Short-term aid or long-term gains? Harnessing Sudan's humanitarian response for the resilience of its health system

The Sudan 2023 Humanitarian Response Plan was revised in May, 2023, due to the escalating violence in the country. This revision increased the scale of assistance and protection activities and suspended the funding allocated for access to livelihood, access to basic services, and for the implementation of resilience solutions. We call to rethink Sudan's current humanitarian response through a pro-resilience and people-centred approach. A pro-resilience approach prioritises investments in national systems and institutions capable of delivering aid and anticipates, prevents, mitigates, and manages imminent and simultaneous shocks. A people-centred humanitarian response involves meaningful engagement of communities and collaborations with civil society organisations, which continue to be the key responders to the ongoing conflict in Sudan. Finally, we propose approaches to effectively operationalise health system resilience to enhance immediate and long-term health outcomes.

COVID-19 vaccine coverage, determinants and inequity amongst refugees and migrants in Pakistan: a cross-sectional study

OBJECTIVE

Migrants and refugees are at a disadvantage in accessing basic necessities. The objective of this study is to assess the inequity in access, needs and determinants of COVID-19 vaccination among refugees and migrant populations in Pakistan.

DESIGN

We conducted a mixed-method study comprising a cross-sectional survey and a qualitative study. In this paper, we will only report the findings from the cross-sectional survey.

SETTING

This survey was conducted in different cities of Pakistan including Quetta, Karachi and Hyderabad.

PARTICIPANTS

A total of 570 participants were surveyed including refugees and migrants, both in regular and irregular situations.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome of the study was to estimate the proportion of refugees and migrants, both in regular and irregular situations vaccinated against COVID-19 and assess the inequity. The χ2 test and Fisher's exact test were used to determine the significant differences in proportions between refugees and migrants and between regions.

RESULTS

The survey showed that only 26.9% of the refugee and migrant population were tested for COVID-19, 4.56% contracted coronavirus, and 3.85% were hospitalised due to COVID-19. About 66% of the refugees and migrants were fully vaccinated including those who received the single-dose vaccine or received all two doses, and 17.6% were partially vaccinated. Despite vaccination campaigns by the government, 14.4% of the refugee and migrant population remained unvaccinated mostly because of vaccines not being offered, distant vaccination sites, limited access, unavailability of COVID-19 vaccine or due to a difficult registration process. Vaccination rates varied across provinces, genders and migrant populations due to misconceptions, and several social, cultural and geographical barriers.

CONCLUSION

This study highlights the COVID-19 vaccine coverage, access and inequity faced by refugees and migrants during the pandemic. It suggests early prioritisation of policies inclusive of all refugees and migrants and the provision of identification documents to ease access to basic necessities.

Have attacks on healthcare become the new normal? a public health call to action for armed conflicts before it is too late

The scale of attacks on healthcare has become more visible and its impact greater in recent armed conflicts in Ukraine, Sudan and Myanmar. In these conflicts, combatants systematically target health facilities and ambulances. We need to ensure that attacks on healthcare do not become the new norm amongst governmental troops and non-State armed groups. There is limited evidence about why and how attacks on healthcare have become "normal" practice amongst many combatants, despite the likely tactical and strategic costs to themselves. We are convinced that the problem now needs to be tackled like any other public health issue by assessing: the scale of the problem; who is the most at risk; identifying risk factors; developing new interventions to prevent the risks or address the issue; and evaluating the effectiveness of these interventions.

Resilience in childhood vaccination: analysing delivery system responses to shocks in Lebanon

INTRODUCTION

Despite rapidly growing academic and policy interest in health system resilience, the empirical literature on this topic remains small and focused on macrolevel effects arising from single shocks. To better understand health system responses to multiple shocks, we conducted an in-depth case study using qualitative system dynamics. We focused on routine childhood vaccination delivery in Lebanon in the context of at least three shocks overlapping to varying degrees in space and time: large-scale refugee arrivals from neighbouring Syria; COVID-19; and an economic crisis.

METHODS

Semistructured interviews were performed with 38 stakeholders working at different levels in the system. Interview transcripts were analysed using purposive text analysis to generate individual stakeholder causal loop diagrams (CLDs) mapping out relationships between system variables contributing to changes in coverage for routine antigens over time. These were then combined using a stepwise process to produce an aggregated CLD. The aggregated CLD was validated using a reserve set of interview transcripts.

RESULTS

Various system responses to shocks were identified, including demand promotion measures such as scaling-up community engagement activities and policy changes to reduce the cost of vaccination to service users, and supply side responses including donor funding mobilisation, diversification of service delivery models and cold chain strengthening. Some systemic changes were introduced-particularly in response to refugee arrivals-including task-shifting to nurse-led vaccine administration. Potentially transformative change was seen in the integration of private sector clinics to support vaccination delivery and depended on both demand side and supply side changes. Some resilience-promoting measures introduced following earlier shocks paradoxically increased vulnerability to later ones.

CONCLUSION

Flexibility in financing and human resource allocation appear key for system resilience regardless of the shock. System dynamics offers a promising method for ex ante modelling of ostensibly resilience-strengthening interventions under different shock scenarios, to identify-and safeguard against-unintended consequences.

Destruction, disruption and disaster: Sudan's health system amidst armed conflict

The ongoing armed conflict in Sudan has resulted in a deepening humanitarian crisis with significant implications for the country's health system, threatening its collapse. This article examines the destruction, disruption, and disastrous consequences inflicted upon Sudan's health system. The conflict has led to the severe compromise of healthcare facilities, with only one-third of hospitals in conflict zones operational. Artillery attacks, forced militarization, power outages, and shortages of medical supplies and personnel have further crippled the health system. The exodus of health workers and escalating violence have exacerbated the crisis. Disrupted service delivery has resulted in the interruption of essential health services, including obstetric care, emergency services, and dialysis. Financial losses to the health system are estimated at $700 million, impacting an already underfunded sector. We identify that in addition to restoration of peace and mobilization of urgent aid, immediate prioritization of the reconstruction of the health system is crucial to mitigate the long-term consequences of the war. Rebuilding a resilient health system is sine qua non for Sudan's progress towards universal health.

