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Health Care Workers in Conflict and Post-Conflict Settings: Systematic Mapping of the Evidence
PLOS ONE
... In addition to the direct consequence, conflict also indirectly deteriorates the health of the population by causing breakdown of the health system, shortage of medical supplies and displacement of healthcare workers, as well as disruption of food and clean water supplies. Furthermore, conflict-related insecurity and a lack of free movement also reduce the provision and utilization of health services, with patients hesitating to seek healthcare due to concerns about their safety or potential targeting when traveling to healthcare facilities [12][13][14]. ...
... This was exemplified by a high number of both violent related and disease related morbidities and mortality in the community reported by the participant [25]. [12] [26][27][28]These can be understood as part of a broader pattern impact of conflict where direct killing of civilians by armed personals, artilleries and armed drones' shelling become the distinguishing feature of several recent armed conflicts [12]. ...
... This was exemplified by a high number of both violent related and disease related morbidities and mortality in the community reported by the participant [25]. [12] [26][27][28]These can be understood as part of a broader pattern impact of conflict where direct killing of civilians by armed personals, artilleries and armed drones' shelling become the distinguishing feature of several recent armed conflicts [12]. ...
Background
Conflict is a complicated topic with a multidimensional consequences for community health. Its effects have a broad pattern, starting from direct war-related morbidity and mortality caused by bullets and bombs to indirect consequences due to the interruption of the delivery of preventive and curative health services. This study aimed to explore the health consequences of the northern Ethiopian conflict in the North Wollo zone, northeast Ethiopia, in 2022.
Methods
This descriptive qualitative study was conducted from May to June 2022 on six conflict-affected Woredas in the north Wollo zone. A total of 100 purposively selected participants, which included patients, pregnant women, elders, community and religious leaders, and health professionals, were interviewed using IDI and FGD. The data was entered, coded, and analyzed using Open Code version 4.03. Thematic analysis approach employed to conduct the interpretation. Data was presented using descriptive statistics in the form of texts and tables.
Results
The findings indicate that the conflict has caused a profound consequence on population health. It has resulted in a wide range of direct and indirect consequences, ranging from war-related casualties, famine, and disruptions of supply chains and forced displacement to instances of violence and rape associated with insecurity. The conflict also caused a breakdown in the health system by causing distraction of health infrastructure, fleeing of health workers and shortage of medication, together with insecurity and lack of transportation, which greatly affected the provision and utilization of health services. Additionally, the conflict has resulted in long-term consequences, such as the destruction of health facilities, interruption of immunization services, posttraumatic stress disorders, and lifelong disabilities. The coping strategies utilized were using available traditional medicines and home remedies, obtaining medications from conflict-unaffected areas, and implementing home-to-home healthcare services using available supplies.
Conclusion
The Northern Ethiopian conflict has an impact on community health both directly and indirectly through conflict-related causalities and the breakdown of the health system and health-supporting structures. Therefore, this study recommends immediate rehabilitation interventions for damaged health infrastructure and affected individuals.
... The results resonate with some common characteristics scholars have pointed out for other post-conflict settings, including the ample exodus of healthcare workers [28], the damaged and/or suboptimal infrastructures and fragmented health service delivery [29], emergency care subject to disruptions in transportation because damaged roads hamper dispatch of ambulances [29], poor coordination and multiplicity of health actors with blurred boundaries between humanitarian relief and health development interventions [30]. Access to care is particularly challenging in these contexts, yet it is a prerequisite for UHC. ...
... Access to care is particularly challenging in these contexts, yet it is a prerequisite for UHC. Post-conflict settings provide an opportunity to develop effective evidence-based interventions and policies to rebuild health systems [28]. Investing in primary care by strengthening the role of community health workers could lead to improved access to care, as they may leverage their physical proximity with community members [29]. ...
Background
The Taliban takeover in August 2021 ended a decades-long conflict in Afghanistan. Yet, along with improved security, there have been collateral changes, such as the exacerbation of the economic crisis and brain drain. Although these changes have altered the lives of Afghans in many ways, it is unclear whether they have affected access to care. This study aimed to analyse Afghans’ access to care and how this access has changed after August 2021.
Methods
The study relied on the collaboration with the non-governmental organisation EMERGENCY, running a network of three hospitals and 41 First Aid Posts in 10 Afghan provinces. A 67-item questionnaire about access to care changes after August 2021 was developed and disseminated at EMERGENCY facilities. Ordinal logistic regression was used to evaluate whether access to care changes were associated with participants’ characteristics.
Results
In total, 1807 valid responses were returned. Most respondents (54.34%) reported improved security when visiting healthcare facilities, while the ability to reach facilities has remained stable for the majority of them (50.28%). Care is less affordable for the majority of respondents (45.82%). Female respondents, those who are unmarried and not engaged, and patients in the Panjshir province were less likely to perceive improvements in access to care.
Conclusions
Findings outline which dimensions of access to care need resource allocation. The inability to pay for care is the most relevant barrier to access care after August 2021 and must therefore be prioritised. Women and people from the Panjshir province may require ad hoc interventions to improve their access to care.
... Despite the paucity of research documenting the impact of conflict on healthcare quality, including receiving the required components of care [36], there is a general expectation that healthcare quality will be less optimal in countries affected by conflict due to weak health systems [37][38][39][40]. The findings of the present study align with this notion. ...
... Additionally, fragility is a fluid concept that can be difficult to measure and most literature framed fragility in relation to conflict, violence or security-related challenges as a main driver or stressor [6]. Therefore, this study only focused on sub-national conflict/organized violence as one aspect of fragility given the granularity of UCDP data and the potential impact of conflict on health systems and quality of care [37][38][39][40]. Future studies may consider analyzing disparities in relation to other fragility indices. ...
Background
Recent global reports highlighted the importance of addressing the quality of care in all settings including fragile and conflict-affected situations (FCS), as a central strategy for the attainment of sustainable development goals and universal health coverage. Increased mortality burden in FCS reflects the inability to provide routine services of good quality. There is also paucity of research documenting the impact of conflict on the quality of care within fragile states including disparities in service delivery. This study addresses this measurement gap by examining disparities in the quality of primary healthcare services in four conflict-affected fragile states using proxy indicators.
Methods
A secondary analysis of publicly available data sources was performed in four conflict-affected fragile states: Cameroon, the Democratic Republic of Congo, Mali, and Nigeria. Two main databases were utilized: the Demographic Health Survey and the Uppsala Conflict Data Program for information on components of care and conflict events, respectively. Three equity measures were computed for each country: absolute difference, concentration index, and coefficients of mixed-effects logistic regression. Each computed measure was then compared according to the intensity of organized violence events at the neighborhood level.
Results
Overall, the four studied countries had poor quality of PHC services, with considerable subnational variation in the quality index. Poor quality of PHC services was not only limited to neighborhoods where medium or high intensity conflict was recorded but was also likely to be observed in neighborhoods with no or low intensity conflict. Both economic and educational disparities were observed in individual quality components in both categories of conflict intensity.
Conclusion
Each of the four conflict-affected countries had an overall poor quality of PHC services with both economic and educational disparities in the individual components of the quality index, regardless of conflict intensity. Multi-sectoral efforts are needed to improve the quality of care and disparities in these settings, without a limited focus on sub-national areas where medium or high intensity conflict is recorded.
... There are challenges to performing this research in conflict settings including security concerns, ethical considerations, potential for bias, lack of funding and resources, lack of a collaborative research environment, and limited research applications. 58,64 The need for further studies for targeted enabling interventions is a prime area for future research efforts but must be implemented with due diligence, being mindful of these challenges in order to determine which interventions are most helpful and effective for the continuation and completion of health professional training taking into consideration the country context and educational system in place. ...
... The conduct of war also changed from face-to-face combat with clearly defined enemies in the early 20th century, to postmodern era conflicts arising from increased globalisation and interdependence with proxy wars being fought using non-state combatants (e.g., terrorists and insurgents). In addition, these postmodern conflicts featured mechanisation and impersonalisation of weapons (e.g., drones and intercontinental missiles) and the deliberate targeting of health care systems and medical personnel with loss of medical neutrality.58 This evolution in medical education and warfare was reflected in differences found in our study regarding the frequency and characteristics of barriers and targeted intervention themes between the modern and postmodern eras. ...
Purpose:
War negatively impacts health professional education when healthcare is needed most. The aims of this scoping review are to describe the scope of barriers and targeted interventions to maintaining health professional education during war and summarize the research.
Methods:
We conducted a scoping review between June 20, 2018, and August 2, 2018. The search was restricted to English publications including peer reviewed publications without date ranges involving war and health professional education (medical school, residency training, and nursing school), with interventions described to maintain educational activities. Two independent reviewers completed inclusion determinations and data abstraction. Thematic coding was performed using an inductive approach allowing dominant themes to emerge. The frequency of barrier and intervention themes and illustrative quotes were extracted. Articles were divided into modern/postmodern categories to permit temporal and historical analysis of thematic differences.
