Health system functionality in a low-income country in the midst of conflict: the case of Yemen

Public health intervention amidst conflict: Violence, politics, and knowledge frames in the 2018-20 Ebola epidemic in Democratic Republic of the Congo

Research, policy, and donor interest in health systems in conflict environments has grown rapidly in recent years. The 2018-20 Ebola outbreak in Democratic Republic of the Congo is a critical case of healthcare militarization. The first-ever such outbreak in an active conflict zone, it grew notorious for violence against response teams, with attacks aggravating the spread of disease. However, while medical responders observed physical attacks, the causes of the violence remained largely unknown. Drawing on interviews and participant observation, we contribute civilian vantages of the way health intervention grew militarized, or associated with conflict. The argument builds in two core steps. A first reconstructs civilian experiences of conflict prior to Ebola to trace how the response took on a political meaning. We find that relationships linking state forces with the health response inadvertently tethered Ebola to what civilians perceived as security threats and that by repeating government statements about conflict, response teams unintentionally endorsed a version of the truth that silenced local voices. A second step addresses a central paradox: residents communicated these concerns directly, repeatedly, and via official response channels, yet healthcare teams failed to apply these insights. We locate this gap in the knowledge structures, or frames, accompanying intervention. Medical emergencies in warzones operate with dual sets of frames casting conflict players as "non-state" and public health resistance as "ignorance." Both frames intersect in ways that amplify invisibilities in each, clouding understandings of the nature of conflict and humanitarians' role in it. We suggest this places intervention teams at heightened risk of mis-stepping on political fault lines-and not understanding why. The study advances work on community engagement by showing that instead of simply providing scientific knowledge, effective engagement requires adjusting socio-political lenses within the response. It contributes to studies on health intervention, humanitarian emergencies, and the limits of medical neutrality.

Impact of the armed conflict in Colombia: consequences in the health system, response and challenges

INTRODUCTION

In Colombia, research on health and conflict has focused on mental health, psychosocial care, displacement, morbidity, and mortality. Few scientific studies have assessed health system functioning during armed conflicts. In a new period characterized by the implementation of the peace agreement with the Revolutionary Armed Forces of Colombia (FARC) armed group, understanding the effects of armed conflict on the health system, the functions, and institutions shaped by the conflict is an opportunity to understand the pathways and scope of post-conflict health policy reforms. Therefore, this study was conducted to assess the effects of armed conflict on the health system, response, and mechanisms developed to protect medical missions during armed conflict in Colombia.

METHODS

This research was conducted using a qualitative approach with semi-structured interviews and focus group discussions. The qualitative guide collected information in four sections: (1) conflict and health system, effects and barriers in health service provision, (2) actions and coordination to cope with those barriers, (3) health policies and armed conflict, and (4) post-accord and current situation. Twenty-two people participated in the interviews, including eight policymakers at the national level and seven at the local level, including two NGOs and five members of international organizations. An academic project event in December 2019 and four focus groups were developed (World Cafe technique) to discuss with national and local stakeholders the effects of armed conflict on the health system and an analytical framework to analyze its consequences.

RESULTS

The conflict affected the health-seeking behavior of the population, limited access to healthcare provision, and affected health professionals, and was associated with inadequate medical supplies in conflict areas. The health system implemented mechanisms to protect the medical mission, regulate healthcare provision in conflict areas, and commit to healthcare provision (mental and physical health services) for the population displaced by conflict.

CONCLUSION

The state's presence, trust, and legitimacy have significantly reduced in recent years. However, it is crucial to restore them by ensuring that state and health services are physically present in all territories, including remote and rural areas.

The Governance of Childhood Vaccination Services in Crisis Settings: A Scoping Review

The persistence of inadequate vaccination in crisis-affected settings raises concerns about decision making regarding vaccine selection, timing, location, and recipients. This review aims to describe the key features of childhood vaccination intervention design and planning in crisis-affected settings and investigate how the governance of childhood vaccination is defined, understood, and practised. We performed a scoping review of 193 peer-reviewed articles and grey literature on vaccination governance and service design and planning. We focused on 41 crises between 2010 and 2021. Following screening and data extraction, our analysis involved descriptive statistics and applying the governance analysis framework to code text excerpts, employing deductive and inductive approaches. Most documents related to active outbreaks in conflict-affected settings and to the mass delivery of polio, cholera, and measles vaccines. Information on vaccination modalities, target populations, vaccine sources, and funding was limited. We found various interpretations of governance, often implying hierarchical authority and regulation. Analysis of governance arrangements suggests a multi-actor yet fragmented governance structure, with inequitable actor participation, ineffective actor collaboration, and a lack of a shared strategic vision due to competing priorities and accountabilities. Better documentation of vaccination efforts during emergencies, including vaccination decision making, governance, and planning, is needed. We recommend empirical research within decision-making spaces.

Association between air raids and reported incidence of cholera in Yemen, 2016-19: an ecological modelling study

BACKGROUND

Yemen continues to endure cholera outbreaks during ongoing conflict and destructive environmental events. Air raids have been used throughout the conflict to target military and civilian infrastructure. We aimed to assess the association between air raids and cholera incidence while taking into account geographical, environmental, economic, and demographic factors that drive outbreaks.

METHODS

In this ecological modelling study, we used data from Sept 12, 2016, to Dec 29, 2019, for the number of air raids, vegetation coverage, surface water, precipitation, temperature, economic variables, and cholera case and population data to model the association between conflict and the weekly incidence of cholera (per 100 000 people) in Yemen. Data were transformed into weekly intervals and governorates were categorised according to air raid severity (the number of raids in the previous 3 months). We used a negative binomial generalised additive model that accounted for geographical location and environmental, temporal, economic, and demographic variables to estimate incidence rate ratios for the association between air raid severity and cases of cholera.

FINDINGS

During the study period, 2 107 912 cases of cholera were reported in Yemen, and a minimum of 11 366 air raids were recorded. After controlling for relevant factors, compared with no air raids, all other levels of air raid severity were significantly associated with cholera incidence. The largest effect was noted in governorates with severe air raid levels (ie, ≥76 during the previous 3 months), which had an incidence rate ratio of 2·06 (95% CI 1·59-2·69; p<0·0001) for cholera compared with governorates with no air raids in the previous 3 months. Economic factors were also significantly associated with increased cholera incidence.

INTERPRETATION

Air raids were significantly associated with the burden of cholera in Yemen, even after controlling for other relevant factors. Quantification of this relationship further shows that the cholera outbreak is largely a result of human action rather than a natural occurrence, and demonstrates the conflict's devastating effects on health. Our findings highlight the need for ceasefire and peacebuilding efforts, as well as infrastructure and economic restoration, to reduce Yemen's cholera burden.

FUNDING

None.

TRANSLATION

For the Arabic translation of the abstract see Supplementary Materials section.

Health system governance assessment in protracted crisis settings: Northwest Syria

BACKGROUND

Since the withdrawal of government forces from Northwest Syria due to the conflict, several national initiatives have aimed to create alternative governance approaches to replace the central governmental system. One of the recent initiatives was the formulation of so-called 'Central Bodies' as institutional governance structures responsible for thematic planning and service provision; for example, the referral unit is responsible for planning and delivering medical referral services. However, the governance and administrative rules of procedures of these bodies could be immature or unsystematic. Assessing the governance of this approach cannot be condoned, especially with the urgent need for a methodical approach to strategic planning, achieving strategic humanitarian objectives, and efficiently utilizing available resources. Multiple governance assessment frameworks have been developed. However, none were created to be applied in protracted humanitarian settings. This research aims to assess the extent to which the existing health governance structure (central bodies) was capable of performing the governance functions in the absence of a legitimate government in Northwest Syria.

METHODS AND MATERIALS

A governance assessment framework was adopted after an extensive literature review and group discussions. Four principles for the governance assessment framework were identified; legitimacy, accountability and transparency, effectiveness and efficiency, and strategic vision. Focus Group Discussions were held to assess the levels of the selected principles on the governance thermometer scale. Qualitative and quantitative data were analyzed using NVivo 12 and SPSS 22 software programs, respectively.

RESULTS

The level of the four principles on the governance thermometer scale was between the lowest and middle quintiles; 'very poor or inactive' and 'fair and requires improvement', respectively. The results indicate that the governance approach of Central Bodies in NWS is underdeveloped and summons comprehensive systematic development. The poor internal mechanisms, poor planning and coordination, and the absence of strategic vision were among the most frequent challenges to developing the approach.

CONCLUSION

Humanitarian actors and donors should pay more attention to health governance approaches and tools in protracted crises. The central bodies must improve coordination with the stakeholders and, most importantly, strategic planning. Establishing or utilizing an independent planning committee, with financial and administrative independence, is crucial to maintain and improving contextual governance mechanisms in Northwest Syria.

Impact of a double catastrophe, war and COVID-19, on health service utilization of a tertiary care hospital in Tigray: an interrupted time-series study

BACKGROUND

In developing nations with fragile healthcare systems, the effect of war is likely to be much worse than it would be in more developed countries. The presence of COVID-19 will also likely exacerbate the war's impact. This study set out to determine the effect of armed conflict and the COVID-19 pandemic on health service utilization at Ayder Comprehensive Specialized Hospital, in the Tigray region of Ethiopia.

METHODS

An interrupted time-series study design was used to analyze patient visits over forty-eight consecutive months (from July 2017 to June 2021) at inpatient, outpatient, and emergency departments. Data were analyzed using segmented regression analysis with a defined outcome of level and trend changes in the number of patient visits. In addition, negative binomial regression analysis was also used to estimate the impact of both COVID-19 and the war on patient flow.

RESULTS

There were 59,935 admissions, 876,533 outpatient visits, and 127,872 emergency room visits. The effect of COVID-19 was seen as soon as the Tigray regional government imposed comprehensive restrictions. Immediately after COVID-19 appeared, all the service areas exhibited a significant monthly drop in visits; [-35.6% (95% CI: -48.2%, -23.1%)] for inpatient, [-60.6% (95% CI: -71.6%, -49.5%)] for outpatient, and [-44.1% (95% CI: -59.5%, -28.7%)] for emergency department visits. The impact of the war became apparent after a lag time of one month. Controlling the effects of time and COVID-19, the war led to a significant fall in inpatient visits [-44.3% (95% CI: -67.2%, -21.5%)], outpatients [-52.1% (95% CI: -82.7%, -21.5%)], and emergency-room attendances [-45.0% (95% CI: -74.8%, -15.2%)]. An upward trend in outpatient flow was observed after the war [1,219.4 (95% CI: 326.1, 2,112.8)].

