Health research and service delivery are often planned and implemented with little direct involvement from the communities they are intended to support, which can result in poor use of resources, unmet goals, and frustration at the local level. In conflict-affected countries, where health systems are already fragile due to insecurity, displacement, and weakened governance structures, the absence of meaningful community engagement can deepen existing inequalities and reduce the effectiveness of interventions. Although community engagement is widely recognised as important for strengthening health systems and improving accountability and ownership, there has been limited effort to examine how it is actually carried out in settings affected by conflict. This review was conducted to map the available evidence, describe the types of engagement approaches used, and identify lessons to guide future health systems interventions and research in these challenging contexts.
The paper employed a structured scoping review approach, in which the authors screened 2,355 records and included 19 studies conducted across 12 conflict-affected countries. Most of the included studies described participatory approaches, while only a few clearly applied co-design or co-creation strategies. Engagement often involved working with community leaders, religious figures, community health workers, and local committees to support service delivery, governance, and accountability. Some initiatives introduced tools to strengthen dialogue between health providers and communities, while others mobilised community members to increase service uptake or helped mediate between health actors and armed or political groups. However, the review found that relatively few studies centred on the lived experiences and direct perspectives of community members. Also, there was limited discussion of sustained system-wide impact.
Several key lessons emerged across the studies. These include engaging respected local actors, which frequently improved trust and cultural appropriateness, yet relying mainly on elites risked excluding marginalised groups, whose voices are often less heard. Therefore, meaningful engagement required careful attention to power relations, safety concerns, language, and social norms, particularly in unstable environments where fear and insecurity shape participation. Moreover, the provision of spaces for feedback and the demonstration that programmes were responsive to community concerns strengthened accountability. The studies conclude that while community engagement holds clear potential to improve health system performance in conflict-affected settings, the existing evidence base remains limited, and future work must prioritise inclusive, context-sensitive approaches that genuinely involve communities in decision-making.