Lessons from the development process of the Afghanistan integrated package of essential health services

In 2017, in the middle of the armed conflict with the Taliban, the Ministry of Public Health decided that the Afghan health system needed a well-defined priority package of health services taking into account the increasing burden of non-communicable diseases and injuries and benefiting from the latest evidence published by DCP3. This leads to a 2-year process involving data analysis, modelling and national consultations, which produce this Integrated Package of Essential health Services (IPEHS). The IPEHS was finalised just before the takeover by the Taliban and could not be implemented. The Afghanistan experience has highlighted the need to address not only the content of a more comprehensive benefit package, but also its implementation and financing. The IPEHS could be used as a basis to help professionals and the new authorities to define their priorities.

Health system resilience: a critical review and reconceptualisation

This Viewpoint brings together insights from health system experts working in a range of settings. Our focus is on examining the state of the resilience field, including current thinking on definitions, conceptualisation, critiques, measurement, and capabilities. We highlight the analytical value of resilience, but also its risks, which include neglect of equity and of who is bearing the costs of resilience strategies. Resilience depends crucially on relationships between system actors and components, and-as amply shown during the COVID-19 pandemic-relationships with wider systems (eg, economic, political, and global governance structures). Resilience is therefore connected to power imbalances, which need to be addressed to enact the transformative strategies that are important in dealing with more persistent shocks and stressors, such as climate change. We discourage the framing of resilience as an outcome that can be measured; instead, we see it emerge from systemic resources and interactions, which have effects that can be measured. We propose a more complex categorisation of shocks than the common binary one of acute versus chronic, and outline some of the implications of this for resilience strategies. We encourage a shift in thinking from capacities towards capabilities-what actors could do in future with the necessary transformative strategies, which will need to encompass global, national, and local change. Finally, we highlight lessons emerging in relation to preparing for the next crisis, particularly in clarifying roles and avoiding fragmented governance.

Monitoring and evaluating the implementation of essential packages of health services

Essential packages of health services (EPHS) are a critical tool for achieving universal health coverage, especially in low-income and lower middle-income countries. However, there is a lack of guidance and standards for monitoring and evaluation (M&E) of EPHS implementation. This paper is the final in a series of papers reviewing experiences using evidence from the Disease Control Priorities, third edition publications in EPHS reforms in seven countries. We assess current approaches to EPHS M&E, including case studies of M&E approaches in Ethiopia and Pakistan. We propose a step-by-step process for developing a national EPHS M&E framework. Such a framework would start with a theory of change that links to the specific health system reforms the EPHS is trying to accomplish, including explicit statements about the ‘what’ and ‘for whom’ of M&E efforts. Monitoring frameworks need to consider the additional demands that could be placed on weak and already overstretched data systems, and they must ensure that processes are put in place to act quickly on emergent implementation challenges. Evaluation frameworks could learn from the field of implementation science; for example, by adapting the Reach, Effectiveness, Adoption, Implementation and Maintenance framework to policy implementation. While each country will need to develop its own locally relevant M&E indicators, we encourage all countries to include a set of core indicators that are aligned with the Sustainable Development Goal 3 targets and indicators. Our paper concludes with a call to reprioritise M&E more generally and to use the EPHS process as an opportunity for strengthening national health information systems. We call for an international learning network on EPHS M&E to generate new evidence and exchange best practices.

Country readiness and prerequisites for successful design and transition to implementation of essential packages of health services: experience from six countries

This paper reviews the experience of six low-income and lower middle-income countries in setting their own essential packages of health services (EPHS), with the purpose of identifying the key requirements for the successful design and transition to implementation of the packages in the context of accelerating progress towards universal health coverage (UHC). The analysis is based on input from three meetings of a knowledge network established by the Disease Control Priorities 3 Country Translation Project and working groups, supplemented by a survey of participating countries.All countries endorsed the Sustainable Development Goals target 3.8 on UHC for achievement by 2030. The assessment of country experiences found that health system strengthening and mobilising and sustaining health financing are major challenges. EPHS implementation is more likely when health system gaps are addressed and when there are realistic and sustainable financing prospects. However, health system assessments were inadequate and the government planning and finance sectors were not consistently engaged in setting the EPHS in most of the countries studied. There was also a need for greater engagement with community and civil society representatives, academia and the private sector in package design. Leadership and reinforcement of technical and managerial capacity are critical in the transition from EPHS design to sustained implementation, as are strong human resources and country ownership of the process. Political commitment beyond the health sector is key, particularly commitment from parliamentarians and policymakers in the planning and finance sectors. National ownership, institutionalisation of technical and managerial capacity and reinforcing human resources are critical for success.The review concludes that four prerequisites are crucial for a successful EPHS: (1) sustained high-level commitment, (2) sustainable financing, (3) health system readiness, and (4) institutionalisation.

Decision-making processes for essential packages of health services: experience from six countries

Many countries around the world strive for universal health coverage, and an essential packages of health services (EPHS) is a central policy instrument for countries to achieve this. It defines the coverage of services that are made available, as well as the proportion of the costs that are covered from different financial schemes and who can receive these services. This paper reports on the development of an analytical framework on the decision-making process of EPHS revision, and the review of practices of six countries (Afghanistan, Ethiopia, Pakistan, Somalia, Sudan and Zanzibar-Tanzania).The analytical framework distinguishes the practical organisation, fairness and institutionalisation of decision-making processes. The review shows that countries: (1) largely follow a similar practical stepwise process but differ in their implementation of some steps, such as the choice of decision criteria; (2) promote fairness in their EPHS process by involving a range of stakeholders, which in the case of Zanzibar included patients and community members; (3) are transparent in terms of at least some of the steps of their decision-making process and (4) in terms of institutionalisation, express a high degree of political will for ongoing EPHS revision with almost all countries having a designated governing institute for EPHS revision.We advise countries to organise meaningful stakeholder involvement and foster the transparency of the decision-making process, as these are key to fairness in decision-making. We also recommend countries to take steps towards the institutionalisation of their EPHS revision process.

Auditing the quality of epidemic decision-making in Somalia: a pilot evaluation

OBJECTIVE

To assess decision-making quality through piloting an audit tool among decision-makers responding to the COVID-19 epidemic in Somalia.

DESIGN AND SETTING

We utilised a mixed-methods programme evaluation design comprising quantitative and qualitative methods. Decision-makers in Somalia piloted the audit tool generating a scorecard for decision-making in epidemic response. They also participated in key informant interviews discussing their experience with the audit process and results.

