The study, led by Finn Holler of the UNICEF Latin America and Caribbean Regional Office together with colleagues from UNICEF offices in Panama City, New York, San José, and Nairobi, set out to close that gap. Conducted between August and October 2024 at four migrant transit points in Costa Rica, Guatemala, and Panama, the project had three goals: to identify existing training materials and clinical guidance relevant to migrant maternal, newborn, child, and adolescent health; to measure the knowledge of frontline health care workers before and after a pilot training program; and to document the priorities and practical lessons that emerged during implementation. The work was carried out as a UNICEF capacity-building initiative in collaboration with national health authorities, funded by the United States Agency for International Development, which had no role in the study design, analysis, or publication.

The first finding was sobering. A desk review of available migrant health training materials, combined with key informant consultations, identified no programs addressing maternal, newborn, child, and adolescent health and nutrition for migrants in short-term transit anywhere in Central America. Existing packages, such as those developed for European reception settings or for longer-term refugee camps, did not fit the realities of transit migration, where families may pass through a facility in hours or days and where clinical guidance tailored to that context simply did not exist. In response, the team developed checklists to support a standardized approach to care at transit points, filling a void that had left individual clinicians to improvise.

The training itself was built as a modular, context-adapted curriculum covering maternal, newborn, child, and adolescent health, nutrition, and intercultural competence. The modular design was a deliberate technical choice: it allows the content to be recombined and scaled according to local needs, staff availability, and the shifting profile of the migrant population at each site. Rather than importing a generic curriculum, the developers drew on the gaps and priorities identified during the needs assessment, ensuring that each session addressed situations the workers were actually encountering, from managing malnutrition in children who have walked for weeks to communicating across language and cultural barriers in the middle of a clinical encounter.

To evaluate whether the training worked, the researchers administered questionnaires before and after each session and collected participant feedback through evaluation surveys. The results were consistent across all three countries. In Costa Rica, average knowledge scores rose from 60 percent to 85 percent, a gain of 25 percentage points. In Guatemala, scores improved from 69 percent to 89 percent, a 20-point increase. In Panama, the improvement was from 57 percent to 81 percent, a gain of 24 points. Participant satisfaction was correspondingly high, at 94 percent in Costa Rica, 100 percent in Guatemala, and 93 percent in Panama. For a program delivered under the logistical constraints of active transit points, where staff time is scarce and patient flows are unpredictable, these figures represent a strong signal that short, targeted training can meaningfully raise the knowledge base of frontline teams.

Equally valuable is what the participants told the researchers about what was missing. Health care workers requested more training time and identified clear priorities for future rounds: psychological first aid, gender-based violence, and reproductive health. These requests reflect the epidemiology of the route itself. Women and girls in transit face elevated risks of sexual violence, and mental health burdens accumulate across an arduous journey. The study’s authors note that mental health and psychosocial support, gender-based violence, and reproductive health emerged as the leading priorities for future training, pointing toward the next iteration of the curriculum.

The technical significance of the study lies partly in its honest framing of what the data can and cannot show. The pre- and post-test design demonstrates a short-term gain in knowledge, but the authors are explicit that effects on clinical practice, service quality, and health outcomes remain to be evaluated. Knowledge scores are a proxy, not a guarantee: whether a worker who can answer a questionnaire correctly will manage a dehydrated infant or counsel a traumatized pregnant woman differently in a crowded shelter clinic is a question that requires follow-up research. The study also did not require ethics committee approval under international guidelines, because it was a descriptive report of programmatic capacity-building activities that collected no identifiable personal data, and the questionnaires were anonymous evaluations conducted for internal program purposes.

The context in which this work unfolded deserves attention. The Darién Gap, the roadless stretch of jungle connecting Colombia to Panama, has become one of the world’s most dangerous migration corridors, and the flow through it surged dramatically in recent years. Children, adolescents, and pregnant women are particularly vulnerable to the hazardous conditions and to the limited access to care along the route. Transit countries such as Panama, Costa Rica, and Guatemala have had to build health responses for a population that is constantly moving, often without documentation, and frequently speaking indigenous languages or languages other than Spanish. Health systems designed for resident populations are poorly equipped for this task, and the intercultural competence component of the training addressed precisely this mismatch.

