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Measuring health system resilience in a highly fragile nation during protracted conflict: South Sudan 2011-15.

ABSTRACT: Health systems resilience (HSR) is defined as the ability of a health system to continue providing normal services in response to a crisis, making it a critical concept for analysis of health systems in fragile and conflict-affected settings (FCAS). However, no consensus for this definition exists and even less about how to measure HSR. We examine three current HSR definitions (maintaining function, improving function and achieving health system targets) using real-time data from South Sudan to develop a data-driven understanding of resilience. We used 14 maternal, newborn and child health (MNCH) coverage indicators from household surveys in South Sudan collected at independence (2011) and following 2 years of protracted conflict (2015), to construct a resilience index (RI) for 9 of the former 10 states and nationally. We also assessed health system stress using conflict-related indicators and developed a stress index. We cross tabulated the two indices to assess the relationship of resilience and stress. For maintaining function for 80% of MNCH indicators, seven state health systems were resilient, compared with improving function for 50% of the indicators (two states were resilient). Achieving the health system national target of 50% coverage in half of the MNCH indicators displayed no resilience. MNCH coverage levels were low, with state averages ranging between 15% and 44%. Central Equatoria State displayed high resilience and high system stress. Lakes and Northern Bahr el Ghazal displayed high resilience and low stress. Jonglei and Upper Nile States had low resilience and high stress. This study is the first to investigate HSR definitions using a resilience metric and to simultaneously measure health system stress in FCAS. Improving function is the HSR definition detecting the greatest variation in the RI. HSR and health system stress are not consistently negatively associated. HSR is highly complex warranting more in-depth analyses in FCAS.

SUBMITTER: Odhiambo J

PROVIDER: S-EPMC7152724 | biostudies-literature | 2020 Apr

REPOSITORIES: biostudies-literature

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Measuring health system resilience in a highly fragile nation during protracted conflict: South Sudan 2011-15.

Odhiambo Jackline J Jeffery Caroline C Lako Richard R Devkota Baburam B Valadez Joseph J JJ

Health policy and planning 20200401 3

Health systems resilience (HSR) is defined as the ability of a health system to continue providing normal services in response to a crisis, making it a critical concept for analysis of health systems in fragile and conflict-affected settings (FCAS). However, no consensus for this definition exists and even less about how to measure HSR. We examine three current HSR definitions (maintaining function, improving function and achieving health system targets) using real-time data from South Sudan to ...[more]

PMID: 31876921

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Project description:ObjectivesThe objective of this study was to assess if children aged 0-23 months in a conflict-affected state of South Sudan were on track with their immunization schedule and to identify predisposing factors that affected this study population from being on track with their routine immunization schedule.DesignCommunity-based cross-sectional study using a semi-structured questionnaire. The binary outcome of interest was defined as being on or off track with routine vaccination schedule. Multivariable logistic regression was used to analyze for the association between the predisposing factors surveyed and being off track with one's routine immunization schedule.SettingRural communities in four counties (Rumbek Center, Rumbek North, Rumbek East and Wulu) of the Western Lakes state in South Sudan during January 10, 2020 to June 10, 2020.ParticipantsWe surveyed 428 children aged 0-23 months and their mothers/caregivers who lived in either of the four counties in the Western Lakes State. Participants were selected using random ballot sampling.ResultsMore than three-quarters of the children surveyed (75.5%) were off track with their vaccination schedule. Children with an immunization card had 71% reduced odds of being off track with their immunization (AOR = 0.29; 95% CI 0.10-0.83, p-value = 0.021) compared to children without immunization cards. Children who reside near health facilities and do not require transportation to facilities had 87% reduced odds of being off track with their immunization compared to those who lived far and required transport to facilities. Giving an adequate immunization notice before conducting immunization outreach visits to communities was also associated with reduced odds (AOR = 0.27; 95% CI 0.09-0.78. p-value = 0.016) of children being off track with their immunization.ConclusionThis study revealed that most children were off track with their vaccination schedule in South Sudan, which is not only influenced by maternal characteristics but mainly by community- and state-level immunization service delivery mechanisms. Policies and interventions to improve child immunization uptake should prioritize these contextual characteristics.

