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Table 2 Summary of peer-reviewed articles

From: Humanitarian health programming and monitoring in inaccessible conflict settings: a literature review

Author Organization Title Location and type of crisis Intervention Goal of intervention Study design Results Additional details Quality
CDC 2008 WHO Progress towards poliomyelitis eradication—Pakistan and Afghanistan 2007 Afghanistan and Pakistan, ongoing conflict Large-scale house-to-house supplementary immunization activities (SIAs) with oral polio vaccine
- 4x national immunization days
- 7x subnational immunization days
Interrupt transmission of WPV in Pakistan and Afghanistan Descriptive case study - Post-SIA coverage below district average
- Suboptimal coverage in insecure and remote areas in both countries
- Up to 20% of children missed in areas of southwest Afghanistan
- In 2007, Afghanistan and Pakistan reported 17 and 32 cases of confirmed polio, respectively
- Extensive cross border movement necessitating SIA synchronization
- Indirect contact made with anti-government groups in an attempt to cease hostilities; increased areas accessible to vaccinators
- Support from tribal and religious leaders, and local communities necessary for reaching insecure areas
Balfour 2015 UNICEF Somalia CLTS in fragile and insecure contexts Somalia, ongoing conflict Community-led total sanitation Improve sanitation access in rural areas and small towns and describe adaptations necessary to adjust to insecure setting Descriptive case study Initially ineffective; gaps and barriers to CLTS approach identified during training of implementers in 2014
- Training in 2015 (emphasis on NGOs that stay in communities for)
- Decentralized approach allowed implementation in presence of weak central government
- Implemented by local NGOs because of their access to communities in conflict-affected areas
- The development of adapted, context-specific protocols essential for effective rollout in fragile contexts
- Involvement of key traditional and religious leaders found to be critical during triggering and implementation
Bharti et al. 2015 Part of the human mobility mapping project Remotely measuring populations during a crisis by overlaying two data sources Côte d’Ivoire, internal political conflict 2010–2012 Nighttime lights satellite imagery and mobile phone call detail records (CDRs)
- Compared composited stable nighttime lights values from 2012 and 2010, the density of phone towers present, and the density of SIMs
- Assessed average population size and dynamic changes across spatial and temporal scales
Rapid, large-scale measures of displaced populations and movement Retrospective analysis - Agreement in average measures of population sizes
- Able to obtain measurements in long- and short-term population dynamics by using two sources
CDRs did not provide long-term data on population movements, a pre-conflict baseline or movement across national boundaries
- Satellite images did not provide high-resolution mobility traces and were sensitive to environmental factors
- Used two complementary data sets to overcome the limitations of each; strongest correlation in economic regions (not administrative regions with varying wealth)
Chu et al. 2011 MSF Providing surgical care in Somalia: a model of task shifting Somalia, ongoing conflict Task shifting
- Expat presence ended Jan 2008 due to increased insecurity
- Surgical program run remotely by coordination team in Nairobi; visit site 2x/year to ensure standards being met
- Services provided by one Somali doc with surgical skills (trained under expat surgeon for 2 years), one surgical nurse, and one anesthetic nurse
- Surgical consult available by email
Continue provision of surgical care by local doctors and nurses following evacuation of expatriate staff Before and after study - 2086 operations were performed between Oct 2006 and December 2009
- After Jan 2008, all procedures (1433) were performed by non-surgeons (doctor with surgical skills and surgical nurse)
- Peri-operative mortality was lower when procedures were performed by non-surgeons (0.2%, 2 cases) between 2008 and 2009, versus 2006–2007 when surgeons were present (1.7%, 6 cases, P < 0.001)
- Low rates of spinal anesthesia due to lack of training of anesthetic nurse (most general anesthesia); extra training for Somali staff required
- Videoconferencing would be beneficial
Enenkel et al. 2015 - MSF
- Vienna University of Technology (TUW)
- International Institute for Applied Systems Analysis (IIASA)
Food security monitoring via mobile data collection and remote sensing: results from the Central African Republic (CAR) CAR, violent conflict Mobile data collection and remote sensing
COLLECT: android application that facilitates rapid and simple data collection
- Local CHWs working with MSF used mobile data collection application on smart phones to conduct nutrition assessments and interviews in the local language
- Inputs from satellite derived drought indicators
Collect information about socio-economic vulnerabilities related to malnutrition, access to resources and coping capacities using smart phones; to capture local conditions as situations evolve on the ground (early warning related to food insecurity) Cross-sectional survey - May 2015: households consumed 0.9 meals per day; average household size was more than nine people; despite this, children between 6 and 59 months were not malnourished
