Lebanon : Provision of emergency mobile primary health care services for Syrian refugees in the south of Lebanon
More than 2.5 million Syrians are now hosted in Lebanon, Jordan, Egypt, Turkey and Iraq, placing unprecedented strain on communities, infrastructure and services in these countries. There has been a massive escalation of the crisis in the past 12 months, with 70% newly registered as refugees during this period. The highest number, 945,461, are hosted in Lebanon. With ongoing violence and a worsening humanitarian crisis inside Syria this figure is predicted to rise to 1.65 million by December 2014.
To date 114,000 refugees are registered in the south of Lebanon, with 2,000 more awaiting registration (there is currently a one week processing period, except for cases classified as health and/or social emergencies). However, the situation is changing rapidly: the UN Refugee Agency (UNHCR) is reporting the secondary migration of refugees from the north, as there is less overcrowding in the south, cheaper accommodation and a relatively more stable security situation.
Women and children under five years of age constitute 70% of the refugee population, the vast majority of whom are completely dependent on humanitarian aid, arriving in Lebanon with little more than the clothes on their backs.
Living Conditions Of Refugees
The host communities in Lebanon are those characterised by the highest levels of poverty and deprivation even prior to this crisis. Competition for already limited social services and jobs against a background of rising inflation and security concerns is already reaching critical levels.
In the absence of properly established camps the early refugees were fortunate enough to find themselves shelter in rented accommodation, with host families or in the already overcrowded Palestinian refugee camps. However, as numbers have increased and prices have escalated these options have largely been exhausted. Increasingly the new arrivals are forced into small, informal “tented settlements” or to squat disused buildings. These improvised shelters are often substandard, with limited or no water or sanitation facilities, and located in areas prone to flooding and at risk of fires. The fact that refugees are so widely dispersed within host communities creates difficulties in terms of access and coordination, placing greater emphasis on community based outreach activities.
Partially built apartment blocks in Saida where refugee families are squatting
Many refugees have been hugely traumatised by their experiences in Syria and subsequent escape. They have no personal possessions or the means to purchase them. Within such a vulnerable population there are particular concerns for women and young children, the elderly, persons with disability and those with existing health problems.
Conditions in a couple of tented settlements in Tyre
Health Services For Refugees
UNHCR is subsidising the cost of primary health care (PHC) for registered refugees using pre-selected government and NGO health providers. However, refugees still have to make a variable contribution to the cost of this care and accessing services remains difficult because of the distances involved and cost of transport. Furthermore, the availability of medication for chronic diseases (eg. diabetes, heart disease) is extremely limited and even simple acute treatments are not always available.
For those patients with life threatening conditions, subject to approval by GlobeMed Lebanon (the recently appointed “referral contractor”), UNHCR will also cover 75% of the cost of secondary care at pre-selected hospitals (100% if the patient is classed as “vulnerable”). However, this still leaves the refugee having to cover 25% of the cost of life saving hospital treatment, and non-emergency cases are not covered at all.
Refugees queuing for food vouchers in Saida
In collaboration with a local partner NGO, Blue Mission, our project began in April 2014. The key objectives are:
- To prevent avoidable death, disease and disability through the provision of high quality, outreach PHC services
- To specifically address the essential health needs of women and young children
- To address emerging public health threats through the delivery of health/hygiene educational programmes and active disease surveillance
We have staffed and equipped a mobile clinic to provide outreach PHC services for a widely dispersed target population of refugees and members of host communities in Saida and Tyre, south Lebanon. Target sites are a mix of tented settlements, improvised shelters and disused buildings. To improve coordination and avoid duplication these sites have been agreed with UNHCR and the limited number of other emergency health care providers in the region.
The mobile clinic operates from 0800 to 1400, five days a week, visiting at least two target sites each working day, returning to each target site at least once every two weeks (according to a schedule agreed with beneficiaries and advertised using all available means. Community mobilisers have been recruited from the refugee population to improve coordination, help organise all health and related activities, and increase beneficiary ownership of the project. Although services are targeted at refugees we do not refuse care to any member of the host community who attends. Patients requiring further investigation and/or specialist assessment are transferred to PHC centres in Saida and Tyre, with onward referral to secondary care as necessary.
Gaza, occupied Palestinian territories (oPt) - Development of Trauma Care Services
- Gaza consists of five provinces and a population of 1.8 million, of whom 75% are refugees. The population is concentrated in seven towns, 10 villages and eight camps, with a total area of only 360 sq. km.
