Quality in Crisis: A Systematic Review of Health Systems in Humanitarian Settings PDF (2021)

Jordan et al. Conflict and Health (2021) 15:7 https://doi.org/10.1186/s13031-021-00342-z REVIEW Open Access Quality in crisis: a systematic review of the...

Jordan et al. Conflict and Health (2021) 15:7 https://doi.org/10.1186/s13031-021-00342-z REVIEW Open Access Quality in crisis: a systematic review of the quality of health systems in humanitarian settings Keely Jordan1* , Todd P. Lewis2 and Bayard Roberts3 Abstract Background: There is a growing concern that the quality of health systems in humanitarian crises and the care they provide has received little attention. To help better understand current practice and research on health system quality, this paper aimed to examine the evidence on the quality of health systems in humanitarian settings. Methods: This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) protocol. The context of interest was populations affected by humanitarian crisis in low- and middle- income countries (LMICs). We included studies where the intervention of interest, health services for populations affected by crisis, was provided by the formal health system. Our outcome of interest was the quality of the health system. We included primary research studies, from a combination of information sources, published in English between January 2000 and January 2019 using quantitative and qualitative methods. We used the High Quality Health Systems Framework to analyze the included studies by quality domain and sub-domain. Results: We identified 2285 articles through our search, of which 163 were eligible for full-text review, and 55 articles were eligible for inclusion in our systematic review. Poor diagnosis, inadequate patient referrals, and inappropriate treatment of illness were commonly cited barriers to quality care. There was a strong focus placed on the foundations of a health system with emphasis on the workforce and tools, but a limited focus on the health impacts of health systems. The review also suggests some barriers to high quality health systems that are specific to humanitarian settings such as language barriers for refugees in their host country, discontinued care for migrant populations with chronic conditions, and fears around provider safety. Conclusion: The review highlights a large gap in the measurement of quality both at the point of care and at the health system level. There is a need for further work particularly on health system measurement strategies, accountability mechanisms, and patient-centered approaches in humanitarian settings. Keywords: Global Health, Health policy, Humanitarian health, Crisis settings, Health systems * Correspondence: [email protected] 1 Department of Health Policy, New York University School of Global Public Health, 665 Broadway, New York, NY 10012, USA Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Jordan et al. Conflict and Health (2021) 15:7 Page 2 of 13 Background Health Commission on High Quality Health Systems in In 2015, the Sustainable Development Goals (SDGs) the SDG Era (HQSS) defined high quality health systems launched with the strong message of leaving no one be- as systems that “optimize health in a given context by hind. These goals cannot be achieved without includ- consistently delivering care that improves or maintains ing the more than 70 million refugees, internally displaced health, being valued and trusted by all people, and persons (IDPs), and asylum-seekers. The right to the responding to changing population needs”. This in- highest attainable health extends to all individuals, regard- cluded, but was not limited to, the quality of care pro- less of their circumstance or legal status. International vided at the point of contact between provider and user. human rights treaties, most notably the International Cov- The definition goes on to state that equity, efficiency, enant on Economic, Social and Cultural Rights, guarantee and resilience are values that underpin a high quality “the right of everyone to the enjoyment of the highest at- health system. Here, equity implies that it is available tainable standard of physical and mental health”. and affordable to all people regardless of underlying so- There has been considerable progress in global health cial disadvantages. An efficient system aims to achieve over the past 20 years driven by expanded access to public the highest possible health improvement with the given health services in low- and middle-income countries resources and a resilient system responds to routine and (LMICs) (e.g., clean water and sanitation) and health ser- catastrophic challenges. vices (e.g., vaccination, antenatal care, and HIV treatment) The conceptual framework developed by the HQSS. These improvements have saved millions of lives pri- Commission (Fig. 1) has three main domains: processes marily by averting deaths from infectious diseases. of care (competent care and user experience), quality However, strengthened strategies will be needed to tackle impacts (better health, confidence in system and eco- chronic and complex conditions and reach the health re- nomic benefit) and foundations (population, governance, lated SDGs. It has become clear that access alone is not platforms, workforce and tools). The HQSS Commis- enough without an accompanying focus on the quality of sion believed that health systems should primarily be services being provided. High quality health systems are assessed based on processes and impacts of care because needed to improve health outcomes. research