Abstract
BackgroundIn response to the rising global NCD burden, humanitarian actors have rapidly scaled-up NCD services in crisis-affected low-and-middle income countries. Using the RE-AIM implementation framework, we evaluated a multidisciplinary, primary level model of NCD care for Syrian refugees and vulnerable Jordanians delivered by MSF in Irbid, Jordan. We examined the programme’s Reach, Effectiveness, Adoption and acceptance, Implementation and Maintenance over time.MethodsThis mixed methods retrospective evaluation, undertaken in 2017, comprised secondary analysis of pre-existing cross-sectional household survey data; analysis of routine cohort data from 2014 to 2017; descriptive costing analysis of total annual, per-patient and per-consultation costs for 2015–2017 from the provider-perspective; a clinical audit; a medication adherence survey; and qualitative research involving thematic analysis of individual interviews and focus group discussions.ResultsThe programme enrolled 23% of Syrian adult refugees with NCDs in Irbid governorate. The cohort mean age was 54.7 years; 71% had multi-morbidity and 9.9% self-reported a disability. The programme was acceptable to patients, staff and stakeholders. Blood pressure and glycaemic control improved as the programme matured and by 6.6 mmHg and 1.12 mmol/l respectively within 6 months of patient enrolment. Per patient per year cost increased 23% from INT$ 1424 (2015) to 1751 (2016), and by 9% to 1904 (2017). Cost per consultation increased from INT$ 209 to 253 (2015–2017). Staff reported that clinical guidelines were usable and patients’ self-reported medication adherence was high. Individual, programmatic and organisational challenges to programme implementation and maintenance included the impact of war and the refugee experience on Syrian refugees’ ability to engage; inadequate low-cost referral options; and challenges for MSF to rapidly adapt to operating in a highly regulated and complex health system. Essential programme adaptations included refinement of health education, development of mental health and psychosocial services and addition of essential referral pathways, home visit, physiotherapy and social worker services.ConclusionRE-AIM proved a valuable tool in evaluating a complex intervention in a protracted humanitarian crisis setting. This multidisciplinary programme was largely acceptable, achieving good clinical outcomes, but for a limited number of patients and at relatively high cost. We propose that model simplification, adapted procurement practices and use of technology could improve cost effectiveness without reducing acceptability, and may facilitate replication.
Highlights
In response to the rising global Non-communicable disease (NCD) burden, humanitarian actors have rapidly scaled-up NCD services in crisis-affected low-and-middle income countries
Individual, programmatic and organisational challenges to programme implementation and maintenance included the impact of war and the refugee experience on Syrian refugees’ ability to engage; inadequate low-cost referral options; and challenges for Médecins sans Frontières (MSF) to rapidly adapt to operating in a highly regulated and complex health system
RE-AIM proved a valuable tool in evaluating a complex intervention in a protracted humanitarian crisis setting
Summary
In response to the rising global NCD burden, humanitarian actors have rapidly scaled-up NCD services in crisis-affected low-and-middle income countries. The literature describing NCD programme implementation or evaluation in humanitarian settings is especially limited [6, 7] In response to this gap, humanitarian actors, including the medical humanitarian non-governmental organisation (NGO) Médecins sans Frontières, have adapted their traditional approaches to care for chronic disease, developing clinical and programmatic guidance, monitoring and evaluation tools and an NCD emergency response kit [8, 9]. As they have gained increasing experience of NCD care delivery, some humanitarians have called for the sustainability of NCD interventions to be considered in their design and for handover to local health structures to occur during protracted crises [2]
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