Blockchain Papers

Natalie Aberer, Philipp Trein, Carla Riberio, Veronika Schoeb

No abstract is available for this record.

Henry Komakech, Lynn Atuyambe, Fadi El‐Jardali, Christopher Garimoi Orach

BACKGROUND: Low- and middle-income countries face several challenges in providing health services, particularly to displaced populations, during all phases of emergencies. However, little is known about how health services are organized to displaced populations following repatriation. This study examined the organization of health services following the repatriation of South Sudanese refugees from the three West Nile districts of Arua, Adjumani, and Moyo in Uganda. METHODS: We conducted a qualitative case study in three West Nile refugee hosting districts, Arua, Moyo, and Adjumani. We used the World Health Organization Health System Framework, focusing on four blocks: health services, financing, medicines and supplies, and human resources. We conducted in-depth interviews with 32 purposefully selected respondents, including health service providers, district civil leaders, local government staff, and non-government organization staff. The data were analyzed using content analysis. RESULTS: Following repatriation, the district health teams in the three districts assumed overall responsibility for planning, managing, and providing health services. Health services followed an integrated model within a decentralized framework in all three districts. Health services were available in most areas except for former refugee settlements where facilities were either closed or relocated. After repatriation, funding for health services was provided through the government's primary health care grant with minimal support from aid agencies. Districts, however, face several challenges, including shortages of medicines and essential supplies, inadequate health workers, and poor infrastructure. CONCLUSION: Refugee repatriation disrupted health service delivery in the refugee hosting districts, leading to a reduction in funding; inadequate skilled health workers and equipment; and the closure of some facilities. To ensure the continuity of health services, government and aid agencies should plan for repatriation and establish strategies to sustain health services in refugee-hosting areas.

Oleksii Nalyvaiko, Віктор Вус, Liliya Zotova, Natalia Kostruba · 5 authors

Introduction: The ongoing war in Ukraine has triggered a large-scale humanitarian crisis, significantly affecting the mental health and psychosocial well-being of the population. In this context, Mental Health and Psychosocial Support (MHPSS) has become a vital component of humanitarian response, requiring coordinated and integrated systems aligned with global standards, such as the Inter-Agency Standing Committee (IASC) framework. Purpose: This research explores how MHPSS coordination mechanisms operate in wartime Ukraine, identifies key actors and systemic barriers, and evaluates the impact of coordinated approaches on access, resilience, and psychosocial well-being. Approach: The study employs a desk-based narrative synthesis methodology, drawing on peer-reviewed literature, humanitarian reports, and policy documents, including the Ukrainian government’s Concept for the Development of Mental Health Care until 2030. Analytical lenses include the IASC MHPSS intervention pyramid and localization theory. The study also proposes visual tools to analyze coordination structures and service delivery pathways. Results: The study finds that Ukraine’s MHPSS coordination system demonstrates notable adaptability and well-developed structures. Core activities such as 4W mapping, non-specialist training programs, and policy alignment initiatives have expanded access, particularly to community-based care. However, challenges including stigma, provider burnout, insufficient funding, and limited rural access continue to constrain effectiveness. Innovative strategies like telehealth platforms and mobile clinics reflect adaptive resilience. Overlapping mandates and data fragmentation further complicate service alignment. Nonetheless, coordinated efforts have reached over 1.2 million individuals in 2023, with early evidence suggesting reductions in psychological distress among internally displaced populations. These findings underscore the critical role of context-sensitive, decentralized approaches in building sustainable MHPSS systems in conflict-affected settings. Conclusions: Ukraine’s MHPSS coordination system demonstrates adaptability and effectiveness in crisis settings, but enduring structural challenges remain. Future priorities should include strengthening local leadership, ensuring long-term financing, and integrating services to ensure sustainable support in crisis contexts.

