Publications

Reducing under-five mortality is a global health priority. Countries need specific data on which interventions have the most potential to lead to improvements to inform their programs and policies. Group-based trajectory modeling was applied to identify distinct trajectories of under-five mortality from 2000 to 2019 in 78 low and lower-middle income countries. Both health and non-health variables were studied as time-stable covariates of trajectory group membership and as time-varying covariates of mortality rates within groups.

Understanding the spread of COVID-19 in humanitarian and fragile settings is challenging for many reasons, including the lack of data on social dynamics and preventive behaviors during an epidemic. We investigate social interactions in three such settings - Democratic Republic of the Congo (DRC), Central African Republic (CAR), Cox’s Bazar (CXB), Bangladesh – and how they changed during the first year of the pandemic. This comparative mixed-methods study uses a representative household survey and focus group discussions or key informant interviews in each site. Descriptive weighted analysis of survey responses was conducted; multivariate logistic regression identified factors associated with changes in social interactions. Thematic analysis was conducted on qualitative data. Nearly all participants had social interactions the day before the survey, although the average number of daily interactions was low. Interactions primarily occurred indoors, at home and without masks. We saw a discrepancy between knowledge about and practice of preventive behaviors. Most respondents reported interacting less often (77.3% CXB, 86.7% CAR, 58.8% DRC) and having shorter meetings (80% CXB, 77.8% CAR, and 47.8% DRC). Reluctance towards the COVID-19 vaccine was a risk factor for non-compliant behaviors in CAR (OR increased frequency = 3.51, 95%CI = 1.41–8.75; OR increased duration = 2.47, 95%CI = 1.15–5.29) and DRC (OR increased duration = 3.06, 95%CI = 1.71–5.49), likely pointing to distrust towards institutional policies. Respondents from IDP communities in DRC were less likely to reduce the frequency of interaction, likely because living conditions did not facilitate physical distancing. Increased knowledge in CXB was associated with compliant behavior (for 1pt-increase: OR increased frequency = 0.47, 95%CI = 0.32–0.68; OR increased duration = 0.46, 95%CI = 0.31–0.69). Understanding social dynamics is fundamental to predict infectious disease spread, particularly in humanitarian settings. More evidence is needed to understand behaviors influencing disease dynamics and drivers of behaviors, including trust in authorities, social, and economic factors. Peace, community engagement, and reduction of misinformation remain critical for epidemic responses in humanitarian settings.

South Sudan ranks among the most fragile nations in the world. Protracted conflict and recurrent shocks have weakened its health system and contributed to high maternal and child mortality rates, despite large amounts of humanitarian and development assistance injected into the country since independence. Factors related to the leadership and governance, financing, and coordination of health services impact the feasibility of implementing the humanitarian-development nexus (HDN). Researchers employed a qualitative case study design drawing from document reviews and individual and group semi-structured interviews with humanitarian and development stakeholders in South Sudan (Juba capital and Bor town). Data was analyzed and findings were synthesized and organized into distinct themes. Forty-one interviews were conducted with 68 participants between November 2022 and January 2023, and 57 documents were analyzed. Findings showed that limited government investment in the health sector has perpetuated reliance on international assistance, and barriers to engagement with government counterparts have restricted coordination. Some nascent HDN coordination platforms exist with minimal political buy-in. Recent reductions in development health funding have complicated progress towards longer-term development objectives, including health systems strengthening. Structural barriers within multi-mandate agencies and differences in programming cycles, funding, and reporting contribute to silos. Continued fragility, a restricted operational environment, shrinking funds, and fragmented coordination have made it challenging to plan, finance, and implement HDN-health interventions. Informal efforts to bridge silos between humanitarian and development actors should become more formalized to use resources more efficiently. Despite certain restrictions in engagement with government, coordination and planning at the sub-national level may still be feasible. Such engagement should be enhanced to ensure sustainability of health services. Investment in health systems strengthening and resilience by humanitarian and development actors should enable communities to absorb recurrent shocks and prevent backsliding in health provision.

