Policies on return and reintegration of displaced healthcare workers towards rebuilding conflict-affected health systems: a review for The Lancet-AUB Commission on Syria

Abstract Background War and armed conflicts severely disrupt all health system components, including the healthcare workforce. Although data is limited on the scale of health care worker (HCW) displacement in conflict zones, it is widely acknowledged that conflict conditions result in the displacement of a significant portion of qualified HCWs from their country of origin. While voluntary HCW return is integral to health system rebuilding in conflict-affected and post-conflict settings, there has been little exploration of the nature of national or international policies which encourage HCW return and reintegration to their home countries in the post-conflict period. Methods We conducted a systematic review to identify policies and policy recommendations intended to facilitate the return of displaced HCWs to their home countries and acknowledge their contribution to rebuilding the post-conflict health system. We searched three bibliographic databases and a range of organisational and national health agency websites to identify peer-reviewed articles and grey literature published in English or Arabic between 1 January 1990 to 24 January 2021, and extracted relevant information. We classified policies and policy recommendations using an adapted version of the UNHCR 4Rs Framework. Results We identified nine peer-review articles and four grey literature reports that fit our inclusion criteria, all of which were published in English. These covered issues of repatriation (n = 3), reintegration (n = 2), health system rehabilitation and reconstruction (n = 2); six documents covered several of these themes. Information was available for nine conflict contexts: Afghanistan, Iraq, Kosovo, Lebanon, Namibia, Northern Uganda, South Sudan, Timor Leste, and Zimbabwe. Findings demonstrate that health system rebuilding and rehabilitation serve as precursors and reinforcers of the successful return, repatriation, and reintegration of displaced HCWs. Conclusions Despite the significant numbers of HCWs displaced by conflict, this study identified few specific policies and limited information explicitly focused on the repatriation and reintegration of such workers to their home country in the post-conflict period. Additional research is needed to understand the particular barriers faced by conflict-displaced HCWs in returning to their home country. Conflict-affected and post-conflict states should develop policies and initiatives that address factors within and beyond the health sector to encourage displaced HCW return and provide sustainable reintegration solutions for those who return to post-conflict health systems.

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The impact of economic sanctions on health and health systems in low- and middle-income countries

European Journal of Public Health ◽

10.1093/eurpub/ckaa165.912 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

M Suhrcke ◽

M Pinna Pintor ◽

C Hamelmann

Keyword(s):

Health Outcomes ◽

Health System ◽

Health Systems ◽

Grey Literature ◽

Economic Sanctions ◽

Political Crisis ◽

Middle Income ◽

Financial Flows ◽

Adverse Health ◽

The Impact

Abstract Background Economic sanctions, understood as measures taken by one state or a group of states to coerce another into a desired conduct (eg by restricting trade and financial flows) do not primarily seek to adversely affect the health or health system of the target country's population. Yet, there may be indirect or unintended health and health system consequences that ought to be borne in mind when assessing the full set of effects of sanctions. We take stock of the evidence to date in terms of whether - and if so, how - economic sanctions impact health and health systems in LMICs. Methods We undertook a structured literature review (using MEDLINE and Google Scholar), covering the peer-reviewed and grey literature published from 1970-2019, with a specific focus on quantitative assessments. Results Most studies (23/27) that met our inclusion criteria focus on the relationship between sanctions and health outcomes, ranging from infant or child mortality as the most frequent case over viral hepatitis to diabetes and HIV, among others. Fewer studies (9/27) examined health system related indicators, either as a sole focus or jointly with health outcomes. A minority of studies explicitly addressed some of the methodological challenges, incl. control for relevant confounders and the endogeneity of sanctions. Taking the results at face value, the evidence is almost unanimous in highlighting the adverse health and health system effects of economic sanctions. Conclusions Quantitatively assessing the impact of economic sanctions on health or health systems is a challenging task, not least as it is persistently difficult to disentangle the effect of sanctions from many other, potentially major factors at work that matter for health (as, for instance, war). In addition, in times of severe economic and political crisis (which often coincide with sanctions), the collection of accurate and comprehensive data that could allow appropriate measurement is typically not a priority. Key messages The existing evidence is almost unanimous in highlighting the adverse health and health system effects of economic sanctions. There is preciously little good quality evidence on the health (system) impact of economic sanctions.

