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Abstract

Background:

The Syrian crisis has resulted in one of the worst humanitarian disasters in modern history. Inadequate access to and use of sexual and reproductive health services is a prevailing issue among adolescent girls and young refugee women in humanitarian settings.

Objectives:

This article aimed to explore and describe the perceived extent of implementation of the different objectives and activities outlined within the minimum initial service package for reproductive health in crisis services in Lebanon, from the perspectives of a diverse set of stakeholders from leading organizations (public, private, primary health centers, nongovernmental organizations) that were directly engaged with the Syrian refugee crisis response.

Design:

This study is a cross-sectional survey conducted using a standardized and validated questionnaire.

Methods:

Centers that provided sexual and reproductive health services to Syrian refugees in Lebanon were mapped. The study was based on a purposive sampling approach, retrieving 52 eligible organizations to cover most areas in the country. A total of 43 centers accepted to take part in the study. The head of the center was then asked to identify one person in their center who holds adequate knowledge of the explained objectives of the survey. Accordingly, the identified person was asked to fill out the survey.

Results:

A considerable portion of the respondents had limited knowledge about the specific minimum initial service package objectives and related sexual and reproductive health services. The study found the presence of a leading reproductive health agency, the Lebanese MoPH, as an essential facilitating factor for sexual and reproductive health service provision in Lebanon and has helped in overseeing the overall sexual and reproductive health coordination response for Syrian refugees (76.74% of all respondents). The identified challenges impeding adequate sexual and reproductive health services provision for Syrian refugees included (1) insufficient supplies (46.51%); (2) insufficient funds (39.53%); and (3) shortage of staff (39.53%).

Conclusion:

The recommendations for improved sexual and reproductive health service provision include the need for (1) enforcing the lead minimum initial service package agency for adequate and effective coordination, reporting, and accountability and (2) increasing funding for training staff and healthcare workers, as well as improving the overall quality of services available with the inclusion of family planning services, purchasing the necessary commodities, supplies and equipment, and covering fees associated with the different sexual and reproductive health services.

Keywords

health services Lebanon minimum initial service package sexual reproductive health Syrian refugees

Introduction

As the Syrian civil war enters its 11th year, a decade of violence and mass forced displacement has severely exacerbated the public health challenges throughout the Middle East and North Africa (MENA) region, including those of reproductive health, particularly among the Syrian refugees dispersed throughout the region. As a result of this crisis, 13.4 million Syrians need humanitarian aid, of which 3.6 million are girls and women of reproductive age.¹ In addition, prolonged disruptions in access to healthcare services have led to poor sexual and reproductive health (SRH) outcomes and high rates of gender-based and intimate partner violence.² The catastrophic and protracted nature of the Syrian war has further mandated the urgency of addressing these debilitating health challenges among Syrian refugee girls and women. Consequently, momentous concerns around planning, financing, and implementing current and prospective SRH services prevail to respond to the existing gaps.

The Lebanese context

In Lebanon, the public health challenges among Syrian refugee girls and women are particularly salient because of the number of refugees living throughout the country. According to the United Nations Higher Commissioner for Refugees (UNHCR), Lebanon retains its position as the country hosting the highest number of refugees per capita in the world, with over 865,531 registered Syrian refugees by the end of December 2021^3,a. While these numbers do not reflect the reality of the total number of Syrian refugees in Lebanon, the Lebanese government estimates over 1.5 million Syrian refugees, accounting for both those registered and unregistered refugees settled throughout the country.⁴ Most Syrian refugees in Lebanon reside in urban areas, due to the governmental policy which prohibits the establishment of formal refugee camps.⁵ Most refugees remain settled in underserved regions of Lebanon, namely, in Beqaa and North Lebanon, characterized by limited human resources and infrastructure.⁶

The healthcare system in Lebanon

Lebanon’s healthcare system is highly privatized and has shifted to a curative care approach rather than primary and preventive care. It is one of the most expensive healthcare systems in the world with high out-of-pocket health expenditure, hindering access to needed health services by Syrian refugees.⁷ The same challenge is evident in the host population, where universally accessible and comprehensive health services have always been a struggle.⁷ Consequently, costs remain high, and a shortage of trained staff, medication, and equipment continues to impede adequate access to needed services.^8,9