- Much of the economic deterioration in recent years is due to the military siege and resulting isolation of the population. Since the start of the second Intifada in 2000 the income per capita has declined sharply and consistently, and the labour force unemployment rate has climbed to 30%. This has resulted in a substantial increase in the number of families falling below the poverty line, reflected by the fact that 75% of the population now receive food assistance.
- Health care in Gaza is delivered by four main providers: the government; UNRWA (the UN agency providing services for registered Palestinian refugees); non-governmental organisations (NGOs: local and international); and the private sector.
- In spite of significant financial and operational constraints the Palestinian health sector has shown great resilience over the years, particularly in continuing to provide reasonably comprehensive primary health care services. Unfortunately the evolution of health services largely ended with the second Intifada, following which donor and provider attention shifted from development to crisis management. This situation has been compounded by the ongoing conflict and related surge in traumatic injuries/damage to infrastructure.
- A brain drain, professional isolation and high attrition rate have contributed to a general lack of appropriately qualified/experienced clinical staff within the health sector.
- Primary health care is provided by government, NGO and UNRWA managed centres, staffed by a variable mix of doctors, nurses, female health workers, pharmacists, dentists and laboratory technicians.
- Of the 27 hospitals in Gaza 13 are managed by the Palestinian Ministry of Health (with a total of 1,500 beds), with the private sector and NGOs managing the remainder (with a total of 500 beds). Most of the hospitals are small, specialist units, with only three Ministry of Health facilities having the capacity to manage major trauma: Shifa hospital, in Gaza city, and the Nasser and European Gaza hospitals in Khan Younis.
- Traumatic injuries account for 35-50% of all emergency admissions to these hospitals. The most common cause of serious injury or death is the ongoing conflict, followed by road traffic accidents and social violence. Airstrikes, incursions and levelling operations continue to threaten the population, with the Israeli military operation “Pillar of Defence” in 2012 killing 174 (including 36 children) and injuring another 1,046. Each escalation in the conflict is also followed by a surge in the number of deaths and injuries caused by explosive remnants of war (ERW), with children particularly vulnerable.
- Hospital emergency departments and trauma surgeons have struggled to cope with the magnitude of the problem, with professional isolation, a lack of resources (primarily consumables because of the blockade) and limited use of standardised care pathways reducing the impact of available services.
- The quality of care provided for major trauma victims has been impossible to monitor or evaluate because of the lack of routinely collected data regarding the nature/severity of the injuries sustained and the eventual outcome. The lack of such data precludes meaningful audit of major trauma care.
- Despite the lack of routinely collected data, senior surgeons at Shifa, Nasser and European Gaza hospitals have confirmed that major limb injuries pose particular problems within Gaza. Reconstructive surgery following initial emergency treatment is not available, forcing patients to wait months for permission to leave and undergo surgery elsewhere. Unfortunately there is no mechanism for monitoring the quality of such interventions and no follow-up care is available once the patient returns to Gaza. This results in a high incidence of long-term complications (poor healing of fractures, chronic bone infections and deformity), ultimately compromising the physical, psychological and social well-being of patients.
- The United Nations Office for the Coordination of Humanitarian Affairs has recognised the extent of the trauma problem and included the following objective as a priority in the 2011 Common Humanitarian Action Plan for the Occupied Palestinian Territories: To strengthen the capacity of health providers and communities to respond to emergencies.
i). Primary Trauma Care (PTC) and difficult airway management training – completed
With funding and logistic support provided by Medical Aid for Palestinians (MAP), IDEALS coordinated a PTC training programme in the Gaza Strip from 2010 to 2012. The Human Resources Development Directorate (HRDD) at Shifa hospital, Gaza city, was the key local partner: identifying the need; selecting the participants and releasing them from their government posts; and hosting the training itself. PTC had its inception in a 1997 proposal to the World Health Organisation (WHO) to reduce the mortality of trauma victims in the developing world, and has now been endorsed by the WHO for that purpose. It is run by the PTC Foundation, in association with the World Federation of Societies of Anaesthesiologists, with training provided free of charge. The training is designed to provide the basic knowledge and skills necessary to identify and treat trauma survivors who require rapid assessment, resuscitation and stabilisation of their injuries. A combination of lectures and practical skill stations are used to learn an approach to trauma management that, unlike alternatives such as the American College of Surgeons ATLS and the EMST Australian course, does not rely on sophisticated equipment and technology and highly skilled support staff. The training is adapted to local circumstances with significant input from senior local doctors. In Gaza 123 doctors, nurses and paramedics attended the PTC training, with 36 subsequently trained as trainers to further disseminate these skills within their facilities and organisations. In 2011-12 further PTC courses were provided for doctors and nurses in the West Bank.
