20150212_HAI Health needs assessment lebanon_Final Report

Health needs assessment of vulnerable older Lebanese

populations and older Syrian Refugees

(Lebanon – February 2015)

Picture by HelpAge International

Final report

Table of Contents

Introduction ............................................................................................................................................ 3

Acknowledgments: ................................................................................................................................. 3

Section 1 Scope and Methodology ........................................................................................................ 4

1. Scope of the assessment ............................................................................................................. 4

2. Assessment methodology ........................................................................................................... 5

Section 2: Assessment limitations ........................................................................................................ 11

Section 3: Key findings and health priorities ........................................................................................ 14

1. 40 + and 60+ years old population estimates. .......................................................................... 14

2. Population estimates in PHC catchment areas ......................................................................... 14

3. Household profile...................................................................................................................... 15

4. Analysis of the household vulnerability criteria ....................................................................... 19

5. Mental health status ................................................................................................................. 25

6. Key findings on Access to health ............................................................................................... 27

7. Health priorities-Programmatic recommendations based on household survey key findings 29

8. Key findings on PHC analysis ..................................................................................................... 31

Introduction:

With over 1.1 million of Syrian Refugees representing around 20% of the population and a poverty

level of 28.6% for nationals; Lebanon faces great challenges for granting the basic human right of

universal access to health. Moreover, 75% of health facilities are private while the two main

ministries in charge of health services, Ministry of Public Health (MoPH) and Ministry of Social Affairs

(MoSA), have limited capacities and often need to rely on local charity organizations and

international aid for ensuring a minimal level of access to vulnerable communities.

In general terms, the health situation in Lebanon is surprising when speaking about a middle income

country with a population of 4+ million people. However, the lack of access to basic services, not

only health, is structural and enrooted with the recent history of the country.

Despite several international initiatives, as the EUR 20 million pilot project of the European Union

Stability funding for Lebanon focusing on enhancing MoPH and MoSA health capacities, the level of

needs are not fully covered yet and its sustainability over time is not ensured.

Whereas Lebanon is the MENA region country with the highest prevalence of NCD (63.8%); the lack

of granted access to health care provokes a direct negative impact on older people and people

affected by chronic diseases from both communities, vulnerable Lebanese and Syrian Refugees.

Often, the absence of a sustainable income for ensuring NCD long-term treatments leads to negative

coping mechanisms such as not accessing to health facilities or not following the prescribed

treatments regularly. Furthermore, there is very little knowledge about the levels of psychological

distress and disability within older Lebanese and Syrian so far due the lack of specific interventions

addressing these problems.

HelpAge International has a developed a strategy for ensuring the access to NCDs treatment working

in collaboration with health partners in Lebanon. On regards to this strategy, the need of a) feeding

the current intervention with evidence-based findings; b) ensuring that the programmatic

interventions are tailored to the specific needs of older people and c) targeting the most vulnerable

population within both communities, justified the implementation of a health focus needs

assessment in four of the country governorates. The needs assessment was carried out between

January 19th

to February 13th

2015 covering Mount Lebanon, South Lebanon, West and North Beeka.

The analysis, findings and operational recommendations reflected in this report are result of this

exercise.

Acknowledgments:

The assessment team would like to thank the continuous and effective support of all the staff

involved during the implementation of this exercise. In particular, we would like to thank HelpAge

staff in London and Lebanon, Amel Association, Imam Sadr Foundation and Makassed for their help

and facilitation. Without their contributions and dedication, the final results of this assessment

wouldn’t reach the level of accuracy and quality required.

Most importantly however HelpAge would like to thank all the older people and key informants who

took part in the assessment and provided the rich evidence and experience on which this report is

based.

Section 1 Scope and Methodology

1. Scope of the assessment

Scope of the assessment and teams’ composition

During the decision –making process of the operational arrangements phase, the geographical scope

of the assessment was divided into four regions corresponding to the governorates political division

in Lebanon: Beirut-Mount Lebanon, South Lebanon, North and West Bekaa. In Beirut - Mount

Lebanon and in the South, one focal point was in charge of two teams of 2 enumerators. For the

Beeka regions, the focal point was supervising 4 teams of 2 enumerators. The gender balance was

respected in all the teams.

Each team of 2 enumerators (1 female, 1 male) was supposed to collect 36 interviews during the 6

days of data collection such that the objective was to collect up to 288 household interviews.

The total number of staff involved in the needs assessment was 23, their division by role and

responsibility was:

1 Assessment Coordinator; 2 Health Advisers; 1 Data Analyst; 3 Focal Points; 16 Enumerators

Scope of the Household Survey data collection

The following table provides the planning of the interviews by region and a type of area subdivision.

The last column presents the number of interviews that were validated and uploaded into the

dataset.

Table 1: Planning of the interviews

Region Type of area Interviews

planned

Valid interviews uploaded

into the dataset

Beirut and Mount

Lebanon

100% of

Urban/periurban 72 79

South

25% ITSs

60% Rural

13% Urban

72 75

West and North

Bekaa 100% Rural 144 135

Grand total: 288 289

Scope of the PHC Facilities assessment

There were 9 facility assessed in the four covered regions. The interviews were made by the focal

points or the assessment coordination team.