Desale T. Abraha

NGOs can foster a more inclusive and effective civil society in the Global South by collaborating and amplifying marginalized voices. Nongovernmental organizations (NGOs) must prioritize establishing robust relationships with local communities and advocating for their needs to achieve a favorable outcome. As Sandri (2017) stated in his article, "Humanitarian aid to refugees in the Jungle refugee camp of Calais necessitates a diverse array of resources," including housing, food, healthcare, and education. This justifies the responsibility for humanitarian assistance. A later study estimates that around 117.2 million people will be displaced worldwide by 2024, mainly in countries at risk from climate change (UNHCR, 2023).As a result, the refugees' grievances are increasingly complex and unmanageable. Consequently, a thorough policy to allocate and maintain a just global responsibility will come into effect. By enabling peer-to-peer crowdfunding and ensuring secure digital storage of identity documents, blockchain technology can present creative options to assist marginalized individuals. However, it is essential to assess the ethical and logistical consequences of these technological advancements and protect the privacy and rights of refugees. Using blockchain technology, a secure digital identification system can be created that helps refugees overcome common Frontiers in Human Dynamics https://www.frontiersin.org/journals/human-dynamics identification obstacles. However, the blockchain system may need to be more effective for refugees in regions with limited access to technology or reliable internet connectivity, as this solution may need to be more practical for them. Also, certain refugees may need the necessary knowledge or resources to navigate and employ a sophisticated digital identification system efficiently. For instance, the absence of internet infrastructure may present a challenge for a refugee residing in a remote camp to access the blockchain system, impeding their ability to verify their identity and access essential services. Mballa et al. (2020) found that refugees residing in urban areas with improved connectivity and resources may find the blockchain system more accessible and advantageous for establishing secure identification. As he stated in his article, this system may encompass critical documents, such as diplomas, health records, and birth certificates, to facilitate the reconstruction of refugees' lives. Although the integration of important documents may be beneficial, it does not address the fundamental problem of internet connectivity and access in remote regions, which remains a significant obstacle to the implementation of a sophisticated digital identification system such as blockchain, as other scholars such as Ager and Stronger (2008) have noted. Problems with internet access might slow down the rollout of blockchain-based identification systems in more remote places. The research primarily centers on the traditional approach to refugee management while shedding light on future developments in refugee management systems, particularly regarding providing aid and assistance. It's important to consider that individuals in these areas may require assistance using such systems as they may have limited access to reliable connectivity.Moreover, relying heavily on online verification procedures can disproportionately affect marginalized communities with limited access to reliable internet services.Additionally, concerns about privacy and security may arise from storing sensitive personal information on a blockchain platform. Despite these challenges, blockchain-based identification systems have the potential to mitigate identity theft, streamline bureaucratic processes, and provide stability and security for displaced individuals. It is imperative to prioritize the needs of countries in the Global South and ensure they have the necessary resources to help those in need cope with the increasing number of refugees (Valenti, 2022). It is imperative to address the root causes of displacement and strive for sustainable solutions.According to Habib et al. (2023), a decentralized strategy focusing on openness and accessibility is a possible solution to the difficulties of sharing resources. This approach encourages stakeholder collaboration and strengthens the sense of community ownership of resources. Due to its immutability and security, blockchain technology can efficiently manage and distribute resources to refugees, as Corte-Real et al. (2022) found. By creating an immutable registry of funds allocated to refugees, aid can be distributed more efficiently and reliably. At the same time, direct peer-to-peer transactions minimize the need for intermediaries and reduce the risk of corruption and fraud (Nwuluu & Damisa, 2023). 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Abdulkarim Ekzayez, Munzer Alkhalil, Preeti Patel, Gemma Bowsher

No abstract is available for this record.

Giovanni Guarducci, Gabriele Messina, Simona Carbone, Nicola Nante

Background: In a Beveridgean decentralized healthcare system, like the Italian one, where regions are responsible for their own health planning and financing, the analysis of patients’ migration appears very interesting as it has economic and social implications. The study aims to analyze both patients’ migration for hospital rehabilitation and if the beds endowment is a driver for these flows; Methods: from 2011 to 2019, admissions data were collected from the Hospital Dis-charge Cards database of the Italian Ministry of Health, population data from Italian National Institute of Statistics and data of beds endowment from the Italian Ministry of Health website. To evaluate patients’ migration, we used Gandy’s Nomogram, while to assess if beds endowments are mobility drivers, we have created two matrices, one with attraction indexes (AI) and one with escape indexes (EI). The beds endowment, for each Italian region, were correlated with AI and EI. Spearman’s test was carried out through STATA software; Results: Gandy’s Nomogram showed that only some northern regions had good hospital planning for rehabilitation. A statistically significant correlation between beds endowment and AI was found for four regions, while with EI for eight regions. Conclusions: Only some northern regions appear able to satisfy the care needs of their residents, with an attraction minus escapes positive epidemiological balance. The beds endowment seems to be a driver of Patients’ migration, mainly for escapes. Certainly, the search for mobility drivers needs further investigation given the events in Molise and Basilicata.

