Learning from sustained service delivery during conflict

People’s access to essential services, such as health care, education and social protection, is often disrupted during conflicts. But people still find a way to get treatment, to keep children learning and find sources of support. Services, whilst weakened, often continue. Nurses, doctors, teachers, social workers and other frontline staff work out ways to carry on working and hospitals and schools remain operatinional even under incredibly challenging circumstances.

Rigorous and systematic evidence on service delivery in situations of fragility, conflict and violence is relatively recent. Over the last decade a series of large, multi-year research programmes funded by the UK’s Foreign, Commonwealth & Development Office (FCDO), some with other donors, have made progress in building a stronger evidence base. However, knowledge has remained siloed, with lessons from the health sector not informing education or social protection and vice versa. At a workshop at the Institute for Development Studies in January 2026, researchers from several FCDO-funded consortia came together to start to synthesise knowledge. This blog summarises the key common messages relating to support to frontline workers from across the sectors.

Common findings

1. Poor pay with limited support

There are huge challenges in ensuring that frontline providers such as teachers, health workers, social workers and other programme staff are paid and adequately supported. Often their salaries are interrupted, sometimes for long periods, and their pay erodes over time without being adjusted for higher living costs and inflation. There are also substantial voluntary workforces – community health workers and volunteer teachers for example.

Both poorly and intermittently paid professionals and volunteers are being asked to continue work in risky and dangerous environments with little support for their safety and security or well-being. The risks are both physical in terms of direct violence and psychological with exposure to high levels of trauma often over many years, with significant impacts on mental health. There are also often very limited career pathways or professional development opportunities for local level workers. The EQUAL Research Consortium conducted a study in Somalia to capture experiences of midwifery students and graduates; respondents indicated they faced opposition from family members from entering the field due to perceptions of poor pay and that their family members expressed concerns about their work insecurity. Security risks impacted midwifery graduates and their family members’ decision-making around accepting positions in more remote areas.

2. Fragmented training and invisible labour

Training is usually highly fragmented and not always what is most needed. Frontline health workers in conflict settings often work extremely long shifts, sometimes up to 24 hours, without overtime pay or additional compensation. Staff shortages and insecurity normalise unpaid labour, particularly for midwives and nurses, contributing to exhaustion and burnout while remaining largely invisible in formal support systems.

3. Resilience and navigating gender norms

In spite of these challenges we see extraordinary resilience and determination from frontline workers in keeping going. People continue to work even when they aren’t being paid and retain strong professional commitments to their jobs and communities. For example, women social assistance frontline workers in Yemen continue working despite difficult conditions  because they feel committed to their communities. Female frontline workers explained that the hardest part of the work is carrying people’s worries while dealing with her own problems at home and that they need to work to ensure women in need are reached, but that this requires careful navigation of social norms that limit women’s mobility and public roles.  Somali midwifery students and recent graduates noted that their motivation came from their desire to support the mother-newborn dyad and to address the extraordinarily high maternal mortality ratio in the country.  Furthermore, they also saw entering this process as a source of empowerment, with a desire to challenge traditional gender norms by successfully completing their education and entering the midwifery workforce.

4. Investing in community-embedded approaches

Baobab’s work on sexual and reproductive health and rights (SRHR) research in refugee settings, offers evidence of the value of investing in and meaningfully supporting frontline workers in humanitarian settings. Across both Uganda and Ethiopia, the programme has intentionally and routinely integrated refugees and host community members into multiple stages of research and intervention delivery, including community entry, data collection, contextualisation, and psychosocial support (through para-social workers). This approach not only strengthens local research capacity, but also builds trusted, community‑embedded frontline teams who can navigate complex social norms, language diversity, and the sensitivities of working in humanitarian settings. These individuals were central to ensuring high‑quality data collection and to providing immediate, culturally informed support to violence survivors during programme implementation.

Policy implications for frontline worker support

There are some clear policy implications arising from such evidence on the wellbeing of frontline staff working in situations of fragility, conflict and violence. There should be much more attention to basic pay, living conditions, safety and well-being for frontline workers. And, given how badly they are currently supported, there is scope for improvements at low cost. On the other hand, motivation is not only about payment/incentives. Many frontline workers, especially midwives, feel undervalued despite their critical role in saving lives and supporting communities. Simple, low-cost measures such as recognition and showing that their work is valued by their health worker colleagues could significantly improve morale, professional identity, and retention. There’s also a need for greater attention to agendas to improve workers’ rights and benefits such as insurance and pensions. People need more structured support and career trajectories. A contextualised gender lens to this support would also ensure support for frontline workers takes into account gendered roles, risks and needs in individual settings.

1. Cost-effective improvements in working conditions

In a study on social assistance frontline workers in Yemen, community-based cash transfer workers in two southern governorates identified a number of ways to improve their working conditions that would be cost-effective relative to overall programme spend. For example, increasing the monthly pay of the lowest tier community outreach workers given the current very low rates they receive would still account for a relatively small proportion of intervention budgets. There were also calls to avoid hiatuses in-between the operationalisation of programmes which translate into contract and pay insecurity for the workers. Another recommendation raised in the study was to  ensure that programmes cover the ‘mahram (male guardian) travel costs that are incurred when the women workers have to travel to carry out their duties does not entail large expenditures, but makes a big difference to the women workers who have to pay those costs out of their inadequate income.