Results:
Screening identified 3,271 articles, with 56 studies meeting inclusion criteria. Publication dates ranged from 1914-2018 with 16 unique wars involving 17 countries. The studies concerned medical students (61.4%), residents (28.6%) and nursing students (10%). Half involved the modern era and half the postmodern era. Thematic coding identified 5 categories of barriers and targeted interventions in maintaining health professions education during war: curriculum, personnel, wellness, resources, and oversight, with most involving curriculum and personnel. The distribution of themes among various health professional trainees was similar. The frequency and specifics changed temporally reflecting innovations in medical education and war, with increased focus on oversight and personnel during the modern era and greater emphasis on wellness, curriculum, and resources during the postmodern era.
Conclusions:
There are overarching categories of barriers and targeted interventions in maintaining health professional education during war which evolve over time. These may serve as a useful framework to strategically support future research and policy efforts.
... They have also emphasized the pressing need for more research to evaluate the delivery of MNH interventions in these challenging settings [76][77][78][79]. Violence against health workers in conflict zones is a reality described by several authors [80]. When conflicts in these areas drag on, health professionals develop a variety of resilience mechanisms. ...
Background
Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country’s protracted crisis context exacerbates the problem. This political economy analysis examines the maternal and newborn health (MNH) prioritization in the DRC, focussing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu.
Methods
Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data were analysed using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender-related factors influencing MNH policy development and implementation.
Results
The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The universal health coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They reveal huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones.
Conclusions
MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel and empowerment of women in crisis areas for better MNH outcomes.
... In addition, few female MNH providers are willing to work in these areas because of the insecurity. Violence against health workers in con ict zones is a reality described by several authors (70). When con icts in these areas drag on, health professionals develop a variety of resilience mechanisms. ...
Background: Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country's protracted crisis context exacerbates the problem. This political economy analysis examines the Maternal and Newborn Health (MNH) prioritization in the DRC, focusing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu.
Methods: Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data was analysis using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender related factors influencing MNH policy development and implementation.
Results: The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The Universal Health Coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They highlight huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones.
Conclusion: MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts, and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel, and empowerment of women in crisis areas for better MNH outcomes.
... Indirectly, conflict also causes breakdown of a breakdown of the health system, shortage of medical supplies, migration, and even death of health care workers (HCWs), as well as ruptures of food and clean water supplies, which deteriorates the health of the population. Conflict-associated insecurity and a lack of free movement reduce the provision and utilization of health services [12][13][14][15]. Conflict also causes a huge spike of humanitarian crisis with many civilians become displaced and many livings in refuges. ...
Armed conflict is a complicated topic with multidimensional impact on population health. This study aimed to assess of the health consequences of the northern Ethiopian conflict, 2022. We used a mixed method study design with a retrospective cross-sectional study supplemented by a qualitative study conducted from May to June 2022. We interviewed 1806 individuals from 423 households and conducted 100 in-depth interviews and focused group discussion. We identified 224 people who self-reported cases of illness (124/1000 people) with only 48 (21%) people who fell ill visited a health institution. We also detected 27 cases of deaths (15/1000 people) during the conflict. The collapse of the health system, evacuation of health personnel, and shortage of medical supplies, and instability with a lack of transportation were consequences of the conflict. The northern Ethiopian conflict has greatly affected the community’s health through the breakdown of the health system and health-supporting structures.
... They are a crucial component of the healthcare workforce, instrumental in recovery and rebuilding efforts post-conflict, thus playing a key role in restoring healthcare systems. 42 Amidst conflicts, advanced medical students often take on critical roles, providing care to both civilians and military personnel affected by the warfare. 43 In accordance with the principles of the Geneva Convention and related protocols, it is imperative to ensure the safety of medical students and the broader medical education system during conflicts. ...
Medical education has always been a vital aspect of both health and educational systems, largely because of its significant role in enhancing health outcomes and its capacity to transform existing governance structures.1, 2Students pursuing medical education form the cornerstone of these systems globally.3Their involvement in medical education extends well beyond the improvement of patient care on an individual level. It has far-reaching impacts, influencing various societal aspects ranging from local to international spheres,2,4including policy implementation, leadership roles, and advocacy efforts.5-6Particularly during critical times,such as pandemics, medical students have played pivotal roles in promoting public health measures, combating misinformation, and enhancing vaccine acceptance.7-9Moreover, medical education and the medical field in general are fundamental to research and innovation,10,11driving advancements in medical science and technology.
... These countries consistently face challenges in achieving healthcare performance comparable to high-income countries [3,4], particularly in sub-Saharan Africa [5]. Most of these countries are experiencing various crises and emergencies (humanitarian, political and security-related in particular), which largely explain their poor health performance [6][7][8][9][10]. In the recent global context, the COVID-19 pandemic has exacerbated underperformance, with 90% of countries reporting significant disruptions to health services [5,11]. ...
Background
This study examines how leadership is provided at the operational level of a health system in a protracted crisis context. Despite advances in medical science and technology, health systems in low- and middle-income countries struggle to deliver quality care to all their citizens. The role of leadership in fostering resilience and positive transformation of a health system is established. However, there is little literature on this issue in Democratic Republic of the Congo (DRC). This study describes leadership as experienced and perceived by health managers in crisis affected health districts in Eastern DRC.
Methods
A qualitative cross-sectional study was conducted in eight rural health districts (corresponding to health zones, in DRC’s health system organization), in 2021. Data were collected through in-depth interviews and non-participatory observations. Participants were key health actors in each district. The study deductively explored six themes related to leadership, using an adapted version of the Leadership Framework conceptual approach to leadership from the United Kingdom National Health Service’s Leadership Academy. From these themes, a secondary analysis extracted emerging subthemes.
Results
The study has revealed deficiencies regarding management and organization of the health zones, internal collaboration within their management teams as well as collaboration between these teams and the health zone’s external partners. Communication and clinical and managerial capacities were identified as key factors to be strengthened in improving leadership within the districts. The findings have also highlighted the detrimental influence of vertical interventions from external partners and hierarchical supervisors in health zones on planning, human resource management and decision-making autonomy of district leaders, weakening their leadership.
Conclusions
Despite their decentralized basic operating structure, which has withstood decades of crisis and insufficient government investment in healthcare, the districts still struggle to assert their leadership and autonomy. The authors suggest greater support for personal and professional development of the health workforce, coupled with increased government investment, to further strengthen health system capacities in these settings.
... A significant number of medical personnel in Syria (847) and Afghanistan (14) have been killed since 2015. [15] There are instances of several doctors being executed in the context of hostile / enemy combatant care scenarios. [16] Because of the inherent danger to life, health-care staff often flee the conflict zones. ...
... Direct consequences include attacks on healthcare services which can in turn affect healthcare utilisation. 4 Indirect consequences include socioeconomic and sociopolitical effects of conflict, ranging from changing roles of women in the community, early or forced marriages, inadequate food or shelter and insecurity. 1 3 Quality of services can also be affected by the forced displacement of trained healthcare workers 5 and interruptions in supply chains and in the range of services required for RMNCH. Data from such settings may be incomplete or unavailable, but increasing reports from local surveys or surveillance provide evidence around the impacts of conflict with reported indicators on under 5 mortality, maternal mortality rates (MMR) and vaccination rates providing some indication of the state of RMNCH in armed conflict. ...
Introduction
Syria’s protracted conflict has devastated the health system reversing progress made on maternal health preconflict. Our aim is to understand the state of maternal health in Syria focused on underage pregnancy and caesarean sections using a scoping review and quantitative analysis; the latter draws on data from the Syrian American Medical Society’s (SAMS) maternal health facilities in northwest Syria.
Methods
We performed a scoping review of academic and grey literature on the state of maternal health across Syria since the onset of conflict (taken as March 2011). Identified articles were screened using pre-established criteria and themes identified. We also performed a retrospective quantitative analysis of maternal health data from SAMS’ facilities in a microcontext in north-west Syria between March 2017 and July 2020, analysing the trends in the proportion of births by caesarean section and age at pregnancy.
Results
Scoping review: of 2824 articles, 21 remained after screening. Main themes related to maternal mortality rates, caesarean sections, maternal age and perinatal care. 12 studies reported caesarean section rates; these varied from 16% to 64% of all births: northern Syria (19%–45%,) Damascus (16%–54%,) Lattakia (64%) and Tartous (59%.) Quantitative analysis: Of 77 746 births across 17 facilities, trend data for caesarean sections showed a decrease from 35% in March 2017 to 23% in July 2020 across SAMS facilities. Girls under 18 years accounted for 10% of births and had a lower proportion of caesarean section births. There was notable geographical and interfacility variation in the findings.