The humanitarian response

In response to the Syrian crisis, multiple actors in Lebanon, including the Ministry of Public Health (MoPH), UNHCR, and other international organizations as well as private clinics have joined efforts to integrate refugees and displaced populations into the Lebanese health system by the provision of services for free and/or at subsidized cost at designated facilities across the country.¹⁰ Yet, Syrian refugees residing in underserved areas in Lebanon are often unaware of the availability of such services. In addition, the provision of secondary and tertiary care is still administered by private providers, thus further crippling cost control and access by refugees.^11,12 Nevertheless, the humanitarian health response has been fragmented and plagued by duplication,¹³ and many Syrian refugees continue to experience financial difficulties when it comes to accessing services.¹⁴ Indeed, the surplus of actors has been attributed to having a negative impact on the overall effectiveness and efficiency of the response, in line with the increased competition for funds and the overlapping mandates and responsibilities.¹⁵ In a recent report, aid workers in Lebanon reiterated this overlap, denoting that some actors are running similar projects in the same areas and outreaching the same beneficiaries in numerous instances.¹⁶ In addition, multiple financing sources cover the cost of healthcare services across both the public and private sectors which include multiple funds that addressed to the same services. To mitigate the fragmentation and inefficiency of the response, the MoPH has called for an integrated approach to health delivery, and established a steering committee that would coordinate the planning, financing, and delivery of services among international agencies.¹³

Sexual reproductive health strategy in Lebanon

The unprecedented increase in demand for healthcare services, along with the ever-expanding shortage of health workers, has placed immense pressure on the Lebanese health system, further reducing access to healthcare for both refugees and host community.⁶ Consequently, Syrian refugee girls and women are unable to access an adequate level of care, particularly SRH services.¹⁷ Against this backdrop, the MoPH has been adopting different measures including (1) offering primary health care services pertinent to Syrian refugee women; (2) managing the public healthcare (PHC) facilities providing care for reproductive health (RH) and other issues; (3) raising awareness on RH information within and out of the centers through educational programs; (4) training staff on clinical protocols for RH; and (5) equipping hospitals for an adequate response to manage high-risk pregnancies and emergency obstetric cases, and detect RH-related diseases like cervical cancer. Indeed, around 220 PHCs and 64 RH dispensaries, run by international non-governmental organizations (INGOs), receive RH drugs from the government to provide adequate care to the Syrian refugees. In addition, the UNHCR subsidizes services in 53 hospitals across Lebanon, contracting public and private hospitals through a third party, covering 75% of obstetric and life-threatening conditions.¹⁸

Minimal initial service package

The inter-agency working group (IAWG) on RH in Crises created the first manual outlining the minimal initial service package (MISP) for RH in crisis, to address challenges faced by girls and women in protracted humanitarian settings in 1999.¹⁹ The MISP consists of a set of life-saving SRH interventions, with the overall goal of preventing a surplus of SRH-related morbidity and mortality during the onset of a humanitarian emergency.²⁰ The 2018 revised MISP objectives were to (1) identify the RH agency to lead its implementation; (2) prevent and manage the consequences of sexual violence; (3) reduce human immunodeficiency virus (HIV); transmission; (4) prevent excess maternal and neonatal morbidity and mortality; (5) prevent unintended pregnancies; and (6) plan for comprehensive services and their integration into existing services.²⁰ Although MISP was developed roughly 20 years ago, a limited number of studies have evaluated its implementation and effectiveness to date.^21,22 Among the available studies, results reflect varying degrees of success and limited implementation.^7,22 In principle, the challenges about the implementation of MISP revolve around its practicality, integration, communication, coordination, availability, quality of referral systems, and most importantly, the lack of national strategies.²² Other inadequacies include the lack of trained staff and actors in addition to the high rates of turnover and logistical difficulties associated with weak coordination.^7,23

MISPs in Lebanon

To cater to the SRH needs of Syrian refugees, the MoPH and UNHCR in Lebanon, along with other INGOs, have administered a wide range of services across multiple channels and service providers.⁶ However, the implementation and scale-up efforts to transition to a comprehensive SRH scheme remain lagging despite the variety of services.⁷ The MoPH has strived to enhance its humanitarian response by forming a steering committee in 2015, followed by developing two consecutive crisis response plans (LCRP 2015–2016 and LCRP 2017–2020). The plans revolved around mobilizing the PHCs’ network to provide specialized SRH services.¹³ Given the absence of a national RH strategy, the challenges of access and quality of SRH services remained significant, despite the continuous support of the World Health Organization (WHO) and the United Nations Population Fund (UNFPA).²⁴ The International Labour Organization (ILO) has also expressed concerns that the services provided by PHCs “seem to be insufficient and are unable to accommodate the additional significant increase of demand—especially in terms of reproductive health.”¹⁷ Thus, adhering to the recommendations of MISP to scale-up equitable coverage of services and sustaining the services in protracted crises remains a prominent challenge in Lebanon, which holds a fragmented healthcare system that lacks basic resources.²⁵