PARTICIPANTS

A total of 18 decision-makers from two humanitarian agencies responding to COVID-19 in Somalia were recruited to pilot the audit tool.

OUTCOME MEASURES AND ANALYSIS

We used thematic analysis to assess the feasibility and perceived utility of the audit tool by intended users (decision-makers). We also calculated Fleiss' Kappa to assess inter-rater agreement in the audit scorecard.

RESULTS

The audit highlighted areas of improvement in decision-making among both organisations including in the dimensions of accountability and transparency. Despite the audit occurring in a highly complex operating environment, decision-makers found the process to be feasible and of high utility. The flexibility of the audit approach allowed for organisations to adapt the audit to their needs. As a result, organisation reported a high level of acceptance of the findings.

CONCLUSION

Strengthening decision-making processes is key to realising the objectives of epidemic response. This pilot evaluation contributes towards this goal by the testing what, to our knowledge, may be the first tool designed specifically to assess quality of decision-making processes in epidemic response. The tool has proven feasible and acceptable in assessing decision-making quality in an ongoing response and has potential applicability in assessing decision-making in broader humanitarian response.

Realistic Evaluation of the Integrated Electronic Diagnosis Approach (IeDA) for the Management of Childhood Illnesses at Primary Health Facilities in Burkina Faso

BACKGROUND

In 2014, Terre des Hommes (Tdh) together with the Ministry of Health (MoH) launched the Integrated electronic Diagnosis Approach (IeDA) intervention in two regions of Burkina Faso consisting of supplying every health centre with a digital algorithm. A realistic evaluation was conducted to understand the implementation process, the mechanisms by which the IeDA intervention lead to change.

METHODS

Data collection took place between January 2016 and October 2017. Direct observation in health centres were conducted. In-depth interviews were conducted with 154 individuals including 92 healthcare workers (HCW) from health centres, 16 officers from district health authorities, 6 members of health centre management committees. In addition, 5 focus groups were organised with carers. The initial coding was based on a preliminary list of codes inspired by the middle-range theory (MRT).

RESULTS

Our results showed that the adoption of the electronic protocol depended on a multiplicity of management practices including role distribution, team work, problem solving approach, task monitoring, training, supervision, support and recognition. Such changes lead to reorganising the health team and redistributing roles before and during consultation, and positive atmosphere that included recognition of each team member, organisational commitment and sense of belonging. Conditions for such management changes to be effective included open dialog at all levels of the system, a minimum of resources to cover the support services and supervision and regular discussions focusing on solving problems faced by health centre teams.

CONCLUSION

This project reinforces the point that in a successful diffusion of IeDA, it is necessary to combine the introduction of technology with support and management mechanisms. It also important to highlight that managers' attitude plays a great place in the success of the intervention: open dialog and respect are crucial dimensions. This is aligned with the findings from other studies.

Re-evaluating Our Knowledge of Health System Resilience During COVID-19: Lessons From the First Two Years of the Pandemic

BACKGROUND

Health challenges like coronavirus disease 2019 (COVID-19) are becoming increasingly complex, transnational, and unpredictable. Studying health system responses to the COVID-19 pandemic is an opportunity to enhance our understanding of health system resilience and establish a clearer link between theoretical concepts and practical ideas on how to build resilience.

METHODS

This narrative literature review aims to address four questions using a health system resilience framework: (i) What do we understand about the dimensions of resilience? (ii) What aspects of the resilience dimensions remain uncertain? (iii) What aspects of the resilience dimensions are missing from the COVID-19 discussions? and (iv) What has COVID-19 taught us about resilience that is missing from the framework? A scientific literature database search was conducted in December 2020 and in April 2022 to identify publications that discussed health system resilience in relation to COVID-19, excluding articles on psychological and other types of resilience. A total of 63 publications were included.

RESULTS

There is good understanding around information sharing, flexibility and good leadership, learning, maintaining essential services, and the need for legitimate, interdependent systems. Decision-making, localized trust, influences on interdependence, and transformation remain uncertain. Vertical interdependence, monitoring risks beyond the health system, and consequences of changes on the system were not discussed. Teamwork, actor legitimacy, values, inclusivity, trans-sectoral resilience, and the role of the private sector are identified as lessons from COVID-19 that should be further explored for health system resilience.

CONCLUSION

Knowledge of health system resilience has continued to cohere following the pandemic. The eventual consequences of system changes and the resilience of subsystems are underexplored. Through governance, the concept of health system resilience can be linked to wider issues raised by the pandemic, like inclusivity. Our findings show the utility of resilience theory for strengthening health systems for crises and the benefit of continuing to refine existing resilience theory.

Strengthening vaccination delivery system resilience in the context of protracted humanitarian crisis: a realist-informed systematic review

Background

Childhood vaccination is among the most effective public health interventions available for the prevention of communicable disease, but coverage in many humanitarian settings is sub-optimal. This systematic review critically evaluated peer-review and grey literature evidence on the effectiveness of system-level interventions for improving vaccination coverage in protracted crises, focusing on how they work, and for whom, to better inform preparedness and response for future crises.

Methods

Realist-informed systematic review of peer-reviewed and grey literature. Keyword-structured searches were performed in MEDLINE, EMBASE and Global Health, CINAHL, the Cochrane Collaboration and WHOLIS, and grey literature searches performed through the websites of UNICEF, the Global Polio Eradication Initiative (GPEI) and Technical Network for Strengthening Immunization Services. Results were independently double-screened for inclusion on title and abstract, and full text. Data were extracted using a pre-developed template, capturing information on the operating contexts in which interventions were implemented, intervention mechanisms, and vaccination-related outcomes. Study quality was assessed using the MMAT tool. Findings were narratively synthesised.

Results

50 studies were included, most describing interventions applied in conflict or near-post conflict settings in sub-Saharan Africa, and complex humanitarian emergencies. Vaccination campaigns were the most commonly addressed adaptive mechanism (n = 17). Almost all campaigns operated using multi-modal approaches combining service delivery through multiple pathways (fixed and roving), health worker recruitment and training and community engagement to address both vaccination supply and demand. Creation of collaterals through service integration showed generally positive evidence of impact on routine vaccination uptake by bringing services closer to target populations and leveraging trust that had already been built with communities. Robust community engagement emerged as a key unifying mechanism for outcome improvement across almost all of the intervention classes, in building awareness and trust among crisis-affected populations. Some potentially transformative mechanisms for strengthening resilience in vaccination delivery were identified, but evidence for these remains limited.