CONCLUSIONS

The present study has clearly indicated that the war and COVID-19 have led to a large reduction in admissions, outpatient attendance, and emergency department visits. The evidence from this study suggests that due to this double catastrophe, thousands of patients could not gain access to healthcare, with probable negative consequences. Governments and organizations should implement measures to buttress the healthcare system to maintain pre-war status of service.

Knowledge, attitudes, and practices toward COVID-19 prevention in Yemen: a community-based cross-sectional study

Background

Pandemics, especially in fragile war-torn countries like Yemen, challenge their already strained health systems. Community adherence to pandemic prevention measures is necessary to curb the severity and spread of emerging pandemics - which is influenced by factors, such as people's knowledge and attitudes toward the pandemic. No studies in Aden have been published on the communities' knowledge, attitudes, and practices (KAP) toward COVID-19 prevention to date. To understand adherence to pandemic prevention measures in contexts with fragile health systems, this study investigated KAP of Yemeni participants toward the COVID-19 pandemic.

Methods

We conducted face-to-face semi-structured questionnaires among 400 eligible participants whom were identified for participation in this study through systematic household sampling from eight districts in Aden, Yemen. Eligible participants were Yemeni community members who were ≥ 18 years, living for more than 10 years in Yemen, and were willing to voluntarily participate in the study. The questionnaire included questions surrounding the participants' COVID-19 knowledge (e.g., awareness of spread and prevention), attitudes (e.g., willingness to accept the vaccine or other prevention measures), and prevention practices during the pandemic (e.g., mask wearing, social distancing, vaccine uptake). Total KAP scores were calculated. Univariate and bivariate statistical analyses were conducted using STATA 13 software.

Results

From January to May 2021 we conducted 400 questionnaires with Yemeni community members. The average age was 41.5 ± 14.5 years (range 18-86 years). The results demonstrated that the participants in this study had an intermediate knowledge (53%) and fair attitude (58%) scores. However, participants reported very poor COVID-19 prevention practices- with only 11% demonstrating these practices. Only 25% (100/400) practiced social distancing, 25% (98/400) wore a mask, and only 6% (27/400) of participants accepted (at least one dose of) the COVID-19 vaccine. Factors associated with increased knowledge were being male, married, and surprisingly those having a primary and middle school education levels (p < 0.05). Also participants who were diagnosed with COVID-19 or had a family member diagnosed with COVID-19 (vs. those not diagnosed OR = 2.08, 95% CI 1.07-3.78, p < 0.05) were more likely to know that the vaccine protects against severe COVID-19 infection and were more likely to apply good practices such as accepting the vaccine (OR = 2.65, 95% CI 1.17-6.00, p < 0.05) compared to those who were not.

Conclusion

These findings raise awareness for the need of community-oriented education programs for COVID-19 which considers associated factors to improve the level of public knowledge, attitudes, and practices.

Analyzing Yemen's health system at the governorate level amid the ongoing conflict: a case of Al Hodeida governorate

Background

Yemen is regarded as one of the Middle East's poorest countries. Decades of political, economic, and social difficulties have culminated in the current protracted conflict. As a result, the globe experienced its worst humanitarian catastrophe. The ongoing war has affected several public services, notably the health sector, which is operating at less than half its capacity. This study aims to examine Yemen's health system at the governorate level (Al Hodeida) amidst the current conflict. It analyzes current challenges and produces suggestions for enhancement.

Methods

The study used qualitative research methods such as Key Informant Interviews (KIIs) and document analysis. The study used WHO's health systems framework to measure health system performance. Twelve KIIs were conducted via Skype with several health stakeholders. In addition, documents were analyzed to inform the subject guide, generate themes, and aid in the triangulation of results.

Results

According to the study findings, the governorate health system managed to offer a minimum level of healthcare services while making some advances in outbreak control jointly with other partners. One of the main difficulties confronting the governorate's health system is a severe lack of financial resources forcing it to rely entirely on external aid. Furthermore, other significant deficiencies include inadequate health system organogram, low reporting capacities, insufficient funding, and scarcity of health professionals.

Conclusion

Yemen's frail health system has been weakened by almost eight years of insecurity and conflict. If the current scenario continues, most of Yemen's health system's operations and indicators will likely deteriorate. On the other hand, progress in some areas, such as primary healthcare (PHC) services and disease management, is remarkable. However, for better performance, Yemen's health system leadership and stakeholders should seek a holistic strategy to improve the entire dimensions of the health system.

Minimal resilience and insurgent conflict: qualitative analysis of the resilience process in six primary health centres in central Mali

BACKGROUND

In the context of universal health coverage in the Sahel, the study focuses on primary health centres and the difficulties of their implementation in the context of insurgency conflicts in central Mali.

METHODS

This is qualitative research through a multiple case study. We selected six health centres according to a reasoned choice to bring together contrasting situations. We conducted 96 semistructured interviews and consulted secondary quantitative data on attendance. By focusing on community health centres, the conceptual approach focuses on the process of resilience that unfolds in a dual context of chronic health system dysfunctions and armed conflict.

RESULTS

The resilience strategies deployed by health professionals were relatively basic and uncoordinated. In the end, it was the individuals who showed absorption. However, their room for manoeuvre was limited. In the most isolated health centres, resilience was based on subordinate, poorly trained staff, often from the locality. Degraded working conditions and fear caused a form of resignation among health workers.

CONCLUSION

The strategies and resources used showed a form of minimal resilience. This form is unfolding in a context marked by two structuring features. On the one hand, the Malian health system was relatively dysfunctional before the crisis, and on the other hand, the type of conflict was relatively low intensity that allowed health centres to remain open.

Recurrence Rate of Pulmonary Tuberculosis in Patients Treated with the Standard 6-Month Regimen: Findings and Implications from a Prospective Observational Multicenter Study

Tuberculosis (TB) recurrence following successful treatment is a significant challenge in TB control programs. However, the rate of TB recurrence varies among studies. It depends on several factors, including the country/region where the investigation occurs, the study design, sample characteristics, and the anti-TB regimen used. In Yemen, a few previous studies examined the rate of TB recurrence and reported high recurrence rates, with a 5-year recurrence rate of approximately 9.5%. However, they were conducted before 2010 using the previous anti-TB regimen which was phased out and replaced with the World Health Organization's (WHO) standard 6-month TB regimen. Consequently, this study aimed to examine the rate of TB recurrence after the implementation of the WHO standard 6-month regimen in Yemen. A prospective observational study was conducted with patients diagnosed with drug-susceptible pulmonary TB. The patients were recruited from five health centers with TB units in five governorates from January to December 2011. All the patients were followed up for five years after treatment completion. A total of 439 patients who completed the anti-TB regimen met the inclusion criteria and were included in the study. During the 5-year follow-up period, 8 patients (1.8%) died, and 13 patients (2.96%) were lost to follow-up, resulting in a final cohort of 418 patients. Of the cohort, 50.5% (n = 211) were male, while 49.5% (n = 207) were female patients. Of the patients, 129 patients (30.9%) were illiterate, 56 (13.4%) had cavitary pulmonary disease, and 6.2% (n = 26) had diabetes. The overall 5-year rate of TB recurrence in this study for the patients receiving the standard 6-month regimen was 2.9% (12/418). Moreover, almost half of the recurrent cases (41.7%; n = 5) were seen during the first year of the follow-up period. Some patient groups with risk factors recorded a higher recurrence rate, including patients with diabetes (15.4%), non-compliant patients (14.3%), pre-treatment lung cavitation patients (8.9%), illiterate patients (7.8%), and underweight patients (5.1%). In conclusion, the overall TB recurrence rate with the standard 6-month regimen was lower than that with the previous TB regimens. However, more efforts are needed to decrease TB recurrence rates further and achieve a durable cure for TB. In addition, healthcare professionals and TB control programs should consider potential risk factors of recurrence and address them to provide optimal care.

Factors associated with reporting good maternal health-related knowledge among rural mothers of Yemen

Increasing women's knowledge about maternal health is an important step towards empowering them and making them aware of their rights and health status, allowing them to seek appropriate health care. In Yemen, the ongoing conflict has hampered the delivery of health information to women in public health facilities. This study examined rural women's knowledge of, and attitude towards, maternal and child health in Yemen and identified the factors associated with good maternal health knowledge. The study was conducted between August and November 2018. A sample of 400 women aged 15-49 years who had delivered in the 6 months prior to the survey were systematically selected from selected public health facilities in Abyan and Lahj. Women were interviewed using a structured questionnaire to gather data on their demographic and economic characteristics, obstetric history and responses to health knowledge and attitude questions. Women's knowledge level was assessed as poor or good using the mean score as a cut-off. Chi-squared test and multiple logistic regression analysis were used to identify statistically significant factors associated with good maternal health knowledge. The percentage of women who had good knowledge was 44.8% (95% CI: 39.8-49.8). Women's attitude towards maternal health was negative in the areas of early ANC attendance, managing dietary regime and weight during pregnancy, facility delivery, PNC visits, cord care and mother and child health management. Women with primary education, whose husbands had received no formal education, who had their first ANC visit from the second trimester of pregnancy and who had fewer than four ANC visits were more likely to have poor health knowledge. Conversely, those with higher household income and only one child were more likely to have good maternal health knowledge. Overall, women's knowledge on maternal and child health care in rural areas of Yemen was low. Strategies are needed to increase rural women's knowledge on maternal and child health in this conflict-affected setting.

Exploring women's experiences during childbirth in health facilities during COVID-19 pandemic in occupied palestinian territory: a cross-sectional community survey

INTRODUCTION

This study aims to assess the prevalence of mistreatment during childbirth in the occupied Palestinian territory and to explore factors associated with mistreatment.

METHODS

A cross-sectional study of women who gave birth in the West Bank and Gaza Strip health facilities. The survey was administered over the phone to women up to 8 weeks post-partum. Data collection took place between July 2020 and March 2021.

