Pakistan is one of two countries globally still endemic for poliovirus. While increasing immunization coverage is a concern, providing equitable access to care is also a priority, especially for conflict-affected populations. Recognizing these challenges, Naunehal, an integrated model of maternal, newborn, and child health (MNCH), immunization, and nutrition services delivered through community mobilization, mobile outreach, and private-sector engagement was implemented in conflict-affected union councils (UCs) with high poliovirus transmission, including Kharotabad 1(Quetta, Balochistan) and Bakhmal Ahmedzai (Lakki Marwat, Khyber Pakhtunkhwa). A quasi-experimental pre-post-design was used to assess the impact of the interventions implemented between April 2021 and April 2022, with a baseline and an endline survey. For each of the intervention UCs, a separate, matched-control UC was identified. At endline, the proportion of fully immunized children increased significantly from 27.5% to 51.0% in intervention UCs with a difference-in-difference (DiD) estimate of 13.6%. The proportion of zero-dose children and non-recipients of routine immunization (NR-RI) children decreased from 31.6% to 0.9% and from 31.9% to 3.4%, respectively, with a significant decrease in the latter group. Scaling up and assessing the adoption and feasibility of integrated interventions to improve immunization coverage can inform policymakers of the viability of such services in such contexts.

UNASSIGNED: Rehabilitation outcomes are important for patients, professionals and policy makers. Most outcome measures (OMs) were developed for \"Western\" contexts and may be inadequate for low-resource and conflict settings, where the ability to demonstrate impact would be critical to strengthening the sector. This study aims to understand perspectives of physiotherapists from challenging environments regarding current practices, value, barriers, and facilitators of measuring rehabilitation outcomes.
UNASSIGNED: Focus group discussions were held in English with 35 physiotherapists from 18 countries. Audio recordings were transcribed verbatim, anonymised, and analysed using reflexive thematic analysis.
UNASSIGNED: Four themes emerged illustrating the levels at which outcomes and measures were discussed: User (patients, families), provider (physiotherapists, rehabilitation workers), application (OMs), and structure (management, health system). Participants discussed diversity in current practices and patient populations, utility of OMs and a neglected rehabilitation sector lacking investment. Barriers to progressing outcome measurement included lacking patient health literacy, rehabilitation provider training, valid OMs, and leadership. Participants suggested improved patient involvement, routine outcome measurement by using, developing, or adapting simple, context- and stakeholder-relevant OMs, and support from management.
UNASSIGNED: These insights illustrate the need of and provide robust recommendations for context-adapted development of rehabilitation outcome measurement in various challenging contexts.
Rehabilitation outcomes are important to show impact in low-resource and conflict settings, but most outcome measures originate from “Western” contextsExperience of physiotherapists from low-resource and conflict settings reveals the barriers and facilitators to measuring rehabilitation outcomes in their workplacesParticipants’ suggest to use or develop simple scales that are contextualised and stakeholder-relevant for standard, routine measurementThis study highlights the need to improve the measurement of rehabilitation outcomes in challenging contexts and provides guidance on how to do so.

BACKGROUND: In conflict-affected settings, access to primary healthcare for displaced populations is constrained by multiple challenges. These include geographical, cultural, communication, logistical and financial barriers, as well as risks posed to health workers and the population by insecurity. Different models of care are used to provide primary healthcare to affected communities. However, there is a paucity of evidence on how these models are selected and implemented by organisations working in conflict and displacement-affected settings. Our aim was to explore the different primary healthcare delivery models used in conflict-affected settings to understand gaps in existing healthcare delivery models.
METHODS: We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The review protocol was registered with the International Prospective Register of Systematic Reviews. We searched six databases for manuscripts published from January 1992 to December 2020. Publications were included if they reported primary healthcare models of care in conflict-affected settings of Africa. Data was analyzed descriptively and thematically using tables, charts and text.
RESULTS: Forty-eight primary research articles were included for analysis from which thirty-three were rated as \"high\" quality. The results showed that the models of care in place in these conflict-affected settings include health facility-based, community-based, mobile clinics, outreach and home visits. Primary healthcare for internally displaced persons and refugees is provided by a wide range of actors including national and international organisations. A range of services is offered, most commonly nutrition, mental health and sexual/reproductive health. Some organisations offer vertical (stand-alone) services, while others use an integrated service delivery model. Multiple cadres of healthcare workers provide services, frequently lay healthcare workers such as Community Health Workers.
CONCLUSIONS: Understanding the different modalities of primary healthcare delivery in conflict-affected settings is important to identify existing practices and gaps in service delivery. Service delivery using community health workers in conflict-affected settings is a low-cost primary care delivery strategy that may help optimize contributions of existing personnel through task shifting.