The study also situates itself within a broader landscape of migration health training initiatives, referencing packages and frameworks developed by the World Health Organization, the Pan American Health Organization, the International Organization for Migration, and other agencies, including efforts in Europe such as EUR-HUMAN, ORAMMA, and the MEM-TP package. What distinguishes the Central American program is its focus on short-term transit, a phase of migration that most existing materials overlook. Migrants in transit are neither settled refugees nor returning travelers; their contact with health services is brief, their needs are acute, and the window for intervention is narrow. Training that assumes a stable clinical relationship does not transfer well to this setting, which is why the development of transit-specific checklists and modules matters.

Looking ahead, the researchers suggest that the modular training could be adapted and scaled to other transit corridors, and the identified priorities, psychological first aid, gender-based violence, and reproductive health, offer a roadmap for the next version. The program’s funders and implementers, including UNICEF and USAID, now face the harder evaluation question: does better-trained staff translate into better outcomes for mothers and children on the move? For now, the study stands as a documented proof of concept that a gap in global health training, one affecting hundreds of thousands of the world’s most vulnerable travelers, can be identified, measured, and partially closed with a modest, well-targeted intervention. In a year when more than 64,000 children crossed one of the planet’s most perilous jungle routes, that is a finding with consequences far beyond the three countries where it was tested.

Subject of Research: Maternal and child health and nutrition training for frontline health workers serving migrants in transit in Central America

Article Title: Enhancing healthcare capacity at migrant transit points: development and implementation of a maternal and child health and nutrition training program in Costa Rica, Guatemala, and Panama

Article References: Holler, F., Baffoe, P., Fautsch-Macías, Y., Manchikanti, S., López Borbón, D., Arts, M., & McQuen Patterson, J. (2026). Enhancing healthcare capacity at migrant transit points: development and implementation of a maternal and child health and nutrition training program in Costa Rica, Guatemala, and Panama. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-03025-4

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03025-4

Keywords: migration health, transit migration, maternal and child health, nutrition, frontline health workers, capacity building, Central America, Darién Gap, UNICEF, psychological first aid, gender-based violence, intercultural competence

The research team, led by Fabian Link, Zeliha Öcek, and Michaela Coenen of LMU Munich together with Apostolos Veizis of INTERSOS Hellas in Athens, interviewed fifteen staff members of civil society organizations between March and May 2024. Participants were recruited through purposive and snowball sampling, a technique in which initial contacts recommend further interviewees, allowing the researchers to reach workers embedded in local, national, and international organizations across the full length of the route. Semi-structured, in-depth interviews covered healthcare access, service gaps, the roles organizations play, the challenges they face, and their relations with institutions. The transcripts were then analyzed using qualitative content analysis, a method that systematically codes textual data into categories and themes. Ethical approval was obtained from the Ethics Committee of the Faculty of Medicine at LMU Munich, and all participants gave written informed consent.

The analytical engine of the study produced four main categories that structure the findings: the structural and sociopolitical context, the situation of people on the move themselves, national healthcare systems, and civil society organizations. This framework matters because it reframes migrant health not as an individual medical problem but as the output of an interacting system. Whether a person with an infected wound or a chronic illness receives care depends on migration governance, the capacity and willingness of national health services, and the presence or absence of an NGO clinic within walking distance of an informal settlement or a police station.

Participants described a landscape of fragmented migration governance in which responsibility for people in transit is dispersed across states, European Union agencies, and international bodies without any single actor owning the outcome. The Balkan Route is not a single road but a shifting mosaic of border crossings, transit camps, informal settlements, and pushback zones, and the legal status of a person can change overnight as they move from one jurisdiction to another. In this environment, the interviewees reported, legal barriers and discrimination operate as determinants of health in their own right. A person without registration may be formally entitled to emergency care yet practically unable to access it, turned away at reception desks, unable to communicate their symptoms, or afraid to present at a facility that they believe may report them to authorities.

The health risks experienced by people on the move are cumulative rather than episodic, according to the accounts gathered in the study. Exhaustion from weeks of walking, injuries sustained during border crossings, exposure to cold and unsanitary conditions, untreated chronic diseases, and the psychological burden of uncertainty and violence compound one another. Structural, administrative, and communication barriers then stack on top of these vulnerabilities. Language interpretation is often unavailable; paperwork requirements assume a fixed address; and the constant threat of removal discourages people from seeking care at all. The result is a population whose medical needs intensify precisely as their access to formal services diminishes.