RESULTS

A total of 745 women participated in the study, 36·25% were from the Gaza Strip and 63·75% from the West Bank. The prevalence of mistreatment was 18·8% in which women reported any verbal abuse, physical abuse, or stigma or discrimination during childbirth, with verbal abuse as the most common form of mistreatment reported. Physical abuse was more likely to be reported by women with no labour companion with them (OR: 3·11, 95%CI: 1·24 - 7·99). Verbal abuse was more likely to be reported by women with less than three live births (OR: 1·71, 95%CI: 1·06 - 2·76, women with no birth companion (OR: 2·72, 95%CI: 1·36 - 3·80) and more likely to be reported if curtains wre not used (OR: 2·55, 95%CI: 1·33 - 4·88). Women with less education were more likely to report long waiting times or delays in receiving services compared to women with higher education (OR: 1·40, 95%CI: 1·06 - 2·10).

CONCLUSION

For the first time using the World Health Organisation (WHO) tool in the Eastern Mediterranean region, the study findings, show the occurrence of mistreatment and identify areas to be strengthened to ensure that all women have a respectful childbirth experience within health facilities.

Adult mortality before and during the first wave of COVID-19 pandemic in nine communities of Yemen: a key informant study

INTRODUCTION

Widespread armed conflict has affected Yemen since 2014. To date, the mortality toll of seven years of crisis, and any excess due to the COVID-19 pandemic, are not well quantified. We attempted to estimate population mortality during the pre-pandemic and pandemic periods in nine purposively selected urban and rural communities of southern and central Yemen (Aden and Ta'iz governorates), totalling > 100,000 people.

METHODS

Within each study site, we collected lists of decedents between January 2014-March 2021 by interviewing different categories of key community informants, including community leaders, imams, healthcare workers, senior citizens and others. After linking records across lists based on key variables, we applied two-, three- or four-list capture-recapture analysis to estimate total death tolls. We also computed death rates by combining these estimates with population denominators, themselves subject to estimation.

RESULTS

After interviewing 138 disproportionately (74.6%) male informants, we identified 2445 unique decedents. While informants recalled deaths throughout the study period, reported deaths among children were sparse: we thus restricted analysis to persons aged ≥ 15 years old. We noted a peak in reported deaths during May-July 2020, plausibly coinciding with the first COVID-19 wave. Death rate estimates featured uninformatively large confidence intervals, but appeared elevated compared to the non-crisis baseline, particularly in two sites where a large proportion of deaths were attributed to war injuries. There was no clear-cut evidence of excess mortality during the pandemic period.

CONCLUSIONS

We found some evidence of a peak in mortality during the early phase of the pandemic, but death rate estimates were otherwise too imprecise to enable strong inference on trends. Estimates suggested substantial mortality elevations from baseline during the crisis period, but are subject to serious potential biases. The study highlighted challenges of data collection in this insecure, politically contested environment.

Long-acting reversible contraceptives utilization and its determinants among married Yemeni women of childbearing age who no longer want children

Some contraceptive methods, such as long-acting and permanent methods, are more effective than others in preventing conception and are key predictors of fertility in a community. This study aimed to determine which factors were linked to married women of childbearing age who no longer desired children using long-acting reversible contraceptives (LARCs) in Yemen. We used a population-based secondary dataset from Yemen's National Health and Demographic Survey (YNHDS), conducted in 2013. The study analyzed a weighted sample of 5149 currently married women aged 15 to 49 years who had no plans to have children. Logistic regression analyses were used to investigate the parameters linked to the present use of LARCs. The final model's specifications were evaluated using a goodness-of-fit test. An alpha threshold of 5% was used to determine statistical significance. Of the total sample, 45.3% (95% CI: 43.3-47.4) were using contraception. LARCs were used by 21.8% (95% CI: 19.6-24.1) of current contraceptive users, with the majority (63.8%) opting for short-acting reversible contraceptives (SARCs). In the adjusted analysis, maternal education, husbands' fertility intention, place of residence, governorate, and wealth groups were all linked to the usage of LARCs. According to the findings, women whose spouses sought more children, for example, were more likely to use LARCs than those who shared their partners' fertility intentions (AOR = 1.44; 95% CI: 1.07-1.94; P = .015). In this study, married women of reproductive age who had no intention of having children infrequently used contraception and long-acting methods. Improving women's education and socioeconomic status could contribute to increasing their use of LARCs.

Early Determination of Case Fatality Rate of Covid-19 Pandemic During the Ongoing Yemeni Armed Conflict

OBJECTIVES

To determine the case-fatality rate (CFR) of coronavirus disease 2019 (Covid-19) and its associated determinants in order to understand the true magnitude of the problem during the ongoing conflict in Yemen.

METHODS

The CFR among the confirmed Covid-19 cases in Yemen was calculated. The data was retrieved from national Covid-19 surveillance between April 10, when the first COVID-19 case reported, and May 31, 2020.

RESULTS

A total of 419 confirmed Covid-19 cases were reported. There were 14.1% and 5.7% of cases who required intensive care and mechanical ventilators, respectively. Out of the total cases, 95 deaths were reported, giving a CFR of 22.6% which is much higher compared to other countries. CFR was significantly higher among elderly people compared to young adults and varied between governorates. Mortality was associated with pre-existing hypertension (OR: 2.30; 95% CI: 1.58, 3.54) and diabetes (OR: 1.68; 95% CI: 1.08, 2.61).

CONCLUSIONS

The elderly and those with comorbidities, in particular hypertension and diabetes, have higher risk for poor outcomes and therefore should receive more attention in the clinical setting. Preventive measures should also be prioritized to protect those groups in order to reduce the severe cases and deaths-associated COVID-19 in armed-conflict.

Research progress of health care in Yemeni children during the war: review

BACKGROUND

Yemen crisis, which has been going on for more than six years, represents one of the most gruesome human plights in the modern history, especially children.

OBJECTIVES

This research aimed to present a comprehensive view of Yemeni children's studies during the ongoing war period, to come up with a comprehensive base that concerns humanitarians, researchers, decision-makers, and general public at large about the reality of the predicament of Yemeni child.

METHOD

We searched databases and identified 373 articles, of which 68 were included in this review. Review of literature between 2014 and 2020 is taken from academic sources, multilateral organizations, donors, and governmental and non-governmental organizations. The data are analyzed by date and governorates.

RESULTS

We chose 68 articles and divided them according to the diseases and health conditions as follows: infectious diseases (15 studies), non-infectious diseases (10 studies), blood-related diseases (7 studies), oral and dental problems (12 studies), accidents and injuries (2 studies), health system (16 studies), family and community (6 studies). Moreover, the studies were divided geographically as follows: 7 studies that were almost comprehensive for all governorates; additional studies were conducted for Amanat Al Asimah (21 studies), Taiz (12 studies), Aden and Al Hudaydah (7 studies for each), Dhamar and Ibb (6 studies for each), Abyan and Lahij (2 study for each). As for Al Bayda, Marib, Sana'a, and Socotra, each of them had one study.

CONCLUSION

Our assessment revealed that the ongoing Yemen crisis is underrated and largely neglected. The studies conducted so far do match the ground reality both in terms of inclusiveness and numbers.

The National Health Cluster in Yemen: assessing the coordination of health response during humanitarian crises

Yemen has been facing political, economic and social challenges since 1990. The fragility of Yemen's situation has led to a widespread conflict in 2015, resulting in the world's largest humanitarian crisis. Amid the humanitarian catastrophe and the collapsing health system, a platform for coordinating humanitarian health response, called the National Health Cluster, has expanded its operations across the country. The study aims to evaluate the performance of the National Health Cluster in Yemen between 2015 and 2019. A qualitative research design was employed, and ten semi-structured interviews with key Health Cluster stakeholders were conducted. The study applied the Active Learning Network for Accountability and Performance in Humanitarian Action (ALNAP) guide to evaluating humanitarian action using the Development Assistance Committee (DAC) criteria. Six evaluation criteria were selected: relevance, effectiveness, efficiency, effects, connectedness and participation. Inputs from interviews were manually transcribed and then analysed using NVivo 12 software. The study results indicate that the Health Cluster in Yemen has contributed to saving lives and strengthening the local health capacities in diseases surveillance. In addition, its positive effect was evident in improving the humanitarian health response coordination. Nevertheless, engaging health stakeholders, especially national organisations, was suboptimal. Exit strategies were lacking, while services to address mental health, non-communicable diseases, senior citizens and people with disabilities were not prioritised in the Health Cluster strategic plans and partners' response. To ameliorate Health Cluster performance, revising its objectives and establishing a cluster-specific rapid response funding mechanism are pivotal. Furthermore, preparing the national health system for recovery and actively engaging all stakeholders in the Health Cluster' response and strategic decisions would maximise its positive impact on Yemen's health system and population.

Impact of the COVID-19 pandemic on the utilisation of health services at public hospitals in Yemen: a retrospective comparative study

BACKGROUND

The COVID-19 pandemic has led to a global crisis, creating an unprecedented situation, which has taken the world by storm, overshadowing on all life' aspects and having a significant impact on the health systems of most countries. In this study, the delivery of health services is investigated both before and during the outbreak of the COVID-19 pandemic at public hospitals in Yemen to assess the impact of COVID-19 on the utilisation of health services.

METHOD

Data collected from 127 hospitals in Yemen were reviewed using the DHIS2 system. The data represented 3 months before the outbreak of COVID-19 between January and March 2020 and during the outbreak of COVID-19 outbreak between April and June 2020. The results were then compared with the same period in 2019. The utilisation pattern of healthcare services during the period of investigation was compiled and analysed by applying a generalised estimating equation (GEE) to examine the effects of the COVID-19 outbreak in Yemen. The data collected from the targeted hospitals included information related to consultations, surgeries, deliveries, C-sections and penta-3rd dose immunisation.

RESULTS

The trendline of health services used during the pandemic showed a gradual decline beginning from April 2020 for consultations, surgeries and penta-3rd dose utilisation. The GEE model revealed a significant effect (p<0.05) during the outbreak compared with preoutbreak in the consultation services (B=-1,343.9; 95% CI -1,767.2 to -920.6; χ²=38.718), surgeries (B=-54.98; 95% CI -79.13 to -30.83, χ²=19.911) and penta-3rd dose (B=-24.47; 95% CI -30.56 to -18.38 and χ²=62.010). As for deliveries and C-sections, the results were shown to be statistically non-significant.