Ana Côrte-Real, Tiago Nunes, Paulo Rupino da Cunha

Background: The increase of forcibly displaced people worldwide is a challenge for health systems and their ability to provide access and equity in Health as a universal right. In the case of migrants and refugees, their journey exacerbates this challenge, as they go through diverse countries, camps, and humanitarian teams. Hence, the collection and analysis of health data are essential in providing quality care. The scientific community has been studying health digital technologies to answer health data consolidation, transparency, and global surveillance efficiency issues. Observing some empirical experiments with Blockchain in migrants and refugee health, we assessed the state-of-the-art by conducting a literature review. Methods: Blockchain applications are still emerging, which means that peer-reviewed literature may still be scarce in life science databases. Therefore, to gather the most appropriate available evidence, we used a diverse and balanced set of databases that compile articles and journals from different fields. We used a multi-step scoping review to refine search keywords and analyse the literature. We included studies between 2008 and 2021 that reported value, utility, or use cases of Blockchain in support of migrant and refugee health. Results: We identified a total of 69 articles, with 22 retained for full-text analysis and 8 of those being relevant. We employed Rayyan application to manage and evaluate the references by two researchers working independently. We identified two main uses of Blockchain technology to support migrant and refugee health: mitigate the lack of personal identification and make health records available. Blockchain also promotes data reliability in humanitarian aid, academic certificates, legal contracts, and financial transactions. Conclusions: The availability of reliable information about individuals facilitates universal health coverage, improves cooperation between diaspora-related countries, and supports global health efficiency in line with the third goal of the Sustainable Development Goals 2030 agenda. Given its characteristics of decentralization, resilience, transparency, and auditability, Blockchain remains a promising avenue for future research in migrant and refugee health.

Nora Gottlieb, Mirjam Schülle

No abstract is available for this record.

