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.