CONCLUSION

The impact of COVID-19 on continuity of health services delivery in Yemen has been distinct and profound, where the study revealed that the number of the consultations, surgeries and number of vaccinated children have been declined during the COVID-19 pandemic, likely due to the partially lockdown measures taken and fear of being infected. However, the deliveries and C-section services remained nearly in the same level and did not affect by the COVID-19 pandemic.

Field Epidemiology Training Program Response to COVID-19 During a Conflict: Experience From Yemen

COVID-19 pandemic has underscored the need for a well-trained public health workforce to save lives through timely outbreaks detection and response. In Yemen, a country that is entering its seventh year of a protracted war, the ongoing conflict severely limited the country's capacity to implement effective preparedness and response measures to outbreaks including COVID-19. There are growing concerns that the virus may be circulating within communities undetected and unmitigated especially as underreporting continues in some areas of the country due to a lack of testing facilities, delays in seeking treatment, stigma, difficulty accessing treatment centers, the perceived risks of seeking care or for political issues. The Yemen Field Epidemiology Training Program (FETP) was launched in 2011 to address the shortage of a skilled public health workforce, with the objective of strengthening capacity in field epidemiology. Thus, events of public health importance can be detected and investigated in a timely and effective manner. During the COVID-19 pandemic, the Yemen FETP's response has been instrumental through participating in country-level coordination, planning, monitoring, and developing guidelines/standard operating procedures and strengthening surveillance capacities, outbreak investigations, contact tracing, case management, infection prevention, and control, risk communication, and research. As the third wave is circulating with a steeper upward curve than the previous ones with possible new variants, the country will not be able to deal with a surge of cases as secondary care is extremely crippled. Since COVID-19 prevention and control are the only option available to reduce its grave impact on morbidity and mortality, health partners should support the Yemen FETP to strengthen the health system's response to future epidemics. One important lesson learned from the COVID-19 pandemic, especially in the Yemen context and applicable to developing and war-torn countries, is that access to outside experts becomes limited, therefore, it is crucial to invest in building national expertise to provide timely, cost-effective, and sustainable services that are culturally appropriate. It is also essential to build such expertise at the governorate and district levels, as they are normally the first respondents, and to provide them with the necessary tools for immediate response in order to overcome the disastrous delays.

Analyzing Healthcare Facility Resilience: Scientometric Review and Knowledge Map

In contemporary “high-risk” society, unexpected disasters (epidemics and extreme weather) and chronic pressures (aging problems) put tremendous pressure on healthcare facilities. Enhancing the healthcare facilities' resilience ability to resist, absorb, and respond to disaster disruptions is urgent. This study presents a scientometric review for healthcare facility resilience research. A total of 374 relevant articles published between 2000 and 2020, collected from Web of Science (WoS) core collection database, Scopus database and MEDLINE database were reviewed and analyzed. The results indicated that research on resilience in healthcare facilities went through three development periods, and the research involved countries or institutions that are relatively scattered. The studies have been focused on the subject categories of engineering, public, environmental, and occupational health. The keywords of “resilience,” “hospital,” “disaster,” “healthcare,” and “healthcare facility” had the most frequency. Furthermore, based on the literature co-citation networks and content analysis, the detected seven co-citation clusters were grouped into four knowledge domains: climate change impact, strengthening resilience in response to war and epidemic, resilience assessment of healthcare facility, and the applications of information system. Moreover, the timeline view of literature reflected the evolution of each domain. Finally, a knowledge map for resilience of healthcare facilities was put forward, in which critical research contents, current knowledge gaps, and future research work were discussed. This contribution will promote researchers and practitioners to detect the hot topics, fill the knowledge gaps, and extend the body of research on resilience of healthcare facilities.

Respiratory Care Profession in Yemen: Past, Present, and Future

The respiratory care (RC) discipline in Yemen emerged 15 years ago. Although there have been significant advancements in the domain, no documented history is available regarding its development and progress over the years. This paper highlights the history and development of the RC field in Yemen and highlights the major events that took place during these times that shaped the development of the RC discipline. A detailed, comprehensive review and assessment were conducted through direct communication, personal interviews, and the review of existing documents in the hospital's archives, academic institutes, Ministry of Public Health and Population, and other relevant resources. The gathered data were evaluated for relevance and grouped on a thematic basis. So far, this is the first paper on the comprehensive history and development of the RC discipline in Yemen. How to cite this article: Hamilah SN, Ahmari MAI, Alsabri MA, Alrubaiee GG. Respiratory Care Profession in Yemen: Past, Present, and Future. Indian J Crit Care Med 2021;25(8):890-895.

Misinformation, perceptions towards COVID-19 and willingness to be vaccinated: A population-based survey in Yemen

BACKGROUND

Since the beginning of the COVID-19 outbreak, many pharmaceutical companies have been racing to develop a safe and effective COVID-19 vaccine. Simultaneously, rumors and misinformation about COVID-19 are still widely spreading. Therefore, this study aimed to investigate the prevalence of COVID-19 misinformation among the Yemeni population and its association with vaccine acceptance and perceptions.

METHODS

A cross-sectional online survey was conducted in four major cities in Yemen. The constructed questionnaire consisted of four main sections (sociodemographic data, misinformation, perceptions (perceived susceptibility, severity, and worry), and vaccination acceptance evaluation). Subject recruitment and data collection were conducted online utilizing social websites and using the snowball sampling technique. Descriptive and inferential analyses were performed using SPSS version 27.

RESULTS

The total number of respondents was 484. Over 60% of them were males and had a university education. More than half had less than 100$ monthly income and were khat chewers, while only 18% were smokers. Misinformation prevalence ranged from 8.9% to 38.9%, depending on the statement being asked. Men, university education, higher income, employment, and living in urban areas were associated with a lower misinformation level (p <0.05). Statistically significant association (p <0.05) between university education, living in urban areas, and being employed with perceived susceptibility were observed. The acceptance rate was 61.2% for free vaccines, but it decreased to 43% if they had to purchase it. Females, respondents with lower monthly income, and those who believed that pharmaceutical companies made the virus for financial gains were more likely to reject the vaccination (p <0.05).

CONCLUSION

The study revealed that the acceptance rate to take a vaccine was suboptimal and significantly affected by gender, misinformation, cost, and income. Furthermore, being female, non-university educated, low-income, and living in rural areas were associated with higher susceptibility to misinformation about COVID-19. These findings show a clear link between misinformation susceptibility and willingness to vaccinate. Focused awareness campaigns to decrease misinformation and emphasize the vaccination's safety and efficacy might be fundamental before initiating any mass vaccination in Yemen.

Neonatal sepsis in Sana'a city, Yemen: a predominance of Burkholderia cepacia

Background

Neonatal sepsis is a global concern with increasing morbidity and mortality. The burden of neonatal sepsis is highest in developing countries, especially in those lacking proper surveillance systems. The causative pathogens and their drug-resistance levels vary between countries with emergence of multidrug resistance organisms. Thus, accurate records on the recent trends of organisms causing neonatal sepsis will provide vital information for appropriate intervention. We aimed to investigate neonatal sepsis, identify its associated factors and causative pathogens and to assess the antibiotic susceptibility patterns in Sana’a city, Yemen.

Methods

A cross-sectional study was conducted on neonates admitted to intensive care units of six hospitals in Sana’a city, Yemen, in the period from January 15, to March 30, 2020. Natal and prenatal medical data were collected using well-structured questionnaire. Neonates were subjected to sepsis work-up including blood culture, complete blood count and C-reactive protein. Organisms were identified by Gram staining and analyzed by the VITEK II system for bacterial bio-typing and antibiotic susceptibility testing.

Findings

Of the 199-neonates with suspected neonatal sepsis, 154 (77.38%) had culture-proven sepsis. Early-onset neonatal sepsis (EOS) was higher (50.25%; 100/199) than late-onset neonatal sepsis (LOS) (27.13%; 54/199). Multivariable analysis identified vaginal delivery as an independent risk factor for neonatal sepsis p = 0.005. Majority of isolated bacteria (74.39%) were gram-negative with Burkholderia cepacia (39%) and Klebsiella oxytoca (13%) being the most common pathogens of EOS and LOS. The most common gram-positive pathogens were Staphylococcus haemolyticus (9.1%) and Staphylococcus epidermidis (7.1%). B. cepacia showed multidrug resistance except for cefepime. All Klebsiella species isolates (100%) and most Pantoea species (93%) were ESBL and carbapenemase positive. All Escherichia coli and Acinetobacter baumannii isolates were ESBL positive. A significant number of gram-positive bacteria showed resistance to vancomycin.

Conclusion

The study findings show a high proportion of neonatal sepsis among neonates admitted to hospitals in Sana’a city with antibiotic-resistant B. cepacia being the single most common pathogen causing EOS and LOS. Findings also emphasize the emerging threat of multidrug-resistant bacteria in neonatal units and will help develop evidence-based management of neonatal sepsis in Yemen.

HIV stigma in the teaching hospitals in Sana'a, Yemen: a conflict and low-resource setting

BACKGROUND

HIV stigma undermines a person's wellbeing and quality of life and hinders HIV control efforts. This study examined the extent and drivers of HIV stigma in the teaching hospitals in Sana'a City, Yemen. The country has low HIV prevalence (4000 (2000-11,000) per 100,000) and limited HIV control funds, worsened by a long conflict and an economic crisis.

METHODS

We conducted a cross-sectional study of 320 Yemeni health professionals in all the four teaching hospitals in Sana'a City. Data were collected anonymously, using an adapted self-completed Arabic version of the Health Policy Project HIV Stigma tool. The questionnaire covered the respondents' background, the stigmatising practices, and potential personal and professional drivers of stigma.