2. Supporting frontline workers in a context of declining aid

This will be harder than ever to resource in the context of declining aid. But, with large amounts still being spent on trying to maintain basic services, finding ways to better support local workers can offer strong value for money and effectiveness gains. And it should be the ethical responsibility and a duty of care for organisations that are trying to support service delivery. This requires continuing investment in research that investigates how limited budgets can ensure the greatest (economical, efficient, effective and equitable) impacts, especially for the frontline workers operating in dangerous and rapidly changing contexts.

3. Teacher pay and affordability in protracted conflicts

A forthcoming ERICC ODI paper on teacher pay in protracted conflicts shows that externally funded teacher incentives often do not meet the national average cost of a basic household expenditure basket, with regional cost-of-living differences also rarely taken into account. Moreover, based on modelling the affordability of teacher salaries within previous levels of external assistance for education between 2018 and 2022, the study finds that bare-minimum teacher pay support (40 USD per month) from sector development aid could have been affordable in the recent past, although it would have displaced other education programming. In Mozambique, for instance, paying 90% of teachers 40 USD per month would have been equivalent to 39% of annual average education development aid. Such aid could make a substantive difference to the wellbeing of teachers in low-income conflict-affected contexts.

4. Systematising community health worker support

There are examples that show the benefits of more effective support. In Somalia, practical experience and forthcoming findings from EQUAL demonstrates that community frontline support is more effective when systematised rather than implemented through fragmented projects.  Community Health Worker (CHW) programmes have high potential to reach women in areas with significantly low access to care, but such programmes are not a simple solution: mistrust by male partners, weak facility linkages (including referrals not being respected), and broader crisis conditions that disrupt continuity are some issues that can undermine outcomes unless these challenges are addressed as integral components of frontline support, together with predictable compensation, clear role definitions, coordination, and accountability.  The country is developing a national community health strategy, with the hope that their aims to clarify CHW roles and strengthen training and supportive supervision, leveraging community trust in local personnel will further the potential for life-saving services to reach more distant contexts.

5. Strengthening recognition, supervision and community support

In South Sudan, EQUAL’s implementation research will be contributing insights into integration of MNH services into the national community health programme (Boma Health Initiative), including distribution of misoprostol for prevention of postpartum haemorrhage and chlorhexidine for umbilical cord care, and what the facilitators and barriers are to service delivery and uptake of life-saving commodities and behaviours.  If the CHWs receive clearer recognition within the health system, more consistent support, and strong links to facilities and supply chain, they would be better able to sustain service delivery and maintain trust with communities. While challenges remain, these initiatives illustrate how investing in frontline workers can strengthen resilience and continuity of care even in highly fragile contexts.

In REBUILD for Resilience we identified several ways to support health workers in these dire situations. In Yemen, health workers emphasised their supervisors as key sources of support and motivation, providing compassionate leadership and regular check-ins. This should be acknowledged by managers and decision makers, and encouraged where possible.  In Türkiye during the recent earthquakes, managers modified shifts to help balance workloads and avoid burnout. This is a low cost and effective way to support health workers.  In Tigray, health workers described family support as a way of coping with the immense pressures of work and motivated them to continue to provide services. Although not an alternative to support from the health system, community and family support is essential for frontline workers feeling valued. Health workers also received mental health support and this helped them to continue to provide essential services to their communities.

6. Building resilient services through resilient workforces

Under Baobab, a model of incorporating refugees and host community members into research and programme implementation proved feasible and highly valued. Extensive training, tool language contexualisation, and co‑facilitation by local trainers not only enhanced technical capacity but also deepened ownership, community buy‑in, and trust, key determinants of effective frontline work in fragile settings. Both trainees and trainers emphasised how rare and empowering such opportunities were, particularly for refugees who had seldom been included meaningfully in research roles. The success of this approach demonstrates that engaging community‑based frontline workers is not only ethical and locally responsive, but also operationally advantageous, strengthening data quality, psychosocial support, and overall programme resilience.

Summary

These approaches have shown that support extends beyond motivation; effective implementation requires predictable compensation, functional referral systems to health facilities, and management structures aligned with national frameworks. Notably, expanding CHW responsibilities without adequate resources may lead to workforce overload, while parallel incentive schemes can create unrealistic compensation expectations. The overarching lesson across sectors is that resilient services depend on resilient and protected frontline workforces.

More reliably paying and supporting people who are keeping services going at great personal risk in the places where they are needed most is a simple but vital message. The fact that it emerges strongly and consistently across health, education and social protection shows its importance and suggests scope for continued exchanges across sectors about what works.

Disclaimer: The views expressed in this opinion piece are those of the author/s and do not necessarily reflect the views or policies of IDS.