Elsevier

The Lancet

Volume 397, Issue 10273, 6–12 February 2021, Pages 533-542
The Lancet

Series
Delivering health interventions to women, children, and adolescents in conflict settings: what have we learned from ten country case studies?

https://doi.org/10.1016/S0140-6736(21)00132-XGet rights and content

Summary

Armed conflict disproportionately affects the morbidity, mortality, and wellbeing of women, newborns, children, and adolescents. Our study presents insights from a collection of ten country case studies aiming to assess the provision of sexual, reproductive, maternal, newborn, child, and adolescent health and nutrition interventions in ten conflict-affected settings in Afghanistan, Colombia, Democratic Republic of the Congo, Mali, Nigeria, Pakistan, Somalia, South Sudan, Syria, and Yemen. We found that despite large variations in contexts and decision making processes, antenatal care, basic emergency obstetric and newborn care, comprehensive emergency obstetric and newborn care, immunisation, treatment of common childhood illnesses, infant and young child feeding, and malnutrition treatment and screening were prioritised in these ten conflict settings. Many lifesaving women's and children's health (WCH) services, including the majority of reproductive, newborn, and adolescent health services, are not reported as being delivered in the ten conflict settings, and interventions to address stillbirths are absent. International donors remain the primary drivers of influencing the what, where, and how of implementing WCH interventions. Interpretation of WCH outcomes in conflict settings are particularly context-dependent given the myriad of complex factors that constitute conflict and their interactions. Moreover, the comprehensiveness and quality of data remain limited in conflict settings. The dynamic nature of modern conflict and the expanding role of non-state armed groups in large geographic areas pose new challenges to delivering WCH services. However, the humanitarian system is creative and pluralistic and has developed some novel solutions to bring lifesaving WCH services closer to populations using new modes of delivery. These solutions, when rigorously evaluated, can represent concrete response to current implementation challenges to modern armed conflicts.

Introduction

Armed conflicts have disastrous effects on civilian populations. More than half a million civilians have been estimated to be killed by combat operations in Syria alone between 2011 and 2019,1 a substantial number of whom were civilians (112 623 casualties), amongst them are women (13173 casualties) and children and adolescents (21065 casualties aged under 18 years). The toll from the extended, indirect effects of conflict due to the destruction of food supplies, roads, electricity and water infrastructure, and health facilities has also been catastrophic.2, 3 In 2017, 701 attacks were reported on health facilities, health-care staff, patients, and ambulances in 23 conflict-affected countries.4 Armed conflicts have also negatively affected the number of forcibly displaced people in the world, increasing each year in the last decade, with 79·5 million people displaced by December, 2019.5 New estimates from Eran Bendavid and colleagues (paper 2 of this Series)6 of the number of women and children affected by conflict—at least 630 million in 2017, including over 50 million women and children displaced by conflict—is, at over 8% of the world's population, strikingly large.6 This Series paper complements the other Series papers by presenting empirical insights from a collection of ten country case studies aiming to assess the provision of women's and children's health (WCH) services in contemporary conflicts in Afghanistan, Colombia, Democratic Republic of Congo, Mali, Nigeria, Pakistan, Somalia, South Sudan, Syria, and Yemen.

Key messages

  • Many lifesaving women's and children's health (WCH) services for key populations in conflict settings are not delivered everywhere

  • Priorities of donors are the primary drivers of influencing the what, where, and how of implementing WCH interventions

  • Priority predefined packages of WCH services are not commonly agreed on and implemented in conflict settings

  • Working within the political and governance systems in conflict settings is increasingly challenging compared to previous decades, given the dynamic nature of modern conflict and the expanding role of non-state armed groups

  • The humanitarian system is creative and has developed new solutions to bring lifesaving WCH services closer to populations in very challenging environments

  • Recognising and valuing the primary role of local actors (ie, local authorities, local service providers, and local non-governmental organisations) would improve timely and appropriate WCH care delivery

The key question we asked is whether traditional humanitarian assistance has had a positive effect on saving lives and mitigating morbidity and mortality in modern armed conflicts. The implicit question is whether the humanitarian community has been able to adapt to the changing nature of armed conflicts and respond to women's, children's, and adolescents' health needs.

