A systematic review of global health capacity building initiatives in low-to middle-income countries in the Middle East and North Africa region

Introduction Low-and Middle-Income Countries (LMICs) in the Middle East and North Africa (MENA) region are facing increasing global health challenges with a reduced ability to manage them. Global Health Capacity Building (GHCB) initiatives have the potential to improve health workforce performance and health outcomes, however little is known about the GHCB topics and approaches implemented in this region. This is the first systematic review of GHCB initiatives among LMICs in the MENA region. Methods An academic database search of Medline (OVID), PubMed, Scopus, Embase.com, and Open Grey was conducted for articles published between January 2009 and September 2019 in English. Next, a grey literature search following a recommended search framework was conducted. Reviewed records addressed a global health topic, had a capacity building component, looked at specific learning outcomes, and reflected an LMIC in the MENA. Primary outcomes included country, topic, modality, pedagogy, and population. Results Reports of GHCB initiatives were retrieved from grey sources (73.2%) and academic sources (26.8%). Most GHCB initiatives were mainly conducted face-to-face (94.4%) to professional personnel (57.5%) through a theoretical pedagogical approach (44.3%). Dominant global health themes were non-communicable diseases (29.2%), sexual and reproductive health (18.4%), and mental health (14.5%). When matched against the Global Burden of Disease data, important gaps were found regarding the topics of GHCB initiatives in relation to the region’s health needs. There were limited reports of GHCB initiatives addressing conflict and emergency topics, and those addressing non-communicable disease topics were primarily reported from Egypt and Iran. Conclusion Innovative and practicum-based approaches are needed for GHCB initiatives among LMICs in the MENA region, with a focus on training community workers. Regional and country-specific analyses of GHCB initiatives relative to their health needs are discussed in the manuscript based on the results of this review.


Introduction
Over the past few decades, the Middle East and North Africa (MENA) region has made progress in reducing rates of disease, injury, and premature death [1]. Although countries in the MENA region are prolonging the lives of their populations and limiting mortality rates, this region continues to experience significant disease burdens, coupled with a reduced capability to manage them [1,2]. Low-to Middle-Income Countries (LMICs) in specific tend to face greater health challenges among countries in the region, largely due to their decreased resources in comparison to Higher-Income Countries (HIC) in the region. In recent years, this has been exacerbated by conflicts occurring in many countries that contributed not only in limited investment towards building the health workforce to meet the health and conflict-related needs, but additionally to an exodus of a large number of experienced health workers, further straining limited resources [3]. Although the MENA region has the third lowest density of doctors and nurses, it experiences one of the highest disease burdens after Southeast Asia and Sub-Saharan Africa [4].
Limited access to education, training, mentoring, and continuous professional development are leading contributing factors that undermine the performance and commitment of healthcare workers [5,6]. Healthcare workers are personnel who engage in service provision or decision-making to improve health in given settings. As an example, many schools and institutions that provide health-related training and education in LMICs face important shortcomings in equipment, physical space, curricula, training materials, faculty, staff, and funding [7,8]. These challenges suppress efforts to improve the quality of training and to expand the diversity and number of health-related programs, which negatively affect their responses to global health threats [7]. In many cases, this also makes it challenging for them to deliver even basic health services [5]. In order to improve health outcomes among LMICs in the MENA region, it is crucial to increase the number of the healthcare workforce and to strengthen their competencies through engaging approaches. Evidence suggests that an effectively trained and deployed health workforce is positively associated with addressing many health challenges, and has the potential to improve health outcomes [9]. Furthermore, ensuring equitable access to a skilled health workforce is a critical element to achieving the health or health-related Sustainable Development Goals (SDGs). This is especially true for LMICs that lack the necessary resources to mobilize efficiently and effectively trained and distributed human resources for health [10].
Global Health Capacity Building (GHCB) initiatives aim to enhance the capabilities of individuals, organizations, and communities to work in or manage global health-related topics [11]. The field of global health is multidisciplinary, and it encompasses health issues that transcend national boundaries [12]. For example, research, practice, and education in global health may cover topics such as communicable and infectious diseases, mental health and substance, traffic and conflictrelated injuries, chronic non-communicable diseases, among others [12]. Implementing GHCB initiatives is a recommended, effective, and efficient strategy to enhance the capabilities of health workers in responding to related challenges [13]. GHCB initiatives enhance the skills, knowledge, and practices of professional and nonprofessional health workers, which may ultimately affect overall health outcomes in a given setting [13,14]. Despite the importance and urgency of the aforementioned, the characteristics and focus areas of GHCB efforts conducted in the MENA region among LMICs have not been documented.
The aim of the present study is to provide the first systematic review of GHCB initiatives delivered in LMICs within the MENA region. Given that GHCB is essential to improving the competency and performance of the health workforce particularly within low-resource settings, this study is important to elucidate the GHCB topics and related approaches currently being addressed in relation to health challenges in the MENA region. This is an essential step to summarize the state of the field, and to identify related strengths and weaknesses.