Table 2: List of facility assessed by geographical area

Name of the facility Qaza Region

Al Ain Amel Association PHC Baalbeck North Bekaa

Al Sader foundation Aita Chaab centre Bint Jbeil South Lebanon

Tyre Amel Association PHC Sour South Lebanon

Al Sadr Foundation Siddiqine Sour South Lebanon

Al Sadr Foundation Kfarhata Saida South Lebanon

Al Bashura Beirut Beirut / Mount Lebanon

Al Harash medical centre Beirut Beirut / Mount Lebanon

Kamed el Loz Amel PHC West Bekaa West Bekaa

Hay el sellom Amel PHC Mount Lebanon Beirut / Mount Lebanon

2. Assessment methodology

The 2015 HelpAge International health needs assessment with focus on older vulnerable Lebanese

and Syrian refugees was carried out in Lebanon for a period of 21 working days between January

19th

to February 13th

.

The assessment objective was twofold;

a) Analysis in 4 country regions of the Primary Health Centres (PHCs) facilities following WHO

criteria of Access, Accessibility/Availability and Quality of health services with the intention

of obtaining a profile of the current PHCs status and;

b) A purposive sample at household level. The main objective of this sample was to collect

enough relevant information regarding the access to health of the vulnerable Lebanese and

Syrian Refugees in any of the regions assessed during the exercise.

The combination of both exercises allowed to HelpAge International to draw an evidence-based

analysis that can be used for future planning and prioritization of its response programmes. This

methodology section details all the staggered phases and methodological approaches applied during

the assessment considering as timeline the agreed planning between the assessment team, HelpAge

International and their partners in Lebanon:

Figure: Assessment timeline

Week starting on

January February

19 26 2 9

Definition of Primary Data tools and assessment

methodology

Focal Points Training

Enumerators Training

Primary data collection

Data uploading

secondary data review & analysis

Analysis workshop and submission of inception report

Reporting

The components and actions taken during each of these phases are as follows:

1. Definition of Primary Data tools and assessment methodology (3 days)

The first three days of the assessment were focused on defining 1) scope of the assessment; 2)

Primary data tools and 3) assessment methodology for ensuring the planned objectives. The scope

of the assessment is already detailed in the above section, regarding the primary data and

methodology:

a. Primary Data rationale:

Rationale:

During the internal discussions before starting the data collection exercise, it was defined to proceed

with a Household Survey sample combining random and purposive modalities.

Random: Each of the four assessed areas followed a “snowball” process for identifying the

households. The first interviewed household was identified by the social workers of the PHCs.

Afterwards; the enumerators together with the support of the focal points identified other

households within the selected categories asking the neighbourhood.

Purposive: This kind of sample was the best one adapted to the assessment objectives. Purposive

modality selects the sample based on certain knowledge of the population and the purpose of the

needs assessment. The selection is based on one or more specific characteristics explained in the

sections below. The following graphic shows how this assessment followed the standard criteria for

a purposive sample modality:

Representative sampling

Precision

Purposive sampling

Convenience sampling

Methodology

Phase I Phase II Phase III & IV

Time and Cost

Source: ACAPS.

b. Data collection tools:

Household Survey Questionnaire: Designed with a combination of HelpAge International expertise

on health needs assessment with tools successfully tested in the region. The format takes some of

the components from the 2013 urban Refugee profile in Southern Turkey (UNHCR) and 2014 SAMI

MSNA for Syria (SAMI). This tool, to be used by the enumerators and area focal points, was

produced in English and Arabic versions.

Health Facilities Questionnaire: The tool was designed for assessing the existing capacities and gaps

on each of the 3 organizations participating in the assessment PHCs following the analysis criteria of:

Access, Availability/Accessibility and Quality of the primary health services. The objective of the

facility assessment was not to evaluate the centres having as reference these three criteria, but to

obtain a better understanding of their capacities and how upcoming programmes would enhance

their current situation. The questionnaire, designed for being used by the assessment coordination

team and focal points, was produced on English version only.

c. Analysis tools:

In addition, two analysis tools were produced with the objectives of a) providing a framework for the

joint analysis phase and b) defining pre-established criteria for ranking and prioritizing responses.

These tools are:

Health Severity Scale: Using the same rationale applied during the SIMA-MSNA and OCHA-HNO1 &

AoO2; the Health Severity Scale template was adapted for the purpose of this exercise. Applying logic

1 HNO: Humanitarian Needs Overview

2 AoO: Area of Origin

of WHO standards and thresholds on access, availability and quality of health services; the

assessment team was able to rank and prioritize the needs and potential responses during the joint

analysis phase.

Households and facilities criteria: Complementing the Severity Scale the questions included in the

Household and Facility questionnaires were grouped on access, availability and quality sections with

the same intention of easing the joint analysis.

d. Categories vulnerable groups:

The assessment team together with HelpAge team, pre-defined a list of categories of the potentially

most vulnerable groups expected to be identified within the sample considering socio-economic

determinants. These determinants are expected to make direct impact in their levels of vulnerability

and coping mechanisms for accessing to health services. Moreover, the division by categories

allowed the identification of the prevalence of each of them and fostered ranking the priorities.

The six selected vulnerable categories were:

. 40+ years old with chronic diseases

. Older People Head of Household (Female /Male)

. Older People living alone (Female /Male)

. Older People no receiving any assistance or HH unregistered by UNHCR

. OP living in HH with + 5 members

. Disabled

The identification at household level of any of these categories was done by the enumerators and

Focal Points once the interview was, not during it, in order ensuring the accuracy.

Figure: Profile of the vulnerable categories assessed.

