Developing capability, partnerships and research in the Middle and Near East (MENA)
Two billion people currently live in areas of conflict and fragility, reflecting a rapid increase in wars, ethnic strife and other man-made disasters since 2010. The world is also experiencing the greatest forced migration crisis since the Second World War with 65.3 million forcibly displaced persons, 40.8 million internally displaced persons, 21.3 million refugees and a further 10 million stateless people. Across the Middle East and North Africa (MENA) region protracted conflicts in countries such as Syria and Libya, as well as Afghanistan, Iraq and Yemen, have led to dramatic increases of refugee populations in Turkey, Lebanon, the Occupied Palestinian Territories and Jordan. War-affected populations from these countries have undergone the epidemiological transition and therefore present new health challenges. In particular, the diagnosis, management and treatment of noncommunicable diseases present new challenges for domestic health systems, as well as for humanitarian and development aid providers. These challenges also threaten domestic health commitments to Universal Health Coverage and the Sustainable Development Goals. This new humanitarian-development-health nexus demands a unique research agenda radically different from traditional approaches that address health challenges in low-income countries with weak governments, institutions and a mainly communicable disease burden. Without proper research capacity to generate crucial evidence to inform health policy and care, it will be impossible for countries in the MENA region to plan for rational and affordable health systems, sound economic policy and more effective aid effectiveness.
The vision for the R4HC (Research for Health in Conflict)-MENA partnership, which was supported by the Global Challenges Research Fund, was to build sustainable research capacity in this region to address major health challenges arising from conflict, specifically cancer and mental health as key NCDs. R4HCMENA will build research capacity in four distinct areas: (1) conflict and health; (2) the political economy of health in conflict; (3) cancer; and (4) mental health research in regions of conflict. The building of research capacity was focused on training staff in a variety of theoretical and practical methods for studying these areas, as well as conducting and publishing research projects to build further capability and disseminate findings. R4HC-MENA aimed to enable lead countries in this region to grow and sustain research capacity that could critically inform aspects of health development that relate to armed conflict in the region. This would inform not only regional and international policy-makers, but also the development of affordable and equitable clinical models of care and pathways in complex NCDs such as cancer and mental health. R4HC-MENA was also intended to link together regional ministries and academic centres, and key international partners, to widen the research to policy translation, and critically inform the health development agenda in other regions affected by conflict.
The project was delivered through a consortium of universities led by King’s College, London and involving Cambridge, Chatham House, and Imperial College, London along with several international partners (most in the MENA region), including the American University of Beirut, Haccetepe University, Bir Zeit University, and the King Hussein Cancer Centre, and Teachers College (Columbia University). The CBR’s contribution fell under the work streams on political economy (Brendan Burchell, Adam Coutts, Mona Jebril, Bothaina Attal, Simon Deakin and Adel Daoud) and mental health (Tomas Folke, Hannes Jarke, Kai Ruggeri and Federica Stablum). The CBR collaborated with a number of other Cambridge-based departments including the Centre for Science and Policy (CSaP) and the Department of Sociology.
The project concluded in March 2022 with a conference in Cambridge, drawing together the results from the different work streams.
The aim of the political economy work stream is to provide systematic and empirically grounded research capacity in the political economy of health in conflict in MENA countries, particularly around methods to examine the historical development and policies of their health systems, and the current role of government, the private sector, international donors and humanitarian agencies. The Syrian conflict and humanitarian crisis have affected almost all countries of the MENA region but have had particularly profound effects on Syria’s immediate neighbours. This new context of crisis requires deepened knowledge about the political economy in the region, guiding the formation of new health policies particularly in NCDs such as cancer and mental health, which have been neglected within the policy response. Indeed, a recent analysis of health in the MENA region highlights the key problems of ignoring political economy approaches in understanding health concerns. In addition to the increasing NCD burden, the region has long suffered from a sustained under-investment in both public health systems and health research. Powerful actors with vested interests – governments, donors, NGOs and the private sector – shape national health agendas, including the formation of social protection systems. However, the research capacity to conduct programs that can inform evidence-based policies is severely lacking. There is an urgent need to design and build multi-sectoral responses based on evidence generated within the MENA region. The project will incorporate multidisciplinary research capacity approaches across policy sectors, such as ministries of development, labour, social affairs and public health.