The discovery that the Oropouche virus (OROV) can be transmitted vertically from an infected pregnant mother to the fetus, resulting in fetal and placental OROV infection, miscarriage, stillbirth, and congenital malformations including microcephaly, has emphasized its public health significance. Because of the importance of breastfeeding in those areas affected by the Oropouche fever outbreak, public health agencies have continued to encourage nursing among mothers who have had OROV infection or who reside or travel in endemic regions. However, the basis for this recommendation has not been stated. At the present time, there have been no reports of the OROV being transmitted from mothers having had Oropouche fever during pregnancy to their infants through breast milk. To further evaluate the potential risk of OROV transmission through breastfeeding, we have examined the peer-reviewed literature to determine if related Orthobunyavirus species infecting humans and animals are transmissible via breast milk. Bibliographic search engines, including PubMed, Scopus, and Google Scholar, were extensively reviewed using keywords, MeSH terms, and other sources cited in the articles examined. Studies investigating Orthobunyavirus species that infect humans and animals, including reassortant strains of OROV and viruses within the Simbu serogroup, were reviewed. We found that there have been no reported events of vertical transmission of any Orthobunyavirus through breast milk. Based on these results, we believe that the advantages of breastfeeding following maternal OROV infection outweigh any negligible risk for vertical transmission.

Health system adaptations were rapidly introduced at the start of the COVID-19 pandemic to protect the public and maintain access to health services. Given the specific vulnerabilities of forced displacement settings, understanding which adaptations were used, how they were implemented, their success, and challenges is important for preparedness and response efforts. In this paper, we characterize adaptations in health service delivery implemented by Ministries of Health, the UN Refugee Agency, and partners to maintain health services provision for refugees in Jordan and Uganda. We conducted 21 key informant interviews with managerial and operational staff across 12 organizations who delivered healthcare services for refugees in Uganda and Jordan during the COVID-19 pandemic and applied a framework analysis to the adaptations characterized. The results are presented by WHO health system building blocks. Most adaptations focused on health service delivery specifically procedures for screening and isolation in the community, COVID-19 community support, and facility-level infection prevention measures. Health service delivery adaptations focused not only on ensuring capacity for COVID-19 patients but on adapting mechanisms to support access for those needing regular care. Many adaptations worked in tandem with others as packages to achieve this. Workforce adaptations included task shifting and staffing surges. Modifications related to medical products, vaccines, and technologies focused on procurement, medication management, supporting vaccine strategies, and building testing capacity. Adaptations in leadership and governance, financial and health information systems were identified but mainly described as essential enablers for other adaptations. Key enablers to successful adaptation in this context included the integration of refugees in National Health systems, strong relationships between partners and a supportive environment for adaptation, existing preparedness plans and access to financing. This study highlights the scale, scope and diversity of innovative adaptations implemented to maintain health services for refugees in Jordan and Uganda during the COVID-19 pandemic.

There are an estimated 850 persons with End-Stage Kidney Disease (ESKD) receiving hemodialysis in the conflict-affected Northwest Syria. This study examines patients’ perspectives, and experiences with hemodialysis and their knowledge about their disease and treatment.

In line with previous progress reports by Countdown to 2030 for Women's, Children's, and Adolescents' Health, this report analyses global and regional trends and inequalities in health determinants, survival, nutritional status, intervention coverage, and quality of care in reproductive, maternal, newborn, child and adolescent health (RMNCAH) and nutrition, as well as country health systems, policies, financing, and prioritisation. The focus is on low-income and middle-income countries (LMICs) where 99% of maternal deaths and 98% of child and adolescent deaths (individuals aged 0–19 years) occur, with special attention to sub-Saharan Africa and South Asia.

