The results are presented according to each RE-AIM domain and subdomain (Table 1). These have been somewhat reordered to facilitate logical presentation.
Reach
We explored the numbers eligible for the programme, numbers reached and representativeness of those reached. According to MSF’s Household Access and Utilisation Survey (2016), one fifth of surveyed adult Syrians self-reported at least one NCD targeted by MSF (21.8% of 8041 surveyed adults aged 18 or over). UNHCR and others estimated that 95% of refugees resident in Irbid governorate in 2017 were registered with UNHCR (n=135,144 in December 2017) of whom 48.7% were adults aged ≥ 18 years (25,35). This implies there were 141,901 total refugees with 69,106 ≥ 18 years. Applying the household survey figure of 21.8% meant 15,065 Syrian refugees ≥ 18 years in Irbid governorate had an MSF-targeted NCD and were therefore eligible for enrolment in the programme. Since 3531 Syrian adult patients were ever-enrolled (limited by the cap on cohort size), 23.4% of the target population was reached by this MSF programme (36). Patients were enrolled on a first-come-first-served basis and news of the programme quickly spread by word of mouth.
Retrospective data were analysed from 5045 patients ever enrolled during the study period. The cohort comprised 3664 (72.6%) Syrians, 1365 (27.1%) Jordanians and 16 (0.3%) refugees of other origins (Palestinian or Iraqi), who were middle-aged [mean 54.7 years (SD 15.7)] with multi-morbidity and relatively high rates of self-reported disability (9.9%). The majority (59.8%) were women and 71% (n=3582) had two or more target NCD conditions, with hypertension (60.4%), type 2 diabetes (53.1%), cardiovascular disease (25.9%), hypothyroidism (7.6%) and asthma (7.0%) the most commonly treated conditions (Supplementary material S6). These findings are consistent with the MSF Household Access Survey, which reported a similar prevalence of target NCDs (25). However, the MSF clinic cohort had greater rates of NCD multi-morbidity compared to the adults with NCDs in the household survey (71% vs. 44.7%). NCD risk factor levels were high at enrolment with obesity levels of 62.6%, self-reported smoking rates of 22.7%, and low or zero self-reported regular physical activity in 37.2% (Supplementary material S6).
Qualitative data highlighted that the MSF team felt the quality of mental health services available from another international NGO in Irbid was inadequate and so MSF developed its own MHPSS service from 2016. This initially involved individual counselling and was later expanded, as detailed below. However, interviewed staff perceived that much mental ill health was going undetected at the time of the study. This seemed largely due to a resistance from both medical staff and patients to MPHSS referral, as they feared it labelled people negatively as having “mental problems”. Thus, by the end of the reporting period, only 0.5% (n=24) of enrolled patients had received a formal diagnosis of a comorbid mental health condition, while only 3.0% (n=154) attended individual counselling sessions. Sixty-six group-counselling sessions were held in 2016, when recording began. MHPSS service data did not capture numbers enrolled in group or waiting room sessions and were not linked to the general dataset.
Access, acceptance and adoption
Under this domain, we described the programme’s components, structures and staffing and we explored patient, provider and stakeholder perspectives on programme accessibility.
Accessibility: We considered access in terms of availability, cost and physical accessibility. MSF services were available to 23.4 % of their targeted Syrian population. MSF took a “cohort approach” to their service provision and both MSF and Jordanian policy required services to also be delivered to the host population. MSF’s policy of providing free care facilitated access to medical consultation, consistent medication supply and laboratory testing for the enrolled Syrians and vulnerable Jordanians. Syrian interviewees, in particular, reported carefully balancing stretched household finances, and choosing to spend on aspects of the service they valued. They prioritised expenditure on transport costs for MSF’s medical consultations over those for MHPSS, health education or laboratory visits. Some purchased their preferred medications from other sources if not provided by MSF.