shows that poor health systems can operate Humanitarian health activities commonly focus on im- even when all the adequate tools are present. The mediate life-saving interventions. This often necessitates foundations of the system included the population’s vertical programming in order to rapidly start and scale- health needs and expectations, governance of the health up health services, particularly for historically key issues of and non-health sectors, accessible and organized plat- preventing disease outbreak and reducing malnutrition. forms of care, skilled workforce in numbers, and tools However, the challenge now is that crises are increasingly such as medicine and data. protracted, which requires longer-term and more coordi- nated and sustainable approaches. There are specific fears Health systems in crisis settings around the lack of continuity of care for conditions that Humanitarian crisis settings can vary widely in context, require multiple visits to the health system, such as ante- but are situations that involve widespread human suffer- natal care (ANC) and postnatal care (PNC) and chronic ing resulting from complex political, economic or social conditions such as HIV/AIDS and diabetes. This re- emergencies and natural hazards requiring large-scale quires greater engagement in the broader health system provisions of aid. These include acute humanitarian cri- and a focus on sustainable quality of care. ses that have a sudden onset and chronic, or protracted, This review examined empirical evidence and provided humanitarian crises including forced displacement. an overview of how the literature defines and measures According to the Lancet Series on health in humanitar- quality in crisis situations. Additionally, as a sub-aim, ian crises, “protracted situations, often with additional this review analyzed the methods used to measure qual- acute emergencies, are becoming the new norm”. ity (i.e., the quality of the quality measure), so that re- Most refugees are not living in camps but rather in searchers can improve their work in this area. This urban and rural areas and are not displaced but rather review aimed to give direction to the humanitarian field entrapped in conflict settings, such as those in Syria and on where future improvement strategies could be tar- Yemen. As a consequence, refugees and IDPs are at their geted. With the current emphasis in the global health highest number in over 50 years. community on quality of health systems this study is ex- In many crisis situations, the health system goes tremely relevant and timely. through a period of degradation and fragmentation due to increasing violence and insecurity, weakening govern- Defining high quality health systems ance, and loss of resources. Reduced government activ- Building on the past work on quality and the develop- ities create a void in services provided that is often filled ments in the field of health systems, the Lancet Global by faith-based, private or informal providers. Jordan et al. Conflict and Health (2021) 15:7 Page 3 of 13 Fig. 1 High Quality Health System Framework Dozens of non-governmental organizations (NGOs) may this paper aims to examine the evidence on the quality be active in any of the main ongoing humanitarian crises of health systems in humanitarian settings. and providing essential health services. These services tend to focus on primary health care for communicable Methods disease control and management, nutrition, reproduct- We conducted a systematic review based on the Pre- ive, maternal newborn and child health (RMNCH) and ferred Reporting Items for Systematic Reviews and more recently mental health and NCDs. They are typic- Meta-Analyses (PRISMA) protocol. ally part of the UN Cluster System, with health care fall- ing under the Health Cluster led by WHO, and Eligibility criteria sometimes in partnership with the local government The context of interest was populations affected by hu-. They commonly follow the Sphere Standards and manitarian crisis in low- and middle- income countries aim to support secondary and tertiary care facilities. (LMICs). We defined the situation of humanitarian set- However, even within the same crisis different actors tings using the criteria specified by the Sphere Standards may pursue inconsistent and uncoordinated health strat- and the income status by the World Bank’s 2019 egies. Assessing the performance of health actors in classifications. We included contexts affected by war, crises is challenging because of: insecurity and limited terrorist attack, political violence or armed conflict. access; population mobility; short operational and fund- Refugee/Internally displaced person (IDP) camps or set- ing time-periods (typically six-monthly cycles); rapidly tlements were also included, as were refugees, IDPs, or developing health events; weak collection and sharing of conflict-affected people who are living in non-camp set- routine health data; and limited monitoring, evaluation tings. This included protracted displacement crises. We and research capacity. excluded large epidemics or pandemics since they vary This need has been magnified by the increasing num- considerably by pathogen and context. We also excluded ber of conflicts in countries with a disease burden post-conflict/post-disaster settings, which we classified already heavily dominated by NCDs (e.g., Syria). To as more than 5 years after the formal end of an armed address these shortcomings there have been increasing conflict (e.g., signing of a peace agreement) or natural efforts in the