The Institute for Global Health and Development
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Item Understanding Resilience in UNRWA Health Response to the Syrian Crisis: Lessons from Causal Loop Analysis(MIT Press, 2025) Ager, Alastair; Diaconu, Karin; Jamal, Zeina; Alameddine, Mohamad; Fouad, Fouad M.; Witter, Sophie; Blanchet, Karl1. Group model building gathers key stakeholders together to develop causal loop analysis of health system responses to experienced shocks. 2. Causal loop analysis can identify important resources and strategies supporting health system resilience. 3. Evidence of absorptive, adaptive, and transformative resilience capacities was demonstrated in UNRWA health response to the Syria crisis across Jordan, Lebanon, and Syria. 4. Analysis highlights the importance of collateral pathways and redundancy; flexible governance and leadership practices; and an organizational culture that sees challenge as an opportunity for learning and innovation. 5. Such evidence has implications for other health systems seeking to integrate provision of services to refugee populations, as well as for UNRWA itself operating in a context of political instability.Item The determinants of the quality of clinical management among diabetic and hypertensive patients in a context of fragility: A cross-sectional survey from Lebanon(Frontiers Media S.A., 2022-07-25) Saleh, Shadi; Muhieddine, Dina; Hamadeh, Randa; Dimassi, Hani; Diaconu, Karin; Arakelyan, Stella; Ager, Alastair; Alameddine, MohamadIntroduction: The management of NCDs is a growing challenge in low- and middle-income settings with the increasing prevalence and the associated demands that such conditions make on health systems. Fragile settings both exacerbate the risk of NCDs and undermine systems capacity. Lebanon is a setting where strategies to address rising NCDs burden have faced particularly acute contextual challenges. Methods: We conducted a cross-sectional survey with patients accessing non-communicable disease across 11 primary care centers within the Greater Beirut and Beqaa areas. Response were received from 1,700 patients. We generated a Clinical Management Index Score as a measure of quality of care, and scores related to a range of socio-demographic characteristics and other context specific variables. Results: Significantly higher clinical management index scores (better quality of care) were associated with patients living in the semi-urban/rural context of Beqaa (compared to Greater Beirut), having health insurance coverage, aged above 60, having high levels of educational attainment, and making partial or full payment for their treatment. Relatively lower index scores (poorer quality of care) were associated with Syrian nationality (compared to Lebanese) and with patients suffering from diabetes or hypertension (compared to comorbid patients). Conclusion: The study identified a wide margin for improving quality of NCDs care in fragile contexts with particular gaps identified in referral to ophthalmology, accessing all prescribed medication and receiving counseling for smoking cessation. Additionally, findings indicate a number of predictors of comparatively poor quality of care that warrant attention, notably with regard to Syrian nationality/legal status, lack of health coverage, seeking free health provision and lower educational attachment. Although these are all relevant risk factors, the findings call on donor agencies, NGOs and provider institutions to design targeted programs and activities that especially ensure equitable delivery of services to diabetic and hypertensive patients with compounded vulnerability as a result of a number of these factors.Item Outpatient use patterns and experiences among diabetic and hypertensive patients in fragile settings: A cross-sectional study from Lebanon(BMJ, 2022-05-23) Saleh, Shadi; Muhieddine, Dina; Hamadeh, Randa S.; Dimassi, Hani; Diaconu, Karin; Noubani, Aya; Arakelyan, Stella; Ager, Alastair; Alameddine, MohamadObjectives: Assess and describe the health service use and delivery patterns for non-communicable disease (NCD) services in two contrasting fragility contexts and by other principal equity-related characteristics including gender, nationality and health coverage. Setting: Primary healthcare centres located in the urbanised area of Greater Beirut and the rural area of the Beqaa Valley. Design: This is a cross-sectional study using a structured survey tool between January and September 2020. Participants: 1700 Lebanese and Syrian refugee patients seeking primary care for hypertension and diabetes. Primary and secondary outcomes: The main outcome is the comprehensiveness of service delivery comparing differences in use and service delivery patterns by fragility setting, gender, nationality and health coverage. Results: Compliance with routine NCD care management (eg, counselling, immunisations, diagnostic testing and referral rates) was significantly better in Beirut compared with Beqaa. Women were significantly less likely to be offered lifestyle counselling advice and referral to cardiologists (58.4% vs 68.3% in Beqaa and 58.1% vs 62% in Beirut) and ophthalmologists, compared with men. Across both settings, there was a significant trend for Lebanese patients to receive more services and more advice related to nutrition and diabetes management (89.8% vs 85.2% and 62.4% vs 55.5%, respectively). Similarly, referral rates were higher among Lebanese refugees compared with Syrian refugees. Immunisation and diagnostic testing were significantly higher in Beirut among those who have health coverage compared with Beqaa. Conclusions: The study discovered significant differences in outpatient