Conflict-sensitivity and healthcare

On 28 May, International Alert held a lessons sharing seminar in Beirut on conflict-sensitivity and healthcare in Lebanon.

The event was attended by over 35 representatives of organisations active in the fields of healthcare and social stability. Alert and its partners presented the key findings, achievements and challenges from a 17-month project on promoting conflict-sensitivity in healthcare in Lebanon.

The presentations and discussions focused on examples of coping with the effects of the Syria refugee crisis on healthcare provision, the impact of capacity-building for conflict sensitivity and the potential of healthcare actors to contribute to social stability.

The panellists of the first session, Christina Bethke, former Health Coordinator with International Medical Corps (IMC) in Beirut, and Dr Fouad Fouad, Assistant Research Professor at the American University of Beirut, discussed the implications of the Syrian refugee presence on Lebanon and how it highlighted grievances the Lebanese had before the crisis.

They outlined various copying strategies and examples of patients struggling to access care as regularly as they used to, as they were bearing a fiscal strain on the household due to reduced work opportunities. As a coping strategy, families were deferring healthcare for family members, prioritising the most important procedures, and some had to stop their chronic medication. Clinics were experimenting with ad hoc measures such as using separate waiting areas for Syrian and Lebanese patients or scheduling appointments at different times of the day or different weekdays.

Suggestions for supporting primary healthcare centres included providing medication support, flexible funding for low-cost renovations, support for hiring additional staff and funding for tailored community activities such as child friendly events, food baskets and referrals to other social service providers. Addressing the difference in out-of-pocket expenses for Lebanese and Syrians was encouraged and ‘bundling’ of healthcare costs for certain conditions, such as pregnancy, was seen as an opportunity for decreasing the stress caused by unexpected expenses.

Most participants agreed that tensions were caused by both competition over access and negative attitudes. According to participants working in primary healthcare centres, causes of tension included: perceptions among the Lebanese that Syrians are receiving more attention; differences in fees; limited space in the health centres; concerns among the Lebanese that they would get infected; competition over jobs; and Syrians feeling humiliated and mistreated.

A significant difference in the level of tensions was reported across different regions, with examples given of tensions being higher in Beqaa than in the south, and of greater challenges working with joint Syrian-Lebanese groups in Mount Lebanon than other regions.

Participants also gave various examples of coping strategies, including equalising out-of-pocket expenses for Lebanese and Syrian patients, hiring additional doctors to reduce the waiting times for Lebanese patients, and ‘task shifting’ between primary healthcare staff. Midwives, for example, were recently authorised to insert intrauterine devices (IUDs), a task that was previously performed only by doctors, thereby reducing costs and increasing access to healthcare.

Bethke and Fouad agreed that the current crisis can stimulate reform and promote development. The challenge is to understand the clear priorities of the government and engage the authorities in defining the pathways for reform.

The second session focused on key lessons learned from Alert’s capacity-building work on conflict-sensitivity in the health sector.

Vesna Matovic (pictured above), Head of Training and Learning at Alert, summarised the key lessons from the project’s capacity-building activities, which combined training, mentoring and support to integrating dialogue in community outreach. Change was registered mostly on the individual level, with healthcare staff seeing beyond the surface, better understanding needs, listening more and better managing their stress. Change also occurred in relationships between staff and patients, and between clinic staff, who became more collaborative and supportive. At the level of social change, Matovic highlighted an increase in teamwork and staff support at the centre level and increased cooperation between centres, giving an example of a new policy adopted by one centre on how to deal with angry patients.

Matovic noted that the effect is bigger when all methodologies are combined (see figure). Training has the tendency to be more effective for change in the practice of the health clinic, as it benefits groups of people who exchange experiences and can be agents of change. Supervision sessions have the tendency to be most effective for personal change, supporting individuals to learn about themselves and their emotions. Dialogue-style awareness sessions have an impact on the community level. To achieve change of practices and policies, however, we need to include clinic’s management and administration, INGOs and UN agencies.

Sarah Assaad from Premiere Urgence–Aide Medicale Internationale (PU-AMI) presented the results and conclusions from the work on family planning and reproductive health for mixed groups of Lebanese and Syrians. The lessons learned for PU-AMI were that Syrians and Lebanese of similar socio-economic status had more interaction, and mixed sessions were more effective when participants shared a common socio-economic background. She recommended awareness-raising sessions in the health clinic waiting rooms and a stronger focus on men who are the decision-makers on family planning issues.

Based on the experience from the pilot initiative, Assaad also recommended activities for children as a way for bringing together Lebanese and Syrian parents, more common spaces for meetings in the community and open events. Addressing priority issues such as rent, childcare and education would also help, as would involving the Lebanese community in aid and NGO-led activities, so that they feel the assistance is not only benefiting the refugees.

Wissam Kheir from the Mental Health Programme of the Ministry of Public Health and Jihane Bou Sleiman from International Medical Corps discussed the pilot initiative on mentoring primary healthcare staff. The initiative included holding 75 mentoring sessions in 15 healthcare centres to discuss conflict and tensions in everyday work. The main challenges in organising mentoring sessions stemmed from the limited staff of the Mental Health Programme and at some PHCs. Overall, staff at the clinics were interested to share their experiences and eager to learn problem-solving techniques.

Stephanie Chammas of AMEL Association International made the final presentation, introducing participants to the achievements, challenges and lessons from organising awareness sessions for Lebanese and Syrian refugees in South Lebanon province. The change in beneficiaries’ relations was visible: in the beginning they sat separately, but after the third session they started sitting together and actively discussing the topics. The social workers who facilitated the sessions also detected sensitive cases during sessions, such as cases of violence and sexual abuse. Chammas outlined the main project impacts as social workers having improved the communication and conflict resolution skills of attendees, and participants from the communities increased their motivation to apply the knowledge they gained and saw the centres as a place where they could express themselves. AMEL recommended extending the use of dialogue in mixed groups to other sectors, such as child protection, and to other regions through mobile medical centres.

Following the engaging discussion, Ilina Slavova from International Alert reiterated the need for an organisational commitment in order to integrate conflict-sensitivity into their programming. For projects to be conflict-sensitive, she argued, the concept needs to be integrated from the outset, during the design phase, and not added on later. Champions in each organisation, often quite junior, need to be supported in this, as they can foster change from within. Commitment at the management and strategic levels is essential for integrating conflict-sensitivity in project interventions. And lastly, allotting time for reflection and building in flexibility in the projects to allow for needed adaptations are important steps both implementers and donors should consider.

Alert held the lessons sharing seminar as part of our work on conflict-sensitive aid, under the EU-funded project on conflict reduction through improved healthcare services, led by the Lebanese Ministry of Public Health and implemented by UNHCR, WHO, UNICEF and Alert. Find out more about the project here.