Search strategy
Multiple search strategies were employed in this systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) in order to identify GHCB initiatives implemented among LMICs in the MENA region. This included an electronic academic database search, and a thorough grey literature mapping search. The latter was based on a WHO mapping framework which is a recommended approach developed by an authoritative source to conduct a mapping exercise. In both search strategies, articles had to reflect a GHCB initiative conducted in a LMIC in the MENA region. According to the World Bank, these countries include Algeria, Djibouti, Egypt, Iran, Iraq, Jordan, Lebanon, Libya, Morocco, Syria, Tunisia, West Bank and Gaza, and Yemen [15]. We used the World Bank classification for countries in the MENA region because it is a commonly used reference to locate countries in specific geographical regions [15]. Finally, we used the global burden of disease data for priority benchmarking throughout our analysis because it is the most widely used authoritative reference for disease rates globally and regionally.

Academic database
An electronic database search was conducted by a medical librarian (LH) using the following academic databases: Medline (OVID), PubMed, Scopus, and Embase. com, and Open Grey. The three concepts were "Global Health", "Capacity Building", and "Middle East and North Africa", and included terms such as "courses", "webinars", "training", "education", "public health" among others. The full search strategy is reported in Additional file 1. Articles were included if they were qualitative, quantitative, and mixed-methods studies written in English and published between January 2009 and September 2019. Articles had to reflect GHCB initiatives conducted in a LMIC in the MENA region (see Table 1 for definitions). Although the field of global health encompasses leadership, management, and communication programs among others, in this review we only captured those that were explicitly health-related. Articles were excluded if they did not meet these criteria, or if they did not cover a global health topic, did not provide examples or cases about capacity building approaches, and were not conducted in a LMIC in the MENA region. Editorials, opinion pieces, letters to the editor, conference abstracts, study protocols, and press releases were excluded.

Grey literature search
A thorough grey literature search was conducted by MEH using two steps of a WHO-developed mapping framework [18]. Since we are addressing capacity building in LMICs in the MENA region, a review of literature published in non-academic sources is vital to systematically identify such initiatives in this area. The first step included an online search of databases that have hosted GHCB initiatives, trainings, and related activities. As such, filtering was done starting with a general scoping google search for online learning databases that offered global health topics. After assessing several potential databases, we only selected those that allowed us to filter the capacity building initiatives by region so that they meet our set inclusion criteria. Accordingly, we searched for GHCB initiatives using the following databases: UNESCO, International Federation of Medical Students' Associations, Kaya, Global Health Training Center, and Relief Web. A specific set of keywords was used for the search that included the following terms: "capacity building initiative", "training programs", "global health", "developing countries", and "low-and-middle income countries". The keywords were linked with Boolean operators <AND > to limit the breadth of the search and ensure that all concepts were included and < OR > to extend the reach of the search to the entirety of words with similar meaning. The second step included a google web search that aimed to locate capacity-building initiatives not identified by the databases. For the google search, reviewers used the following search term "global health training [country name]". All relevant links from the first 10 google pages were viewed and assessed for capacity building information that matched the researcher's criteria. The search for the GHCB initiatives was conducted during a period of 5 months from July 2019 until December 2019. Capacity building initiatives were included in the search if they addressed a global health topic in a LMIC in the MENA, and if they appeared within the first 10 pages of the web-based search.

Data Collection & Analysis Academic databases
Articles were retrieved by a medical librarian (LH), imported into an Endnote file, and shared with two reviewers (HN and MEH) who conducted the screening process. After a calibration exercise, the two reviewers each screened the titles and abstracts of all studies based on set eligibility criteria. Full texts of all potentially eligible articles were later screened based on the same eligibility criteria. In both phases, a third reviewer (MEK) was assigned to resolve disagreements. Next, one reviewer (HN) extracted the data.

