KEY POINTS
Lebanon is currently hosting 1.1 million Syrian refugees, the highest per capita refugee population in the world.
These refugees face a high burden of disease, and the obligation to address their health needs has put substantial pressure on the Lebanese health care system, particularly in terms of access, cost and quality.
To help inform the provision of health services for refugees in Lebanon, a team at the Center for Systematic Reviews on Health Policy and Systems Research (SPARK) applied the following knowledge production and translation tools: priority-setting, systematic reviews, development of a briefing note (knowledge translation) and convening of a national policy dialogue (knowledge uptake).
INTRODUCTION
The world in general and the Middle East and North Africa (MENA) region in particular are witnessing the highest level of population displacement on record (1). Turkey, Lebanon, Jordan, Iraq and Egypt are hosting about 5 million Syrian refugees (2). Lebanon, a middle-income country in the MENA region, is hosting 1.1 million refugees, equivalent to one Syrian refugee for every four Lebanese citizens, the highest per capita refugee population in the world (3). Syrian refugees in Lebanon face a high burden of communicable and noncommunicable diseases. According to a recent survey, 50% of Syrian refugees reported having chronic health conditions, and 70% reported needing medical care for their children (3). Refugees’ primary reasons for seeking medical care in Lebanon included communicable diseases (40.3%), noncommunicable diseases (13.7%), gynecological problems (12.1%) and injuries (9.1%) (3). As this crisis has shifted from the acute humanitarian response to a more chronic, protracted phase, the management of noncommunicable diseases has become more important.
The large influx of refugees and the obligation to address their health needs has put substantial pressure on the Lebanese health care system, particularly in terms of access, cost and quality. The Lebanese government is giving Syrian refugees access to most basic health care services mainly through the network of Primary Health Care (PHC) Centers and other public sector institutions. The PHC Centers provide Syrian refugees with a comprehensive package of outpatient services, including medical consultations, laboratory tests, immunizations, essential drugs, dental and oral health care, antenatal care and other reproductive health services, and management of chronic diseases. The PHC Centers are subsidized by the United Nations High Commissioner for Refugees (UNHCR), and Syrian refugees pay only minimal fees for care through these Centers. In addition, the UNHCR covers 75% of treatment costs in secondary and tertiary hospitals, with the refugees covering the remaining 25%. Complete coverage is provided for victims of sexual violence, torture or gender-based violence (4, 5). In addition to the government and UNHCR, many local and international nongovernmental organizations are involved in providing humanitarian assistance and health care services to refugees in Lebanon.
An integrated level of engagement helped secure buy-in from and commitment of all the major stakeholders and increased the likelihood that the evidence would be used in policy-making.
Providing health services to this large number of refugees is a real challenge, given the current capacity of the system and the pre-existing economic crisis. There are also concerns about how provision of health care to refugees is affecting access to and quality of care provided to the host community (5, 6).
THE APPROACH
The Center for Systematic Reviews on Health Policy and Systems Research (SPARK) at the American University of Beirut (AUB) in Lebanon aimed to contribute to enhancing the provision of health services for refugees in Lebanon by informing the decisions of policy-makers (7). The mission of SPARK is to produce high-quality systematic reviews that respond to health policy and systems priority issues at the national and regional levels. SPARK follows the impact-oriented framework for evidence-informed health policies and practices () to guide its work (8). This framework aims to engage policy-makers throughout the process, from setting priorities to knowledge uptake and impact assessment. SPARK collaborates with the Knowledge to Policy (K2P) Center within the Faculty of Health Sciences at AUB for its knowledge translation activities (9). The K2P Center draws on synthesized evidence and context-specific knowledge by producing briefs and conducting policy dialogues to affect policy agendas and encourage action. To help inform the provision of health services for refugees in Lebanon, the following knowledge production and translation tools were applied: (1) priority-setting meeting, (2) conduct of systematic reviews to address the questions identified in the priority-setting step (evidence synthesis), (3) development of a briefing note (knowledge translation) and (4) convening of a national policy dialogue (knowledge uptake).
Impact-oriented framework for evidence-informed health policies and practices, as applied to the case of Syrian refugees in Lebanon.
THE PRIORITY-SETTING MEETING
SPARK held a priority-setting exercise in January 2014 in response to the issue of the health of Syrian refugees in Lebanon. The objective was to engage policy-makers and stakeholders in framing the problem and in prioritizing questions for a systematic review tackling this topic. It was felt that engaging policy-makers in the priority-setting step would increase their utilization of the resultant research evidence. To ensure that the most relevant stakeholders were represented in the priority-setting exercise, policy-makers, stakeholders and researchers working in the provision and/or financing of health services for refugees in Lebanon were invited to participate. Fifty-four participants from multidisciplinary backgrounds joined the priority-setting exercise; they included representatives from the Ministry of Public Health (MOPH), Lebanese National Council for Research, World Health Organization (WHO) Country Office, United Nations Development Programme, UNHCR, United Nations Relief and Works Agency for Palestine Refugees in the Near East, International Organization for Migration and UK Department for International Development, in addition to academics and researchers from AUB and other universities in Lebanon.
