Inside the MAPS Ghras el Khayr health facility
A Tale of Two Clinics
5 December 2023
As part of a field trip to ReBUILD for Resilience’s Learning Site in Majdal Anjar, Lebanon, the team visited four health facilities in the municipality. Here, Nick Hooton reflects on what we saw in two of these facilities, the contrasts and what this means for healthcare access in this community.
Majdal Anjar is a community close to the Syrian border in the Beqaa Valley of eastern Lebanon, where as a result of the ongoing conflict, a large number of Syrian refugees currently live alongside the host Lebanese population. With minimal funding from central government, the health needs of all communities in the municipality have to be met through a range of facilities – both formal (officially authorized and controlled by the state, the Ministry of Public Health (MoPH) or the Ministry of Social Affairs) and informal (unregistered or unauthorized facilities, established by community initiatives). The facilities we visited were fairly typical examples of the wider formal and informal health facilities in the region. The contrasts between them were marked, and perhaps surprising.
We visited the Karagheusian Primary Health Centre (PHC), a ‘formal’ vaccination clinic, affiliated to the MoPH, but funded through the Karagheusian Association [opens new tab] – an Armenian NGO based in Beirut. This clinic has been run by the same family for several decades, operating out of the family home. On days when the doctor visits, the clinic offers vaccinations, basic consultations and medications, both for the Lebanese and Syrian populations.
We also visited the Ghras el Khayr clinic – an ‘informal’ health facility, run by Multi Aid Programs (MAPS) [opens new tab] – a Syrian-led NGO which has been registered in Lebanon since 2013, and is funded by donations and international remittances including from the Syrian diaspora. Whilst currently unregistered with the MoPH, the clinic is serving patients from both the Lebanese and Syrian communities out of much larger premises. As well as consultations for illness, the clinic offered general and specialized clinics.
In both facilities, the dedication of the health workers was obvious, and their passion for the work they were doing was palpable.
The day-to-day running of the ‘formal’ Karagheusian PHC is managed by the daughter of the original founder. She has 15 years’ experience of this role but no formal medical training, and is supported by her own daughter, a graduate in biomedical sciences. A doctor visits the clinic just twice a week to deliver the vaccinations, consultations and medications.
The ‘informal’ Ghras el Khayr clinic, in contrast, has a large staff of 62 people, including 18 doctors and 5 dentists, as well as nurses and midwives. Staff are from both the Lebanese and Syrian communities, but staffing is complicated by the fact that Syrian refugees cannot officially work in these professional positions, and risk being deported if found to be doing so.
Here was a striking contrast. Whilst just over 100 patients had visited the ‘formal’ Karagheusian PHC in the past month, the ‘informal’ Ghras el Khayr clinic had treated more than 8000 patients over the same time. Both clinics reached both sections of the community – Lebanese and Syrian, with no formal restriction in accessing services. However, with so many of the displaced Syrian population not registered with UNHCR, the data held by the Karagheusian PHC limited the proactive contact with new mothers in the Syrian community for promoting vaccinations. The Ghras el Khayr clinic served far more Syrian patients – approximately 75% of the current daily patients – although the proportion of Lebanese patients had risen considerably since onset of the financial crisis.
Services, resources and information systems
Here was another striking contrast. Whilst being the ‘informal’ facility, the Ghras el Khayr clinic is hugely better resourced, benefitting from an organised fundraising system, attracting funds both from the Syrian community (locally and internationally) and increasingly from the Lebanese community. The most obvious manifestation of this was the range of services, number of paid staff and diagnostic facilities, including in-house laboratory (blood testing), radiography and mammography, and ultrasound scans. Open every day, patients can visit for primary and follow up consultations for medical and trauma problems, maternity clinics and dentistry and preventative clinics. The cost of a consultation is around $3, with additional (but subsidised) costs for imagery and investigations.
Whilst benefitting from an internal electronic record system for patients’ visits and health records, with obvious benefits for quality of care and follow up, there is currently no significant link to the MoPH, for information systems or for resources. Referrals to hospitals are made where needed, including for all maternal deliveries.
