The Institute for Global Health and Development
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Item Refugee integration in national health systems of low- and middle-income countries (LMICs): evidence synthesis and future research agenda(Elsevier, 2025-09-12) Olabi, Amina; Palmer, Natasha; Bertone, Maria Paola; Loffreda, Giulia; Bou-Orm, Ibrahim; Sempé, Lucas; Vera Espinoza, Marcia; Dakessian, Arek; Kadetz, Paul; Ager, Alastair; Witter, SophieThis paper reviews evidence on healthcare responses for refugees, documenting the different approaches and their effectiveness and impact in particular in relation to supporting integrating refugees into national health systems. The review adopted a purposeful, iterative approach, utilizing electronic databases, grey literature, and reference lists from relevant studies. A total of 167 studies, primarily from low- and middle-income countries (LMICs), focusing on refugees and forcibly displaced persons with empirical data, were included. The review highlights a substantial literature on refugee health and healthcare access, with well-covered areas including delivery models, access barriers, gaps in coverage, and specific health services such as psychosocial care, non-communicable diseases, mental health, and maternal and child health. However, less attention is given to integration models, health system responses, and their impact on system resilience and social cohesion. Few studies examine the costs, feasibility, or sustainability of integration models, and little research focuses on health system perspectives or comparative analyses. Moreover, the host health system's status, capacity, and needs are often underexplored. Some countries are particularly well-represented in studies, e.g. Turkey, Jordan, Lebanon, Bangladesh, Democratic Republic of Congo (DRC), and Uganda. There is however a paucity of data that would provide the basis for more quantitative or analytical evaluation from a systems perspective. This gap highlights the need for further research on effective integration models, their operational aspects, and their long-term impact on local health systems' resilience and sustainability. To support this research agenda, we propose a conceptual framework to provide analytic guidance for future research on healthcare responses for refugees and health system integration.Item Barriers and Opportunities for WHO ‘Best Buys’ Non-Communicable Disease Policy Adoption and Implementation From a Political Economy Perspective: A Complexity Systematic Review(Maad Rayan Publishing Company, 2023-12-31) Loffreda, Giulia; Arakelyan, Stella; Bou-Orm, Ibrahim; Holmer, Hampus; Allen, Luke N.; Witter, Sophie; Ager, Alastair; Diaconu, KarinBackground: Improving the adoption and implementation of policies to curb noncommunicable diseases (NCDs) is a major challenge for better global health. The adoption and implementation of such policies remain deficient in various contexts, with limited insights into the facilitating and inhibiting factors. These policies have traditionally been treated as technical solutions, neglecting the critical influence of political economy dynamics. Moreover, the complex nature of these interventions is often not adequately incorporated into evidence for policymakers. This study aims to systematically review and evaluate the factors affecting NCD policy adoption and implementation. Methods: We conducted a complex systematic review of articles discussing the adoption and implementation of WHO's ‘best buys' NCD policies. We identified political economy factors and constructed a causal loop diagram (CLD) program theory to elucidate the interplay between factors influencing NCD policy adoption and implementation. A total of 157 papers met the inclusion criteria. Results: Our CLD highlights a central feedback loop encompassing three vital variables: 1) the ability to define, (re)shape and pass appropriate policy into law; 2) the ability to implement the policy (linked to the enforceability of the policy and to addressing NCD local burden); 3) ability to monitor progress, evaluate and correct the course. Insufficient context-specific data impedes the formulation and enactment of suitable policies, particularly in areas facing multiple disease burdens. Multisectoral collaboration plays a pivotal role in both policy adoption and implementation. Effective monitoring and accountability systems significantly impact policy implementation. The commercial determinants of health (CDoH) serve as a major barrier to defining, adopting, and implementing tobacco, alcohol, and diet-related policies. Conclusion: To advance global efforts, we recommend focusing on the development of robust accountability, monitoring, and evaluation systems, ensuring transparency in private sector engagement, supporting context-specific data collection, and effectively managing the CDoH. A system thinking approach can enhance the implementation of complex public health interventions.Item Political Economy of Non-Communicable Disease (NCD) prevention and control in Lebanon: identifying challenges and opportunities for policy change and care provision reforms(BioMed Central, 2023-12-18) Bou-Orm, Ibrahim; Loffreda, Giulia; Diaconu, Karin; Witter, Sophie; deVos, PolIntroduction: Lebanon is a middle-income country facing substantial fragility features. Its health profile shows a high burden of NCD morbidity and mortality. This paper intends to analyse the political economy of NCD prevention and control in Lebanon. Methods: This study adopted a literature-based case study research design using a problem-driven political economy analysis framework. A total of 94 peer-reviewed articles and documents from the grey literature published before June 2019 were retrieved and analysed. Results: Lebanon’s political instability and fragile governance negatively affect its capacity to adapt a Health-in-All-Policies approach to NCD prevention and enable the blocking of NCD prevention