Evidence on the social determinants of mental health conditions and violence among people who inject or use drugs (PWUD) is limited, particularly in conflict-affected countries. We estimated the prevalence of symptoms of anxiety or depression and experience of emotional or physical violence among PWUD in Kachin State in Myanmar and examined their association with structural determinants, focusing on types of past migration (migration for any reason, economic or forced displacement).
A cross-sectional survey was conducted among PWUD attending a harm reduction centre between July and November 2021 in Kachin State, Myanmar. We used logistic regression models to measure associations between past migration, economic migration and forced displacement on two outcomes (1) symptoms of anxiety or depression (Patient Health Questionnaire-4) and (2) physical or emotional violence (last 12 months), adjusted for key confounders.
A total of 406, predominantly male (96.8%), PWUD were recruited. The median age (IQR) was 30 (25, 37) years, most injected drugs (81.5%) and more commonly opioid substances such as heroin or opium (85%). Symptoms of anxiety or depression (PHQ4 ≥ 6) were high (32.8%) as was physical or emotional violence in the last 12 months (61.8%). Almost one-third (28.3%) had not lived in Waingmaw for their whole life (migration for any reason), 77.9% had left home for work at some point (economic migration) and 19.5% had been forced to leave home due to war or armed conflict (forced displacement). A third were in unstable housing in the last 3 months (30.1%) and reported going hungry in the last 12 months (27.7%). Only forced displacement was associated with symptoms of anxiety or depression [adjusted odds ratio, aOR 2.33 (95% confidence interval, CI 1.32-4.11)] and recent experience of violence [aOR 2.18 (95% CI 1.15-4.15)].
Findings highlight the importance of mental health services integrated into existing harm reduction services to address high levels of anxiety or depression among PWUD, particularly among those who have been displaced through armed conflict or war. Findings reinforce the need to address broader social determinants, in the form of food poverty, unstable housing and stigma, in order to reduce mental health and violence.

Health system governance has been recognized as critical to strengthening healthcare responses in settings with conflict-affected populations. The aim of this review was to examine existing evidence on health system governance in settings with conflict-affected populations globally. The specific objectives were (1) to describe the characteristics of the eligible studies; (2) to describe the principles of health system governance; (3) to examine evidence on barriers and facilitators for stronger health system governance; and (4) to analyse the quality of available evidence. A systematic review methodology was used following Preferred Reporting Items for Systematic Review and Meta-Analysis criteria. We searched six academic databases and used grey literature sources. We included papers reporting empirical findings on health system governance among populations affected by armed conflict, including refugees, asylum seekers, internally displaced populations, conflict-affected non-displaced populations and post-conflict populations. Data were analysed according to the study objectives and informed primarily by a governance framework from the literature. Quality appraisal was conducted using an adapted version of the Mixed Methods Appraisal Tool. Of the 6511 papers identified through database searches, 34 studies met eligibility criteria. Few studies provided a theoretical framework or definition for governance. The most frequently identifiable governance principles related to participation and coordination, followed by equity and inclusiveness and intelligence and information. The least frequently identifiable governance principles related to rule of law, ethics and responsiveness. Across studies, the most common facilitators of governance were collaboration between stakeholders, bottom-up and community-based governance structures, inclusive policies and longer-term vision. The most common barriers related to poor coordination, mistrust, lack of a harmonized health response, lack of clarity on stakeholder responsibilities, financial support and donor influence. This review highlights the need for more theoretically informed empirical research on health system governance in settings with conflict-affected populations that draws on existing frameworks for governance.