Interviewed patients and staff perceived that most patients considered the MSF clinics accessible, in terms of distance, transport and convenience. A home visit service was introduced in 2015 to improve access for housebound and frail patients. The team included a nurse, doctor and driver.
The patients generally appreciated the appointment system (which minimised the long waits and prevented the perceived favouritism they experienced in the MOH system) and the SMS (short message service) reminders. However, most saw the system as rigid and inaccessible outside of prescribed appointment times. Staff strongly encouraged patients to attend at their planned appointment day and time, achieving a 90% adherence rate by 2017.
Qualitative data confirmed that Syrian community members had limited access to alternative, affordable primary level NCD services in north Jordan.
“…access to good quality care… that is reliable and regular and predictable…. I think that is a big challenge. Affordability is another challenge…” MSF management staff member.
The MSF Household Access Survey corroborates our qualitative finding that cost was the main barrier to obtaining NCD care from other providers. Around a quarter of surveyed adult refugees with self-reported NCDs did not seek care when they felt it was needed. Only 10% reported poor availability as the reason, while the majority (60%) cited cost. Among those who received care, around half made a co-payment (25). Interviewed MSF patients described their difficulty in obtaining a regular supply of affordable NCD medications before enrolling with MSF:
“It’s difficult to buy the medicine always because I can’t afford it. Thank god when I registered at (the MSF clinic) … I started to have it free. Before I used to take from other places by small amounts of money (or) from the community pharmacy I paid it all.” Syrian FGD participant.
Other international NGOs also provided NCD care to registered and unregistered refugees in Irbid governorate with some requiring co-payments. Registered refugees’ access to MOH primary care clinics was initially free-of-charge but increasing co-payments were introduced from 2014. Most interviewed patients described such co-payments and travel costs as unaffordable. Despite the other available options, staff reported they had a long waiting list of people wishing to access the MSF service.
When asked how NCD patients in their community who were not enrolled in the MSF programme coped, interviewees reported that they skipped medications, shared with family or neighbours or purchased from private pharmacies:
Syrian patient: “If there is a family that can’t bring medicine, we collect pills from here and here, so people help each other ... because there is extra. So people give to each other. I know a kid who takes insulin…I give to people. I’m forced to help people.”
Staff perceived that most Jordanian patients did not, in fact, meet vulnerability inclusion criteria and could, therefore, access alternative free-of-cost services via national or military insurance. This was the case for all interviewed Jordanian patients.
We focussed particularly on the theme of access to specialist referral services. In the middle-income setting of Jordan, secondary and tertiary care services were widely available within the public and private sector, including essential NCD referral services such as ophthalmology, endocrinology, cardiology, nephrology and emergency services. However, as described by our interviewees, accessing specialist services for NCD complications or other conditions via the humanitarian system referral pathway was complex, inconsistent and burdensome for patients, while accessing them directly was costly. In addition to funding primary level MOH access, UNHCR funded registered and unregistered refugees’ access to limited public and private specialist services via their implementing partner Jordan Health Aid Society (JHAS). JHAS played a gatekeeper role and interviewees from MSF and other NGOs perceived their decision-making process as “unhelpful” and lacking clear criteria:
“We don’t really have any … clear structure dealing with (specialised secondary referrals). The identified system through JHAS and UNHCR, as the funding partner, is complex and lacks clarity and doesn’t always suit our patients.” MSF clinical staff member.
MSF clinical staff could also refer patients to services provided by other NGOs. They reported feeling frustrated and disempowered by the lack of clarity and consistency regarding these referral pathways, the lack of clinical information returned to them by most referral services and their inability to refer directly to MOH specialist care. To address this, MSF had successfully brokered specific agreements with other NGOs to meet particular referral needs e.g. retinopathy screening and angiography. The latter were performed free-of-cost to patients as part of a defined short-term project. The solution to referral gaps, according to interviewed MSF staff, MOH and other stakeholders, was to encourage other international actors to fund and implement these services.
