Digital health In settings of extreme adversity: improving quality of care for vulnerable populations

Improving the quality of healthcare delivery is a major priority around the world. However, the barriers to improving healthcare quality can vary significantly by context, environment, and population. In settings such as conflict-affected areas or areas of sustained humanitarian crisis, challenges to improving healthcare quality can be extremely complex. In this blog, the term settings of extreme adversity is used to describe these areas, but other terms such as fragile and conflict-affected and vulnerable states, have also been used in research. This blog is written by Olivia Lounsbury, Quality and Safety Programme Co-ordinator, John Hopkins University School of Medicine.

Why is it difficult to deliver healthcare in extreme adversity settings?

The nature of extreme adversity settings introduces unique and complex challenges for the health and well-being of all those involved in receiving and delivering healthcare. Health systems face significant challenges in delivering even basic care to their populations. Similarly, the resources necessary to deliver adequate care may be destroyed or removed within conflict-affected areas.

From the patient perspective, patients in extreme adversity settings often lack accessible information to make decisions about where and how to seek care. From the health professional perspective, the inability to collect data for improvement, limited learning and development opportunities for healthcare workers, and poor patient engagement in care are  key challenges to overcome when providing high-quality care in extreme adversity settings. Because of these unique challenges, innovation is necessary to meet the needs of these populations.


“Whole populations can frequently and abruptly move within these circumstances, which can make it difficult to coordinate care and manage chronic diseases. Challenges like conflict, famine, extreme poverty, and national political fragility are often so insurmountable that prioritising quality in healthcare delivery, in addition to basic care, becomes difficult.”

– Olivia Lounsbury, Quality and Safety Program Coordinator, Johns Hopkins Children’s Center


A digital health solution? 

Digital health technologies have emerged as a promising avenue in the pursuit of improving healthcare quality around the world. Particularly in extreme adversity settings, digital health technologies offer the promise of improving flexibility of care, remote monitoring, control over personal health information, and chronic disease management. However, there needs to be better understanding of actionable ways in which digital health technologies can be utilised in extreme adversity settings. Within Imperial College London’s Institute of Global Health Innovation (IGHI) we sought to understand how digital health technologies may play a role in improvement.

We interviewed six experts with lived experience improving the quality of care delivery in extreme adversity settings. Our results showed that engagement in care, continuity of care, workforce operations, and data collection were areas in which digital health technologies have the potential to improve the quality of care in extreme adversity settings.

Interviewees also identified a number of potential opportunities for impactful digital innovation in extreme adversity settings. First, there was a need to improve the terminology used to describe the topic.  Similarly, interviewees highlighted the need to establish shared and clear priorities for digital innovation to better allocate attention and resources. Patient identification and ability to travel with health information were also mentioned as opportunities for improvement, particularly for refugee populations.  Because the needs of those in extreme adversity settings are very unique, interviewees emphasised the need to develop digital health solutions tailored to their needs. Finally, coordination and standardisation, as well as sustainability, were highlighted as key opportunities to use digital health for improved healthcare quality in extreme adversity.

Our findings show that delivering healthcare quality in settings of extreme adversity is particularly challenging. In future settings where resources are inevitably limited like climate catastrophes or future conflicts, healthcare will be incredibly difficult to deliver, and therefore we need good, robust evidence and research into this area.


“This study highlights the potential of digital technologies to improve the patient journey in fragile, conflict-affected and vulnerable settings, both at micro and macro levels. Future work should focus on embracing the opportunities for improvement identified, and developing and robustly evaluating interventions that address the unmet needs of these populations.”

– Ana Luisa Neves, Associated Director & Advanced Research Fellow, Imperial NIHR Patient Safety Translational Research Centre


The findings from this study highlight the need for policy development, and resource allocation to care for one of the most vulnerable populations.  


“With increasing numbers of settings in crisis situations, it is essential to deepen our understanding of how to improve the safety and quality of care. At IGHI, we are working to develop an evidence base through our research on patient safety in fragile, conflict-affected and vulnerable settings, from which interventions can be developed.”

– Alex Shaw, Policy Fellow, Institute of Global Health Innovation


It is apparent in our findings that there is a need to further understand the nuances of environments in which healthcare is difficult to deliver. IGHI will continue to examine interventions that can be applied to improve access to high-quality healthcare in vulnerable populations.

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