sexual/reproductive health (SRH) and gender-based violence (GBV) outcomes among women and girls in humanitarian and fragile settings. Methods: We included empirical studies of all design types that collected any self-reported primary data related to SRH/GBV using information and communication technology, in the absence of in-person interactions, from women and girls in humanitarian and fragile settings. The search was run in March 2021 without filters or limits in Ovid Medline, Embase, Web of Science, Clinicaltrials.gov, and Scopus. Quality was assessed using an adapted version of the MMAT tool. Two reviewers independently determined whether each full text source met the eligibility criteria, and conflicts were resolved through consensus. A-priori extraction fields concerned methodological rigor and ethical considerations. Results: 21 total studies were included. The majority of studies were quantitative descriptive, aiming to ascertain prevalence. Telephone interviews, online surveys, and mobile applications, SMS surveys, and online discussion forums were used as remote data collection tools. Key methodological considerations included the overuse of non-probability samples, lack of a defined sampling frame, the introduction of bias by making eligibility contingent on owning/accessing technology, and the lack of qualitative probing. Ethical consideration pertained to including persons with low literacy, participant safety, use of referral services, and the gender digital divide. Conclusion: Findings are intended to guide SRH/GBV researchers and academics in critically assessing methodological and ethical implications of using remote data collection tools to measure SRH and GBV in humanitarian and fragile settings.

Evaluating an e-learning program to strengthen the capacity of humanitarian workers in the MENA region: the Humanitarian Leadership Diploma

BackgroundThe Middle East and North Africa (MENA) region is consistently plagued with humanitarian crises while having little response capacity. Despite their obvious growing need, there exist limited educational opportunities for humanitarian workers to develop their capacity in humanitarian topics. The present study evaluates an online training program, the Humanitarian Leadership Diploma (HLD), which targeted humanitarian workers across the MENA region.MethodsA mixed-methods design was used, comprising short and long-term quantitative and qualitative data, targeting individual and organizational-level outcomes. A total of 28 humanitarian workers across the MENA region enrolled in the program starting September 2019 until October 2020, 18 of which completed the full diploma. Short-term quantitative data such as knowledge assessments, course evaluations, and reflective commentaries were collected from all learners, whereas long-term qualitative data was collected only from those who completed the full diploma and from peers at their organizations, 6 months after completion. Data was triangulated, analyzed using qualitative content analysis, and reported as themes.ResultsThe program was overall successful given multiple factors reported by participants such as enhanced knowledge, high satisfaction, and improved practice, with some important challenges being identified. Themes under the strengths category related to (1) online learning, (2) significance of diploma, (3) course content, (4) instructors, (5) transfer of learning into practice, and (6) personal development. Themes under the challenges category related to (1) barriers to applying changes in behavior and performance, (2) engagement and interaction, and (3) pedagogical approach.ConclusionThis is one of very few evaluations of locally developed and delivered online learning programs for humanitarian actors in the MENA region. The findings are especially important as they may inform researchers and humanitarian actors looking to design and deliver similar programs in the MENA region or other fragile settings. Key recommendations are discussed in the manuscript, and include to combine synchronous and asynchronous approaches, design concise course materials, limit theoretical pedagogical approaches, ensure topics are contextualized to the region, and consider continuous engagement strategies for learners.