Acceptance and adoption/participation:
Under this domain, we described the programme location, cadres of staff and qualifications. During interviews we explored patients’, staff’s and stakeholders’ acceptance of the programme. With patients, we explored their sources information and support; their experiences of receiving NCD care and how programme participation influenced their well-being. For staff, we examined similar themes as well their experience of using the MSF clinical guideline.
The programme was highly acceptable to patients, staff and stakeholders alike. Interviewed patients felt they received good quality care in a caring and respectful environment. They trusted the service and most continued attending. Cohort data confirmed that most patients were still attending follow-up appointments six months after cohort entry (85%; n=4289). Patients reported that they valued the free medications, regular laboratory and vital sign testing most highly but were also positive about the healthy living advice and “encouragement” given by staff. According to one female patient:
“(MSF is) honestly caring about the patient, caring about his appointments even the medication availability. We have never come here and told us that the medication is not available. Their performance is great.”
Interviewed patients reported being largely unaware of the MHPSS or HLO components of the service, while the medical team were initially distrusting of the MHPSS service and were reluctant to refer (see our related paper) (29). However, staff reported that the “Living Well” groups for specific patients, such as diabetic teenagers and their parents, were very well received by participants and staff.
In contrast to the positive view of MSF services, MOH services were less acceptable for a variety of reasons. These included: cost, long waiting times, rushed consultations with limited physical examination, no psychosocial or healthy living support, inconsistent medication supplies, limited access to laboratory investigations, staff with poor manners and preferential treatment of some attendees.
MSF national and international staff generally prided in their work for MSF:
“…Syrians, we save their lives, … for me this service is like life… this disease is very difficult and chronic …and treatment costs a lot,” Clinic staff member.
Clinical staff were mainly Jordanian medical and paramedical university graduates, many with previous NGO experience. They were committed to the MSF team and their patients and derived satisfaction from observing patients’ improvements.
“I learned here how to see others problems… the disaster they are coming from…how we work here like a team or a family for the benefit of the patients; how you can give to the people…without taking, with nothing in return.” Clinical staff member.
There was low turnover among clinical cadres other than non-specialist doctors, who tended to resign after gaining several months’ experience with MSF to pursue specialist training. This turnover was considered problematic by clinical supervisors, other staff and patients, all of whom valued continuity of care. A minority of staff expressed dissatisfaction with the perceived lack of promotion opportunities or job security (given the limited duration of MSF programmes), high workload and six-day working week. Interviewed stakeholders valued the programme since it relieved a significant burden on the MOH. Several called for it to be expanded in terms of coverage and scope (for example, by financing specialist referral care).
All interviewed medical staff described the MSF NCD guideline as largely acceptable and “useful”. It covered most clinical scenarios they encountered. They appreciated that it could be flexible, adapted to the local context and could be used as a means to negotiate patient demands. However, staff reported encountering several challenges in relation to guidelines, principally the limited guidance on complex patients, the perceived promotion of poly-pharmacy and the inadequate programmatic guidance. The guideline discussed each condition in a stand-alone manner, with limited guidance on complex, multi-morbid patients, such as diabetic patients with significant renal impairment. This vertical treatment of each condition seemed to promote the use of multiple drugs and did not address “de-prescribing”, whereby medications are tapered or discontinued. Management staff requested additional programmatic guidance, such as how to define and set limits to primary level NCD care (“what components are included…that is not clear”); and predicting the numbers needing referral services for complications. Clinical supervisors, who were generally of non-Jordanian origin, identified that some Jordanian doctors felt the guideline limited their autonomy and offered “second-class” care since it recommended older, generic medications. All interviewed Jordanian doctors also commented on the limited user-friendliness of the paper-based guideline. They preferred a digital application that could be easily accessed on their smart phones during consultations.
Effectiveness
To evaluate Effectiveness, we examined clinical and quality indicators (Table 2) using retrospective analysis of routine clinical and programmatic data and clinical audit. Perceived effectiveness was explored using qualitative data.
