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 Effect of contributing factors on the incidence of non-communicable diseases among adults with common mental health disorders: a systematic review(National Institute for Health and Care Research, 2024-05) Jamal, Zeina; Horn, Rebecca; Ager, AlastairBackground Individual, social and environmental factors play a dynamic role in determining mental health outcomes. The linkage between mental health and non-communicable disease is widely noted, but the mechanisms are poorly understood. The current systematic review aims to identify common contributing factors linking mental health to non-communicable disease incidence among adults to inform planned preventive interventions for high-risk non-communicable disease and mental ill-health populations. Methods MEDLINE, PsycINFO, EMBASE and CINAHL were searched from February to August 2019 for case-control and longitudinal studies of adults with common mental health disorders (depression and anxiety) assessing the causal effect of individual, environmental and social factors on the incidence of common non-communicable diseases (cancers, cardiovascular diseases, chronic obstructive pulmonary disease and diabetes mellitus). There were no geographical restrictions for the selected studies and the results were generated utilising a narrative synthesis. Results Of 15,266 unique documents identified by search terms, 419 met criteria for full-text review and 11 studies met inclusion criteria for data extraction. None of the identified studies had the onset of chronic obstructive pulmonary disease as an outcome. The majority of the studies showed a significant effect of depression and/or post-traumatic stress disorder on non-communicable disease incidence. The chronicity of mental health disorders appears to exacerbate their effect on non-communicable disease onset. Older age, higher body mass index, female sex, smoking status and number of cigarettes smoked, low educational attainment and ethnicity were found to exert a significant effect on the association between mental health disorders and non-communicable disease onset. Conclusion Findings from this review provide evidence to guide health practice and policy to reduce the burden of non-communicable diseases and mental health disorders. Interventions targeted towards identifying and treating mental health illnesses and the factors linking mental and physical health lower the burden of mental disorders and prevent the subsequent development of non-communicable diseases. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Global Health Research programme (NIHR award ref: 16/136/100). A plain language summary of this research article is available on the NIHR Journals Library Website https://doi.org/10.3310/CTDH4677.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.Item Forced migration and sexual and gender-based violence: findings from the SEREDA project in Scotland(University of Birmingham, 2022) Phillimore, Jenny; Jamal, Zeina; Noubani, Aya; Hourani, Jeanine; Baillot, HelenForced migration is gendered with men and women experiencing displacement in different ways and nearly half of the world’s forced migrants being women and children. All forced migrants are vulnerable to sexual and gender-based violence (SGBV) which includes any form of violence whether physical, emotional, sexual, structural or symbolic which is inflicted on the basis of socially ascribed gender roles. However, women and children are most vulnerable to SGBV. The SEREDA project sought to understand the nature and incidence of SGBV experienced by forced migrants residing in countries of refuge. This report outlines the findings of SEREDA interviews in Scotland focusing on the Scottish policy context and how SGBV survivors might be better protected and supported within this context.Item Social determinants and mental health needs of Palestine refugees and UNRWA responses in Gaza during the COVID-19 pandemic: a qualitative assessment(BioMed Central, 2022-12-08) Jamal, Zeina; ElKhatib, Zoheir; AlBaik, Shatha; Horino, Masako; Waleed, Mohammed; Fawaz, Farah; Loffreda, Giulia; Seita, Akihiro; Witter, Sophie; Diaconu, KarinBackground: Due to pre-existing difficulties, refugees are especially susceptible to the negative effects of the pandemic; nonetheless, the pandemic’s effect on this group is still unclear. The purpose of this study was to determine the effects of the COVID-19 pandemic on the mental health of Palestine refugees in Gaza by identifying the role of social determinants. During the pandemic, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) enacted a number of policies and measures. The purpose of this research was to assess their efficacy and acceptability. Methods: This qualitative study took place between August and November 2020. Twenty-nine key-informant interviews were conducted remotely with UNRWA Headquarters, field and clinical staff in Gaza and with community members, aged ≥18 years and residing in Rafah and Jabalia camps. We sought informed consent verbally or via email. Data was coded based on the framework for social determinants of mental health. Results: Interview results indicated that the relationship might be unidirectional, with COVID-19 causing the degradation of living conditions and vice versa, with living conditions exacerbating the COVID-19 situation by facilitating virus transmission. In other instances, the association between mental health determinants and COVID-19 might be bidirectional. In terms of experiencing violence and anxieties, women, children, and daily-paid employees were significantly more disadvantaged than other groups in the community. UNRWA modified its service delivery techniques in order to continue providing essential services. In general, UNRWA’s strategies throughout the pandemic were deemed beneficial, but insufficient to meet the needs of Gazans. Conclusion: The pandemic highlights the need to go beyond disease treatment and prevention to address social determinants to improve refugees’ health and reduce their susceptibility to future shocks. UNRWA has rapidly implemented telemedicine and mental telehealth services, making it imperative to assess the efficacy of these novel approaches to provide care at a distance. A long-term option may be to employ a hybrid strategy, which combines online and in-person therapy.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.