Conditions for health system resilience in the response to the COVID-19 pandemic in Mauritania

INTRODUCTION

A country's ability to manage a crisis depends on its level of resilience. Efforts are made to clarify the concept of health system resilience, but its operationalisation remains little studied. In the present research, we described the capacity of the local healthcare system in the Islamic Republic of Mauritania, in West Africa, to cope with the COVID-19 pandemic.

METHODS

We used a single case study with two health districts as units of analysis. A context analysis, a literature review and 33 semi-structured interviews were conducted. The data were analysed using a resilience conceptual framework.

RESULTS

The analysis indicates a certain capacity to manage the crisis, but significant gaps and challenges remain. The management of many uncertainties is largely dependent on the quality of the alignment of decision-makers at district level with the national level. Local management of COVID-19 in the context of Mauritania's fragile healthcare system has been skewed to awareness-raising and a surveillance system. Three other elements appear to be particularly important in building a resilient healthcare system: leadership capacity, community dynamics and the existence of a learning culture.

CONCLUSION

The COVID-19 pandemic has put a great deal of pressure on healthcare systems. Our study has shown the relevance of an in-depth contextual analysis to better identify the enabling environment and the capacities required to develop a certain level of resilience. The translation into practice of the skills required to build a resilient healthcare system remains to be further developed.

Action research and health system strengthening: the case of the health sector support programme in Mauritania, West Africa

Background

Access to qualitative and equitable healthcare is a major challenge in Mauritania. In order to support the country’s efforts, a health sector strengthening programme was set up with participatory action research at its core. Reinforcing a health system requires a customised and comprehensive approach to face the complexity inherent to health systems. Yet, limited knowledge is available on how policies could enhance the performance of the system and how multi-stakeholder efforts could give rise to changes in health policy. We aimed to analyse the ongoing participatory action research and, more specifically, see in how far action research as an embedded research approach could contribute to strengthening health systems.

Methods

We adopted a single-case study design, based on two subunits of analysis, i.e., two selected districts. Qualitative data were collected by analysing country and programme documents, conducting 12 semi-structured interviews and performing participatory observations. Interviewees were selected based on their current position and participation in the programme. The data analysis was designed to address the objectives of the study, but evolved according to emerging insights and through triangulation and identification of emergent and/or recurrent themes along the process.

Results

An evaluation of the progress made in the two districts indicates that continuous capacity-building and empowerment efforts through a participative approach have been key elements to enhance dialogue between, and ownership of, the actors at the local health system level. However, the strong hierarchical structure of the Mauritanian health system and its low level of decentralisation constituted substantial barriers to innovation. Other constraints were sociocultural and organisational in nature. Poor work ethics due to a weak environmental support system played an important role. While aiming for an alignment between the flexible iterative approach of action research and the prevailing national linear planning process is quite challenging, effects on policy formulation and implementation were not observed. An adequate time frame, the engagement of proactive leaders, maintenance of a sustained dialogue and a pragmatic, flexible approach could further facilitate the process of change.

Conclusion

Our study showcases that the action research approach used in Mauritania can usher local and national actors towards change within the health system strengthening programme when certain conditions are met. An inclusive, participatory approach generates dynamics of engagement that can facilitate ownership and strengthen capacity. Continuous evaluation is needed to measure how these processes can further develop and presume a possible effect at policy level.

Migrants’ social determinants of health: living conditions, violence exposure, access to healthcare

Background

WHO and some other authors consider migration as a social determinant of health. MdM identifies it being composed of different factors such as living conditions, exposure to violence and access to healthcare.

Methods

We analysed a comparative quali-quantitative survey in 4 locations, in Niger, Morocco and Tunisia, based on questionnaires and focus groups, with basic statistical tests and a complementary qualitative analysis.

Results

461 migrants were interviewed, 59% women, median age 28 year, 98.5% sub-Saharan African origin, 63% with no legal documents.

46% travelled for more than 6 months, 47% stayed in the country of interview more than 12 months, even if most of them wanted to go on. 83.8% faced violence during their life, 61% during migration.

58% of violence was psychological in nature, confiscation of money and/or documents, or violence by police or army. The types of violence’s vary according to gender and localization. Only 39% did not face barriers to access to healthcare. The 3 main barriers are financial, lack of understanding of the health system and discrimination. 50% of migrants considered their health status as medium, bad or very bad, what is insufficient for such a young population.

Conclusions

Some events are always part of migration: long duration, violence, barriers to access healthcare, with an overall negative impact on health. Recommendations: Authorities should address the structural factors of violence against migrants. The health needs of migrants should be taken into account in policies at all levels. Health services should always consider migrants’ needs: determinants of health, mental health, consequences of violence and difficult access to healthcare. Research needs: What are the specific social determinants of health in migration?

Key messages

The health status of migrants seems to get worse along the road. Some migration events should be considered as social determinants of health and addressed by health services.