The power of knowledge: evidence-based action in the local governance of the Lebanese health system
The influx of Syrian refugees into Lebanon since 2011 and the socio-economic crisis it triggered, coupled with political instability, the collapse of the economy and the mass emigration of healthcare workers, has challenged Lebanon’s health system.
ReBUILD for Resilience partners, American University of Beirut, established a learning site in Majdal Anjar, in the Zahle District of the Beqaa Governorate – the home to a large Syrian refugee population. There the teams mentored the establishment of a Municipal Health Committee (MHC) which comprised local stakeholders, including health officials from different non-state actors, and members of the Majdal Anjar Municipal Board. The purpose of the MHC was to co-develop and implement innovative interventions to help deliver inclusive, gender-equitable and quality healthcare in the area.
What problem is being addressed?
Whilst they were enthusiastic and willing to work together for the good of their communities, most MHC members knew little about using evidence-based processes to implement health projects. Some, including those appointed by the Mayor, continued to act in their own interests rather than in line with available evidence. Others, who had been responsible for specific initiatives, exhibited a poor understanding of the outcomes of what were sometimes costly interventions.
It was decided that MHC members required capacity building to enable them to understand the importance of adopting an approach based on equity, accessibility, inclusiveness, accountability, and evidence-based governance. The aim was to convince the new leaders, who had previously acted on impulse, of the value of knowledge production and use, with a view to improving the planning, implementation and assessment of programmes to meet their community’s needs.
What did we do?
The capacity strengthening process had several strands:
Training: The MHC comprised a varied range of local actors, with different educational backgrounds and experiences in the field. Together they were affiliated with many different organisations including Ministry of Public Health (MoPH) regulated facilities, the private sector, local NGOs, international NGOs, the humanitarian sector providing health services to Palestinian refugees, and the Syrian informal health sector, as well as with the Municipality of Majdal Anjar.
When the MHC was formed, training workshops were conducted, covering areas including participatory action research, the health systems resilience framework, gender equity and health, research design and quantitative and qualitative methodologies, data collection, and the rules of research participation.
Participation in brainstorming sessions and discussion around particular themes: Throughout the development of the learning site, local partners took part in regular planning and strategy meetings where they reflected on the various project management steps and on-going activities, conducted key informant interviews, and participated in thematic analysis. This culminated in a Group Model Building workshop, which resulted in the selection of an intervention. This new approach, which was based on evidence, equity and inclusivity, demonstrated the benefit of collaboration between academia and local team partners.
“This model of cooperation between academia and the municipality and local organizations is new. We worked on various projects with INGOs and with academics but this triad between academia, municipality and local NGOs is unique. If it will be successful, it will surely be a new model of community work.” Director of a local NGO
Emphasis on practice: The AUB team encouraged local partners to practice what they had learned and to gain hands-on experience, ensuring a sense of ownership of the overall project. The co-production of knowledge between local partners and ReBUILD consolidated the relationship and enhanced trust among all actors. If a member made a proposal not in line with agreed principles, extensive discussion and compromise eventually led to consensus. During the first critical reflective meeting one of the respondents said :
“We learned many skills. During COVID-19 we worked haphazardly, now with the MHC we progressed beyond hazardous work and we now know how to work following a methodology and a plan. During the strategic planning workshop, we learned how to identify possible obstacles and to think of how to overcome them and choose the right path.” Municipal health officer
Exposure to negotiations with external actors: To promote relevant and high impact interventions based on the health needs of the local population, the AUB team questioned the long-term impact of every intervention or programme proposed by external donors. In three instances, members of the MHC evaluated the evidence and scientific arguments during meetings between academia and potential implementers of externally-funded programmes. This led to the modification of interventions, making them more relevant and in line with the MHC strategic plan:
1. A programme proposed by “Doctory” for ad hoc screening and telemedicine, was transformed into a population-wide systematic, multifactorial health screening and referral system.
2. A programme funded by the Syrian American Medical Society for dental checks of Syrian school children was transformed in the oral health component of a universal and comprehensive school health programme targeting all children in the village.
3. Discussions with Action Against Hunger transformed their Malnutrition Screening programme targeting selected families into a universal door-to-door programme including breastfeeding support, screening for malnutrition and treatment of child obesity.
This strategic approach resulted in the gradual shift in power from political to technical, where the gathering and use of evidence became the basis for ensuring relevant and sustainable programmes.
In the early days of the MHC, the trust of the group was granted exclusively to members of the political hierarchy. As the intervention developed this shifted towards members with more technical capacity and readiness to perform particular activities, such as organisational capacities, the ability to analyse figures, and previous experience of managing health programmes.
When a member of the Municipal Board, present as guest at one of the meetings, proposed increasing the number of residents in order to secure more funds, the protest against the move came from his Board colleagues. Their arguments showed an increased and skilled use of evidence-based decision making, developed during their time on the MHC and exposure to evidence-based planning. That same member’s attempts to keep hold of power was refuted by his colleagues, who again argued for an evidence-based approach to ensure success and long-term impact.
The impact of the Participatory Action Research approach was particularly evident during the Group Model Building and Strategic Planning workshops, during which participants committed to a knowledge generation process based on responsiveness and contributions from all partners. This resulted in the identification of appropriate interventions and the development of an evidence based, comprehensive strategic plan, focused on the values of social justice and equity of access. One of participants said: “Even the Ministry of Public Health does not have a strategic plan of this quality.”
More on the Majdal Anjar learning site project and related outputs can be found here.
Image: Members of the MHC and ReBUILD team outside the Majdal Anjar municipality building