Clinical indicators: Among 4044 adult patients meeting our inclusion criteria (i.e. diagnosed with hypertension and/or Type II diabetes (DMII) and enrolled during the study period), 2912 (72.0%) had hypertension and 2546 (63.0%) had DM II, while 1530 (37.8%) had a dual diagnosis. From the programme perspective, mean per visit SBP decreased among patients with hypertension by 14 mmHg during the study period [143.9 mmHg (95%CI: 140.9-146.9) in December 2014 to 129.9 mmHg (95%CI: 128.9-130.8) in December 2017]. Among patients with DM II, mean FBG decreased by 26.9 mg/dL after 12 months. [from 193.7 (95%CI: 180.8 to 206.7) to 166.8 mg/dL (95%CI: 160.2-173.3)]. Mean HbA1c control improved from 8.9% (95%CI: 8.0 to 9.7) in month one to a mean consistently below the target of 8% (95%CI: 7.0-7.7). From the patient perspective, the proportion of hypertensive patient visits achieving SBP control improved from a baseline of 59% (95%CI: 57%-60%) to 73% (95%CI: 70%-75%) by month six. Among patients with DM II, mean FBG improved from 187.5 (95%CI: 183.6-191.3) at enrolment/new diagnosis to 161.6 mg/dL (95%CI: 156.2-166.9) by six months. These results and those related to treatment interruption are elaborated on in our companion paper (30).
Quality indicators: Additional clinical outcome and process indicators are presented in Table 2. At each health education session patients were asked to categorise their exercise level as active, inactive, moderately active, and moderately inactive but exercise was not otherwise quantified. Activity levels did not seem to improve significantly. We could not determine whether smoking behaviour had changed since it was not quantified and patients’ self-reported smoking behaviour change was only recorded relative to their previous visit. Some activities were under-performed e.g. statin prescribing, CVD risk scoring and performance of annual urinary protein testing in diabetic patients.
Perceived effectiveness: Interviewed staff and patients perceived the programme as effective. Patients reported feeling physically better after attending the programme.
Jordanian patient: “I feel relieved and comfortable since the first day I came here, I felt the difference in my disease. I used to take pills for diabetes and hypertension but nothing changed.”
Their physical wellbeing was linked to having a regular supply of medications but also to a relief of their psychological stress, due to reduced financial burden and worries around obtaining their medications.
Staff observed greater physical improvements and commitment to behaviour change among Jordanians versus Syrian patients. They linked this to Syrian patients having more limited finances affecting their food choices, fewer options for exercise and increased stress and insecurity.
Table 2. Effectiveness Indicator Results
a. Clinical Outcome Indicators
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Result or Comment
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% ≥ 0.5 mmol/L reduction in total cholesterol from enrolment to last visit (those enrolled >= 90 days)
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Among those with a cholesterol test who were in the cohort for at least 90 days (2585), 651 had ≥ reduction of 0.5 mmol/L in total cholesterol = 25.1%
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% patients with asthma free from exacerbations/ admissions in previous 6 months
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Among 382 patients with asthma, 25 recorded exacerbations in total during the study period.
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% patients who report decreased/quitting smoking
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Not available as self-reported smoking category (stopped, decreased, increased, resumed, unchanged) was reported relative to the last appointment.
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% patients who report increased levels of exercise from baseline
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At each visit the category (active, inactive, moderately active, and moderately inactive) for recent activity behaviour was recorded. 3347 patients enrolled in the project at least 90 days had a first and last measurement. 610 (18.2%) had improved activity. 593 (17.7%) had worse activity. 2144 (64.1%) stayed the same. There was no significant improvement (chi sq =0.284, p=0.594).
