Health equity of displaced Syrians in Lebanon

Abstract Lebanese government data indicates that the country hosts 1.5 million displaced Syrians (DS). Providing care for DS is a challenge, especially when barriers and discrimination issues arise in accessing the Lebanese health system. This study therefore aimed to understand the causes of biases, their mechanisms, their forms and their consequences on access and quality of care for DS in Lebanon. A qualitative study using in-depth semi-structured interviews was utilized. In 2021, 28 semi-structured interviews were conducted with doctors (n = 12) and nurses (n = 16). Six group interviews were conducted with DS (n = 22) in different Lebanese healthcare facilities. The recruitment of participants was based on reasoned and targeted sampling. The interviews were recorded and transcribed for later narrative content analysis. Thematic analysis was performed to identify common themes in participants’ experiences of DS in accessing Lebanese healthcare. The results showed a barrier of access to care related to transportation and financial issues. Discrimination emerged as an underlying mechanism that drives health inequity. Several factors contributed to the presence of biases in the Lebanese healthcare system. Healthcare services provided to the Syrian population may not be the best due to inequity to access the health system attributable to the discriminatory behavior of healthcare providers. The underlying causes of discrimination are due to the fragility of the Lebanese healthcare system facing a humanitarian crisis with a collapsed infrastructure torn by previous wars and current socio-political and financial problems. Global initiatives can provide the help needed for the equitable provision of health services by providing the resources necessary to address this problem. The findings of this study highlight the changes that should be performed at the micro (cultural skills) and macro (equitable distribution of resources) levels to grant quality of healthcare services for DS. Key messages The health equity of DS in Lebanon is influenced by the lack of resources and the socio-political situation. Measures should be examined to deliver equally health services for both Lebanese and Syrians.

Issue/Problem: COVID-19 was declared a pandemic in March 2020. Information systems, particularly those related to laboratory testing notification, became extremely important as a mechanism of fast identification of cases. In Portugal, any test performed in a professional setting is of mandatory notification. For a local public health unit in northern Portugal, much like in other regions worldwide, challenges related to lack of human and material resources were felt over the course of the pandemic. Description of the problem: In 2021, an intensive surveillance strategy was implemented using up to date notification database analysis through R programming, focusing on simplified data availability for contact tracing team members and accuracy of notifications submitted by laboratories, including verification of individual identifying information. Results: Some laboratories were identified has having lower data completion rate, which had negative effects on contact tracing timeliness, while others failed to notify tests conducted. Public Health workers warned partners of these failures and worked with them to develop solutions. Interventions included facilitation of access to technologies to notify test results, as well as revision of internal processes to ensure correct patient identification. During the intervention, successful notification rates were increased, and new informal and formal partnerships were developed, leading to faster identification of clusters.

Lessons:
Establishing partnerships with stakeholders and developing support systems is beneficial towards epidemiological surveillance efforts. Adequate analysis of notification procedures was an important step towards standardization and correctness of information required for epidemiological surveillance. Key messages: Resilient information systems are important for surveillance, especially during a pandemic. Partnerships with community stakeholders are essential to timely and adequate epidemiological response. Lebanese government data indicates that the country hosts 1.5 million displaced Syrians (DS). Providing care for DS is a challenge, especially when barriers and discrimination issues arise in accessing the Lebanese health system. This study therefore aimed to understand the causes of biases, their mechanisms, their forms and their consequences on access and quality of care for DS in Lebanon. A qualitative study using indepth semi-structured interviews was utilized. In 2021, 28 semi-structured interviews were conducted with doctors (n = 12) and nurses (n = 16). Six group interviews were conducted with DS (n = 22) in different Lebanese healthcare facilities. The recruitment of participants was based on reasoned and targeted sampling. The interviews were recorded and transcribed for later narrative content analysis. Thematic analysis was performed to identify common themes in participants' experiences of DS in accessing Lebanese healthcare. The results showed a barrier of access to care related to transportation and financial issues. Discrimination emerged as an underlying mechanism that drives health inequity. Several factors contributed to the presence of biases in the Lebanese healthcare system. Healthcare services provided to the Syrian population may not be the best due to inequity to access the health system attributable to the discriminatory behavior of healthcare providers. The underlying causes of discrimination are due to the fragility of the Lebanese healthcare system facing a humanitarian crisis with a collapsed infrastructure torn by previous wars and current socio-political and financial problems. Global initiatives can provide the help needed for the equitable provision of health services by providing the resources necessary to address this problem. The findings of this study highlight the changes that should be performed at the micro (cultural skills) and macro (equitable distribution of resources) levels to grant quality of healthcare services for DS. Key messages:

2.R. Achieving universal health coverage
The health equity of DS in Lebanon is influenced by the lack of resources and the socio-political situation.
Measures should be examined to deliver equally health services for both Lebanese and Syrians.

Background:
Italy was heavily hit by the COVID-19 pandemic. According to official statistics, during 2020 there were more than 75,000 excess deaths compared to the average expected mortality in 2015-2019. General mortality (GM) is a good measure of both the direct and indirect effects of the pandemic because it's exempt from potential bias due to misclassification of events. Evidence shows a greater burden of disease and mortality attributable to COVID-19 among disadvantaged populations, with the risk of an exacerbation of existing health inequalities. We aim to analyse the trend of social inequalities in mortality during the first pandemic year in two Italian regions (Piedmont and Emilia-Romagna) using data from Administrative Population Registries (APR) and statistical databases.

Methods:
Data on deaths occurred between Jan 2015 and Jan 2021 in subjects 65, stratified by educational level, were obtained from Regional APR and the Census. Using a time series approach, we computed Standardized Mortality Rates (SMR), Relative Index of Inequalities (RII) and Slope Index of Inequalities (SII), adjusted by age, gender, month and region. SMR, RII and SII from March 2020 were forecasted using Holt-Winters method and compared to the observed values in the same period.

Results:
SMRs were higher than expected during the two 2020 epidemic waves (Mar-Apr, Oct-Dec) in both regions. RII didn't increase significantly. Absolute inequalities instead rose in Piedmont during both pandemic waves, mostly among women, and in Emilia-Romagna in March among men.

Conclusions:
The impact of the pandemic on inequalities in GM has been at least of the same size of the impact of other mechanisms of unequal mortality. APR coupled with sociodemographic data are a quick and reliable source for assessing the unequal impact of the COVID-19 pandemic on health. Further research is needed to explore mechanisms underlying these effects e.g. inequalities in cause-specific mortality and access to health services.

Key messages:
The unequal impact of the pandemic on mortality was confirmed.
Administrative data linked with Census and health data are efficient and reliable sources for a timely monitoring of health inequalities. It is therefore critical not to forget these people when organizing public health measures, especially when addressing a pandemic or other infectious diseases (HIV, Hepatitis). A group specific information approach is of paramount importance to reach such subpopulations. Non-insurance is a known barrier for universal access to care.