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Experiences of healthcare workers displaced by conflict: lessons from past conflicts and implications

European Journal of Public Health ◽

10.1093/eurpub/ckaa165.308 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

U Moqeem ◽

O Mukhtar ◽

A Abbara ◽

S Jabbour ◽

M Abouzeid

Keyword(s):

Healthcare Workers ◽

English Language ◽

Grey Literature ◽

Host Countries ◽

Conflict Zones ◽

Post Conflict ◽

Open Coding ◽

Support Mechanisms ◽

The Individual ◽

Systemic Support

Abstract Background Conflicts cause mass displacement, including of healthcare workers (HCWs). Understanding experiences of HCWs over the displacement trajectory, from push factors out of conflict zones, to barriers and facilitators in transit and host countries, is key to developing support mechanisms and informing policy discussions regarding return and reintegration. Methodology We systematically reviewed 6 academic databases and grey literature using combined search terms for HCWs, displacement, conflict, and experiences to identify English-language literature documenting personal or professional experiences of HCWs displaced by conflict, published between 1945 to 2020. Open coding and thematic analysis were used to identify emerging themes. Quality appraisal was conducted. Results 25 publications from academic journals, snowballed references, and grey literature from 10 geographical contexts and various types of HCW met inclusion criteria, many from conflicts in the Middle-East. 5 themes emerged: Conflict drives displacement: HCWs fled due to direct violence and deteriorating working conditions caused by increased workload, depleting resources, workforce attrition and attacks on healthcare. Giving back: Refugee HCWs were determined to continue working but had to do so informally or by working with humanitarian agencies. Personal and professional integration in host countries: refugee HCWs overcame barriers to relicense after which they reported disadvantage in job applications due to professional gaps and discrimination; many ended up working under-qualified jobs. Psychological toll on HCWs was pronounced. Prospects on return: HCWs desired to return to their home countries but feared political instability and violence. Conclusions Policies which support HCW retention during conflict, integration into host health systems, and encourage return post-conflict must be implemented. Further research is required to understand the individual and systemic support mechanisms required. Key messages Displaced HCWs experience many personal and professional challenges. Policies that support HCWs across the displacement trajectory and support return and post-conflict system rebuilding are required.

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Conflict affected, parallel health systems: challenges to collaboration between ethnic and government health systems in Kayin State, Myanmar

Conflict and Health ◽

10.1186/s13031-021-00396-z ◽

2021 ◽

Vol 15 (1) ◽

Author(s):

Colette Pang Biesty ◽

Aung Ja Brang ◽

Barry Munslow

Keyword(s):

Health System ◽

Health Systems ◽

Health Workers ◽

Health Providers ◽

Peace Accord ◽

Government Health ◽

Peace Processes ◽

Post Conflict ◽

Observation Methods ◽

Minority Ethnic Groups

Abstract Background Myanmar has had a long history of civil wars with its minority ethnic groups and is yet to see a sustainable peace accord. The conflicts have had a significant impact on health in Myanmar, with ethnic populations experiencing inequitable health outcomes. Consequently, to meet the health needs of ethnic people, Ethnic Health Organisations and Community-Based Health Organisations (EHO/CBHOs) created their own health system. The EHO/CBHO and Government health systems, provided by the Myanmar Ministry of Health and Sports (MoHS), remain parallel, despite both stakeholders discussing unification of the health systems within the context of ongoing but unresolved peace processes. EHO/CBHOs discuss the ‘convergence’ of health systems, whilst the MoHS discuss the integration of health providers under their National Health Plan. Methods A qualitative study design was used to explore the challenges to collaboration between EHO/CBHOs and the MoHS in Kayin state, Myanmar. Twelve health workers from different levels of the Karen EHO/CBHO health system were interviewed. Semi-structured, in-depth interviews were digitally recorded, transcribed, and coded. Data was analysed thematically using the Framework method. Topic guides evolved in an iterative process, as themes emerged inductively from the transcripts. A literature review and observation methods were also utilised to increase validity of the data. Results The challenges to collaboration were identified in the following five themes: (1) the current situation is not ‘post conflict’ (2) a lack of trust (3) centralised nature of the MoHS (4) lack of EHO/CBHO health worker accreditation (5) the NHP is not implemented in some ethnic areas. Conclusions Ultimately, all five challenges to collaboration stem from the lack of peace in Myanmar. The health systems cannot be ‘converged or ‘integrated’ until there is a peace accord which is acceptable to all actors. EHO/CBHOs want a federal political system, where the health system is devolved, equitable and accessible to all ethnic people. External donors should understand this context and remain neutral by supporting all health actors in a conflict sensitive manner.