This research aimed to explore and describe the perceived extent of the implementation of the different activities outlined within each of MISP objectives in Lebanon, from the perspectives of a diverse set of stakeholders from leading organizations (public, private, primary health centers, and NGOs) who were directly engaged with the Syrian refugee crisis response. This study also explored the ability to transition to comprehensive SRH service delivery based on the perceived experiences of these selected stakeholders.

Methodology

Design

This study is a cross-sectional survey conducted using a standardized and validated questionnaire adapted from the IAWG^b tool for the assessment of countries’ readiness to provide MISP for SRH during a humanitarian crisis. The questionnaire aimed to explore and describe the perceived extent of the implementation of MISP services in Lebanon, in response to the Syrian refugee crisis (Please see Annex 1 for the Objectives of MISP and Annex 2 for the survey). Accordingly, it was contextualized to resonate with the local context, translated and adapted to Arabic by a certified translator, and later reviewed by the study team.

Target population

The target population includes different stakeholders from selected organizations (public, private, primary health centers, NGOs).

Inclusion/exclusion criteria

The inclusion criteria for selection were predominantly based on whether the NGO and/or PHC provided SRH services to Syrian refugees in Lebanon. Centers that did not provide SRH services, and/or did not receive Syrian refugees were excluded.

Sample

The research team intended to recruit 50 organizations to include different regions in Lebanon and different types of centers. For that purpose, the study was based on a purposive sampling approach; thus, no power analysis was done to deduce a sample size.

Sample selection was based on a rapid community assessment using standardized criteria to identify the most representative stakeholders to take part in this study. It revolved around mapping the different stakeholders based on the following attributes: (1) the perceived value of the organization in SRH service delivery; (2) their expertise in SRH service delivery; (3) their contribution to the MISP implementation and response in the context of the Syrian Refugee crisis; and (4) the extent of their geographical coverage. The mapped organizations were then scanned to identify those who are directly and heavily involved in the delivery of MISP services to Syrian refugees. The total identified sample of potential participants consisted of 52 different organizations and/or their affiliated health centers.

Recruitment

The 52 identified organizations, health centers, and units were contacted and asked to participate voluntarily in the study, out of which 43 centers/organizations confirmed participation. The remaining 9 eligible organizations were either unavailable or did not provide consent to participate.

Once the centers approved their participation, the head of the center was asked to identify one person who held adequate knowledge of the explained objectives of the survey. An invitation email to participate in the study was subsequently shared with the identified person who was eligible to answer the survey questions.

Data collection tools and process

The survey was circulated using Lime Survey, an online survey tool, whereby a link was shared with the participants via email. A proceeding email was shared with the participants, which included a consent form ensuring that the survey was voluntary and anonymous, and it would only be shared with collaborators from the WHO. The questionnaire was divided into eight main sections as follows:

Section I: General information related to the respondent and the institution/entity he or she is affiliated with. No names/contact details were collected to ensure the de-identification of responses.

Section II: Country-specific background information related to the implementation of MISP in Lebanon and the institutions that are responding in that regard.

Section III: Respondent’s knowledge and involvement in MISP implementation and/or training if any.

Section IV: Assessment of the respondent’s knowledge of MISP objectives.

Section V: Evaluation of the respondent’s knowledge of MISP-associated activities.

Section VI: Knowledge regarding the presence of a national Disaster Risk Reduction agency, and any activities it pertains to.

Section VII: Preparedness undertook before the onset of the crisis regarding health services.

Section VIII: SRH response activities done regarding the crisis.

The study period was from May 2017 to October 2019, and the data were collected in 2018.

Ethical considerations

The study methods and procedures were approved by the American University of Beirut (AUB)—Social and Behavioral Institutional Review Board (IRB) (SBS-2017-0620) in November 2018.