BACKGROUND: The guidelines for differentiated service delivery (DSD) for HIV treatment became operational in Cameroon in 2017 with the Test and Treat national strategy elaborating services that can be decentralized and task shifted at community level, but with little to no guidelines for DSD in fragile and conflict-affected settings. Since 2016, more than 680,000 Cameroonians have been internally displaced due to the conflict in the North West and South West regions (NWSW). This conflict has impacted on the health system with numerous attacks on health facilities and staff, reducing access to health care for internally displaced persons. The outbreak of COVID-19 further reduced humanitarian responses for fear of spreading COVID-19. Mobile clinics were utilized as a model of care in piloting DSD for HIV in conflict-affected settings within the COVID-19 context.
METHODS: The HIV DSD framework was used to evaluate a project that used mobile clinics in 05 divisions across the NWSW to provide primary health care to internally displaced persons in hard-to-reach areas. These mobile clinics were operated in the COVID-19 context and integrated HIV services in the benefit package. The mobile clinics mainstreamed HIV and COVID-19 sensitization during community mobilization, HIV consultations, HIV testing and referrals, and in some cases antiretroviral (ARV) dispensation. The project ran from March to October 2020. The results from the evaluation of this model of HIV care delivery were analysed in 06 of 08 mobile clinics.
RESULTS: In 07 months, a total of 14,623 persons living in conflict-affected settings were sensitized on HIV, 1979 received HIV testing from which 122 were positive and 33 placed on ARVs. 28 loss-to-follow up people living with HIV were relinked to treatment and 209 consultations for persons living with HIV were conducted. Despite the good collaboration at regional and field level, there was distrust by ARV centers for humanitarian organizations.
CONCLUSIONS: Mobile clinics are a model of care which could be leveraged in fragile and conflict-affected settings as an alternative model of care for HIV DSD to ensure continuum of HIV care and treatment. However this should be integrated within the benefit package of primary health care services offered by mobile clinics.

BACKGROUND: Community health workers (CHWs) are crucial for increasing access to health services to communities. Due to decades of conflict and under-funding, access to health care in South Sudan remains severely limited. To improve equitable access to healthcare, the government has introduced \"the Boma Health Initiative (BHI)\", a strategy to harmonise community health programmes across the country. In order to scale up the BHI, it is necessary to assess the recent CHW programmes and draw lessons for future implementation. This study aimed to explore the characteristics, barriers, and facilitators to the implementation of CHW interventions in South Sudan between 2011 and 2019.
METHODS: The study used a qualitative approach drawing from 26 key informant interviews and a scoping review of 21 Health Pooled Fund (HPF) programme reports from October 2016 to June 2018 and policy documents from 2011 to 2019. The results were thematically analysed based on a conceptual framework on factors influencing the performance of CHWs.
RESULTS: Funding of CHW programmes has come from international donors, channelled through non-governmental organisations (NGOs) that have implemented a variety of CHW programmes. Communities have been participating in the selection of voluntary CHWs, intervention areas, and occasionally in the supervision of activities performed by CHWs. The coordination mechanisms among stakeholders have been weak, leading to wastage and duplication of resources. Although training of CHWs is done, training duration was short, and refresher-trainings were rare. There were and still are disparities in the type of incentives provided to CHWs. Monitoring and supportive supervision activities have been insufficient; drug misuse and stock-outs were common.
CONCLUSIONS: Despite their challenges, CHW programmes can be implemented in conflict-affected South Sudan if the local human capital is leveraged and engaged by NGOs as implementing partners. Robust coordination efforts are required to build synergies among stakeholders for the effective implementation of the BHI strategy.