Country case study teams comprised of local and international research partners are often supported by relief agencies. Their work was guided by a common research protocol (panel),7 with desk review parameters, quantitative analysis of national datasets (when available), primary qualitative data collection tools, and fieldwork strategies adapted to examine factors influencing planning and implementation of WCH services in each setting. Detailed results from each country are published elsewhere.7 This paper presents the synthesised results and implications from the analysis of the ten country case studies.

Section snippets

Social determinants affecting the health of women, newborns, children, and adolescents

The effects of armed conflicts are the combination of several risks factors, including the nature and exposure to conflicts, the social determinants of health, and the level of risks and vulnerabilities experienced by women, newborns, children, and adolescents. The social determinants affecting their health in conflict settings include: reduced access to safe water and sanitation; poor quality housing; poor nutrition; and limited access to quality health services. These determinants influence

The nature of contemporary armed conflicts: analysing security attributes of the ten case study countries

Humanitarian actors (ie, international and national humanitarian organisations) are confronted by increasingly complex armed conflicts. As analysed by Paul Wise and colleagues (paper 1 of this Series),8 each conflict possesses its own unique character and history, and the impact of each conflict on civilian populations is rooted in complex political, strategic, and military determinants. Derived and expanded from the conceptual framework presented by Wise and colleagues,8 table 1 presents

When conflicts undermine primary health-care delivery

Our analyses found no clear patterns on WCH intervention delivery in conflict settings. In Afghanistan and Pakistan, our analysis suggested a statistically significant difference in coverage of various WCH interventions between severely or moderately and minimally conflict-affected provinces or districts based on the battle-related deaths.16, 17 In Colombia, maternal mortality, antenatal care coverage, caesarean section rate, and fertility in adolescents aged between 15 and 19 years were

Pre-conflict capacity of health systems as a determinant of WCH priorities

There were differences among countries in terms of what services were delivered and how. These differences can be attributed both to the intensity and nature of the conflict (eg, whether active, protracted, or cyclical) and the capacity of the health system before the conflict. For example, Syria was a middle-income country before the conflict and had a functioning health system providing free-at-the-point-of-delivery primary health-care services. Participants in our study reported that during

Prioritising among WCH interventions: who decides?

As it stands, the prioritisation of WCH interventions is not very clear. Priority in all the case study settings is given to a set of specific interventions: antenatal care, basic emergency obstetric and newborn care (BEmONC), CEmONC for pregnant women, immediate care for newborns, childhood immunisation, treatment of common childhood illnesses, infant and young child feeding (IYCF), and malnutrition screening and treatment through inpatient, outpatient, and stabilisation centres, as these were

Tensions between the humanitarian system and the national health system

The differences in terms of approach between different humanitarian actors or between national authorities and humanitarian actors illustrate the unpredictability and uncertainty of situations that require constant adaptability.

Many case study countries reported needing to frequently adapt their WCH interventions to the escalation of insecurity in some parts of the country, the constant changes of the conflict (eg, nature, scale, movement of troops, nature, and intention of belligerents), and

Strategies to deliver WCH services

Humanitarian actors (local and international) and national authorities are confronted by various obstacles to deliver WCH interventions, as previously explained. For the purpose of this study, we developed health27 and humanitarian system building blocks (an adaptation of the WHO health systems building blocks),27 and classified our findings according to the following domains: leadership, governance, and coordination; health financing and health workforce; essential medicine and supplies;

Conclusion

Working within the political and governance systems in modern conflict settings is increasingly challenging given the dynamic nature of modern conflicts and the expanding role of non-state armed groups who are often in control of large geographic areas, which pose new challenges to delivering services to women, children, and adolescents.

Decision making processes vary by government, organisation, and context. We categorised them into four different models (centralised, humanitarian actors-led,

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