“What’s happening in Syria even affects the rocks”: a qualitative study of the Syrian refugee experience accessing noncommunicable disease services in Jordan

Abstract

Background Humanitarian actors and host-countries in the Middle East and North Africa region are challenged with meeting the health needs of Syrian refugees and adjusting the response to contemporary humanitarian conditions – urban-based refugees, stressed host-country health systems and high NCD prevalence. Although several studies have explored NCD prevalence, utilization of services and barriers to access, these analyses took place prior to dramatic shifts in Jordanian health policy and did not account for nuances in health seeking and utilization behaviors or operational barriers. Accordingly, we aimed to understand the depth and nuances of Syrian refugees’ experiences accessing NCD services in urban and semi-urban settings in Jordan. Methods A qualitative study was conducted to explore the healthcare experiences of Syrian refugees in Jordan. The study team conducted 68 in-depth interviews with Syrian refugees in urban and semi-urban locations in central and northern Jordan. Results The findings indicated four themes key to understanding the healthcare experience: (1) emotional distress is a central concern and is frequently highlighted as the trigger for a non-communicable disease or its exacerbation; (2) service provision across all sectors – government, NGO, private – is complex, inadequate, expensive and fragmented, making engagement with the health sector physically and financially burdensome; (3) given financial constraints, participants make harmful decisions that further damage their health in order to reduce financial burdens, and (4) host-community members actively exhibit solidarity with their refugee neighbors and specifically do so during emergency health episodes. The findings from this study can be used to inform program design for forcibly displaced persons with NCDs and identify points of entry for effective interventions. Conclusions Opportunities exist for humanitarian and host-country actors to provide more comprehensive NCD services and to improve the relevance and the quality of care provided to Syrian refugees in Jordan. Global and national funding will need to align with front-line realities and foster better coordination of services between host-country health systems, private actors and non-governmental organizations.

MSF experiences of providing multidisciplinary primary level NCD care for Syrian refugees and the host population in Jordan: an implementation study guided by the RE-AIM framework

“…This proved the key challenge to implementing and maintaining effective NCD care in the Syrian refugee population (29). Our nding that the programme was being delivered within the framework of a complex and fragmented humanitarian system is consistent with reports from other authors (24,27). Staff struggled to assist patients in navigating an often opaque, frustrating and unresponsive referral system.…”

“…One of the key themes that emerged was lack of access to affordable NCD care for those not enrolled in the MSF programme and for MSF patients to access care for other conditions, consistent with the literature (24)(25)(26)(27). Affordability and accessibility were likely to have been further impacted by the 2018 change in Jordanian government policy to signi cantly increase MOH co-payments for Syrian refugees to "foreigner" levels, which was later reversed in 2019 (27). McNatt et al reported that NCD patients sought care from the NGO sector rather than MOH services following this 2018 policy change.…”

“…However, nancial barriers (including the addition of user co-payments from 2014, which have varied over time reaching full "foreigner" rate by 2018), complex care pathways and referral systems, and limited health facility capacity have impeded refugees' access to these services (24). The burden, access issues and the broader health system response to Syrian refugees' NCD needs in Jordan are well documented (24)(25)(26)(27).…”

“To die is better for me”, social suffering among Syrian refugees at a noncommunicable disease clinic in Jordan: a qualitative study

“…The daily stressors, financial precarity, the myriad barriers to accessing care experienced by Syrian refugee NCD patients in Jordan and the potentially harmful decisions they make as a result of stretched finances have been well documented in our own and others' studies [43,[55][56][57][58]. The free care provided by MSF goes some way to alleviating the NCD-related financial burden affecting their current cohort.…”

Addressing noncommunicable diseases among urban refugees in the Middle East and North Africa - a scoping review

“…The Middle East and North Africa (MENA) accounts for 6% of the global population but comprises 25% of the 'population of concern' to the UN Refugee Agency (including refugees, internally displaced persons, asylum-seekers and stateless persons). The vast majority of refugees in the MENA region live outside of camp settings in urban and semi-urban environments in Jordan, Lebanon and Turkey [1][2][3]. In addition to large numbers of displaced persons in urban settings, the region is also undergoing an epidemiologic transition towards more noncommunicable diseases (NCDs).…”