- Satellite-derived information about rainfall/soil moisture conditions and the Standardized Precipitation Evapotranspiration Index confirmed that the food insecurity situation in 2013/2014 was related to violent conflicts rather than to a climatic shock
- Recording the location of assessments via the smart phones’ GPS receiver enabled analysis and display of coupling between drought risk and impacts (direct link to satellite derived info)
- Complementary use of information from satellites and SATIDA COLLECT can support the translation of early warnings into action, reducing false alarms and strengthening disaster preparedness
Kevany et al. 2014 - The global fund
- Afghanistan Ministry of Health
- National Malaria and Leishmaniasis Control Programme (NMLCP)
Global health diplomacy investments in Afghanistan: adaptations and outcomes of global fund malaria programs Afghanistan, ongoing conflict Adaptation of global fund-supported malaria treatment and prevention programs:
1- amendment of educational materials for rural populations
2- religious awareness in gender groupings for health educational interventions
3- recruitment of local staff, for quality assurance and service delivery
4- alignment with diplomatic principles and avoidance of confusion with broader strategic and military initiatives
5- amendments to program “branding” procedures
- Ensure security of staff
- Improve local acceptability, coverage, and service utilization
Qualitative study and retrospective program evaluation - Service utilization improvements, improved access of service delivery in insecure regions
- Temporal association noted between intervention and improved uptake of nets
- Intervention implementation and safe passage for program staff facilitated by negotiations with community elders
- Prestige and acceptability of international donor activities were observed to improve
- Successful adaptation of interventions to insecure regions may help build international presence in otherwise-inaccessible areas, which would, in turn, be impossible without appropriate adjustments to program design, selection and delivery
- Must maintain explicit distinctions between development, military and political agendas
Lee et al. 2006 Backpack Health Worker Team
Mortality rates in conflict zones in Karen, Karenni, and Mon states in eastern Burma Burma (Myanmar), ongoing conflict - Cluster surveys conducted by indigenous mobile health workers
- Interviewed heads of households over 3 month time periods in 2002 and 2003
Estimate mortality rates in conflict-affected areas in eastern Burma inaccessible to international organizations Cross-sectional mortality survey Completed surveys from 1290 (64.5%) households in 2002 and 1609 (80.5%) households in 2003.
- Estimates of vital statistics for 2002 and 2003 respectively: infant mortality rate: 135 (95% CI 96–181) and 122 (95% CI 70–175) per 1000 live births; under-five mortality rate: 291 (95% CI 238–348) and 276 (95% CI 190–361) per 1000 live births; crude mortality rate: 25 (95% CI 21–29) and 21 (95% CI 15–27) per 1000 persons per year
- No other governmental or international organizations working with this population from within Burma.
- Use of indigenous mobile health workers provides means of measuring health status among populations normally be inaccessible due to conflict; advantages: familiarity with local communities, are highly trusted by the villagers, and visit communities in the course of their normal work
- Low response likely underestimated mortality
Mahn et al. 2008 - Back Pack Health Worker Team (BPHWT)
- Karen Department of Health and Welfare (KDHW)
- Local ethnic organizations
- Regional and international partners
Multi-level partnerships to promote health services among internally displaced in eastern Burma Burma (Myanmar), civil conflict and government restrictions Cross-border local-global partnerships
- BPHWT indigenous health workers travel to villages to provide general medical, maternal, and child health care; provide education workshops
- BPHTW partners with KDHW, village leaders and village health volunteers, Burma Medical Association, the National Health and Education
Committee, the Mae Tao Clinic, the Center for Public Health and Human Rights at the Johns Hopkins Bloomberg
School of Public Health
- International NGOs provide technical support
- Twice annually, BPHWT team leaders cross from Burma into Thailand to program’s administrative headquarters, to resupply, receive training, and compile collected health information
Provide critical health services to IDPs in eastern Burma Descriptive case study In 2005:
- HWs had 95% diagnosis accuracy and 85% treatment accuracy for common illnesses
- Treated nearly 78,000 cases throughout their IDP service areas
- Administered nearly 43,000 doses of Vitamin A, as well as deworming treatments, to children and postpartum women
- The local-global partnership was able to provide care to inaccessible IDPs
Key factors contributing to their success:
- Local access
- Multi-ethnic collaboration
- Coordination (of who delivers what services, supply procurement and delivery, etc.)