The ‘formal’ Karagheusian PHC offers a much more limited service – primarily vaccinations and child health advice, but with consultations available on the two days per week when the doctor is present. The clinic receives free child vaccines directly from MoPH, while the running cost of the centre is covered by the Karagheusian Association. Like all other affiliated vaccination centres they receive some technical support, cold chain supply and essential medicines from the MoPH. There are reporting systems for vaccination and disease outbreaks, support for temperature monitoring for vaccine storage, and the centre receives posters and public health information material from the Ministry. Fees are low – vaccinations for children are free and the doctor’s consultation costs around $2.
Official ‘place in the system’
Of the two facilities, only the Karagheusian PHC officially ‘exists’ within the formal health system. Routine vaccinations in Lebanon are only delivered through specific vaccination centres affiliated to the MoPH, including this one. Whilst being a ‘formal’ centre, the links with the MoPH are limited, with little in the way of resources for the services.
At the moment, despite reaching so many patients and offering a wide range of services, the Ghras el Khayr clinic remains outside the formal health system – part of the wider ‘fragmentation’ which characterises health services in fragile settings like this. Whilst there is a process for registering health facilities with the MoPH, no facility of this type had been registered at the time of our visit. However, the Director of the clinic was hopeful that the facility would be successful in this process soon.
Importantly, separate to the national government system, staff from both facilities are now part of the new Municipal Health Committee (MHC) for Majdal Anjar. This committee is made up of elected local officials and health workers from a range of facilities in the community, and has members from both Lebanese and Syrian communities. With the support of ReBUILD for Resilience colleagues from the American University of Beirut, the MHC is working to better understand and prioritise the health needs of people across the communities in Majdal Anjar. With better information and evidence, the committee is starting to successfully coordinate the health needs with support for appropriate services, including community health workers, and both formal and informal facilities like the ones we visited. Staff from both facilities were hugely enthusiastic about the opportunities this represented for better overall health outcomes for the community, and the part their own facilities could play in this.
Whilst the Karagheusian PHC clearly continues to provide a critically important service in the delivery of routine vaccinations, and a pathway for public health information for the families who visit the centre, apart from the two days when the doctor visits the centre remains relatively empty. In contrast, the ‘informal’ Ghras el Khayr clinic is perpetually crowded. What explains the huge difference in attendance and services between these facilities?
It is difficult to make any comparison on quality of care. Staff in both centres are clearly motivated, but those in the Ghras el Khayr clinic are able to translate this motivation to offer a more wide-ranging healthcare. And there does seem to be a clear difference in vision and ambition.
Whilst being long-established, benefitting from the support of the Karagheusian Association, and remaining a point of influence and ‘continuity’ in the community, the Karagheusian PHC remains largely dependent on the same central funding. In the absence of increased funding and innovation, there seems little that can be done beyond maintaining the existing limited services.
In contrast, despite being in a somewhat precarious position in the current political environment, the Ghras el Khayr clinic, with the funding available from MAPS, is not only currently offering a much wider range of important services, but, with a stated focus on population needs, is planning to expand the size and scope of services, and to improve its own health information systems so that it can better meet the healthcare needs of both the Syrian and Lebanese communities.
MAPS describes itself as a ‘refugee-led humanitarian organisation’ working for the ‘dignified futures of marginalised communities’. It was striking that in describing his own motivation and this ambition, the Ghras el Khayr Director talked about refugees being able to serve refugees and host communities in “dignity”.
Further information on our work in Lebanon
- Study: Close-to-community providers addressing gender norms and power dynamics: participatory action research in fragile and shock-prone settings – details here
- Study: The gendered experience of close-to-community providers in fragile and shock-prone settings: implications for policy and practice during and post COVID-19 – details here
- Blog post: ReBUILD’s visit to Majdal Anjar
- Blog post: Women, mothers, wives, refugees, health workers, activists: the roles of close-to-community health workers in Lebanon
- Blog post: Interview with a member of Beqaa’s Working Women group