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Trend in referrals to another facility for acute complications/specialist care (% of active cohort)
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Trend in referral by type of referral service and volume of referrals were analysed
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b. Process Indicators
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% recommended referrals to other services that are appropriate as per guideline
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Not tested
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% of active patients with CVD* prescribed a statin
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N = 369 (25.8%)
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% of patients with CVD* prescribed aspirin
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N = 717 (50.1%)
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% of patients with CVD* prescribed at least one anti-hypertensive^ drug
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N = 1007 (70.4%)
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% of patients with asthma# with inhaler technique check documented
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N=48 (94%)
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No./% of times when appropriate clinical action taken based on clinical or laboratory findings
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Among 130 randomly audited diabetic patient files, 100% had cholesterol checked; 73.8% (n=82) had a CVD risk score subsequently calculated. Of these, 65.9% had a statin correctly prescribed (or not prescribed) according to MSF guidelines&.
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Description of cohort deaths
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2.6% (n=139) of enrolled patients died by end of study period. Deaths were determined by word of mouth and a defaulter survey. Among all exited∞ patients deaths accounted for 9.3% (139 of 1489 exits).
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Legend: * 1431 patients with new or established CVD were ever enrolled during the study period
^ Including: amlodipine, atenolol, bisoprolol, enalapril, hydrochlorothiazide, valsartan; excluding: exclusively frusemide or spironolactone
#Among 51 asthma patients randomly selected for clinical audit
& Technically, the MSF guideline did not require cholesterol testing to be performed before calculating a CVD risk score, but qualitative data confirmed most clinicians waited for cholesterol results before calculating it.
∞ Exited patients refers to those that were known to have died, were lost to follow up despite efforts to trace them or who had informed the team that they would no longer be attending the MSF service.
Implementation
Under this domain, we examined the fidelity of programme delivery, the challenges and facilitators to implementation, the subsequent adaptations made and the costs of programme delivery.
Fidelity of programme delivery: Indicators exploring fidelity of programme implementation are presented in Table 3 and were determined via routine cohort data analysis and clinical audit.
Table 3. Implementation Indicator Results
Indicator
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Result or comment
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% HTN patients with annual FBG performed
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Not available (not calculated)
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% DM patients* with annual eye check performed
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Annual^ fundoscopy documented OR referred for retinal screening = 50.8%
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% of DM patients* with micro-albuminuria or urinary protein tested
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Annual^ Albumin creatinine ratio checked in 83.8%
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% of DM patients* on ACE inhibitor with creatinine checked
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Annual^ creatinine check in 98.5%
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% of active cohort with health education session at last clinical visit
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66.9%&
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Number of MHPSS group sessions monthly
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Average 5.5 per month in 2016 and 2017
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% of referred patients attending MHPSS individual counselling
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Not available as number of internal MHPSS referrals was not captured
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Number/% of follow-up consultations performed by nurses
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6% in 2017
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Legend: *Among 130 randomly selected diabetic patients’ charts analysed for the clinical audit
^ Annual referred to the 12 months preceding their most recent appointment
&Among patients active in 2017 (n= 4011)
Key: ACE=angiotensin-converting enzyme; FBG=fasting blood glucose; HTN=hypertension; MHPSS=mental health and psychosocial support;
Challenges and Facilitators: Our qualitative data highlighted that the impact of war and the refugee experience was the key challenge to implementing and maintaining effective NCD care for the Syrian refugee population. Syrian patients’ social suffering had profound implications for their ability to engage with the programme in terms of medication adherence, dietary and lifestyle advice, and affordability of access. This theme was explored in detail in our linked paper (29):
“The hypertension goes high not all the time but when I get sad and remember my sons in Syria and they tell me what happens with them I keep crying and crying then my hypertension goes high or goes down. I don’t know. Then I take a hypertension pill to settle down whenever I read some news about them,” Syrian patient.
