In this commentary we propose four questions to be addressed while building a meaningful public primary healthcare response in Lebanon today. These questions emerge from two imperatives: the necessity to consider both short- and longer-term struggles in a context of protracted conflict and the need to protect public health as a public good whilst the public Primary Healthcare Network (PHCN) is facing the Covid19 pandemic. In order to identify how these questions are related to the need to be working short and long, we look at the imprints left by past and present shocks. Profound shocks of the past include the Lebanese civil war and the Syrian refugee crisis. We analyse how these shocks have resulted in the PHCN developing resilience mechanisms in order to ensure a space for healthcare provision that stands public in Lebanon today. Then, we consider how two present shocks -- the economic breakdown and the blast of ammonium nitrate in Beirut port -- are affecting and threatening the progress made by the PHCN to ensure that primary healthcare remains a public good, a fragile space acquired with difficulty in the past half century. We identify what questions emerge from the combined consequences of such traumas, when the immediate constraints of the present meet the impediments of the past. We consider what such questions mean more broadly, for the people living in Lebanon today, and for the PHCN ability to respond to the Covid 19 pandemic in a relevant way. Our hypothesis is that in a protracted conflict, such as the one defining the circumstances of Lebanon now, public access to primary healthcare might persist for the people as one safeguard, in which social and moral continuity can be anchored to protect a sense of public good.

BackgroundThe Syrian crisis has put tremendous strain on the Lebanese health system, particularly in the historically underserved border region. The ICRC Primary Health Care program has focused on refugee and host communities in these areas. This study objectives were: 1) to determine whether the ICRC program was reaching the most vulnerable populations; 2) to understand the key perceived health needs in the catchment areas of the ICRC supported facilities; and 3) to identify barriers to utilization of health care services.MethodsBetween July and September 2017 we conducted two cross-sectional studies - one randomized household survey and one clinic-based - in the catchment areas of three ICRC-supported facilities, targeting women of reproductive age and caretakers of children under five. Differences between groups were analysed with t-test or chi-squared test.ResultsIn the household survey, similar socio-demographic profiles were observed between Syrian refugee women and vulnerable Lebanese hosts. With regard to the study objectives:The most vulnerable populations were those seen in the ICRC-supported facilities.For both populations, the most common reasons for seeking care were non-communicable diseases (40.6%) and sexual and reproductive health issues (28.6%). Yet the people reaching the ICRC supported facilities were more likely to seek care for communicable diseases affecting their children (37.8%), rather than for the most common reasons expressed in the household survey.In the catchment areas, reported gaps included low immunization coverage and low levels of antenatal care and family planning both for Syrian and Lebanese. Dental care also emerged as an issue. Out of pocket expenditures was reported as a critical barrier for utilization of primary health care services for both populations, while the most important barrier for utilization of ICRC-supported services was lack of awareness.ConclusionsDespite the ICRC reaching the most vulnerable Syrian and Lebanese communities, the population-based survey revealed that important gaps exist in terms of utilization of health care services among women of reproductive age and their children. A stronger outreach component is needed to address lack of awareness. Innovative solutions are also needed to address cost barriers at the levels of both facility and individual user.

In humanitarian contexts, it is a difficult and multi-faceted task to enlist academics, humanitarian actors and health authorities in a collaborative research effort. The lack of research in such settings has been widely described in the past decade, but few have analysed the challenges in building strong and balanced research partnerships. The major issues include considering operational priorities, ethical imperatives and power differentials. This paper analyses in two steps a collaborative empirical endeavour to assess health service utilization by Syrian refugee and Lebanese women undertaken by the International Committee of the Red Cross (ICRC), the Lebanese Ministry of Public Health (MoPH) and the Harvard François-Xavier Bagnoud (FXB) Center. First, based on challenges documented in the literature, we shed light on how we negotiated appropriate research questions, methodologies, bias analyses, resource availability, population specificities, security, logistics, funding, ethical issues and organizational cultures throughout the partnership. Second, we describe how the negotiations required each partner to go outside their comfort zones. For the academics, the drivers to engage included the intellectual value of the collaboration, the readiness of the operational partners to conduct an empirical investigation and the possibility that such work might lead to a better understanding in public health terms of how the response met population needs. For actors responding to the humanitarian crisis (the ICRC and the MOPH), participating in a technical collaboration permitted methodological issues to be worked through in the context of deliberations within the wider epistemic community. We find that when they collaborate, academics, humanitarian actors and health authorities deploy their respective complementarities to build a more comprehensive approach. Barriers such as the lack of uptake of research results or weak links to the existing literature were overcome by giving space to define research questions and develop a longer-term collaboration involving individual and institutional learning. There is the need ahead of time to create

In this commentary we propose four questions to be addressed while building a meaningful public primary healthcare response in Lebanon today. These questions emerge from two imperatives: the necessity to consider both short- and longer-term struggles in a context of protracted conflict and the need to protect public health as a public good whilst the public Primary Healthcare Network (PHCN) is facing the Covid19 pandemic. In order to identify how these questions are related to the need to be working short and long, we look at the imprints left by past and present shocks. Profound shocks of the past include the Lebanese civil war and the Syrian refugee crisis. We analyse how these shocks have resulted in the PHCN developing resilience mechanisms in order to ensure a space for healthcare provision that stands public in Lebanon today. Then, we consider how two present shocks -- the economic breakdown and the blast of ammonium nitrate in Beirut port -- are affecting and threatening the progress made by the PHCN to ensure that primary healthcare remains a public good, a fragile space acquired with difficulty in the past half century. We identify what questions emerge from the combined consequences of such traumas, when the immediate constraints of the present meet the impediments of the past. We consider what such questions mean more broadly, for the people living in Lebanon today, and for the PHCN ability to respond to the Covid 19 pandemic in a relevant way. Our hypothesis is that in a protracted conflict, such as the one defining the circumstances of Lebanon now, public access to primary healthcare might persist for the people as one safeguard, in which social and moral continuity can be anchored to protect a sense of public good.

When Lebanon’s primary healthcare network meets Covid-19 in the midst of an economic collapse and a disaster, what are the crucial questions? In this commentary we look at the impact of three profound shocks (the Lebanese civil war, the Syrian refugee crisis, and the current economic breakdown) which the Lebanese primary healthcare network (PHCN) has met in the last half century. We examine the past and current constraints that these events have imposed on the capacity of the PHCN to respond to the Covid-19 pandemic. In the context of impending economic collapse, rising social and political tensions–and now the devastating explosion in the capital on 4 August 2020–we identify the broader and deeper issues at stake as the Lebanese primary health care network struggles to fulfil its mandate to support the delivery of essential primary health care to Lebanon’s most vulnerable populations. Our finding is that in a protracted conflict, such as the one defining the circumstances of Lebanon now, access to health care persists for the people as one safeguard in which social and moral continuity can be anchored and protected.