policies by opposed stakeholders. Recent economic crises limit the fiscal capacity to address health financing issues and resulting health inequities. NCD care provision is twisted by powerful stakeholders towards a hospital-centred model with a powerful private sector. Stakeholders like the MOPH, UN agencies, and NGOs have been pushing towards changing the existing care model towards a primary care model. An incremental reform has been adopted to strengthen a network of primary care centres, support them with health technologies and improve the quality of primary care services. Nevertheless, outpatient services that are covered by other public funds remain specialist-led without much institutional regulation. Conclusion: Our study revealed a locked equilibrium in NCD prevention policymaking in Lebanon, but with an incremental progress in service delivery reforms towards a primary care model. Advocacy and close monitoring by policy entrepreneurs (such as civil society) could initiate and sustain the implementation of policy change and care model reforms.Item Provision of mental health and psychosocial support services to health workers and community members in conflict-affected Northwest Syria: a mixed-methods study(BioMed Central, 2023-10-04) Bou-Orm, Ibrahim; Moussallem, Marianne; Karam, Joelle; deLara, Manuel; Varma, Vinod; Diaconu, Karin; Apaydin, Murat Can Birand; Van den Bergh, Rafael; Ager, Alastair; Witter, SophieBackground: Northwest Syria (NWS) is a conflict area with challenging political, economic, demographic and social dynamics. The region has a high number of internally displaced persons with increasingly disrupted delivery of basic services, including healthcare. Mental health needs have been increasing in the region while the infrastructure and capacity of the health sector has been negatively affected by the conflict. This study aimed to explore the provision of mental health and psychosocial support (MHPSS) services to communities in NWS (including healthcare workers) and to assess the experiences of beneficiaries with MHPSS services. Methods: The study followed a mixed-methods research design that included qualitative and participatory methods (44 semi-structured interviews and a group model building workshop with 15 participants) as well as a survey with 462 beneficiaries. Results: Findings suggested an improvement of MHPSS services in the region over the last few years due to the creation of a specific Technical Working Group for MHPSS that contributed to assessment of community needs and support of the MHPSS response. The key elements of this response were: (1) training non-specialized health workers to address the shortage in specialized providers; (2) securing funding and coordination of services between different organizations; and (3) addressing gaps in the availability and geographical distribution of other needed resources, such as medicines. While those elements contributed to improving access to services and the quality of services—especially among health workers seeking MHPSS services—findings suggested gaps in the sustainability of services and a need to scale up those interventions in an integrated approach. Conclusion: The study findings add to the evidence base on the challenges in scaling up MHPSS interventions and their long-term sustainability concerns. Priority actions should address the intermittent funding of the MHPSS response, incorporate MHPSS outputs and outcomes in the reimbursement of routine services, improve coordination between health partners and non-health actors in order to expand the scope of MHPSS response, and address the inequitable availability of resources in the region.Item Experiences of communities with Lebanon’s model of care for non-communicable diseases: a cross-sectional household survey from Greater Beirut(BMJ Publishing Group, 2023-09-04) Bou-Orm, Ibrahim; deVos, Pol; Diaconu, KarinObjectives Assess community perceptions of the Lebanese care model for non-communicable diseases (NCDs) and trust in the health system among others, and test association between them. Design Cross-sectional study using multistage random sampling and targeting adult community members living with NCDs. Setting Households in Greater Beirut—Lebanon. Participants 941 respondents including 574 Lebanese community members and 367 Syrian refugees. Primary and secondary outcomes Three main outcomes (barriers to care seeking, perceptions of the care model and trust in healthcare) were assessed including by multiple linear regressions. Results Reported NCDs were hypertension (51.3%) and diabetes (34.5%), followed by chronic respiratory conditions (21.9%) and other cardiovascular diseases (20.0%). Communities reported seeking care from different sources. While 78% of Lebanese participants had visited private clinics at least once within the 6 months preceding the survey, 56% of Syrian refugees had done so. Determinants of access to care were health coverage, gender, and employment among Lebanese, and socioeconomic status among Syrian refugees. Lebanese community members had more positive perceptions of the care model compared with Syrian refugees and determinants included sociodemographic characteristics and the type of providers. Trust in the health system was higher among Syrian compared with Lebanese participants and was significantly influenced by the care model score and barriers to care seeking. Conclusion Our study generated evidence about the experience of people living with NCDs with Lebanon’s care model and can inform service delivery interventions towards a more inclusive person-centred approach.Item Prevalence and clinical characteristics of diabetes mellitus in Lebanon: a national survey(World Health Organization, 2020-02) Bou-Orm, Ibrahim; Adib, SalimBackground: Diabetes mellitus in all its forms has been rapidly increasing worldwide, especially in the Eastern Mediterranean Region. Aims: This national study aimed to assess the prevalence