Background: Despite many efforts to achieve better coordination, fragmentation is an enduring feature of the global health landscape that undermines the effectiveness of health programmes and threatens the attainment of the health-related Sustainable Development Goals. In this paper we identify and describe the multiple causes of fragmentation in development assistant for health at the global level. The study is of particular relevance since the emergence of new global health problems such as COVID-19 heightens the need for global health actors to work in coordinated ways. Our study is part of theLancet Commission on Synergies between Universal Health Coverage, Health Security and Health Promotion.Methods: We used a mixed methods approach. This consisted of a non-systematic literature review of published papers in scientific journals, reports, books and websites. We also carried out twenty semi-structured expert interviews with individuals from bilateral and multilateral organisations, governments and academic and research institutions between April 2019 and December 2019.Results: We identified five distinct yet interconnected sets of factors causing fragmentation: proliferation of global health actors; problems of global leadership; divergent interests; problems of accountability; problems of power relations. We explain why global health actors struggle to harmonise their approaches and priorities, fail to align their work with low- and middle-income countries’ needs and why they continue to embrace funding instruments that create fragmentation.Conclusions: Many global actors are genuinely committed to addressing the problems of fragmentation, despite their complexity and interconnected nature. This paper aims to raise awareness and understanding of the causes of fragmentation and to help guide actors’ efforts in addressing the problems and moving to more synergistic approaches.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). E-learning has been heralded as a revolutionary force for medical education, especially for low-resource countries still suffering from a dire lack of health care workers. Yet, despite over two decades of e-learning endeavours and interventions across sub-Saharan Africa and other low- and middle-income countries, e-learning for medical education has not gained momentum and continues to fall short of the anticipated revolution. Many e-learning interventions have been cul-de-sac pilots that have not been scaled up but rather terminated after the pilot phase. Thus, the majority of e-learning evaluations have failed to provide scientifically sound evidence of the effectiveness of e-learning for medical education in low-resource countries. Instead, it appears that technological development has overwhelmed rather than revolutionized medical education. The question remains of how to kick e-learning into a higher gear in low-resource countries. Providing e-learning as technology is insufficient. E-learning needs to be vigorously and sustainably integrated into the local educational setting and aligned with national strategies and other national endeavours and interventions. Adhering to a standardized framework for the implementation and evaluation of e-learning endeavours is key, especially to bridge the gap in robust evidence that should also guide e-learning implementations. The primary objective of e-learning for medical education is to strengthen the health system to serve the population's health care needs and expectations. Currently, medical e-learning does not measure up to its potential or do justice to medical students in low-resource countries. Technology may help unfold the potential of e-learning, but an all-encompassing change is needed. This can only be achieved through a joint effort that follows a systematic and standardized framework, specifically for implementation and evaluation.

War in Yemen started three years ago, and continues unabated with a steadily rising number of direct and indirect victims thus leaving the majority of Yemen’s population in dire need of humanitarian assistance. The conflict adversely affects basic socioeconomic and health conditions across the country. This study analyzed the recent ongoing diphtheria outbreak in Yemen and in particular, the health system’s failure to ensure immunization coverage and respond to this outbreak. Data from the weekly bulletins of the national electronic Disease Early Warning System’s (eDEWS) daily diphtheria reports and district immunization coverage were analyzed. The number of diphtheria cases and deaths, and immunization coverage (DPT) were reviewed by district including the degree to which a district was affected by conflict using a simple scoring system. A logistic regression and bivariate correlation were applied using the annual immunization coverage per district to determine if there was an association between diphtheria, immunization coverage and conflict. The study results confirm the association between the increasing cases of diphtheria, immunization coverage and ongoing conflict. A total of 1294 probable cases of diphtheria were reported from 177 districts with an overall case fatality rate of 5.6%. Approximately 65% of the patients were children under 15 years, and 46% of the cases had never been vaccinated against diphtheria. The risk of an outbreak increased by 11-fold if the district was experiencing ongoing conflict p < 0.05. In the presence of conflict (whether past or ongoing), the risk of an outbreak decreased by 0.98 if immunization coverage was high p > 0.05. The conflict is continuously devastating the health system in Yemen with serious consequences on morbidity and mortality. Therefore, the humanitarian response should focus on strengthening health services including routine immunization procedures to avoid further outbreaks of life-threatening infectious diseases, such as diphtheria.