Statistical analysis

The de-identified data from the survey were extracted into an Excel sheet and subsequently analyzed. Analysis revolved mainly around univariate and bivariate, using the Statistical Package for the Social Sciences (SPSS). The aim of the analysis was descriptive, including frequencies, simple associations, and the construction of contingency cross-tabulations.

Results

Description of the sample

Most of the sample (60.47%) consisted of local NGOs across Lebanon, mainly in South and North Lebanon (Figure 1). In terms of geographical distribution, 14 organizations in the sample (30.23%) were in the Beqaa region, 9 (20.90%) in South Lebanon, 7 (16.28%) in North Lebanon, 6 (13.95%) in Mount Lebanon, and 5 (11.63%) in the capital, Beirut. Most respondents (n = 38, 88.37%) held managerial positions in their organization (Figure 2). The respondents had worked, on average, 10.44 ± 7.91 years with their organization, with a range of 1–33 years. The respondents reported 5.21 ± 1.64 years of working on issues related to the Syrian crisis (data not shown).

Figure 1.

Type and geographic location of organizations (N), n = 40.

Figure 2.

Positions of respondents within the organizations (N, %) n = 43.

Knowledge of MISP and Training on SRH

Out of the 43 respondents, only 9 expressed their awareness of the MISP objectives: 2 out of 6 Ministry of Social Affairs (MoSA) centers, 6 out of 29 local NGOs, and 1 out of 6 INGOs. Health managers were most likely to know about the MISP (Table 1). Among the 9 respondents who knew about the MISP package, all 9 selected “through my current organization” and “MISP Distance Learning Module online course,” 4 selected “MISP course at university” and only 1 respondent selected “experience from the field.” A total of 22 (51.16%) respondents indicated that they participated in MISP/SRH-related services training at their organization. Figure 3 describes training based on organization type.

Table 1.

Knowledge of MISP by position at organization (N), n = 43.

	Have you ever heard of MISP?
	Yes	No
Manager	3	39
Health Manager	4	30
Health Supervisor	1	38
Assistant Manager	0	36
Nurse/Midwife	1	39
Total	9	34

MISP: minimum initial service package.

Figure 3.

Training on MISP/SRH services by organization type (N), n = 40.

Most of the respondents (N = 30, 70.00%) were least familiar with the “Prevention and Management of the consequences of Sexual violence” objective (Table 2). When asked about the additional priorities, 36 (83.72%) identified all 4 correctly, and only 4 (9.30%) were unable to identify any (Table 2). All objectives were identified by at least 37 individuals (86.05%).

Table 2.

MISP objectives and additional objectives identified.

	Percentage (%)	Frequency (N)
MISP objectives identified
Ensure that the health group has identified an organization that is leading the implementation of the MISP package	90.70	39
Prevention and management of sexual violence outcomes	69.77	30
Reduce HIV transmission	88.37	38
Preventing increased morbidity and mortality of mothers and newborns	83.72	36
Planning to move to comprehensive reproductive health services and integrate them into primary health care as the situation allows	90.70	39
Number of additional MISP objectives identified correctly
Zero	9.30	4
Two	4.65	2
Three	2.33	1
Four	83.72	36

MISP: minimum initial service package.

Knowledge of the specific MISP activities under each of the six MISP objectives was highly variable as highlighted in Table 3. Knowledge was assessed by mentioning the objectives and asking the participant if she or he thinks it is one of the MISP objectives or not. For the objectives on HIV, maternal mortality and morbidity, and comprehensive services, most respondents (38 [88.37%], 32 [74.42%], and 39 [90.70%], respectively) identified the activities correctly. For the objective on the lead agency, most respondents 30 (69.77%) were able to identify only one or two activities correctly. For the sexual and gender-based violence (SGBV) objective, none of the respondents were able to identify all activities correctly, and 27 (62.79%) were able to identify two out of three activities (Table 3).

Table 3.

Number of MISP activities identified correctly under each objective.

	Score^a	Frequency (N)	Percentage (%)
Role of the organization that is leading the implementation of the MISP package	0	6	13.95
	1	15	34.88
	2	15	34.88
	3	3	6.98
	4	4	9.30
Prevent and manage sexual violence outcomes	0	16	37.21
	2	27	62.79
	3	0	0.00
Reduce HIV transmission	0	4	9.30
	2	1	2.33
	3	38	88.37
Preventing increased morbidity and mortality of mothers and newborns	0	3	6.98
	3	1	2.33
	4	7	16.28
	5	32	74.42
Planning to move to comprehensive reproductive health services	0	4	9.30
	4	39	90.70

MISP: minimum initial service package.

