Primary health care service delivery by international actors in humanitarian emergencies

Abstract

Primary health care (PHC) is usually the first point of contact people have with a country's health system. The aim of PHC is to provide comprehensive, accessible, community-based care that meets the health needs of individuals throughout their lifetime. Humanitarian emergencies (HEs) are characterised by an inability of affected populations to cope with an event using their own resources. In HEs, international actors often provide humanitarian assistance to affected populations. The majority of health services are delivered at the PHC level. In fact, approximately 90% of the activity of the largest humanitarian medical actor, Medecins sans Frontieres (MSF), is conducted at the PHC level each year. Despite the significance of PHC activity in HEs, there are currently no established guidelines for the humanitarian community on service implementation, particularly related to the context, national health system capacity and the expectations of affected communities.

The overarching aim of this thesis is to provide empirical evidence to describe the PHC system of a HE from the perspective of international actors. To achieve this aim, I addressed three key research questions: 1. What is currently known about how PHC services are delivered in HEs by international actors? 2. How do key concepts of PHC apply in a HE? and 3. What does a health systems approach look like with respect to PHC delivery in a HE?

To answer the first question, I undertook a scoping narrative literature review of peer-reviewed literature from 1978 to 2016 and grey literature from 2013 to 2018. I included primary reports of PHC interventions delivered in the acute phase of a HE by international actors, and analysed these interventions against an existing PHC framework. I found that the PHC system collapses during a HE, that international actors delivered PHC services according to their own capacity, setting their own aims and objectives, and that little consideration was given to community empowerment in service delivery.

I used field visits to MSF projects in northern Nigeria and Lebanon as case studies to answer the second research question. In northern Nigeria, a visit and realist analysis of a MSF maternal health care project highlighted the importance of understanding the 'context' of an intervention, particularly the role of PHC in comprehensively addressing maternal and neonatal mortality and morbidity. In the Bekaa valley region of Lebanon, I used routinely collected patient data on non-communicable diseases (NCDs) from four MSF PHC clinics to investigate the concepts of geographic accessibility, availability of facilities, adjustment to population health needs and continuity of care for patients seeking NCD care. I found that access to care was dependent on context, that there was a relationship between continuity of care and access to a clinic, and that humanitarian access plays a key role in these settings.

The final research question was answered using principles of complex adaptive systems theory and the findings from the case studies. I developed a conceptual framework to explain the dynamic relationship between the national health system of a country, the system created by international actors and that of individuals and communities affected by a HE.

The findings presented in this thesis have important implications for practice and further research. International health actors working in HEs need to better understand the context in which PHC services are delivered to provide effective and relevant health care. The principles of PHC are relevant in HEs, however they need to be adapted. If we are to achieve the goals of the Declaration of Astana to 'leave no one behind', we must place greater emphasis on understanding the inter-dependent relationships between the national health system, international actors and communities themselves. Show more