Essential medicines in conflict-affected settings: a systematic review of accessibility and affordability across fragile health systems.

BACKGROUND: Conflict disrupts health systems and limits access to essential medicines; however, evidence on accessibility and affordability in conflict settings remains limited. This systematic review synthesizes empirical evidence on these outcomes. METHODS: We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Web of Science, Embase, and Google Scholar were searched in October 2025. Studies were eligible if they assessed accessibility to or affordability of essential medicines in conflict settings and reported quantitative outcomes. Two reviewers independently screened studies in Covidence. Risk of bias was assessed and results were synthesized using descriptive statistics and narrative analysis. RESULTS: Fourteen studies across 12 conflict-affected settings met the inclusion criteria. Medicines for infectious diseases were generally more accessible than those for noncommunicable diseases. Public-sector facilities often reported lower accessibility than private outlets, leading patients to seek medicines in higher-priced private pharmacies and clinics. Affordability challenges were common, especially for uninsured patients and for chronic disease medicines. Key drivers included disrupted supply chains, damaged infrastructure, workforce shortages, and economic shocks such as inflation and rising transport costs. CONCLUSION: Conflict-affected settings face challenges maintaining equitable access to essential medicines. While medicines for acute infectious conditions are often prioritized in humanitarian responses, those for chronic diseases are less accessible and affordable. This gap may undermine continuity of care. Strengthening pharmaceutical supply chains, improving coordination between national and humanitarian procurement systems, and expanding financial protection mechanisms may improve access.