Syrian Arab Republic: tackling noncommunicable diseases (NDCs) in emergencies through primary health care

Patient reviewing the treatment plan for her diabetes with doctor in north-western Syria Arab Republic
Patient reviewing the treatment plan for her diabetes with doctor in north-western Syria Arab Republic
WHO/Syrian Arab Republic

5 August 2019 -- “I visited the primary healthcare center because I started to feel my heart flutter, my chest began to tighten, I felt pain and a shortness of breath. I could hardly walk. At the center, I got an appointment with the internal medicine doctor, and they did laboratory tests and an electrocardiogram for me, then, they gave me the needed medications and diet instructions. I’ve followed the instructions and, thank God, I got better and feel well now. I pay regular visits to the doctor and have less symptoms than before,” said Hana Haj Omar, a woman from Mardebseh in Idlib governorate in the Syrian Arab Republic. She was fortunate enough to be able to visit a centre like this, which could give her the health services she needed.

Providing primary health care services in a country like the Syrian Arab Republic, which is facing one of the world’s most complex humanitarian emergencies, presents many challenges for addressing noncommunicable diseases (NCDs). With a severely weakened health system, challenges include short supplies of medicines and ensuring access and continuity in health services.

In the country, an estimated 45% of all deaths are related to NCDs, which include cardiovascular disease, diabetes, cancer and chronic respiratory disease among others. Cardiovascular disease alone accounts for 25% of all deaths. NCDs are also increasing in younger people and tend to be chronic. Risk factors include tobacco use, physical inactivity, harmful use of alcohol, and unhealthy diets.

“In north-western Syria priorities such as trauma care remain but this does not mean that the impact of chronic illnesses related to NCDs should be underestimated. The problem is not visible enough due to the ongoing conflict,” says Annette Heinzelmann, World Health Organization (WHO) Emergency Lead for the response in north-western Syrian Arab Republic.

To lessen the impact of NCDs on individuals and society, WHO integrated NCD care into primary health care (PHC) for the first time in 2018, with financial support of USAID. Delivering NCD interventions through primary health care strengthens early detection and timely treatment, especially in a setting with limited resources. It is an important way to reduce the risk factors associated with these diseases and implement low-cost solutions for treatment.

Nine health facilities in north-western Syrian Arab Republic piloted the integrated approach to treating NCDs, which encompassed improving diagnosis and treatment at the primary care level. WHO and its partners had to find innovative solutions to fit the care setting, which, due to the emergency situation, can frequently change.

“Oftentimes, patients don’t realize the severity of their symptoms and don’t seek care. But also, with a diagnosis, there is often no continuity of care for various reasons including displacement, shortages in medicines and of medical staff. However, despite immense challenges and limited resources, WHO is investing in NCD care,” said Heinzelmann.

Nurse filling in newly-introduced NCD form to ensure consistent documentation for monitoring and follow-up of patient's progress
Nurse filling in newly-introduced NCD form to ensure consistent documentation for monitoring and follow-up of patient's progress
WHO/Syrian Arab Republic

Improving health worker capacity

Controlling NCDs involves more than medicines or medical supplies. It requires skilled health workers who work according to standard protocols and put patients at the heart of care.

In order to ensure that local health workers were able to diagnose and treat patients with NCDs, WHO trained over 240 people from the nine pilot facilities in the PEN (Package of Essential Noncommunicable disease) protocols for diagnosis and treatment of NCDs in resource-limited settings. Due to security limitations, trainings for participants from north-western Syrian Arab Republic were held in Gaziantep, Republic of Turkey.

Returning as master trainers, they cascaded trainings for all staff working in the selected health facilities. This created standardized treatment through a structured drug protocol, improved patient-centric services, consistent monitoring and follow-up, and increased screening. These are all vital components in the road to recovery for NCD patients.

WHO and its partner Primary Care International (PCI) provided remote mentoring and support to the health facilities and implementing partners through the duration of the programme to ensure adherence to protocols for diagnosis and treatment of major NCDs for several months. The trainings sought to develop ‘NCD champions’: health workers with clinical NCD skills, and understanding of the systems and leadership required to deliver good NCD care.

“I am confident that the remote mentoring has resulted in direct positive outcomes for NCD patients in north-western Syrian Arab Republic, in terms of diagnosis, treatment, and more evidence-based use of limited resources. The doctors and nurses I worked with here have been extraordinarily enthusiastic, and keen to cascade the training to their colleagues.” Dr Adam Sandell, PCI clinical team.

Increasing treatment capacity

Part of the remote mentoring included WHO providing NCD emergency kits comprising medical equipment and 22 essential medicines for chronic diseases such as hypertension, cardiac diseases, diabetes, chronic respiratory disease, and selected mental health and neurological conditions. They also included ‘field guides’ illustrating NCD treatment protocols based on WHO standards.

These kits were reviewed and updated in 2016, and again in 2018, to fit the context in the Syrian Arab Republic. Used for the first time in north-western Syrian Arab Republic, by the end of the programme, 27 NCD emergency kits had been distributed, which provided a three-month supply of medicine for 90000 people.

During the course of the programme, Syria Relief and Development, an NGO partner, reported marked increases in the number of patients being diagnosed with and treated for NCDs.

Interlinking access to medicines and medical supplies with capacity building activities ensures continuity of care for patients.

Doctor explaining to patient how to take the prescribed medicines
Doctor explaining to patient how to take the prescribed medicines
WHO/Syrian Arab Republic

Leave no one behind

Universal health coverage means no one must be left behind, including people living in emergency settings. In the difficult context of a complex humanitarian emergency, it is all the more important for WHO and partners to work together to ensure that the people of the Syrian Arab Republic receive the health care services they need.

Perspectives from Mardebseh primary healthcare center

“This patient today (Hana), was not aware that she has hypertension which led to an oedema in her leg and accelerated heart rate. These are complications as a result of her heart failure, caused by the hypertension. When we saw those symptoms; an electrocardiogram and laboratory tests were done, she was given the needed medications - diuretic pills and antihypertensive drugs - and has made noticeable progress. This is one of the success stories of this centre.”

Dr Jamal Alwan,
Internal Medicine doctor at Mardebseh primary healthcare center.