The score refers to the number of activities identified correctly under each of the MISP objectives. The higher the score, the better the knowledge.

Readiness and response

When asked whether there is an agency or department for disaster risk reduction (DRR), 40 answered. Eighteen (45.00%) respondents answered yes, out of which more than half (55%) mentioned that it was the High Committee in Lebanon. When asked about policies or strategies for DRR, most respondents (n = 23, 57.50%) answered that no such policies are present. Among the 17 that answered yes, 14 (82.35%) answered that these policies include (RH) and the most vulnerable populations.

A total of 24 (55.81%) organizations made prior arrangements and preparations for SRH services at the start of the crisis. However, there was no significant difference between the different types of organizations (Table 4). Table 4 presents the different SRH programs that were prepared at the start of the crisis by the 24 organizations that answered yes. Maternal health, family planning, and sexually transmitted infections (STIs) preparedness were the most readily available in most of the centers, while access to safe blood and standard precautions was the least available. Most organizations (n = 28 of the 40 respondents, 70.00%) initiated an SRH response within the first 2 years of the crisis, whereby only 6 (15.00%) organizations initiated an immediate response that is, within 3 to 4 weeks of the start of the crisis. Maternal health was provided by all 40 centers at the start of the crisis, with the least available services being (1) access to safe blood and (2) management of the consequences of sexual violence (Table 4). Only 4 (10.00%) of the respondents indicated the distribution of clean delivery packages. As for the main distribution methods, for pregnant women, it was upon registration and/or at clinics during antenatal visits. For condom distribution, 37 (92.50%) centers indicated condom distribution, of these 32 indicated distribution to selected clinics (Table 4).

Table 4.

SRH organizational preparedness, programs prepared, response to RH needs, first SRH activity implemented at the start of the crisis by organizational type (N), n = 40.

SRH program	Organization type
SRH program	INGO (n = 6)	NGO (n = 26)	MOSA (n = 6)	MoPH (n = 2)
SRH Organizational preparedness at the start of the crisis	4	14	4	1
SRH programs were prepared at the start of the crisis
Maternal health	5	14	1	1
Neonatal health	2	7	1	1
Condom distribution	4	10	1	1
Access to safe blood	2	4	1	1
Standard precautions	2	6	1	1
Prevention of sexual violence	2	10	2	1
Response to sexual violence	2	9	2	1
STIs	4	13	2	1
Family planning	4	12	2	1
ARVs (immunodeficiency) for continuing users	4	6	1	1
Time from the start of the crisis organization began responding to RH’s needs
Within 3–4 weeks	0	5	0	1
After 4 weeks	0	3	2	0
2 years	5	10	2	0
3 years	1	2	0	0
4 years	0	2	0	0
5 years	0	1	0	0
6 years	0	1	1	1
7 years	0	1	1	0
The first SRH activities implemented
Maternal health	6	26	6	2
Neonatal health	5	17	6	2
Condom distribution	5	18	6	2
Access to Safe Blood	1	3	1	2
Standard precautions	6	13	4	2
Prevention of sexual violence	5	15	2	2
Response to sexual violence	4	9	2	2
STIs	6	23	6	2
Family planning	5	18	6	2
ARVs (immunodeficiency) for continuing users	6	15	5	2

RH: reproductive health; SRH: sexual and reproductive health; INGO: International Non-Governmental Organizations; MOSA: Ministry of Social Affairs; STI: sexually transmitted infection; ARVs: Anti-retrovirals.

Coordination

Thirty respondents (69.77%) identified the Lebanese MoPH as the lead organization responsible for coordinating SRH services for Syrian refugees in Lebanon. Twelve (27.90%) respondents identified the leading organization as MoPH along with another agency (e.g., premiere urgency, French Relief, MADAR, UNHCR, Médecins Sans Frontiers [MSF], International Medical Corps [IMC]). Only one organization did not mention MoPH and identified IDEALS as the coordinating agency. When asked about whether there is an available list of associations implementing reproductive health response projects, most respondents (n = 37, 86.05%) answered no (data not shown).

