Fill That Gap supports community health workers in Lebanon

Sharing experiences from the frontline, Fill That Gap highlight the community health workers and vulnerable populations in Lebanon.

Fill That Gap is a not for profit organisation specialising in the support and deployment of human resources for health in low to middle income countries. As part of our mission we work to enhance the capacity of all community members to establish universal healthcare coverage within their own community.

In March 2019 Fill That Gap (FTG) hosted a roundtable in collaboration with the Palestine Children’s Relief Fund (PCRF) in Beirut. Our focus? Community health needs and community health workers in Lebanon. The 15 participants represented 13 different NGO and aid organisations working in this field in Lebanon.

Lebanon and refugees

Lebanon now hosts the highest proportion of refugees per capita in the world.¹ This includes roughly 1.5 million Syrians who have fled the Syrian conflict and an estimated 180,000 pre-existing Palestinian refugees.² These population estimates are likely inaccurate, due to a 2015 policy that halted the registration of refugees. The sudden increase in the nation’s population has overburdened the country’s healthcare system.³ A vulnerability assessment by the Lebanese government found that nearly 2.5 million people are currently in need of improved and comprehensive access to healthcare.^1,3,4 The highest burden of disease is from reproductive health, hypertension and diabetes.

The country’s healthcare system is highly privatised rendering many services inaccessible to those living in precarious situations due to out of pocket costs (user fees and transport).⁵ More than two thirds of the primary healthcare services are provided by non-governmental organisations (NGOs).⁶

If one manages to register as a refugee in Lebanon then it is possible to access one of 30 the primary healthcare facilities financed by the United Nations High Commissioner for Refugees (UNHCR) and to have coverage of 75-90% of life saving emergency care in 56 hospitals.⁷ Palestinian refugees are able to access care at the United Nations Relief and Works Agency for Palestinian Refugees (UNRWA). However as of 2018, budget cuts have limited the scope and scale of care that this organisation provides, thereby intensifying the needs of this population.⁸

Although many NGOs provide care at a subsidised rate to those in need, with 28.6% of the population living below the poverty line, even a nominal healthcare fee can be unaffordable.⁷ This is why organisations are seeking to develop sustainable solutions to cover the gaps in healthcare for refugees and other vulnerable populations. One example of such a solution is the recruitment and training of community health workers (CHW).

Successful community health worker programmes

CHW programmes have been proven to improve health equity and fill gaps in healthcare systems.⁹ Evidence also shows that these programmes are cost effective, and as a result can decrease healthcare expenditure.^10,11

CHWs can generally be separated into three categories (lay health workers; level 1 and level 2 paraprofessionals) depending on training and remuneration.⁹ These distinctions allow for clarification of job titles and expectations from the workers.

According to the World Health Organization (WHO) a successful CHW programme relies on regular training along with reliable support and supervision, this in turn increases the motivation and job satisfaction of workers.^12,13 Furthermore, the effective integration of CHW programmes into health systems can improve system performance, and lead to better service delivery and health outcomes.¹⁴ Support from the Ministry of Public Health to create a sustainable and enabling environment for CHWs can create a thriving program.¹²

NGOs in Lebanon have the opportunity to coordinate care and work together to further improve the lives of vulnerable populations in the country. The organisations who participated in our roundtable are currently providing community empowerment programmes; skills training; conducting outreach and referrals; as well as many more resources.

The round table discussion: “Sharing our experiences in community health in Lebanon”

The roundtable discussion provided the opportunity for organisations to share their experiences working within different communities in Lebanon and to discuss the strengths and areas for growth within their programmes.

• For example, Premiere Urgence AMI shared their success in holding awareness sessions to promote health in schools, villages, and municipality buildings. Over one hundred women and children attend these sessions and are followed up for weeks at a time.
• Other organisations work to raise vaccine awareness. In Lebanon vaccinations are free of charge to any children under 12 years nationality. However only 59% of Syrian households were aware of this benefit.⁶ Medical Teams International are working to connect refugees to these services, as well as primary and secondary healthcare centres.
• The country is facing a critical shortage of mental health professionals, with an average of three mental health professionals per 100,000 people. It has been found that approximately 17% of the population suffers from mental health problems, with 90% lacking access to treatment.¹⁵ Some NGOs in the field are able to provide mental health services like psychotherapy and group support. Beit Atfal Asumoud provide psychotherapy as well as music therapy. All participants agreed on the need to destigmatise the mental health services that are available to the population.
• The Ministry of Public Health (MoPH) has not formally acknowledged or legalised the role of CHWs. Participants testify that this lack of recognition and legal status means displaced, or non-Lebanese workers cannot be reimbursed for the invaluable work they do nor can their roles be clearly defined. This has led to organisations using different titles for the workers such as volunteers, community health teams and refugee outreach volunteers. Although there is no official title for these positions in Lebanon it should be a priority to give those who are working some sort of legal protection.
• Another challenge reported is competition to recruit competent and motivated new CHWs or health volunteers. Enlisting male health workers continues to be challenging, although their engagement and connection to their community is essential. Overall, the search for those who are ambitious, willing to work for little to no income, and meet minimal standards has posed a problem for enrollment into the CHW programmes.