Conclusion
The quality of available literature was poor with country-level generalisations. Research which explores microcontexts in Syria is important given the different effects of conflict across the country and the fragmented health system. Our quantitative analysis provides some evidence around the changes to caesarean section rates in northwest Syria. Despite limitations, this study adds to sparse literature on this important topic.
... Despite that, the effect on them has been very limited in the literature, especially during the "Arab Spring" and the subsequent events. 10,11 The Arab Spring destabilized several governments resulting in a significant increase in terrorist attacks with many Tin, Fares, Al Mulhim, et al today still arguing that the instability in the MENA region is not only about differences in religion, cultures, or identities, but about power, political control, and social privileges. 12 In the 1970s, Iraq had developed a free, centralized, and universal health care system, funded by the country's oil export profits. ...
Background
The Middle East and North Africa (MENA) region has been, like many parts of the world, a hotbed for terrorist activities. Terrorist attacks can affect both demand for and provision of health care services and often places a unique burden on first responders, hospitals, and health systems. This study aims to provide an epidemiological description of all terrorism-related attacks in the Middle East sustained from 1970-2019.
Methods
Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all events which occurred in Iraq, Yemen, Turkey, Egypt, Syria, West Bank and Gaza Strip, Israel, Lebanon, Iran, Saudi Arabia, Bahrain, Jordan, Kuwait, United Arab Emirates, North Yemen, Qatar, and South Yemen from January 1, 1970 - December 31, 2019. Primary weapon type, primary target type, country where the incident occurred, and number of deaths and injuries were collated and the results analyzed.
Results
A total of 41,837 attacks occurred in the Middle East from 1970-2019 accounting for 24.9% of all terrorist attacks around the world. A total of 100,446 deaths were recorded with 187,447 non-fatal injuries. Fifty-six percent of all attacks in the region occurred in Iraq (23,426), 9.4% in Yemen (3,929), and 8.2% in Turkey (3,428). “Private Citizens and Properties” were targeted in 37.6% (15,735) of attacks, 15.4% (6,423) targeted “Police,” 9.6% targeted “Businesses” (4,012), and 9.6% targeted “Governments” (4,001). Explosives were used in 68.4% of attacks (28,607), followed by firearms in 20.4% of attacks (8,525).
Conclusion
Despite a decline in terrorist attacks from a peak in 2014, terrorist events remain an important cause of death and injuries around the world, particularly in the Middle East where 24.9% of historic attacks took place. While MENA countries are often clustered together by economic and academic organizations based on geographical, political, and cultural similarities, there are significant differences in terrorist events between countries within the region. This is likely a reflection of the complexities of the intricate interplay between politics, culture, security, and intelligence services unique to each country.
Conflicts affect health care systems not only during but also well beyond periods of violence and immediate crises by draining resources, destroying infrastructure, and perpetrating human resource shortages. Improving health care worker retention is critical to limiting the strain placed on health systems already facing infrastructure and financial challenges. We reviewed the evidence on the retention of health care workers in fragile, conflict-affected, and post-conflict settings and evaluated strategies and their likely success in improving retention and reducing attrition. We conducted a systematic review of studies, following PRISMA guidelines. Included studies (1) described a context that is post-conflict, conflict-affected, or was transformed by war or crisis; (2) examined the retention of health care workers; (3) were available in English, Spanish, or French, and (4) were published between 1 January 2000 and 25 April 2021. We identified 410 articles, of which 25 studies, representing 17 countries, met the inclusion criteria. Most of the studies (22 out of 25) used observational study designs and qualitative methods to conduct research. Three studies were literature reviews. This review observed four main themes: migration intention, return migration, work experiences and conditions of service, and deployment policies. Using these themes, we identify a consolidated list of six push and pull factors contributing to health care worker attrition in fragile, conflict-affected, and post-conflict settings. The findings suggest that adopting policies that focus on improving financial incentives, providing professional development opportunities, establishing flexibility, and identifying staff with strong community links may ameliorate workforce attrition.
Conducting health research in conflict-affected areas and other complex environments is difficult, yet vital. However, the capacity to undertake such research is often limited and with little translation into practice, particularly in poorer countries. There is therefore a need to strengthen health research capacity in conflict-affected countries and regions.
In this narrative review, we draw together evidence from low and middle-income countries to highlight challenges to research capacity strengthening in conflict, as well as examples of good practice. We find that authorship trends in health research indicate global imbalances in research capacity, with implications for the type and priorities of research produced, equity within epistemic communities and the development of sustainable research capacity in low and middle-income countries. Yet, there is little evidence on what constitutes effective health research capacity strengthening in conflict-affected areas. There is more evidence on health research capacity strengthening in general, from which several key enablers emerge: adequate and sustained financing; effective stewardship and equitable research partnerships; mentorship of researchers of all levels; and effective linkages of research to policy and practice.
Strengthening health research capacity in conflict-affected areas needs to occur at multiple levels to ensure sustainability and equity. Capacity strengthening interventions need to take into consideration the dynamics of conflict, power dynamics within research collaborations, the potential impact of technology, and the wider political environment in which they take place.
Background:
“Health Care Workers in Conflict Areas” emerged as one of the priority themes for a Lancet Commission addressing health in conflict. The objective of our study was to conduct a scoping review on health workers in the setting of the Syrian conflict, addressing four topics of interest: violence against health care workers, education, practicing in conflict setting, and migration.
Methods:
Considering the likelihood of scarcity of data, we broadened the scope of the scoping review to include indirect evidence on health care workers from other countries affected by the “Arab Spring”. We electronically searched six electronic databases. We conducted descriptive analysis of the general characteristics of the included papers. We also used the results of this scoping review to build an evidence gap map.
Results:
Out of the 11 165 identified citations, 136 met our eligibility criteria. The majority of the articles tackled the issue of violence against health care workers (63%) followed by practicing in conflict setting (19%), migration (17%) and education (10%). Countries in focus of most articles were: Syria (35%), Iraq (33%), and Bahrain (29%). News, editorials, commentaries and opinion pieces made up 81% of all included papers, while primary studies made up only 9%. All the primary studies identified in this review were conducted on Iraq. Most of the articles about violence against health care workers were on Bahrain, followed by Syria and Iraq. The first and corresponding authors were most frequently affiliated with institutions from non-Arab countries (79% and 79% respectively).
Conclusions:
Research evidence on health care workers in the setting of the “Arab Spring” is scarce. This review and the gap map can inform the research agendas of funders and researchers working in the field of health care workers in conflict setting. More well-designed primary studies are needed to inform the decisions of policymakers and other interested parties.
Background:
Research-conducive environments are mandatory for planning, implementing and translating research findings into evidence-informed health policies.
Aim:
This study aimed at comprehensive situation analysis of health research institutions in the Region.
Methods:
We collected data on: institutional characteristics, research scope, capacity building, ethics, governance and resources.
Results:
We contacted 575 institutions, of which, 223 (38.8%) responded, indicating that they conducted population research (82%). Reported studies were mostly in medicine, public health and epidemiology, while reported capacity building mainly focused on scientific writing (20.6%), research proposal writing (18%) and quantitative research methods (17%). Most institutions reported having collaborating partners (82%) - predominantly national (77%). Sixty-four percent of institutions received their own funding, with 48% reporting always having access to national databases.
Conclusion:
Governments in the Eastern Mediterranean Region and international funding agencies are called upon to support health research production through increasing allocated support and capacity building in health research.
Conflict and fragility are increasing in many areas of the world. This context has been referred to as the ‘new normal’ and affects a billion people. Fragile and conflict-affected states have the worst health indicators and the weakest health systems. This presents a major challenge to achieving universal health coverage. The evidence base for strengthening health systems in these contexts is very weak and hampered by limited research capacity, challenges relating to insecurity and apparent low prioritisation of this area of research by funders. This article reports on findings from a multicountry consortium examining health systems rebuilding post conflict/crisis in Sierra Leone, Zimbabwe, northern Uganda and Cambodia. Across the ReBUILD consortium's interdisciplinary research programme, three cross-cutting themes have emerged through our analytic process: communities, human resources for health and institutions. Understanding the impact of conflict/crisis on the intersecting inequalities faced by households and communities is essential for developing responsive health policies. Health workers demonstrate resilience in conflict/crisis, yet need to be supported post conflict/crisis with appropriate policies related to deployment and incentives that ensure a fair balance across sectors and geographical distribution. Postconflict/crisis contexts are characterised by an influx of multiple players and efforts to support coordination and build strong responsive national and local institutions are critical. The ReBUILD evidence base is starting to fill important knowledge gaps, but further research is needed to support policy makers and practitioners to develop sustainable health systems, without which disadvantaged communities in postconflict and postcrisis contexts will be left behind in efforts to promote universal health coverage.