humanitarian sector to engage in account- disaster. ability – particularly ensuring perspectives of affected We included studies where the intervention of interest, populations are included. In addition, despite the health services for populations affected by crisis, was many epidemiological studies that have been conducted provided by the formal health system. We defined the on humanitarian crises, there has been persistent con- formal health system to be care by a trained provider, in- cern over the quality of data for humanitarian crises [9, cluding public, NGO and private facilities. We excluded 18–23], and how data have been used to guide humani- studies that fell outside the formal health system, for ex- tarian health interventions and ultimately improve ample school-based malnutrition campaigns. health outcomes [24–28]. To help better understand Our outcome of interest was descriptive- how these current practice and research on health system quality, studies defined and measured quality in the formal Jordan et al. Conflict and Health (2021) 15:7 Page 4 of 13 health system. We used the definition of high-quality came together to discuss the process. Two reviewers health systems presented by HQSS and detailed above. screened the entire set of abstracts (KJ and TL). We sep- We excluded studies if they reported solely on coverage arately applied the criteria to the entire data set and ad- or access to health care but did not specifically focus on judicated conflicts through consensus building. Full text quality. reviews were done for the final sample by one reviewer We included primary research studies published in (KJ) and reviewed by a second (TL). English between January 2000 and January 2019 using quantitative methods (any experimental, quasi- Data extraction and analysis experimental, or observational design). We included ran- We applied the High Quality Health System Framework domized controlled trials if the outcome of interest was (Fig. 1) to help organize and analyze the data. This a quality measure but excluded clinical trials that aimed framework was chosen because it addresses health sys- to prove only efficacy. Qualitative methods (any design) tem quality more broadly, rather than just quality of were included. care, is uniquely applicable to LMICs, and is easily adapted to humanitarian settings. Specifically, we ex- Data sources and search terms tracted data related to the framework’s domains and We used a combination of information sources to iden- sub-domains of quality health systems (Box 1). tify studies meeting the inclusion criteria: (1) electronic We extracted data from the final eligible studies using bibliographic databases for published studies, using a a standardized form. The following variables were ex- comprehensive search; (2) grey literature; and (3) the ref- tracted: year of publication, title, study type, evaluated erence lists of studies included in the review. For the country, study setting, population type, number of par- bibliographic databases, we searched published literature ticipants, study description, quality domain (from frame- in PubMed, Embase, and Web of Science. For the grey work, Box 1), quality sub-domain (from framework, Box literature, we searched the following databases and web- 1), methodological quality, main findings/results, miscel- sites: WHO Global Health Library, UNHCR database, laneous. A deductive approach was used to organize the Reproductive Health Response in Crisis Consortium analysis within the domains of the High Quality Health (RHRC), and the Inter-Agency Working Group on Re- System Framework and then an inductive approach used productive Health in Crisis (IAWG). To approach litera- to explore emerging themes from within the domains of ture saturation, we checked reference lists of included the framework. studies. We documented the information sources, in- To assess the methodological quality of the included cluding the name of each search, the date range studies, we evaluated each study in six domains: selection searched and the search platform. bias, appropriateness of data collection, appropriateness of For the bibliographic database searching, we used data analysis, generalizability, ethical considerations and Medical Subject Headings (MeSH) terms and key words clarity of the study’s methods. This domain-based from prior published literature. We constructed sets of evaluation was chosen instead of a scale or checklist due search terms to capture four concepts: quality health to its ability to critically assess different domains separ- system (which includes but is not limited to “quality of ately, as suggested by The Cochrane Collaboration. care”), focus on low- and middle-income countries, pop- ulations, and humanitarian settings (e.g., “quality” AND Results “LMIC” AND “population” AND “humanitarian set- We identified 2269 records through the database search ting”). The search strategy for PubMed is outlined in the and an additional 16 records through the other sources. Additional file 1: Appendix A. This strategy was applied After removal of duplicates and screening, 55 papers to the other electronic databases and modified if remained for full-review (the screening process and main necessary. reasons for exclusion are provided in Fig. 2). Of the 55 papers included in the systematic review the Screening process majority of studies were published since 2015 (34; 62%). We downloaded and saved all search results into refer- Multiple study designs were used: 17 (31%) were quanti- ence management software (EndNote version X7) and