Affected population

40+ years old with chronic

diseases

Older People Head of

Household (Female /Male)

Older People living alone

(Female /Male)

Older People no receiving assistance

OP living in HH with + 5

membersDisabled

Vulnerable Lebanese

Syrian Refugees

Non affected population

2. Focal Points Training (1 day)

The Focal Points of each of the regions included in the assessment were trained during one day on a

quick inception on needs assessments & information needs; primary data collection techniques;

questionnaires and operational arrangements required for the data collection phase.

Training materials for this phase are available upon request.

3. Enumerators Training (1 day)

Focal Points trained their teams partially replicating the Focal Points’ training and focusing on the

scope and use of tools for the data collection. Moreover, all the 16 enumerators read and signed

HelpAge International Protection Policy and Code of Conduct before their deployment and as pre-

condition for being considered part of the assessment team.

4. Primary data collection, data uploading and secondary data review & analysis (7 days)

Data collection: The primary data collection lasted for six days and according to the aspects detailed

in the scope of the assessment section. The coordination team visited each of the areas on daily

basis and kept constant communication with the Focal Points in order to solve any problem or

discuss their doubts and suggestions.

Data uploading: Simultaneously to the data collection, the assessment team uploaded the

household and facilities interviews on daily for ensuring a smooth implementation. While the

responsibility mainly relied on the assessment team, HelpAge implementing partners supported this

task providing temporal data clerks. Data upload included a quality control check of the

questionnaires submitted; those ones not having an optimal level of reliability were rejected.

Secondary data review & analysis: Having as main focus the production of population estimates of

vulnerable Lebanese and Syrian refugees for Lebanon and the regions covered by the assessment;

the assessment team made a review and analysis of the secondary data of the already existing

reliable sources. The final results of this process are core part of this report while the full

methodology and supporting documents as included as report annexes

5. Analysis workshop and submission of inception report (2 days)

Analysis Workshop: HelpAge team, Focal Points and partners participated in the analysis workshop.

The one-day session was divided into two different sections:

. Briefings on Household and PHC assessment results.

. Analysis using the tools designed (Severity Scale and criteria)

The analysis session brought as result a prioritization and ranking of the initial findings which defined

the main recommendations reflected in this report. The importance of the analysis session relies on

the need of joint package of conclusions endorsed by all stakeholders involved in the assessment

ensuring that the final profile, identification of needs and programmatic recommendations will be

followed by a programme and strategic design in the coming period.

Inception report: Looking for the endorsement and recommendations from HelpAge International in

London, an inception report was submitted a day after the analysis session showing the initial

findings and recommendations agreed at field level.

6. Reporting (7 days)

Last days of the deployment were focus on producing the final version of the assessment report

ensuring all findings and conclusion were evidence-based and aligned to the initial objectives and

goals defined.

Section 2: Assessment limitations

In order to avoid the risk of misusing the results, several limitations need to be taken in c

consideration

when using this assessment figures.

Population figures: Out of the household sample, population figures are based on estimations either

for national level or catchment areas not accurate data. However, the methodology applied

including the triangulation of reliable sources and already tested methodologies can be perfectly

consider by health stakeholders as starting point for programme planning purposes.

Sampling: As explained in the methodology section, the sampling methodology chosen was

purposive limiting the scope to the population of interest of this exercise. Therefore, the

percentages and figures showing the health status at household level are corresponding to the

sample itself only; they cannot be projected for analysing the health status of the overall population

of the two assessed groups.

Data on mental health and disability: The information collected for these two sections relied on the

enumerators’ responsibility without having a particular expertise for professionally screening for any

of them. While the resulted figures can be used for highlighting the metal health and disability status

of the households assessed, they cannot be considered neither for the identification of patients nor

for health referral purposes.

Age and gender breakdown in our sample

Syrian above 40 with NCD or Syrian above 60 Lebanese above 40 with NCD or Lebanese above 60 Sample composition including all HH members

Sex and age disaggregating data

Syrian population Lebanese population

Female Male Total Female Male Total

60+ yo: 2.8% 2.9% 5.7% 5.4% 5.8% 11.2%

40+ yo: 10.3% 10.5% 20.8% 17.9% 17.1% 35%

Physical health and access to health care

Republic of Lebanon: Health Needs assessment dashboard for 289 households in 4 assessed governorates

� Among the people

suffering from NCDs,

9 out of 10 people

have at least 2

diseases

� 1 out of 3 Syrian suffering

from NCDs is not taking

regular medication

� 90% of the people not

taking medication cannot

afford it

This dashboard highlights the findings and recommendations, product of the collation and analysis of secondary and primary data. The

assessment findings identify the most important needs of the targeted groups and their underlying factors.

� Almost half of the population

in South Lebanon reports

signs of distress

� 70% of the host community

reports some level of

disability

Facility assessment results

Quality: moderate problem

� Case management is not up to date or

accurate

� Information management tools are

not standardised or computerised

� Some essential non-medical

equipment is missing

Operational recommendations:

� Providing the PHCs with the essential

non-medical equipment � Standardising tools for information

management

Availability: moderate to major

� 6 out of the 9 centres experience

shortages most of the time


� Building contingency stock at PHC

level

� Accreditation of the centres by

YMCA’s chronic disease medication

programme

Access: major problem

� Centres comply with 58% of the

recommendations on information

provision

� 55% of the centre have a mobile unit

� Centres comply with 58% the

guidance on age-friendliness


� Long-term: outreach activities;

Short-term: increasing the use of the

mobile clinics

� Organise age-friendly hours to avoid

� Improve information display in the

centre on NCD services and

prevention

� Refurbish the centres to increase the

physical access

Section 3: Key findings and health priorities

This section describes the key findings and priorities identified during the assessment process. Profile,

conclusions and recommendations reflected in the following paragraphs are product of a staggered

three levels of analysis; 1st) Secondary and Primary Data collation and ranking; 2

nd)Database

comparative analysis and 3rd

) Joint analysis exercise.