Background
High quality health systems research (HSR) in fragile and conflict-affected states (FCAS) is essential to guiding the policies and programmes that will improve access to health services and, ultimately, health outcomes. Yet, conducting HSR in FCAS is challenging. An understanding of these challenges is essential to tackling them and to supporting research conducted in these complex environments. Led by the Thematic Working Group on Health Systems in FCAS, the primary aim of this study was to develop a research agenda on HSR in FCAS. The secondary aim was to identify the challenges associated with conducting HSR in these contexts. This paper presents these challenges.
Methods
Guided by a purposely-selected steering group, this qualitative study collected respondents’ perspectives through an online survey (n = 61) and a group discussion at the Third Global Symposium on HSR in September 2014 (n = 11). Respondents with knowledge and/or experience of HSR in FCAS were intentionally recruited.
Results
Of those ever involved in HSR in FCAS (45/61, 75%), almost all (98%) experienced challenges in conducting their research. Challenges fall under three broad thematic areas: (1) lack of appropriate support; (2) complex local research environment, including access constraints, weak local research capacity, collaboration challenges and lack of trust in the research process; and (3) limited research application, including rapidly outdated findings and lack of engagement with the research process and results.
Conclusions
This study shows that those familiar with HSR in FCAS face many challenges in gaining support for and in conducting and applying high-quality research. There is a need for more sustainable support, including commitment to and long-term funding of HSR in FCAS; investment in capacity building within FCAS to meet the challenges related to implementation of research in these complex environments; relationship and trust building among stakeholders involved in HSR, particularly between local and international researchers and between researchers and participants; and innovative and flexible approaches to research design and implementation in these insecure and rapidly changing contexts.
Electronic supplementary material
The online version of this article (doi:10.1186/s12961-017-0204-x) contains supplementary material, which is available to authorized users.
Ethical challenges facing research and reporting from conflict-affected zones are well known; among them is the difficulty of finding reliable information; the tendency to take sides and define actors as either good or evil; the precarious security situation of residents and the ever-changing scenarios on the ground. We observed, however, that these challenges go unacknowledged in research and reporting on health state and on the health system from the conflict in Iraq and Syria, with the lines between science and journalistic reporting routinely blurred in the literature. What should be the restraining factor of academic research against prejudiced reporting on injury, death and the healthcare system has mostly failed in the Syrian conflict. Even social media, with its promise of ‘independent’ and ‘citizens' voice’, can be skewed, with much of the output in the Syria crisis coming from one side only, largely due to access issues. While researchers in conflict-affected zones, such as Syria, may need to take a position on one side or another when reporting, death, destruction and disease, it is important that they admit to the challenges of accessing unbiased data, the near impossibility of obtaining representative samples and the risk of the contamination of evidence, clinical or otherwise. The example of the Syrian and Iraqi conflicts (as context) indicates a need to reassess research ethics in conflict zones and their implications for policy.
Qualified healthcare workers within an effective health system are critical in promoting and achieving greater health outcomes such as those espoused in the Millennium Development Goals. Liberia is currently struggling with the effects of a brutal 14-year long civil war that devastated health infrastructures and caused most qualified health workers to flee and settle in foreign countries. The current output of locally trained health workers is not adequate for the tasks at hand. The recent Ebola Virus Disease (EVD) exposed the failings of the Liberian healthcare system. There is limited evidence of policies that could be replicated in Liberia to encourage qualified diaspora Liberian health workers to return and contribute to managing the phenomenon. This paper reviews the historical context for the human resources for health crisis in Liberia; it critically examines two context-specific health policy options to address the crisis, and recommends reverse brain drain as a policy option to address the immediate and critical crisis facing the health care sector in Liberia.
Key words: Liberia • Human Resources for Health • Health System • Health Policy • Health Workers • Brain Drain • Diaspora Option • West Africa • Ebola Virus
Copyright © 2015 Budy. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.
Background
Timor-Leste built its health workforce up from extremely low levels after its war of independence, with the assistance of Cuban training, but faces challenges as the first cohorts of doctors will shortly be freed from their contracts with government. Retaining doctors, nurses and midwives in remote areas requires a good understanding of health worker preferences.
Methods
The article reports on a discrete choice experiment (DCE) carried out amongst 441 health workers, including 173 doctors, 150 nurses and 118 midwives. Qualitative methods were conducted during the design phase. The attributes which emerged were wages, skills upgrading/specialisation, location, working conditions, transportation and housing.
Findings
One of the main findings of the study is the relative lack of importance of wages for doctors, which could be linked to high intrinsic motivation, perceptions of having an already highly paid job (relative to local conditions), and/or being in a relatively early stage of their career for most respondents. Professional development provides the highest satisfaction with jobs, followed by the working conditions. Doctors with less experience, males and the unmarried are more flexible about location. For nurses and midwives, skill upgrading emerged as the most cost effective method.
Conclusions
The study is the first of its kind conducted in Timor-Leste. It provides policy-relevant information to balance financial and non-financial incentives for different cadres and profiles of staff. It also augments a thin literature on the preferences of working doctors (as opposed to medical students) in low and middle income countries and provides insights into the ability to instil motivation to work in rural areas, which may be influenced by rural recruitment and Cuban-style training, with its emphasis on community service.
Aim:
The aim of this analysis was to compare the level of self-perceived competencies of primary health care physicians in Kosovo with patients' viewpoint, as well as the necessary (required) level of such competencies from decision-makers' standpoint.
Methods:
Three cross-sectional studies were carried out in Kosovo in 2013 including: i) a representative sample of 1340 primary health care users aged ≥18 years (49% men; overall mean age: 50.5±17.9 years; response rate: 89%); ii) a representative sample of 597 primary health care physicians (49% men; overall mean age: 46.0±9.4 years; response rate: 90%), and; iii) a nationwide representative sample of 100 decision-makers operating at different primary health care institutions or public health agencies in Kosovo (63% men; mean age: 47.7±5.7 years). A structured self-administered questionnaire (consisting of 37 items) was used in the three surveys in order to assess physicians' competencies regarding different domains of the quality of health care.
Results:
There was a significant gap in the level of self-perceived physicians' competencies and patients' perspective in transitional Kosovo. Furthermore, there was a gap in the level of self-perceived physicians' competencies and the necessary (required) level of physicians' competencies from decision-makers perspective which was less evident in Prishtina, but considerable in the other regions of Kosovo.
Conclusion:
Our analysis provides valuable evidence about the level of competencies of primary health care physicians in Kosovo from different stakeholders' perspectives. There is an urgent need for continuous professional development of family physicians in post-war Kosovo.
Background:
Growing evidence supports the use of Western therapies for the treatment of depression, trauma, and stress delivered by community health workers (CHWs) in conflict-affected, resource-limited countries. A recent randomized controlled trial (Bolton et al. 2014a) supported the efficacy of two CHW-delivered interventions, cognitive processing therapy (CPT) and brief behavioral activation treatment for depression (BATD), for reducing depressive symptoms and functional impairment among torture survivors in the Kurdish region of Iraq.
Methods:
This study describes the adaptation of the CHW-delivered BATD approach delivered in this trial (Bolton et al.2014a), informed by the Assessment-Decision-Administration-Production-Topical experts-Integration-Training-Testing (ADAPT-ITT) framework for intervention adaptation (Wingood & DiClemente, 2008). Cultural modifications, adaptations for low-literacy, and tailored training and supervision for non-specialist CHWs are presented, along with two clinical case examples to illustrate delivery of the adapted intervention in this setting.
Results:
Eleven CHWs, a study psychiatrist, and the CHW clinical supervisor were trained in BATD. The adaptation process followed the ADAPT-ITT framework and was iterative with significant input from the on-site supervisor and CHWs. Modifications were made to fit Kurdish culture, including culturally relevant analogies, use of stickers for behavior monitoring, cultural modifications to behavioral contracts, and including telephone-delivered sessions to enhance feasibility.
Conclusions:
BATD was delivered by CHWs in a resource-poor, conflict-affected area in Kurdistan, Iraq, with some important modifications, including low-literacy adaptations, increased cultural relevancy of clinical materials, and tailored training and supervision for CHWs. Barriers to implementation, lessons learned, and recommendations for future efforts to adapt behavioral therapies for resource-limited, conflict-affected areas are discussed.
Staff well-being including stress awareness and stress management skills is usually not a priority in (mental) health policies. In Kosovo, the level of stress amongst primary health care (PHC) professionals is high because health professionals are part of the population seriously affected by conflict. The need to support staff and look after their well-being was recognised by the Director of the Centre for Development of Family Medicine, Head of Primary Care. In response, the Antares Foundation and the Kosovo Rehabilitation Centre for Torture Victims (KRCT), in close cooperation with the Centers for Disease Control and Prevention, implemented an integrated psycho-social capacity building programme for PHC professionals.