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Contexts and mechanisms that promote access to healthcare for populations experiencing homelessness: a realist review

10.21203/rs.3.rs-79236/v1 ◽

2020 ◽

Cited By ~ 1

Author(s):

Rikke Siersbaek ◽

John Ford ◽

Sara Burke ◽

Clíona Ní Cheallaigh ◽

Steve Thomas

Keyword(s):

Health System ◽

Health Systems ◽

Healthcare Access ◽

Grey Literature ◽

Realist Review ◽

Access To Healthcare ◽

Staff Retention ◽

Programme Theory ◽

Eligibility Criteria

Abstract Objective: The objective of this study was to identify and understand the health system contexts and mechanisms that allow for homeless populations to access appropriate healthcare when needed.Design: A realist review.Data sources: Ovid MEDLINE, embase.com, CINAHL, ASSIA and grey literature until April 2019. Eligibility criteria for selecting studies: The purpose of the review was to identify health system patterns which enable access to healthcare for people who experience homelessness. Peer reviewed articles were first identified through a systematic search, grey literature searching, citation tracking and expert recommendations. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded to identify data relating to contexts, mechanisms and/or outcomes.Analysis: Inductive coding was used to generate Context-Mechanism-Outcome configurations which were refined and then used to build several iterations of the overarching programme theory.Results: Searching identified 330 review articles, of which 24 were included. Additional searching of grey literature yielded 50 records of which 12 were included. An additional 11 grey literature and primary sources were identified through citation tracking and expert recommendation for a total of 47 included sources. The analysis found that healthcare access for populations experiencing homelessness is improved when services are coordinated and delivered in a way that is organised around the person with a high degree of flexibility and a culture that rejects stigma generating trusting relationships between patients and staff/providers. Health systems should provide long-term, dependable funding for services to ensure sustainability and staff retention. Conclusions: With homelessness on the rise internationally, this study will inform health systems policy-making and implementation. It contributes to our understanding how healthcare systems can be more accessible for populations experiencing homelessness by providing long-term stable funding, promoting inclusive cultures and limiting stigma. Health systems should be flexible, timely and connected.

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Reimagining community relationships for organizational learning: a scoping review with implications for a learning health system

BMC Health Services Research ◽

10.1186/s12913-021-06640-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Crystal Milligan ◽

Whitney Berta

Keyword(s):

Organizational Learning ◽

Transformative Learning ◽

Health System ◽

Health Systems ◽

Scoping Review ◽

English Language ◽

Explicit Knowledge ◽

Grey Literature ◽

Specific Patient ◽

Learning Health System

Abstract Background Communities represent a highly relevant source of knowledge with regard to not only healthcare performance but also sociocultural context, yet their role in learning health systems has not been studied. Situating the learning health system as an organization, this paper explores the phenomenon of organizational learning from or with communities (defined as one of ‘the people,’ such as a town, a specific patient group or another group directly receiving a healthcare service). Methods We conducted a scoping review to determine what is known about organizational learning from or with communities that the organization serves, and to contribute to a more comprehensive evidence base for building and operating learning health systems. In March 2019, we systematically searched six academic databases and grey literature, applying no date limits, for English language materials that described organizational learning in relation to knowledge transfer between an organization and a community. Numerous variables were charted in Excel and synthesized using frequencies and thematic analysis. We updated this search in August 2020. Results In total, 42 documents were included in our analysis. We found a disproportionate emphasis on learning explicit knowledge from community rather than on tacit knowledge or learning in equal partnership with community. Our review also revealed inconsistently defined concepts, tenuously linked with their theoretical and empirical foundations. Our findings provide insight to understand the organization-community learning relationship, including motives and power differentials; types of knowledge to be learned; structures and processes for learning; and transformative learning outcomes. Conclusions Our review makes a singular contribution to organizational learning literatures by drawing from diverse research disciplines such as health services, business and education to map what is known about learning from or with community. Broadly speaking, learning health systems literature would benefit from additional research and theory-building within a sociological paradigm so as to establish key concepts and associations to understand the nature of learning with community, as well as the practices that make it happen.