tative, 16 (30%) were qualitative, and another 13 (24%) screened using an abstract management software used mixed quantitative and qualitative methods. Eleven (Abstrackr). Prior to the screening process we created a (20%) took place in the WHO African Region, two (4%) detailed selection criteria worksheet, which can be found in the European Region, eight (14%) in the South East in the Additional file 2: Appendix B, which all reviewers Asia Region, 25 (45%) in the Eastern Mediterranean Re- (KJ and TL) built consensus around and used through gion, two (4%) in the Western Pacific Region, and seven the screening process. We then did a pilot round apply- (13%) were multi-country studies that spanned multiple ing the selection criteria to a subset of abstracts and regions. The majority of studies took place in conflict- Jordan et al. Conflict and Health (2021) 15:7 Page 5 of 13 Box 1 High Quality Health System Framework Domains and Sub-Domains Domain Definition Sub-Domain Domain: Process of Care Competent care and systems Evidence-based, effective care: systematic assessment, correct diagnosis, appropriate treatment, counseling, and referral; capable systems: safety, prevention and detection, continuity and integration, timely action, and population health management Positive user experience Respect: dignity, privacy, non-discrimination, autonomy, confidentiality, and clear communication; user focus: choice of provider, short wait times, patient voice and values, affordability, and ease of use Domain: Quality Impacts Better health Level and distribution of patient-reported outcomes: function, symptoms, pain, wellbeing, quality of life, and avoiding serious health-related suffering Confidence in system Satisfaction, recommendation, trust, and care uptake and retention Economic benefit Ability to work or attend school, economic growth, reduction in health system waste, and financial risk protection Domain: Foundations Population Individuals, families, and communities as citizens, producers of better health outcomes, and system users: health needs, knowledge, health literacy, preferences, and cultural norms Governance Leadership; policies: regulations, standards, norms, and policies for the public and private sector, institutions for accountability, supportive behavioral architecture, and public health functions; financing; learning and improvement: institutions for evaluation, measurement, and improvement, learning communities, and trustworthy data Platforms Assets: number and distribution of facilities, public and private mix, service mix, and geographic access to facilities; care organization; connective systems: emergency medical services, referral systems, and facility community outreach Workforce Health workers, laboratory workers, planners, managers: number and distribution, skills and skill mix, training in ethics and people-centered care, supportive environment, education, team work, and retention Tools Hardware: equipment, supplies, medicines, and information systems; software: culture of quality, use of data, supervision, and feedback affected settings (45; 82%), eight (14%) in refugee settle- competent care (23; 44%). Table 2 depicts the numbers ments, and only two (4%) studies taking place in a post- of addressing the domains and sub-domains. natural disaster setting. About one third of the popula- tion type studied was refugees, IDPs, or conflict-affected Process of care cross-boarder migrants (17; 31%). Fifteen studies (27%) The majority of the studies included addressed process focused on women and/or children, and 11 (20%) fo- of care as a quality domain. A theme that emerged cused solely on health care providers. Table 1 describes within those studies was that poor diagnosis and treat- the characteristics of included studies. ment was a major barrier health systems faced in con- We intentionally did not restrict the papers included flict settings. Common manifestations of poor quality by study design in order to gain insight from qualitative were incorrect diagnosis [37, 40, 44, 66, 69] and inappro- and mixed methods studies. The rigor of the studies was priate treatment of illness [44, 46, 73, 81, 82]. Lainez and assessed and the majority (34, 62%) of the studies ad- colleagues highlighted the issue of “competent care” in equately addressed at least five of the six quality areas. their study on the prevalence of respiratory symptoms in Fifty-one (93%) studies used a sample that was appropri- Afghanistan and found that there was a gap in diagnosis ate to its research questions, 49 (89%) studies collected with 23.8% of patients with TB-suggestive symptoms go- the data appropriately, 46 (84%) analyzed the data ap- ing undiagnosed. Another manifestation of the propriately, 31 (56%) studies had results that were trans- “competent care” sub-domain was necessary patient re- ferable by setting, 23 (42%) adequately addressed ferrals [32, 34, 66, 69, 77]. For example, Elmusharaf et al. potential ethical issues, and 48 (87%) studies were clear found that outcomes were better for pregnant women in in their overall approach. South Sudan where there was no facility available rather We used the High Quality Health Systems Framework than when the woman accessed a non-functioning facil- to analyze the included studies by quality domain and ity, and the absence of a health care provider was better sub-domain. The majority of studies (46; 84%) addressed than the presence of a non-competent provider. multiple quality domains simultaneously, with a strong This finding was primarily influenced by inadequate re- emphasis on workforce (38; 69%), tools (26; 45%), and ferral systems (including late referrals to appropriate Jordan et al. Conflict and Health (2021) 15:7 Page 6 of 13 Fig. 2 Flowchart showing the selection of studies facilities and multiple referrals). In two studies the lack patient’s confidence in the system, seven focused on bet- of continuity of care was expressed as a quality concern ter health, and three focused on economic benefit. [35, 66]. However, when care was integrated (e.g., mental The patient’s confidence in the health system was most health services into primary health care) a positive out- commonly measured as care satisfaction [35, 39, 47, 53, 62, come was seen [40, 76]. 