How Health Systems 'Software' Factors Affect Frontline Health Workers' Humanitarian Response Efforts During...

Humanitarian settings face a growing healthcare workforce crisis marked by staff shortages, unsafe working conditions, and limited professional development. Despite being critical intermediaries in outbreak responses, demands on health workers come at a substantial cost to their health and wellbeing. Research on health workers responding to the Rohingya refugee crisis in Cox's Bazar, Bangladesh, is limited. Focussing on health systems "software" (relationships between people and structures), this study explores health workers' interactions with different levels of governance structures, including humanitarian response governance, the health sector coordination leadership team, and their affiliated NGO management structures when responding to disease outbreaks in the camps, particularly during COVID-19. Qualitative research consisted of 33 interviews and 4 data validation workshops with frontline health workers, and 13 key informant interviews with humanitarian stakeholders. Health workers' dependence on government camp authorities for their safety and public health enforcement produced complex relationships and sometimes compromised medical practices and professional support. Through the support of the health sector leadership team, infection prevention and control training was perceived as a key strength; however, health workers reported limited inclusion in decision-making and being professionally unprepared during outbreaks. These experiences compounded risks to their mental and physical health, and they reported receiving minimal organisational support. These relational and structural tensions undermined worker resilience and patient-provider trust. The findings underscore the need for outbreak preparedness and strategic reforms in humanitarian decision-making that prioritise health workers' safety, promote inclusiveness in decision-making, and embed sustained professional support in humanitarian health systems for future outbreaks.