Staff reported that patients who attended group MHPSS sessions had a positive experience and felt that more of these groups should be undertaken. However, apart from social acceptability, space, patient transport costs and limited patient engagement were barriers to their implementation. Clinical supervisors described the style used by staff delivering individual health education as “didactic”, “harsh” and “combative”. Staff also used a knowledge-based approach with patients, which involved “telling them what to do”. A “solution-focused” approach and motivational interviewing techniques were preferred:
“(Using) words like ‘you are not being honest’, ‘I don’t feel like you’re telling the truth’,’ if you only would’ … doesn’t work… This concept of patient-centred care, solution focused therapy, it’s what works,” Clinical supervisor.
The MSF clinical team described additional contextual challenges around healthy living education and behaviour change. These included diet and exercise norms (high fat, high salt diet and low habituation to exercise for health or leisure), the acceptance of smoking (especially in men), the obesogenic environment and most patients’ reliance on medications to provide solutions.
Staff also reported that low education levels presented challenges around medication education and adherence support. They felt ill equipped to deal with Syrian patients’ war-related trauma and found it personally challenging. However, staff perceived that excellent patient-staff rapport, positive experiences of supervision, support and training, and good teamwork with colleagues assisted them with programme implementation.
Adaptations: Interviewed management and clinical staff described how the programme adapted dynamically to the patient and programmatic challenges that they identified. Adaptations involved modifying the original programme design, based on a high-income country primary care model, to a humanitarian setting. The MHPSS service was an essential addition to the programme. It started with individual counselling sessions and was expanded and reoriented to provide ad hoc psycho-education sessions in waiting rooms, peer-support groups and a targeted group ‘living well’ programme combining health education and psychosocial support. In response to the initial distrust and low rate of referrals from the programme doctors, the MHPSS undertook multidisciplinary staff training sessions, referral rights were extended to nurses and depression screening was introduced. The latter was later paused as the numbers identified by screening overwhelmed existing service capacity. At the time of the study, the team reported a lack of good quality referral options for patients requiring prescription of psychotropic medications or psychiatric input. Therefore, management staff planned to train one family medicine specialist and to expand MSF’s medication list to address this need. The HLO social work role was introduced to address Syrians’ social and protection needs. It was reportedly underutilised as few referrals were made by the clinical team.
Interviewed staff reported learning to adapt health education messages to patients’ literacy and education levels, their limited financial means and their living environments. Staff also involved family members as informal treatment supporters. As mentioned, the team introduced the home visit service to better serve elderly, frail or housebound patients and this was later expanded. Management staff reported introducing clearer admission criteria relating to patient vulnerability. To increase efficiency, they formalised an appointment system with SMS appointment reminders and created an appointment tool. The care of “stable”, less complex patients was task-shared to nurses and their appointment interval was increased to three months, while family medicine specialists were added to the team to support management of more complex patients. Proposed task shifting of stable patients’ medical reviews to nurses had occurred in a very limited manner by the end of 2017 because of lack of clarity on clinical activity and patient flow, lack of clear eligibility criteria, reported resistance from patients and medical staff, national regulations limiting nurses’ roles. Medication supply and dispensing had also proven a “bottleneck” and the pharmacy team was expanded as a result.
Costs: The total annual financial cost of the NCD programme from the provider perspective increased annually in parallel with greater patient volume, greater service complexity and with the addition of specialist staff. It increased by 52% from INT$ 4,206,481 in 2015 to INT$ 6,400,611 in 2016 and by a further 5% to INT$ 6,739,438 in 2017. Per patient per year cost increased 23% from INT$ 1,424 (2015) to 1,751 (2016), and by 9% to 1,904 (2017), while cost per consultation increased from INT$ 209 to 253 (2015-2017). The major cost drivers were human resources (accounting for 38.9%-42.6% of total annual costs) and medications (34.8-43.2%). The costs are reported in detail in a related paper (28).
Maintenance
Under the Maintenance domain, we explored the challenges and facilitators related to programme maintenance at the individual and organisational level.