Needs of community health workers

Delivering high quality healthcare interventions and working in complex situations can create high levels of professional stress. Frequent exposure to deteriorating conditions and limited budgets can lead to burnout and volunteer dropout. Many organisations in Lebanon are combating this by offering stress relieving sessions, psychological support and teaching tools to manage one’s personal health and wellness.

UNRWA gave details about de-stressing sessions provided for their volunteers. Medical Teams International shared that thanks to the support that is given to their volunteers, they have a high retention rate of CHWs.

The roundtable members generally agreed that CHWs need continuous support and protection. With a solid support base, they could create a career from their CHW roles.

Recommendations

The positive response to our roundtable discussion clearly showed that a number of organisations are actively working in this area. They share the view that given how severely overstretched the healthcare system is in Lebanon, community health workers can be an invaluable resource for providing healthcare access to those in the greatest need. The roundtable discussion offered the following recommendations for further developing the use of CHWs for refugees and other vulnerable populations in Lebanon:

1. Organisations should work collaboratively to better understand the full potential of community health workers in Lebanon;
2. Develop a clear definition of a community health worker in Lebanon and advocate for the support of community health worker programmes by both governmental and non-governmental organisations;
3. Develop a clear and detailed understanding of the training and support needs of community health workers in Lebanon and use it to create targeted training modules;
4. Utilise SPHERE guidelines to address the needs of the population while also targeting the burden of disease;
5. Assess means of providing supervision and professional support for community health workers in Lebanon, both in country and via telemedicine tools; and
6. Develop learning and further recommendations from this effort to further refine the use of community health workers in Lebanon.

For the full text version of this policy brief, including references, please visit us at www.fillthatgap.org. You can also follow our blog on the website to keep up to date with our efforts to support efforts in community health for vulnerable persons living in Lebanon.

References

1. Lebanon. European Civil Protection and Humanitarian Aid Operations Service tools. https://ec.europa.eu/echo/where/middle-east/lebanon_en. Published August 3, 2019.
2. Lebanon Crisis Response Plan 2017-2020. Government of Lebanon and the United Nations; 2019. http://www.LCRP.gov.lb and http://data.unhcr.org/syrianrefugees/regional.php.
3. Primary Health Care Systems (PRIMASYS): Comprehensive Case Study from Lebanon. Geneva: World Health Organization; 2017.
4. Global Trends: Forced Displacement in 2015. United Nations High Commissioner for Refugees; 2015. http://reliefweb.int/sites/reliefweb.int/files/ resources/2017_2020_LCRP_ENG-1.pdf. Accessed April 15, 2019.
5. Lebanon Health Profile 2015. Regional Office for the Eastern Mediterranean: World Health Organization; 2016.
6. Vulnerability Assessment of Syrian Refugees in Lebanon (VASyR-17). World Food Programme, UN Children’s Fund, UN High Commissioner for Refugees; 2017.
7. World development indicators. World Bank Group. http://databank.worldbank.org/data/views/variableSelection/selectvariables. aspx?source=world-development-indicators. Published 2014. Accessed March 26, 2019.
8. Defunding UNRWA: Ramifications for Countries Hosting Palestinian Refugees. Arab Center Wahington DC. http://arabcenterdc.org/policy_analyses/defunding-unrwa-ramifications-for-countries-hosting-palestinian-refugees/. Accessed September 4, 2018.
9. Olaniran A, Smith H, Unkels R, Bar-Zeev S, van den Broek N. Who is a community health worker? – a systematic review of definitions. Global Health Action. 2017;10(1):1272223. doi:10.1080/16549716.2017.1272223
10. Vaughan K, Kok MC, Witter S, Dieleman M. Costs and cost-effectiveness of community health workers: evidence from a literature review. Human Resources for Health. 2015;13(1). doi:10.1186/s12960-015-0070-y
11. The World Bank In Lebanon. The World Bank. https://www.worldbank.org/en/country/lebanon/overview#1. Published October 11, 2019. Accessed March 29, 2019.
12. Community Health Workers: What Do We Know about Them? Geneva: World Health Organization: Department of Human Resources for Health; 2007.
13. Kok MC, Kane SS, Tulloch O, et al. How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature. Health Research Policy and Systems. 2015;13(1). doi:10.1186/s12961-015-0001-3
14. Scott K, Beckham SW, Gross M, et al. What do we know about community-based health worker programmes? A systematic review of existing reviews on community health workers. Human Resources for Health. 2018;16(1). doi:10.1186/s12960-018-0304-x
15. Lee C. Addressing mental health needs in Lebanon. Humanitarian Practice Network. https://odihpn.org/magazine/addressing-mental-health-needs-in-lebanon/. Published September 2011. Accessed April 22, 2019.

Participants to roundtable

• United Nations Relief and Work Agency for Palestine Refugees in the Near East (UNRWA);
• Beit Atfal Asumoud;
• United Nations High Commissioner for Refugees (UNHCR);
• Anera;
• Medical Teams International;
• INTERSOS;
• Healthcare Society;
• International Medical Corps;
• The Popular Aid for Relief and Development;
• Medecins du Monde; and
• Premiere Urgence AMI.

Mariah Johnson, MPH
Mandana Mehta
Executive Director
Fill That Gap
+32 498973110
mariah.t.johnson@gmail.com
mandana@fillthatgap.org
https://www.fillthatgap.org/

This article will appear in Health Europa Quarterly Issue 11, which is available to read now.

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