Project description:BackgroundHealth systems resilience (HSR) research is a rapidly expanding field, in which key concepts are discussed and theoretical frameworks are emerging with vibrant debate. Fragile and conflict-affected settings (FCAS) are contexts exposed to compounding stressors, for which resilience is an important characteristic. However, only limited evidence has been generated in such settings. We conducted a scoping review to: (a) identify the conceptual frameworks of HSR used in the analysis of shocks and stressors in FCAS; (b) describe the representation of different actors involved in health care governance and service provision in these settings; and (c) identify health systems operations as they relate to absorption, adaptation, and transformation in FCAS.MethodsWe used standard, extensive search methods. The search captured studies published between 2006 and January 2022. We included all peer reviewed and grey literature that adopted a HSR lens in the analysis of health responses to crises. Thematic analysis using both inductive and deductive approaches was conducted, adopting frameworks related to resilience characteristics identified by Kruk et al., and the resilience capacities described by Blanchet et al. RESULTS: Thirty-seven studies met our inclusion criteria. The governance-centred, capacity-oriented framework for HSR emerged as the most frequently used lens of analysis to describe the health responses to conflict and chronic violence specifically. Most studies focused on public health systems' resilience analysis, while the private health sector is only examined in complementarity with the former. Communities are minimally represented, despite their widely acknowledged role in supporting HSR. The documentation of operations enacting HSR in FCAS is focused on absorption and adaptation, while transformation is seldom described. Absorptive, adaptive, and transformative interventions are described across seven different domains: safety and security, society, health system governance, stocks and supplies, built environment, health care workforce, and health care services.ConclusionsOur review findings suggest that the governance-centred framework can be useful to better understand HSR in FCAS. Future HSR research should document adaptive and transformative strategies that advance HSR, particularly in relation to actions intended to promote the safety and security of health systems, the built environment for health, and the adoption of a social justice lens.

Project description:BackgroundThis study investigates the frequency of near-miss events and compares correlates in the world's newest nation.MethodsA cross-sectional study was carried out to audit near-miss events and their causes. A total of 1,041 mothers were sampled. Data were gathered using World Health Organization near-miss evaluation tools according to morbidity and organ failure-based criteria. Intensive care unit admission criteria were not used (as there is no functional intensive care unit in Juba Teaching Hospital). Descriptive statistics and bivariate and multivariable logistic regression were used to analyze the data. The study adhered to the Declaration of Helsinki.ResultsNearly half (49.7%) of the clients were young pregnant women (aged 15-24 years), with a mean age of 25.07±5.65 years. During the study period, there were 994 deliveries, 94 near-misses, and 10 maternal deaths. This resulted in maternal near-miss and mortality rates of 94.1 per 1,000 and 1,007 per 100,000 live births, respectively. Severe maternal outcome and maternal near-miss rates were 10.47 per 1,000 (morbidity-based criteria) and 41.3 per 1,000 (organ failure-based criteria), respectively. The likelihood of mortality was 25% (95% CI 10%-51%) for a ruptured uterus, 9% (95% CI 4%-17%) for severe postpartum hemorrhage, and 11% (95% CI 3%-30%) for eclampsia. Anemia, hemorrhage, and dystocia were the highest contributory factors in the occurrence of maternal near-misses.ConclusionThe near-miss rate was high. Contributing factors were lack of resources, low quality of primary health care, and delays in care. All near-misses should be regarded as opportunities to improve the quality of maternity care. Health institutes should address delays in conducting interventions, referral barriers, and personnel gaps. Fully functional intensive-care units must be created in all facilities, including Juba Teaching Hospital and other hospitals. Notification policies for all near-miss cases should be in place in all health care units, with a "no shame, no blame" approach.

