Armed conflict disproportionately affects women, newborns, children, and adolescents. Our study presents insights from a collection of ten country case studies aiming to assess the provision of sexual, reproductive, maternal, newborn, child and adolescent health and nutrition (abbreviated to women's and childern's health, i.e WCH in this paper) interventions in conflict-affected settings in Afghanistan,

This Campbell systematic review examines the effectiveness, efficiency and implementation of cash transfers in humanitarian settings. The review summarises evidence from five studies of effects, 10 studies of efficiency and 108 studies of barriers and facilitators to implementation of cash‐based humanitarian assistance. Studies assessing effectiveness of cash‐based approaches were experimental and quasiexperimental studies. Studies analyzing efficiency were experimental, quasi‐experimental or observational studies with a cost analysis or economic evaluation component. Studies examining barriers and facilitators included these study types as well as other qualitative and mixed methods studies. Unconditional cash transfers and vouchers may improve household food security among conflict‐affected populations and maintain household food security among food insecure and drought‐affected populations. Unconditional cash transfers led to greater improvements in dietary diversity and quality than food transfers, but food transfers are more successful in increasing per capita caloric intake than unconditional cash transfers and vouchers. Unconditional cash transfers may be more effective than vouchers in increasing household savings, and equally effective in increasing household asset ownership. Mobile transfers may be a more successful asset protection mechanism than physical cash transfers. Cash transfers can be an efficient strategy for providing humanitarian assistance. Unconditional cash transfer programmes have a lower cost per beneficiary than vouchers which, in turn, have a lower cost per beneficiary than in‐kind food distribution. Cash transfer programs can also benefit the local economy. Voucher programmes generated up to $1.50 of indirect market benefits for each $1 equivalent provided to beneficiaries and unconditional cash transfer programmes generated more than $2 of indirect market benefits for each $1 provided to beneficiaries. Intervention design and implementation play a greater role in determining effectiveness and efficiency of cash‐based approaches than the emergency context or humanitarian sector. Factors which influence implementation include resources available and technical capacity of implementing agencies, resilience of crisis‐affected populations, beneficiary selection methods, use of new technologies, and setting‐specific security issues, none of which are necessarily unique to cash‐based interventions. Plain language summary Cash‐based humanitarian assistance approaches can increase food security and are more cost effective than in‐kind food transfersBoth cash‐based approaches and in‐kind food assistance can be effective means of increasing household food security for people who live in areas of conflict. The review in briefCash‐based approaches have become an increasingly common strategy for the provision of humanitarian assistance. Both cash‐based approaches and in‐kind food assistance can be effective means of increasing household food security among conflict‐affected populations and maintai...

Background Maternal and perinatal death surveillance and response (MPDSR) is a system of identifying, analysing and learning lessons from such deaths in order to respond and prevent future deaths, and has been recommended by WHO and implemented in many low-and-middle income settings in recent years. However, there is limited documentation of experience with MPDSR in humanitarian settings. A meeting on MPDSR in humanitarian settings was convened by WHO, UNICEF, CDC and Save the Children, UNFPA and UNHCR on 17th–18th October 2019, informed by semi-structured interviews with a range of professionals, including expert attendees. Consultation findings Interviewees revealed significant obstacles to full implementation of the MPDSR process in humanitarian settings. Many obstacles were familiar to low resource settings in general but were amplified in the context of a humanitarian crisis, such as overburdened services, disincentives to reporting, accountability gaps, a blame approach, and politicisation of mortality. Factors more unique to humanitarian contexts included concerns about health worker security and moral distress. There are varying levels of institutionalisation and implementation capacity for MPDSR within humanitarian organisations. It is suggested that if poorly implemented, particularly with a punitive or blame approach, MPDSR may be counterproductive. Nevertheless, successes in MPDSR were described whereby the process led to concrete actions to prevent deaths, and where death reviews have led to improved understanding of complex and rectifiable contextual factors leading to deaths in humanitarian settings. Conclusions Despite the challenges, examples exist where the lessons learnt from MPDSR processes have led to improved access and quality of care in humanitarian contexts, including successful advocacy. An adapted approach is required to ensure feasibility, with varying implementation being possible in different phases of crises. There is a need for guidance on MPDSR in humanitarian contexts, and for greater documentation and learning from experiences.