This case study explored the current drivers of Maternal and Newborn Health (MNH) prioritization in Somalia, a fragile country with very high maternal and neonatal mortality rates. To enhance MNH prioritization and improve outcomes, we need to understand macro contextual and health system factors that influence the level of attention and investment since 2012 with the establishment of the federal government of Somalia. This study consisted of a desk review and 20 semi-structured interviews with stakeholders in MNH policy and implementation, including government, donors, private sector, and non-governmental and multilateral organizations. The Health Policy Analysis triangle guided the analysis of findings, to capture policy content, context, actors, and processes. Our findings show a complex picture for MNH prioritization in Somalia. There is a level of priority for MNH through technical advancements driven by international partners, including development of policies, strategies, and guidelines. However, there is inadequate government ownership of the MNH agenda through poor domestic financial investment and capacity for governance (including partner coordination) in the health sector. The study found gaps in implementation of programs, and competing priorities due to insecurity and other health and social needs. Respondents highlighted a need to address fragmented accountability and oversight processes, and ensure meaningful inclusion of actors such as the private sector and the diaspora and women leaders.

The Syrian Civil War has resulted in significant devastation, including widespread displacement of millions and extensive damage to infrastructure, particularly healthcare infrastructure. Attacks on healthcare facilities have been frequent, leading to a drastic reduction in available medical services and the exodus of healthcare workers. The resulting impact on civilians, compounded by energy shortages, has been severe, limiting access to essential services. In response to these challenges, the Union of Syrian Medical Relief Organizations (UOSSM) has introduced the solar-powered electric vehicles for healthcare transportation in Northwest Syria. This development is a significant step toward sustainable energy solutions in conflict zones, providing a reliable source of power for essential services such as healthcare delivery. In this paper, we document this experience which underscores the importance of local involvement and partnerships in implementing such solutions, as well as the need for broader research and education initiatives to ensure the long-term viability of renewable energy systems. These initiatives allow for a sustainable future solution while enabling local actors to participate in their development and maintenance. By prioritizing sustainability and autonomy, initiatives like UOSSM’s solar-powered electric car demonstrate the potential for innovative responses to complex humanitarian crises around the world, following Syria’s example.

The United States government (USG) is a key global actor in preventing mortality and supporting lifesaving health services among women and children in low- and middle-income countries (LMICs). Since the Foreign Assistance Act of 1961, USG has funded global health programmes targeting specific conditions and strengthening health systems for the delivery of essential services via the United States Agency for International Development (USAID) and other USG agencies. However, directly quantifying and attributing the impact of USG health investments is challenging due to the inability of conducting randomised control trials for such large programmes at scale. In this study, we compared two quasi-experimental impact evaluation approaches to estimate the effects of sustained USG health investments on mortality among women of reproductive age (WRA).

Humanitarian emergencies are postulated to increase rates of early marriage and early childbearing, as drivers of both are heightened or exacerbated in crisis settings. There is a critical need for research that explores the causal mechanisms that motivate family formation, i.e. the process from marriage into childbearing, and how this process is affected by conflict and displacement.

Pregnancy induces physiological decline in maternal immunity. Ebola virus disease (EVD) in pregnancy is associated with obstetrical complications, and vaccination in early pregnancy is recommended, but may not be without risk. We described neonatal survival after spontaneous maternal EVD recovery. This neonate was born to a 25-year-old mother admitted to an Ebola Treatment Unit (ETU) in July, 2020, after 11 days of symptoms. She was vaccinated with rVSV-ZEBOV three days before symptom onset and her real-time polymerase chain of reaction (RT-PCR) results confirmed EVD and malarial infection two days after, but she refused hospitalization. She was treated at home with PO ASAQ, amoxicillin, paracetamol, albendazole, omeprazole, and papaverine. Eleven days later, due to clinical deterioration and onset of vaginal hemorrhage, she finally accepted to be transferred in ETU. She was Parity 2, fetal age at admission was 5 weeks and 3 days. Upon admission, her EVD PCR measured NP 26.3 and GP 32.9. She did not receive monoclonal therapy against Ebola infection due to stock shortage. She received intravenous, artesunate, ceftriaxone, and papaverine. She experienced spontaneous resolution of EVD 18 days after symptom onset and was discharged. At 40 weeks gestation, seven and a half months after EVD recovery, she delivered a healthy female infant, APGAR 10/10/10, weighing 3450 g. Maternal blood, adnexal, and newborn blood samples were RT-PCR negative, and the mother and the baby were discharged after 14 days. At our last follow-up, in June 2023 (2 years, 3 months after delivery), the mother and the baby were in good health.