Grey literature search
One reviewer (MEH) located the capacity building initiatives from the databases and google searches and extracted the data into an excel sheet.

Analysis
Extracted variables from both searches included objective of the initiative, global health topic, target population, country, pedagogic approach, learning modality, outcomes, and funding source. We conducted and reported a descriptive analysis of data gathered from both search strategies. The results illustrated the geographical distribution of initiatives among LMICs in the MENA region, the global health theme of the initiatives, the pedagogic approaches used, the learning modalities, and the target populations.

General findings
Records included in this review (n = 179; see Fig. 1) were mainly from grey sources (see Additional file 2) (n = 131, 73.2%), and included governmental and non-governmental reports of GHCB initiatives (see Table 2). With regard to records retrieved from academic sources (26.8% of all records), out of 5972 articles screened (see Fig. 1), 244 were eligible for full-text review, and 48 articles were analysed and had their data extracted (see Table 3). Of all the reviewed records, almost all reported capacity-building initiatives were conducted face-to-face (94.4%), and adopted online (1.7%) or blended (2.2%) learning modalities. Half of the reported GHCB initiatives followed a theory-based (51.4%) pedagogic approach, whereas the rest were interactive (30.6%), mixed theory and practice (11.8%), or were only practical (6.3%). The most frequent target population (see Table 1 for definitions) was professional personnel (57.5%), followed by the general public (18.4%) and community workers (3.9%).

GHCB topics
The global health topics that were addressed in the capacity building initiatives included non-communicable diseases, communicable diseases, child health, disaster/ emergency preparedness, epidemiology, global health, health system, mental health, oral and dental health, refugee support, and sexual and reproductive health (see Table 1). The most addressed topics were categorized under non-communicable diseases (29.2%), sexual and reproductive health (18.4%) and mental health (14.5%).

GHCB topics by country
The frequency and themes of GHCB initiatives varied by country (see Fig. 2). Iran (N = 32), Lebanon (N = 30), Egypt (N = 27), and Yemen (N = 19) reported the highest number of GHCB initiatives. In Iran, non-communicable diseases and health system topics were the most common among the reported GHCB initiatives, whereas in Lebanon GHCB topics mainly targeted mental health, sexual and reproductive health, and communicable diseases. In Yemen, the highest number of reported initiatives addressed sexual and reproductive health, similarly to Egypt who in addition to that, also commonly reported on non-communicable diseases, and emergency and disaster topics. The least documented GHCB initiatives were derived from West Bank and Gaza (N = 9), Algeria (N = 7), Libya (N = 7), Syria (N = 6), Morocco (N = 3), and Djibouti (N = 1). In Djibouti, only one initiative was reported, and it focused on non-communicable diseases, whereas in Morocco the three reported initiatives targeted mental health, epidemiology, and non-communicable diseases. Initiatives reported from West Bank and Gaza, Algeria, and Syria primarily tackled mental health topics. The highest number of records found from Tunisia addressed sexual and reproductive health topics, and the case was similar in Libya who in addition mostly reported on health system topics. Finally, in Iraq and Jordan, retrieved records mostly targeted emergency and disaster topics, in addition to mental health.