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Public Health and Health Systems Impacts of SARS-CoV-2 Variants of Concern: A Rapid Scoping Review

10.1101/2021.05.20.21257517 ◽

2021 ◽

Author(s):

Janet A Curran ◽

Justine Dol ◽

Leah Boulos ◽

Mari Somerville ◽

Bearach Reynolds ◽

...

Keyword(s):

Public Health ◽

Health System ◽

Health Systems ◽

Scoping Review ◽

Grey Literature ◽

Current Evidence ◽

Risk Of Death ◽

Health Measures ◽

Guidance Documents ◽

The Impact

Background: As of April 2021, three SARS-CoV-2 variants of concern (VOC: B.1.1.7, B.1.351 and P.1) have been detected in over 132 countries. Increased transmissibility of VOC has implications for public health measures and health system arrangements. This rapid scoping review aims to provide a synthesis of current evidence related to public health measures and health system arrangements associated with VOC. Methods: Rapid scoping review. Seven databases were searched up to April 7, 2021 for terms related to VOC, transmission, public health and health systems. A grey literature search was conducted up to April 14, 2021. Title, abstracts and full text were screened independently by two reviewers. Data were double extracted using a standardized form. Studies were included if they reported on at least one of the VOC and public health or health system outcomes. Results: Of the 2487 articles and 59 grey literature sources retrieved, 37 studies and 21 guidance documents were included. Included studies used a wide range of designs and methods. Most of the studies and guidance documents reported on B.1.1.7, and 18 studies and 4 reports provided data for consideration in relation to public health measures. Public health measures, including lockdowns, physical distancing, testing and contact tracing, were identified as critical adjuncts to a comprehensive vaccination campaign. No studies reported on handwashing or masking procedures related to VOC. For health system arrangements, 17 studies were identified. Some studies found an increase in hospitalization due to B.1.1.7 but no difference in length of stay or ICU admission. Six studies found an increased risk of death ranging from 15-67% with B.1.1.7 compared non-B.1.1.7, but three studies reported no change. One study reported on the effectiveness of personal protective equipment in reducing VOC transmission in the hospital. No studies reported on screening staff and visitors, adjusting service provisions, or adjusting patient accommodations and shared spaces, which is a significant gap in the literature. Guidance documents did not tend to cite any evidence and were thus assumed to be based on expert opinion. Conclusion: While the findings should be interpreted with caution as most of the sources identified were preprints, findings suggest a combination of non-pharmaceutical interventions (e.g., masking, physical distancing, lockdowns, testing) should be employed alongside a vaccine strategy to improve population and health system outcomes. While the findings are mixed on the impact of VOC on health system arrangements, the evidence is trending towards increased hospitalization and death.

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Facilitators, Barriers, and Strategies for Health-system Guidance Implementation: A Protocol for a Critical Interpretive Synthesis

10.21203/rs.3.rs-127473/v1 ◽

2020 ◽

Author(s):

Qi Wang ◽

Xiajing Chu ◽

Ying Zhu ◽

Mohammad Golam Kibria ◽

Qiangqiang Guo ◽

...

