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The search strategy on contextual factors captured a large number of related peer-reviewed articles (2224), the vast majority of which (2160) either did not discuss humanitarian crises, or did not consider the impact of access to healthcare when looking at public health interventions during crises.
There is only a modest body of available evidence assessing the impact of access to healthcare on the effectiveness of health interventions during humanitarian crises (64 papers).
There is increasing interest in the characterisation of the impact of access on healthcare interventions during humanitarian crises, with 58/64 (91%) of all studies conducted since 1980 being published in the last decade.
The majority of available evidence is of low to moderate quality: 18/64 (28%) of papers were from category C evidence, 27/64 (42%) were from category B, and 19/64 (30%) were from category A.
All studies were observational. 32/64 (50%) of studies were descriptive in design and of these 14/32 (44%) were comparative: half the comparative studies (7/14) compared changes during the period of a humanitarian crisis, the other half (7/14) compared changes before and after a crisis struck. 31/64 (48%) employed a cross sectional design and one paper (2%) was a retrospective cohort study.
Of the location-identified research on health access during humanitarian crises, the country most commonly studied was Afghanistan (10/64, 16%), followed by Pakistan (8/64, 13%), Sri-Lanka (5/64, 8%), then Burma (4/64, 6%). As a region, Africa followed Asia in being the most intensely studied, with 13/64 (20%) articles focusing on countries including, DRC (2), Côte d’Ivoire (2), Sudan (2), Botswana (1), Guinea-Bissau (1), Kenya (1), Nigeria (1), Sierra Leone (1) and Somalia (1). Indeed, these countries represent some of the most violent environments to live in during their respective times of conflict and would be expected to have been associated with reduced access to healthcare for their populations. Other countries studied included China (3), Colombia (3), Haiti (3), Indonesia (2), Jordan (2), Nepal (2), Nicaragua (1), Peru (1) and Syria (1). 5/64 (8%) papers studies multiple countries.
Evidence for the different types of humanitarian crises focused heavily on armed conflict, which constituted 53/64 (83%); 11/64 (17%) considered natural disaster, in particular earthquakes (8) and tsunamis (2).
Most papers (39/64, 61%) focused on the general population, 15/64 (23%) considered IDPs, and one paper compared the general population with IDPs. 9/64 (14%) papers considered refugee populations.
Most papers (41/64, 64%) considered both urban and rural settings, 14/64 (22%) considered only the rural setting, and 9/64 (14%) considered only the urban environment.
Evidence for access to healthcare during humanitarian crises focused principally on the access of end-users (56/64, 88%). Of these papers, 25/64 (39%) considered all aspects of access of end-users, 16/64 (25%) considered only their physical access, 4/64 (6%) only economic access, two papers focused on the issue of non- discrimination in healthcare access; and one on informational access. Only 3/64 (5%) articles considered primarily the access of health workers to provide healthcare to end-users. Of these, two papers considered their economic access in terms of feasibility of their planned public health interventions; one paper considered their physical access. Finally, 5/64 (8%) papers considered access issues of both end-user and health workers together.
Regarding the types of public health interventions, 36/64, (56%) articles studied access to existing medical services. 18/64 (28%) articles considered access to international medical assistance or existing services supplemented by international intervention. The remaining articles (10/64, 16%) considered a combination of local governmental, non-governmental or an undefined mechanism of supplementation of existing medical services.
Female reproductive health, antenatal and obstetric services together formed the health topic most studied regarding access (12/64, 19%). 10/64 (16%) papers considered all health services in general, 8/64 (13%) papers considered primary care and 4/64 (6%) considered mental health services. There was also specific evidence on access to infectious disease control: 6/64 (9%) papers studied malaria, 4/64 papers (6%) TB, and two papers HIV/AIDS.
Concerning the stage of crisis, 10/64 (16%) studies focused on the acute phase, 5/64 (8%) on early recovery, and the vast majority (49/64, 77%) on chronic situations.
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