Albert K. De Vries, Niek Klazinga

This policy analysis provides insight into the ongoing process of mental health reform and the difficulty of sustaining such reform in post-conflict areas. It is based on experiences in Bosnia Herzegovina and Kosovo in the former Yugoslavia. This could be the first health policy analysis specifically on the subject of mental health reform in post-conflict areas. Mental health reforms started in 1995 in Bosnia Herzegovina and in Kosovo in 1999, immediately following the end of armed conflict in these regions. As a result, there are now sufficient literature studies and experience available in both areas to make an initial evaluation and policy analysis. Both areas were studied during various stages of the implementation of mental health reform, and because of this provided insight into the different phases of this ongoing process. The insights provided by this study could have implications for things such as the development of strategies for improving the sustainability of mental health reform in similar situations in future. Mental health problems account for five of the 10 leading causes of disability worldwide, which amounts to 12% of the total global burden of disease.1 In general, war-related disabilities (physical injuries) and mental disorders have an increasing impact on the global burden of disease. Projections for 2020 rank unipolar major depression and war-related disabilities in first and eighth place, respectively, in their impact on the global burden of diseases; in 1990 they ranked fourth and sixteenth.1 Mental health reform refers to a shift from institutional mental health care towards community mental health and mental health care. The WHO's World Health Report 2001 showed worldwide interest in community mental health care, considered to be more cost-effective than institutional care. Care of this kind makes it possible to intervene early when mental disorders are developing, and to limit the stigma attached to treatment.2,3 This shift from institutional mental health care towards community mental health and mental health care marks an important change in the whole of Eastern Europe and the former Soviet Union.4,5 Mental health reforms in the post-conflict areas of Bosnia Herzegovina and Kosovo have specific characteristics and dynamics, and are taking place within the context of huge foreign donor influence, overall health care reforms and reform of health care financing systems. There are many definitions of sustainability.6 Sustainability is defined here as a lasting, successful shift from a system where the main focus is on institutional, clinical mental health care to a system focusing on community mental health and integrated mental health care. The successful continuity of these new services also depends on cultural and financial characteristics. The following examples illustrate the difficulty of sustaining mental health reform in Bosnia Herzegovina and Kosovo: Planned community mental health centres are being implemented slowly.7–10 The general public is unaware of the mental health reforms and does not understand them.8–10 There are increasing problems of economic access to mental health care and services.11–14 Literature study of ‘grey’ policy documents and articles on health policy (including mental health policy) in Bosnia Herzegovina and Kosovo was undertaken. Policy documents were collected from many different actors such as the World Bank, several non-governmental organizations (NGOs) including Médecins Sans Frontières, HealthNet International (HNI) and the International Organization for Migration, the WHO, the United Nations High Commission for Refugees, key mental health and other health professionals and local ministries of health. For Bosnia Herzegovina, key informant interviews took place in August 2001 with: Various mental health and other health professionals (psychiatrists, psychologists, nurses and social workers) and patients in 15 mental health institutions, including university hospitals with psychiatric departments, psychiatric clinics, psychiatric wards of general hospitals and community mental health centres all over Bosnia Herzegovina; Several NGOs (HNI, Medica Zenica, Vive Zene and War Child); WHO office for Bosnia Herzegovina; International Committee of the Red Cross; Swiss Agency for Development and Cooperation, Coordination office Sarajevo, Embassy of Switzerland; Assistant Minister of Human Rights of the state of Bosnia Herzegovina; Entity Ministry of Health of the Republika Srpska. For Kosovo, key informant interviews took place in March 2002 in Geneva with those WHO mental health professionals consulted on mental health reform in Kosovo. In addition, there were email contacts with mental health professionals working in Kosovo (in the Pristina university hospital and in community mental health centres) and with WHO support staff in Kosovo. Walt's analytical framework15,16 was used here to analyse the data collected in Bosnia Herzegovina and Kosovo. This framework distinguishes context, content and process, and the various actors involved in mental health reform. It is a systematic framework that can broadly analyse the implementation of health policies (involving many disciplines and sectors); such a broad analysis is necessary here for evaluating mental health reform. For the context analysis, data were collected on political history, the history of mental health services, psychiatric epidemiology, foreign influences, health care financing systems, medical anthropology and societal values. For the content analysis, data were collected on principles of mental health reform and implementation characteristics (like the establishment of community mental health centres and education of mental health professionals). For the process analysis, data were collected on the timing and pace of mental health reform. For the actors (or stakeholders) analysis, Michael Reich's initial political mapping17,18 was used within Walt's framework to show political and other support for and opposition to the various actors in mental health reform in these highly complex, political environments. Data were collected through on-the-spot interviews and literature study. In particular, the interviews with local actors could prevent information bias by the literature, which is mainly oriented towards international donors. A great deal of grey literature (all types of policy documents) was used, which is common practice for policy analysis. To strive for the maximum degree of reliability, triangulation of this qualitative information was done by double-checking information during the interviews and using information from various local and international sources with different interests. This triangulation resulted in further convergence towards the results. Meta-analysis of the results detected the most important central theme: the role of foreign influence. This resulted in the main findings on