Keyword(s):

Health System ◽

Health Systems ◽

Data Extraction ◽

Comparative Method ◽

Grey Literature ◽

Relevant Literature ◽

Quality Criteria ◽

Theoretical Framework ◽

Implementation Framework ◽

Critical Interpretive Synthesis

Abstract Background: As systematically developed statements about possible courses of action, health-system guidance (HSG) can assist with making decisions and developing policies to address problems or achieve goals in health systems. However, there are conceptual and methodological challenges related to HSG implementation due to the complexity of health systems and policymaking, the diversity of available evidence, and vast differences in contexts. To address these gaps, we aim to develop a theoretical framework for supporting the implementation of HSG as part of an effort to promote evidence-informed policymaking about health systems. Methods: To develop a theoretical framework about facilitators, barriers, and strategies to the implementation of HSG, we will apply a critical interpretive synthesis (CIS) approach to synthesize the findings from a range of relevant literature. We will search eleven electronic databases and grey literature websites to identify relevant published and grey literature. We will check the references of included studies and papers recommended by experts. Finally, we will conduct purposive searches to identify literature that fills any identified conceptual gaps. We will use relevance and a general five-items quality criteria to assess included papers. A standardized form will be developed for extracting information. We will use an interpretive analytic approach to synthesize the findings from included papers, including the constant comparative method throughout the analysis. The literature screening and relevance assessment will be conducted by two independent reviewers and disagreements will be resolved through discussion. Data extraction and synthesis will be extracted by the principal investigator and the sample of extracted data will be checked by a second reviewer for consistency and accuracy. Discussion: A new theoretical framework about facilitators, barriers, and strategies for HSG implementation will be developed using the CIS approach. The HSG implementation framework could be widely used for different HSG with varied topics and in different contexts (including low-, middle-, high-income countries and settings). In later work we will develop a tool for supporting HSG implementation based on the theoretical framework. Systematic review registration: PROSPERO CRDXXXX (Pending)

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Conflict Affected, Parallel Health Systems: Challenges to Collaboration Between Ethnic and Government Health Systems in Kayin State, Myanmar

10.21203/rs.3.rs-51832/v1 ◽

2020 ◽

Author(s):

Colette Pang Biesty ◽

Brang Aung Ja ◽

Barry Munslow

Keyword(s):

Health System ◽

Health Systems ◽

Health Workers ◽

Health Providers ◽

Peace Accord ◽

Government Health ◽

Peace Processes ◽

Post Conflict ◽

Observation Methods ◽

Minority Ethnic Groups

Abstract Background Myanmar has had a long history of civil wars with its minority ethnic groups and is yet to see a sustainable peace accord. The conflicts have had a significant impact on health in Myanmar, with ethnic populations experiencing inequitable health outcomes. Consequently, to meet the health needs of ethnic people, Ethnic Health Organisations and Community-Based Health Organisations (EHO/CBHOs) created their own health system. The EHO/CBHO and Government health systems, provided by the Myanmar Ministry of Health and Sports (MoHS), remain parallel, despite both stakeholders discussing unification of the health systems within the context of ongoing but unresolved peace processes. EHO/CBHOs discuss the ‘convergence’ of health systems, whilst the MoHS discuss the integration of health providers under their National Health Plan. Methods A qualitative study design was used to explore the challenges to collaboration between EHO/CBHOs and the MoHS in Kayin state, Myanmar. 12 health workers from different levels of the Karen EHO/CBHO health system were interviewed. Semi-structured, in-depth interviews were digitally recorded, transcribed, and coded. Data was analysed thematically using the Framework method. Topic guides evolved in an iterative process, as themes emerged inductively from the transcripts. A literature review and observation methods were also utilised to increase validity of the data. Results The challenges to collaboration were identified in the following five themes: (1) the current situation is not ‘post conflict’ (2) a lack of trust (3) centralised nature of the MoHS (4) lack of EHO/CBHO health worker accreditation (5) the NHP is not implemented in some ethnic areas. Conclusions Ultimately, all five challenges to collaboration stem from the lack of peace in Myanmar. The health systems cannot be ‘converged or ‘integrated’ until there is a peace accord which is acceptable to all actors. EHO/CBHOs want a federal political system, where the health system is devolved, equitable and accessible to all ethnic people. External donors should understand this context and remain neutral by supporting all health actors in a conflict sensitive manner.