and clinical aspects of diabetes mellitus in Lebanon with special focus on type 1 (T1DM). Methods: A national multistage, random household sample survey was conducted, using face-to-face interviews with 1 questionnaire per household. A total of 4500 households were selected from all areas based on a pre-existing sampling frame of the Lebanese population. Results: The prevalence of previously diagnosed diabetes mellitus in the surveyed population of 17 832 persons (mean age ~36 years) was 7.95%. The prevalence of T1DM in particular was estimated at 0.1%, or almost 1% of all detected cases of diabetes mellitus. Most persons with diabetes mellitus reported obtaining their usual care from endocrinologists rather than primary healthcare physicians. Delayed performance of haemoglobin A1c test was reported in 25% of 1418 patients. Hypoglycaemic episodes recently occurred in 30% of patients; of whom, at least one third required medical attention, including hospital admission. Diagnosed complications were reported in 22% of cases, with retinopathy being the most common. Conclusions: Prevalence of T1DM in this population was lower than international estimates. Diabetes mellitus management appears to be deficient, based on delays in standard control testing, hypoglycaemic episodes and diabetes mellitus-related complications. Coordination of diabetic care management should be devolved to primary healthcare physicians, who can keep track of the need for referral to various types of diabetes mellitus care.Item Participation by conflict-affected and forcibly displaced communities in humanitarian healthcare responses: A systematic review(Elsevier, 2020-12-09) Rass, Ella; Lokot, Michelle; Brown, Felicity L; Fuhr, Daniela C; Asmar, Michèle Kosremelli; Smith, James; McKee, Martin; Bou-Orm, Ibrahim; Yeretzian, Joumana Stephan; Roberts, BayardBackground Community participation in health responses in humanitarian crises is increasingly promoted by humanitarian actors to support adoption of measures that are relevant and effective to local needs. Our aim was to understand the role of community participation in humanitarian health responses for conflict-affected populations (including forcibly displaced populations) in low- and middle-income countries and the barriers and facilitators to community participation in healthcare responses. Methods Using a systematic review methodology, following the PRISMA protocol, we searched four bibliographic databases for publications reporting peer-reviewed primary research. Studies were selected if they reported how conflict-affected populations were involved in healthcare responses in low- and middle-income settings, and associated changes in healthcare responses or health outcomes. We applied descriptive thematic synthesis and assessed study quality using study design-specific appraisal tools. Results Of 18,247 records identified through the database searching, 18 studies met our inclusion criteria. Various types of community participation were observed, with participation mostly involved in implementing interventions rather than framing problems or designing solutions. Most studies on community participation focused on changes in health services (access, utilisation, quality), community acceptability and awareness, and ownership and sustainability. Key barriers and facilitators to community participation included political will at national and local level, ongoing armed conflict, financial and economic factors, socio-cultural dynamics of communities, design of humanitarian responses, health system factors, and health knowledge and beliefs. Included studies were of mixed quality and the overall strength of evidence was weak. More generally there was limited critical engagement with concepts of participation. Conclusion This review highlights the need for more research on more meaningful community participation in healthcare responses in conflict-affected communities, particularly in framing problems and creating solutions. More robust research is also required linking community participation with longer-term individual and health system outcomes, and that critically engages in constructs of community participation.Item Colorectal cancer screening knowledge and uptake in Lebanon: a national survey(Elsevier Masson, 2022-03-24) Moussallem, Marianne; Jreij, Marc; Yeretzian, Joumana Stephan; Asmar, Michèle Kosremelli; Bou-Orm, IbrahimObjective The main aim of this national survey was to identify the levels of colorectal cancer screening knowledge and uptake in Lebanon. Methods A total of 1200 participants were enrolled in this cross-sectional household survey targeting the Lebanese population aged 50 years and above. The sample was recruited using a two-stage stratified cluster sampling approach. Results Of the total sample, 38.3% knew about any screening test for colorectal cancer but only 7.5% had ever used any. Thirty-nine percent of the participants rated their risk of getting colorectal cancer as very low or low, and only 53.5% were confident in their ability to undertake a screening test. Almost all participants agreed that medical advice and test reimbursement would encourage them to do a screening test. At the multivariate analysis level, hearing of an awareness campaign in the last two years showed the strongest association with the knowledge of a colorectal cancer screening test with an estimated ORadj = 5.12 (95%CI: 3.67 – 7.15). Other factors that were significantly associated with this knowledge variable included: a family history of colorectal cancer, a personal history of colorectal illness, having a health coverage, and knowledge of colorectal cancer signs and symptoms. Discussion This national study highlights an alarming lack of uptake and low levels of knowledge of colorectal cancer screening tests even though it is among the most prevalent cancers in Lebanon and its prevalence has been continuously increasing in the past years. The evidence suggests