The participants split into two groups to discuss the health of Syrian refugees in Lebanon, focusing mainly on the issue of health services provision. Each round table discussion was moderated by one facilitator who aimed to achieve consensus among participants on a common priority topic. The participating policy-makers and stakeholders prioritized the issue of limited coordination between organizations and agencies providing health services to refugees. They agreed that the lack of coordination was hindering their work and leading to both duplication and gaps in delivery of those services, as well as inequitable distribution of resources that was not based on the needs of the refugees. The participants actively engaged in framing the review question, defining the PICOS (Population, Intervention, Comparator, Outcome and Setting) of the review and specifying the objectives.
EVIDENCE SYNTHESIS
Over the period February to May 2014, SPARK conducted two systematic reviews addressing the prioritized question: a systematic review of effectiveness (10) and a systematic review of published mechanisms and models of coordination (11). To expedite the systematic review process, a large team of skilled full-time researchers was convened to complete the screening in a timely manner. For the second review, no quality assessment was conducted, because the aim was to describe existing models of coordination. Importantly, only the preliminary key findings of the review (and not the peer-reviewed manuscripts themselves) were used to feed into the knowledge translation product described below.
A number of challenges were encountered in conducting evidence synthesis in the area of refugee crisis. First, the initial scoping review highlighted the scarcity of evidence specific to the context of Syrian refugees. Therefore, the scope was broadened to capture indirect evidence from other humanitarian crises; in addition, all types of study designs were included. Second, it was surmised that pertinent evidence was not being published in the peer-reviewed literature, so additional evidence was sought in the grey literature and at the websites of organizations and agencies providing health services and humanitarian assistance to refugees.
KNOWLEDGE TRANSLATION
SPARK partnered with the K2P Center to translate the findings of the systematic reviews and to promote uptake of the evidence that was produced. The K2P Center aims at strengthening and influencing policy and promoting evidence-informed decision-making at the national and regional levels.
The key findings of the two systematic reviews were incorporated into a briefing note (12). In addition to these key findings, the briefing note gathered and synthesized global and local research evidence, contextualizing the evidence according to the Lebanese health system. The briefing note described the priority issue, synthesized global and context-specific evidence, and offered evidence-based recommendations for action.
KNOWLEDGE UPTAKE
In June 2014, the K2P Center convened a policy dialogue, entitled “Promoting access to essential health care services for Syrian refugees in Lebanon” and informed by the briefing note described in the previous section. The aim was to allow focused and informed discussions about this high-priority issue to support policy action. The briefing note was circulated to participants before the dialogue, so that it could serve as the starting point for discussions and deliberations.
The dialogue was attended by 28 stakeholders, policy-makers and decision-makers involved in providing and/or financing health services for refugees in Lebanon. The participants included representatives from relevant Lebanese government ministries (MOPH and Ministry of Social Affairs), representatives of UN agencies (WHO, UNHCR), representatives of international organizations (International Committee of the Red Cross, Médecins du Monde, International Medical Corps), representatives of local nongovernmental organizations (including Amel and Caritas Lebanon Migrant Center), directors of PHC Centers and district-level doctors, as well as researchers and academics. The recommendations provided in the briefing note were discussed, revised and agreed upon by the diverse stakeholders who participated. The dialogue summary report provides details on the stakeholders’ deliberations and recommendations (13).
THE OUTCOMES
Policy impact
On the basis of the evidence-based recommendations presented in the briefing note (10) and the next steps agreed upon during the policy dialogue, the Lebanese MOPH recruited a refugee health coordinator. The MOPH asked SPARK to develop terms of reference for the coordinator, informed by context-specific and global evidence (see Box 1).
The coordinator reconvened all of the stakeholders who participated in the policy dialogue to form a Health Steering Committee. This committee is responsible for implementing and monitoring a national Health Response Strategy and for coordinating and monitoring the flow of aid, to ensure that funding is needs based. The national strategy and its implementation plan were influenced by the deliberations of the policy dialogue. A new mechanism of coordination was set in place to ensure successful implementation of the strategy. The coordinator developed the Health Response Strategy, with guidance from a number of officials and policy-makers in the MOPH; this document was released in late 2015 (5) and then updated in 2016 (14). By developing this national strategy, the MOPH assumed a leadership role in coordinating and guiding health response efforts.
