Editorial: Health governance in fragile contexts: building trust and resilience

Health governance in fragile contexts: building trust and resilienceThe provision of health service delivery in low-and lower-middle-income countries (LMICs) differs substantially from that in high-income nations -not only because of differences in resources and access but also due to the complexity of governance systems.It is encouraging that the governance research in these contexts is moving beyond simply identifying gaps, towards a more solution-focused approach that takes in to account the local realities (Bennett et al., 2018;Saif-Ur-Rahman et al., 2019).Conflict settings, where health systems face extraordinary pressure, bring this need for adaptive, context-specific governance into sharp focus (Levy and Sidel, 2016).As a demand for healthcare increases, active conflicts put additional strain on already fragile health systems, reducing access and availability.In such conditions, the health sector must rapidly adapt, often involving multiple actors and resulting in fragmented responses (Lokot et al., 2022).Today, the global landscape is shaped by rising nationalism, economic shifts, reductions in international aid and the growing toll of conflict and displacement.Delivering fair, efficient healthcare is now even more difficult for LMICs, which are already grappling with systemic challenges (WHO, 2020).Against this backdrop, the special section of this issue of the International Journal of Health Governance spotlights student-led and student-assisted research focused on health governance in LMICs and conflict-affected populations.These contributions aim to offer new perspectives and practical solutions for one of the most pressing challenges of our time.The articles included in the special section of this issue -one examining Nepal's Madhesh region and the other exploring the Garmian region of Iraq -highlight the multifaceted nature of health governance in fragile settings.Bhandari's study from Nepal examines how ethnic divisions between the Pahadi majority and Madhesi minority influence perceptions of healthcare.Despite a history of political exclusion, Madhesi patients largely reported positive interactions with state-run healthcare services, valuing tangible benefits like free services and availability of healthcare professionals.Significantly, these positive experiences translated into broader trust in the government.Yet, this optimism rests on a precarious foundation: sustained quality and equitable service delivery.Meanwhile, healthcare providers -mainly from the Pahadi community -often viewed Madhesi clients through a lens of cultural stereotypes, exposing a concerning gap between patient and provider perceptions.Closing this gap will be essential for building lasting health system legitimacy in Nepal and similar contexts (Brinkerhoff et al., 2012;Kruk et al., 2010;Saulnier et al., 2024).Complementing this perspective, Ayad's study on Iraq's Kalar (Garmian region) documents the systemic governance challenges following the mass displacement triggered by ISIS advances.Kalar's health infrastructure struggled under the weight of a sudden influx of internally displaced persons (IDPs), leading to shortages of supplies, uneven service delivery and blurred governance responsibilities.Despite efforts like IDP health committees and NGO partnerships, chronic underfunding and coordination challenges persisted.Legal protections for IDPs' healthcare rights existed on paper but often fell short in practice.This study underscores the necessity of proactive, inclusive governance structures that is able to cope with shocks and not collapse into reactive crisis management (Akbarzada and Mackey, 2018;Lokot et al., 2022;Masefield et al., 2020;WHO, 2020).Together, these studies act as a reminder that health governance in fragile and conflictaffected settings requires development of cultural competence and sensitivity training for healthcare providers that can bridge ethnic divides and protect the fragile trust patients have extended to the system.