ESSAYS ON COMPLEX HEALTH INNOVATIONS FOR CHILDREN AND ADOLESCENTS IN FRAGILE AND CONFLICT-AFFECTED COUNTRIES

Abstract

Fragile and conflict-affected countries (FCAS) encounter unique healthcare delivery challenges due to political instability, weak infrastructures, and often scarce resources, making traditional health service models frequently inadequate (World Health Organization [WHO], 2020). According to WHO, FCAS is a broad term describing a range of situations including humanitarian crises, protracted emergencies, and armed conflicts (WHO, 2020). These regions often deal with disrupted medical services, damage to healthcare facilities, and significant population displacement (Witter et al., 2020). FCAS lag behind more stable contexts in meeting international health goals (Burt, 2014; Organization for Economic Co-Operation and Development [OECD], 2015). Despite the significant decline in child and maternal mortality over the last 20 years, estimates indicate 60% of preventable maternal deaths, 53% of deaths in children under five, and 45% of neonatal deaths take place in FCAS (UN IGME, 2024, Zeid et al., 2015). According to the Fragile States Index, 9 FCV countries were classified as “very high alert” or “high alert”, with maternal mortality rates (MMRs) ranging from 30 (the Syrian Arab Republic) to 1223 (South Sudan) in 2020 (Fragile States Index [FSI], 2020; WHO, 2023a). Immunization rates are also critically low in these areas; five of the ten countries with the lowest coverage for the three recommended doses of diphtheria, tetanus, and pertussis vaccine (DTP3) were among the top ten countries on the Fragile States Index in 2021 (WHO & UNICEF, 2022). Approximately, 49% of children who are not vaccinated or only partially vaccinated reside in FCAS countries, making them highly susceptible to diseases, especially in these precious environments (UNICEF Data, 2023). In almost two-thirds of countries, women are more likely than men to report food insecurity, which is fueled by conflict and climate change (World Food Programme [WFP], 2021). There is a growing focus on developing resilient health systems that can withstand ongoing conflicts and crises. A resilient health system can absorb shocks, adapt to changing conditions, and transform in ways that ensure sustainable improvements in health and well-being (Blanchet et al., 2017; Campbell, 2015; Lebel et al., 2006; Thomas et al., 2013). In FCAS, resilience in health systems is critical to ensure continuous delivery of essential health services amidst instability and violence (Truppa et al., 2024). One significant innovation is the One Health Workforce Next Generation initiative in the Democratic Republic of the Congo (DRC), which focuses on training public health leaders using mobile training units and online learning platforms to reach remote and conflict-prone areas (Kerlin, 2019; USAID, 2023). Task shifting in Nigeria is another critical strategy where community health workers are trained to perform duties typically handled by doctors, addressing workforce shortages and maintaining healthcare delivery in conflict zones (Okoroafor et al., 2023). This approach is supported by findings that CHWs in fragile settings improve service delivery to vulnerable populations, leveraging their community ties and cultural understanding (Miller et al., 2020). Technological advancements, such as telemedicine in South Sudan, have facilitated remote diagnostics and consultations, providing essential healthcare services when traditional infrastructures are compromised (WHO, 2021). In Somalia, mobile health technologies and portable diagnostic tools improve disease surveillance and data management, enabling a more efficient response to health emergencies (Exemplars in Global Health Partner Network, 2021; WHO, 2024). Additionally, the use of digital health records in the South of Chad has proven vital for maintaining continuity of care for frequently displaced populations, ensuring that patient information is accessible and up-to-date despite frequent relocations (Léchenne et al., 2024). Despite these advancements, significant gaps remain in research and implementation in health systems within these fragile areas, primarily due to the complex nature of these environments (Blanchet et al., 2013). Implementing established health strategies and technologies is particularly challenging in FCAS compared to other equally impoverished but more stable countries (Newbrander et al., 2011). Health systems research (HSR) in FCAS is underdeveloped due to inherent difficulties such as ethical issues, field access, security concerns, data quality, local research capacity, and terminology problems (Woodward et al., 2017). Although there is limited research on adapting proven health interventions in FCAS, evidence is not always applied optimally, often because the findings become rapidly outdated due to the changing nature of these environments (Woodward et al., 2017). HSR