Ramadan Marwa, Tappis Hannah, Brieger William
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Department of Community Medicine and Public Health, Alexandria University, Alexandria, Egypt.
Confl Health. 2022 Jun 15;16(1):36. doi: 10.1186/s13031-022-00466-w.
Recent global reports highlighted the importance of addressing the quality of care in all settings including fragile and conflict-affected situations (FCS), as a central strategy for the attainment of sustainable development goals and universal health coverage. Increased mortality burden in FCS reflects the inability to provide routine services of good quality. There is also paucity of research documenting the impact of conflict on the quality of care within fragile states including disparities in service delivery. This study addresses this measurement gap by examining disparities in the quality of primary healthcare services in four conflict-affected fragile states using proxy indicators.
A secondary analysis of publicly available data sources was performed in four conflict-affected fragile states: Cameroon, the Democratic Republic of Congo, Mali, and Nigeria. Two main databases were utilized: the Demographic Health Survey and the Uppsala Conflict Data Program for information on components of care and conflict events, respectively. Three equity measures were computed for each country: absolute difference, concentration index, and coefficients of mixed-effects logistic regression. Each computed measure was then compared according to the intensity of organized violence events at the neighborhood level.
Overall, the four studied countries had poor quality of PHC services, with considerable subnational variation in the quality index. Poor quality of PHC services was not only limited to neighborhoods where medium or high intensity conflict was recorded but was also likely to be observed in neighborhoods with no or low intensity conflict. Both economic and educational disparities were observed in individual quality components in both categories of conflict intensity.
Each of the four conflict-affected countries had an overall poor quality of PHC services with both economic and educational disparities in the individual components of the quality index, regardless of conflict intensity. Multi-sectoral efforts are needed to improve the quality of care and disparities in these settings, without a limited focus on sub-national areas where medium or high intensity conflict is recorded.
近期全球报告强调，在包括脆弱和受冲突影响地区（FCS）在内的所有环境中改善医疗服务质量，是实现可持续发展目标和全民健康覆盖的核心战略。FCS地区死亡率上升反映了无法提供高质量的常规服务。此外，关于冲突对脆弱国家医疗服务质量的影响（包括服务提供方面的差异）的研究也很匮乏。本研究通过使用替代指标，考察四个受冲突影响的脆弱国家初级医疗服务质量的差异，以填补这一衡量差距。
对四个受冲突影响的脆弱国家（喀麦隆、刚果民主共和国、马里和尼日利亚）公开可用的数据源进行二次分析。使用了两个主要数据库：人口与健康调查以及乌普萨拉冲突数据计划，分别获取医疗服务组成部分和冲突事件的信息。为每个国家计算了三项公平性指标：绝对差异、集中指数和混合效应逻辑回归系数。然后根据邻里层面有组织暴力事件的强度，对每个计算出的指标进行比较。
总体而言，四个研究国家的初级医疗服务质量较差，质量指数在国家以下层面存在显著差异。初级医疗服务质量差不仅限于记录有中度或高度冲突的社区，在没有冲突或冲突强度低的社区也可能出现。在两类冲突强度下，个体质量组成部分均存在经济和教育方面的差异。
四个受冲突影响的国家初级医疗服务总体质量较差，质量指数的各个组成部分均存在经济和教育方面的差异，与冲突强度无关。需要多部门共同努力，以改善这些地区的医疗服务质量和差异，而不仅仅关注记录有中度或高度冲突的国家以下地区。
