Conflict Reduction through Improving Healthcare Services for the Vulnerable Population in Lebanon
Project funded by the European Union
Lebanon is experiencing unprecedented increase in population from neighboring Syria. Primary Healthcare Centers (PHCs) are currently overstretched and the Ministry of Public Health’s (MoPH) communicable disease surveillance and response system is being put under stress.
Led by MoPH and funded by the European Union(EU), the main goal of the IFS/EU project ‘Conflict Reduction through Improving Healthcare Services for the vulnerable population in Lebanon’, is for the MoPH to better respond to the challenge of serving and protecting the residents of Lebanon through strategic institutional support using a conflict sensitive approach and leading to enhanced access to primary health services and increased capacity to monitor and respond to communicable disease outbreaks.
Through the IfS/EU project, the MoPH, with the support of the European Union and implementing partners, intends to
increase the PHC centers resources to ensure that local population including all vulnerable Lebanese have enhanced access to quality primary health care, ensuring adequate provision of vaccines and essential medications (especially the chronic medications), and increasing the capacity of these PHC centers to implement its programmes using a conflict sensitive approach
strengthen its capacity to undertake early warning and response to communicable diseases outbreaks
The IFS/EU project is implemented by United Nations High Commission for Refugees (UNHCR), in partnership with the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), the International Relief and Development (IRD) and the International Alert (Alert)
Project in Focus
A-Primary Health Care (PHC) Centers
(Mainly MoPH PHC network)
In Lebanon, the primary health care system offers a multitude of services including preventive programs, reproductive health programs (including family planning, prenatal and postnatal care), child vaccination and care, non-communicable diseases program and mental health program. The number of people benefiting from these services and the quality of the services varies by region and provider. The utilization of primary healthcare centers has increased by four folds between 2002 and 2010. And this is accentuated with the advent of the Syrian crisis and the increased displacement to Lebanon.
In order to standardize the quality of care in PHCs, the MoPH has developed various guidebooks such as Diabetes Mellitus type II (2006), Reproductive health (2008), and mental health (2008). The American University of Beirut has also contributed to that by updating the “Primary Care Clinical Guide” developed in 2000 into its second edition of 2011. The guide encompasses evidence-based recommendations for diseases mostly encountered at PHC level. Each chapter covers the definition and epidemiology of the disease, history, physical examination, diagnosis, management of the disease, references used, and other relevant sections.
Under IfS/EU project, many of these guidelines are being updated, other guidelines are being developed, and staff are being trained accordingly. Medical equipment and sufficient quantities of essential medications (for chronic and non chornic patients) and vaccines are also being supplemented to prevent any gaps in the medical services at PHC level. Additional staff to MoPH and to PHCs in overstretched areas were also provided.
The intended impact is that MoPH increases the capacity of the PHC centers under its network to deliver quality PHC services, including reproductive and child health, for the vulnerable community, using a conflict sensitive approach, thus decreasing tension linked with access to healthcare.
1. General PHC Centers Support
The general support to PHC centers include the update of the Primary Heathcare Clinical Guidelines, the provision of basic medical equipment and supplies and the increase of essential medication and vaccines stock.
Primary Healthcare(PHC) Clinical Guidelines
The MoPH is focusing on strengthening the capacity of PHCs in the area of clinical case management including acute and chronic conditions. With the support of the WHO, the MoPH has already initiated a plan to integrate non-communicable diseases at the level of primary healthcare in terms of early detection, risk assessment and provision of treatment.
Under IfS/EU project, WHO in collaboration with the Lebanese Society of Family Medicine has conducted a major review of the primary care management guidelines (previously set with the support of AUB-MC). The updated guidelines provide evidence-based recommendations for preventive services that should be provided at primary healthcare level and services that are intended to improve health outcomes such as heart diseases, cancer, metabolic diseases, infectious diseases, and other conditions and events that impact the health of children, adolescents, adults, and pregnant women.
Capacity building trainings took place in 2015 to ensure that these updated guidelines are properly implemented.
Medical Equipment and Medications
IfS/EU project supported the provision of basic medical equipment for consultation rooms at the PHC centers, in addition to some advanced maternal and child health equipment and supplies with the support of WHO and UNHCR. It also increased the level of medications stock with the support of WHO (in collaboration with YMCA for the procurement of essential chronic medications) and UNICEF (for the procurement of vaccines and essential non chronic medications) to ensure that all beneficiaries enrolled in PHC program have sufficient supply of medications in line with the MoPH guidelines and list of essential medications.