the role of foreign influence in mental health reforms in post-conflict areas. The collected qualitative and some quantitative data from the interviews and available literature were structured within Walt's framework. Tables 1 and 2 give the most important interview and literature data. The references cited within the tables refer to the relevant literature and Internet sources for each topic. Context of mental health reform in Bosnia Herzegovina and Kosovo Table 1 shows the most important context analysis data for mental health reform in Bosnia Herzegovina and Kosovo. Table 2 shows the most important content and process analysis data for Bosnia Herzegovina and Kosovo. Content and process of mental health reform in Bosnia Herzegovina and Kosovo Figure 1 is explained more extensively because this figure's characteristics are not as familiar in public health literature. Figure 1 shows political support for and opposition to different actors in mental health reform in Bosnia Herzegovina and Kosovo. The assessment of the amount of power per actor is interpreted from the interviews and policy documents.8–13 The footnotes to this figure explain the characteristics of the relevant health ministries. In general, figure 1 makes clear the processes of decentralization, economic dependency and involvement of professionals in mental health and health policy. Informal networking between the actors and other micropower processes are beyond the scope of this analysis. A more extensive explanation follows to give more specific insights into the interpretation of supporting or opposing power for every actor. Political mapping: showing political support for and opposition to different mental health reform actors in Bosnia Herzegovina and Kosovo In Bosnia Herzegovina, international donors are very powerful because they are funding the reform in an economically unstable country. After decentralization, the National Ministry of Health lost power in terms of responsibility for the health care system (such as financing and determining the essential drug list). On the other hand, the Federation's cantonal ministries and the entity ministry of Republika Srpska gained a great deal of power. Mental health professionals have a lot of power because they play key roles in implementing this reform and because some health professionals hold key positions in the different ministries. Some key mental health professionals oppose the reform, especially in Republika Srpska's entity ministry and in a number of the Federation's cantonal ministries. They prefer to maintain the pre-war institutional mental health care organization, and support further specialization of mental health care services, such as specialized clinics for patients with post-traumatic stress disorder (PTSD). The public is not well organized (as in strong patient organizations), is not involved in policy making and so is not very powerful. Still, the public does have some power because they are the actual users of community mental health services. In Kosovo, international donors are very powerful for the same reason as they are in Bosnia Herzegovina. In 2002, decentralizing health care responsibilities towards the municipalities existed only on paper. Early in 2001, policy making and financial control of all health care was still a central responsibility of the United Nations (UN) Interim Administration Mission Kosovo Department of Health and Social Welfare. In 2002, this UN Department of Health started to transfer power to Kosovar ministries. From the beginning, mental health professionals have been heavily involved in drawing up the strategic plan for mental health reform in Kosovo; they reported no opposition to this. Public power has the same characteristics as those mentioned for Bosnia Herzegovina. Having all the data available in tables 1 and 2 and figure 1, triangulation and meta-analysis of these data resulted in further convergence towards the most important results on the identified central theme of foreign influence. The role of foreign influence was a central theme in many of the results. The context and process analysis showed that both areas became UN international protectorates and financially highly dependent on foreign donor funding. As a result, they became economically and politically dependent on the international community. The initiation, funding and also part of the operationalization of mental health reform was done by international organizations. For example, during the armed conflicts NGOs started new ambulatory emergency mental health services, and after the end of armed conflicts many NGOs entered the areas with their temporary ambulatory mental health activities focusing mainly on traumatization. Western health care financing models (mixed public–private insurance models) were quickly introduced in Bosnia Herzegovina, and health care financing became highly dependent on foreign donor funding. Local health administrators had to work according to new Western principles of efficiency and cost-effectiveness. The content analysis showed that many different mental health professionals were trained by a number of international organizations in the new concept of community mental health and mental health care. The actors analysis confirmed the power of international organizations to provide political support for mental health reform and also identified the concept of decentralization of political health care responsibilities supported by the international community. Particularly in the Federation of Bosnia Herzegovina, drastic decentralization took place using a Swiss cantonal model, which resulted in many small cantonal ministries of health.19 The input of qualitative data from the literature used was comparable for both Bosnia Herzegovina and Kosovo. The input of qualitative data from personal interviews differed between Bosnia Herzegovina and Kosovo. Although extensive personal interviews were held with many actors in Bosnia Herzegovina, owing to practical limitations the same kind of personal interviews were not possible inside Kosovo. This may have affected the input of qualitative data for Kosovo. To reduce this difference, thorough personal interviews took place with those WHO mental health professionals who were consultants on mental health reform there, and e-mail contacts were established with key mental health professionals. All these effects of foreign influence leave us with the following question: do they have a positive effect on mental health reform and its sustainability? Foreign technical and economic support versus lack of local awareness and lack of local ownership. Clearly, foreign influence, with its technical, political and economic support, pushed the reform forward just after the end of armed conflict. In particular, the foreign training of many different mental health professionals in the new concept of community mental health and mental health care was an important positive