When asked about how effective the NGOs are at coordinating with each other, 29 (70.73%) reported that some NGOs coordinate weekly meetings among themselves, 8 (19.51%) indicated that there is no coordination at all, with 2 (4.88%) indicated that some NGOs coordinate with occasional meetings, and 2 (4.88%) indicated very good coordination with weekly meetings. Reproductive health coordination meetings occur “whenever they are called” as selected by 12 (27.91%) respondents, never by 9 (20.93%), once a month by 8 (18.60%), bi-weekly by 7 (16.28%), and weekly by 7 (16.28 %).

Tables 5 and 6 describe the distribution of perceived factors (facilitators and barriers), as indicated by the respondents, to impact the SRH response for Syrian refugees in the country. Most of the respondents (n = 33, 76.74%) indicated the Leading Reproductive Health Agency as one of the main positive facilitators, followed by funding for the response (n = 21, 48.84%) and MISP protocols (n = 20, 46.51%), respectively (Table 5). When asked about the factors impeding SRH response, almost half reported the absence of sufficient supplies (n = 20, 46.51%), jointly followed by the absence/presence of sufficient funding for the response and adequate availability of human resources (n = 17, 39.53%) (Table 6).

Table 5.

Perceived factors that facilitated and impeded the SRH response for Syrian refugees in Lebanon.

	Percentage of respondents selected answer (%)
Factors that facilitated the implementation of the SRH response
Leading Reproductive Health Agency	76.74
Funding for the response	48.84
Sufficient supplies	44.19
Adequate employment (working personnel)	44.19
MISP protocols	46.51
Emergency preparedness through MISP training	39.53
Preparedness through supplies storage	37.21
Preparedness through the distribution of supplies	44.19
Factors that impeded the implementation of the SRH response
No leading Reproductive Health Agency	69.77
Lack of funding for the response	60.47
Insufficient supplies	53.49
Lack of employment	60.47
Lack of MISP protocols	69.47
Lack of Emergency preparedness through MISP training	65.12
Lack of preparedness through supplies storage	69.77
Lack of preparedness through the distribution of supplies	65.12

SRH: sexual and reproductive health; MISP: minimum initial service package.

Table 6.

Perceived factors that impeded the implementation of the SRH response for Syrian refugees in Lebanon.

Factors that impeded the implementation of the SRH response	Percentage of respondents selected to answer (%)
Leading Reproductive Health Agency	30.23
Funding for the response	39.53
Sufficient supplies	46.51
Adequate employment (working personnel)	39.53

SRH: sexual and reproductive health.

Discussion

This study provides a comprehensive overview and a critical appraisal of the different objectives and activities outlined within the MISP in Lebanon and the respective coordination systems put in place, in response to the Syrian refugee crisis. The study identified the main facilitating factors as well as barriers impacting the provision of these services and the ability to transition to comprehensive SRH services, by analyzing the field experiences of more than 40 actively engaged institutions/centers. According to a recent narrative review assessing MISP for Syrian refugee women in Lebanon, limited data and assessments exist in Lebanon that critique the SRH response to Syrian refugees in the country.²¹ Our assessment is the first to highlight and analyze the extent of MISP readiness and response to the Syrian refugee crisis in Lebanon, using a globally standardized assessment tool and informed by comprehensive sample selection criteria that allow for the identification and selection of the most relevant SRH stakeholders working in this field.

The overall results indicate a general lack of awareness of the different MISP objectives and underlying activities outlined for each objective among the sampled institutions/centers, despite years of engagement in direct SRH service delivery to Syrian refugees in Lebanon.²³ Only one out of five respondents reported having ever heard of the MISP as a comprehensive package encompassing six objectives that culminate in the transition to comprehensive SRH service delivery. This finding is surprising given the fact that more than half of respondents indicated to have participated in SRH-related training. These results could be attributed to the fact that MISP is not widely recognized as a concept/package in Lebanon,²¹ and consequently, the different SRH services provided under the MISP, even when related, were not referred to or framed as MISP. Indeed, when the respondents were first approached, none of them were aware of the MISP and its objectives. However, when the objectives and activities were explained to them, they were able to identify them. This finding is not surprising, however, given the fact that the different MISP services are adequately aligned with the national reproductive health strategies and related services enforced in Lebanon.

