Suchergebnisse

AbstractReducing excess population mortality caused by crises due to armed conflict and natural disasters is an existential aim of humanitarian assistance, but the extent to which these deaths are averted in different humanitarian responses is mostly unknown. This information gap arguably weakens governance and accountability. This paper considers methodological challenges involved in making inferences about humanitarian assistance's effect on excess mortality, and outlines proposed approaches. Three possible measurement questions, each of which contributes some inferential evidence, are presented: (1) whether mortality has remained within an acceptable range during the crisis (for which different direct estimation options are presented); (2) whether the humanitarian response is sufficiently appropriate and performant to avert excess mortality (a type of contribution analysis requiring in-depth audits of the design of humanitarian services and of their actual availability, coverage and quality); and (3) the actual extent to which humanitarian assistance has reduced excess deaths (potentially the most complex question to answer, requiring application of causal thinking and careful specification of the exposure, and for which either quasi-experimental statistical modelling approaches or a combination of verbal and social autopsy methods are proposed). The paper concludes by considering possible 'packages' of the above methods that could be implemented at different stages of a humanitarian response, and calls for investment in improved methods and actual measurement.

Accurate, relevant and timely public health information is paramount in a humanitarian crisis: it can help to identify needs and priorities, guide decisions on interventions and resource allocation, monitor trends, evaluate the effectiveness of the response, support advocacy for human rights, and extract lessons that could be relevant in similar contexts. The present review shows, however, that the public health information available in humanitarian crises is, in general, inadequate and that its application is secondary to reasoning and incentives of a political nature, thus contributing to the recurrent failings of humanitarian action. This article reviews the causes of this state of affairs - cultural, political/institutional/methodological and ethical - that hinder the production, dissemination, and use of information for determining which interventions should be implemented or modified. Traditional epidemiological skills and methods are poorly suited to humanitarian contexts. The approaches and tools that have been introduced in crisis contexts require validation and improvement. There is a need for more field "barefoot epidemiologists" who are able to collaborate with anthropologists, demographers, and sociologists to better understand the priorities to be addressed in a crisis. Evidence, however, is not enough per se: it is political will that is the key factor in the use, or not, of information in decision-making concerning humanitarian resources and interventions.

INTRODUCTION: Over the past 30 years, south-central Somalia, Puntland (north-east) and Somaliland (north-west) have experienced recurring drought- and conflict-related crises. By the end of 2018, the number of internally displaced persons (IDPs) in the region had reached 2.6 million; most were displaced to larger towns under government control, where humanitarian assistance was more accessible. Understanding the drivers of crisis-related displacement can provide insight into how responses can best manage and respond to displacement to prevent downstream morbidity and mortality. We aimed to explore the temporal patterns and crisis-related risk factors for population displacement in Somalia from 2016 to 2018, a period of severe drought. METHODS: We conducted an ecological study of secondary panel data stratified by district and month. The study population included all people in the region from 2016 to 2018. The outcome was defined as the number of new out-migrating internally displaced persons (IDPs) per district-month. Exposure variables included armed conflict, rainfall, food insecurity and food security services. Lags at one, two and three months were generated to explore possible delayed effects. All univariate and multivariate analyses were conducted using negative binomial regression models with mixed effects incorporating the district as a random effect. RESULTS: From 2016 to 2018, the proportion of IDPs increased from 9% to 25% in Somalia, Puntland and Somaliland. We observed strong associations between IDP out-migration rate and failed rains at a three-month lag, food insecurity at a one-month lag, and the presence of therapeutic food services with no lag. IDP out-migration rate was not associated with armed conflict intensity, and cash- and rations-based food security services. DISCUSSION: This study identified temporal, and socially and biologically plausible associations between key crisis-related risk factors and displacement in Somalia. The findings suggest a sequence of events spanning a few months, ...

Background: There has been increasing focus on tackling the growing burden of non-communicable diseases (NCD) in crisis settings. The complex and protracted crisis in Syria is unfolding against a background of increasing NCD burden. This study investigated factors influencing implementation of NCD healthcare in Syria. Methods: This is a qualitative study, whereby semi-structured interviews were conducted with fourteen humanitarian health staff working on NCD healthcare in Syria. Results: Challenges to NCD care implementation were reflected at several stages, from planning services through to healthcare delivery. There was a lack of information on unmet population need; little consensus among humanitarian actors regarding an appropriate health service package; and no clear approach for prioritising public health interventions. The main challenges to service delivery identified by participants were conflict-related insecurity and disruption to infrastructure, hampering continuity of chronic illness care. Collaboration was a key factor which influenced implementation at all stages. Conclusions: The historical context, the conflict situation, and the characteristics of health actors and their relationships, all impacted provision of NCD care. These factors influenced each other, so that the social views and values (of individuals and organisations), as well as politics and relationships, interacted with the physical environment and security situation. Infrastructure damage has implications for wider healthcare across Syria, and NCD care requires an innovative approach to improve continuity of care. There is a need for a transparent approach to resource allocation, which may be generalisable to the wider humanitarian health sector.

