Introduction

In the midst of protracted emergencies, the focus of humanitarian health response has traditionally been on acute conditions, often overlooking the significant impact of noncommunicable diseases (NCDs) in low- and middle-income countries and disaster-prone areas. Syria, for instance, witnessed a high mortality rate from NCDs, with 45% of all deaths attributed to these conditions, including cardiovascular diseases (25%) and cancers (9%). Compounded by limited access to shelter and healthcare services, disrupted drug provision, diagnosis and treatment, the risk of NCD-related complications escalates. To address this issue, WHO initiated a pilot project in 12 primary healthcare centers, introducing NCD Emergency Kits to manage prevalent NCDs such as diabetes, hypertension, chronic respiratory disease and selected mental health conditions. Each NCD Emergency Kit contained medicines, devices and supplies to meet the priority NCD health needs of 10 000 people for three months.

Context

The Syrian conflict, which began in 2011, resulted in the collapse of the country's health system. It was only through the collaborative efforts of international and local nongovernmental organizations and support from donors and United Nations agencies like WHO that the system could be partially restored. However, the management of NCDs remained suboptimal, characterized by high out-of-pocket expenses, inadequate quality care provision, lack of coordination and follow-up, and the absence of a functioning insulin cold-chain delivery and management system.

Recognizing the urgent need to address NCDs in this context, WHO established the Gaziantep Hub for Northwest Syria in 2016. Mental health and psychosocial support (MHPSS) initiatives were implemented alongside various interventions to enhance NCD drug distribution, capacity building, diagnosis, management and treatment. WHO adapted its Package of Essential Noncommunicable Disease Interventions (WHO PEN) for use in Northwest Syria, training over 200 primary healthcare physicians in Idlib and Aleppo, to implement these interventions. The Mental Health Gap Action Programme was also introduced in formerly besieged areas, such as Eastern Ghouta and rural Damascus.

Initiative

With the support of the WHO Regional Office for the Eastern Mediterranean, the WHO Gaziantep Hub began standardizing NCD and mental health diagnosis, management and treatment. In 2018, the NCD Emergency Kit was piloted in three primary healthcare centers, followed by an expansion to nine additional centers across Northwest Syria in 2019.

The integration of NCDs into these centers involved establishing an NCD system of care, adapting the WHO PEN guidelines and implementing the HEARTS technical package for the prevention and management of cardiovascular diseases. Dedicated NCD Care Teams were created within these centers, developing Standard Operating Procedures (SOPs) and conducting screenings for cardiovascular diseases among patients aged 40 and above. Clinical and pharmaceutical management were provided to diagnosed patients, while a Field Monitoring Team ensured regular on-the-job training and supervision of healthcare staff. Monthly monitoring tools were employed to maintain the quality of NCD care, including proper management of the NCD Emergency Kits.

Impact

Despite the challenging conflict situation and frequent airstrikes necessitating transfers to safer facilities, the nine primary healthcare centers successfully served a population of approximately 126 000 people and managed a total of 23 457 new and follow-up cases over an eight-month period. Within this period, 23 096 individuals aged 40 and above were screened for cardiovascular diseases using standardized screening forms and risk charts. The involvement of triage nurses and primary healthcare physicians facilitated effective screening implementation.

To ensure the delivery of quality NCD care, the WHO Gaziantep Hub developed SOPs, work algorithms, an NCD monitoring tool checklist, record forms, NCD patient identity cards and management forms for primary healthcare guards. Additionally, the Hub employed a range of essential personnel such as data clerks, reception clerks, triage nurses, laboratory technicians, cleaners and pharmacists.

The integration of NCDs into these primary healthcare centers has had a positive impact on patient care. It has led to improved adherence to medications, increased follow-up rates, better blood pressure control and enhanced patient outcomes. The initiative has taken a comprehensive approach to NCD care by collaborating with partner nongovernmental organizations, who have supported the integration of NCDs into primary healthcare centers. This collaboration has also involved the implementation of the Mental Health Gap Action Programme and the hiring of psychosocial workers. Furthermore, primary healthcare physicians have received training on the Mental Health Gap Action Programme, enabling them to effectively address mental health disorders and the psychological consequences of other NCDs.

Lessons learnt

Integration of NCDs into primary healthcare. The integration of NCDs into primary healthcare serves as a crucial strategy for strengthening the health system, particularly at the primary healthcare level. This approach demonstrates that even in a protracted emergency, existing health systems can be reinforced to effectively address NCDs.

Implementation of WHO Package of Essential NCD Interventions (WHO PEN). The implementation of the WHO PEN has played a key role in the integration of NCDs into primary healthcare. This package of essential interventions provides a framework for managing NCDs and has been instrumental in guiding healthcare providers in delivering quality care.

Utilization of NCD Emergency Kits. The utilization of NCD Emergency Kits has been essential in mitigating the consequences resulting from interruptions in the supply chain. These kits ensure the availability of essential medications and supplies for NCD management, even in emergency situations.

Contribution to district health information system. The integration of the WHO PEN and NCDs into primary healthcare has significantly contributed to the development of Northwest Syria's district health information system. This integration has incorporated valuable data and information on NCD management and treatment into the system, enabling a more comprehensive understanding of NCDs within the region.

Evidence-based decision-making. The incorporation of NCDs into the district health information system supports evidence-based decision-making for improved healthcare delivery. By having access to accurate and up-to-date data on NCDs, healthcare providers and policymakers can make informed decisions to enhance the quality of care and address the specific needs of individuals with NCDs.

Opportunities

The success of the initiative demonstrates the feasibility of integrating NCDs and mental health and psychosocial support at the primary healthcare level, even in emergency contexts. The positive impact achieved in just eight months highlights the potential for scaling up the programme.

The WHO Gaziantep Hub plans to replicate and expand the NCD integration initiative to an additional 25 primary healthcare centers in Northwest Syria. This includes procuring NCD Emergency Kits for a 12-month period, as well as incorporating mental health and psychosocial support and Mental Health Gap Action Programme-trained professionals within the NCD Care Teams.

References

Noncommunicable diseases country profiles 2018

Story originated in 2021.