78, 79, 83]. The findings around satisfaction were mixed. User experience, including feeling that the health staff Some studies reported that patients were dissatisfied with was judgmental or discriminatory was cited as a major bar- the low quality care they received [47, 78, 79], and Kibiribiri rier to high quality care and impacted care seeking behavior et al. found that refugees were more dissatisfied than the [33, 36, 41, 47, 67]. For example, the study by Kruk and col- general population in South Africa. However, other leagues on population preferences for health care in Liberia studies reported that patient satisfaction was high even showed that a patient’s choice of clinic was influenced by where quality was poor [35, 39, 83]. In their study on per- respectful treatment along with other factors such as ceptions and utilization of primary health care services in provision of a thorough physical exam, availability of medi- Iraq, Burnham and colleagues showed that high satisfaction cines, and government management. Language barriers corresponded with low expectations of the health system and the lack of clear communication also negatively im-. The patient’s perception of the low quality of care was pacted the patient-provider relationship in the studies ex- a barrier to care uptake and retention in the health system amined [33, 45, 50, 67, 72, 75]. This was particularly true [32, 67, 78]. A qualitative study by Hunter-Adams et al. on for refugees in host countries [33, 45, 50, 72]. the language barriers between South African health care providers and conflict-affected cross-boarder migrants sug- Quality impacts gested that providing interpretive services could increase About one third of included studies addressed “quality the patient’s confidence in the system and potentially in- impacts” as a quality domain. Nine focused on the crease preventative care visits. Jordan et al. Conflict and Health (2021) 15:7 Page 7 of 13 Table 1 Characteristics of included studies Study Characteristics No. (%) of studies (n = 55) Year 2000–2009 [32–37] 6 (11) 2010–2014 [38–52] 15 (27) 2015–2019 [53–86] 34 (62) Study Type Quasi-experimental [38, 41, 68] 3 (5) Cohort [49, 65] 2 (4) Cross-sectional [36, 39, 43, 53, 62–64, 77, 81–83] 11 (20) Mixed methods [37, 45, 46, 48, 57, 60, 69, 71, 72, 75, 80, 85, 86] 13 (23) Qualitative [33, 42, 44, 47, 50, 56, 59, 61, 66, 67, 73, 74, 76, 78, 79, 84] 16 (30) Case study [32, 34, 35, 40, 51, 52, 54, 55, 58, 70] 10 (18) WHO Region Americas 0 African [33, 36, 41, 53, 59, 62, 67, 68, 81, 85, 86] 11 (20) European [64, 82] 2 (4) South-East Asia [35, 38, 44, 45, 49, 51, 60, 73] 8 (14) Eastern Mediterranean [32, 37, 39, 40, 42, 46–48, 52, 55, 56, 61, 63, 65, 66, 69–71, 74, 75, 77–80, 83] 25 (45) Western Pacific [34, 84] 2 (4) Multiple Regions [43, 50, 54, 57, 58, 72, 76] 7 (13) Setting Conflict-affected (including IDPs and cross-boarder migrants) [32–34, 36, 37, 39–42, 44, 47–59, 61, 63–71, 73–75, 77–80, 82–86] 45 (82) Refugee settlements [43, 45, 46, 60, 62, 72, 76, 81] 8 (14) Natural disaster [35, 38] 2 (4) Population Type Women and/or children [34, 43, 45, 48, 49, 57, 60, 66, 68, 70, 71, 75, 77–79] 15 (27) Refugees/IDPs/conflict-affected cross-boarder migrants [32, 33, 35, 36, 38, 50, 62, 65, 67, 69, 72, 73, 80–84] 17 (31) Health care providers [40, 42, 44, 46, 51, 56, 58, 61, 64, 74, 76] 11 (20) General population [37, 39, 41, 52, 53, 55, 85, 86] 8 (14) Patients and providers [47, 54, 59, 63] 4 (8) In many studies, clinical outcomes, most commonly for them was still too high. Bertone et al. examined hospital mortality, were used to measure the quality of how performance based financing (PBF) can be adapted in care provided by the health system [34, 43, 49, 54, 65, fragile settings and found that providing free care to IDPs, 75, 77]. For example, Auto et al. discussed the import- even where free care was not an official government pol- ance of hospital quality improvement strategies to start icy, successfully improved access by reducing financial with a clear understanding of (child) mortality, its burden. Additionally, a study on health service resili- causes, and distribution. ence in Nigeria found that political instability had a direct The economic burden that poor quality care had both impact on financial barriers, which through multiple path- on the patient and the system was only addressed in three ways influenced utilization of health services. This studies [84–86]. Chuah and colleagues used a qualitative study found that drug subsidy schemes and programs of- approach to assess the health system responses to the fering free services “moderated the health impact of the health needs of refugees and asylum-seekers in Malaysia. disruption of livelihoods resulting from insurgency”. One of the key findings was that healthcare financing was a major challenge in responding to refugee health