Abstract
Background
Large international humanitarian actors support and directly deliver health services for millions of people in crises annually, and wield considerable power to decide which health services to provide, how and to whom, across a vast spectrum of health areas. Despite decades of reform aiming to improve accountability in the sector, public health practice among humanitarian actors is not heavily scrutinized in either the countries where they are headquartered or those where they provide healthcare. We surveyed current healthcare governance practice among large international humanitarian actors to better understand what organisations are doing to ensure oversight and accountability for health services in humanitarian responses.

Methods
The term 'healthcare governance' was defined and categorised into seven domains: implementation of health management information systems (HMIS) and use of resulting data; professional development of health sector staff; audits of health service performance; management of clinical incidents; evidence-based practice; pharmaceutical supply; and beneficiary engagement. Senior health professionals at 32 leading international actors providing humanitarian health services were contacted between July and August 2019 to complete a 109-question online survey about their organisation's practice in these domains.

Results
Respondents from 13 organisations completed the questionnaire. Healthcare governance practices were undertaken to varying degrees by all organisations but were often driven by donor requirements and external factors rather than improvement of programme performance. Common strengths were the inclusion of governance in organisational policies, high availability of technical guidelines, and close monitoring of pharmaceutical services. Recurring weaknesses were poor beneficiary engagement, inconsistent use of health information for decision making, unsystematic implementation of healthcare audits, inconsistent management of clinical incidents, and lack of training and professional development opportunities.

Conclusions
To our knowledge, this is the first study to describe healthcare governance practice among humanitarian actors. Leading international humanitarian healthcare providers are already implementing many healthcare governance activities; however, these are inconsistently applied and generally not reflective of systematic policies or earmarked organisational resources. There is a need for sector-wide consensus on how the humanitarian sector defines healthcare governance, the domains that constitute it, which actors in the humanitarian system are implicated, and how malpractice should be systematically addressed.

Background: Since December 2018, the latest wave of anti-government protests in Sudan has led to deaths, injuries and detentions. We estimated the number of people killed and described patterns of deaths, injuries and detentions up to 9 April 2019. Methods: We tabulated data from three publicly available lists maintained by Sudanese civil society sources (the Independent Movement, the Sudan Doctors' Union and the "Lest We Forget" project), and applied to these a capture-recapture statistical technique that models the overlap among lists to estimate the number of deaths not on any list. Results: We estimated that about 117 civilians were killed in demonstrations during the above period, a considerably larger number than hitherto reported. Most decedents and injury victims were shot. Conclusions: This analysis demonstrates the importance of real-time data on political violence collected by civil society initiatives. The de facto Sudanese government should immediately cease attacks against peaceful civilian protesters and put in place guarantees for their safety.

AbstractBackgroundArmed conflicts are known to have detrimental impact on availability and accessibility of health services. However, little is known on potential impact on utilisation of these services and health seeking behaviour. This study examines whether exposure to different types of war incidents affected utilisation of key health services—outpatient consultations, antenatal care, deliveries, and C-sections, in conflict affected areas of north west Syria between 1 October 2014 and 30 June 2017.MethodsThe study is an observational study using routinely collected data of 597,675 medical consultations and a database on conflict incidents that has 11,396 events. Longitudinal panel data analysis was used with fixed effect negative binomial regression for the monthly analysis and distributed lag model with a lag period of 30 days for the daily analysis.ResultsThe study found strong evidence for a negative association between bombardments and both consultations and antenatal care visits. The monthly Risk Ratio was 0.95 (95% CI 0.94–0.97) and 0.95 (95% CI 0.93–0.98); and the cumulative daily RR at 30 days was 0.19 (95% CI 0.15–0.25) and 0.42 (95% CI 0.25–0.69) for consultations and antenatal care respectively. Explosions were found to be positively associated with deliveries and C-sections. Each one unit increase in explosions in a given month in a given village was associated with about 20% increase in deliveries and C-sections; RR was 1.22 (95% CI 1.05–1.42) and 1.96 (95% CI 1.03–3.74) respectively.ConclusionThe study found that access to healthcare in affected areas in Syria during the study period has been limited. The study provides evidence that conflict incidents were associated negatively with the utilisation of routine health services, such as outpatient consultations and antenatal care. Whereas conflict incidents were found to be positively associated with emergency type maternity services—deliveries, and C-sections.