RESULTS

The majority of the participants were: females (68%), 20-39 years old (85%), nurses (84%), and holding a nursing diploma (69%) or a bachelor's degree (27%). None of the hospitals had institutional policies against HIV stigma, and 93% of the participants believed the current infection control measures were inadequate. Less than half of the participants provided care for people living with HIV (PLHIV) (45%), had received HIV training (33%), and were confident that their HIV knowledge was adequate (23%). The majority indicated a preference to test patients for HIV prior to surgical procedures (77%) and disclose positive HIV results to others (99%) without prior knowledge or consent. All the participants had exhibited a form of HIV-related stigmatization, such as avoiding physical contact with PLHIV (87%) or wearing gloves throughout the consultation (96.5%). These practices were significantly correlated with the fear of infection, high perceived risk of infection, and poor work environment (p < 0.05).

CONCLUSION

PLHIV face widespread stigmatizing behaviour in the teaching hospitals in Sana'a City, consistent with the higher level of stigma in low HIV prevalence countries and its links to the fear of infection, poor HIV knowledge, and limited funding for HIV control. Stigma reduction interventions are required at institutional and individual levels. In addition, anti-discrimination policies and structural adjustments are needed, in combination with training on HIV and universal precautions, and action to tackle negative attitudes towards PLHIV and key populations.

Inequalities in catastrophic health expenditures in conflict-affected areas and the Colombian peace agreement: an oaxaca-blinder change decomposition analysis

BACKGROUND

The present study analyzes inequalities in catastrophic health expenditures in conflict-affected regions of Meta, Colombia and socioeconomic factors contributing to the existence and changes in catastrophic expenditures before and after the sign of Colombian Peace Agreement with FARC-EP guerilla group in 2016.

METHODS

The study uses the results of the survey Conflicto, Paz y Salud (CONPAS) conducted in 1309 households of Meta, Colombia, a territory historically impacted by armed conflict, for the years 2014 and 2018. We define catastrophic expenditures as health expenditures above 20% of the capacity to pay of a household. We disaggregate the changes in inequalities in catastrophic expenditures through the Oaxaca-Blinder change decomposition method.

RESULTS

The incidence of catastrophic expenditures slightly increased between 2014 to 2018, from 29.3 to 30.7%. Inequalities in catastrophic expenditures, measured through concentration indexes (CI), also increased from 2014 (CI: -0.152) to 2018 (CI: -0.232). Results show that differences in catastrophic expenditures between socioeconomic groups are mostly attributed to an increased influence of specific sociodemographic variables such as living in rural zones, being a middle-aged person, living in conflict-affected territories, or presenting any type of mental and physical disability.

CONCLUSIONS

Conflict-deescalation and the peace agreement may have facilitated lower-income groups to have access to health services, especially in territories highly impacted by conflict. This, consequently, may have led to higher levels of out-of-pocket expenditures and, therefore, to higher chances of experiencing catastrophic expenditures for lower-income groups in comparison to higher-income groups. Therefore, results indicate the importance of designing policies that guarantee access to health services for people in conflict -affected regions but also, that minimize health care inequalities in out-of-pocket payments that may arouse between people at different socioeconomic groups.

Epidemiology of type 2 diabetes in the Middle East and North Africa: Challenges and call for action

Type 2 diabetes continues to be a serious and highly prevalent public health problem worldwide. In 2019, the highest prevalence of diabetes in the world at 12.2%, with its associated morbidity and mortality, was found in the Middle East and North Africa region. In addition to a genetic predisposition in its population, evidence suggests that obesity, physical inactivity, urbanization, and poor nutritional habits have contributed to the high prevalence of diabetes and prediabetes in the region. These risk factors have also led to an earlier onset of type 2 diabetes among children and adolescents, negatively affecting the productive years of the youth and their quality of life. Furthermore, efforts to control the rising prevalence of diabetes and its complications have been challenged and complicated by the political instability and armed conflict in some countries of the region and the recent coronavirus disease 2019. Broad strategies, coupled with targeted interventions at the regional, national, and community levels are needed to address and curb the spread of this public health crisis.

Forms of Health System Fragmentation During Conflict: The Case of Yemen

The continuous and protracted conflict in Yemen has evolved into the worst humanitarian situation in modern history. All public structures in the country, including the health system and its basic functions, have been under tremendous pressures. One of the key obstacles to improve the health outcomes in Yemen is fragmentation of the health system. This study aims at exploring and documenting the forms of health system fragmentation in humanitarian and conflict-affected contexts by studying Yemen as a case study. We collected national qualitative data from key informants through in-depth interviews. A pool of respondents was identified from the Ministry of Public Health and Population, donors, and non-governmental organizations. Data were collected between May and June 2019. We interviewed eight key informants and reviewed national health policy documents, and references provided by key informants. Interviews were recorded, transcribed, and analyzed using qualitative content analysis. We further conducted a literature review to augment and triangulate the findings. Six themes emerged from our datasets and analyses, representing various forms of fragmentation: political, structural, inter-sectoral, financial, governance, and health agenda-related forms. Health system fragmentation in Yemen existed before the conflict eruption and has aggravated as the conflict evolves. The humanitarian situation and the collapsing health system enabled the influx of various national and international health actors. In conclusion, the protracted conflict and fragile situation in Yemen have accentuated the fragmentation of the health system. Addressing these fragmentations' forms by all health actors and building consensus on health system agenda are recommended. Health system analysis and in-depth study of fragmentation drivers in Yemen can be beneficial to build common ground and priorities to reduce health system fragmentation. Furthermore, capacity building of a health system is fundamental for the humanitarian development nexus, health system integration, and recovery efforts in the future.

Resilience to maintain quality of intrapartum care in war torn Yemen: a retrospective pre-post study evaluating effects of changing birth volumes in a congested frontline hospital

BACKGROUND

Fragile and conflict-affected states contribute with more than 60% of the global burden of maternal mortality. There is an alarming need for research exploring maternal health service access and quality and adaptive responses during armed conflict. Taiz Houbane Maternal and Child Health Hospital in Yemen was established during the war as such adaptive response. However, as number of births vastly exceeded the facility's pre-dimensioned capacity, a policy was implemented to restrict admissions. We here assess the restriction's effects on the quality of intrapartum care and birth outcomes.

METHODS

A retrospective before and after study was conducted of all women giving birth in a high-volume month pre-restriction (August 2017; n = 1034) and a low-volume month post-restriction (November 2017; n = 436). Birth outcomes were assessed for all births (mode of birth, stillbirths, intra-facility neonatal deaths, and Apgar score < 7). Quality of intrapartum care was assessed by a criterion-based audit of all caesarean sections (n = 108 and n = 82) and of 250 randomly selected vaginal births in each month.

RESULTS

Background characteristics of women were comparable between the months. Rates of labour inductions and caesarean sections increased significantly in the low-volume month (14% vs. 22% (relative risk (RR) 0.62, 95% confidence interval (CI) 0.45-0.87) and 11% vs. 19% (RR 0.55, 95% CI 0.42-0.71)). No other care or birth outcome indicators were significantly different. Structural and human resources remained constant throughout, despite differences in patient volume.

CONCLUSIONS

Assumptions regarding quality of care in periods of high demand may be misguiding - resilience to maintain quality of care was strong. We recommend health actors to closely monitor changes in quality of care when implementing resource changes; to enable safe care during birth for as many women as possible.

COVID-19 in Conflict: The devastating impact of withdrawing humanitarian support on universal health coverage in Yemen

The authors warn that, in the context of Yemen, the closure of humanitarian lifesaving programmes and shifting support toward health security, i.e. to support COVID-19 response, at the expense of primary health care support, will undermine existing health system strengthening efforts, worsen the humanitarian crisis and will accentuate the impact of COVID-19. The authors urge the international community and the Government of Yemen to carefully consider a more comprehensive approach to support Yemen's COVID-19 response while maintaining, and strengthening, essential public health services.

Healthcare workers' knowledge, preparedness, counselling practices, and perceived barriers to confront COVID-19: A cross-sectional study from a war-torn country, Yemen

Background

The coronavirus disease of 2019 (COVID-19) represents a difficult challenge and could have devastating consequences for the healthcare system and healthcare workers in war-torn countries with poor healthcare facilities such as Yemen. Our study aimed to evaluate the knowledge, preparedness, counselling practices of healthcare workers regarding COVID-19, and the perceived barriers to adequately prevent and control COVID-19 in Yemen.

Methods

Healthcare workers (HCWs) from major healthcare facilities participated in this cross-sectional study. A self-administered questionnaire comprising of five main domains (demographics, knowledge, self-preparedness, counselling practice, perceived barriers) was distributed among HCWs after obtaining informed consent. A convenient sampling technique was used. Descriptive and inferential analyses were applied using SPSS software.

Results

A total of 1000 participants were initially targeted to participate in the study with 514 (51.4%) responding, of which 55.3% were female. Physicians and nurses constituted the largest proportion of participants, with 39.5% and 33.3%, respectively. The median scores for knowledge, self-preparedness, and counselling practice were 8 (out of 9), 9 (out of 15), and 25 (out of 30), respectively. The physician group showed a statistically significant association with better knowledge compared to the nurse group only, P<0.001. Males had higher preparedness scores than females, p<0.001. Also, the intensive care unit (ICU) and emergency departments presented a statistically significant difference by which the participants from these departments were more prepared compared to the others (e.g. outpatients, paediatrics and surgery) with P < 0.0001. The lack of awareness among the general population about COVID-19 preventive measures was perceived as the most common barrier for the adequate prevention and control of COVID-19 in Yemen (89.1%).

Conclusion

The major highlight of this study is that HCWs have, overall, good knowledge, suboptimal preparedness, and adequate counselling practices prior to the outbreak of COVID-19 in Yemen, despite the high number of perceived barriers. However, urgent action and interventions are needed to improve the preparedness of HCWs to manage COVID-19. The perceived barriers also need to be fully addressed by the local healthcare authorities and international organisations working in Yemen for adequate prevention and control measures to be in place in managing COVID-19.