This case-study describes how staff well-being was integrated into the PHC system in Kosovo. This was accomplished through raising awareness on staff well-being and stress management as well as strengthening knowledge of and skills in stress management. Eighteen national PHC staff were trained and more than a thousand family doctors and nurses attended stress management workshops. A steering committee consisting of key stakeholders was responsible for overseeing the execution of the programme. This steering committee successfully advocated for integration of staff well-being and stress management in the revised mental health strategy 2014-2020. The curriculum developed for the training was integrated in the professional staff development programme for family doctors and nurses. The effectiveness of the programme was assessed through an evaluation (including a survey among PHC professionals trained under the programme).
Evaluation findings showed that offering structured support, entailing the opportunity to discuss work related problems and providing tools to deal with stress related to work or personal life, helps staff to continue their professional tasks under challenging conditions. Evaluation findings suggest that results can be sustained through an integrated approach and involvement of key stakeholders. The case study may be of interest to policy makers involved in health reform processes and for managers implementing changes in complicated post conflict contexts. For both groups, acknowledgment of staff well-being could be a key ingredient in the motivation of staff and the quality of services.
Background: The north-east (NE) region of Sri Lanka observed a critical health workers’ shortage after the long-lasting armed conflict. This study aimed to explore medical students’ attitudes towards working in the NE and to identify factors determining such attitudes. Methods: A semi-structured, self-administered questionnaire survey was conducted in two medical schools, one in the NE and the other near the capital, in October 2004. Data were qualitatively analysed using the framework approach. Results: Three main themes were identified: 1) Professional motives and career plans; 2) Students’ perceptions of the healthcare situation in the NE; and 3) Students’ choice of the NE as a future practice location. It was found that familiarity with the difficulties faced by the NE people was a major motivation for medical students to work in the NE in the future. For NE students, familiarity was linked to their sense of belonging. For non-NE students, their personal experience of the NE familiarized them with the difficult situation there, which positively influenced their willingness to work there. Demotivations to work in the NE were poor working and living conditions, fewer opportunities for postgraduate education, language differences, insecurity, and fear of an unpleasant social response from the NE communities. Conclusions: NE local medical students had a sense of belonging to the NE and compassion for the Tamil people as members of the ethnic group. They were willing to work in the NE if their concerns about difficult working and living conditions and postgraduate education could be solved. Non-NE students who were familiar with the NE situation through their personal experience also showed a willingness to work there; thus, early exposure programmes in medical education might help to increase the health workforce in the NE. It is also expected that non-NE physicians working for the NE people would facilitate reconciliation and the rebuilding of trust between two ethnic groups.
Global Health Initiatives (GHIs) respond to high-impact communicable diseases in resource-poor countries, including health systems support, and are major actors in global health. GHIs could play an important role in countries affected by armed conflict given these countries commonly have weak health systems and a high burden of communicable disease. The aim of this study is to explore the influence of two leading GHIs, the Global Fund and the GAVI Alliance, on the health systems of conflict-affected countries.
This study used an analytical review approach to identify evidence on the role of the Global Fund and the GAVI Alliance with regards to health systems support to 19 conflict-affected countries. Primary and secondary published and grey literature were used, including country evaluations from the Global Fund and the GAVI Alliance. The WHO heath systems building blocks framework was used for the analysis.
There is a limited evidence-base on the influence of GHIs on health systems of conflict-affected countries. The findings suggest that GHIs are increasingly investing in conflict-affected countries which has helped to rapidly scale up health services, strengthen human resources, improve procurement, and develop guidelines and protocols. Negative influences include distorting priorities within the health system, inequitable financing of disease-specific services over other health services, diverting staff away from more essential health care services, inadequate attention to capacity building, burdensome reporting requirements, and limited flexibility and responsiveness to the contextual challenges of conflict-affected countries.
There is some evidence of increasing engagement of the Global Fund and the GAVI Alliance with health systems in conflict-affected countries, but this engagement should be supported by more context-specific policies and approaches.
Rwanda, known as the “Land of a Thousand Hills,” is a small, East African country that was the site of the devastating 1994 genocide. In the past 18 years, this post-conflict country has made tremendous progress in rebuilding itself and its health infrastructure. The country has recovered or surpassed many of its pre-1994 health levels, including reduction in HIV/AIDS prevalence, under-five mortality and road traffic accidents. Nevertheless, Rwanda continues to face a high burden of disease. The leading causes of mortality in Rwanda include complications of HIV/AIDS and related opportunistic infections, severe malaria, pulmonary infections, and trauma, and are best managed with emergency and acute care services. However, health care personal resources remain significantly lacking, and there is currently no emergency medicine-trained workforce.
The Rwandan government, partnering with international organizations, has launched a campaign to improve human resources for health, and as a part of that effort the creation of training programs in emergency medicine is now underway. The Rwandan Human Resources for Health program can serve as a guide to the development of similar programs within other African countries. The emergency medicine component of this program includes two tracks: a 2-year postgraduate diploma course, followed by a 3-year Masters of Medicine in Emergency Medicine. The program is slated to graduate its first cohort of trained Emergency Physicians in 2017.
Afghanistan is a country that has been in conflict for decades, resulting in the destruction of much of its social infrastructure including the health system. In 2003, after the intervention of US-led NATO forces, the new government with support from its international partners designed a Basic Package of Health Services to provide services to the majority rural population; its specific focus is on women and children. The workforce to deliver these services consists of Community Health Workers (CHWs). In this paper we aim to 1) describe the CHW program, 2) explore the gender dynamics of the workforce, and 3) identify facilitators and challenges to the program.
Our descriptive, qualitative study involved an analysis of policy and administrative documents, in-depth interviews and focus groups, and non-participant observation. Ethical approval for the fieldwork was obtained from the University of Ottawa, and the Afghanistan National Public Health Institute.
There are more than 20,000 CHWs across the country serving as village primary care providers, functioning as a liaison between the community and health-care facilities, and working as community developers; more than half are women. Noteworthy is a gender hierarchy: as one moves up the hierarchy of supervision and training, management and decision-making, the ratio of women to men diminishes. We found that female CHWs accomplished their tasks vis-à-vis maternal child health with greater ease than their male counterparts, as societal gender dynamics influences task allocation. Volunteerism helps to deploy a larger number of CHWs, but also makes their retention difficult. Community participation facilitates tasks of CHWs, but also poses challenges to the program, such as traditional leaders influencing the recruitment of CHWs that may not be the best choice for the community. Drug supply and support for CHWs is vital to the effectiveness of the program.
This case study of the decade-long, rural health workforce CHW program in Afghanistan suggests that CHWs play an important role in post-conflict, developing countries, potentially contributing to health system strengthening.
In post-conflict settings, severe disruption to health systems invariably leaves populations at high risk of disease and in greater need of health provision than more stable resource-poor countries. The health workforce is often a direct victim of conflict. Effective human resource management (HRM) strategies and policies are critical to addressing the systemic effects of conflict on the health workforce such as flight of human capital, mismatches between skills and service needs, breakdown of pre-service training, and lack of human resource data. This paper reviews published literatures across three functional areas of HRM in post-conflict settings: workforce supply, workforce distribution, and workforce performance. We searched published literatures for articles published in English between 2003 and 2013. The search used context-specific keywords (e.g. post-conflict, reconstruction) in combination with topic-related keywords based on an analytical framework containing the three functional areas of HRM (supply, distribution, and performance) and several corresponding HRM topic areas under these. In addition, the framework includes a number of cross-cutting topics such as leadership and governance, finance, and gender. The literature is growing but still limited. Many publications have focused on health workforce supply issues, including pre-service education and training, pay, and recruitment. Less is known about workforce distribution, especially governance and administrative systems for deployment and incentive policies to redress geographical workforce imbalances. Apart from in-service training, workforce performance is particularly under-researched in the areas of performance-based incentives, management and supervision, work organisation and job design, and performance appraisal. Research is largely on HRM in the early post-conflict period and has relied on secondary data. More primary research is needed across the areas of workforce supply, workforce distribution, and workforce performance. However, this should apply a longer-term focus throughout the different post-conflict phases, while paying attention to key cross-cutting themes such as leadership and governance, gender equity, and task shifting. The research gaps identified should enable future studies to examine how HRM could be used to meet both short and long term objectives for rebuilding health workforces and thereby contribute to achieving more equitable and sustainable health systems outcomes after conflict.