The mental health work stream aims to build interdisciplinary research capability for mental health in both Palestine and Lebanon. Armed conflict and organised violence cause and amplify psychosocial stressors (e.g. poverty, malnutrition, inadequate housing and social isolation), which adversely affect people’s mental health and wellbeing. Conflict-affected populations have been shown to have a higher prevalence of both common and severe mental disorders compared to the general population. Treatment gaps are widened especially in conflict affected areas of the MENA region due to inadequate infrastructure and human resources. A recent assessment of a refugee population in North and Bekaa region in Lebanon reported a significant 65% impairment in daily functioning due to untreated trauma experiences and feelings of hopelessness in the individuals. The situation has been shown to be particularly grave for refugees and internally displaced persons, with treatment gaps reaching over 90% in some areas. At a systems level, there is limited government spending on mental health (Palestine: 2.5%; Lebanon: 5%); minimal inpatient facilities, day care or residential facilities; a severe lack of staff and no mental health law. In line with the WHO’s Mental Health Action Plan 2013-2020, Palestine and Lebanon have begun to design and implement their nation’s own mental health strategy by investing in delivering affordable and equitable mental health care for both domestic and refugee populations. Unfortunately, there is a lack of systematic mental health research conducted in these regions, due to capacity issues. The project will fill this gap.
In the political economy work stream the project will be focusing on training MENA and UK faculty to conduct systematic analysis of regional health policy and systems in conflict. This will involve a contextual analysis looking at population movements, protection and asylum policies before and as crises unfold (e.g. implications of countries not signatories of 1951 Refugee Convention such as Lebanon), health system preparedness with regards to cancer and mental health, and more broadly related to Universal Health Coverage, as well as governance and organizational arrangements of healthcare for refugees and internally displaced persons (IDPs) as part of the humanitarian response. In collaboration with our MENA partners the CBR will utilise existing Ministry of Health (Lebanon and Jordan), UNHCR and World Bank data. An audit of existing secondary data sets such as the Multiple Indicator Cluster Survey (MICS) and the Demographic and Health Surveys (USAID) will also be undertaken as research training. The CBR will establish contextual sensitive population surveys in collaboration with the work streams focusing on cancer and mental health to build research capacity around the use of multilevel regression models to capture the hierarchical nature of our sampling procedure (individuals living in households, in villages, in cities, in wider regions). The CBR will also use matching procedures to reduce model bias and ensure comparability between the analysed cases.
In the mental health workstream, the CBR assists the Global Mental Health Lab, Teachers College, Columbia University in expanding their local capacity-building projects on depression care for both the Lebanese and the displaced communities in Lebanon, in line with Lebanon Ministry of Public Health’s National Mental Health Strategy. Activities to be implemented and assessed include the scale-up of Interpersonal Psychotherapy (IPT) and Interpersonal Counseling for primary care (IPC) among mental health providers in Lebanon; scale-up and evaluation of adoption of IMPACT collaborative care platform (University of Washington AIMS Center) in primary healthcare centres; as well as evaluation of IPT’s effectiveness in treatment of common mental health conditions in these settings. CBR will provide shared expertise in building research capacity in Implementation Science and Policy Research through delivery of certificate-based training workshops. Other deliverables will encompass the national dissemination of IPT in Lebanon, and setting up a local supervisory network and online collaborative platform. CBR will also validate an Arabic version of the European Social Survey’s Well-being questionnaire, and evaluate the impacts of IPT implementation on the policy-level.
Initial work scoping a political economy audit (‘PEA’) of the Lebanese, Jordanian and Turkish health systems was carried out and interviews were conducted from 2018 with key stakeholders in the region including health ministries, private sector health providers, the UN and NGOs in partner countries. Extensive drafts of the political economy reports on Lebanon and Jordan were completed in the course of the summer of 2019. Work continued on these reports in 2020 and they were largely completed by the end of September 2020.
Following her appointment in the autumn of 2018, Mona Jebril conducted a critical literature review on the political economy of health in Gaza and analysed it using MAXQDA software. After her submission of the PEA draft report in August 2019, Mona started preparing for fieldwork in the Gaza Strip via Skype and telephone from Cambridge. Mona used a snowballing method to reach participants. She conducted a number of in-depth interviews with policy makers, and health officials from different health sectors in Gaza including the Ministry, UNRWA, NGOs, and private institutions. She also conducted interviews with carers of patients in the Gaza Strip. Mona developed a journal of personal reflections on the interviews using Scrivener software. She then transcribed all interviews by herself. Mona coded the interviews using the MAXQDA software. The report was published in November 2021. Mona made numerous presentations of her work in a variety of forms (blogs, podcasts, animations and a play which was staged at the Cambridge Junction in July 2021).