Humanitarian assistance has saved millions of lives, improved public health outcomes, and strengthened communities in crisis.¹From responding to armed conflicts and natural disasters to advancing disease control and poverty reduction, the humanitarian and development sectors have played an indispensable role in reducing suffering worldwide. However, despite these successes, the existing humanitarian system is not fit for purpose in today's rapidly evolving geopolitical landscape of conflict and displacement.²Reform is essential, but it should be undertaken strategically—rooted in evidence and accountability, and with affected populations at the centre.³ Simply dismantling existing structures without a clear strategy for the future will set back humanitarian assistance for decades, cause catastrophic harm to the most vulnerable, and further destabilise global health security.⁴

Given the many approaches to and definitions of gender responsive monitoring and evaluation (M&E) for health programs and interventions there is a lack of clarity on how to operationalize it including what to measure and how to measure it. We conducted a scoping review to understand what makes M&E gender responsive. We included 31 studies and conducted two rounds of extraction to delineate ways in which gender was integrated into M&E. Twelve articles described the use of theory to guide M&E though most were not related to gender. Twelve articles employed a gender score in data collection, most of which measured Likert scale responses related to gender equity. Even though most studies did not use a specific gender framework, most incorporated gender domains in their analysis. Seven studies used participatory methods in the design and implementation of M&E. Most studies conducted M&E on programs or interventions that were designed to be gender intentional and related to gender issues. Gender responsive M&E intentionally integrates gender into the M&E process, regardless of how gender-intentional the program or intervention is. Gender dimensions can be identified through gender theories, models, scores, and frameworks to inform tool development, data collection, analysis, and stakeholder engagement processes.

Protracted violent conflict has severely reduced healthcare provision in northwest Syria (NWS), and this is especially concerning for postoperative care as conflict-related injuries have further compounded this strain. Without sufficient postoperative care, minor complications can evolve into life-threatening events. In this study, we aim to understand healthcare workers’ attitudes, practices and perceptions regarding postoperative care in NWS and identify key barriers to postoperative care.

Ebola-HIV and malaria co-infection is one of the rare clinical situations that remains complex to manage even in the context of unlimited resources. In pregnancy, each of these infections can compromise maternal and fetal outcomes. The synergy of their effects on maternal immunity are often fatal, and survival is an exception, especially in a context of limited resources, such as in Ebola Treatment Units (ETUs).

Syria's health-care system has undergone profound upheaval over the past decade, shaped by conflict, fragmentation, and now, a tenuous political transition. The acute conflict phase (2011–15) devastated health infrastructure, with systematic attacks on medical facilities and the mass exodus of health-care workers.¹ This phase was followed by a protracted phase (2015–23) in which parallel governance structures resulted in a fractured and inconsistent health-care landscape.² Now, with the fall of the Assad regime and the emergence of a transitional government, Syria faces a daunting challenge: reconstructing a unified, resilient health-care system from these disparate remnants.

On 20 January 2025, the day of his second inauguration as president, Donald Trump signed an executive order rescinding the Biden era policy that restricted Immigration and Customs Enforcement (ICE) operations at “sensitive” locations, including schools, churches, and healthcare facilities.12 The negative impact has been immediate. Patients are fearful, public health is under threat, and providers are braced for ethical challenges.

There is a dearth of evidence on the scale, scope and quality of midwifery education programs in conflict-affected settings. This study sought to assess the extent to which midwifery pre-service education programs meet national and global standards, and to explore how conflict affects pre-service midwifery education in Yobe State Nigeria and the Benadir and Galgaduud regions of Somalia.

This longitudinal experimental study aimed to profile audiometric hearing loss, explore the feasibility and efficacy of low-cost hearing devices, and examine their social and emotional impact on participants in South Sudan, a low-resource humanitarian setting.