1. 40 + and 60+ years old population estimates.

There is no precise census providing sex and age disaggregated data for both Syrian and Lebanese

population. However, having a clear idea on the number of older people in the population is critical to

ensure their effective inclusion in aid programmes.

As an alternative, a secondary data review and analysis was done to estimate the population. Several

sources were used for triangulation. They included the Multi-Indicator Cluster Survey (2009) elaborated

by UNICEF and the government of Lebanon, estimations made by HelpAge International (2013),

estimations provided by UNDESA (2010) and the UNHCR data (2015).

Details of the methodology are provided in the Secondary Data Review annex. The final estimation gives

the following results for the Lebanese population:

40+ yo: at least 35% (of which 45.4% female and 54.6% male)

60+ yo: at least 11.2% (of which 48% female and 52%male)

Following the conservative assumption that 11.2% of the Lebanese population is aged above 60, we can

estimate that there are 486,202 older Lebanese in the country.

The final estimation for the Syrian population gives:

40+ yo: at least 20.8% (49.6% female/50.4% male)

60+ yo: at least 5.7 % (49.1% female/50.8%male)

On the contrary to the Lebanese population, there is no certain figure on the number of Syrian refugee

population in Lebanon. As a result, the assessment team does not consider suitable to estimate a total

number for older Syrian currently residing in Lebanon. However, if considering other similar previous

analysis either inside Syria or neighboring countries and the displacement trends of all family members

moving together; it seems likely that in terms of percentages it will be close to the 5.7% from the total

refugee population.

2. Population estimates in PHC catchment areas

A key element of the access to health services is the catchment areas of the facilities in order to be able

of prioritize intervention areas and actions. This variable is hard to estimate as the facilities usually do

not have a clear estimation of the population they serve. In addition, the population of Lebanon is

estimated and the number of refugees is uncertain.

To at least provide a rough estimate of the catchment population in the assessed regions, it was

considered the total Lebanese population estimated for each municipality (Qaza), added the number of

refugees and divided this number by the number of PHCs in the Qaza. In some cases (Baalbek, Bint Jbeil)

the estimations didn’t provide any result. The table below provides the details of the estimation:

Name of the PHC Qaza Lebanese

population

Refugee

population

Number of

facilities

Catchment

areas

Al Ain Amel Association PHC Baalbek 231648 130366 Not

available

Not

available

Al Sader foundation Aita

Chaab centre Bint Jbeil 82345 8359

Not

available

Not

available

Tyre Amel Association PHC Sour 221040 32400 30 8448

Al Sadr Foundation Siddiqine Sour 221040 32400 30 8448

Al Sadr Foundation Kfarhata Saida 224624 48408 52 5251

Al Bashura Beirut 390238 30354 48 8762

Al Harash medical centre Beirut 390238 30354 48 8762

Kamed el Loz Amel PHC West

Bekaa 78916 68405 21 7015

Hay el sellom Amel PHC Mount

Lebanon 483777 94499 34 17008

3. Household profile

As explained in the methodology section, the sample was not representative of the whole host

community and refugee population as the households interviewed were selected according to two

criteria:

- Including a member aged above 60

- Including a member suffering from an NCD and aged above 40

Consequently, the paragraphs and graphs below provide an overview of the 289 assessed households

only.

Gender and Age composition

In our sample, there are overall 52% of women and 48% of men. In all regions appear to have a slight

higher of female;

Regarding age, as the figure below shows the age composition of our sample the proportion of people

aged above 60 is a lot higher (18%) than what is found in the SADD population estimates. This

percentage is mostly explained due the sampling selection criteria; however it provides a good picture of

the composition of the assessed households. It highlights a notable percentage of mid-age (22% 40-60

years old) and older people (3rd

age group) at risk or already suffering from NCDs and facing access

difficulties to treatments due their socio-economic vulnerability.

Figure 2: Age composition of the sample, including family members

Source: HelpAge International needs assessment data

Figure 1: Gender balance of the sample (289 HHs)

SADD sample composition of the targeted population (40+ with Chronic Diseases and 60+ years old)

Figure 3: Age and gender disaggregation

Lebanese households Syrian households

In our sample of interest represents 40% of the total household members, the proportion of people

aged above 60 years old reaches 80% for the Lebanese and 55% for the Syrian. The population aged

between 40 and 59 represent 20% of the Lebanese and 45% of the Syrian.

Country of origin of the interviewees

The figure below presents the composition of the sample grouped by citizenship. The key findings for

this section are:

- Mixed Lebanese and Syrians households represent a small minority of the sample (1 to 4%)

- Whereas in Mount Lebanon the sample is balanced between Syrian and Lebanese, in the South,

there were less Syrian than Lebanese probably due to the lower of Syrian refugees in the South

if compared if other regions of the country.