3. Mother and Child Health
A particular focus in the project’s support for PHC centers’ capacities is on maternal and child health care which constitutes 50-75% of consultations at the level of PHC centers. Existing primary health care programmes are being revitalized by strengthening reproductive/maternal & child health services, the introduction of IMCI guidelines, the duplication of Wadi Khaled initiative model, the strengthening of the routine vaccinations and outreach campaigns.
Under the IfS/EU project, the World Health Organization (WHO), in collaboration with La Sagesse University, has completed the adaptation to the Lebanese context of a WHO guidelines, the “Integrated Management of Childhood Illnesses” (IMCI), with the aim to offer effective and simple means to prevent and manage the leading causes of serious illness and mortality in young children. The clinical guidelines promote evidence-based assessment and treatment, using a syndromic approach that supports the rational, effective and affordable use of drugs.
The guidelines is in line with the national Lebanese treatment guidelines and other policies and include:
Methods for checking a child’s immunization and nutrition status;
Teaching parents how to give treatments at home;
Assessing a child’s feeding and counseling to solve feeding problems; and
Advising parents about when to return to a health facility.
The approach is designed for use in outpatient clinical settings with limited diagnostic tools, limited medications and limited opportunities to practice complicated clinical procedures. During 2015, WHO with the support of MoPH led training workshops on IMCI guidelines in PHC settings targeting 2 nurses and 2 doctors per PHC.
Vaccines and Cold Chain
In its policy to ensure the safe access of free-of-charge vaccines to all children living in Lebanon based on National Calendar, MoPH is ensuring the provision of these vaccines to all PHC centers and dispensaries as needed. It is also ensuring the needed training for a safe preservation of vaccine. In 2008, MoPH received the “International Cold Chain Certificate” from WHO and UNICEF, becoming between the 5 countries worldwide to get this certification.
Under the IfS/EU project and in response to the increased population due to the Syrian crisis, additional stock of vaccines were procured with the support of UNICEF and made available in all PHC centers and dispensaries. Vaccines fridges were also procured.
Routine Vaccination and Outreach Campaign:
Under the execution of the MoPH and as part of its Expanded Program on Immunization (EPI ),UNICEF has secured in 2014 enough vaccinations via IfS/EU support, to cover all children under the age of five in vulnerable areas across Lebanon, regardless of nationality. Routine vaccination is provided in PHC centers, dispensaries and informal settlements through Mobile Medical Units free of charge according to the National Calendar of Vaccines.
Under EPI, vaccination mop-up campaigns (Jul-Aug-Sept 2014) and national immunization campaigns against Polio (Oct-Nov 2014) have been executed by the MoPH and UNICEF reaching out to the most vulnerable and at-risk (low vaccination coverage) caza.
Most of the maternal morbidities and death are preventable if diagnosed early and are well managed, thus a capacity building program targeting health care attendants in obstetrical wards and clinics will impact positively the outcome of birth in both maternal and children health.
In 2010 - 2011, the MOPH, WHO and the society of OBGYN have jointly agreed on conducting a series of workshops in the different parts of Lebanon. The project was well received, and reached around 200 practicing physicians and midwives.
IfS/EU project supported the continuity of these trainings provided by qualified obstetricians according to specific modules, and ensuring that the below objectives are met:
To enable the obstetrical attendants to identify early signs of high risk obstetrical conditions
To enable the obstetrical attendants to properly manage high risk obstetrical conditions
To provide to the obstetrical attendants the requirements for a quality prenatal and preconception care
This training parallels the neonatal resuscitation course that is targeting hospital staff taking care of newborns.
Mother and Child Health (MCH) Initiative - Wadi Khaled Model
The “Mother and Child Health Care” Initiative aims to provide quality primary healthcare services to pregnant women and children. This initiative is implemented by the Ministry of Public Health in partnership with the World Health Organization and in collaboration with the Makassed Philanthropic Organization. It allows Lebanese pregnant women and children (two years of age or younger) who do not have any form of health coverage to benefit from a comprehensive package of healthcare services at no cost.