Against this backdrop, the study’s central finding is the mediating role of civil society organizations. Although participants consistently viewed states as the actors primarily responsible for healthcare provision, they reported that CSOs fill critical gaps in three distinct ways. First, they deliver health-related services directly, from basic medical care and hygiene support to referrals for specialist treatment. Second, they facilitate access through mediation, accompanying individuals to hospitals, translating, navigating bureaucracy, and vouching for patients who would otherwise fall through the cracks. Third, they advocate for more equitable healthcare, pressing authorities and international agencies to recognize and close the gaps they observe on the ground. This triple function, service provision, brokerage, and advocacy, makes CSOs the connective tissue between a mobile population and health systems that were never designed to receive it.

Yet the study is equally clear that this role is constrained from multiple directions. Unstable funding keeps organizations in a permanent state of short-term planning, with projects that can end when donor priorities shift. Workforce shortages mean that a handful of coordinators, nurses, and cultural mediators must cover enormous geographic and caseload spans. Political pressures add another layer: organizations operating in countries where migration is a charged political issue face suspicion, obstruction, and in some contexts the risk of being accused of facilitating irregular movement. Perhaps most corrosive are the ethical tensions participants described regarding the substitution of state responsibilities. When an NGO clinic becomes the de facto primary care provider for a transit population, it relieves the state of pressure to fulfill its own obligations, and it does so without the mandate, resources, or accountability of a public health system. Workers described the discomfort of propping up a parallel structure they know should not need to exist.

What emerges as the decisive variable separating effective support from failure is trust. The interviewees emphasized that collaboration between civil society organizations, healthcare providers, public authorities, local communities, and people on the move themselves is essential for healthcare to reach those who need it. Trust operates at every interface: a hospital that trusts an NGO’s referral accepts its patients; a local community that trusts a organization tolerates its presence; a person in transit who trusts a cultural mediator discloses symptoms that would otherwise remain hidden. Where these relationships exist, the machinery of care functions despite the structural obstacles. Where they do not, even well-funded interventions stall.

The technical significance of the study lies in its transnational scope and its grounding in the operational perspective of frontline staff rather than in policy documents or patient surveys alone. By sampling across eleven countries and across organizational scales, from small local groups to international humanitarian agencies, the researchers captured the heterogeneity of the route rather than a single national snapshot. Qualitative content analysis allowed them to move from individual anecdotes to system-level categories, showing how the same structural forces, fragmented governance, limited health system capacity, discrimination, and legal exclusion, reproduce themselves at every point along the corridor. The consistency of these themes across such different political contexts is itself a finding: the barriers to healthcare for people on the move are not local anomalies but features of the European migration architecture.

The authors’ conclusions point toward a specific reform agenda rather than a vague call for improvement. Strengthening trust-based collaboration, they argue, must go hand in hand with preserving the independence of civil society organizations and maintaining state accountability for healthcare provision. In other words, the goal is not to formalize the substitution of NGOs for the state but to use their mediating capacity to pull states back into their proper role. As migration pressures persist and the Balkan Route continues to shift with border politics, the study suggests that the health of people in transit will depend less on any single clinic or program than on whether the fragile web of trust connecting volunteers, doctors, officials, and migrants can be strengthened before it frays. For now, along the forests and border towns of southeastern Europe, it is civil society that keeps the promise of healthcare alive, one mediated referral at a time.

Subject of Research: Civil society organizations' roles and obstacles in providing healthcare access to people on the move along the Balkan migration route

Article Title: Health support for people on the move: a qualitative exploration of civil society organizations’ roles and obstacles along the Balkan route

Article References: Link, F., Öcek, Z., Veizis, A., & Coenen, M. (2026). Health support for people on the move: a qualitative exploration of civil society organizations’ roles and obstacles along the Balkan route. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-03048-x

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03048-x

Keywords: Balkan Route, migration health, civil society organizations, healthcare access, qualitative research, refugees, migrants, health equity, humanitarian aid, public health, Europe, health systems