The general lack of awareness of the MISP objectives delineates the importance of training as an effective tool to address the prevailing knowledge gap among pertinent organizations/ institutions in the country.²³ As per our findings, more emphasis should be on expanding relevant training to improve the knowledge and expertise particularly of the MISP objectives two and four i.e., “the prevention and management of sexual violence outcomes”, and “the prevention of increased morbidity and mortality of mothers and newborns”, as these were the least identified objectives by the respondents. Data from UNHCR suggests that poor training is one of the main challenges that hinder the effective clinical management of rape (SGBV, the second MISP objective) in humanitarian crises.²⁶ On the other hand, and as pertinent to the fourth MISP objective, a significant portion of pregnancy-related complications was correlated with poor antenatal care compliance. Similarly, the latter reflects a similar need for training of health care providers coupled with increasing women refugees’ awareness around the importance of regular antenatal care during pregnancy. These figures coupled with the evidence from our study highlight a crucial need for training at the level of service providers, one that specifically focuses on the second and the fourth objectives of the MISP.²⁷

As for readiness and response, results showed a general lack of information/ambiguity among organizations and institutions regarding the availability of a national DRR governance and strategy in Lebanon. Many of the respondents indicated that they did not know it existed in the country and among those who had a brief knowledge of the DRR, most noted that the strategy lacks the inclusion of SRH preparedness plans. The results denote that the NGOs and relevant institutions were better prepared compared with public sector organizations for the emerging SRH needs that arose as a result of the Syrian refugee crisis. More than half of the respondents indicated having made prior preparatory arrangements for SRH services at the start of the crisis, without any significant differences between the different types of organizations. Most of the services that were prioritized to become readily available were those of maternal health, family planning, and STI. This, as already indicated, could be attributed to the existing national health strategies that continuously advocate for the availability of these services nationally, long before the onset of this crisis.

As for coordination of SRH services provision, most NGOs and institutions were able to identify that the Lebanese MoPH steers the coordination of SRH service response for the Syrian refugees in the country. They noted that MoPH serves as the lead organization, alone or along with other agencies such as Premiere Urgence, French Relief, MADAR, UNHCR, MSF, and IMC, etc. This can be attributed to the health coverage plan that is implemented by UNHCR, whereby Syrian refugees in Lebanon get their essential services, including SRH services, through the MoPH and its dispersed PHCs.^12,28 On the contrary, most of the NGOs and institutions perceived the ongoing coordination for SRH response to be non-satisfactory between and among themselves; less than 5% of the respondents reported perceiving the existent coordination as proper (with weekly meetings), and almost half reported that they never organized and/or participated in any reproductive health coordination meetings.²³ This is thought to be attributed to the absence of a lead coordinator within their organization, who is responsible for proper communication and coordination among pertinent institutions, which was also evident in a similar review in Lebanon.²¹

Several factors were reported to have facilitated the delivery of SRH response for Syrian refugees, these included the availability of a Leading Reproductive Health Agency—about the MoPH, as one the most important enablers. MoPH is heavily engaged in the provision of a multitude of services to Syrian refugees in this regard, including reproductive health care, family planning services, and basic medications.^12,28 Moreover, adequate funding for the response and availability of MISP protocols was also highlighted as an equally important enabler, shedding the light on the integral role of INGOs in funding such programs, predominantly UNHCR, in prioritizing the SRH needs of Syrian refugees and in taking appropriate measures to mitigate them. On the contrary, it was noted that the response was impacted by several challenges. The deficiencies in the implementation of the MISP objectives and related activities in the context of the protracted Syrian crisis in Lebanon can be attributed to a general shortage or insufficient availability of supplies to carry out the SRH response and duplication of response efforts among partners due to a lack of adequate communication among them. These findings are in line with the narrative review assessing MISP on Syrian refugee women in Lebanon.²¹ Additional factors impeding the implementation of the MISP objectives in the context of the crisis in Lebanon include insufficient funding and inadequate availability of personnel. The results of our assessment indirectly amplified the importance of coordination: the first objective of MISP, and the crucial need to enhance the activities of the lead MISP agency to coordinate the SRH response nationally and alleviate some of the observed pitfalls.