In addition, IDEALS collaborated with HRDD to provide emergency department doctors and anaesthetists in Gaza with advanced training in the management of difficult airways: a critical component of trauma care management.
MAP was key to the success of the above projects, with implementation completely reliant on their long-term presence in the region and effective working relationships with both the Israeli and Palestinian authorities. Senior surgeons and anaesthetists from King’s College Hospital (KCH), London, and the Royal Victoria hospital, Belfast, delivered the PTC and airway management training.
ii). Development of limb reconstruction services – ongoing
iii). Support for the restructuring of trauma care services – ongoing
IDEALS is also providing support for the Ministry of Health’s attempts to restructure trauma care services in Gaza, drawing on the experience of trustees who have been closely involved in the same, lengthy process in London and the south of England. A workshop held in Gaza in January 2013 produced a set of recommendations that were subsequently agreed by all stakeholders, and further meetings in November 2013 began the process of implementing those recommendations.
Occupied Palestinian territories (oPt) - Development of Rehabilitation Services
- In theory the Ministry of Social Affairs (MoSA) has the lead responsibility for ensuring an integrated package of care for persons with disability (PWD) and their families in the Gaza Strip and the West Bank. However, despite the presence of very favourable legislation, implementation is poor.
- In terms of rehabilitation there are no specialist services provided by the government or UNRWA: services are found only in the NGO and private sectors.
- Rehabilitation services are not available within the existing network of primary health care centres.
- Training institutes for rehabilitation workers (physicians, physiotherapists, occupational therapists and psychologists) do exist within the oPt, but the courses provide little practical experience for trainees.
- Many agencies are registered with the MoSA as providing rehabilitation services for PWD in the Gaza Strip and the West Bank. In reality, very few provide a sustained, credible level of service.
- The absolute lack of service provision for PWD and their families is further compounded by the extremely limited coordination and integration of available services: leading to greater inequity in terms of accessing those services.
- A major 2011 survey in the oPt reported that, largely as a result of failing to enter or complete formal education, 91% of PWD aged 15yrs and over were unemployed; very few PWD have ever been offered any form of vocational training; and although existing legislation requires 5% of public employees to be PWD, it has not been enforced due to financial constraints and a lack of appropriately qualified PWD.
i). Partnership with the National Society for Rehabilitation (NSR), Gaza – ongoing
This NGO was established in 1991 following the amalgamation of a number of pre-existing rehabilitation NGOs in the Gaza Strip. They have a large office in Gaza city, complete with administrative/accounting support, meeting rooms and a small workshop. A computer laboratory has been established, with linked vocational training courses in computer repair and maintenance: these 30 hour courses are offered to groups of young men and women with disabilities, with the most successful graduates provided with the seed money to establish small businesses. However, the focal point of NSR’s operation is a team of 15 community based rehabilitation (CBR) workers (and four supervisors) supporting PWD in their own homes. The service covers four of the five provinces, excluding the north. The CBR workers are mainly from a social work background, with a few rehabilitation specialists (degree or diploma level), and they conduct a detailed preliminary assessment of a PWD and their family situation following referral from a wide network of other NGOs. This leads to a jointly agreed action plan, incorporating direct interventions (individual/group counselling, provision of a limited number and range of home aids and adaptations, summer camps, and the intermittent distribution of donated mobility and hearing aids), the promotion of inclusive education and the referral, as needed, to other rehabilitation agencies or for medical assessment. NSR does not receive any funding from the government or UNRWA.
The workshop has recently been expanded to maintain and repair manual wheelchairs, walking frames and other simple assistive devices. Spare parts are charged at cost if families can afford it, but otherwise the service is free. The technician is well qualified and very experienced.
Initially IDEALS funded a general upgrade of the workshop (a new soldering/de-soldering station and DC power supply). We then purchased a Huntron Protrack 1 Model 20 plus Scanner, to facilitate the component part analysis of electric scooters/wheelchairs, and provided the technician with the necessary training to use this equipment. Whilst it is important to not overly promote the use of electric scooters/wheelchairs, as the use of manual devices helps maintain muscle tone and core stability for those with paraplegia, it is equally important to ensure that those unable to use manual devices (those with dense hemi or tetraplegia for example) have access to electric alternatives. Previously there was no accessible repair service for electric devices in the Gaza Strip, so the high initial investment was wasted as soon as a component part failed.
More recently we purchased five Braille computer-speakers to allow those with visual impairment to utilise the computer laboratory.
We hope to build on this developing relationship with a very effective and reliable partner.
ii). Development of occupational therapy services, Gaza – completed
Al Asdiqaa Association is a local NGO that runs a community based rehabilitation (CBR) programme for the disabled in Rafah, south Gaza.