issues Foundations and even with the discounted fee for refugee patients at The majority of the studies included addressed the foun- public healthcare facilities the out-of-pocket expenditure dations of a health system. A common theme that Jordan et al. Conflict and Health (2021) 15:7 Page 8 of 13 Table 2 Quality domains addressed in included studies Domain Studies Sub-Domain Domain: Process of Care Competent care [32, 34, 37, 40, 41, 43, 44, 46, 49, 51, 57, 59, 60, 65, 66, 68–70, 75–77, 81, 83] 23 Competent systems [35, 41, 43, 45, 66, 69, 72, 73, 76, 82, 85] 11 Positive user experience [33, 36, 39, 41, 45, 47, 50, 59, 62, 64, 67, 72, 75, 79] 14 Domain: Quality Impacts Better health [34, 49, 54, 65, 77, 81, 84] 7 Confidence in system [32, 33, 35, 39, 53, 62, 67, 78, 83] 9 Economic benefit [84–86] 3 Domain: Foundations Population [45, 53, 58, 67, 73, 79, 84–86] 9 Governance [34, 38, 52, 55, 61, 80, 84–86] 9 Platforms [39, 52, 57, 70, 81, 85] 6 Workforce [33, 34, 37, 38, 40, 42, 43, 45–49, 51, 52, 56–61, 63, 64, 66, 67, 69–72, 74–76, 78–81, 84–86] 38 Tools [32, 34, 38, 39, 41, 42, 45, 48, 52, 54, 57–61, 63, 64, 70, 72, 79, 81, 83–86] 26 emerged was an emphasis on the workforce and tools went on to detail how communities “pooled resources quality sub-domains. The evidence identified on work- (knowledge, transport and finance) to enable physical force constraints focused on human resource shortages and financial access to health facilities for those in need”. [34, 39, 57, 63, 80, 81, 84], low workforce moral [47, 75], Communities also played a key role in mobilizing polit- and inadequate provider training [48, 51, 56, 58, 61, 71, ical will for quality care. “Platform” barriers to qual- 74] as the most cited causes of poor quality. A qualita- ity care were included in six studies and addressed the tive study in Afghanistan articulated the intense physical number and distribution of facilities [39, 52, 57, 85] and and mental pressures that medical staff face in the field the disorganized structure of service delivery [70, 81]. A and assured that sub-optimal care was unlikely deliber- study looking at the implementation of Afghanistan’s ate but rather the result of “conflicting priorities, the Basic Package of Health Services (BPHS) found that ac- workload, poor clinical skills and the struggle for sur- cess to and utilization of primary health care services in vival”. The physical resources needed for a function- rural areas increased dramatically because the number of ing health system was often used in the studies as a BPHS facilities more than doubled. Governance im- quality measure, specifically limited access to medicines provements, specifically political commitment and en- [32, 34, 38, 57, 60, 61, 79, 81, 84] and supplies [42, 48, hanced leadership, were highlighted as necessary ways to 57–60, 63, 64, 70, 72, 79]. Mowafi and colleagues improve health system performance [34, 38, 52, 55, 61, highlighted the severe material and human resource 80, 84–86]. A study in Afghanistan by Anwari et al. sug- constraints that Syrian trauma hospitals operate under gested that improvements in stakeholder engagement, including the large amount of nonfunctioning diagnostic cultivating accountability, setting a shared strategic dir- equipment (e.g., 23% broken X-ray machines). ection and stewarding resources responsibility were pos- Other quality sub-domains were also addressed, sible by implementing a people-centered governance though to a lesser degree. Within the “population” sub- approach. domain, the cultural barriers patients faced during ser- vice delivery were raised in a number of studies [45, 53, Discussion 58, 67, 73, 79, 84, 85]. In a study on refugee and migrant This systematic review, which included 55 studies, ex- women’s views of antenatal ultrasound, Rijken and col- amined the evidence on the quality of health systems leagues suggested that “transient embarrassment or providing care in humanitarian settings. It was the first shame on exposing the abdomen (a part not normally study to our knowledge that addressed this topic. The exposed in public by local women in this culture)” was a key findings suggest: poor diagnosis and inappropriate potential barrier to receiving medical attention. treatment of illness (including inadequate patient refer- Community resources and cohesion, as described by rals) were commonly cited barriers to quality care; there Ager et al., was identified as a key driver of pathways of was a limited focus on the health impacts that health influence mitigating the impacts of the crisis. The study systems have in the studies identified; and a strong focus Jordan et al. Conflict and Health (2021) 15:7 Page 9 of 13 was placed in these studies on the foundations of a found that 47% of improvement research was targeted health system with emphasis on the workforce and tools. towards these two sub-domains. Though foundations The implications from these findings for future research are essential to health-care provision, prior studies have include: expanding the definition of quality to include commented on the weak associations between input quality impacts, developing and validating quality mea- measures and care competence. The HQSS Commis- sures suitable for crisis settings, and incorporating more sion therefore recommended a shift in measurement diverse and rigorous study designs. away from foundations (or inputs) to what matters most There are many contextual challenges highlighted in to people: competent care, user experience, health out- the identified literature to providing quality