Strengths and limitations

Our study is the first to explore the perceived extent to which the provision of essential SRH services and coordination systems are available as outlined in MISP in response to the Syrian refugee crisis in Lebanon. The results pinpointed important facilitating factors and barriers impacting the implementation of the different MISP objectives and related activities. Some methodological limitations should also be noted. The limited sample size and reliance on convenience-based sampling could have led to selection bias and limited the generalizability of the results. To mitigate these effects, however, the research team ensured that the selection of the stakeholders’ organizations/institutions was guided by a comprehensive community mapping exercise using standardized selection criteria discussed above. This allowed for the identification of the most prominent organizations/institutions in the country engaged in the SRH Syrian refugees’ response. Another limitation is that the head of the organization was the one who recommended the selection of the most perceived-suited personnel to answer the survey. This was not always efficient and created differences among the different types of respondents in this assessment. However, even when managers were chosen to answer the survey, these managers generally supervised the different projects within their organization and thus had adequate knowledge of their organizations’ policies and activities. Even in the event where they could have had limited knowledge, they were able to refer to their colleagues for additional information. For this reason, we believe the quality of the collected data is valid. An additional limitation pertains to the nature of the questions in the survey itself. For instance, assessing the respondents’ knowledge as pertinent to the different MISP objectives should be more rigorous and standardized. Finally, one of the main limitations of this study is that MISP as a concept is not widely recognized or used in Lebanon. However, as described earlier, the respondents were aware of the objectives/activities, and were actively engaged in the delivery of one or more of its objectives and related activities, but when it came to describing the package of SRH services they were providing, they were not that these set of essential SRH services make up the MISP.

Conclusion

Even though the higher relief committee in Lebanon is the leading agency for DRR, and many of the surveyed stakeholders indicated that they have SRH policies in their strategies for vulnerable populations, however, the implementation of these policies was/is perceived to be compromised in response to the Syrian refugee crisis.

In the absence of a lead coordinator (which was perceived as a predominant problem during the Syrian refugee response in Lebanon), the first objective and attribute of MISP, a lot of gaps and concerns directly impacted SRH services’ planning, delivery, quality, and accessibility. Nonetheless, a considerable portion of its objectives and SRH-associated activities were addressed, despite the limited conceptual awareness of MISP at the service-provider level. The presence of a leading RH agency was reported as one of the facilitating factors for SRH provision in Lebanon. On the contrary, insufficient resources, funds, and specialized human resources were the main factors that hindered the provision of SRH services in Lebanon.

Based on the findings of this assessment, it is important to highlight the following recommendations to enhance the current national SRH preparedness strategy for Syrian refugees in Lebanon: (1) emphasize the importance of coordination (by ensuring an increased level of communication, reporting, and accountability) among all the different stakeholders (such as donors, providers, and local health authorities) and (2) advocate for an increase in allocated funds for SRH-related resources to better address the implications on service quality and provision resulting from the lack of resources. Funding should be mainly directed toward (1) ensuring adequate SRH supplies and equipment; (2) training enough health workers and personnel; (3) covering the overall response and the services that it encompasses; and (4) emphasizing the need for training at the level of service providers.

Finally, additional and regular training of health care providers is essential to ensure adequate delivery of good quality and SRH-responsive services. Specific training focused on the second and the fourth MISP objectives “the prevention and management of sexual violence outcomes” and “the prevention of increased morbidity and mortality of mothers and newborns” as also identified to be needed as many of the surveyed samples demonstrated limited knowledge of the MISP activities associated with these two objectives.

Supplemental Material

sj-docx-1-whe-10.1177_17455057231171486 – Supplemental material for Perceived facilitators and barriers to the provision of sexual and reproductive health services in response to the Syrian refugee crisis in Lebanon

Supplemental material, sj-docx-1-whe-10.1177_17455057231171486 for Perceived facilitators and barriers to the provision of sexual and reproductive health services in response to the Syrian refugee crisis in Lebanon by Fouad M Fouad, Mahmoud Hashoush, Jasmin Lilian Diab, Dana Nabulsi, Sarah Bahr, Sarah Ibrahim, Theresa Farhat and Loulou Kobeissi in Women's Health

Footnotes

Acknowledgements

The authors thank the Lebanese Ministry of Health (MOPH) as well as the WHO Lebanon Country Office for facilitating the needed approvals as well as for providing guidance and direction. They also thank the entire data collection team, including the field research assistants and data collection facilitators, who tirelessly worked to collect the data for this study, as well as all the key informants who took part in the assessment.

Declarations

ORCID iDs

Fouad M. Fouad

Mahmoud Hashoush

Jasmin Lilian Diab

Supplemental material

Supplemental material for this article is available online.

Notes

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