Conclusion

A number of interventions to support adaptations to routine immunisation delivery in the face of protracted crisis are identifiable, as are key unifying mechanisms (multi-level community engagement) apparently irrespective of context, but evidence remains piecemeal. Adapting these approaches for local system resilience-building remains a key challenge.

Framing rehabilitation through health policy and systems research: priorities for strengthening rehabilitation

Background

Recent estimates report that 2.4 billion people with health conditions globally could benefit from rehabilitation. While the benefits of rehabilitation for individuals and society have been described in the literature, many individuals, especially in low- and middle-income countries do not have access to quality rehabilitation. As the need for rehabilitation continues to increase, it is crucial that health systems are adequately prepared to meet this need. Practice- and policy-relevant evidence plays an important role in health systems strengthening efforts. The aim of this paper is to report on the outcome of a global consultative process to advance the development of a research framework to stimulate health policy and systems research (HPSR) for rehabilitation, in order to generate evidence needed by key stakeholders.

Methods

A multi-stakeholder participatory technical consultation was convened by WHO to develop a research framework. This meeting included participants from selected Member States, rehabilitation experts, HPSR experts, public health researchers, civil society and other stakeholders from around the world. The meeting focused on introducing systems approaches to stakeholders and deliberating on priority rehabilitation issues in health systems. Participants were allocated to one of four multi-stakeholder groups with a facilitator to guide the structured technical consultations. Qualitative data in the form of written responses to guiding questions were collected during the structured technical consultations. A technical working group was then established to analyse the data and extract its emerging themes. This informed the development of the HPSR framework for rehabilitation and a selection of preliminary research questions that exemplify how the framework might be used.

Results

A total of 123 individuals participated in the multi-stakeholder technical consultations. The elaborated framework is informed by an ecological model and puts forth elements of the six WHO traditional building blocks of the health system, while emphasizing additional components pertinent to rehabilitation, such as political priority, engagement and participatory approaches, and considerations regarding demand and access. Importantly, the framework highlights the multilevel interactions needed across health systems in order to strengthen rehabilitation. Additionally, an initial set of research questions was proposed as a primer for how the framework might be used.

Conclusions

Strengthening health systems to meet the increasing need for rehabilitation will require undertaking more HPSR to inform the integration of rehabilitation into health systems globally. We anticipate that the proposed framework and the emerging research questions will support countries in their quest to increase access to rehabilitation for their populations.

Health systems resilience in practice: a scoping review to identify strategies for building resilience

Background

Research on health systems resilience has focused primarily on the theoretical development of the concept and its dimensions. There is an identified knowledge gap in the research on how to build resilience in health systems in practice and ‘what works’ in different contexts. The aim of this study is to identify practical strategies for building resilient health systems from the empirical research on health systems resilience.

Methods

A scoping review included empirical research on health systems resilience from peer-reviewed literature. The search in the electronic databases PubMed, Web of Science, Global Health was conducted during January to March 2021 for articles published in English between 2013 to February 2021. A total of 1771 articles were screened, and data was extracted from 22 articles. The articles included empirical, applied research on strategies for resilience, that observed or measured resilience during shocks or chronic stress through collection of primary data or analysis of secondary data, or if they were a review study of empirical research. A narrative summary was done by identifying action-oriented strategies, comparing them, and presenting them by main thematic areas.

Results

The results demonstrate examples of strategies used or recommended within nine identified thematic areas; use of community resources, governance and financing, leadership, surveillance, human resources, communication and collaboration, preparedness, organizational capacity and learning and finally health system strengthening.

Conclusions

The findings emphasize the importance of improved governance and financing, empowered middle-level leadership, improved surveillance systems and strengthened human resources. A re-emphasized focus on health systems strengthening with better mainstreaming of health security and international health regulations are demonstrated in the results as a crucial strategy for building resilience. A lack of strategies for recovery and lessons learnt from crises are identified as gaps for resilience in future.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08544-8.

How to do (or not to do)…Using Causal Loop Diagrams for Health System Research in Low- and Middle-Income Settings

Causal loop diagrams (CLDs) are a systems thinking method that can be used to visualize and unpack complex health system behaviour. They can be employed prospectively or retrospectively to identify the mechanisms and consequences of policies or interventions designed to strengthen health systems and inform discussion with policymakers and stakeholders on actions that may alleviate sub-optimal outcomes. Whilst the use of CLDs in health systems research has generally increased, there is still limited use in low- and middle-income settings. In addition to their suitability for evaluating complex systems, CLDs can be developed where opportunities for primary data collection may be limited (such as in humanitarian or conflict settings) and instead be formulated using secondary data, published or grey literature, health surveys/reports and policy documents. The purpose of this paper is to provide a step-by-step guide for designing a health system research study that uses CLDs as their chosen research method, with particular attention to issues of relevance to research in low- and middle-income countries (LMICs). The guidance draws on examples from the LMIC literature and authors’ own experience of using CLDs in this research area. This paper guides researchers in addressing the following four questions in the study design process; (1) What is the scope of this research? (2) What data do I need to collect or source? (3) What is my chosen method for CLD development? (4) How will I validate the CLD? In providing supporting information to readers on avenues for addressing these key design questions, authors hope to promote CLDs for wider use by health system researchers working in LMICs.

The development of Afghanistan's Integrated Package of Essential Health Services: Evidence, expertise and ethics in a priority setting process

Health systems in fragile states need to respond to shifting demographics, burden of disease and socio-economic circumstances in the revision of their health service packages. This entails making difficult decisions about what is and is not included therein, especially in resource-constrained settings offering or striving for universal health coverage. In this paper we turn the lens on the 2017-2021 development of Afghanistan's Integrated Package of Essential Health Services (IPEHS) to analyse the dynamics of the priority setting process and the role and value of evidence. Using participant observation of meetings and interviews with 25 expert participants, we conducted a qualitative study of the consultation process aimed at examining the characteristics of its technical, socio-cultural and organisational aspects, in particular data use and expert input, and how they influenced how evidence was discussed, taken up, and used (or not used) in the process. Our analysis proposes that the particular dynamics shaped by the context, information landscape and expert input shaped and operationalized knowledge sharing and its application in such a way to constitute a sort of "vernacular evidence". Our findings underline the importance of paying attention to the constellation of the priority setting processes in order to contribute to an ethical allocation of resources, particularly in contexts of resource scarcity and humanitarian need.