Conflict and Cholera: Yemen's Man-Made Public Health Crisis and the Global Implications of Weaponizing Health

The cholera epidemic in Yemen, which began in October 2016 and reached its peak in 2017, was the largest disease outbreak in modern history. Suspected cases topped 1 million, and there were more than 2,000 confirmed deaths in the first 8 months of the outbreak. Although cholera is an ancient disease, and there were other countries around the globe experiencing outbreaks at the same time as the outbreak in Yemen, Yemen's outbreak had a number of unique features. The outbreak spread at an unprecedented pace and has been directly linked to the country's ongoing armed conflict. In this article we ask: What does the recent cholera outbreak in Yemen teach us about the relationship between conflict and infectious disease? Is the intentional targeting of infrastructure, as is occurring in Yemen, the new face of modern warfare? And what implications does a strategy of infrastructure destruction have for global health security? To answer these questions, we examined the history of the conflict in Yemen, the relationship between conflict and infectious disease, the intentional destruction of infrastructure throughout Yemen, and the resulting cholera outbreak. We discuss health as a weapon of war and seek to understand whether this indirect form of biological warfare is a new standard war tactic. Lastly, we address what the weaponization of health means for both global health security and US national security.

Morbidities & outcomes of a neonatal intensive care unit in a complex humanitarian conflict setting, Hajjah Yemen: 2017-2018

BACKGROUND

The protracted conflict in Yemen has taken a massive toll on the health system, negatively impacting the health of children, especially the most vulnerable age group; the newborns.

METHODS

A 2-year retrospective study of admissions into the Neonatal Intensive Care Unit (NICU) in Al-Gomhoury Hospital Hajjah, Northwest Yemen was conducted. Data was analyzed with IBM SPSS® version 25.0 statistical software using descriptive/inferential statistics.

RESULTS

A total of 976 newborns were eligible and included in this study; 506 preterm newborns (51.8%) and 470 term newborns (48.2%). Over half, 549 (56.3%) newborns were admitted within 24 h after birth and 681 (69.8%) newborns travelled for over 60 min to arrive at the NICU. The most common admission diagnoses were complications of prematurity (341; 34.9%), perinatal asphyxia (336; 34.4%), neonatal jaundice (187; 18.8%), and neonatal sepsis (157, 16.1%). The median length of stay in the NICU was 4 days. There were 213 neonatal deaths (Facility neonatal mortality rate was 218 neonatal deaths per 1000 livebirths); 192 (90.1%) were preterm newborns, while 177 (83.1%) were amongst newborns that travelled for more 60 min to reach the NICU. Significant predictors of neonatal deaths are preterm birth (aOR = 3.09, 95% CI: 1.26-7.59, p = 0.014 for moderate preterm neonates; aOR = 6.18, 95% CI: 2.12-18.01, p = 0.001 for very preterm neonates; and aOR = 44.59, 95% CI: 9.18-216.61, p <  0.001 for extreme preterm neonates); low birth weight (aOR = 3.67, 95% CI: 1.16-12.07, p = 0.032 for very low birth weight neonates; and aOR = 17.42, 95% CI: 2.97-102.08, p = 0.002 for extreme low birth weight neonates); and traveling for more than 60 min to arrive at the NICU (aOR = 2.32, 95% CI: 1.07-5.04, p = 0.033). Neonates delivered by Caesarean section had lower odds of death (aOR = 0.38, 95% CI 0.20-0.73, p = 0.004) than those delivered by vaginal birth.

CONCLUSIONS

Preterm newborns bear disproportionate burden of neonatal morbidity and mortality in this setting which is aggravated by difficulties in accessing early neonatal care. Community-based model of providing basic obstetric and neonatal care could augment existing health system to improve neonatal survival in Yemen.

Assessment of Healthcare System Capabilities and Preparedness in Yemen to Confront the Novel Coronavirus 2019 (COVID-19) Outbreak: A Perspective of Healthcare Workers

Background: In the past decade, Yemen has witnessed several disasters that resulted in a crumbled healthcare system. With the declaration of COVID-19 a global pandemic, and later the appearance of first confirmed cases in Yemen, there is an urgent need to assess the preparedness of healthcare facilities (HCFs) and their capacities to tackle a looming COVID-19 outbreak. Herein, we present an assessment of the current state of preparedness and capabilities of HCFs in Yemen to prevent and manage the COVID-19 outbreak.

Methods: An online survey for HCFs was developed, validated, and distributed. The questionnaire is divided into five main sections: (1) Demographic variables for participants. (2) HCFs capabilities for COVID-19 outbreak. (3) Support received to face the emergence and spread of COVID-19. (4). Current practices of infection prevention and control measures in the HCFs. The last section focused on the recommendations to ensure effective and timely response to this outbreak in Yemen. Descriptive analysis was used to analyze data using statistical package for social sciences (SPSS), version 23.

Results: Responses were received from healthcare workers (HCWs) from 18 out of 22 governorates in Yemen. Out of the 296 HCWs who participated in the study, the vast majority (93.9%) believed that the healthcare system in Yemen does not have the resources and capabilities to face and manage a COVID-19 outbreak. Approximately 82.4% of participants rated the general preparedness level of their HCFs as very poor or poor. More specifically, the majority of HCWs rated their HCFs as very poor or poor in term of availability of the following: an adequate number of mechanical ventilators (88.8%), diagnostic devices (88.2%), ICU rooms and beds (81.4%), and isolation rooms (79.7%).

Conclusions: The healthcare facilities in Yemen are unprepared and lack the most basic resources and capabilities to cope with or tackle a COVID-19 outbreak. With the current state of a fragile healthcare system, a widespread outbreak of COVID-19 in Yemen could result in devastating consequences. There is an urgent need to provide support to the healthcare workers and HCFs that are on the frontline against COVID-19.

Health information and health-seeking behaviour in Yemen: perspectives of health leaders, midwives and mothers in two rural areas of Yemen

Background

Humanitarian crises can lead to the rapid change in the health needs of women and newborns, which may give rise to a complex situation that would require various interventions as solutions. This study aimed to examine the health education and promotion patterns, health-seeking behaviour of mothers, and barriers to the use of maternal health services from public health facilities in two rural areas of Yemen.

Methods

We used a qualitative approach. We conducted in-depth interviews and focus group discussions with frontline health professionals and mothers respectively. Nine in-depth interviews were conducted with the health professionals, including 4 health leaders and 5 midwives, and 2 focus group discussions with mothers aged 18–45 years in Abyan and Lahj. Thematic analysis approach was used to analyze the data in Atlas.ti (version 8) Software.

Results

Our data showed that health education and promotion activities on maternal health were ad hoc and coverage was poor. Maternal health services were underutilized by women. According to the data from the focus group discussions, the poor quality of services, as indicated by inadequate numbers of female doctors, lack of medical equipment and medicines, and costs of services were barriers to use maternal health services. Moreover, the use of prenatal and postnatal care services was associated with women’s’ perceived need. However, according to the health professionals, the inadequate human resource, workload, and inadequate funding from government have contributed significantly to the perceived quality of maternal health services provided by public health facilities. Despite the identified barriers, we found that a safe motherhood voucher scheme was instituted in Lahj which facilitated the use of maternal health services by disadvantaged women by removing financial barriers associated with the use of maternal health services.

Conclusion

This study identified several obstacles, which worked independently or jointly to minimize the delivery and use of health services by rural women. These included, inadequate funding, inadequate human resources, poor quality of health services, and high cost of services. These barriers need to be addressed to improve the use of reproductive health services in Yemen.

Repurposing NGO data for better research outcomes: a scoping review of the use and secondary analysis of NGO data in health policy and systems research

Background

Non-governmental organisations (NGOs) collect and generate vast amounts of potentially rich data, most of which are not used for research purposes. Secondary analysis of NGO data (their use and analysis in a study for which they were not originally collected) presents an important but largely unrealised opportunity to provide new research insights in critical areas, including the evaluation of health policy and programmes.

Methods

A scoping review of the published literature was performed to identify the extent to which secondary analysis of NGO data has been used in health policy and systems research (HPSR). A tiered analytical approach provided a comprehensive overview and descriptive analyses of the studies that (1) used data produced or collected by or about NGOs; (2) performed secondary analysis of the NGO data (beyond the use of an NGO report as a supporting reference); and (3) analysed NGO-collected clinical data.

Results

Of the 156 studies that performed secondary analysis of NGO-produced or collected data, 64% (n = 100) used NGO-produced reports (mostly to a limited extent, as a contextual reference or to critique NGO activities) and 8% (n = 13) analysed NGO-collected clinical data. Of these studies, 55% (n = 86) investigated service delivery research topics and 48% (n = 51) were undertaken in developing countries and 17% (n = 27) in both developing and developed countries. NGOs were authors or co-authors of 26% of the studies. NGO-collected clinical data enabled HPSR within marginalised groups (e.g. migrants, people in conflict-affected areas), albeit with some limitations such as inconsistent and missing data.

Conclusion

We found evidence that NGO-collected and produced data are most commonly perceived as a source of supporting evidence for HPSR and not as primary source data. However, these data can facilitate research in under-researched marginalised groups and in contexts that are hard to reach by academics such as conflict-affected areas. NGO–academic collaboration could help address issues of NGO data quality to facilitate their more widespread use in research. The use of NGO data use could enable relevant and timely research in the areas of programme evaluation and health policy and advocacy to improve health and reduce health inequalities, especially in marginalised groups and developing countries.

Health care workers in conflict and post-conflict settings: Systematic mapping of the evidence

BACKGROUND

Health care workers (HCWs) are essential for the delivery of health care services in conflict areas and in rebuilding health systems post-conflict.

OBJECTIVE

The aim of this study was to systematically identify and map the published evidence on HCWs in conflict and post-conflict settings. Our ultimate aim is to inform researchers and funders on research gap on this subject and support relevant stakeholders by providing them with a comprehensive resource of evidence about HCWs in conflict and post-conflict settings on a global scale.

METHODS

We conducted a systematic mapping of the literature. We included a wide range of study designs, addressing any type of personnel providing health services in either conflict or post-conflict settings. We conducted a descriptive analysis of the general characteristics of the included papers and built two interactive systematic maps organized by country, study design and theme.

RESULTS

Out of 13,863 identified citations, we included a total of 474 studies: 304 on conflict settings, 149 on post-conflict settings, and 21 on both conflict and post-conflict settings. For conflict settings, the most studied counties were Iraq (15%), Syria (15%), Israel (10%), and the State of Palestine (9%). The most common types of publication were opinion pieces in conflict settings (39%), and primary studies (33%) in post-conflict settings. In addition, most of the first and corresponding authors were affiliated with countries different from the country focus of the paper. Violence against health workers was the most tackled theme of papers reporting on conflict settings, while workforce performance was the most addressed theme by papers reporting on post-conflict settings. The majority of papers in both conflict and post-conflict settings did not report funding sources (81% and 53%) or conflicts of interest of authors (73% and 62%), and around half of primary studies did not report on ethical approvals (45% and 41%).

