Repository logo
 

The Institute for Global Health and Development

Permanent URI for this collectionhttps://eresearch.qmu.ac.uk/handle/20.500.12289/9

Browse

Author: search.filters.author.Witter, SophieSubject: search.filters.subject.Health System

Search Results

Now showing 1 - 4 of 4
  • Thumbnail Image
    Item
    Refugee integration in national health systems of low- and middle-income countries (LMICs): evidence synthesis and future research agenda
    (Elsevier, 2025-09-12) Olabi, Amina; Palmer, Natasha; Bertone, Maria Paola; Loffreda, Giulia; Bou-Orm, Ibrahim; Sempé, Lucas; Vera Espinoza, Marcia; Dakessian, Arek; Kadetz, Paul; Ager, Alastair; Witter, Sophie
    This paper reviews evidence on healthcare responses for refugees, documenting the different approaches and their effectiveness and impact in particular in relation to supporting integrating refugees into national health systems. The review adopted a purposeful, iterative approach, utilizing electronic databases, grey literature, and reference lists from relevant studies. A total of 167 studies, primarily from low- and middle-income countries (LMICs), focusing on refugees and forcibly displaced persons with empirical data, were included. The review highlights a substantial literature on refugee health and healthcare access, with well-covered areas including delivery models, access barriers, gaps in coverage, and specific health services such as psychosocial care, non-communicable diseases, mental health, and maternal and child health. However, less attention is given to integration models, health system responses, and their impact on system resilience and social cohesion. Few studies examine the costs, feasibility, or sustainability of integration models, and little research focuses on health system perspectives or comparative analyses. Moreover, the host health system's status, capacity, and needs are often underexplored. Some countries are particularly well-represented in studies, e.g. Turkey, Jordan, Lebanon, Bangladesh, Democratic Republic of Congo (DRC), and Uganda. There is however a paucity of data that would provide the basis for more quantitative or analytical evaluation from a systems perspective. This gap highlights the need for further research on effective integration models, their operational aspects, and their long-term impact on local health systems' resilience and sustainability. To support this research agenda, we propose a conceptual framework to provide analytic guidance for future research on healthcare responses for refugees and health system integration.
  • Thumbnail Image
    Item
    Understanding and addressing mental health needs and non-communicable disease in situations of fragility: RUHF research programme synopsis
    (NIHR, 2025) Ager, Alastair; Witter, Sophie; Diaconu, Karin; Wurie, Haja; Samai, Mohamed; Saleh, Shadi
    Background: Fragile settings – marked by conflict and political, environmental, social, or economic crisis – present severe challenges to population health and the delivery of services. This is particularly the case for health conditions that require continuity of care such as non-communicable disease and mental ill-health. Objectives: To understand existing patterns of health seeking in relation to noncommunicable disease and mental health and the barriers to equitable access to quality provision. To then evaluate the feasibility, effectiveness and quality of interventions designed to address these conditions in contexts of fragility. Design and methods: Building on a foundation of focused scoping reviews, we used participatory methods – including group model building – to map pathways of access to community and health system resources in relation to non-communicable diseases and mental health. We then used a range of surveys and key informant interviews to evaluate implemented interventions. In addition, we undertook a series of global reviews of relevant topics, such as conceptualisation of fragility, the role of trust in health-seeking for noncommunicable disease care in fragile settings, analysis of policy and funding priorities of global actors regarding non-communicable diseases in low- and middle-income countries, and the political economy of NCD policy adoption and implementation at national level. Setting and participants: Field studies were focused at the district or governorate level in a range of fragile settings, including Lebanon, Sierra Leone, El Salvador and, latterly, Nigeria and Gaza. Participants included service users, (formal and informal) health providers and policy makers. Interventions: Interventions addressing NCDs included treatment protocols for hypertension and diabetes (with report cards and desk guides supporting primary care-based disease management) and a local co-created salt reduction programme (featuring community drama, school outreach and radio messaging). Mental health needs were primarily addressed in relation to the provision of community-based psychosocial support either through specific interventions (including a lay-woman-led problem solving intervention for perinatal women) or the development of assessment tools (such as a Participatory Assessment Tool for Mapping Social Connections) and contextually valid screening measures (including the Sierra Leone Psychological Distress Scale and the Sierra Leone Perinatal Psychological Distress Scale) to inform interventions. The programme also developed relevant training interventions. Main outcome measures: Measures focused on access to, and utilisation and quality of, services, including user perceptions of provision. Results: We identified a range of barriers to effective health provision in fragile settings. These reflected the cultural, political, social, economic particularities of the setting and its health system. However, trust (in specific health providers, within social and community networks, and in government) was consistently found to be a key factor in securing targeted outcomes. The skills, methods and confidence of providers was also found to be an important influence on such outcomes. Providing contextually relevant training, mentorship and tools equipped health providers in primary care settings to maintain effective, evidencebased management of diabetes and hypertension despite the ongoing challenges of their fragile context. Mobilisation of community-level resources to address non-communicable disease and mental health needs was demonstrated as relevant, feasible and potentially effective in all settings. Limitations: There was great diversity across the particular settings studied, as well as ongoing gaps in knowledge in relation to these conditions