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Background Measuring and improving equitable access to care is a necessity to achieve universal health coverage. Pre-pandemic estimates showed that most conflict-affected and fragile situations were off-track to meet the Sustainable Development Goals on health and equity by 2030. Yet, there is a paucity of studies examining health inequalities in these settings. This study addresses the literature gap by applying a conflict intensity lens to the analysis of disparities in access to essential Primary Health Care (PHC) services in four conflict-affected fragile states: Cameroon, Democratic Republic of Congo, Mali and Nigeria. Methods For each studied country, disparities in geographic and financial access to care were compared across education and wealth strata in areas with differing levels of conflict intensity. The Demographic Health Survey (DHS) and the Uppsala Conflict Data Program were the main sources of information on access to PHC and conflict events, respectively. To define conflict intensity, household clusters were linked to conflict events within a 50-km distance. A cut-off of more than two conflict-related deaths per 100,000 population was used to differentiate medium or high intensity conflict from no or low intensity conflict. We utilized three measures to assess inequalities: an absolute difference, a concentration index, and a multivariate logistic regression coefficient. Each disparity measure was compared based on the intensity of conflict the year the DHS data was collected. Results We found that PHC access varied across subnational regions in the four countries studied; with more prevalent financial than geographic barriers to care. The magnitude of both educational and wealth disparities in access to care was higher with geographic proximity to medium or high intensity conflict. A higher magnitude of wealth rather than educational disparities was also likely to be observed in the four studied contexts. Meanwhile, only Nigeria showed statistically significant interaction between conflict intensity and educational disparities in access to care. Conclusion Both educational and wealth disparities in access to PHC services can be exacerbated by geographic proximity to organized violence. This paper provides additional evidence that, despite limitations, household surveys can contribute to healthcare assessment in conflict-affected and fragile settings.

Background Midwives are the key skilled birth attendants in Afghanistan. Rapid assessment of public and private midwifery education schools was conducted in 2017 to examine compliance with national educational standards. The aim was to assess midwifery education to inform Afghanistan Nurses and Midwives Council and other stakeholders on priorities for improving quality of midwifery education. Methods A cross-sectional assessment of midwifery schools was conducted from September 12–December 17, 2017. The Midwifery Education Rapid Assessment Tool was used to assess 29 midwifery programs related to infrastructure, management, teachers, preceptors, clinical practice sites, curriculum and students. A purposive sample of six Institute of Health Sciences schools, seven Community Midwifery Education schools and 16 private midwifery schools was used. Participants were midwifery school staff, students and clinical preceptors. Results Libraries were available in 28/29 (97%) schools, active skills labs in 20/29 (69%), childbirth simulators in 17/29 (59%) and newborn resuscitation models in 28/29 (97%). School managers were midwives in 21/29 (72%) schools. Median numbers of students per teacher and students per preceptor were 8 (range 2–50) and 6 (range 2–20). There were insufficient numbers of teachers practicing midwifery (132/163; 81%), trained in teaching skills (113/163; 69%) and trained in emergency obstetric and newborn care (88/163; 54%). There was an average of 13 students at clinical sites in each shift. Students managed an average of 15 births independently during their training, while 40 births are required. Twenty-four percent (7/29) of schools used the national 2015 curriculum alone or combined with an older one. Ninety-one percent (633/697) of students reported access to clinical sites and skills labs. Students mentioned, however, insufficient clinical practice due to low case-loads in clinical sites, lack of education materials, transport facilities and disrespect from school teachers, preceptors and clinical site providers as challenges. Conclusions Positive findings included availability of required infrastructure, amenities, approved curricula in 7 of the 29 midwifery schools, appropriate clinical sites and students’ commitment to work as midwives upon graduation. Gaps identified were use of different often outdated curricula, inadequate clinical practice, underqualified teachers and preceptors and failure to graduate all students with sufficient skills such as independently having supported 40 births.

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