The package for pregnant women includes 4 antenatal visits and 1 postnatal visit according to the MOPH protocol, in addition to delivery at the assigned hospital in the catchment area. The package for children comprises 6 medical visits and vaccination coverage based on the MOPH vaccination calendar.
This initiative was initially implemented in Wadi Khaled in 2003. Under the EU funded Instrument for Stability (IfS/EU) project, and since March 2015, the initiative was expanded to 3 new regions; Rashayya, and Beirut suburbs and Tripoli.
In Rashayya, the initiative capacitates four primary healthcare centres (El Abrar Medical Center, Child Development Center, the Women Committee of Rashayya and West Bekaa, and the primary health care unit in Rashayya Governmental Hospital) with the deliveries taking place at Rashayya Governmental Hospital.
4 .Non Communicable Diseases
With the support of the WHO, the MoPH previously initiated a plan to integrate non-communicable diseases at the level of primary healthcare in terms of risk assessment and early detection of hypertension and diabetes (NCD initiative), and provision of case management and needed medication treatment (NCD program). Guidelines were also set to provide evidence-based recommendations for preventive services at primary healthcare level and services and that are intended to improve health outcomes such as heart diseases and diabetes
Under IfS/EU project and aiming at ensuring the continuity of this initiative implementation, refresher sessions were held for previously trained health care providers from PHC centers across Lebanon. The NCD initiative (i.e. the risk assessment and early detection of hypertension and diabetes) was also reinforced through the procurement of NCD kits
The project is also ensuring that PHC centers which serve the MoPH PHC network have enough chronic medications for the enrolled beneficiaries to meet the increasing demands and cover reported shortages and therefore help in reducing tension in local communities where limited access to medication has been further strained due to the large number of refugees. This is translated into the procurement of essential chronic medications and making them available for all PHCs enrolled beneficiaries independently from nationality.
Furthermore, the World Health Organization (WHO), with the collaboration of the Youth Men Christian Association (YMCA), conducted a series of trainings during the first quarter of 2015 targeting PHC health staff on the rational use of medications and the chain of logistic management of drugs. The objective of the training is to increase the knowledge of health staff involved in the supply chain to better understand the supply chain system and to avoid shortage in medications and make sure the latter is available to the PHC beneficiaries at all times.
In 2014, the MoPH launched the National Mental Health Program. The newly launched program seeks to establish preventive and curative services for persons with mental health disorders through a comprehensive approach covering everything from legislation to capacity building. One main priority for the first two years is the integration of mental health into primary care, linkage with the secondary level and referral to tertiary care. This priority is part of a National Health Strategy of reforming Mental Health in Lebanon.
In 2014, under the IfS/EU project and with the support of WHO, a total of 106 participants from 48 PHC centres were trained on the mental health Gap Action Programme - Intervention Guide (mhGAP-IG). The mhGAP-IG is a technical tool developed by WHO to assist in implementation of mhGAP. The model guide presents integrated management of priority conditions using protocols for clinical decision-making for use by health-care providers working in non-specialized health-care settings.Throughout the training, primary healthcare providers learned the general principles of care and the key actions such as establishing communication and building trust, conducting assessments, management of cases, referrals and follow ups for priority conditions, namely, depression, psychosis, epilepsy, developmental and behavioural disorders in children and adolescents, dementia, alcohol and drug use disorders, self-harm/suicide, and other significant emotional or medically unexplained complaints. They were trained on how to offer psychosocial support through psycho-education and addressing psychosocial stressors both for the patient and for the carers. Medical doctors were trained on prescribing adequate medication, following up appropriately and referring for advanced care. In addition, participants were sensitized to the importance of self-care and were given sessions on stress, problem solving and psychological first aid.
Under IfS/EU project, Alert is working with its partners in Lebanon to increase understanding of the existing tensions related to provision of health services and encourage more conflict sensitive care.
Medical workers can play an important role in mitigating conflict. They should be praised for working longer hours, serving a much higher number of patients and dealing with increased stress at the workplace. Likewise, nurses, administrators and doctors need to be offered support in dealing with the stress, improving their communication and dispute resolution skills and copying with increased administrative demands related to the humanitarian funding.