Understanding HIV testing determinants in different settings is vital to reducing new infections. This study assessed HIV testing rates during antenatal care (ANC) in seven sub-Saharan African countries designated as high, medium, low or no conflict intensity settings. We ranked and plotted concentration curves for HIV testing by socioeconomic inequality and determined their concentration indices (CCI). Testing for HIV during ANC was highest in Zimbabwe (95.7%) and lowest in Sudan (3.6%). Countries with medium and high conflict intensity experienced higher HIV testing inequality (CCI = 0.38) than countries with low or no conflict (CCI = 0.15). Low HIV testing rates were associated with no education, rural areas, poorest wealth index quintiles and home birth, which demonstrate that determinants of HIV testing during ANC in conflict-affected areas are complex and context-based. Programme implementation and policymakers must acknowledge these complexities and local contexts in their program designs and planning.

BACKGROUND: Fragile and conflict-affected settings (FCAS) have a strong need to improve the capacity of local health workers to conduct health research in order to improve health policy and health outcomes. Health research capacity building (HRCB) programmes are ideal to equip health workers with the needed skills and knowledge to design and lead health-related research initiatives. The study aimed to review the characteristics of HRCB studies in FCASs in order to identify their strengths and weaknesses, and to recommend future directions for the field.
METHODS: We conducted a scoping review and searched four databases for peer-reviewed articles that reported an HRCB initiative targeting health workers in a FCAS and published after 2010. Commentaries and editorials, cross-sectional studies, presentations, and interventions that did not have a capacity building component were excluded. Data on bibliographies of the studies and HRCB interventions and their outcomes were extracted. A descriptive approach was used to report the data, and a thematic approach was used to analyse the qualitative data.
RESULTS: Out of 8822 articles, a total of 20 were included based on the eligibility criteria. Most of the initiatives centred around topics of health research methodology (70%), targeted an individual-level capacity building angle (95%), and were delivered in university or hospital settings (75%). Ten themes were identified and grouped into three categories. Significant challenges revolved around the lack of local research culture, shortages in logistic capability, interpersonal difficulties, and limited assessment and evaluation of HRCB programmes. Strengths of HRCB interventions included being locally driven, incorporating interactive pedagogies, and promoting multidisciplinary and holistic training. Common recommendations covered by the studies included opportunities to improve the content, logistics, and overarching structural components of HRCB initiatives.
CONCLUSIONS: Our findings have important implications on health research policy and related capacity building efforts. Importantly, FCASs should prioritize (1) funding HRCB efforts, (2) strengthening equitable international, regional, and national partnerships, (3) delivering locally led HRCB programmes, (4) ensuring long-term evaluations and implementing programmes at multiple levels of the healthcare system, and (5) adopting engaging and interactive approaches.

BACKGROUND: Antibiotic resistance (ABR) is a major global threat. Armed and protracted conflicts act as multipliers of infection and ABR, thus leading to increased healthcare and societal costs. We aimed to understand and describe the socioeconomic burden of ABR in conflict-affected settings and refugee hosting countries by conducting a systematic scoping review.
METHODS: A systematic search of PubMed, Medline (Ovid), Embase, Web of Science, SCOPUS and Open Grey databases was conducted to identify all relevant human studies published between January 1990 and August 2019. An updated search was also conducted in April 2020 using Medline/Ovid. Independent screenings of titles/abstracts followed by full texts were performed using pre-defined criteria. The Newcastle-Ottawa Scale was used to assess study quality. Data extraction and analysis were based on the PICOS framework and following the PRISMA-ScR guideline.
RESULTS: The search yielded 8 studies (7 publications), most of which were single-country, mono-center and retrospective studies. The studies were conducted in Lebanon (n = 3), Iraq (n = 2), Jordan (n = 1), Palestine (n = 1) and Yemen (n = 1). Most of the studies did not have a primary aim to assess the socioeconomic impact of ABR and were small studies with limited statistical power that could not demonstrate significant associations. The included studies lacked sufficient information for the accurate evaluation of the cost incurred by antibiotic resistant infections in conflict-affected countries.
CONCLUSIONS: This review highlights the scarcity of research on the socioeconomic burden of ABR on general populations in conflict-affected settings and on refugees and migrants in host countries, and lists recommendations for consideration in future studies. Further studies are needed to understand the cost of ABR in these settings to develop and implement adaptable policies.