CONCLUSIONS

This systematic mapping provides a comprehensive database of evidence about HCWs in conflict and post-conflict settings on a global scale that is often needed to inform policies and strategies on effective workforce planning and management and in reducing emigration. It can also be used to identify evidence for policy-relevant questions, knowledge gaps to direct future primary research, and knowledge clusters.

Reproductive, maternal, newborn and child health service delivery during conflict in Yemen: a case study

BACKGROUND

Armed conflict, food insecurity, epidemic cholera, economic decline and deterioration of essential public services present overwhelming challenges to population health and well-being in Yemen. Although the majority of the population is in need of humanitarian assistance and civil servants in many areas have not received salaries since 2016, many healthcare providers continue to work, and families continue to need and seek care.

METHODS

This case study examines how reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH+N) services have been delivered since 2015, and identifies factors influencing implementation of these services in three governorates of Yemen. Content analysis methods were used to analyze publicly available documents and datasets published since 2000 as well as 94 semi-structured individual and group interviews conducted with government officials, humanitarian agency staff and facility-based healthcare providers and six focus group discussions conducted with community health midwives and volunteers in September-October 2018.

RESULTS

Humanitarian response efforts focus on maintaining basic services at functioning facilities, and deploying mobile clinics, outreach teams and community health volunteer networks to address urgent needs where access is possible. Attention to specific aspects of RMNCAH+N varies slightly by location, with differences driven by priorities of government authorities, levels of violence, humanitarian access and availability of qualified human resources. Health services for women and children are generally considered to be a priority; however, cholera control and treatment of acute malnutrition are given precedence over other services along the continuum of care. Although health workers display notable resilience working in difficult conditions, challenges resulting from insecurity, limited functionality of health facilities, and challenges in importation and distribution of supplies limit the availability and quality of services.

CONCLUSIONS

Challenges to providing quality RMNCAH+N services in Yemen are formidable, given the nature and scale of humanitarian needs, lack of access due to insecurity, politicization of aid, weak health system capacity, costs of care seeking, and an ongoing cholera epidemic. Greater attention to availability, quality and coordination of RMNCAH services, coupled with investments in health workforce development and supply management are needed to maintain access to life-saving services and mitigate longer term impacts on maternal and child health and development. Lessons learned from Yemen on how to address ongoing primary health care needs during massive epidemics in conflict settings, particularly for women and children, will be important to support other countries faced with similar crises in the future.

Measuring health system resilience in a highly fragile nation during protracted conflict: South Sudan 2011-15

Health systems resilience (HSR) is defined as the ability of a health system to continue providing normal services in response to a crisis, making it a critical concept for analysis of health systems in fragile and conflict-affected settings (FCAS). However, no consensus for this definition exists and even less about how to measure HSR. We examine three current HSR definitions (maintaining function, improving function and achieving health system targets) using real-time data from South Sudan to develop a data-driven understanding of resilience. We used 14 maternal, newborn and child health (MNCH) coverage indicators from household surveys in South Sudan collected at independence (2011) and following 2 years of protracted conflict (2015), to construct a resilience index (RI) for 9 of the former 10 states and nationally. We also assessed health system stress using conflict-related indicators and developed a stress index. We cross tabulated the two indices to assess the relationship of resilience and stress. For maintaining function for 80% of MNCH indicators, seven state health systems were resilient, compared with improving function for 50% of the indicators (two states were resilient). Achieving the health system national target of 50% coverage in half of the MNCH indicators displayed no resilience. MNCH coverage levels were low, with state averages ranging between 15% and 44%. Central Equatoria State displayed high resilience and high system stress. Lakes and Northern Bahr el Ghazal displayed high resilience and low stress. Jonglei and Upper Nile States had low resilience and high stress. This study is the first to investigate HSR definitions using a resilience metric and to simultaneously measure health system stress in FCAS. Improving function is the HSR definition detecting the greatest variation in the RI. HSR and health system stress are not consistently negatively associated. HSR is highly complex warranting more in-depth analyses in FCAS.

Health for all by all-pursuing multi-sectoral action on health for SDGs in the WHO Eastern Mediterranean Region

The WHO Eastern Mediterranean Region is endowed with deep intellectual tradition, interesting cultural diversity, and a strong societal fabric; components of a vibrant platform for promoting health and wellbeing. Health has a central place in the Sustainable Development Goals (SDGs) for at least three reasons: Firstly, health is shaped by factors outside of the health sector. Secondly, health can be singled out among several SDGs as it provides a clear lens for examining the progress of the entire development process. Thirdly, in addition to being an outcome, health is also a contributor to achieving sustainable development. Realizing this central role of health in SDGs and the significance of collaboration among diverse sectors, the WHO is taking action. In its most recent General Program of Work 2019–2023 (GPW 13), the WHO has set a target of promoting the health of one billion more people by addressing social and other determinants of health through multi-sectoral collaboration. The WHO Regional Office for the Eastern Mediterranean Region, through Vision 2023, aims at addressing these determinants by adopting an equity-driven, leaving no one behind approach. Advocating for Health in All Policies, multi-sectoral action, community engagement, and strategic partnerships are the cornerstone for this approach. The focus areas include addressing the social and economic determinants of health across the life course, especially maternal and child health, communicable diseases, non-communicable diseases, and injuries. The aspirations are noteworthy – however, recent work in progress in countries has also highlighted some areas for improvement. Joint work among different ministries and departments at country level is essential to achieve the agenda of sustainable development. For collaboration, not only the ministries and departments need to be engaged, but the partnerships with other stakeholders such as civil society and private sector are a necessity and not a choice to effectively pursue achievement of SDGs.

Association of Exposure to Civil Conflict With Maternal Resilience and Maternal and Child Health and Health System Performance in Afghanistan

IMPORTANCE

Current studies examining the effects of Afghanistan's conflict transition on the performance of health systems, health service delivery, and health outcomes are outdated and small in scale and do not span all essential reproductive, maternal, newborn, and child health interventions.

OBJECTIVE

To evaluate associations of conflict severity with improvement of health system performance, use of health services, and child nutrition outcomes in Afghanistan during the 2003 to 2018 reconstruction period.

DESIGN, SETTING, AND PARTICIPANTS

This population-based survey study included a sequential cross-sectional analysis of individual-level panel data across 2 periods (2003-2010 and 2010-2018) and a difference-in-differences design. Surveys included the 2003 to 2004 and 2010 to 2011 Multiple Indicator Cluster Surveys and the 2018 Afghanistan Health Survey. Afghanistan's 2013 National Nutrition Survey was used to assess nutritional outcomes, and the annual Balanced Scorecard data sets were used to evaluate health system performance. Participants included girls and women aged 12 to 49 years and children younger than 5 years who completed nationally representative household surveys. All analyses were conducted from January 1 through April 30, 2019.

EXPOSURES

Provinces were categorized as experiencing minimal-, moderate-, and severe-intensity conflict using battle-related death data from the Uppsala Conflict Data Program.

MAIN OUTCOMES AND MEASURES

Health intervention coverage was examined using 10 standard indicators: contraceptive method (any or modern); antenatal care by a skilled health care professional; facility delivery; skilled birth attendance (SBA); bacille Calmette-Guérin vaccination (BCG); diphtheria, pertussis, and tetanus vaccination (DPT3) or DPT3 plus hepatitis B and poliomyelitis (penta); measles vaccination; care-seeking for acute respiratory infection; oral rehydration therapy for diarrhea; and the Composite Coverage Index. The health system performance was analyzed using the following standard Balanced Scorecard composite domains: client and community, human resources, physical capacity, quality of service provision, management systems, and overall mission. Child stunting, wasting, underweight, and co-occurrence of stunting and wasting were estimated using World Health Organization growth reference cutoffs.

RESULTS

Responses from 64 815 women (mean [SD] age, 31.0 [8.5] years) were analyzed. Provinces with minimal-intensity conflict had greater gains in contraceptive use (mean annual percentage point change [MAPC], 1.3% vs 0.5%; P < .001), SBA (MAPC, 2.7% vs 1.5%; P = .005), BCG vaccination (MAPC, 3.3% vs -0.5%; P = .002), measles vaccination (MAPC, 1.9% vs -1.0%; P = .01), and DPT3/penta vaccination (MAPC, 1.0% vs -2.0%; P < .001) compared with provinces with moderate- to severe-intensity conflict after controlling for confounders. Provinces with severe-intensity conflict fared significantly worse than those with minimal-intensity conflict in functioning infrastructure (MAPC, -1.6% [95% CI, -2.4% to -0.8%]) and the client background and physical assessment index (MAPC, -1.0% [95% CI, -0.8% to 2.7%]) after adjusting for confounders. Child wasting was significantly worse in districts with greater conflict severity (full adjusted β for association between logarithm of battle-related deaths and wasting, 0.33 [95% CI, 0.01-0.66]; P = .04).

CONCLUSIONS AND RELEVANCE

Associations between conflict and maternal and child health in Afghanistan differed by health care intervention and delivery domain, with several key indicators lagging behind in areas with higher-intensity conflict. These findings may be helpful for planning and prioritizing efforts to reach the United Nations' Sustainable Development Goals in Afghanistan.

Ophthalmic services during ongoing conflict: the eye health system in Yemen

There is little information on the provision of ophthalmic services and the eye health system in Yemen. Using the WHO framework for analysing health systems, we aim to assess what is known about the current eye health system in Yemen with ongoing conflict. Financial constraints, transportation difficulties and security instability are barriers for many of Yemen’s people in need of healthcare. The most recent cataract surgical rate reported in 2012 is 2473 operations per million population, with an increase in operations performed in charity eye camps and the private sector. We identify many governorates of Yemen have inadequate ophthalmic resources. We describe the need for short-term solutions to reduce the backlog prevalence of blindness while local infrastructure is rebuilt, and the importance of long-term reconstruction and transition to local ownership with a sustainable workforce and health service as peace is restored.