Figure 4: Origin of the households

Refugee household profile

Majority of the interviewed refugees are from Rural Damascus (15.6%) or Aleppo (14.2%). More

precisely, 27% the refugees interviewed in Mount Lebanon and 16% in the South came from Aleppo. The

interviewees in West and North Bekaa came, for the majority, from Rural Damascus (30%). The

concentrations by area of origin can be partially justified with three non-exclusive explanations:

- Staggered phases of the refugees influxes over the time. The different influxes faced by Lebanon

during the Syrian crisis have been always related with the military offensives inside Syria;

- Pull factor within refugees from the same area of origin looking for re-establishing their social

networks;

- Political/religious affiliations between the Syrian refugees and the hosting communities in

Lebanon.

The figure below gives averages across Lebanon.

Registration status

Most of the sample was registered under UNHCR (94% registered against 6% unregistered). In the

South, all households interviewed were registered. In Mount Lebanon, 95% of the households were

registered. Registration rates dropped in the Bekaa Valley regions where only 91% of the households

were registered.

Figure 5: Area of origin of the Syrian refugees

4. Analysis of the household vulnerability criteria


As described in the methodology section, in order to foster a comprehensive analysis of the household

sampling; there were 6 pre-defined vulnerability criteria disaggregated by gender for the 40+ suffering

from a chronic disease and 60+ years old.

The following table provides an overview of the composition of the sample of the vulnerable groups

following these criteria by each of the areas assessed during the exercise in Lebanon. The percentages

highlighted in red, represents the highest percentage per category and area.

Table 1: proportion of household entering the vulnerability criteria by area

North and West

Bekaa

Mount

Lebanon

South

Lebanon

Head is older man 27% 53% 43%

Head is older woman 10% 22% 20%

Older woman alone 5% 4% 11%

Older man alone 0% 0% 0%

Person aged above 40 with NCD 95% 100% 99%

Disabled 48% 76% 52%

Older person living with 5 other household

members at least 18% 32% 9%

Older person not receiving assistance or not

registered to UNHCR 4% 27% 0%

Hereby there is a description of each of the vulnerability criteria categories:

Households headed by an older person:

North and West

Bekaa

Mount

Lebanon

South

Lebanon

Head is older man 27.4% 53.2% 42.7%

Head is older woman 10.4% 21.5% 20.0%

In some regions as Mount Lebanon, older man head of Household reaches over 50% of the assessed

sampling. It is easy to conclude on the particular challenges these households will face for ensuring a

sustainable income. Negative coping mechanisms practices are highly expected within this category.

One of them would be the interruption to their medical treatments due the costs.

Older person living alone:

North and West

Bekaa

Mount

Lebanon

South

Lebanon

Older woman alone 5% 4% 11%

Older man alone 0% 0% 0%

Interestingly, we identified no older man living alone in our sample. Older women living alone are not

very frequent but still represent 11% of the households interviewed in the South, 5% of the households

in North and West Bekaa and 4% in Mount Lebanon. Half of these women are Lebanese, 39% are Syrian

and 11% are from another country.

One of the reasons explaining the strong discrepancy between genders under this criterion lies in

cultural reasons. In both societies, older people are unlikely to be left alone. This could explain the

absence in our sample and the low frequency of older women living alone. The analysis group pointed

out that their current social status (widowed, single etc.) would justify their current situation. The higher

number of older women alone could be explained because older men can remarry younger women,

while older widows often do not remarry.

Despite the low frequency of these categories if compared with others, the level of vulnerability of these

women living alone is supposed to be high or very high. Lack of access to livelihoods or family support

will lead this group to high levels of vulnerability hampering their access to health in a context where

social services are very limited.

Person aged above 40 with NCD

North and West

Bekaa

Mount

Lebanon

South

Lebanon

Person aged above 40 with NCD 95% 100% 99%

The proportion of households including a member aged above 40 and suffering from a chronic disease is

very high. It is 100% in Mount Lebanon, 95% in North and West Bekaa and 99% in the South. This fact is

explained by two factors:

a) There is a very high rate of chronic diseases in the Lebanese and refugee population;

b) The methodology applied for the sampling was a purposive, therefore the enumerators were

selecting the household according to two criteria: HH that include members who are “over 60

years old” or “over 40 with chronic disease”. As a result, in our sample anyone interviewed who

is under 60 is suffering from an NCD.

However, among the older people, who were selected on their age and not on their health status, rates

remain high. In fact, it is 100% Mount Lebanon, 92% in North and West Bekaa and 98% in the South. In

terms of analysis, the prevalence of NCDs among the interviewed households can be considered as

evidence for the assessment purposes only; it cannot be extrapolated to the rest of the population as

total percentages.

In addition and as comparative analysis, the following figure highlights the rates of co-morbidity by

region.

Comparative analysis I: Prevalence of co-morbidity for chronic

diseases by region

The figure shows that among the people suffering from an NCD, 92% suffer from more than one in

Mount Lebanon. In North and West Bekaa, 60% of the people the chronically ill people have more than

one disease. In the South, this proportion is slightly lower but remains worryingly high: 50%.

Without surprise, the rate of co-morbidity is higher among older people (69%) than among the younger

cohort (63%). This can be due to the fact that chronic diseases are the result of a longer term life habits,

such that older people are more likely to develop them.

Disabled:

North and West

Bekaa

Mount

Lebanon

South

Lebanon

Disabled 48% 76% 52%

The proportion of households with an Older Person or 40+ years old with disability varies between 75%

and 48%. This is high compared with the 15% of Global Disability prevalence (World Disability Report,

WHO). As HelpAge and Handicap International report (2014)3 underlines: in that sample, the proportion

of people suffering from a physical or cognitive impairment is closer to 20% in Lebanon.