Conceptualising and assessing health system resilience to shocks: a cross-disciplinary view

Health systems worldwide face major challenges in anticipating, planning for and responding to shocks from infectious disease epidemics, armed conflict, climatic and other crises. Although the literature on health system resilience has grown substantially in recent years, major uncertainties remain concerning approaches to resilience conceptualisation and measurement. This narrative review revisits literatures from a range of fields outside health to identify lessons relevant to health systems. Four key insights emerge. Firstly, shocks can only be understood by clarifying how, where and over what timescale they interact with a system of interest, and the dynamic effects they produce within it. Shock effects are contingent on historical path-dependencies, and on the presence of factors or system pathways (e.g. financing models, health workforce capabilities or supply chain designs) that may amplify or dampen impact in unexpected ways. Secondly, shocks often produce cascading effects across multiple scales, whereas the focus of much of the health resilience literature has been on macro-level, national systems. In reality, health systems bring together interconnected sub-systems across sectors and geographies, with different components, behaviours and sometimes even objectives – all influencing how a system responds to a shock. Thirdly, transformability is an integral feature of resilient social systems: cross-scale interactions help explain how systems can show both resilience and transformational capability at the same time. We illustrate these first three findings by extending the socioecological concept of adaptive cycles in social systems to health, using the example of maternal and child health service delivery. Finally, we argue that dynamic modelling approaches, under-utilised in research on health system resilience to date, have significant promise for identification of shock-moderating or shock-amplifying pathways, for understanding effects at multiple levels and ultimately for building resilience.

Meeting the health needs of displaced people fleeing Ukraine: Drawing on existing technical guidance and evidence

The invasion of Ukraine has unleashed a humanitarian crisis and the impact is devastating for millions displaced in Ukraine and for those fleeing the country. Receiving countries in Europe are reeling with shock and disbelief and trying at the same time to grapple with the reality of providing for a large, unplanned, unprecedented number of refugees mainly women and children on the move. Several calls for actions, comments and statements express outrage, the risks, and the impending consequences to life and health. There is a need to constantly assess the situation on the ground, identify priorities for health and provide guidance regarding how these needs could be addressed. Therefore, the Lancet Migration European Regional Hub conducted rapid interviews with key informants to identify these needs, and in collaboration with the World Health Organization Health and Migration Programme, summarized how these could be addressed. This viewpoint provides a summary of the situation in receiving countries and the technical guidance required that could be useful for providing assistance in the current refugee crisis.

How is hygiene behaviour affected by conflict and displacement? A qualitative case study in Northern Iraq

This research aimed to qualitatively explore whether the determinants of handwashing behaviour change according to the duration of displacement or the type of setting that people are displaced to. We conducted an exploratory qualitative study in three different post-conflict settings in Northern Iraq–a long-term displacement camp, a short-term displacement camp, and villages where people were returning to post the conflict. We identified 33 determinants of handwashing in these settings and, of these, 21 appeared to be altered by the conflict and displacement. Determinants of handwashing behaviour in the post-conflict period were predominantly explained by disruptions to the physical, psychological, social and economic circumstances of displaced populations. Future hygiene programmes in post-conflict displacement settings should adopt a holistic way of assessing determinants and design programmes which promote agency, build on adaptive norms, create an enabling environment and which are integrated with other aspects of humanitarian response.

How does handwashing behaviour change in response to a cholera outbreak? A qualitative case study in the Democratic Republic of the Congo

Background

Handwashing with soap has the potential to curb cholera transmission. This research explores how populations experienced and responded to the 2017 cholera outbreak in the Democratic Republic of the Congo and how this affected their handwashing behaviour.

Methods

Cholera cases were identified through local cholera treatment centre records. Comparison individuals were recruited from the same neighbourhoods by identifying households with no recent confirmed or suspected cholera cases. Multiple qualitative methods were employed to understand hand hygiene practices and their determinants, including unstructured observations, interviews and focus group discussions. The data collection tools and analysis were informed by the Behaviour Centred Design Framework. Comparisons were made between the experiences and practices of people from case households and participants from comparison households.

Results

Cholera was well understood by the population and viewed as a persistent and common health challenge. Handwashing with soap was generally observed to be rare during the outbreak despite self-reported increases in behaviour. Across case and comparison groups, individuals were unable to prioritise handwashing due to competing food-scarcity and livelihood challenges and there was little in the physical or social environments to cue handwashing or make it a convenient, rewarding or desirable to practice. The ability of people from case households to practice handwashing was further constrained by their exposure to cholera which in addition to illness, caused profound non-health impacts to household income, productivity, social status, and their sense of control.

Conclusions

Even though cholera outbreaks can cause disruptions to many determinants of behaviour, these shifts do not automatically facilitate an increase in preventative behaviours like handwashing with soap. Hygiene programmes targeting outbreaks within complex crises could be strengthened by acknowledging the emic experiences of the disease and adopting sustainable solutions which build upon local disease coping mechanisms.

Evaluating COVID-19 decision-making in a humanitarian setting: The case study of Somalia

The global COVID-19 pandemic is unprecedented in its scope and impact. While a great deal of research has been directed towards the response in high-income countries, relatively little is known about the way in which decision-makers in low-income and crisis-affected countries have contended with the epidemic. Through use of an a priori decision framework, we aimed to evaluate the process of policy and operational decision-making in relation to the COVID-19 response in Somalia, a chronically fragile country, focusing particularly on the use of information and the role of transparency. We undertook a desk review, observed a number of key decision-making fora and conducted a series of key informant and focus group discussions with a range of decision-makers including state authority, civil society, humanitarian and development actors. We found that nearly all actors struggled to make sense of the scale of the epidemic and form an appropriate response. Decisions made during the early months had a large impact on the course of the epidemic response. Decision-makers relied heavily on international norms and were constrained by a number of factors within the political environment including resource limitations, political contestation and low population adherence to response measures. Important aspects of the response suffered from a transparency deficit and would have benefitted from more inclusive decision-making. Development of decision support tools appropriate for crisis-affected settings that explicitly deal with individual and environmental decision factors could lead to more effective and timely epidemic response.