service use by setting, nationality and gender to differentials. A rigorous and comprehensive appraisal of NCD programmes and services is imperative for providing policy makers with evidence-based recommendations to guide the design, implementation and evaluation of targeted programmes and services necessary to ensure equity in health services delivery to diabetic and hypertensive patients. Such programmes are an ethical imperative considering the protracted crises and compounded fragility.Item Health system resilience in the face of crisis: Analysing the challenges, strategies and capacities for UNRWA in Syria(Oxford University Press, 2019-10-18) Jamal, Zeina; Alameddine, Mohamad; Diaconu, Karin; Lough, Graham; Witter, Sophie; Ager, Alastair; Fouad, Fouad M.Health system resilience reflects the ability to continue service delivery in the face of extraordinary shocks. We examined the case of the United Nations Relief and Works Agency (UNRWA) and its delivery of services to Palestine refugees in Syria during the ongoing crisis to identify factors enabling system resilience. The study is a retrospective qualitative case study utilizing diverse methods. We conducted 35 semi-structured interviews with UNRWA clinical and administrative professionals engaged in health service delivery over the period of the Syria conflict. Through a group model building session with a sub-group of eight of these participants, we then elicited a causal loop diagram of health system functioning over the course of the war, identifying pathways of threat and mitigating resilience strategies. We triangulated analysis with data from UNRWA annual reports and routine health management information. The UNRWA health system generally sustained service provision despite individual, community and system challenges that arose during the conflict. We distinguish absorptive, adaptive and transformative capacities of the system facilitating this resilience. Absorptive capacities enabled immediate crisis response, drawing on available human and organizational resources. Adaptive capacities sustained service delivery through revised logistical arrangements, enhanced collaborative mechanisms and organizational flexibility. Transformative capacity was evidenced by the creation of new services in response to changing community needs. Analysis suggests factors such as staff commitment, organizational flexibility and availability of collaboration mechanisms were important assets in maintaining service continuity and quality. This evidence regarding alternative strategies adopted to sustain service delivery in Syria is of clear relevance to other actors seeking organizational resilience in crisis contexts.Item Resilience capacities of health systems: Accommodating the needs of Palestinian refugees from Syria(Elsevier, 2018-10-21) Alameddine, Mohamad; Fouad, Fouad M.; Diaconu, Karin; Jamal, Zeina; Lough, Graham; Witter, Sophie; Ager, AlastairResilience is increasingly recognised as a key process mitigating the impact of shocks and stressors on functioning. The literature on individual and community resilience is being extended to address characteristics of resilient service delivery systems in contexts of adversity. The validity and utility of a capacity-oriented resilience framework (including absorption, adaptation and transformation) is examined with respect to the functioning of United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) health systems in Lebanon and Jordan in the context of the Syrian crisis. We completed 62 semi-structured interviews (30 in Lebanon in November - December, 2016, and 32 in Jordan in January 2017) with professionals at primary care, area, and country management levels. Participants reflected on changes in population health status and health service delivery during the Syrian crisis, notably with respect to the influx of refugees from Syria. Interviews were analysed through inductive thematic analysis and used to critically interrogate health systems resilience against a pro-capacities framework. We find that UNRWA systems in Lebanon and Jordan were broadly resilient, deploying diverse strategies to address health challenges and friction between host and refugee populations. Absorptive capacity was evidenced by successful accommodation of increased patient numbers across most service areas. Adaptive capacities were reflected in broadening of collaboration and reconfiguration of staff roles to enhance service delivery. Transformative capacities were demonstrated in the revision of the service packages provided. While manifest as technical capacities, these clearly drew upon solidarity and commitment linked to the political context of the Palestinian experience. The study adds to the limited literature on health system and organizational resilience and indicates that capacity-oriented framings of resilience are valuable in extracting generalizable lessons for health systems facing adversity. The proposed resilience framework promises to guide strategies for sustained care delivery in these contexts.Item In support of UNRWA appeal for health and dignity of Palestinian refugees(Elsevier, 2018-03-31) Alameddine, Mohamad; Witter, Sophie; Fouad, Fouad M; Diaconu, Karin; Jamal, Zeina; Lough, Graham; Ager, AlastairOur research into the UN Relief and Works Agency (UNRWA)'s delivery of health services to Palestinian refugees during the Syria crisis1 puts us in a unique position to anticipate the challenges of the organisation's current funding crisis.2 We have conducted over 90 interviews with health workers and managers, a series of systems modelling sessions, and rigorous analysis of UNRWA health data from 2007–16, and conclude the following.