must often be designed specifically for the unique conditions of FCAS rather than merely conducted within them (Health System Global, 2013; Newbrander et al., 2011; Swanson et al., 2015; Warsame, 2014; Woodward et al., 2017). Therefore, there is a need for innovative and customized approaches to research design and implementation in FCAS. For example, using longitudinal studies can be crucial for understanding long-term impacts on health systems (Bowling et al., 2014). Additionally, mixed methods approaches that combine quantitative data with qualitative insights can provide a comprehensive understanding of health system dynamics (Creswell & Plano Clark, 2017). Participatory action research (PAR) engages local communities and stakeholders in the research process, ensuring that the findings are contextually relevant and actionable (Baum, MacDougall, & Smith, 2006). Collaborating with local researchers and institutions enhances in-country research capacity and ensures the sustainability of research efforts (Sitthi-amorn & Somrongthong, 2000). These strategies are essential for adapting research methodologies to the complexities of FCAS and generating robust, applicable insights for health system strengthening. Chad and Mali exemplify the severe implications of conflict on healthcare systems. Chad is grappling with political instability, frequent violence, and a lack of infrastructure, which has led to dire health outcomes for its population of approximately 18 million (World Bank Data, 2023). The country’s healthcare challenges are compounded by severe poverty and insufficient healthcare facilities, which limit access to essential services (Jaeger et al., 2018; Nassirou et al., 2005). Particularly concerning are Chad's low immunization rates and high infant mortality (Samaké-Roman, 2022; Gavi, 2023). Only a small fraction of children receives all the recommended vaccines, leading to outbreaks of preventable diseases such as measles and polio (Gavi, 2023). Additionally, Chad has one of the highest rates of infant mortality in the world, with many deaths attributed to malnutrition and preventable diseases (UNICEF, 2023). Mali, on the other hand, faces continuous security threats from insurgent groups that have destabilized the northern regions, affecting around 23 million inhabitants (Baldaro, 2019; International Peace Institute [IPI], 2019; World Bank Data, 2023). This instability hampers healthcare delivery and exacerbates issues such as high maternal and infant mortality rates and limited access to essential health services (Ataullahjan et al., 2020; Degni et al., 2015; Masset, 2022; Tsujimoto & Kijima, 2020). In addition to these challenges, Mali struggles with endemic diseases such as malaria and tuberculosis, which thrive in conditions where healthcare access is sporadic, and the population is frequently displaced (Debarre, 2018; WHO, 2023b). The ongoing conflict has also led to significant mental health issues, with a large portion of the population experiencing trauma and stress without adequate psychological support services (Debarre, 2018; Poudiougou et al., 2021; Sekou et al., 2012; WHO, 2022). Both Chad and Mali exemplify the severe implications of conflict on healthcare systems and the urgent need for tailored health interventions that address both the immediate and long-term needs of their populations. Present dissertation papers This dissertation integrates three distinct papers, each exploring innovative approaches to healthcare in medically challenging and socio-politically complex environments. The overarching problem addressed is the introduction and implementation of complex health innovations in fragile settings, where both the innovation and the context present significant complexities. Through various methods and different tracers, these papers collectively aim to shed light on health innovations impacting child and adolescent outcomes. The collective goal of these papers is to provide a framework for the design, integration, and expansion of such interventions in countries affected by fragility and conflicts. It addresses key issues related to the implementation and scale-up of complex innovations in these settings, contributing to the broader discourse on improving healthcare systems under conditions of uncertainty and adversity. As previously noted, conventional healthcare delivery systems fall short of meeting the population’s needs in FCAS (WHO, 2020). Innovative and adaptive healthcare strategies are essential to ensure continuous healthcare services. One such approach is the proactive community case management (ProCCM) strategy, which has shown potential in improving child health outcomes in Mali (Johnson et al., 2018). ProCCM involves training and deploying community health workers (CHWs) to actively seek out and treat common childhood illnesses, rather than waiting for patients to seek care (Whidden et al., 2019). This strategy is particularly effective in Mali, where