The definition of disability during the assessment was limited to “difficulties” to hear, see, speak, move

or learn without any further scoring. The rationale behind this approach was to follow WHO’s position

on ageing and disability for which is concluded that “the proportion of people with disabilities is higher

among older persons (60+), mainly due to decreasing mobility, and the prevalence of chronic health

conditions associated with disability (incl. diabetes, cardiovascular diseases, and mental illness)”4.

Older people living in households with more than 5 members:

North and West

Bekaa

Mount

Lebanon

South

Lebanon

Older person living with 5 other household

members at least 18% 32% 9%

There are strong variations in the number of older people living in households with more than 5

members (32% in Mount Lebanon vs. 9% in the South). Importantly, 75% of the older people living with

more than 5 household members are Syrian in Mount Lebanon. Considering the scarce resources of

these households and the price of housing in urban areas, it is possible that different households

gathered under the same roof in Lebanon, resulting in more household members on average as coping

mechanism due the limited access to income. In terms of older people’s access to health, it is expected

these households residing in urban areas will prioritize other vulnerable groups (pregnant women,

children) or acute diseases. Therefore we can expect that this behavior is putting on risk regular access

to older people and their specific needs for long-term NCD treatments.

3 HelpAge International and Handicap International, Hidden Victims of the Syria crisis: disabled, injured and older

refugees, 2014 4 World Disability Report, WHO

Older person not receiving assistance:

North and West

Bekaa

Mount

Lebanon

South

Lebanon

Older person not receiving assistance or not

registered to UNHCR 4% 27% 0%

27% of the households interviewed in Mount Lebanon declared not receiving assistance. This figure is

high, both in absolute terms and relatively to the other regions. Within these households, 62% are

Lebanese, who may have a misperception of what is considered “assistance”. The figure may be

considered just as an indication of the level of assistance provided by the Ministry of Public Health

(MoPH) and Ministry of Social Affairs (MoSA). These Ministries are the key actors in terms of primary

health care provision for vulnerable Lebanese.

On the other hand, the 4% in Beeka Valley is probably connected to unregistered households or pitfalls

in the targeting selection criteria applied by the humanitarian actors in Lebanon due the lack of funding.

Comparative analysis II: Multiple vulnerability categories

Proportion of households entering in several vulnerability categories

The previous figure highlights the high proportion of households entering several vulnerability

categories. These rates are particularly high in Mount Lebanon with almost 8 out of 10 households

interviewed entering in 2 or more categories and 4 out of 10 entering 3 or more categories. In the other

regions, there is a high proportion of households fitting into 2 or more categories but he proportion of

households entering 3 or more categories are lower (under 10%).

The graph highlights the urgency of the situation, in particular in Mount Lebanon, in terms of access to

treatment and follow up for non-communicable diseases.

5. Mental health status


The household survey implemented did not aimed to be a professional Mental Health and Psychosocial

screening following the IASC MHPSS guidelines as our team of data collectors had no previous

experience in this field. The assessment aimed to at least draw some basic information about the

Mental Health status of the population interviewed.

Someone presents strong signs of psychosocial suffering if they answer “all of the time” to two or more

of these questions. Overall, the prevalence of psychosocial distress is high, with 37% of the population

presenting strong signs of it. The most common symptom is the restlessness, with almost a third of the

people interviewed declaring feeling restless all of the time. Sleeping problems and fear are the least

common symptoms, with 13% of the people reporting such problems all of the time over the past few

weeks.

Mont Lebanon North and West

Bekaa South Lebanon

People reporting serious signs of

psychological distress (2 out of 6 “All

the time” answers)

28% 38% 44.0%

The prevalence of psychological distress varies somewhat between regions. In Mount Lebanon, 28% of

the people report a sign of serious psychological distress. In North and West Bekaa, this prevalence is

higher, 38%, and in the South it reaches 44%.

Previous analysis performed by HelpAge International highlighted the correlation between psychological

distress and non-communicable disease. This correlation is also found here as people suffering from

NCDs are also 48% more likely to report strong signs of distress. This emphasizes the importance of

developing psychosocial activities targeted at people suffering from chronic diseases.

6. Key findings on Access to health

Overall, 25% of the people suffering from an NCD do not take regular medication for it. Hypertension

and diabetes left untreated lead to severe, even deadly, complications. It is therefore important to

ensure access to regular medication for everyone. In this respect, Lebanese are twice as likely as Syrian

to take their medication. Also, the region of Beirut - Mount Lebanon is particularly vulnerable with half

of the cases of NCD reported left untreated. The following figure illustrates this fact.

Figure 1: Proportion of people suffering from NCD

not taking medication

Within the people declaring that they are not taking medication. The most common reason is the price

of the treatment. The following figure illustrates the reasons given and their frequency.

Figure 2: Proportion of people suffering from NCD not taking medication

Frequency of the visits to the health centre for NCDs:

Figure 3 : frequency of the visits to the health centre for NCD

The interpretation of the previous figure is not straightforward as the recommendations on the

frequency of the doctor’s visits vary according to the disease and to the phase of the treatment. We can

highlight three phases:

� Diagnosis/screening: the doctor needs to see the patients very regularly to be able to monitor

the disease

� Treatment definition: the doctors sees the patient regularly to monitor the effect of the

treatment and adjust the medication accordingly

� Follow-up: the doctor needs to see the treatment occasionally (every 6 months) to be able to

see the longer term impact of the treatment and lifestyle changes made by the patient

As per YMCA and MOPH guidelines, the follow up visits should happen at least every 6 months in order

for the patients to access their medication. As a result, we consider here that people seeing their doctor

less than every 6 months are not followed up enough. In our sample, 1 out 5 people suffering from an

NCD is in this case. They are therefore at risk of following an inadequate treatment or of ignoring the

worsening of their condition. In both cases, there are live-threatening consequences such that action is

required.