that people who had an experience with colorectal cancer diagnostic tests, either personally or through a family member, and those who have heard of an awareness campaign about colorectal cancer in the last two years are more likely to know its screening tests. Conclusion Colorectal cancer screening knowledge and uptake in Lebanon are limited and justify the need for public health interventions. This study gives evidence that awareness campaigns, coupled with the involvement of medical providers and the reimbursement of screening test fees, would alleviate the burden of colorectal cancer in Lebanon.Item Health system governance in settings with conflict-affected populations: a systematic review(Oxford University Press, 2022-03-22) Lokot, Michelle; Bou-Orm, Ibrahim; Zreik, Thurayya; Kik, Nour; Fuhr, Daniela C; El Masri, Rozane; Meagher, Kristen; Smith, James; Asmar, Michele Kosremelli; McKee, Martin; Roberts, BayardHealth system governance has been recognized as critical to strengthening healthcare responses in settings with conflict-affected populations. The aim of this review was to examine existing evidence on health system governance in settings with conflict-affected populations globally. The specific objectives were (1) to describe the characteristics of the eligible studies; (2) to describe the principles of health system governance; (3) to examine evidence on barriers and facilitators for stronger health system governance; and (4) to analyse the quality of available evidence. A systematic review methodology was used following Preferred Reporting Items for Systematic Review and Meta-Analysis criteria. We searched six academic databases and used grey literature sources. We included papers reporting empirical findings on health system governance among populations affected by armed conflict, including refugees, asylum seekers, internally displaced populations, conflict-affected non-displaced populations and post-conflict populations. Data were analysed according to the study objectives and informed primarily by a governance framework from the literature. Quality appraisal was conducted using an adapted version of the Mixed Methods Appraisal Tool. Of the 6511 papers identified through database searches, 34 studies met eligibility criteria. Few studies provided a theoretical framework or definition for governance. The most frequently identifiable governance principles related to participation and coordination, followed by equity and inclusiveness and intelligence and information. The least frequently identifiable governance principles related to rule of law, ethics and responsiveness. Across studies, the most common facilitators of governance were collaboration between stakeholders, bottom-up and community-based governance structures, inclusive policies and longer-term vision. The most common barriers related to poor coordination, mistrust, lack of a harmonized health response, lack of clarity on stakeholder responsibilities, financial support and donor influence. This review highlights the need for more theoretically informed empirical research on health system governance in settings with conflict-affected populations that draws on existing frameworks for governance.Item Evolution and lessons from an integrated service delivery network in North West Syria(BioMed Central, 2023-03-24) Witter, Sophie; Diaconu, Karin; Bou-Orm, Ibrahim; Jamal, Zeina; Shroff, Zubin Cyrus; Mahmoud, Abdulbaki; Daher, Mahmoud; Varma, VinodBackground: Northwest Syria (NWS) is a complex and extremely fragile operating environment, with more than 2.8 million people needing humanitarian assistance. To support a common standard of care delivery and enable coordination among the multiple providers in NWS, WHO developed an Essential Health Services package (EHSP) in 2016-17 and subsequently supported a facility network model to deliver the EHSP. This article provides an evaluation of the network to date, aiming to inform further development of the network and draw wider lessons for application of similar approaches in complex emergency settings. Methods: This mixed method study included document review, participatory, qualitative and quantitative data, gathered in the first half of 2021. Participatory data came from two group model building workshops with 21 funders and implementers. Semi-structured interviews with 81 funders, health professionals and community members were also conducted. Analyses of the workshops and interviews was inductive, however a deductive approach was used for synthesising insights across this and the document review. The final component was a survey of health providers (59 health care professionals) and service users (233 pregnant women and 214 persons living with NCDs) across network and other comparable facilities, analysed using routine descriptive and inferential statistics. Findings across all methods were triangulated. Results: The study finds that the network and its accompanying essential service package were relevant to the dynamic and challenging context, with high but shifting population needs and multiple uncoordinated providers. Judged in relation to its original goals of comprehensive, coordinated services, equitable access and efficient service delivery, the data indicate that gains have been made in all three areas through the network, although attribution is challenging, given the complex environment. The context remains challenging, with shifting boundaries and populations displaced by conflict, difficulties in retaining staff, the need to import medicines and supplies across borders, and governance gaps. Conclusion: This study adds to a very limited literature on coordinated network approaches used to raise care quality and improve referrals and efficiency in a complex emergency setting. Although areas of ongoing challenge, including for sustainability, are noted, the network demonstrated some resilience strategies and can provide lessons for other similar contexts.