Barriers | |
Security | Being in an insecure environment was often mentioned as a hindrance to the delivery of interventions. Health facilities are destroyed, patients were also unable to access clinics due to security issues. This was especially relevant for services such as emergency obstetric care when women may need to be referred to hospitals. |
Lack of resources | Shortages of supplies/resources (medicine, diagnostic tests) during a period of conflict were also noted as barriers and hampered both maternal and newborn care. Materials such as gloves for delivery, obstetric equipment or beds for premature babies were some of the ones noted as missing.43 111 |
Population movement | The continuous population movement limits both delivery and access to health services. |
Lack of skilled health workers | The limited training of health workers was a major barrier in the delivery of interventions such as obstetric and newborn care. A few studies mentioned the lack of obstetric specialists as a barrier.43 104 A short training although helping to increase knowledge was also noted as not being enough. |
Social norms/stigma | This was noted as a barrier for both patients as well as healthcare workers. Refugees may also be stigmatised by their hosts.63 |
Lack of funding | Limited funding was also noted as a barrier as it limited to range of services and materials available. |
Limited movement for the women/cost barriers | Conflict reduces means of generating income, especially during displacement. Therefore, the cost of getting health services or of transport might be weighed against other priorities. In some instances where healthcare is not subsidised, cost of care also influenced where women delivered.49 |
Staff affected by conflict | Health services were also limited as staff are also affected by displacement and security concerns. Shortage of staff was a big concern and in some areas was caused by the warring party. In one study, the Taliban were preventing female health providers from working.106 Some areas also experienced a high staff turnover, especially in a prolonged conflict.134 |
Limited services | Conflict reduces the range of available services. For maternal health, this was especially dangerous in cases where there is limited EmOC services as needed surgical facilities were not available or there was no training in the management of postpartum complications,33 64 emergency referral services were also not always available. |
Quality of care | There were some differences noted between the quality of care delivered at hospitals, compared with clinics; hospitals having a higher quality.111 ANC and postnatal care were also not always delivered to their full extent. |
Lack of guidelines | A few studies mentioned lack of guidelines for STI prevention or lack of newborn-specific clinical and referral protocols as barriers to implementation.112 |
Facilitators | |
Collaboration | Multisectoral collaboration between international NGOs, the Ministry of Health and existing district health offices/public sector was noted as facilitators. Working with local NGOs was also a facilitator as they are already connected to the community. |
Staff training | Training improved the skills of health workers and increased motivation. Continuous supervision/refresher training was encouraged, especially if provided by trained paediatricians or obstetricians.122 S-CORT modules are an innovative approach that focuses on training on the clinical services included in the MISP.122 One NGO developed a simple and low-cost 38-hour training course to upgrade the skills of TBAs.113 |
Availability of funding/resources | Having adequate funding allowed for more resources. |
CHW involvement/outreach workers | Having maternal CHWs from the same community or refugee population was noted as a facilitator in educating women about maternal health. |
Use of existing infrastructure | Using the existing infrastructure facilitated the delivery of interventions.71 110 |
Technological/systems innovations | Improving systems such as introducing an ultrasound in outreach settings was noted as a facilitator,23 or introducing ANC into family medicine clinics as shown by Homan et al.57 Using GIS technology with a mobile clinic was shown as being effective in delivering SRH services to IDPs.114 Having a free ambulance along with good infrastructure (roads, telephone network) was a facilitator.91 |
Refugee participation | Refugee participation was noted as a facilitator as it provided manpower and community leadership.90 Refugee services run by refugees were shown to be feasible if there is sustained funding and technical assistance.130 |
Dedicated staff | Having dedicated healthcare workers was noted multiple times as being a facilitator.86 106 121 |
ANC, antenatal care; CHWs, community health workers; EmOC, emergency obstetric care; GIS, geographic information system; IDPs, internally displaced persons; MISP, Minimum Initial Service Package; MNH, maternal and neonatal health; NGOs, non-governmental organisations; SRH, sexual and reproductive health; STI, sexually transmitted infection; TBAs, traditional birth attendants.