7. Health priorities-Programmatic recommendations based on household survey key

findings

The key findings detailed in the previous points of this section, bring as general conclusion the need of

an intervention on health to support the effective inclusion of the targeted population in the primary

health care system of Lebanon. As result of the analysis of findings, it is possible to define a list of key

interventions which will immediately improve the current situation. This report groups the

recommendations identified during the process into the Access and Accessibility criteria without any

particular ranking as all of them are considered suitable for immediate implementation.

Recommendations on Access:

Better access to Information:

� Design and implementation of Information campaigns on cost and availability of care. These

campaigns have to be age-friendly and able to reach the population in the catchment areas.

� Awareness campaigns and enhanced communication between GPs / MMUs and the population to

build up the trust in the health system.

� Increase prevention and health education. Not only to the population at risk, but all the household

members for ensuring impact and sustainability.

Better access to healthcare:

� Free medication and follow-up visits. First consultation still should include a fee to ensure patient’s

commitment to start the treatment.

� Training of health workers on special needs of older people and guidelines on chronic disease,

especially in the cases of co-morbidity.

� The link between patient and PHC needs to be reinforced: focal points at PHC level to manage the

follow up of patients are recommended.

Better physical access to health:

� Making the centres age-friendly following WHO guidance to easier physical access.

� Enhance home visits methods and outreach activities from the PHCs such that they reach the most

vulnerable.

� Use the Medical Mobile Unit (MMU) as a tool for follow up visits to reduce transportation costs. In

particular, the use of MMU is recommended as they can be recycled at the end of the programmes

into units specialised for older people and people with specific needs.

Recommendations on Accessibility/Availability:

� Increase the provision of devices for special needs like wheelchairs, glasses etc.

� Work towards the accreditation of the centres by the MOPH or the YMCA to secure sustainable

access to NCD medication.

8. Key findings on PHC analysis


Legend:

In the Summary tables the lowest value is highlighted in red font over pink background; the highest

value is highlighted in green over light green background.

The problem ranking tables are based on the Severity Scale criteria used during the assessment

annexed to this report.

Access to Primary Health Care facilities:

Access-Summary table

Accessible information on services provided, prices, opening hours etc.

The average score on information display within the assessed facilities is 58%, meaning that more than

40% is not offered. However, this average figure hides large variation between facilities. The scores go

from 20% of the required information available in Al Ain (N. Bekaa) to 100% in Al Bashura and Al Harash

(Beirut-Mount Lebanon) medical centres. There is margin for improvement in the display of

information in most centres.

Physical access, outreach and referral to secondary and tertiary care

The measure of physical access is based on the WHO guidelines on age-friendliness. Here again, the

average score of 58% hides large variations between centres. Hay el Sellom (Beirut-Mount Lebanon) and

Al Ain only complied with a third of the guidelines while Al Harash respected 90% of the WHO advice.

Physical access for older people can be improved in most centres.

Opening hours are not standardized; most centres are open 36 hours for 6 working days per week or

less. None of them has established age-friendly hours to avoid long waits during the peak hours.

Name of the centre Region

Information and

awareness

material

displayed

Compliance

with age-

friendly

guidelines

Mobile

unit

Distance to

secondary or

tertiary care

in km

Total

opening

hours

per

week

Al Ain Amel

Association PHC North Bekaa 20% 30% Yes 0 33

Al Sader foundation South Lebanon 40% 80% No 14 36

Tyre Amel Association

PHC

South Lebanon 40% 80% Yes 3 36

Al Sadr

Foundation/Siddiqine

South Lebanon 60% 60% No 3 36

Al Sadr

Foundation/Kfarhata

South Lebanon 40% 50% No 20 36

Al Bashura Mount

Lebanon 100% 60% Yes 3 51

Al Harash medical

centre

Mount

Lebanon 100% 90% Yes 1 51

Kamed el Loz PHC West Bekaa 60% 40% Yes 0.5 48

Hay el sellom Mount

Lebanon 60% 30% No 5 36

Only five of the centres have a mobile unit available while these are key instruments to increase the

access to services for remote villages.

On average, the closest secondary health care centre is 5.5 km away. However, this Al Sadr foundation

centre in Kfarhata (South Lebanon) is 20 km away from the closest secondary or tertiary care provider

and does not have a mobile unit. A referral system is sometimes in place but the good monitoring of

patients is at risk in these centres. This level of monitoring is connected the Quality analysis of

information/case management of this same section.

Key findings on access to Primary Health Care facilities:

Major

problem

� On average, centres comply with only 58% of the recommendations on information provision

and physical access to the centre.

� Only 55% of the centre have a mobile unit

� Centres are open 40 hours per week on average

� No centre is further than 20 km away from the closest secondary or tertiary care provider

Consequences:

Non-communicable diseases are not being normally managed and access to medication is frequently

interrupted because clinics aren’t open for long enough or are far away. Complications requiring

secondary treatment are estimated to be frequent. Data on health is outdated or inaccurate. The

population cannot cope with the current situation without external aid.