Project description:Background:South Sudan has endured decades of armed conflict, with the most recent in 2016. This has left the health system and infrastructure overstretched by a myriad of infectious diseases like tuberculosis. Our study aimed at quantitatively and qualitatively documenting TB dynamics and challenges with access to health care during a period of civil unrest in Wau. Materials & Methods:A cross sectional study was carried out between January and February 2016 at Wau Teaching Hospital (WTH). Sputum was randomly collected from 207 of the 1035?TB suspects and analyzed using Ziehl-Neelsen (ZN) and Fluorescent Microscopy (FM), Culture, Capilia MTBC Neo, and DST. The laboratory results and questionnaire metadata were used for descriptive statistics, logistic regression in R version 3.4.2. These results were presented along with results from a qualitative assessment of the situation at WTH. Results:Of 207?TB suspects, 39 (18.8%) were positive on FM with bacilli growth on culture, later confirmed as Mycobacterium tuberculosis complex. Only 5.4% of the cases were resistant to Isoniazid. Age; 20-45 OR?=?13 (95%CI?=?2.4-25.6, p?=?0.011),?>?46 OR?=?3 (95%CI?=?0.5-58, p?=?0.005) and raw milk consumption OR?=?2.2 (95%CI?=?0.37-42.48, p?=?0.005) were associated with being TB positive. The qualitative evaluation reveals that gunfights in the surroundings of Wau influenced the number of patients attending WTH, with some travelling up to 545?km to seek medical attention. Conclusion:We report a high prevalence of tuberculosis among patients who presented at WTH, with approximately 1 out of 5 individuals testing positive for tuberculosis. This is likely an underestimation given the challenges patients had to endure as they sought medical attention. Tuberculosis epidemiology is likely to be driven by individual and household factors, but further investigations are needed to fully understand the risk profile. The tools in use were adequate for TB diagnostics and we observed a remarkably low prevalence of drug resistance, a statistic that is worth preserving. We therefore call for action from all stakeholders.

Project description:BackgroundThe health system in South Sudan faces extreme domestic resource constraints, low capacity, and protracted humanitarian crises. Supportive supervision is believed to improve the quality of health care and service delivery by compensating for flaws in health workforce management. This study aimed to explore the current supervision practices in South Sudan and identify areas for quality improvement.MethodsThe study employed qualitative approaches to collect and analyse data from six purposefully selected counties. Data were collected from 194 participants using semi-structured interviews (43 health managers) and focus group discussions (151 health workers). Thematic content analysis was used to yield an in-depth understanding of the supervision practices in the health sector.ResultsThe study found that integrated supportive supervision and monitoring visits were the main approaches used for health services supervision in South Sudan. Supportive supervision focused more on health system administration and less on clinical matters. Although fragmented, supportive supervision was carried out quarterly, while monitoring visits were either conducted monthly or ad hoc. Prioritization for supportive supervision was mainly data driven. Paper-based checklists were the most commonly used supervision tools. Many supervisors had no formal training on supportive supervision and only learned on the job. The health workers received on-site verbal feedback and, most times, on-the-job training sessions through coaching and mentorship. Action plans developed during supervision were inadequately followed up due to insufficient funding. Insecurity, poor road networks, lack of competent health managers, poor coordination, and lack of adequate means of transport were some of the challenges experienced during supervision. The presumed outcomes of supportive supervision were improvements in human resource management, drug management, health data reporting, teamwork, and staff respect for one another.ConclusionSupportive supervision remains a daunting task in the South Sudan health sector due to a combination of external and health system factors. Our study findings suggest that strengthening the processes and providing inputs for supervision should be prioritized if quality improvement is to be attained. This necessitates stronger stewardship from the Ministry of Health, integration of different supervision practices, investment in the capacity of the health workforce, and health infrastructure development.

Project description:There is a rich body of research addressing the issues of conflict-related sexual violence, and a similar wealth of scholarship focused on resilience. To date, however, these literatures have rarely engaged with each other. This article developed from an ongoing research project that seeks to address this gap, by exploring how victims-/survivors of conflict-related sexual violence in three highly diverse settings - Bosnia-Herzegovina, Colombia and Uganda - demonstrate resilience. This research is the first to apply the Adult Resilience Measure (ARM), a 28-item scale that seeks to measure protective resources across individual, relational, and contextual subscales, to the context of conflict-related sexual violence. A total of 449 female and male participants in the three aforementioned countries completed the ARM (in the framework of the study questionnaire) as part of this research. This article presents some of the results of the analyses. Specifically, we first sought to establish through Confirmatory Factor Analysis whether the ARM was actually measuring the same construct in all three countries, by confirming the invariance (or otherwise) of the factor structure. The second aim was to explore how different resources function and cluster in different cultural contexts, to arrive at a more nuanced understanding of the different protective factors in the lives of study participants. We generated different factor structures for BiH, Colombia, and Uganda respectively, suggesting that a single factor structure does not sufficiently capture the diverse groupings of protective factors linked to the particularities of each country, including the dynamics of the conflicts themselves. Ultimately, we use the findings to underscore the need for policy approaches that move away from a deficit model and give greater attention to strengthening and investing in the (often overlooked) protective resources that victims-/survivors may already have in their everyday lives.