In December 2014 and January 2015 Alert trained 120 health workers in understanding conflict, dealing with stress and communicating better. Through these trainings staff from 71 primary healthcare centres improved their skills and had an opportunity to share experiences with colleagues. “Lebanese seem to think that Syrians get everything for free but while that is not true, some displaced Syrian also think that and then accuse us of taking advantage of them. Most of my energy is spent explaining, clarifying and mediating between both sides,” says a nurse from a centre in Beirut, who attended the trainings.
Alert also started a partnership with the MOPH Mental Health Programme that includes supervision and mentoring of health workers from Primary Healthcare Centres. In the first four months of 2015 the Mental Health Programme supported by International Medical Corps, staff in 15 healthcare centers were mentored on dealing with tensions and stress at the workplace.
B-Communicable Diseases- Early Warning And Response System (EWARS)
Early warning and response system is defined as the functions of an integrated surveillance system aiming to detect any abnormal communicable diseases phenomenon and to provide an adequate and timely response.
Disrupted during the civil war, the surveillance of communicable diseases was re-activated in 1995 through a project with the World Bank. The early warning and response system is being reinforced under IfS/EU project with updated guidelines, capacity building, additional MoPH staff and lab reinforcement to adapt to the increased population following the Syrian crisis, allowing enhanced surveillance and response.
1- Surveillance and Response: Guidelines and Capacity Building
Under IfS/EU project and with the support of WHO, MoPH developed and updated the epidemiologic surveillance and response guidelines. Physicians and nurses from around 700 dispensaries and primary health care centers and health workers at schools all over Lebanon received a refresher training on the main epidemiologic surveillance and response guidelines, and were also trained on infection control including the use by doctors of personal protective equipment (PPE), especially in case of Ebola and MERS-COV/Level D and C minus, and how to deal with suspected communicable disease patients (Ebola and MERS-COV).
2- Laboratories Reinforcement:
Since 2007 and with the central public health laboratory closure, the regular drinking water monitoring conducted by the MOPH and the municipalities was interrupted. Drinking water was tested if alert or outbreak appeared. Thus, the need emerges to re-activate the routine drinking water sampling and testing. MOPH intends to decentralize the process through the establishment of well-equipped and staffed laboratories at Mohafaza level.
The IFS/EU project includes the implementation of drinking water laboratories in each mohafaza to ensure regular drinking water monitoring.
The drinking water laboratories are located in the following public hospitals: Rafik Hariri University Hospital (RHUH), Dahr El Bachek, Tripoli, Halba, Zahle, Baalbeck, Saida and Marjeoun. Each laboratory has the capacity to cover monthly testing for 20 municipalities or areas. Laboratories have been rehabilitated with the support of UNHCR/IRD, and equipped through WHO.
16 recruited laboratory staff trained on standard operating procedures, modalities of testing and quality control to ensure regular drinking water monitoring and environmental municipality staff for around 20 caza per mohafaza to be trained on water sampling techniques.
In addition, municipalities are being trained by WHO on water sampling with a scheduled plan based on the local water distribution, and the size of the population. The municipality staff will be in charge of conducting the sampling and sending them to the regional water laboratories. In case of water contamination, early measures will be taken with partners to eliminate the source of contamination in order to prevent disease.
Note: Municipalities were selected based on the following criteria:
Geographical distribution, all cazas need to be covered
Documentation of occurrence of water-borne diseases (data from the national surveillance system for communicable diseases)
Classification of high vulnerable area by UNICEF/UNHCR
3- Negative Pressure Rooms:
MoPH has put a response plan by which there are referral hospitals with negative pressure rooms in case there is a communicable disease outbreak at Mohafaza level.
Under the IfS/EU project, 4 negative pressure rooms were established in Rafik Hariri University Hospital in partnership with UNHCR/IRD, and 1 negative pressure room in each of the following governmental hospitals: Baabda, Baalback, Tripoli and Bent Jbeil.
-------------------------------------------------------------------------------- A negative room pressure means that the air pressure in the isolation room is negative or always less than the pressure outside the room. It uses an isolation technique to prevent contaminations with airborne contagious diseases from room to room. It includes a ventilation system designed so that air from the corridors, or any adjacent area, flows into the negative pressure room, ensuring that contaminated air cannot escape from the negative pressure room to other parts of the health facility. In October 2014, under the IfS project, 4 negative pressure rooms were established in Rafik Hariri University Hospital in partnership with UNHCR/IRD.