Understanding the factors, coverage, and quality of care, influencing the choice of different models of delivering primary health care in conflict-affected settings of Cameroon and Nigeria

Abstract

ABSTRACT Background: Globally, two billion people live in a fragile, violent or conflict setting, and 8000 people are forced to flee their home every day because of violence, conflict or disaster. In conflict-affected settings, access to health care for displaced population is constrained by insecurity, geographical, cultural, communication, logistical and financial barriers. In addition, health systems are deteriorated, and primary health care (PHC) services are delivered using various models of care. There is paucity of evidence guiding the selection and design of PHC delivery models in humanitarian settings making it unclear which models are best to improve and maintain quality care in these complex environments. The North West and South West (NWSW) regions of Cameroon are experiencing protracted humanitarian crises for seven years now which has caused 27% (253/933) of health facilities to be non-functional. In North East Nigeria (NEN), the crises have been protracted for 13 years causing the closure of 26 % (613/2367) of health facilities. The closure of health facilities coupled with population displacement has prompted the use of different PHC delivery models in these settings. The goal of this PhD is to understand the PHC landscape in conflict-affected settings of NWSW regions of Cameroon and NEN including determinants of choice of PHC delivery models and the quality interventions selected by humanitarian organisations. Methodology: Out of the three types of mixed methods that exist: convergent mixed methods, sequential explanatory mixed methods and sequential exploratory mixed methods, the explanatory sequential mixed methods was selected for this research. The sequential explanatory mixed methods research starts with quantitative data collection and analysis, followed up with qualitative data collection and analysis, which leads to interpretation. First, a systematic review of the evidence on models of care used to deliver PHC services in conflict settings of Africa was performed using the PRISMA guidelines for conducting systematic reviews. This was followed by a mapping study of humanitarian organisations delivering PHC services in conflict-affected populations of NWSW regions of Cameroon and NEN using a desk review and cross-sectional survey that was conducted online targeting one participant per organisation. A qualitative study using in-depth interviews and focus group discussions explored factors influencing models of care used. Further in-depth interviews were conducted to explore aspects of quality of care in service delivery using different models of care. Qualitative data analysis was done using the framework analysis approach. Analysis and findings from this research informed two co-creation workshops to develop a framework to guide the selection and use of models of care in conflict-affected areas. Results: Forty eight articles were included in the systematic review with most studies amongst included publications reporting PHC delivery in settings experiencing protracted conflict (N=36, 75%). A total of 160 humanitarian organisations completed the survey, 42 senior humanitarian professionals/experts were interviewed, and 85 internally displaced persons/host community members took part in the qualitative study. The systematic review identified five models of care with PHC for conflict-affected populations being delivered by both national and international organisations. These five models of care were health facilities, mobile clinics, home visits, community-based interventions and outreach. The systematic review also revealed that international organisations the most involved in delivering services for internally displaced persons and refugees. The mapping survey revealed that national organisations lead service delivery in conflict-affected communities and identified two additional models of care (telemedicine and hybrid). The qualitative studies highlighted factors influencing model of care selection with funders, communities and the government playing key roles. The qualitative studies further revealed two more models of care (Ambulances and Rapid Response Mechanisms). Overall, this research identified nine models of care used in conflict-affected settings of Cameroon and Nigeria. Analysis showed that several factors categorised into six themes influence the use of models of care including; stakeholders, outer organisational setting factors, inner organisational setting factors, services, coordination and the models of care themselves. Results show the presence of various organisations mostly clustered in close geographic proximity delivering services with the prominence of national and community-based organisations as key providers of services. Health facilities, community-based interventions and mobile clinics are the most used models, each having limitations. International non-governmental organisations have quality considerations in place though there exist complexities and challenges of providing quality healthcare in conflict-affected settings. Also, the necessity for precise information sharing on which model of care is used to deliver services was revealed in this study. Conclusion: This research sheds light on the complexities and challenges inherent in PHC model selection and in delivering quality PHC in conflict-affected settings. Notably, the findings in this thesis advocate for revisiting the humanitarian 5W mapping matrix (“Who” is offering “What” kind of service, “Where”, “Why” and for “Who”) suggesting the introduction of a 6th W, the establishment of coordination bubbles with the inclusion of community representatives. Further, the delivery of PHC services should use an integrated approach with recognition of unmet mental health and non-communicable disease needs. Moreover, results in this work call for the use of hybrid models of care to complement service delivery and provide enhanced coverage of higher quality. A key output from this PhD was a decision-making framework and quality toolkit providing structured and evidenced-based decision-making process of PHC model selection and use. The practical application and testing of the decision-making framework developed in this PhD will be essential to assess its effectiveness in guiding the process of selecting models of care. There is need to advocate for use of this decision-making framework and quality toolkit in conflict-affected settings of Cameroon and Nigeria and beyond in other conflict-affected settings.