in particular. Caution should be shown in generalisation of specific findings to other situations that may not share important features. The COVID 19 pandemic disrupted data collection in both Sierra Leone and Lebanon, although the targeted power of studies was generally secured. More generally, the pandemic significantly impacted health systems operations in all settings studied, an influence that is discussed in all relevant papers. Conclusions: The research programme contributed to addressing gaps in the literature regarding effective tools and strategies to strengthen provision regarding mental health and non-communicable disease in fragile settings. Assessment of needs and barriers to accessing services is an important foundation for effective working in such contexts. This is achievable with research methods (such as group model building and remote data capture) that can accommodate the diverse challenges and uncertainty associated with these settings. Incorporating such information in service design – at the level of the community, health facility or policymaker – can secure improvement in access to, and quality of, important services. Donors and policy makers need to attend not just to the drivers of fragility but also to coherent investment in public health systems and in processes of community engagement if health needs are to be meaningfully addressed. Future work: The conceptualisation of fragility (and resilience) developed through this programme is informing the design of community, health system and wider cross-sectoral interventions in fragile contexts through the ReBuild for Resilience programme in settings including Sierra Leone, Lebanon, Myanmar and Nepal. Further work across diverse contexts of fragility is required to both identify common features and principles required for health response in these settings and refine strategies and tools that can readily be adapted to the unique characteristics of any particular context.
  • Thumbnail Image
    Item
    Exploring factors driving the performance of rural health care in Papua New Guinea [Policy Note]
    (World Bank, Washington, DC, 2018-06-06) Cairns, Alan; Witter, Sophie; Hou, Xiaohui
    Examining performance patterns of sub-national units, such as provinces and districts, within a health system is important to understand their drivers and what might be needed to improve outputs. Such literature is relatively rare in low and middle-income countries. It is particularly relevant for Papua New Guinea, which is underperforming in relation to its neighbours and targets for core health indicators and faces particular geographical challenges, with a dispersed and diverse population. In this analysis, we undertake simple correlation analysis between remoteness of populations, expenditure on frontline services and core outputs by provinces and regions, such as antenatal care, outpatient visits, outreach clinics, referrals of patients and facility supervision in 2012. In the context of the challenging geography of Papua New Guinea, these are expected to be important factors. Some expected patterns were found – for example, between remoteness and higher service costs, as well as between remoteness and higher outreach services. Outpatient visits, however, increased with remoteness, which was surprising. Our correlation analyses suggest a virtuous circle operating in some areas (even in the most geographically challenged) between outreach clinics, immunisation coverage, supervision, frontline spending and overall health system performance, which merits further investigation into the factors supporting these and how they can be reinforced elsewhere. Whilst expenditure did not correlate closely with provincial performance, it was evident that the provinces with higher performance across the selection of metrics typically were also the higher spenders on frontline services. There was some correlation of higher performance with density of public provision. More fine-grained assessment, including at the district level, will be needed to understand the low levels of outreach clinics, transfers and supervision, all of which are critical for quality health care in these kinds of contexts. The analysis illustrates what can be learned from combining routine data sources, as well as the limits and the need to complement such analysis with more detailed local qualitative investigations. It also reinforces the message that local leadership, supportive supervision and resources directed to frontline services can be effective in raising health system performance, even in challenging settings.
  • Thumbnail Image
    Item
    Ebola in the context of conflict affected states and health systems: Case studies of Northern Uganda and Sierra Leone
    (BioMed Central, 2015-08) McPake, Barbara; Witter, Sophie; Ssali, S.; Wurie, H.; Namakula, Justine; Ssengooba, F.
    Ebola seems to be a particular risk in conflict affected contexts. All three of the countries most affected by the 2014-15 outbreak have a complex conflict-affected recent history. Other major outbreaks in the recent past, in Northern Uganda and in the Democratic Republic of Congo are similarly afflicted although outbreaks have also occurred in stable settings. Although the 2014-15 outbreak in West Africa has received more attention than almost any other public health issue in recent months, very little of that attention has focused on the complex interaction between conflict and its aftermath and its implications for health systems, the emergence of the disease and the success or failure in controlling it. The health systems of conflict-affected states are characterized by a series of weaknesses, some common to other low and even middle income countries, others specifically conflict-related. Added to this is the burden placed on health systems by the aggravated health problems associated with conflict. Other features of post conflict health systems are a consequence of the global institutional response. Comparing the experience of Northern Uganda and Sierra Leone in the emergence and management of Ebola outbreaks in 2000-1 and in 2014-15 respectively highlights how the various elements of these conflict affected societies came together with international agencies responses to permit the outbreak of the disease and then to successfully contain it (in Northern Uganda) or to fail to do so before a catastrophic cost had been incurred (in Sierra Leone). These case studies have implications for the types of investments in health systems that are needed to enable effective response to Ebola and other zoonotic diseases where they arise in conflict- affected settings.