Background. It is recognized that decisions taken in the early recovery period may affect the development of health systems. Additionally, some suggest that the immediate post-conflict period may allow for the opening of a political ‘window of opportunity’ for reform. For these reasons, it is useful to reflect on the policy space that exists in this period, by what it is shaped, how decisions are made, and what are their long-term implications. Examining the policy trajectory and its determinants can be helpful to explore the specific features of the post-conflict policy-making environment. With this aim, the study looks at the development of policies on human resources for health (HRH) in Sierra Leone over the decade after the conflict (2002-2012).
Methods. Multiple sources were used to collect qualitative data on the period between 2002 and 2012: a stakeholder mapping workshop, a document review and a series of key informant interviews. The analysis draws from political economy and policy analysis tools, focusing on the drivers of reform, the processes, the contextual features, and the actors and agendas.
Findings. Our findings identify three stages of policy-making. At first characterized by political uncertainty, incremental policies and stop-gap measures, the context substantially changed in 2009. The launch of the Free Health Care Initiative provided to be an instrumental event and catalyst for health system, and HRH, reform. However, after the launch of the initiative, the pace of HRH decision-making again slowed down.
Conclusions. Our study identifies the key drivers of HRH policy trajectory in Sierra Leone: (i) the political situation, at first uncertain and later on more defined; (ii) the availability of funding and the stances of agencies providing such funds; (iii) the sense of need for radical change – which is perhaps the only element related to the post-conflict setting. It also emerges that a ‘windows of opportunity’ for reform did not open in the immediate post-conflict, but rather 8 years later when the Free Health Care Initiative was announced, thus making it difficult to link it directly to the features of the post-conflict policy-making environment.
Active screening by mobile teams is considered the most effective method for detecting gambiense-type human African trypanosomiasis (HAT) but constrained funding in many post-conflict countries limits this approach. Non-specialist health care workers (HCWs) in peripheral health facilities could be trained to identify potential cases for testing based on symptoms. We tested a training intervention for HCWs in peripheral facilities in Nimule, South Sudan to increase knowledge of HAT symptomatology and the rate of syndromic referrals to a central screening and treatment centre.
METHODOLOGY/PRINCIPAL FINDINGS We trained 108 HCWs from 61/74 of the public, private and military peripheral health facilities in the county during six one-day workshops and assessed behaviour change using quantitative and qualitative methods. In four months prior to training, only 2/562 people passively screened for HAT were referred from a peripheral HCW (0 cases detected) compared to 13/352 (2 cases detected) in the four months after, a 6.5-fold increase in the referral rate observed by the hospital. Modest increases in absolute referrals received, however, concealed higher levels of referral activity in the periphery. HCWs in 71.4% of facilities followed-up had made referrals, incorporating new and pre-existing ideas about HAT case detection into referral practice. HCW knowledge scores of HAT symptoms improved across all demographic sub-groups. Of 71 HAT referrals made, two-thirds were from new referrers. Only 11 patients completed the referral, largely because of difficulties patients in remote areas faced accessing transportation.
CONCLUSIONS/SIGNIFICANCE The training increased knowledge and this led to more widespread appropriate HAT referrals from a low base. Many referrals were not completed, however. Increasing access to screening and/or diagnostic tests in the periphery will be needed for greater impact on case-detection in this context. These data suggest it may be possible for peripheral HCWs to target the use of rapid diagnostic tests for HAT.
In conflict and disaster settings, medical personnel are exposed to psychological stressors that threaten their wellbeing and increase their risk of developing burnout, depression, anxiety, and PTSD. As lay medics frequently function as the primary health providers in these situations, their mental health is crucial to the delivery of services to afflicted populations. This study examines a population of community health workers in Karen State, eastern Myanmar to explore the manifestations of health providers' psychological distress in a low-resource conflict environment.
Mental health screening surveys were administered to 74 medics, incorporating the 12-item general health questionnaire (GHQ-12) and the posttraumatic checklist for civilians (PCL-C). Semi-structured qualitative interviews were conducted with 30 medics to investigate local idioms of distress, sources of distress, and the support and management of medics' stressors.
The GHQ-12 mean was 10.7 (SD 5.0, range 0--23) and PCL-C mean was 36.2 (SD 9.7, range 17--69). There was fair internal consistency for the GHQ-12 and PCL-C (Cronbach's alpha coeffecients .74 and .80, respectively) and significant correlation between the two scales (Pearson's R-correlation .41, P<.05). Qualitative results revealed abundant evidence of stressors, including perceived inadequacy of skills, transportation barriers, lack of medical resources, isolation from family communities, threats of military violence including landmine injury, and early life trauma resulting from conflict and displacement. Medics also discussed mechanisms to manage stressors, including peer support, group-based and individual forms of coping.
The results suggest significant sources and manifestations of mental distress among this under-studied population. The discrepancy between qualitative evidence of abundant stressors and the comparatively low symptom scores may suggest marked mental resilience among subjects, or substantial differences in distress burden between the quantitative and qualitative samples. Alternatively, this discrepancy may be due to the inadequacy of standard screening tools not validated for this population and potential cultural inappropriateness of established diagnostic frameworks. The importance of peer-group support as a protective factor suggests that interventions might best serve healthworkers in conflict areas by emphasizing community- and team-based strategies.
Sexual assault is a threat to public health in refugee and conflict affected settings, placing survivors at risk for unintended pregnancy, unsafe abortion, STIs, HIV, psychological trauma, and social stigma. In response, the International Rescue Committee developed a multimedia training tool to encourage competent, compassionate, and confidential clinical care for sexual assault survivors in low-resource settings. This study evaluated the effect of the training on healthcare providers' attitudes, knowledge, confidence, and practices in four countries.
Using a mixed-methods approach, we surveyed a purposive sample of 106 healthcare providers before and 3 months after training to measure attitudes, knowledge, and confidence. In-depth interviews with 40 providers elaborated on survey findings. Medical record audits were conducted in 35 health facilities before and 3 months after the intervention to measure healthcare providers' practice. Quantitative and qualitative data underwent statistical and thematic analysis.
While negative attitudes, including blaming and disbelieving women who report sexual assault, did not significantly decrease among healthcare providers after training, respect for patient rights to self-determination and non-discrimination increased from 76% to 91% (p < .01) and 74% to 81% (p < .05) respectively. Healthcare providers' knowledge and confidence in clinical care for sexual assault survivors increased from 49% to 62% (p < .001) and 58% to 73% (p < .001) respectively following training. Provider practice improved following training as demonstrated by a documented increase in eligible survivors receiving emergency contraception from 50% to 82% (p < .01), HIV post-exposure prophylaxis from 42% to 92% (p < .001), and STI prophylaxis and treatment from 45% to 96% (p < .01).
Although beliefs about sexual assault are hard to change, training can improve healthcare providers' respect for patient rights and knowledge and confidence in direct patient care, resulting in more competent and compassionate clinical care for sexual assault survivors.
Member states across the Eastern Mediterranean region face unprecedented health challenges, buffeted by demographic change, a dual disease burden, rising health costs, and the effects of ongoing conflict and population movements - exacerbated in the near-term by instability arising from recent political upheaval in the Middle East. However, health actors in the region are not well positioned to respond to these challenges because of a dearth of good quality health research. This review presents an assessment of the current state of health research systems across the Eastern Mediterranean based on publicly available literature and data sources. The review finds that - while there have been important improvements in productivity in the Region since the early 1990s - overall research performance is poor with critical deficits in system stewardship, research training and human resource development, and basic data surveillance. Translation of research into policy and practice is hampered by weak institutional and financial incentives, and concerns over the political sensitivity of findings. These problems are attributable primarily to chronic under-investment - both financial and political - in Research and Development systems. This review identifies key areas for a regional strategy and how to address challenges, including increased funding, research capacity-building, reform of governance arrangements and sustained political investment in research support. A central finding is that the poverty of publicly available data on research systems makes meaningful cross-comparisons of performance within the EMR difficult. We therefore conclude by calling for work to improve understanding of health research systems across the region as a matter of urgency.
This article discusses the training of mental health workers whose basic job is with clients that have been seriously affected by armed conflict and/or natural disasters by using ‘helping through talking’, and who have had little education that is relevant to this work. It sums up the characteristics required of the workers, their learning needs, the messages that the training needs to convey, and the characteristics and potential contents of a tailor made, participants-oriented 1 In earlier publications (e.g. van der Veer, 2003; 2006) referring to the same approach the first author has used the term person-oriented or contact-focussed. programme. This approach is illustrated with a few key points from such a training programme.
Background: Rwanda is a landlocked East-African country that was the site of the 1994 genocide, during which much of its health infrastructure was destroyed. It remains one of the poorest and least developed countries in the world. In the last two decades, there have been significant efforts to rebuild its healthcare system. No study has since examined Rwanda’s emergency medicine (EM) infrastructure.
Study objective: To perform an initial descriptive study of EM infrastructure in post-conflict Rwanda.