Factors associated with healthcare workers willingness to participate in disasters: a cross-sectional study in Sana'a, Yemen

OBJECTIVES

Willingness to participate in disasters is usually overlooked and not addressed in disaster preparedness training courses to ensure health service coverage. This will lead to issues during the disaster's response. This study, therefore, aims to assess healthcare workers willingness to participate in biological and natural disasters, and to identify its associated factors.

DESIGN

This is a cross-sectional study using a self-administered questionnaire. The questionnaire was distributed to 1093 healthcare workers. The data were analysed using multiple logistic regression with significance level p<0.05. Ethical clearance and consent of the participants were duly obtained.

SETTING

In three public hospitals that provide tertiary-level healthcare in Sana'a City, Yemen.

PARTICIPANTS

There were 692 nurses and doctors (response rate 63.3%) completed the questionnaires.

RESULTS

Almost half of the participants 55.1% were nurses and 44.9% were doctors. The study found that self-efficacy was associated with willingness to participate in disaster response for any type of disasters (OR 1.319, 95% CI 1.197 to 1.453), natural disasters (OR 1.143, 95% CI 1.069 to 1.221) and influenza pandemic (OR 1.114, 95% CI 1.050 to 1.182). The results further show that willingness is associated with healthcare workers being young, male and having higher educational qualifications.

CONCLUSION

Self-efficacy has been found to be an important factor associated with willingness. Improving self-efficacy through training in disaster preparedness may increase willingness of healthcare workers to participate in a disaster.

When political solutions for acute conflict in Yemen seem distant, demand for reproductive health services is immediate: a programme model for resilient family planning and post-abortion care services

The political situation in Yemen has been precarious since 2011 when popular protest broke out amid the Arab Spring, calling for President Saleh to step down. In March 2015, a Houthi insurgency took control of the capital, Sana’a and ignited a civil conflict that is now characterised by foreign political and military involvement. Since 2015, health facilities have been a primary target for airstrikes and bombing. Seaports have been blockaded barring the delivery of essential medicines and supplies, contributing to the near collapse of an already fragile health system. Since 2012, Save the Children (SC) has been implementing a Family Planning (FP) and Post-abortion Care (PAC) programme in two governorates heavily affected by the conflict. Despite the risks associated with the conflict, there remains a strong demand for SC's FP and PAC services. Ongoing programmatic support and capacity strengthening have allowed quality FP and PAC services to continue for Yemenis even when humanitarian access is impeded. Since the onset of conflict in March 2015, 16 facilities provided services to 43,218 new FP clients (with 23% accepting a long-acting method) and treated 3627 women with PAC. Over 93% of FP clients would recommend FP services at the facility to a friend or family member. Findings support growing evidence that women affected by conflict require family planning services, and that demand does not decline as long as quality services remain accessible. An adaptable reproductive health programme model that embraces innovative approaches is necessary for establishing services and maintaining quality during acute conflict.

Risk factors associated with the recent cholera outbreak in Yemen: a case-control study

OBJECTIVES

The cholera outbreak in Yemen has become the largest in the recent history of cholera records, having reached more than 1.4 million cases since it started in late 2016. This study aimed to identify risk factors for cholera in this outbreak.

METHODS

A case-control study was conducted in Aden in 2018 to investigate risk factors for cholera in this still-ongoing outbreak. In total, 59 cholera cases and 118 community controls were studied.

RESULTS

The following risk factors were associated with being a cholera case in the bivariate analysis: a history of travelling and having had visitors from outside Aden Province; eating outside the house; not washing fruit, vegetables, and khat (a local herbal stimulant) before consumption; using common-source water; and not using chlorine or soap in the household. In the multivariate analysis, not washing khat and the use of common-source water remained significant risk factors for being a cholera case.

CONCLUSIONS

Behavioural factors and unsafe water appear to be the major risk factors in the recent cholera outbreak in Yemen. In order to reduce the risk of cholera, hygiene practices for washing khat and vegetables and the use and accessibility of safe drinking water should be promoted at the community level.

Health financing in fragile and conflict-affected settings: What do we know, seven years on?

Over the last few years, there has been growing attention to health systems research in fragile and conflict-affected setting (FCAS) from both researchers and donors. In 2012, an exploratory literature review was conducted to analyse the main themes and findings of recent literature focusing on health financing in FCAS. Seven years later, this paper presents an update of that review, reflecting on what has changed in terms of the knowledge base, and what are the on-going gaps and new challenges in our understanding of health financing in FCAS. A total of 115 documents were reviewed following a purposeful, non-systematic search of grey and published literature. Data were analysed according to key health financing themes, ensuring comparability with the 2012 review. Bibliometric analysis suggests that the field has continued to grow, and is skewed towards countries with a large donor presence (such as Afghanistan). Aid coordination remains the largest single topic within the themes, likely reflecting the dominance of external players, not just substantively but also in relation to research. Many studies are commissioned by external agencies and in addition to concerns about independence of findings there is also likely a neglect of smaller, more home-grown reforms. In addition, we find that despite efforts to coordinate approaches across humanitarian and developmental settings, the literature remains distinct between them. We highlight research gaps, including empirical analysis of domestic and external financing trends across FCAS and non-FCAS over time, to understand better common health financing trajectories, what drives them and their implications. We highlight a dearth of evidence in relation to health financing goals and objectives for UHC (such as equity, efficiency, financial access), which is significant given the relevance of UHC, and the importance of the social and political values which different health financing arrangements can communicate, which also merit in-depth study.

Perspectives on Rebuilding Health System Governance in Opposition-Controlled Syria: A Qualitative Study

Background: Ongoing conflict and systematic targeting of health facilities and personnel by the Syrian regime in opposition-controlled areas have contributed to health system and governance mechanisms collapse. Health directorates (HDs) were established in opposition-held areas in 2014 by the interim (opposition) Ministry of Health (MoH), to meet emerging needs. As the local health authorities responsible for health system governance in opposition-controlled areas in Syria, they face many challenges. This study explores ongoing health system governance efforts in 5 oppositioncontrolled areas in Syria.

Methods: A qualitative study design was selected, using in-depth key informant interviews with 20 participants purposely sampled from HDs, non-governmental organisations (NGOs), donors, and service-users. Data were analysed thematically.

Results: Health system governance elements (ie, strategic vision, participation, transparency, responsiveness, equity, effectiveness, accountability, information) were considered important, but not interpreted or addressed equally in opposition-controlled areas. Participants identified HDs as primarily responsible for health system governance in opposition-controlled areas. Main health system governance challenges identified were security (eg, targeting of health facilities and personnel), funding, and capacity. Suggested solutions included supporting HDs, addressing health-worker loss, and improving coordination.

Conclusion: Rebuilding health system governance in opposition-controlled areas in Syria is already progressing, despite ongoing conflict. Local health authorities need support to overcome identified challenges and build sustainable health system governance mechanisms

High burden of co-morbidity and mortality among severely malnourished children admitted to outpatient therapeutic programme facilities in the conflict setting of Borno, Nigeria: a retrospective review

OBJECTIVE

To present evidence on the burden and outcomes of co-morbidities among severely malnourished (SAM) children admitted to outpatient therapeutic programme (OTP) facilities in the conflict setting of Borno, Nigeria.

DESIGN

Retrospective medical chart review.

SETTING

Facility-based study.ParticipantsChildren aged 6-59 months with SAM enrolled in OTP between June and November 2016 whose medical records were analysed. Only pneumonia and diarrhoea were examined due to data limitations. Stata software was used for descriptive, multivariate and survival analyses.

RESULTS

Records of 396 children with median age of 15 months were identified and analysed from the date of enrolment to exit from OTP. Mean length of stay in OTP was 61d, with co-infected SAM children having shorter stay (P=0·006). Of the total, 148 (37·4 %) had at least one co-morbidity (pneumonia or diarrhoea), of which thirty-nine (26·4 %) had both. Cumulative rate of mortality during follow-up time was 9·5 (95 % CI 6·0, 15·1) per 10 000 child-days; SAM children with co-morbidities were ten times more likely to die than those without (hazard ratio=10·2; 95 % CI 3·4, 31·0). In multivariable analysis, co-morbidity (P=0·01), oedema (P=0·003), dehydration (P=0·02) and weight on admission (P=0·01) were associated with mortality. Both recovery and defaulter rates (57·8 and 36·1 %, respectively) did not meet SPHERE standards.

CONCLUSIONS

Children with SAM and co-morbidities are less likely to survive, presenting a significant barrier in improving child survival. The findings call for integrated OTP models that incorporate clinical algorithms and ensure prompt referral for SAM children with co-morbidity.

Cause-specific child mortality performance and contributions to all-cause child mortality, and number of child lives saved during the Millennium Development Goals era: a country-level analysis

BACKGROUND

During the Millennium Development Goal (MDG) era, impressive reductions in the under-5 mortality rate (U5MR) have been observed, although the MDG 4 target was not met. So far, cause-specific progress in child mortality has been analyzed and discussed mainly at the global and regional levels.

OBJECTIVES

We aimed to explore annual changes in cause-specific mortality at the country level, assess which causes contributed the most to child mortality reduction in 2000-2015, and estimate how many child lives were saved.

METHODS

We used the cause-specific child mortality estimates published by Liu and colleagues. We derived average annual changes in cause-specific child mortality rates and cause-specific contribution to overall child mortality in 2000-2015. We estimated the number of cause-specific child deaths averted during the MDG era, assuming that cause-specific child mortality remained the same as in 2000. We targeted the 75 Countdown countries where 95% of maternal and child deaths occurred during the MDG era.

RESULTS

Wide disparities existed across causes within countries, both in neonatal and post-neonatal mortality reduction, except for a few countries such as China, Rwanda, and Cambodia. In 20 of the 45 sub-Saharan African countries, malaria was the main contributor to post-neonatal mortality reduction, and pneumonia was the main contributor in only six countries. A single disease often contributed to a substantial proportion of the child mortality reduction, particularly in west and central African countries. Diarrhea-specific post-neonatal child mortality reduction accounted for 7.1 million averted child deaths (24.5%), while pneumonia accounted for another 6.7 million averted child deaths (23%).

CONCLUSIONS

This study demonstrates country-specific characteristics with regards to cause-wise child mortality that could not be identified by global or regional analyses. These findings provide the global community with evidence for formulating national policies and strategies to achieve the Sustainable Development Goals in child mortality reduction.