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

Resilience of Primary Health Care in Ukraine: Challenges of the Pandemic and War

This commentary examines the resilience of primary health care in Ukraine amidst the ongoing war, drawing a few reflections relevant for other fragile and conflict-affected situations. Using personal observations and various published and unpublished reports, this article outlines five reflections on the strengths, challenges, and necessary adaptations of Primary Health Care (PHC) in Ukraine. It underscores the concerted efforts of the government to maintain public financing of PHC, thereby averting system collapse. The research also highlights the role of strategic adaptations during the COVID-19 pandemic in fostering resilience during the war, including the widespread use of digital communication and skills training. The commentary emphasizes the role of managerial and financial autonomy in facilitating quick and efficient organizational response to crisis. It also recognizes emerging challenges, including better access to PHC services among the internally displaced persons, shifting patient profiles and service needs, and challenges related to reliance on local government financing. Finally, the authors advocate for a coordinated approach in humanitarian response, recovery efforts, and development programs to ensure the sustainability and effectiveness of PHC in Ukraine.

Health information management systems and practices in conflict-affected settings: the case of northwest Syria

BACKGROUND

In conflict settings, as it is the case in Syria, it is crucial to enhance health information management to facilitate an effective and sustainable approach to strengthening health systems in such contexts. In this study, we aim to provide a baseline understanding of the present state of health information management in Northwest Syria (NWS) to better plan for strengthening the health information system of the area that is transitioning to an early-recovery stage.

METHODS

A combination of questionnaires and subsequent interviews was used for data collection. Purposive sampling was used to select twenty-one respondents directly involved in managing and directing different domains of health information in the NWS who worked with local NGOs, INGOs, UN-agencies, or part of the Health Working Group. A scoring system for each public health domain was constructed based on the number and quality of the available datasets for these domains, which were established by Checci and others.

RESULTS & CONCLUSIONS

Reliable and aggregate health information in the NWS is limited, despite some improvements made over the past decade. The conflict restricted and challenged efforts to establish a concentrated and harmonized HIS in the NWS, which led to a lack of leadership, poor coordination, and duplication of key activities. Although the UN established the EWARN and HeRAMS as common data collection systems in the NWS, they are directed toward advocacy and managed by external experts with little participation or access from local stakeholders to these datasets.

RECOMMENDATIONS

There is a need for participatory approaches and the empowerment of local actors and local NGOs, cooperation between local and international stakeholders to increase access to data, and a central domain for planning, organization, and harmonizing the process. To enhance the humanitarian health response in Syria and other crisis areas, it is imperative to invest in data collection and utilisation, mHealth and eHealth technologies, capacity building, and robust technical and autonomous leadership.

Community health volunteers' performance in rural areas of Yemen: a community-based satisfaction survey

Objectives

Many developing countries utilize the services of community health volunteers (CHVs) to enhance healthcare services in underserved regions. Evaluating client satisfaction with CHVs' performance is crucial for ensuring the effective utilization of their services. This study aims to assess clients' satisfaction with the provision of basic reproductive health services by CHVs in the governorates of Ibb and Al Mahweet, Yemen.

Materials and Methods

A cross-sectional study was conducted, collecting data via structured questionnaires administered by trained data collectors to clients of CHVs. A total of 510 households were interviewed, with 255 from each governorate, distributed across 30 clusters (villages). Each governorate comprised 15 clusters in 12 districts (six districts in Ibb and five in Al Mahweet, excluding one district for security reasons). Within each cluster, 17 households were randomly selected for interviews. Descriptive analysis was performed using the SPSS version 22.

Results

The majority of the clients were female (84.7%), most were aged 20-39 years (55.7%), and more than half of them had received at least primary education (54.2%). The study findings indicate that a significant proportion of respondents were highly satisfied with CHVs' performance (93%). Almost all respondents confirmed that CHVs resided in their villages (94%) and were easily accessible for consultation (99%). Most of the respondents (97%) expressed trust in the CHVs, stating that they were helpful to all villagers and treated them well. Additionally, nearly all the respondents reported easy access to services (98.6%), although a considerable percentage experienced a gap of three months or more since their last interaction with a CHV (39.1%).