Methods: We employed two methods. The first was 160 h of direct observation at six healthcare sites in the capital city of Kigali leading to a descriptive understanding of Rwanda’s EM infrastructure. The second method utilized face-to-face narrative interviews based on a 5-item open-ended questionnaire with a convenience sample of 54 healthcare workers.
Results: A relatively basic EM infrastructure was found to exist. Emergency care is available to all, though timely access and demand for payment are barriers to care. Emergency care is delivered at all levels, from local community health centres to district hospitals to national referral centres. The majority of physicians working in the Emergency Departments (EDs) are general practitioners, and only one hospital provides specialised training at the BLS level to EM practitioners. Prehospital care is almost entirely missing. The three most commonly cited problems facing EM infrastructure in Rwanda were lack of resources (94% of respondents), need for specialised EM training (89%), and absence of prehospital care (74%). All except one worker surveyed (98%) were satisfied with the progress Rwanda has made to improve EM in the last 10 years.
Conclusion: Despite ongoing challenges, the infrastructure for the delivery of emergency care is much improved since 1994, and Rwanda’s continuing progress can serve as a model for EM development in other developing and/or post-conflict countries in Africa.
Following twenty years of economic and social growth, Liberia's fourteen-year civil war destroyed its health system, with most of the health workforce leaving the country. Following the inauguration of the Sirleaf administration in 2006, the Ministry of Health & Social Welfare (MOHSW) has focused on rebuilding, with an emphasis on increasing the size and capacity of its human resources for health (HRH). Given resource constraints and the high maternal and neonatal mortality rates, MOHSW concentrated on its largest cadre of health workers: nurses.
Based on results from a post-war rapid assessment of health workers, facilities and community access, MOHSW developed the Emergency Human Resources (HR) Plan for 2007-2011. MOHSW established a central HR Unit and county-level HR officers and prioritized nursing cadres in order to quickly increase workforce numbers, improve equitable distribution of workers and enhance performance. Strategies included increasing and standardizing salaries to attract workers and prevent outflow to the private sector; mobilizing donor funds to improve management capacity and fund incentive packages in order to retain staff in hard to reach areas; reopening training institutions and providing scholarships to increase the pool of available workers.
MOHSW has increased the total number of clinical health workers from 1396 in 1998 to 4653 in 2010, 3394 of which are nurses and midwives. From 2006 to 2010, the number of nurses has more than doubled. Certified midwives and nurse aides also increased by 28% and 31% respectively. In 2010, the percentage of the clinical workforce made up by nurses and nurse aides increased to 73%. While the nursing cadre numbers are strong and demonstrate significant improvement since the creation of the Emergency HR Plan, equitable distribution, retention and performance management continue to be challenges.
This paper illustrates the process, successes, ongoing challenges and current strategies Liberia has used to increase and improve HRH since 2006, particularly the nursing workforce. The methods used here and lessons learned might be applied in other similar settings.
This study aimed to assess post-traumatic stress symptoms and vicarious traumatization (VT) versus post-traumatic growth (PTG) among Israeli practitioners who shared war-related reality with their clients during the Second Lebanon–Israel war (2006). In addition, the contribution of potency (one's personal resource) and the role of peri-traumatic dissociation (the emotional detachment activated during or immediately after a traumatic event) were examined. Two months after the war, a convenience sample of 204 practitioners (seventy-six nurses and 128 social workers), all residents and employees in the Haifa area, were administered a self-report questionnaire. Findings showed that nurses had higher post-traumatic growth (PTG) compared with social workers. Personal resource (potency) was found to contribute to the reduction of vicarious traumatization (VT), whereas peri-traumatic dissociation was found to contribute to both PTG and VT in the group of social workers.
Humanitarian agencies are increasingly engaged in research in conflict and post-conflict settings. This is justified by the need to improve the quality of assistance provided in these settings and to collect evidence of the highest standard to inform advocacy and policy change. The instability of conflict-affected areas, and the heightened vulnerability of populations caught in conflict, calls for careful consideration of the research methods employed, the levels of evidence sought, and ethical requirements. Special attention needs to be placed on the feasibility and necessity of doing research in conflict-settings, and the harm-benefit ratio for potential research participants.
Background
As demand grows for health policies based on evidence, questions exist as to the capacity of developing countries to produce the health policy and systems research (HPSR) required to meet this challenge.
Methods
A postal/web survey of 176 HPSR producer institutions in developing countries assessed institutional structure, capacity, critical mass, knowledge production processes and stakeholder engagement. Data were projected to an estimated population of 649 institutions.
Results
HPSR producers are mostly small public institutions/units with an average of 3 projects, 8 researchers and a project portfolio worth $155,226. Experience, attainment of critical mass and stakeholder engagement are low, with only 19% of researchers at PhD level, although researchers in key disciplines are well represented and better qualified. Research capacity and funding are similar across income regions, although inequalities are apparent. Only 7% of projects are funded at $100,000 or more, but they account for 54% of total funding. International sources and national governments account for 69% and 26% of direct project funding, respectively. A large proportion of international funds available for HPSR in support of developing countries are either not spent or spent through developed country institutions.
Conclusions
HPSR producers need to increase their capacity and critical mass to engage effectively in policy development and to absorb a larger volume of resources. The relationship between funding and critical mass needs further research to identify the best funding support, incentives and capacity strengthening approaches. Support should be provided to network institutions, concentrate resources and to attract funding.
In 2000 the nongovernmental organisation (NGO) HealthNet TPO started mental health and psychosocial support services in Burundi, a country that has been severely affectedby civil war. Within a time frame of eight years, a wide range of mental health and psychosocial services were established, covering large parts of the country. During the programme period the NGO activities shifted from the delivery of direct services to capacity building activities aimed at embedding psychiatric services and psychosocial assistance withinexisting local health services and social systems. Among the strategies used were 1) training and supervision in mental health for government nurses and doctors in provincial hospitals, 2) trainingin psychosocial assistance and supervision of governmental social workers, and 3) building the capacity of psychosocial volunteers and local community based organisations. The handover of mental health and psychosocial services presented formidable challenges arising from difficulties for the state in sustaining mental health and psychosocial services within their systems, and from difficulties for users in contributing financially to the provision of services. Major lessons are that installing basic mental health within general care should be firmly rooted in a general health-system-strengthening approach and also that healing the social wounds of war should be embedded within an approach to strengthening ‘community systems’.
In the wake of the recent increase in acts of terror and natural disasters, research literature has begun to focus more attention
on situations in which trauma workers and their clients are simultaneously exposed to the same threat. However, less attention
had been paid to the role of social workers in continuous shared traumatic situations. This article presents three case descriptions
of events that emerged from social workers ‘under fire’. The cases reveal that these situations oscillate from events that
become routine, to events that combine extreme trauma and loss, and events that allow for the provision of assistance from
broader elements of the community. The questions that emerged from the narratives call for rethinking and revision of conceptualisations
of the role of social work and social work practitioners in war and emergency situations. To conclude, practical recommendations
at all levels of intervention are offered.
Background: Rates of perinatal depression in low and middle income countries are reported to be very high. Perinatal depression not only has profound impact on women's health, disability and functioning, it is associated with poor child health outcomes such as pre-term birth, under-nutrition and stunting, which ultimately have an adverse trans-generational impact. There is strong evidence in the medical literature that perinatal depression can be effectively managed with psychological treatments delivered by non-specialists. Our previous research in Pakistan led to the development of a successful perinatal depression intervention, the Thinking Healthy Program (THP). The THP is a psychological treatment delivered by community health workers. The burden of perinatal depression can be reduced through scale-up of this proven intervention; however, training of health workers at scale is a major barrier. To enhance access to such interventions there is a need to look at technological solutions to training and supervision. Methods/design: This is a non-inferiority, single-blinded randomized controlled trial. Eighty community health workers called Lady Health Workers (LHWs) working in a post-conflict rural area in Pakistan (Swat) will be recruited through the LHW program. LHWs will be randomly allocated to Technology-assisted Cascade Training and Supervision (TACTS) or to specialist-delivered training (40 in each group). The TACTS group will receive training in THP through LHW supervisors using a tablet-based training package, whereas the comparison group will receive training directly from mental health specialists. Our hypothesis is that both groups will achieve equal competence. Primary outcome measure will be competence of health workers at delivering THP using a modified ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale immediately post training and after 3 months of supervision. Independent assessors will be blinded to the LHW allocation status. Discussion: Women living in post-conflict areas are at higher risk of depression compared to the general population. Implementation of evidence-based interventions for depression in such situations is a challenge because health systems are weak and human resources are scarce. The key innovation to be tested in this trial is a Technology-assisted Cascade Training and Supervision system to assist scale-up of the THP.
