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The search strategy was designed to be sensitive, and as a result captured 28,199 papers. An initial filter, removing papers that did not discuss humanitarian crises, health service delivery or lower and middle income countries reduced this number to 2,534 papers. The second and final filter only included studies that discussed the acute stage of crises, the effectiveness of health service delivery and put a quantifiable figure on the effectiveness of health services. Thirty-two papers met these inclusion criteria.
A number of websites were reviewed for grey literature but no papers met the inclusion criteria.
The majority of papers (28/32, 87.5%) considered only outputs of health service delivery, such as the number of patient consultations performed. These papers were considered to be category C and since they did not evaluate health outcomes they were not further assessed for quality. The four papers from category B (which considered health outcomes but did not assess their statistical significance) assessed quality using the adapted STROBE quality criteria and all four papers were assessed as being low quality. See Figure 26 for the trends of papers over time.
There appears to be an increasing interest in evaluating the effectiveness of health service delivery in humanitarian crises. 69% (22/32) of papers have been published since 2000, including 3 of the 4 category B papers (Figure 26).
All 32 papers were of cross sectional study design. The studies assessed a single point in time rather than following up the effectiveness of health services over a period of time, which constitutes a lower quality study design for the evaluation of effectiveness.
38% (12/32) of studies were conducted by multiple agencies. The most common type of research agency was academic institutions (21/32, 66%). 50% (16/32) of studies were conducted by medical facilities, 13% (4/32) were by NGOs, 9% (3/32) by the army or navy and 9% (3/32) by government agencies.
It was not possible to identify which agency had funded the research in any of the papers reviewed.
Research was conducted in a range of global locations (Figure 27). The most common region for study was the Middle East (11/32, 34%), followed by Asia (8/32, 25%), Eastern Europe (5/32, 16%), the Caribbean (3/32, 9%), Africa (2/32, 6%) and South America (1/32, 3%). One paper (3%) considered multiple countries and one paper (3%) did not detail the countries under analysis.
All of the studies conducted in Eastern Europe and Africa considered armed conflict. Studies conducted in the Middle East considered equally natural disasters (5/11) and armed conflict (6/11). Studies in Asia were predominantly about natural disasters (7/8), and all studies in South America, across multiple countries and where the country was unknown, considered natural disasters.
Papers were split as to the type of humanitarian crisis researched: 56% (18/32) were of natural disasters and 44% (14/32) of armed conflict (Figure 28)
The papers reviewed spanned a range of health settings. 25% (8/32) of papers evaluated an urban location, 28% (9/32) evaluated a rural setting, 34% (11/32) spanned both urban and rural locations, 9% (3/32) evaluated a camp setting, and one paper (3%) compared a rural location and a camp setting.
he majority of studies (72%, 23/32) evaluated the acute crisis, and a further 2 papers (6%) considered both the acute stage and early recovery (Figure 29).
Papers were split between discussing health services that met all health needs (14/32, 44%) and services that focused specifically on casualty management (14/32). Four papers (13%) tackled more specific health needs: orthopaedic casualties and infection, paediatric services, surgery, and HIV, tuberculosis and family planning.
The majority of papers (17/32, 53%) focused on secondary care services. Papers also focused on primary care (6/32, 19%) or looked at the interconnection between primary and secondary care (5/32, 16%), and possibly also tertiary care (1/32, 3%). Smaller numbers of papers discussed ambulatory (2/32, 6%) and self care (1/32, 3%). See Figure 30.
Most papers (18/32, 56%) evaluated the effectiveness of health service delivery in terms of numbers of patients seen or procedures performed (Figure 31). A number of other health outcomes were also evaluated, albeit by smaller numbers of papers: mortality (4/32, 13%), outputs of a procedures, such as patient transfer or discharge (3/32, 9%), equity (2/32, 6%), patient satisfaction (2/32, 6%), quality (1/32, 3%), security (1/32, 3%) and the appropriateness of an assessment for locating field hospitals (1/32, 3%).
Statistical analysis of the effectiveness of health service delivery was fairly crude. Twenty five papers (78%) presented numbers and/or percentages as measures of health outcomes, four papers (13%) measured mean scores, two papers (6%) measured rates and one (3%) calculated the difference between means.
Nine papers (28%) examined how existing health services within a country managed the crisis. Of these papers, six focused on rescue and casualty management and three discussed the impact on general health services. Twenty-two papers (69%) examined the implementation of temporary health services to help manage the crisis. Of these, 12 papers discussed field hospitals, seven discussed war hospitals and three examined health services in relief camps. One paper (3%) compared existing health services across a rural district and temporary health services in a camp (Figure 32).
Seventeen papers (53%) included discussion of the impact of external factors on health service delivery – these factors were discussed, not evaluated. Common factors touched on included facilitation by the Ministry of Health, financial assistance and the availability, or lack of, local health personnel.
None of the papers included discussion of the impact that health service delivery had on any external factors.
Eight (25%) papers referenced the use of guidelines within health services. No two papers referenced the same guidelines, however. The guidelines referred to were: WHO/PAHO essential requirements; the RAND/UCLA appropriateness method for determining field hospital setting in an earthquake; NATO guidelines for mass casualties; and Zung’s Self Rating Depression Scale; as well as locally produced guidelines for patient transfer, performance appraisal and war surgery.
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