Feasibility, acceptability, and effectiveness of non-pharmaceutical interventions against infectious diseases among crisis-affected populations: a scoping review

Background

Non-pharmaceutical interventions (NPIs) are a crucial suite of measures to prevent and control infectious disease outbreaks. Despite being particularly important for crisis-affected populations and those living in informal settlements, who typically reside in overcrowded and resource limited settings with inadequate access to healthcare, guidance on NPI implementation rarely takes the specific needs of such populations into account. We therefore conducted a systematic scoping review of the published evidence to describe the landscape of research and identify evidence gaps concerning the acceptability, feasibility, and effectiveness of NPIs among crisis-affected populations and informal settlements.

Methods

We systematically reviewed peer-reviewed articles published between 1970 and 2020 to collate available evidence on the feasibility, acceptability, and effectiveness of NPIs in crisis-affected populations and informal settlements. We performed quality assessments of each study using a standardised questionnaire. We analysed the data to produce descriptive summaries according to a number of categories: date of publication; geographical region of intervention; typology of crisis, shelter, modes of transmission, NPI, research design; study design; and study quality.

Results

Our review included 158 studies published in 85 peer-reviewed articles. Most research used low quality study designs. The acceptability, feasibility, and effectiveness of NPIs was highly context dependent. In general, simple and cost-effective interventions such as community-level environmental cleaning and provision of water, sanitation and hygiene services, and distribution of items for personal protection such as insecticide-treated nets, were both highly feasible and acceptable. Logistical, financial, and human resource constraints affected both the implementation and sustainability of measures. Community engagement emerged as a strong factor contributing to the effectiveness of NPIs. Conversely, measures that involve potential restriction on personal liberty such as case isolation and patient care and burial restrictions were found to be less acceptable, despite apparent effectiveness.

Conclusions

Overall, the evidence base was variable, with substantial knowledge gaps which varied between settings and pathogens. Based on the current landscape, robust evidence-based guidance is not possible, and a research agenda is urgently required that focusses on these specific vulnerable populations. Although implementation of NPIs presents unique practical challenges in these settings, it is critical that such an agenda is put in place, and that the lessons learned from historical and present experiences are documented to build a firm evidence base.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-022-00935-7.

Impact of conditional and unconditional cash transfers on health outcomes and use of health services in humanitarian settings: a mixed-methods systematic review

BACKGROUND

Cash transfers, payments provided by formal or informal institutions to recipients, are increasingly used in emergencies. While increasing autonomy and being supportive of local economies, cash transfers are a cost-effective method in some settings to cover basic needs and extend benefits of limited humanitarian aid budgets. Yet, the extent to which cash transfers impact health in humanitarian settings remains largely unexplored. This systematic review evaluates the evidence on the effect of cash transfers on health outcomes and health service utilisation in humanitarian contexts.

METHODS

Studies eligible for inclusion were peer reviewed (quantitative,qualitative and mixed-methods). Nine databases (PubMed, EMBAS, Medline, CINAHL, Global Health, Scopus, Web of Science Core Collection, SciELO and LiLACS) were searched without language and without a lower bound time restriction through 24 February 2021. The search was updated to include articles published through 8 December 2021. Data were extracted using a piloted extraction tool and quality was assessed using The Joanna Briggs Critical Appraisal Tool. Due to heterogeneity in study designs and outcomes, results were synthesised narratively and no meta-analysis was performed.

RESULTS

30 673 records were identified. After removing duplicates, 17 715 were double screened by abstract and title, and 201 in full text. Twenty-three articles from 16 countries were included reporting on nutrition outcomes, psychosocial and mental health, general/subjective health and well-being, acute illness (eg, diarrhoea, respiratory infection), diabetes control (eg, blood glucose self-monitoring, haemoglobin A1C levels) and gender-based violence. Nineteen studies reported some positive impacts on various health outcomes and use of health services, 11 reported no statistically significant impact on outcomes assessed and 4 reported potential negative impacts on health outcomes.

DISCUSSION

Although there is evidence to suggest a positive relationship between cash transfers and health outcomes in humanitarian settings, high-quality empirical evidence, that is methodologically robust, investigates a range of humanitarian settings and is conducted over longer time periods is needed. This should consider factors influencing programme implementation and the differential impact of cash transfers designed to improve health versus multipurpose cash transfers.

PROSPERO REGISTRATION NUMBER

CRD42021237275.

Use of COVID-19 evidence in humanitarian settings: the need for dynamic guidance adapted to changing humanitarian crisis contexts

BACKGROUND

For humanitarian organisations to respond effectively to complex crises, they require access to up-to-date evidence-based guidance. The COVID-19 crisis has highlighted the importance of updating global guidance to context-specific and evolving needs in humanitarian settings. Our study aimed to understand the use of evidence-based guidance in humanitarian responses during COVID-19. Primary data collected during the rapidly evolving pandemic sheds new light on evidence-use processes in humanitarian response.

METHODS

We collected and analysed COVID-19 guidance documents, and conducted semi-structured interviews remotely with a variety of humanitarian organisations responding and adapting to the COVID-19 pandemic. We used the COVID-19 Humanitarian platform, a website established by three universities in March 2020, to solicit, collate and document these experiences and knowledge.

RESULTS

We analysed 131 guidance documents and conducted 80 interviews with humanitarian organisations, generating 61 published field experiences. Although COVID-19 guidance was quickly developed and disseminated in the initial phases of the crisis (from January to May 2020), updates or ongoing revision of the guidance has been limited. Interviews conducted between April and September 2020 showed that humanitarian organisations have responded to COVID-19 in innovative and context-specific ways, but have often had to adapt existing guidance to inform their operations in complex humanitarian settings.

CONCLUSIONS

Experiences from the field indicate that humanitarian organisations consulted guidance to respond and adapt to COVID-19, but whether referring to available guidance indicates evidence use depends on its accessibility, coherence, contextual relevance and trustworthiness. Feedback loops through online platforms like the COVID-19 Humanitarian platform that relay details of these evidence-use processes to global guidance setters could improve future humanitarian response.