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Reimagining Community Relationships for Organizational Learning: a Scoping Review With Implications for a Learning Health System

10.21203/rs.3.rs-135727/v1 ◽

2020 ◽

Author(s):

Crystal Milligan ◽

Dorothy Wong ◽

Whitney Berta

Keyword(s):

Organizational Learning ◽

Transformative Learning ◽

Health System ◽

Health Systems ◽

Scoping Review ◽

English Language ◽

Explicit Knowledge ◽

Grey Literature ◽

Specific Patient ◽

Learning Health System

Abstract Background: Communities represent a highly relevant source of knowledge with regard to not only healthcare performance but also sociocultural context, yet their role in learning health systems has not been studied. Situating the learning health system as an organization, this paper explores the phenomenon of organizational learning from or with communities (defined as one of ‘the people,’ such as a town, a specific patient group or another group directly receiving a healthcare service).Methods: We conducted a scoping review to determine what is known about organizational learning from or with communities that the organization serves, and to contribute to a more comprehensive evidence base for building and operating learning health systems. In March 2019, we systematically searched six academic databases and grey literature, applying no date limits, for English language materials that described organizational learning in relation to knowledge transfer between an organization and a community. Numerous variables were charted in Excel and synthesized using frequencies and thematic analysis. We updated this search in August 2020. Results: In total, 42 documents were included in our analysis. We found a disproportionate emphasis on learning explicit knowledge from community rather than on tacit knowledge or learning in equal partnership with community. Our review also revealed inconsistently defined concepts, tenuously linked with their theoretical and empirical foundations. Our findings provide insight to understand the organization-community learning relationship, including motives and power differentials; types of knowledge to be learned; structures and processes for learning; and transformative learning outcomes.Conclusions: Our review makes a singular contribution to organizational learning literatures by drawing from diverse research disciplines such as health services, business and education to map what is known about learning from or with community. Broadly speaking, learning health systems literature would benefit from additional research and theory-building within a sociological paradigm so as to establish key concepts and associations to understand the nature of learning with community, as well as the practices that make it happen.

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The COVID-19 pandemic and healthcare systems in Africa: a scoping review of preparedness, impact and response

BMJ Global Health ◽

10.1136/bmjgh-2021-007179 ◽

2021 ◽

Vol 6 (12) ◽

pp. e007179

Author(s):

Gizachew A Tessema ◽

Yohannes Kinfu ◽

Berihun Assefa Dachew ◽

Azeb Gebresilassie Tesema ◽

Yibeltal Assefa ◽

...

Keyword(s):

Health Services ◽

Health System ◽

Health Systems ◽

Scoping Review ◽

Grey Literature ◽

Healthcare Systems ◽

Strengthen Health System ◽

Global Engagement ◽

Scoping Reviews ◽

Meta Analyses

BackgroundThe COVID-19 pandemic has overwhelmed health systems in both developed and developing nations alike. Africa has one of the weakest health systems globally, but there is limited evidence on how the region is prepared for, impacted by and responded to the pandemic.MethodsWe conducted a scoping review of PubMed, Scopus, CINAHL to search peer-reviewed articles and Google, Google Scholar and preprint sites for grey literature. The scoping review captured studies on either preparedness or impacts or responses associated with COVID-19 or covering one or more of the three topics and guided by Arksey and O’Malley’s methodological framework. The extracted information was documented following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension checklist for scoping reviews. Finally, the resulting data were thematically analysed.ResultsTwenty-two eligible studies, of which 6 reported on health system preparedness, 19 described the impacts of COVID-19 on access to general and essential health services and 7 focused on responses taken by the healthcare systems were included. The main setbacks in health system preparation included lack of available health services needed for the pandemic, inadequate resources and equipment, and limited testing ability and surge capacity for COVID-19. Reduced flow of patients and missing scheduled appointments were among the most common impacts of the COVID-19 pandemic. Health system responses identified in this review included the availability of telephone consultations, re-purposing of available services and establishment of isolation centres, and provisions of COVID-19 guidelines in some settings.ConclusionsThe health systems in Africa were inadequately prepared for the pandemic, and its impact was substantial. Responses were slow and did not match the magnitude of the problem. Interventions that will improve and strengthen health system resilience and financing through local, national and global engagement should be prioritised.

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