Growing political instability around the world has exposed an increasing number of communities to military conflict. Social
workers and other mental health professionals who work as trauma workers, and who both live and practise within these communities,
are doubly exposed: directly and indirectly, personally and professionally. The present study examined the consequences on
trauma workers and on the therapeutic process itself of working in a continuous Shared Traumatic Reality. The study was based
on content analysis of three focus groups conducted among thirty trauma workers, between the ages of thirty and sixty, who
were trained in a variety of therapeutic professions, mainly social work. Findings suggest that a high level of exposure to
life threats and emotional distress can coexist with high levels of professional functioning and resilience. Results further
point to complex implications associated with therapeutic relationships and settings that include: diminution of the transitional
space, strengthened sense of identification between workers and clients, and acceleration of the therapeutic process. The
discussion reviews the variables that facilitate and impede the professionals' functioning and highlights the unique effects
of continuous exposure.
The purposes of this article are to describe a program of training a pioneering group of family therapists in a developing country delivered by trainers from abroad, and discuss the benefits of such a project and the difficulties it encounters. The four-year Kosova Systemic Family Therapy Training Program is in the first half of its third year when these lines are being written. It is sponsored by the Kosova Health Foundation and carried out by an International Family Therapy Association-affiliated team of traveling trainers who come to Kosovo from various parts of the world. The trainers vary considerably in personality and theoretical orientations. The training includes five main components: An overview of the field, its history and its diverse theoretical orientations and approaches to practice, a wide scale systematic integration, skills development, personal development, and supervised practice. The training is conducted by short, in loco, direct-contact modules and by distance learning and supervision. Kosovo, formerly an semi-independent region in the south of Serbia and a part of Yugoslavia, populated mainly by Muslim Albanians, declared its independence in 2008, ten years after the culmination of a bitter war. Kosovo is now struggling with the after-effect of the war and with rapid social, demographic, and cultural changes running fast ahead of its political and economical development. The effects of all these changes on the functioning of families are dramatic. The goals of the training program are to train a first generation of family therapists who will hopefully serve the affected community and eventually prepare the next generation. So far, this has proved a rewarding, but by no means easy, task.
Health care systems need organizational direction, physical plants, and fiscal resources to deliver services to their constituents. This article addresses how or whether these needs are being met in low- and middle-income countries. Over the past 10 years, debates on global health have paid increasing attention to the importance of health care systems, which encompass the institutions, organizations, and resources (physical, financial, and human) assembled to deliver health care services that meet population needs. It has become especially important to emphasize health care systems in low- and middle-income countries because of the substantial external funding provided for disease-specific programs, especially for drugs and medical supplies, and the relative underfunding of the broader health care infrastructures in these countries.(1) A functioning health care system is fundamental to the achievement of universal coverage for health ...
Due to the war in Gaza in 2009, Ben-Gurion University's Medical School for International Health with a student body of 165 international multicultural students canceled a week of classes. Third-year students continued clerkships voluntarily and fourth-year students returned to Israel before departing for electives in a developing country. A debriefing session was held for the entire school.
To assess the academic and psychological effects of political conflict on students.
We asked all students to fill out an anonymous Google electronic survey describing their experience during the war and evaluating the debriefing. A team of students and administrators reviewed the responses.
Sixty-six students (40% of the school) responded (first year 26%, second year 39%, third year 24%, fourth year 8%, taking time off 3%, age 23-40 years old). Eighty-three percent were in Israel for some portion of the war and 34% attended the debriefing. Factors that influenced individuals' decision to return/stay in the war zone were primarily of an academic and financial nature. Other factors included family pressure, information from peers and information from the administration. Many reported psychological difficulties during the war rather than physical danger, describing it as "draining" and that it was difficult to concentrate while studying. As foreigners, many felt their role was undefined. Although there is wide variation in the war's effect on daily activities and emotional well-being during that time, the majority (73%) reported minimal residual effects.
This study lends insight to the way students cope during conflict and highlights academic issues during a war. Open and frequent communication and emphasis on the school as a community were most important to students.
In 2008, the local nongovernmental organisation TPO Uganda and the Uganda Ministry of Health began a project aimed of improving the availability of mental health services in three districts in Northern Uganda. The project consisted of: 1) training of general health workers in the primary health care system in mental health; 2) strengthening the capacity of the specialised mental health workers to deliver and supervise mental health outreach services; and 3) increasing the capacity of community members to respond effectively to mental health and psychosocial needs of people within their communities. The project provided assistance to ‘patient support groups’ that then provided support to patients with mental disorders.
At the end of the 22 month project, the capacities of health workers and Village Health Teams to provide mental health services were strengthened. Major gaps, that still need to be addressed, were attrition of government health workers and a lack of drugs. Lessons learnt also include: the importance of coordination and joint planning between nongovernmental organisations and the government; the importance of support supervision; the important role of village health team members in community mobilisation and sensitisation; and the roles of patient support groups in complementing medical/clinical activities.
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In 2006, Home-Based Life-Saving Skills was introduced in three Liberian counties, in partnership with Africare-Liberia and the Liberian Ministry of Health and with funding by the United States Agency for International Development.
Traditional midwives and trained traditional midwives (N = 412) underwent pre- and immediate posttesting on four topics. Three hundred eighty-nine (94%) of the original participants also completed 1-year follow-up posttesting.
Mean scores significantly improved between pre- and immediate posttests and knowledge improvement was stable at 1 year. Correct responses on individual steps for each of four topics significantly increased over the course of training. The data demonstrate a major change in the knowledge base of the traditional and trained traditional midwives acting as village guides.
Home-Based Life-Saving Skills is a viable means by which to improve community knowledge and decrease maternal and neonatal morbidity and mortality.
This article presents the findings of a small scale study which explored the impact of the 2nd Intifada on the work of Palestinian social workers and psychosocial workers. It is one of a trilogy of comparative studies that investigated the experience of social workers and psychosocial workers working in situations of acute political conflict. Two other studies were conducted in Israel (Ramon, 2004) and in Northern Ireland (Campbell & McCrystal, 2005). Twenty-six interviews were conducted with workers from the West Bank and Gaza in the period 2003-2004, during a crisis phase in this long-term conflict when Israeli forces reoccupied the West Bank and Gaza. Interview data were supplemented by two surveys of psychosocial workers in the Occupied Palestinian Territories. The findings document the resourcefulness and commitment of workers to providing services in such a difficult context in which all workers and their clients were affected to some degree by the conflict. This common experience appeared to lead to feelings of collective solidarity in which survival becomes a form of resistance. However, working in such context takes a toll on workers, and the cumulative impact of being both a helper and a victim/survivor in times of war increased stress and feelings of anger and presented challenges to professional values. A further source of stress for these workers was the lack of status and recognition given to their role and work. Social work and psychosocial counseling are emerging professions in Palestine. Structures which might support workers practicing in a context of long-term, and enduring conflict need to be developed. The discussion and conclusion suggests that these should be at personal/professional levels, occupational levels, systems levels, and at governance levels. International alliances and dialogue to build alliances and share and develop approaches to professional practice in such context are also suggested.
One important objective of Technical Co-operation is institutional strengthening. Human resource development is understood as a means of improving the implementation of health care system development and an important factor for sustainability. Health care system reform is also a concern in Cambodia, where it has suffered from a period of war and insecurity previously, and now is beginning to aim for long term development. The implementation of the reform started four years ago with external support. This paper will show how capacity can be built and services developed under the specific circumstances of Cambodia, with technical cooperation and support from neighbouring countries through the SEAMEO TROPMED network. Training courses have been developed and research studies have been conducted to strengthen the role of the National Institute of Public Health and to aim for quality improvement. In addition, impact of training to improve management at provincial/district level was measured.
Our program attempted to integrate community mental health in primary care settings in Cambodia and to evaluate the effects of training on local providers. The training program underwent an extensive evaluation to determine its impact on the mental health knowledge, confidence in performing medical and psychiatric procedures, skills and attitudes of its trainees. One hundred four Cambodian primary care practitioners (PCPs) were trained in a primary care setting in Siem Reap, Cambodia, over a 2-year period. There was a significant improvement in PCPs' confidence in all clusters of medical and psychiatric procedures (counseling, medical evaluation, prescribing medications, psychiatric diagnosis, assessing risk for violence, traditional treatments, and treating trauma victims) comparing baseline to posttraining and baseline to 2-year follow-up (p < 0.05). Only confidence in prescribing psychotropic medications improved from posttraining to 2-year follow-up. This study supports the feasibility of training PCPs in a culturally effective manner in a postconflict society.
25 years of conflict has left Afghanistan's health system in pieces. The health ministry has issued an urgent call to expat doctors to come back to help provide essential health care. But, despite an enthusiastic response from Afghans abroad, finances are hurting the plan. Nellie Bristol reports.