Territorial control by non-state armed groups and gendered access to healthcare in conflict using a new complex adaptive systems framework

The growing prevalence and influence of non-state armed groups (NSAGs) in armed conflict requires a deeper understanding of how their territorial control and contestation affect sub-national healthcare availability and outcomes, particularly with regards to gender dynamics. However, there are gaps in existing research in understanding how NSAG governance influences health care outcomes. Furthermore, a disconnect exists between the literature on international humanitarian interventions, NSAG governance and national health systems. Each perspective tends to prioritise a specific health service provider—whether NSAGs, State actors, or international humanitarian organisations—and often treats populations as homogenous. To address these gaps, we propose a complex adaptive system framework centred on the influence of territorial control for health services in intra-state conflict settings, with a gender lens. This systems framework accounts for the influence of all parties significant for health service delivery. It recognises that those governing the localised health system may differ from those physically delivering health services. Our framework enables empirical examination of health service delivery and outcomes. We apply the framework to three conflict-affected settings (Colombia, Iraq, Mali) using publicly available data and offer recommendations for policymakers and practitioners targeting health service provision in intra-state conflict contexts.