The Political Economy workstream produced a parallel report on the political economy of health in Lebanon, How Politics Made a Nation Sick. The Political Economy of Health in Lebanon, published by Conflict and Health Research Group at King’s College, London. The lead author was Professor Fouad Fouad of the American University of Beirut, and contributing CBR researchers included Adam Coutts, Adel Douad and Simon Deakin. The research draws on extensive interviews and data analysis. The report dissects the causes of the weak political response to a series of health crises in Lebanon and calls for a shift away from the current reliance on the private sector to deliver public health, arguing for a new model that better balances private and public provision.
Bothaina Attal joined the CBR as a CARA Visiting Fellow in 2020. She is a medical health professional and researcher previously based in Yemen. Bothaina carried out research on the governance of public health in Yemen, using the methodology developed for the R4HC project, and published a number of papers relating to the health situation in Yemen.
During 2020 and 2021 Simon Deakin worked on a paper exploring governments’ response to Covid-19 using a theoretical framework which explores the role of the state in delivering public health and related collective good (see the report on the Research in the Theory and Practice of Governance project for further details).
To meet R4HC aims for year one (2017-2018), the CBR’s partners in the Global Mental Health Lab (Teachers College, Columbia University) trained mental health providers in Lebanon to meet competency criteria in Interpersonal Psychotherapy (IPT) as supervisors and providers; systematically collected outcomes of patients who accessed individual IPT treatment; piloted integration of the IMPACT collaborative care platform in a primary healthcare center in Lebanon; and have been engaging with stakeholders expand treatment in primary and specialty clinics serving host and refugee communities.
In 2018-19, the mental health stream of the R4HC project made steady progress toward the project aims, and continued to support the work of our partners at Columbia. Kai Ruggeri and Tomas Folke worked towards generating the necessary behavioural and mental health data from Lebanon. The survey was completed in the summer of 2019 following several rounds of feedback including from local partners and Lebanese academics at the American University of Beirut, with whom the CBR team interacted at the Lancet Palestinian Health Alliance Conference 27-28/03/2019, and with whom they have approval from the Lebanese Ministry of Public Health to collect the data. The survey was translated into Modern Standard Arabic by a professional translator.
In 2019-20 Hannes Jarke joined the team and worked with Kai and Tomas, on a survey of mental health, trust, and decision-making in refugees and the general population in Lebanon. The survey was subsequently completed with the help of IPSOS in Lebanon. In 2021 Federica Stablum joined the team to contribute generally to the work of the mental health stream.
In 2020-21 many aspects of the work had to be adapted due to lingering political instability, worsened by the pandemic, and the continued fallout from the August 2020 explosion in Beirut. Multiple initiatives were started and halted for various reasons, but the team still ended up with several critical outputs. Their primary empirical study on decision-making/risk-taking and mental health in Lebanon was published in May 2021, with a second paper forthcoming most likely in late 2021. Once regular travel resumes, the aim is to get more visibility for this work, though team members were able to present in-person to the Max Planck Institute for Human Development in Berlin. The first paper was also converted into a policy brief that was provided to participants in subsequent training and partnership programs.
Several initiatives were developed as adaptations to the original evidence-based policy training, planned initially to offer remote engagement for colleagues in and from Lebanon working in mental health policy. The aim of this programme is to strengthen the bridge between research and policy in the field of public health and mental health. Delivered in collaboration with the Cambridge Centre for Science and Policy (CSaP) during 2021, the R4HC – Cambridge Knowledge Exchange Programme (KEP) consisted of one-to-one meetings between five ECRs and policymakers (‘Partners’) from Lebanon and experts from the University of Cambridge selected on the relevance of their work. After the meetings the Partners of the KEP and a wider network of roughly 20 ECRs from the MENA region were invited to two workshops, one led by the PRG on ‘Evidence-based behavioural policy’ and one led by Dr Iris Elliott (external) on ‘Communicating research evidence’.