Impact beyond initial aim
Both SPARK and the K2P Center were invited by the Lancet–AUB Commission on Syria: Health in Conflict to support and contribute to its work. The Commission chose SPARK and the K2P Center as strategic partners, given their previous experiences
BOX 1TERMS OF REFERENCE FOR THE REFUGEE HEALTH COORDINATOR
Assisting MOPH in playing a major role by coordinating and establishing effective partnerships and communication with local and international agencies, donors and academic institutions and conducting monitoring and evaluation.
Helping in developing refugee health information system at MOPH.
Developing the action plan and timelines for the implementation of recommendations that came out of the policy dialogue in June 2014.
Helping provide guidance to agencies and nongovernmental organizations and other stakeholder organizations involved in health assistance (including reporting requirements for MOPH).
Assisting MOPH in developing a long-term planning process for addressing the health needs of refugees.
Ensuring agreement on the basic division of responsibilities among agencies, in accordance with their respective mandates and capacities.
Ensuring consultation with authorities, other ministries and nongovernmental organizations on matters regarding the planning and implementation of health-related assistance.
Assisting in overseeing the development of a comprehensive strategic plan for responding to the health needs of Syrian refugees in Lebanon.
Acquiring knowledge about the experiences of other ministries of health (e.g., Turkey and Jordan) in responding to the health needs of refugees.
in identifying and responding to research priorities related to the Syrian refugee crisis in Lebanon. Specifically, these two centres will contribute to evidence synthesis and knowledge translation. The Lancet–AUB Commission on Syria aims to raise the profile of the Syrian crisis in global health and to mobilize a stronger international response through its work (
15). SPARK conducted a rapid scoping review (
16) to support the Commission’s first policy paper (
17).
REFLECTIONS ON THE PROCESS
Implementation of the impact-oriented framework to guide work on the health of Syrian refugees has revealed several challenges and generated some key lessons.
First, although the process may seem straightforward, it builds on years of preparatory work, which has included increasing the awareness of policy-makers, stakeholders, civil society organizations and media on the importance of evidence in policy-making; building their capacities in accessing and using evidence; and raising demand for evidence. Work on evidence-informed policy-making was initiated two years before launching SPARK and the K2P Center. Specifically, policy-makers and stakeholders were surveyed about the barriers and facilitators to the use of evidence in decision-making (18). A series of workshops was also conducted with policy-makers to sensitize them and enhance their awareness of the importance of evidence and the role of systematic reviews and knowledge translation tools in promoting evidence-informed policy-making. In addition, all key policy-makers and stakeholders were invited to the official launch of SPARK and the K2P Center. These activities helped to enhance the receptiveness and buy-in of policy-makers and stakeholders.
Second, there was a realization of how the existing political context can influence the receptiveness of policy-makers to evidence-informed policy-making. In the case of Lebanon, the MOPH plays a key role in health policy-making, and its senior and middle-level officials have strong input into decision-making. Therefore, these senior and middle-level officials at the MOPH and other health-related ministries were strategically targeted. Ministers change frequently, but middle-level managers rarely do; this continuity of personnel decreases the need to build relationships and capacities of new contacts and policy-makers in senior positions. Access to policy-makers was further facilitated by the relatively small size of Lebanon (population 4.4 million) and the relatively small number of policy-makers in the country’s various ministries and its parliament.
Third, adopting a holistic knowledge approach facilitated evidence-informed policy-making and practice. The unique collaboration between SPARK and the K2P Center allowed coverage of the spectrum from priority-setting to systematic review production, knowledge translation and knowledge uptake. It also allowed leveraging of common resources, capacities and expertise, which enhanced the feasibility and effectiveness of this approach to evidence-informed health policy-making.
Fourth, the case of Syrian refugees posed unique challenges. The magnitude of the refugee crisis, its social, health and economic implications, and the multiple stakeholders involved emphasized the need to convene policy-makers and stakeholders and to come up with timely solutions to address the crisis. This presented an ideal window of opportunity for SPARK to take the lead. A deliberate choice was made to engage key national policy-makers, stakeholders, professional associations, national and international nongovernmental organizations, funding bodies, and representatives of the public across the entire process, from defining priorities, to framing the review questions, to setting the outline for the briefing note, to contextualizing policy recommendations in the policy dialogue, and finally to assessing impacts (through follow-up with key stakeholders). This integrated level of engagement helped secure buy-in from and commitment of all the major stakeholders and increased the likelihood that the evidence would be used in policy-making.
Finally, it is worth noting that a key challenge facing the implementation of this process was the need to respond to policy-makers in a timely way. Accordingly, SPARK and the K2P Center have recently scaled up their capacity by building rapid response services to cater to the requests of policy-makers in a timely manner (rapid response services are described in more detail in Chapter 8 of this Methods Guide, concerning challenges in the conduct of policy-relevant evidence synthesis).
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