Abstract
Within fragile, conflict-affected and vulnerable settings (FCVs), health system governance arrangements have evolved in response to conflict, creating a complex foundation for service provision. Service provision is often pluralist in nature comprising state actors, foreign operators and local private-not-for-profit and for-profit providers. This brief focuses on this wide terrain of governance interaction and the effects this has on health service delivery and access for conflict-affected populations. It outlines three strategies for policy response and associated tools. Country cases reviewed for the brief have focused on well-known FCVs and those suffering from a confluence of crises related to security, humanitarian, political, and economic factors.

Key messages

• Within FCVs, policy response to private sector governance varies and is influenced by underlying health system attributes, capacities, and relational arrangements often shaped by conflict.
• Achieving a balanced response to health sector governance in FCVs requires navigating the complexities of immediate health service needs alongside long-term governance and capacity building efforts.
• Opportunities for improvement lie in promoting state stewardship, integrating private sector actors into health system development, and leveraging governance interventions for improved health system performance.
• Policy tools such as regulation, service organization, contracting, information management, and coordination should be situated within broader policy response and serve to address service quality and access for conflict-affected populations.