contribution to mental health reform. However, many years after the reform's initiation the general public is still not aware of this new concept, and some mental health professionals perceive it as a reform from abroad. This public lack of awareness together with the perception by professionals creates a lack of local ownership for mental health reform. Obviously, this endangers the reform's sustainability. Although it may be very difficult to change local beliefs on mental health-seeking behaviour and professional perceptions, the following two possible strategies could influence these firmly held beliefs and attitudes more successfully. Possible strategies. First of all, there could be more methodical ‘marketing'. In other words, taking local beliefs into account when developing mental health promotion strategies for the new concept of community mental health and mental health care could result in more successful sustainability of mental health reform. Examples of such marketing within the Bosnian and Kosovar context are mental health promotion within family, school and religious networks, and integrating community mental health services into existing somatic health services. Also, more anthropological research on mental health-seeking behaviour patterns could help tailor mental health promotion strategies. Secondly, the example of Kosovo showed that immediate involvement of local mental health professionals in strategic plans for mental health reform results in more sustainable reform. This is because local key mental health professionals will not perceive the changes as a reform from abroad, and will therefore be less likely to develop opposition to the reform in a later phase. Considering the epidemiology with its high prevalence of PTSD, it was logical for the different NGOs to start mental health programmes that focused on this mental health problem. However, parallel and overlapping mental health activities (‘trauma businesses') appeared that were unmanaged and chaotic. These were temporary, and because of this, endangered the sustainability of overall mental health reform, which includes all mental health problems. Possible strategies. If NGOs better combined their mental health activities, with PTSD treatment as a first priority, with existing mental health and somatic health services now under reform, sustainable mental health reform would probably stand a better chance. Introducing Western insurance models and privatization created increasing problems of access to mental and other health care. Private insurance schemes were implemented only by law, not in practise. Bosnia Herzegovina in particular did not seem to be ready for an insurance model. In 2001 Kosovo did not yet have a health care financing system, and even the World Bank suggested reintroducing the old national health insurance or tax model with payroll tax. Possible strategies. Introducing a financing system closer to the original existing system and taking into account to what extent the area is ready for this could result in increased chances for both sustainable mental health reform and a more sustainable health care system in general. The concept of decentralization promoted by many international organizations aimed at more local involvement was in part counterproductive, especially in Bosnia Herzegovina. It produced microbureaucratic procedures for many health care financing issues like insurance logistics. This created increasing access problems to mental and other health care. Local health care administrators used to centralized bureaucratic principles suddenly had to work from a decentralized, powerful position according to new utilitarian principles like cost-effectiveness and efficiency. One cannot expect a centralized East European post-conflict country to be immediately ready to switch to a decentralized Swiss cantonal model. Possible strategies. Introducing decentralization less drastically at a local level and at a slower pace by well-trained administrators ready to take over responsibilities would probably reduce the risk of additional access problems and increase local involvement and the chances for sustainability. As shown by the examples of Bosnia Herzegovina and Kosovo, this policy analysis provides insight into the difficult policy and process of mental health reform in post-conflict areas. These examples show the difficulty of sustaining mental health reform several years after the end of armed conflict and the initiation of such reform. This insight was gained by collecting all kinds of data (mostly qualitative, some quantitative) on many different topics and themes and from many different sources from various political positions. The method of analysis used—Walt's framework together with Michael Reich's political mapping—was a useful way to structure all these different and extensive qualitative data. This manner of structuring, along with ongoing triangulation and meta-analysis of the data, resulted in convergence towards the most important results, which follow here. As illustrated by the examples of Bosnia Herzegovina and Kosovo, foreign influence in post-conflict areas appeared to be a central theme of these results. Foreign influence has the following effects on mental health reform and its sustainability: Foreign influence has a stimulating effect on the initiation of mental health reforms by introducing this new concept and by technical and economic support along with technical education. Foreign influence by various actors can threaten the sustainability of mental health reform in the following ways: by creating a lack of local ownership of the new concept of community mental health and mental health care; by creating chaos with many overlapping short-term mental health programmes (mainly dealing with traumatization); by forcing rapid changes in health care financing systems (such as privatization), and introducing new insurance models too rapidly; and by forcing rapid decentralization of health care responsibilities. In conclusion, to achieve sustainable mental health reform, foreign aid provided in these difficult post-conflict situations has to achieve a balance between measured foreign influence and involvement of existing local structures. This policy analysis provides insight into mental health reform and the difficulty of sustaining such reform in post-conflict areas. Foreign influence accelerates mental health reform in post-conflict areas, but can also threaten its sustainability in various ways. The insights help to develop strategies for studying and improving sustainability of health reforms in similar (post-conflict) situations. Walt's analytical framework with Michael Reich's political mapping is a suitable method to analyse health reforms in post-conflict areas. Foreign influence in post conflict areas can threaten health reforms by creating chaos and a lack of local ownership and by forcing quick privatization and decentralization.