care in hu- comes, and confidence in the system. This people- manitarian settings, however, there are also findings centered approach places the emphasis on the user of from this review that are broadly in line with evidence the health system and aims to create a setting in which from more stable LMICs. In terms of “process of care” people have agency over their own health and health- the HQSS Commission also found that many LMICs care decisions. This can be particularly challenging in struggle to consistently deliver high quality care and the face of violence, displacement or forced migration. well-known, effective treatments are not consistently Strengthening health system quality has unique chal- provided. Many of the studies included in this review lenges in crisis situations, particularly when the majority attempted to improve care competence with short in- of services are provided by NGOs and large gaps exist in service provider trainings. However, there are many critical services, and inequity in the distribution of those studies that attest to the know-do gap (i.e., the gap be- services. The studies in this review suggest that a key tween provider knowledge and clinical care provided) step is assessing the needs of the population in crisis, [87, 88], suggesting that these efforts may not have the who are often vulnerable groups that face further long-term quality improvements they are aiming for. marginalization due to context. Keeping equity and the Further, the disrespectful care that many of the studies underserved a priority from the beginning requires local- attested to is widespread throughout LMIC health sys- izing health system improvements. The low emphasis tems. The HQSS Commission found that 1 in 3 patients that the studies placed on “population” needs suggest it experienced disrespectful care, short consultations, poor is an area to focus for improvement. As many of the communication or long wait times. studies in this review point out changes towards a The limited focus that the studies included in this re- people-centered health system take strong local political view placed on “quality impacts” belies the primary goal of commitment and leadership. In support of this finding, health systems, which is to improve or maintain health. the WHO National Quality Policy and Strategy Hand- The initial findings from this review suggest potentially book suggested that well-aligned policies and strategies lower levels of satisfaction in crisis settings than the gen- be based on locally-accepted definitions of quality and eral population. High satisfaction with health care is com- national goals for improved outcomes. mon across LMICs even where quality is poor, possibly The findings from this review are in line with the due to low expectations, and the HQSS Commission broader literature on humanitarian settings and highlight warned that patient satisfaction as a measure of quality the limited evidence on health impacts of interventions should be carefully interpreted. A lack of confidence in and use of economic methods in humanitarian settings the health system can in turn hinder care uptake and re- [92, 93]. There were many studies that fell outside the tention, which is already fragile given the setting. Al- eligibility criteria of this review that assessed the role of though causes of death and disease are multifactorial user fees and performance incentives on quality and some conditions are highly dependent on quality of care utilization rates that could offer lessons and areas for fu- and how well the health system is working, such as mater- ture study [94–96]. Additionally, there is a call to in- nal and newborn deaths. The emphasis that the stud- crease measurement in humanitarian settings and link ies in this review placed on measuring maternal, newborn, that to a focus on accountability mechanisms [6, 16]. and child mortality is therefore in line with other LMIC Different quality measurement techniques have been health system quality indicators. High quality health sys- used in humanitarian contexts but an overarching theme tems generate many economic benefits, such as reducing was that consideration and adaption of design processes premature mortality and reducing health system waste. are needed to meet local circumstances [6, 97]. Process The studies in this review, however, primarily forced on fi- of care measures (i.e., what a provider does to maintain nancial risk protection [85, 86]. or improve health) have shown to play an important role The “foundations” of a health system are often the in assessing care for vulnerable populations and this most cited and measured elements of quality [7, 90]. review suggests they could be particularly useful to in- Workforce and facility constraints, specifically, are wide- form the users about the care they should expect to re- spread through LMICs and the HQSS Commission ceive and increase demand for high quality. There are Jordan et al. Conflict and Health (2021) 15:7 Page 10 of 13 additional measurement constraints in crisis settings due show attribution of interventions to changes in health to insecurity and other contextual challenges and re- outcomes. However, this review included a large number source constraints, which in many instances make more of qualitative and mixed-methods studies, which pro- rigorous study designs, particularly experimental studies, vides a unique insight into user experience. operationally and ethically challenging [9, 99, 100]. The two areas of methodological quality in which in- There are, however, many