Project description:This mixed-methods exploratory study identified and then developed and validated a quantitative measure of a new construct of mental suffering in the occupied Palestinian territory: feeling broken or destroyed.Group interviews were conducted in 2011 with 68 Palestinians, most aged 30-40, in the West Bank, East Jerusalem, and the Gaza Strip to discern local definitions of functioning. Interview participants articulated of a type of suffering not captured in existing mental health instruments used in regions of political conflict. In contrast to the specific difficulties measured by depression and PTSD (sleep, appetite, energy, flashbacks, avoidance, etc.), participants elaborated a more existential form of mental suffering: feeling that one's spirit, morale and/or future was broken or destroyed, and emotional and psychological exhaustion. Participants articulated these feelings when describing the rigors of the political and economic contexts in which they live. We wrote survey items to capture these sentiments and administered these items-along with standard survey measures of mental health-to a representative sample of 1,778 32-43 year olds in the occupied Palestinian territory. The same survey questions also were administered to a representative subsample (n = 508) six months earlier, providing repeated measures of the construct.Across samples and time, the feeling broken or destroyed scale: 1) comprised a separate factor in exploratory factor analyses, 2) had high inter-item consistency, 3) was reported by both genders and in all regions, 4) showed discriminate validity via moderate correlations with measures of feelings of depression and trauma-related stress, and 5) was more commonly experienced than either feelings of depression or trauma-related stress.Feeling broken or destroyed can be reliably measured and distinguished from conventional measures of mental health. Such locally grounded and contextualized measures should be identified and included in assessments of the full impact of protracted political conflict on functioning.

Project description:BackgroundAn active conflict in South Sudan in late 2013/early 2014 displaced approximately 2 million people over the course of several months. In May 2015, the International Rescue Committee and UNICEF conducted a mixed-methods case study of the impact of that acute emergency on integrated community case management (iCCM) of childhood illness programming in Payinjiar County, Unity State. The objective was to document the operations of an iCCM program during an acute crisis and to assess the program's ability to continue operations.ResultsThis mixed-methods case study is comprised of semi-structured interviews and focus groups with key stakeholders such as policymakers, program implementers, community health workers (CHWs), and caregivers on their experience with iCCM programming during this time period. Routine program data were also analyzed to assess the effect of the crisis on key health indicators.FindingsInternally displaced persons (IDPs) nearly doubled the population in Payinjiar. Some displaced CHWs continued to provide treatment in host communities when they were able to take supplies with them. Despite no formal community mobilization effort by the iCCM program, many IDPs identified CHWs in the communities they were displaced to and obtained care from them. Caregivers who had been internally displaced reported preferring care from CHWs especially in contrast to risking an insecure journey to health facilities. The total number of treatments provided per month by CHWs dropped during the acute crisis, but recovered to pre-crisis levels within six months. CHW supervisors attempted to continue supervision by utilizing their networks to track down displaced CHWs and assess the security situation prior to visits. The monthly supervision rate dropped to the lowest level of 77% in February 2014, but rebounded to 91% by August 2014. Several CHWs and community leaders qualitatively validated this claim of sustained supervision.ConclusionsCHWs, including those who were internally displaced, continued to provide treatment for childhood illnesses during an acute emergency, and service provision recovered faster to pre-crisis levels than the formal health sector. International donors and humanitarian actors should recognize iCCM as a potentially high-impact humanitarian response. Flexible funding from donors would enable further evidence generation on iCCM approaches and improvements that could both sustain and enhance programming in acute crisis.

Dataset Information

Measuring health system resilience in a highly fragile nation during protracted conflict: South Sudan 2011-15.

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Measuring health system resilience in a highly fragile nation during protracted conflict: South Sudan 2011-15.

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