access to formal healthcare facilities is limited. By bringing healthcare services directly to the community, ProCCM addresses both the access and availability issues prevalent in FCAS. This innovative approach is vital in FCAS because they utilize the trust and local knowledge inherent in CHWs (Grant et al., 2017). These workers are often community members themselves, which typically results in higher levels of trust compared to external health providers, an essential element in areas where skepticism towards outsiders may be prevalent due to ongoing conflicts or socio-political unrest (Shepard, 2016). Additionally, the local knowledge CHWs bring to their roles allows them to tailor health interventions in culturally sensitive ways, enhancing both receptiveness and effectiveness. This adaptability is crucial for addressing the specific health challenges and barriers that communities in conflict zones face (Miller et al., 2020). However, CHWs encounter several challenges. Logistically, they often operate in environments with underdeveloped infrastructure, complicating efforts to reach patients or deliver supplies (Miller et al., 2020). Security concerns are paramount, as CHWs can be at risk of harm while fulfilling their responsibilities in unstable regions (Miller et al., 2020). Moreover, they often lack sufficient professional support from the formal healthcare system and may face high levels of stress and fatigue, leading to potential burnout due to their demanding roles and the critical nature of their work (Johnson et al., 2022). As for the numbers and coverage of CHWs in Mali, the country has taken significant steps to expand its network of community health workers to tackle widespread health access issues (Oliphant et al., 2022). Mali's community health program is designed to provide extensive coverage, especially in rural and underserved areas, with thousands of CHWs trained and deployed throughout the nation (Ministère de la Santé et de l’Hygiène Publique [MSHP], 2015). These workers handle various tasks, from maternal and child health to managing non-communicable diseases and preventive care (MSHP, 2015). Despite these efforts, the CHW-to-population ratio remains variable and is influenced by several factors, including funding, regional health priorities, and ongoing security challenges (MSHP, 2015). The need for a more systematic approach to scaling up and evaluating the impact of CHWs in Mali is a critical part of ongoing public health discussions in the country (MSHP, 2015). Building on this, my first dissertation paper is motivated by the need to improve healthcare delivery in FCAS and addresses the gap in evidence by providing insights into the operational dynamics and impact of CHW programs, specifically, assessing the effectiveness of ProCCM on reducing all-cause under-five mortality (U5MR) compared to a traditional iCCM, which involves a fixed, site-based passive workflow, delivered by CHWs. This study, structured as a pragmatic, cluster-randomized controlled trial in the Bankass health district of the Mopti region in Mali, aims to fill the gap by estimating the intervention effects using a mixed-effects logistic regression model on the intention-to-treat population. The findings highlight the challenges of implementing and evaluating complex health interventions in FCAS. The insights from this study provide crucial guidance for the optimal deployment of CHWs, not only in Mali but across similar settings in sub-Saharan Africa, potentially informing the design and scale-up of analogous CHW initiatives. Digital solutions are increasingly recognized as a transformative tool for improving health outcomes in sub-Saharan Africa (Ibeneme et al., 2022; Jousset et al., 2023; Kipruto et al., 2022; Rinke de Wit, 2022; Olu et al., 2019). Specifically, digital health technologies are essential for enhancing healthcare access in FCAS (Pattanshetty et al., 2024). The use of suitable and customized digital tools can improve the quality, accessibility, and availability of healthcare services (Marwaha et al., 2022). Additionally, digital payments facilitate the secure and transparent transfer of funds, crucial for mobilizing resources and ensuring that they reach the intended recipients without delays and risks associated with cash transfers (Nimpagaritse et al., 2020; Pazarbasioglu et al., 2020). Moreover, digital payment platforms enable better tracking and accountability of funds, vital in settings where corruption and mismanagement are prevalent (Pazarbasioglu et al., 2020). However, challenges such as unreliable infrastructure, including intermittent internet and power supply, often hinder their effectiveness (Ibeneme et al., 2022). By integrating technology into healthcare delivery, this approach streamlines the process of payment for workers. Although there is increasing focus on payment digitization, there is limited rigorous evidence on the impacts on health system outcomes (Joshi et al., 2020; Muralidharan et al., 2017). Nevertheless, the deployment of these systems must consider the local context to address specific barriers such as financial literacy and access to mobile technology, ensuring that digital payment solutions are accessible to all members of affected communities (Cambaza, 2023; Klapper & Bull, 2023). In the context of limited evidence on the experiences of health workers and managers in rolling out digital payment systems, my second dissertation paper investigates the implementation of a digital payment system for immunization workers in Chad. This research assesses the relationship between the intervention and job motivation and satisfaction. Employing a mixed-methods approach, this study combines a quantitative one-time survey with qualitative semi-structured interviews to provide a comprehensive analysis of the intervention's implementation. The novelty of this study is two-pronged: (1) the application of expectancy theory to understand the complex mechanisms by which digital payment systems influence health workers’ motivation and job; and (2) the use of mixed methods, which are particularly suited and necessary for understanding the multifaceted challenges in FCAS. These insights will inform policymakers and health administrators aiming to implement digital payment systems to strengthen health services and improve public health outcomes in low- and middle-income countries (LMICs). Even with significant strides in lowering new HIV infections and improving access to effective treatments, governments face substantial difficulties in addressing HIV care in FCAS (UNAIDS, 2019; UNAIDS, 2024). Individuals in these regions often face severe difficulties, including reduced or complete loss of access to HIV prevention, treatment, care and support services (UNAIDS, 2024). For example, less than 20% of people in FCAS receive antiretroviral therapy (ART) (Ferreyra, 2014). In Chad, the HIV epidemic disproportionately affects youth, with stark disparities in access to treatment and testing (UNAIDS, 2023). According to UNAIDS (2023), in 2022, an estimated 26.3% of new HIV infections in Chad were in youth (ages 15-24 years) (UNAIDS, 2023). Additionally, young women continue to suffer disproportionately from the epidemic, more specifically due to the HIV triple threat from the combination of new HIV infections, sexual and gender-based violence (SGBV), and adolescent pregnancies (Global Communities, 2022). In 2022, young women had HIV infection rates four times as high as men, accounting for 19.5% of all new infections in Chad (UNAIDS, 2023). Despite efforts to improve health education and services, only a fraction of HIV-positive children and adolescents receive the necessary retroviral treatment, and there is a lack of consistent supply of antiretrovirals (ARVs) and adequate healthcare infrastructure (Chad DHS 2014-15, 2015). For instance, only 22% of HIV-positive children in Chad have access to necessary treatment, with reported irregular availability of ARV drugs and insufficient pediatric care provisions (UNICEF, 2023b). Overall, the data underscores the need for Chad to intensify efforts for addressing the HIV epidemic among young populations, emphasizing gender-sensitive approaches and improving healthcare access and quality to curb the epidemic’s impact on adolescents (UNICEF, 2023b; UNICEF, 2023c). To optimize HIV services for adolescents in Chad, there needs to be a concerted effort to make these services more accessible, confidential, and tailored to the diverse needs of young people. My third dissertation paper is a secondary data analysis from a parent study employing grounded theory design to understand youth’s sensemaking and service utilization in the context of SRH and HIV care in Chad (Bedingar et al., 2024). This study focuses on the pathways to care for youth in Chad from diagnosis to ART adherence. We analyze the data collected using thematic analysis to identify barriers and facilitators to HIV care. The novelty of this study lies in its grounded theory approach and youth-centric focus, providing a comprehensive and in-depth understanding of the specific needs and challenges of adolescents in accessing HIV care in Chad. Research on HIV in youth in sub-Saharan Africa, especially in FCAS, is lacking. The findings suggest that tailored interventions that are culturally sensitive and context-specific are likely to be more effective. These interventions could serve as models for similar settings in sub-Saharan Africa, contributing to improved HIV care and outcomes for youth across the region. These examples underscore the urgent need for innovative healthcare strategies in FCAS. The findings from the three papers demonstrate that by addressing specific challenges and integrating both local insights and global health innovations, we can identify promising strategies to enhance health outcomes in some of the world’s most challenging environments.