Yemen was affected by a major cholera epidemic in 2016, while a civil war, which has devastated the country since March 2015, has exacerbated the humanitarian situation. Cholera is a disease caused by the bacterium Vibrio cholera, thus this study aims to analyze the epidemiological features of the outbreak and explore the relation of the outbreak to the current armed conflict situation. The data were obtained from the national surveillance system in Yemen. This contains details of 15,074 cases registered as suspected cholera patients per governorate from week 39 to 52 in 2016. In addition to the data concerning cholera, other data on conflict-related injuries, and population movement (numbers of Internally Displaced Persons – IDPs – and number of displaced returnees) were used to assess the correlation using Spearman's rho analysis. The data analysis shows the intensity of the conflict as measured by the total casualties per governorate (conflict-related injuries and death) is significantly correlated with the number of cholera cases per governorate (r 0.483, P = 0.026). The analysis also shows a positive, but not significant correlation between cholera cases, and both the number of conflict internal displaced people (IDPs) (r 0.389, P = 0.081), and number of returnees (r = 432, P = 0.050).

Background: This study aims to describe malnutrition among children under five and to describe the food insecurity status during the current conflict in Yemen. Methods: Data were obtained from a Yemeni nutrition surveillance program (pilot phase) targeting 4142 households with 5276 children under five from two governorates (Ibb and Sana’a). Results: Global acute malnutrition was found in 13.3% of overall screened children, while 4.9% had severe acute malnutrition (SAM) and 8.4% had moderate acute malnutrition. One-fifth of the children under six months of age were acutely malnourished, followed by children under two years at 18.5% based on weight-for-height z scores. Significant associations between malnutrition and other diseases included suspected measles at three times higher rates (4.5%, p < 0.00) among SAM cases than other children. Diarrhea, fever, and cough were significantly higher among the SAM group (p < 0.05). Most households depended on market food purchases in the month preceding this survey (84.7%). Household coping mechanisms to secure daily meals included borrowing food to survive, changing types and quality of food, and decreasing the number of meals per day; some families sent their children to live with relatives. Conclusion: Malnutrition is a serious public health problem. The humanitarian community needs to adopt alternative strategies to improve food security and the nutrition status in Yemen.

As anemia remains a major public health problem in Ghana, we examined the effect of dietary intakes, and antenatal care (ANC) practices on red cell indices and anemia prevalence during the pregnancy continuum for 415 women. Dietary history was taken using the Food and Agriculture Organization minimum dietary diversity indicator for women (MDD-W). Intake of ≥5 food groups was a proxy for micronutrient adequacy. Odds for anemia and meeting the MDD-W were estimated using ordinal and binary logistic regressions respectively. Intakes of 41.4% were micronutrient inadequate. At any time point in pregnancy, 54.4% were anemic (mild = 31.1%; moderate = 23.1%; severe = 0.2%) with 10%-point variation across the first (57.3%), second (56.4%) and third (53.3%) trimesters and pre-delivery (47.7%); 27.8% were anemic throughout pregnancy while 17.1% were never anemic. Morphologically, microcytic (79.4%) and hypochromic (29.3%) anemia were most prevalent, indicating nutritional deficiencies. Planning the pregnancy was a significant determinant for meeting the MDD-W. Overall, adolescence, poor diet, suboptimum ANC and underweight were associated with moderate and severe anemia. In specific time-points, dietary counselling, malaria, iron-folic acid supplementation, sickle cell disease and preeclampsia were observed. Decline of anemia during pregnancy suggests the positive impact of ANC services and supports strengthening education on dietary diversification during ANC.