Reducing the impact of the coronavirus on disadvantaged migrants and ethnic minorities

Studies from several countries have shown that the COVID-19 pandemic has disproportionally affected migrants. Many have numerous risk factors making them vulnerable to infection and poor clinical outcome. Policies to mitigate this effect need to take into account public health principles of inclusion, universal health coverage and the right to health. In addition, the migrant health agenda has been compromised by the suspension of asylum processes and resettlement, border closures, increased deportations and lockdown of camps and excessively restrictive public health measures. International organizations including the World Health Organization and the World Bank have recommended measures to actively counter racism, xenophobia and discrimination by systemically including migrants in the COVID-19 pandemic response. Such recommendations include issuing additional support, targeted communication and reducing barriers to accessing health services and information. Some countries have had specific policies and outreach to migrant groups, including facilitating vaccination. Measures and policies targeting migrants should be evaluated, and good models disseminated widely.

Understanding the health needs of internally displaced persons: A scoping review

We seek to strengthen understanding of the health needs of internally displaced persons (IDPs) in contexts of conflict or violence. Based upon a scoping review, our paper identified limited evidence on IDP health, but nevertheless indicates that IDPs tend to experience worse health outcomes than other conflict-affected populations across a range of health issues; and this is due to the particularly vulnerable situation of IDPs relative to these other populations, including reduced access to health services. Further research is required to better understand these needs and the interventions that can most effectively address these needs.

When Refugees Care for Refugees in Lebanon: Providing Contextually Appropriate Care from the Ground Up

Despite a surge in initiatives to integrate foreign-trained physicians into local health systems and a drive to learn from localised humanitarian initiatives under the COVID-19 pandemic, we still know little about the on-the-ground strategies developed by refugee doctors to meet the needs of refugee patients. In Lebanon, displaced Syrian health professionals have mounted informal, local responses to care for displaced Syrian patients. Drawing on ethnographic work shadowing these healthcare providers across their medical and non-medical activities, we explore how clinical encounters characterised by shared histories of displacement can inform humanitarian medicine. Our findings shed light on the creation of breathing spaces in crises. In particular, our study reveals how displaced healthcare workers cope with uncertainty, documents how displaced healthcare workers expand the category of ‘appropriate care’ to take into account the economic and safety challenges faced by patients, and locates the category of ‘informality’ within a complex landscape of myriad actors in Lebanon. This research article shows that refugee-to-refugee healthcare is not restricted to improvised clinical encounters between ‘frontliners’ and ‘victims of war’. Rather, it is proactively enacted from the ground up to foster appropriate care relationships in the midst of violent, repeated, and protracted disruptions to systems of care.

Sanctioned countries in the global COVID-19 vaccination campaign: the forgotten 70

COVAX, the global initiative on COVID-19 vaccines, has set the target of achieving a COVID-19 vaccination coverage of up to 30% of the population of 135 countries in 2 years. Here, we argue that COVAX should anticipate important and unforeseen challenges with regard to sanctioned countries. For those, COVAX needs to provide a higher percentage of the vaccines. Otherwise, the problems of vaccination will linger, risking the advent of new variants and preventing an effective global response in reigning the pandemic under control.

A health systems resilience research agenda: moving from concept to practice

Health system resilience, known as the ability for health systems to absorb, adapt or transform to maintain essential functions when stressed or shocked, has quickly gained popularity following shocks like COVID-19. The concept is relatively new in health policy and systems research and the existing research remains mostly theoretical. Research to date has viewed resilience as an outcome that can be measured through performance outcomes, as an ability of complex adaptive systems that is derived from dynamic behaviour and interactions, or as both. However, there is little congruence on the theory and the existing frameworks have not been widely used, which as diluted the research applications for health system resilience. A global group of health system researchers were convened in March 2021 to discuss and identify priorities for health system resilience research and implementation based on lessons from COVID-19 and other health emergencies. Five research priority areas were identified: (1) measuring and managing systems dynamic performance, (2) the linkages between societal resilience and health system resilience, (3) the effect of governance on the capacity for resilience, (4) creating legitimacy and (5) the influence of the private sector on health system resilience. A key to filling these research gaps will be longitudinal and comparative case studies that use cocreation and coproduction approaches that go beyond researchers to include policy-makers, practitioners and the public.

Building a multisystemic understanding of societal resilience to the COVID-19 pandemic

The current global systemic crisis reveals how globalised societies are unprepared to face a pandemic. Beyond the dramatic loss of human life, the COVID-19 pandemic has triggered widespread disturbances in health, social, economic, environmental and governance systems in many countries across the world. Resilience describes the capacities of natural and human systems to prevent, react to and recover from shocks. Societal resilience to the current COVID-19 pandemic relates to the ability of societies in maintaining their core functions while minimising the impact of the pandemic and other societal effects. Drawing on the emerging evidence about resilience in health, social, economic, environmental and governance systems, this paper delineates a multisystemic understanding of societal resilience to COVID-19. Such an understanding provides the foundation for an integrated approach to build societal resilience to current and future pandemics.

Models of care for patients with hypertension and diabetes in humanitarian crises: a systematic review

Care for non-communicable diseases, including hypertension and diabetes (HTN/DM), is recognized as a growing challenge in humanitarian crises, particularly in low- and middle-income countries (LMICs) where most crises occur. There is little evidence to support humanitarian actors and governments in designing efficient, effective, and context-adapted models of care for HTN/DM in such settings. This article aimed to systematically review the evidence on models of care targeting people with HTN/DM affected by humanitarian crises in LMICs. A search of the MEDLINE, Embase, Global Health, Global Indexus Medicus, Web of Science, and EconLit bibliographic databases and grey literature sources was performed. Studies were selected that described models of care for HTN/DM in humanitarian crises in LMICs. We descriptively analysed and compared models of care using a conceptual framework and evaluated study quality using the Mixed Methods Appraisal Tool. We report our findings according to PRISMA guidelines. The search yielded 10 645 citations, of which 45 were eligible for this review. Quantitative methods were most commonly used (n = 34), with four qualitative, three mixed methods, and four descriptive reviews of specific care models were also included. Most studies detailed primary care facility-based services for HTN/DM, focusing on health system inputs. More limited references were made to community-based services. Health care workforce and treatment protocols were commonly described framework components, whereas few studies described patient centredness, quality of care, financing and governance, broader health policy, and sociocultural contexts. There were few programme evaluations or effectiveness studies, and only one study reported costs. Most studies were of low quality. We concluded that an increasing body of literature describing models of care for patients with HTN/DM in humanitarian crises demonstrated the development of context-adapted services but showed little evidence of impact. Our conceptual framework could be used for further research and development of NCD models of care.