Conclusion

The CHVs contribute to the well-being of the rural populations in Yemen by delivering satisfactory services, particularly regarding family planning. However, ensuring the sustainability of the CHV programs remains a challenge, which requires attention from the program managers and decision makers in the Yemeni healthcare sector.

Segmentation and fragmentation of health systems and the quest for universal health coverage: conceptual clarifications from the Mexican case

Health systems are complex entities. The Mexican health system includes the private and public sectors, and subsystems that target different populations based on corporatist criteria. Lack of unity and its consequences can be better understood using two concepts, segmentation and fragmentation. These reveal mechanisms and strategies that impede progress toward universality and equity in Mexico and other low- and middle-income countries. Segmentation refers to separation of the population by position in the labour market. Fragmentation refers to institutions, and to financial aspects, health care levels, states' systems of care, and organizational models. These elements explain inequitable allocation of resources and packages of health services offered by each institution to its population. Overcoming segmentation will require a shift from employment to citizenship as the basis for eligibility for public health care. Shortcomings of fragmentation can be avoided by establishing a common package of guaranteed benefits. Mexico illustrates how these two concepts characterize a common reality in low- and middle-income countries.

Seroprevalence and factors associated with SARS-CoV-2 infection among healthcare workers: cross-sectional study

BACKGROUND

Healthcare workers (HCWs) are at a higher risk of contracting COVID-19 due to their close contact with infected patients. However, the true burden of COVID-19 among HCWs in Yemen is unknown due to the inadequate availability of healthcare and the subclinical nature of the disease. This study aims to estimate the seroprevalence of SARS-CoV-2 infection among HCWs in two Yemeni governorates and identify associated factors using a cross-sectional design.

METHOD

A total of 404 HCWs were surveyed from June 2022 to September 2022 in Lahj and AL-Dhalea hospitals. A self-administered questionnaire collected demographic data, COVID-19 infection history, and vaccination status. A total of 404 human sera were tested using a specific electrochemiluminescence immunoassay assay. Association analysis was conducted to identify associations between antibody prevalence and demographic and vaccine-related variables.

RESULT

The median age of the HCWs was 31 (Range 20-64) years, with 65.0% being male and 35.0% female. Of all HCWs, 94% were SARS-CoV-2 seropositive and 77.0% had no confirmed test of COVID-19-related symptoms. There was no significant association between seropositivity and demographic factors such as age, gender, occupation, or COVID-19 vaccination (P > 0.05).

CONCLUSION

The seroprevalence of SARS-CoV-2 was high among HCWs in Yemen, primarily due to natural infection rather than vaccination. Compliance with infection prevention and control measures did not significantly affect seropositivity. This study highlights the need for improved healthcare systems and resources to reduce the burden of COVID-19 and promote infection prevention and control (IPC) measures among HCWs in Yemen.

Evaluation of a Transitional Care Strategy Implemented in Adults With High-Risk and Multimorbidity in Chile

OBJECTIVES

Fragmentation of continuity of care impacts the health system's efficiency and increases inequity. It severely affects high-risk patients with multimorbidity, requiring coordinated care to avoid preventable complications. The Centro de Innovación en Salud ANCORA UC, together with the Servicio de Salud Metropolitano Sur Oriente, and the National Health Fund, implemented a transitional care strategy for high-risk adults with multimorbidity at 3 hospitals in the southeast of Santiago. The study aimed to evaluate the impact on length of hospital stay, consultations with primary care physicians and contacts after discharge, and also to describe the implementation process of the transition nurse activities.

METHODS

A cohort study was performed between 2017 and 2019, with 137 hospitalizations from exposed patients and 167 hospitalizations from unexposed patients. The results of the study showed a significant decrease in the length of hospital stays and an increase in consultations with physicians.