Discussion
LMICs in the MENA region experience a high burden of disease, and they have limited resources for health education and training [1,6,7]. Thus, they have a high need to develop a competent health workforce through GHCB initiatives in order to respond to health challenges. However, very little is known about the topics and approaches of GHCB initiatives being implemented throughout the region. In this systematic review, we summarized GHCB initiatives among LMICs in the MENA region, with a focus on the learning modality, pedagogical approaches, and global health topics. We also matched the documented GHCB topics against the Global Burden of Disease data in order to identify priority areas.
Our findings revealed that over the past decade, all of the reviewed GHCB initiatives among LMICs in the MENA region were conducted face-to-face, with the exception of a handful delivered through online or blended learning modalities. It may be important for LMICs in the MENA region to start adopting innovative learning modalities since these may have strong potential in facilitating the delivery of global health education and training especially in underserved settings with limited resources [67]. For example, there are different reports on digital resources that include online global health courses being available for worldwide use, that have been recommended as effective tools to address the shortage of qualified health workers in LMICs and low-resource settings [68]. Being relevant to some of the health challenges faced in the MENA region, it would be ideal to complement such online courses and distance-based learning platforms with locally-developed, adapted, or contextualized global health material. To that end, more research may be needed to document and evaluate these initiatives along with their effectiveness among LMICs in the MENA region.
Furthermore, our findings showed that theoretical and interactive models were the most commonly used pedagogic approaches in GHCB initiatives, as opposed to practical approaches. Notwithstanding the value of theoretical and interactive approaches, especially those that        Overall, professional personnel were the main target groups of the GHCB initiatives, and community workers were the least addressed population. While it is expected that most initiatives would be directed towards professionals, it is crucial for future initiatives to place added attention to community workers. Community health workers play a vital role in healthcare systems, especially those in conflict areas with limited resources, since they can provide less expensive and more tailored services to their communities [69]. Research shows that community workers may be very effective for such purposes, and in many instances, may complement the work of professionals in delivering health-related education to members in some communities largely due to the relationships they build with them [69,70].
The most commonly addressed GHCB topics among LMICs in the MENA were categorized under noncommunicable diseases, sexual and reproductive health, and mental health. Although this is congruent with the overall health needs of the MENA region [1,71,72], we have identified some important gaps. First, despite the prevalence of GHCB initiatives that target non-communicable diseases, they were concentrated in Egypt and Iran, and they were under-documented in most other countries. It may be important for other countries such as Lebanon, Jordan, Morocco, Tunisia, and Algeria, to implement and report more efforts regarding GHCB initiatives targeting non-communicable diseases. Second, conflict-related mortalities are among the most common causes of death in the West bank and Gaza, Syria, Libya, Yemen, and Iraq [1,71], and our results indicate that there is a greater need for emergency and injury-related GHCB in these countries due to their protracted social conflicts. Nevertheless, our findings indicate that mental health GHCB initiatives, which are crucial in war and conflict settings, are commonly reported in some of these countries. Third, although communicable diseases are decreasing overall in the MENA region [1,71], they still present major concerns in lower-resource settings, and more emphasis should be placed on addressing these topics in countries such as Djibouti.
That said, very few records of GHCB initiatives represented initiatives from Algeria, Djibouti, Libya, Morocco, Syria, and the West Bank and Gaza. These countries, in addition to Jordan, Tunisia, and Yemen, also showed the least academic research activity, given that out of all peer-reviewed articles included in this research, they each had published one or no GHCB study. The majority of initiatives were reported from Egypt, Iran, Lebanon, and Yemen (see Fig. 2). Iran in specific appeared to have the most academic research outputs to disseminate GHCB results. Potentially, as indicated by our findings, this may be related to the availability of local funding for their initiatives, as opposed to the rest of the countries who seemed to rely on international funding from HICs. This may be an important indication supporting the need to prioritize the allocation of resources and funding from local sources to encourage the development, implementation, and dissemination of GHCB initiatives. It is probable that due to the limited publications along with the research gaps in this region [73,74], many GHCB initiatives may have not been disseminated in the literature and consequently not reported in this review.

Limitations
Despite the use of two search strategies from grey and academic sources, some records may have still been missed. For example, some initiatives may have not being reported online or disseminated in the literature, especially those in low-resource settings, which may reduce communication among the global health community and which poses a risk for duplication of efforts and inefficiency. Also, while some distance-learning platforms such as Massive Online Open Courses (MOOCs) and others that are available for worldwide use [68,75], may have reached learners in the MENA region, these were not covered by the scope of our review if they did not explicitly report implementation in a LMIC in the MENA region. Furthermore, some countries in the MENA region may have a lower technical capacity or may be less inclined to allocate resources to publish research outputs. Taken together, these limitations highlight the need to support LMICs in the MENA region to enhance their research production. Additionally, the fact that we only included English records may have limited our range of reviewed records. It is also important to consider that some capacity building records may have not been disseminated under the term "Global Health", which may have influenced the search and screening process. Finally, although efforts may have been directed to each country's health needs, we only reviewed records that had a training and/or educational component, and so initiatives such as awareness campaigns and others were not included in this review.

Conclusion
In light of the escalating global health challenges among LMICs in the MENA region, this systematic review presents the first timely summary and comprehensive analysis of GHCB initiatives being conducted in this setting. Several critical points were identified from this review, such that more GHCB initiatives targeting NCDs and emergency-related topics are needed for most of the reviewed countries. It is also important for this region to increase their adoption of innovative learning modalities and practical and hands-on approaches, and to target more community health workers. Finally, it may be essential for countries to prioritize and mobilise resources and local funding to increase the development, implementation, and dissemination of GHCB initiatives.