In late August 2021, we completed the final wave of training for the Knowledge Exchange Programme, which focused on training courses in evidence-based behavioral policy as well as research communication. In completing the R4HC project in 2022, the primary final output from the mental health team was a publication in which we validated one of the behaviour/risk metric frameworks that we used in Lebanon. This article was published somewhat out of order as it had been run during the period that data collection was not possible in Lebanon (data were from Italy), but we paused writing it once we could focus on the Lebanon materials and partnerships (covered in the 2021 report). The published work included three CBR affiliates (Folke, Stablum, Ruggeri).
Verra, S., Benzerga, A., Jiao, B., and Ruggeri, K., (2018) “Health promotion at work: a comparison of policy and practice across Europe”, Safety and Health at Work, forthcoming.
Jebril, M. and Deakin, S. (2022) ‘The political economy of health in the Gaza strip: reversing de-development’ Journal of Global Health jogh.org/2022/jogh-12-03014
Jebril, M. (2021) “Gaza’s Pandemic Quandary”, Carnegie Endowment for International Peace.
Huppert, F. and Ruggeri, K. (2018) “Policy challenges: well-being as a priority in public mental health.” In D. Bhugra, K. Bhui, S. Wong, & S. Gilman (eds.), Oxford Handbook of Public Mental Health (Oxford: OUP).
Ruggeri, K. (2019) Behavioral Insights for Public Policy: Cases and Concepts (London and New York: Routledge).
Ruggeri, K., Robbiani, A., Tamming, T., Evans, H., Jones, L., & Folke, T. (under review), “It’s not what you nudge, it’s who you nudge: Communicating evidence to policymakers and the public”, Palgrave Communications.
Jebril, M. (2021) The Political Economy of Health in the Gaza Strip (Cambridge: CBR)
Fouad, F., Diab, J., Barkil-Oteo, A., Kaloti, R., Maiki, C., Coutts, A., Deakin, S., Daoud, A., Ismail, S., Sullivan, R. (2022) How Politics Made a Nation Sick. The Political Economy of Health in Lebanon (London: King’s College). Published by the Conflict & Health Research Group under the R4HC MENA Programme. ISBN: 978-1-3999-1469-7
A major part of the R4HC MENA project is to bridge gap between evidence and policy. In collaboration with the Centre for Science and Policy (CSaP), University of Cambridge), we have helped select and organise visits for seven policy fellows from the MENA region to come to Cambridge and London during autumn 2018 to engage with the project. They were:
- Dr Ibrahim Bou-Orm, Consultant, Ministry of Public Health, Lebanon and PhD student
- Hilda Harb, Head of Department of Statistics, Ministry of Public Health, Lebanon
- Nour Kik, Policy and Advocacy Coordinator, Ministry of Public Health, Lebanon
- Dr Samah Jabr, Head of Mental Health, Ministry of Health, Palestinian National Authority
- Dr Asem Mansour, Director, King Hussein Cancer Centre Jordan
- Rana Nashashibi, Director, Palestine Counselling Centre
- Dr Meltem Şengelen, Lecturer, Department of Public Health, Hacettepe University, Turkey
These seven policy fellows had 173 meetings with researchers, policy makers and other experts in the UK during busy programmes in the UK.
This first cohort have responsibilities including cancer care, mental health policy, and have interests in how health policies respond to the impact of conflict and migration in the region.
In general, their feedback was that the interdisciplinary nature of the researchers that the policy fellows met was valued: expertise was provided from varied fields including oncology, palliative care, mental health, health economics, sociology, political science and more. In addition, professionals in health, policy and consultancy met the policy fellows. Each policy fellow provided feedback via questionnaires and further conversations on how what they learned from their meetings might help with their professional roles and indicated possibilities for collaboration.
The collaborations include – Adam Coutts, Adrian Gheorghe and Sharif Ismail collaborating on research with Ibrahim Bou-Orm and Hilda Harb (Ministry of Public Health, Lebanon). Rana Nashashibi in Palestine has also requested the possibility of Tomas Folke travelling to assist with research in Palestine.
Generally, the logistical arrangements for travel and accommodation for the busy programmes worked well and all had orientation meetings with CSaP. The policy fellows who attended as a group (four attended in one week) generally had a more rounded programme in the UK, whereas those who had a week ‘on their own’ were less able to feel part of the R4HC MENA programme despite individual meetings. It was generally harder to find a wide range of expertise in the UK to help the policy fellows from Palestine, given the particular nature of the health, social and political issues there. There may be some improvements we can discuss with the R4HC investigators about how to keep the policy fellows in touch and associated with the project.