The team, consisting of physiotherapists, psychologist and community volunteers, accepts both external agency and self-referrals, and conducts a comprehensive assessment of each client, leading to an action plan. In the case of predominantly sensory or learning disability, this largely involves referral to other agencies. In the case of predominantly physical disability a number of options are available: education/awareness raising for all members of the family; provision of physiotherapy and/or psychological support; training of family member(s) to provide simple physiotherapy; and the provision of assistive devices (mobility aids and home aids/adaptations), either from the Association or through referral to another agency. Attempts are also made to secure financial support from the community, UNRWA and the government as appropriate.
The team also works within the wider community, helping to raise awareness, improve access to Mosques, schools, government buildings and other public places, and to support the local Union of Disabled Persons.
The lack of occupational therapy (OT) input to the project was a major limitation, given the profession’s skills in physical rehabilitation, environmental adaptation, assistive devices and provision of psychological support. Thus, funded by Interpal, we recruited an experienced occupational therapist for a 12 month period from 2011-12. During this time the therapist added OT input to the assessment, implementation and follow-up process with new and existing referrals, but also provided in-service training for the remaining team members and helped develop guidelines, thus enhancing organisational capacity in a sustainable manner.
iii). Livelihood support project for persons with disability, West Bank - ongoing
This new project, funded by Interpal and IDEALS, began in the north of the West Bank in December 2013. Together with our local partner, Palestinian Medical Relief Society (PMRS), we are attempting to improve the social integration and financial independence of 18 PWD through the provision of: vocational training (hairdressing and wheelchair/scooter maintenance); training in the management of a small business; and a start-up grant to establish their own small business. This is an exciting new project, one which we hope to expand and replicate within the Gaza Strip.
i). Assistance post earthquake 2005-6 – completed
ii). Bedadi village 2006-9 – completed
The villagers of Bedadi on the Pakistan Kashmir border were made homeless when their houses were destroyed in the earthquake of 2005. After initially providing emergency relief (in the form of shelter, food and essential non-food items) IDEALS then purchased a piece of land on which to build new homes. After lengthy administrative delays and an intensive building programme, fully funded by IDEALS and managed by CAMP (a local NGO), 26 families moved into new earthquake proof houses in February 2009: thus giving them great security and preserving their sense of community. Many of the villagers used the opportunity to acquire building skills under the supervision of master craftsmen and these skills will be used to support their families. A mains electricity supply was subsequently connected to each household and the children integrated into local schools.
The deeds of their houses were handed over to the villagers at a ceremony in Islamabad, attended by John Beavis and Andrew Ferguson, in April 2010.
Supported by IDEALS, a comprehensive survey was conducted at Bedadi village in 2008. We identified a number of children with significant health problems, including severe malnutrition, anaemia and visual impairment. Subsequently all these children were assessed and investigated by child health and eye specialists in nearby Mansehra city, receiving drug treatment and corrective glasses as needed. We also supported a three month supplementary feeding programme for the most underweight children at Bedadi, in conjunction with a series of health and hygiene workshops for all Bedadi families (to raise awareness of good feeding practices and reduce the risk of diarrhoeal and related illnesses): this was hugely successful, resulting in a significant reduction in the global malnutrition rate within the village.
iii). Development of trauma care services in the Federally Administered Tribal Area (FATA) 2006-9 – completed
There is a huge burden of trauma within FATA, arising primarily from road traffic accidents, gunshot wounds and landmines/unexploded ordnance. Obviously the burden is currently much greater given the conflict and floods ravaging the region. Due to a lack of suitably skilled health workers and the necessary equipment people are dying unnecessarily and being left with avoidable disability. In conjunction with CAMP, a local NGO, and the FATA Health Directorate, we began to address these issues with the following interventions:
The Primary Trauma Care (PTC) Course is the World Health Organisation (WHO) approved trauma care training package for remote, resource-poor environments. Over the three years we conducted a series of PTC Courses in Peshawar. Subsequently a group of highly respected local instructors established a Faculty (with representatives from each of the major teaching hospitals) dedicated to the teaching of PTC.
With our continued support the Peshawar PTC Faculty trained a cohort of 75 senior doctors from FATA hospitals. 17 of the most dedicated and skilled of these doctors were trained as instructors, to disseminate the PTC Course to the remaining hospital workforce in FATA.