Violence against healthcare in conflict: a systematic review of the literature and agenda for future research

BACKGROUND

Attacks on health care in armed conflict, including those on health workers, facilities, patients and transports, represent serious violations of human rights and international humanitarian law. Information about these incidents and their characteristics are available in myriad forms: as published research or commentary, investigative reports, and within online data collection initiatives. We review the research on attacks on health to understand what data they rely on, what subjects they cover and what gaps exist in order to develop a research agenda going forward.

METHODS AND FINDINGS

This study utilizes a systematic review of peer-reviewed to identify and understand relevant data about attacks on health in situations of conflict. We identified 1479 papers published before January 1, 2020 using systematic and hand-searching and chose 45 articles for review that matched our inclusion criteria. We extracted data on geographical and conflict foci, methodology, objectives and major themes. Among the included articles, 26 focused on assessment of evidence of attacks, 15 on analyzing their impacts, three on the legal and human rights principles and one on the methods of documentation. We analyzed article data to answer questions about where and when attacks occur and are investigated, what types of attacks occur, who is perpetrating them, and how and why they are studied. We synthesized cross-cutting themes on the impacts of these attacks, mitigation efforts, and gaps in existing data.

CONCLUSION

Recognizing limitations in the review, we find there have been comparatively few studies over the past four decades but the literature is growing. To deepen the discussions of the scope of attacks and to enable cross-context comparisons, documentation of attacks on health must be enhanced to make the data more consistent, more thorough, more accessible, include diverse perspectives, and clarify taxonomy. As the research on attacks on health expands, practical questions on how the data is utilized for advocacy, protection and accountability must be prioritized.

An Integrated eDiagnosis Approach (IeDA) versus standard IMCI for assessing and managing childhood illness in Burkina Faso: a stepped-wedge cluster randomised trial

BACKGROUND

The Integrated eDiagnosis Approach (IeDA), centred on an electronic Clinical Decision Support System (eCDSS) developed in line with national Integrated Management of Childhood Illness (IMCI) guidelines, was implemented in primary health facilities of two regions of Burkina Faso. An evaluation was performed using a stepped-wedge cluster randomised design with the aim of determining whether the IeDA intervention increased Health Care Workers' (HCW) adherence to the IMCI guidelines.

METHODS

Ten randomly selected facilities per district were visited at each step by two trained nurses: One observed under-five consultations and the second conducted a repeat consultation. The primary outcomes were: overall adherence to clinical assessment tasks; overall correct classification ignoring the severity of the classifications; and overall correct prescription according to HCWs' classifications. Statistical comparisons between trial arms were performed on cluster/step-level summaries.

RESULTS

On average, 54 and 79% of clinical assessment tasks were observed to be completed by HCWs in the control and intervention districts respectively (cluster-level mean difference = 29.9%; P-value = 0.002). The proportion of children for whom the validation nurses and the HCWs recorded the same classifications (ignoring the severity) was 73 and 79% in the control and intervention districts respectively (cluster-level mean difference = 10.1%; P-value = 0.004). The proportion of children who received correct prescriptions in accordance with HCWs' classifications were similar across arms, 78% in the control arm and 77% in the intervention arm (cluster-level mean difference = - 1.1%; P-value = 0.788).

CONCLUSION

The IeDA intervention improved substantially HCWs' adherence to IMCI's clinical assessment tasks, leading to some overall increase in correct classifications but to no overall improvement in correct prescriptions. The largest improvements tended to be observed for less common conditions. For more common conditions, HCWs in the control districts performed relatively well, thus limiting the scope to detect an overall impact.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02341469 ; First submitted August 272,014, posted January 19, 2015.

Setting research priorities for sexual, reproductive, maternal, newborn, child and adolescent health in humanitarian settings

Background

An estimated 70.8 million people are forcibly displaced worldwide, 75% of whom are women and children. Prioritizing a global research agenda to inform guidance, service delivery, access to and quality of services is essential to improve the survival and health of women, children and adolescents in humanitarian settings.

Method

A mixed-methods design was adapted from the Child Health and Nutrition Research Initiative (CHNRI) methodology to solicit priority research questions across the sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) domains in humanitarian settings. The first step (CHNRI) involved data collection and scoring of perceived priority questions, using a web-based survey over two rounds (first, to generate the questions and secondly, to score them). Over 1000 stakeholders from across the globe were approached; 177 took part in the first survey and 69 took part in the second. These research questions were prioritized by generating a research prioritization score (RPP) across four dimensions: answerability, program feasibility, public health relevance and equity. A Delphi process of 29 experts followed, where the 50 scored and prioritized CHRNI research questions were shortlisted. The top five questions from the CHNRI scored list for each SRMNCAH domain were voted on, rendering a final list per domain.

Results

A total of 280 questions were generated. Generated questions covered sexual and reproductive health (SRH) (n = 90, 32.1%), maternal health (n = 75, 26.8%), newborn health (n = 42, 15.0%), child health (n = 43, 15.4%), and non-SRH aspects of adolescent health (n = 31, 11.1%). A shortlist of the top ten prioritized questions for each domain were generated on the basis of the computed RPPs. During the Delphi process, the prioritized questions, based on the CHNRI process, were further refined. Five questions from the shortlist of each of the SRMNCAH domain were formulated, resulting in 25 priority questions across SRMNCAH. For example, one of the prioritized SRH shortlisted and prioritized research question included: “What are effective strategies to implement good quality comprehensive contraceptive services (long-acting, short-acting and EC) for women and girls in humanitarian settings?”

Conclusion

Data needs, effective intervention strategies and approaches, as well as greater efficiency and quality during delivery of care in humanitarian settings were prioritized. The findings from this research provide guidance for researchers, program implementers, as well as donor agencies on SRMNCAH research priorities in humanitarian settings. A global research agenda could save the lives of those who are at greatest risk and vulnerability as well as increase opportunities for translation and innovation for SRMNCAH in humanitarian settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00353-w.