Individual level: At the individual patient level, we explored retention in care, medication burden, challenges and supports around psychosocial issues and adherence to medication and healthy living advice. Routine cohort data analysis showed that the majority of patients enrolled during the study period (N= 5045) were retained in care for over six months, that is, 85.2% attended a follow-up appointment six-months (+/- 30 days) after enrolment; one third of enrolled patients had exited (including 12.5% cumulative loss to follow up and 2.6% deaths) (Table 3).
Over half of adherence survey participants (N=300; 74.4%) were prescribed four or more MSF-provided medications (Supplementary material S4B). The majority (60.4%) also took medications obtained from another source. Most patients (89%) had very high self-reported medication adherence scores. While the majority of individual interview participants (especially Syrians) declared themselves “very committed” to taking medications, several described stopping, taking intermittently or sharing medications with those in need. Staff and patients both emphasised the negative impact of mental distress on adherence to medications and healthy living advice:
“As I was hearing the stories I thought…this man’s problem is not that he’s smoking too much. His problem is that he … experienced sexual violence, physical violence in prison in Syria… these two are linked.” Clinical staff member.
Qualitative data confirmed that patients’ medication adherence and behaviour change was facilitated by support from family and MSF staff.
Organisational level: Here we explored costs of programme maintenance, challenges and modifications made in terms of the broader organisational, contextual and policy environment. We explored potential cost savings that could be gained from reorganisation of medical consultation workflow in our related paper. The frequency of contact with the facility had the greatest influence on cost-savings. As more patients were categorised as “stable”, more were suitable for nurse review and for longer review intervals (28).
Multiple interviewees emphasised the difficulties the programme encountered around the lack of adequate referral pathways:
“The credibility of any service…depends on its ability to refer upwards…That is just as true for people with angina … (as it is) for mental health,” Management staff member.
As discussed earlier, MSF management staff reported making significant efforts to establish accessible and affordable referral pathways through negotiation and advocacy with UNHCR and other NGO actors.
Challenges also related to the Jordanian regulatory and policy environment, including: the requirement that medications must be locally purchased; the lack of focal point or set of regulations governing NGOs; significant bureaucratic delays; and tight regulation (e.g. around psychotropic medications and nurse-prescribing). Care delivery was also complicated by the culture of private medical care and patients’ care seeking behaviour, with both nationalities tending to visit multiple concurrent providers and to prefer branded medication. However, the availability of highly qualified Jordanian professional staff facilitated implementation of a complex, multidisciplinary programme.
Qualitative data highlighted the importance placed by MSF staff on providing a good quality service that fulfilled MSF’s humanitarian remit. There was a perceived tension between their desire to continually improve the programme and the need to consider long-term planning and a potential future handover. While the MOH was considered by some management staff as the likely handover partner, they emphasised its limited capacity and the gulf between current MSF and MOH models of NCD care.
Management staff also discussed the internal debate within MSF around the appropriateness of a humanitarian NGO engaging in chronic NCD care and their relative inexperience in doing so:
“An NCD Programme is a relatively recent departure for MSF and it is getting very close to the dividing line between humanitarian and development aid. (There is a) general sense among the humanitarian community that NCDs are an epidemic and need to be dealt with, but I am not sure we have …(a clear) view of how this should be managed...” Management staff member.
Several MSF management staff on the ground noted that MSF’s more familiar approach, characterised as providing relatively short-term solutions to health care gaps in populations in crisis, was inadequate in the setting of chronic disease care. Several also questioned the sustainability and/or the potential to hand over the complex Irbid care model. Senior MSF staff highlighted the rationale for maintaining the specific vertical programme in Irbid. It served as an opportunity for MSF to “learn by doing” and to understand the essential components of NCD care. Several staff members suggested that MSF could engage more closely with pre-existing health systems in designing future NCD interventions, and could build on their HIV service model, by maximising task sharing and decentralisation of care to community level. They acknowledged that operating in the context of a middle-income country with established systems, regulations and policies required a different type of engagement and negotiation with authorities compared to other contexts where MSF has traditionally worked.