valuable studies on health sys- cluded studies were lacking were generalizability and tem resilience and rebuilding in post-conflict and fragile ethical considerations. In terms of generalizability, most settings that could be useful in humanitarian contexts of the studies included in our review were on conflict- [101, 102]. Also, alternate designs have proven successful affected settings and the findings may not be applicable in humanitarian settings at showing changes in health to other crises such as natural disasters. There are many outcomes over time, such as stepped wedge designs, ethical challenges when doing research in humanitarian greater use of longitudinal data and routine health ser- crises considering the added vulnerability of the vices data, and collection of process data that can be a population. reliable proxy for health outcome data [9, 103, 104]. Additionally, due to the complexity of health systems re- Conclusion search a more narrow approach that focuses on specific There has been a growing interest on the quality of care aspects of quality may be beneficial for future work as health systems provide in humanitarian settings well as a stronger use of interdisciplinary research (e.g., throughout the past two decades. However, a large gap social science, political science, epidemiology). still exists on studies that systematically measure quality The findings from this study have many policy relevant both at the point of care and at the health system level. implications and they point to the need for ‘macro-level’ The findings from this review highlight key quality issues system wide transformations. First, they highlight the including incorrect diagnoses and treatments, low levels need for new and improved quality measurements that of confidence in the health system, and a disproportional move beyond the foundational aspects of quality. Adopt- emphasis on the health workforce and tools. The review ing measures that focus on system competence (e.g., also suggests some barriers to high quality health sys- timeliness and continuity of care), user experience and tems that are specific to humanitarian settings such as health outcomes could potentially shape future quality language barriers for refugees in their host country, dis- improvement strategies. Second, they point to a need for continued care for migrant populations with chronic initiatives that focus on improving accountability in hu- conditions, and fears around provider safety. Individuals, manitarian settings. Multipronged strategies that build families, and communities in humanitarian crises have partnerships across the system are needed that combine specific health needs that require an understanding of legal, performance and social accountability tools. This their culture, preferences, and health knowledge in order potentially involves legislating for vulnerable people’s to be met. There is need to expand work on the topic, right to quality health care, educating the population on particularly for focusing on health system measurement their rights, creating strong regulations and standards, strategies, accountability mechanisms, and patient- and enforcing mechanisms for remedy and redress. Fi- centered approaches in humanitarian settings. nally, they suggest that there has been a failure to respond to key health system concepts such as patient-centered care. All people deserve to be treated with respect and dig- Supplementary Information The online version contains supplementary material available at https://doi. nity within the health system. Additionally, health workers org/10.1186/s13031-021-00342-z. need to receive the support they need to fulfill their pro- fessional duty even under the most dire circumstances. A Additional file 1. high-quality people-centered health system should take Additional file 2. into account the needs, experiences, and preferences of even the most vulnerable populations. Acknowledgements I would like to thank Thomas D’Aunno, Margaret E. Kruk, and Diana R. Silver for their continued support. Limitations We may not have captured all the data available on Authors’ contributions quality of care in humanitarian settings. In particular, we KJ and BR conceived and designed the review. KJ completed the search, KJ limited our review to English language studies, only used and TL screened the results, and KJ completed the data extraction. KJ wrote three electronic bibliographic databases, and though the the first draft with subsequent input from TL and BR. The author(s) read and approved the final manuscript. entire first round was double screened only one screener did the final full text reviews. The absence of experimen- Funding tal designs is also a limitation considering they could There was no funding source for this study. Jordan et al. Conflict and Health (2021) 15:7 Page 11 of 13 Availability of data and materials 19. Garfield R. Studies on young child malnutrition in Iraq: problems and The data that support the findings of this study are available from the insights, 1990–1999. Nutr Rev. 2000;58(9):269–77. corresponding author upon reasonable request. 20. Spiegel PB, Salama P, Maloney S, Van Der Veen A. Quality of malnutrition assessment surveys conducted during famine in Ethiopia. Jama. 2004;292(5): Ethics approval and consent to participate 613–8. Not applicable. 21. Bostoen K, Bilukha OO, Fenn B, et al. Methods for health surveys in difficult settings: charting progress, moving forward. BioMed Central; 2007. 22. Prudhon C, Spiegel PB. 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