In addition all of the Agency Headquarter hospitals within FATA were provided with the basic equipment necessary to provide life-saving trauma care for victims. By providing this equipment, those trained in PTC were able to utilise (and thus consolidate) their new skills immediately.
iv). Disability Resource Centre, Mansehra District 2009-10 - completed
In conjunction with CAMP, a local NGO, we funded and ran a disability programme in Mansehra district for two years. This operated from a Resource Centre in Mansehra city, which acted as a focal point for the coordination of disability services in the district and the dissemination of information relating to those services to the disabled, their carers and the wider community. The multidisciplinary team also provided extensive outreach services: awareness raising workshops and collaboration with local schools to promote inclusive education for children with disabilities; household surveys to identify children and adults with disabilities; physical rehabilitation programmes, together with relevant training for the disabled and their carers; referral of the disabled to other agencies providing specialist services in the area (including those fitting prosthetic and orthotic devices); and the provision of mobility aids to the disabled (walking sticks, crutches and wheelchairs).
v). Development of community midwifery services in FATA 2008-12 – completed
Maternal and newborn health outcomes in the region are appalling. The lack of skilled health workers contributes hugely to the problem. In partnership with CAMP, a local NGO, and in collaboration with the FATA Health Directorate, we began this initiative in December 2008: having recruited 15 young women with the necessary academic qualifications, motivation and family support, their 20 month training programme to become the first community midwives to operate in Khyber Agency and adjacent Frontier Regions began in April 2009. The training took place in Peshawar, coordinated by the Provincial Health Services Academy, under the auspices of the Pakistan Nursing Council. All 15 graduated successfully at the end of 2010, although they didn’t receive their professional certificates from the Pakistan Nursing Council and thus start work in their home communities until 2012. They are now providing essential ante-natal, delivery and post-natal care for mothers and their newborn babies, and IDEALS supported two of them to go on to complete further training to become lady health visitors. We also funded major rehabilitation and construction work at their training institute in Peshawar, upgrading facilities for future students.
vi). Assistance post floods/conflict 2010 – ongoing
As evidenced by the projects above, our nine year partnership with Community Appraisal & Motivation Programme (CAMP) in Pakistan has proved extremely successful. In those projects described above IDEALS acted as both donor and partner. Since then our contribution has been purely technical, with Dr Andrew Ferguson acting as CAMP’s health programme manager, providing: training for CAMP’s senior staff; support for health needs assessment and the development of health related proposals and grant applications; support for the monitoring and evaluation of existing health projects; and liaison with UN, governmental and NGO partners, and donors. This collaboration has resulted in a series of successful grant applications and the successful delivery of a series of emergency and developmental health projects in Khyber Pakhtunkhwa (KP) and Balochistan Provinces and the Federally Administered Tribal Area (FATA), regions devastated by floods and ongoing conflict in recent years. With CAMP we ran an emergency health programme in the flood affected Jaffarabad district of Balochistan that incorporated both static and mobile clinics, and continue to provide essential primary health care and maternal/child health services from two static clinics in Jalozai Internally Displaced Persons (IDP) camp, Nowshera district, KP: the largest IDP camp in Pakistan, with a population that has varied from 70-100,000 in recent years.
Ongoing projects are summarised below:
FATA Emergency Health Care Project
This is a major project funded by the German government, aiming to significantly increase emergency care capacity within hospitals and other key health facilities in the region. The priority setting (for construction work and purchase of equipment for target health facilities throughout FATA) process is now complete and a formal procurement process has begun. We are now developing resources for the training component of the project, which will focus on emergency care and major disaster response, as well as considering options for an expansion of the project over the next three years.
Health Centres at Jalozai IDP Camp, Nowshera District, KP
As a result of increasing beneficiary numbers (the camp population has again climbed to over 90,000 as a result of an escalation in the conflict between government and extremist forces in FATA) the World Health Organisation (WHO) asked us to establish a second health centre at Jalozai in May 2012, working alongside the four centres operated by MERLIN. Both our centres are seeing an average of 175 patients per day and recently received an extremely positive evaluation from the WHO (the current donor). Funding is secure until mid January 2014 and further grant applications have already been submitted to the WHO for a further project extension. The need remains high, as demonstrated by a recent and extremely worrying rise in the level of acute childhood malnutrition within the camp.
Health Recovery Project, Charsadda and Nowshera Districts, KP
The second phase of this project was completed at the end of September 2013, with a further 11 (one more than originally planned) health facilities repaired/re-equipped and a further 443 government health workers attached to these facilities (lady health workers and paramedics) having received our intensive maternal/child health training programme. The German government has funded phase three, which will see another eight health facilities repaired/re-equipped and 400 government health workers trained in the 12 month period from October 2013.
Acute Respiratory Infection (ARI) Centre, Lower Dir District, KP
The project closed as originally planned at the end of the ARI season, but will hopefully be launched again next year.