RESULTS

The results of the implementation process showed that the transition nurse followed-up in a mean of 24 hospitalizations monthly, and 91% of the discharged patients were contacted via the telephone within 7 days. The implementation process showed that the transition nurse's tasks merged with the daily clinical activities in which training on case management, transition care, and continuous support were key aspects of success.

CONCLUSION

We conclude that transitional care intervention has a strong potential in addressing fragmentation of care and is feasible to install and sustain over time in the Chilean context. Finally, this study provides a detailed description of the intervention strategy contributing to its spread and scale-up.

Unpacking the challenges of fragmentation in community-based maternal newborn and child health and health system in rural Ethiopia: A qualitative study

INTRODUCTION

In Ethiopia, country-wide community-based primary health programs have been in effect for about two decades. Despite the program's significant contribution to advancing Maternal Newborn and Child Health (MNCH), Ethiopia's maternal and child mortality is still one of the highest in the world. The aim of this manuscript is to critically examine the multifaceted fragmentation challenges of Ethiopia's Community Health Workers (CHWs) program to deliver optimum MNCH and build a resilient community health system.

METHODS

We conducted a qualitative case study in West Shewa Zone, rural Ethiopia. A purposive sampling technique was used to recruit participants. Data sources were two focus group discussions with sixteen CHWs, twelve key informant interviews with multilevel public health policy actors, and a policy document review related to the CHW program to triangulate the findings. Thematic analysis of the qualitative data was conducted. The World Health Organization's health systems framework and socio-ecological model guided the data collection, analysis, and interpretation.

RESULTS

The CHWs program has been an extended arm of Ethiopia's primary health system and has contributed to improved health outcomes. However, the program has been facing unique systemic challenges that stem from the fragmentation of health finance; medical and equipment supply; working and living infrastructures; CHWs empowerment and motivation, monitoring, supervision, and information; coordination and governance; and community and stakeholder engagement. The ongoing COVID-19 and volatile political and security issues are exacerbating these fragmentation challenges.

CONCLUSION

This study emphasized the gap between the macro (national) level policy and the challenge during implementation at the micro (district)level. Fragmentation is a blind spot for the community-based health system in rural Ethiopia. We argue that the fragmentation challenges of the community health program are exacerbating the fragility of the health system and fragmentation of MNCH health outcomes. This is a threat to sustain the MNCH outcome gains, the realization of national health goals, and the resilience of the primary health system in rural Ethiopia. We recommend that beyond the current business-as-usual approach, it is important to emphasize an evidence-based and systemic fragmentation monitoring and responsive approach and to better understand the complexity of the community-based health system fragmentation challenges to sustain and achieve better health outcomes. The challenges can be addressed through the adoption of transformative and innovative approaches including capitalizing on multi-stakeholder engagement and health in all policies in the framework of co-production.

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.

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.

Clinical and Epidemiological Presentation of COVID-19 among Children in Conflict Setting

Background: This study aims to describe the observable symptoms of children with COVID-19 infection and analyze access to real-time polymerase chain reaction (RT-PCR) testing among children seeking care in Yemen. Method: In the period of March 2020−February 2022, data were obtained from 495 children suspected to have been infected with COVID-19 (from a larger register of 5634 patients) from the Diseases Surveillance and Infection Control Department at the Ministry of Public Health and Population in Aden, Yemen. Results: Overall, 21.4% of the children with confirmed COVID-19 infection were asymptomatic. Fever (71.4%) and cough (67.1%) were the most frequently reported symptoms among children, and children were less likely to have fever (p < 0.001), sore throat (p < 0.001) and cough (p < 0.001) compared to adults. A lower frequency of COVID-19-associated symptoms was reported among children with positive RT-PCR tests compared to children with negative tests. A lower rate of testing was conducted among children (25%) compared to adults (61%). Fewer tests were carried out among children <5 years (11%) compared to other age groups (p < 0.001), for children from other nationalities (4%) compared to Yemeni children (p < 0.001) and for girls (21%) compared to boys (30%) (p < 0.031). Conclusion: Understanding and addressing the cause of these disparities and improving guidelines for COVID-19 screening among children will improve access to care and control of the COVID-19 pandemic.