Akik C, El Dirani Z, Willis R, Truppa C, Zmeter C, Aebischer Perone S, Roswall J, Hamadeh R, Blanchet K, Roberts B, Fouad M F, Perel P, Ansbro É
Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Lebanon.
Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
J Migr Health. 2024 Oct 3;10:100269. doi: 10.1016/j.jmh.2024.100269. eCollection 2024.
The burden of non-communicable diseases (NCDs) is increasing among populations living in humanitarian settings. Continuity of care (CoC) involves following an individual over time and across different levels of healthcare (management, longitudinal, informational and interpersonal continuity); it is an essential component of good quality, person-centred NCD care. Providing CoC is particularly challenging in humanitarian crises where health care access may be interrupted or restricted. This paper aimed to explore health actors' experiences of continuity of hypertension and diabetes care for Syrian refugees and vulnerable Lebanese in Lebanon.
We conducted 20 in-depth qualitative interviews with health actors, including eleven with health care providers at four urban-based health facilities supported by international humanitarian agencies that provide NCD care to Syrian refugees and vulnerable Lebanese, one representative of a governmental institution, one international delegate and seven humanitarian actors. Thematic analysis, combining inductive and deductive approaches, was guided by a conceptual framework for NCD models of care in humanitarian settings. We reported our findings against the conceptual framework's domains relating to health system inputs and intermediate goals, reflecting on their impact on the domains of CoC.
Existing health system weaknesses and novel challenges (the economic crisis, COVID-19 pandemic and Beirut blast) to continuity of NCD care were identified. Health system input challenges: governance and financing (weakened governance, limited central financing, historical dependence on local NGOs for primary healthcare, a dominant private sector), health workforce (exodus of health care providers from the public system), inconsistent medicines and equipment supplies, and limited health information systems (no unified system across institutions or levels of care, lack of formal referral systems, and inconsistent facility-level data collection) contributed to limited public primary care, poorly integrated within a fragile, pluralistic health system. These factors negatively impacted the intermediate health system goals of access, standardisation and quality of NCD care for Syrian refugee and Lebanese patients, and collectively hampered the management, longitudinal, informational and interpersonal continuity of NCD care in Lebanon.
We recommend that humanitarian actors continue the work underway with the Lebanese Ministry of Public Health to align with and strengthen health system inputs, including supporting health governance through the accreditation process, exploring new funding mechanisms, strengthening the workforce via task sharing and training, supporting the medication supply chain, improving access to facilities and service quality, and supporting the development, standardisation and interoperability of referral and information systems. In combination, these elements will support better CoC for people living with hypertension and diabetes in Lebanon.
在生活在人道主义环境中的人群中，非传染性疾病（NCDs）的负担正在增加。连续性照护（CoC）涉及随着时间推移并跨越不同医疗保健层面（管理、纵向、信息和人际连续性）对个体进行跟踪；它是以患者为中心的优质非传染性疾病照护的重要组成部分。在人道主义危机中，提供连续性照护尤其具有挑战性，因为医疗保健服务的获取可能会中断或受到限制。本文旨在探讨卫生工作者对黎巴嫩境内叙利亚难民和脆弱的黎巴嫩人进行高血压和糖尿病连续性照护的经验。
我们对卫生工作者进行了20次深入的定性访谈，其中包括对11名在由国际人道主义机构支持的4个城市卫生设施中为叙利亚难民和脆弱的黎巴嫩人提供非传染性疾病照护的医疗服务提供者、1名政府机构代表、1名国际代表以及7名人道主义行动者进行的访谈。结合归纳法和演绎法的主题分析，由人道主义环境中非传染性疾病照护模式的概念框架指导。我们对照概念框架中与卫生系统投入和中间目标相关的领域报告了我们的研究结果，并反思了它们对连续性照护领域的影响。
确定了非传染性疾病照护连续性方面现有的卫生系统弱点和新出现的挑战（经济危机、新冠疫情和贝鲁特爆炸）。卫生系统投入方面的挑战：治理和融资（治理薄弱、中央融资有限、初级医疗保健在历史上依赖当地非政府组织、私营部门占主导地位）、卫生人力（公共系统中医疗服务提供者外流）、药品和设备供应不一致以及卫生信息系统有限（各机构或照护层面没有统一系统、缺乏正式转诊系统以及机构层面数据收集不一致）导致公共初级保健有限，在脆弱的多元化卫生系统中整合不佳。这些因素对叙利亚难民和黎巴嫩患者获得非传染性疾病照护、照护的标准化和质量等卫生系统中间目标产生了负面影响，并共同阻碍了黎巴嫩非传染性疾病照护的管理、纵向、信息和人际连续性。
我们建议人道主义行动者继续与黎巴嫩公共卫生部开展正在进行的工作，以协调并加强卫生系统投入，包括通过认证过程支持卫生治理、探索新的筹资机制、通过任务分担和培训加强卫生人力、支持药品供应链、改善设施获取和服务质量，以及支持转诊和信息系统的开发、标准化和互操作性。综合起来，这些要素将支持为黎巴嫩的高血压和糖尿病患者提供更好的连续性照护。