Programmatic recommendations:

� In the long run, training community health workers to ensure outreach activities is a solution to the

access problem. In the short run, increasing the use of the mobile clinics is recommended

� In accordance with age friendly policies, organise age-friendly hours to avoid long wait for older people

� Improve information display in the centre about the prices, the services available and prevention of

diabetes and hypertension

� Refurbish the centres to increase the physical access

Availability of Primary Health Care facilities:

Availability-Summary table

Availability of services and medication

Five centres out of the nine assessed provide 50% or less than half of the services related to NCD

diagnosis, treatment and management as per YMCA and MOPH standards as well as important support

services, like a laboratory. In this index, we took into account the presence of 9 essential staff: 1 General

Practitioner, 1 trained nurse, 1 pharmacist, 1 cardiologist, 1 dentist, 1 endocrinologist, 1

ophthalmologist, 1 health educator and 1 laboratory technician.

All centres normally provide more than half of the types of NCD medication recommended by the

MoPH. However, two thirds of the centres declared that they ran out of medication more than half of

the time. The figure below illustrates the frequency of drug shortages:

Frequency of the shortages in the PHCs


NCD

services

available in

house

NCD medication

normally

provided by the

facility

drug shortage

Al Ain Amel Association PHC North Bekaa 40% 57% Once every few months

Al Sader foundation South Lebanon 50% 86% 75% of the time or more

Tyre Amel Association PHC South Lebanon 50% 57% 75% of the time or more

Al Sadr Foundation/Siddiqine South Lebanon 90% 100% Once every few months

Al Sadr Foundation/Kfarhata South Lebanon 60% 57% 75% of the time or more

Al Bashura

Mount

Lebanon 80% 100% 50% of the time

Al Harash medical centre

Mount

Lebanon 80% 100% 50% of the time

Kamed el Loz PHC West Bekaa 40% 71% 75% of the time or more

Hay el sellom

Mount

Lebanon 30% 86% Only happened once

Key findings on availability of Primary Health Care facilities:

Moderate to

major

problem

� On average, 58% of the services necessary to manage chronic disease and their

complications are available.

� 79% of the recommended medication to manage NCD are normally offered by the centres

� However, 6 out of the 9 centres experience shortages most of the time

Consequences:


interrupted. Complications requiring secondary treatment are estimated to be frequent. Data on health is

outdated or inaccurate. The population cannot cope with the current situation without external aid.


� Building up contingency stocks of the centres in order to be able to fill in the gaps in the medication

provision.

� Work towards the accreditation of the centres by YMCA to ensure sustainability of the medication

provision.

Quality of Primary Health Care facilities:

Quality-Summary table

Quality of the provision of primary health services

There was no significant variation in the level of medical equipment of the facilities. All facilities

complied with the standards. Broad variations appeared in the non-medical equipment with facilities

lacking essential infrastructure like toilets. In Al Bashura centre, half of the non-medical equipment was

missing.

This gap in terms of equipment may hamper the management of information on patients and drugs.

Indeed, three centres (Al Ain, Tyre and Kfarhata) had significant gaps in their information management

system. Systems are not standardized and not fully computerized. There is scope to improve the

equipment in order to have better management of the information and as a result, better

management of chronic diseases and the referral to secondary and tertiary care.

Drug storage conditions were mostly complying with the WHO guidelines. However, in some cases the

storage space was small such that it did not allow for increasing the stock of medication, keeping the

storage up to the standard. As the stock of medication is not sufficient to deal with the demand, more

storage equipment will be required to increase the stocks in good conditions.


Score on patient

and drug

information

management

Score on

drug

storage

Quality of

premises (non-

medical

equipment)

Quality of

the medical

equipment

Al Ain Amel Association

PHC North Bekaa 50% 83% 57% 100%

Al Sader foundation South Lebanon 100% 83% 86% 100%

Tyre Amel Association PHC South Lebanon 50% 100% 93% 85%

Al Sadr Foundation/

Siddiqine South Lebanon 100% 100% 93% 100%

Al Sadr Foundation/

Kfarhata South Lebanon 50% 100% 86% 100%

Al Bashura Mount Lebanon 100% 83% 50% 100%

Al Harash medical centre Mount Lebanon 100% 100% 100% 100%

Kamed el Loz PHC West Bekaa 100% 100% 57% 100%

Hay el sellom Mount Lebanon 100% 100% 79% 92%

Key findings on quality of Primary Health Care facilities:

Moderate

problem

� On average, 83% of the information management tools are in place at least partially.

� 84% of the drug storage recommendations by WHO are respected

� On average centres have 78% of the non-medical equipment available although in some

cases essential non-medical is missing.

Consequences:


interrupted. Complications requiring secondary treatment are estimated to be frequent. Data on health is

partially updated or accurate. The population can cope with the current situation without external aid.

Moderate actions are highly recommended in order to enhance quality of services


� Information management tools are not standardised, and not computerised. Reaching some level of

computerisation and standardisation would improve the management of the facility

� Centres normally have a good level of non-medical equipment, including access to a phone, internet, a

computer etc. However, in some cases, some basic equipment is missing (for example, toilets). In this

instance, action is required.

List of annexes

1. Needs assessment dashboard

2. Health severity scale

3. Health facility and household criteria

4. Sex and Age Disaggregated Data estimates

4.b Supporting document: Needs Response and Gaps group (NRG) SADD estimation

5. Needs assessment covered areas

6. Household survey questionnaire (English)

7. Household survey questionnaire (Arabic)

8. Health facility questionnaire

Documents

20150212_HAI Health needs assessment lebanon_Final Report