- Standard data collection; information used for advocacy
Martinez-Garcia 2014 MSF A retrospective analysis of pediatric cases handled by the MSF tele-expertise system 28 countries, conflict or unstable locations Telemedicine
- three telemedicine networks combined into single multilingual system,
- Case-coordinator receives referral and allocates to specialist; individual case follow-up (progress report) automatically requested from referrers since Oct 2013
Provide specialized pediatric medical consultations in remote areas Retrospective program analysis
- Pediatric cases referred to MSF telemedicine platform from April 2010 to March 2014 inclusive
- 467 cases total, 48 then randomly selected
- Mean rating for the quality of information provided by the referrer was 2.8 (on a scale from 1 (very poor) to 5 (very good); mean rating for appropriateness of the response was 3.3 (same scale)
- 2/3 of responses were useful to the patient, 3/4 responses were useful to the medical team
Mattli and Gasser 2008 ICRC A neutral, impartial and independent approach: key to ICRC’s acceptance in Iraq Iraq, ongoing conflict - Reinforced assistance programs through remote-control mechanisms: work with trusted implementing partners, periodic short visits by ICRC expatriate staff
- Moved staff to Amman, Jordan and kept only a core staff in Iraq
- Remote-control for WASH: mobilization of network of local contractors and consultants working with ICRC engineers
- New operational framework in 2006:
• Minimized movements to reduce staff exposure
• Increased networking to promote acceptance
- Implement programs of increasing scope and size and build acceptance through networking and communication with low-visibility presence
- Increase level of competence and responsibility of ICRC local staff
Descriptive case study - 2.7 million people directly benefitted from ICRC W&S activities in 2007
- In 2007, 54 water and sanitation projects were carried out under direct ICRC supervision and 78 projects under remote control
Keys to the success of the remote-control model:
- Highly experienced, motivated and committed ICRC Iraqi employees;
– Strong collaboration with and ownership by local authorities;
– An extensive network of local contractors/consultants throughout the country;
– Strong control mechanisms for needs assessment and project design, implementation, monitoring and evaluation
- Downside: limited contacts, limited capacity for coordination
Richard et al. 2009 - Karen Department of Health and Welfare (KDHW)
- Back Pack Health Worker Team (BPHWT)
Essential trauma management training: addressing service delivery needs in active conflict zones in eastern Myanmar Myanmar, civil conflict Trauma management program
- 4-6-day trauma course for health workers
- Part of CBO-run health system providing care for approximately
250,000 IDPs and war-affected residents
Improve the capacity of indigenous health workers to deliver effective trauma care Retrospective analysis of program - Since 2000, around 300 health workers have received
- Between June 2005 and June 2007, more than 200 patients recorded in the trauma patient registry; majority were victims of weapons-related trauma.
- Trauma victims treated by health workers survived in 91% of cases
Shanks et al. 2012 MSF Treatment of multidrug-resistant tuberculosis in a remote, conflict-affected area of the Democratic Republic of Congo DRC, ongoing conflict - Remote support of non-TB clinicians by TB specialist via mobile phone
- Use of simplified monitoring protocols
- Addressed stigma to support adherence
Provide remote support from TB specialist to non-TB clinicians using simplified monitoring protocol Case series - Able to successfully treat patients with simplified protocol
- All three DR-TB patients completed treatment
- Standardized forms helpful in maintaining overview of treatment despite multiple staff changing; however, susceptible to transcription error
- Communication between treating staff and headquarters was a challenge
Tong et al. 2011 MSF Challenges of controlling sleeping sickness in areas of violent conflict: experience in the Democratic Republic of Congo DRC, violent conflict HAT detection and treatment campaign Targeted medical interventions to address operational and medical challenges of managing HAT in conflict areas Descriptive case study - 2007: 46,000 screened and 1570 treated for HAT
- 2009: 2 centers forced to closed due to insecurity; reopened early 2010
- Complexity of HAT diagnosis and treatment prevented any emergency handover to local partners; operations suspended
- 2010: 770 patients treated
- Active screening and follow up compromised in conflict
- Community awareness and acceptance necessary for health program
- Displacement potentially creates new foci of transmission in previously cleared areas
-Insufficient international support and funding
Zachariah et al. 2012 MSF Practicing medicine without borders: tele-consultations and tele-mentoring for improving pediatric care in a conflict setting in Somalia? Somalia, ongoing conflict Tele-consultations and tele-monitoring
- To support Somali clinicians when expatriate staff were no longer able to be physically on site
- Specific risk criteria requiring mandatory referral defined
- Consultations with specialist in Nairobi scheduled every afternoon- “Tele-mentoring” (education) also provided by specialist
Improve quality of pediatric care in remote conflict setting Retrospective analysis of program data with historical control
(2010 data prior to implementation of telemedicine)
- Of 3920 pediatric admissions, 346 (9%) were referred for telemedicine.
- In 222 (64%) children, a significant change was made to initial case management
- In 88 (25%), a life-threatening condition was detected that had been initially missed
- Adverse outcomes fell from 7.6% in 2010 (without telemedicine) to 5.4% in 2011 (with telemedicine); 30% reduction, odds ratio 0.70, 95% CI 0.57–0.88, P = 0.001
- All 7 clinicians involved rated it to be of high value
- Held meetings with community elders to raise awareness and understanding of new technology; led to acceptance of technology in community with cultural beliefs that negate the use of cameras
- Reasons clinicians found it to be of high value: helped to improve recognition of risk signs (7/7), improved management protocols and prescription practices (6/7), built a relationship of solidarity through direct contact with distant specialist colleagues (5/7)