Responsiveness of Lebanon's primary healthcare centers to non-communicable diseases and related healthcare needs

Authors

  • Rami Yassoub,

    1. Department of Health Management and Policy, American University of Beirut, Lebanon
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  • Suha Hashimi,

    1. Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Lebanon
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    • Point of Care Testing (POCT) Coordinator.

  • Siham Awada,

    1. Department of Health Management and Policy, American University of Beirut, Lebanon
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  • Fadi El-Jardali

    Corresponding author
    1. Department of Health Management and Policy, American University of Beirut, Lebanon
    • Correspondence to: F. El-Jardali, American University of Beirut, Research, Advocacy and Public Policy-making (RAPP), Issam Fares Institute for Public Policy and International Affairs, Lebanon. E-mail: fe08@aub.edu.lb

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    • Associate Professor of Policy.


SUMMARY

Lebanon currently faces a rise in non-communicable diseases (NCD) that is stressing the population's health and financial well-being. Preventive care is recognized as the optimal health equitable, cost-effective solution. The study aims to assess the responsiveness of primary health care centers (PHCs) to NCD, and identify the needed health arrangements and responsibilities of PHCs, the Ministry Of Public Health and other healthcare system entities, for PHCs to purse a more preventive role against NCD. Single and group interviews were conducted via a semi-structured questionnaire with 10 PHCs from Lebanon's primary health care network that have undergone recent pilot accreditation and are recognized for having quality services and facilities. This manifested administrative aspects and NCD-related services of PHCs and generated information regarding the centers' deficiencies, strengths and areas needing improvement for fulfilling a more preventive role. Administrative features of PHCs varied according to number and type of health personnel employed. Variations and deficiencies within and among PHCs were manifested specifically at the level of cardiovascular and respiratory diseases and cancer. PHCs identified the pilot accreditation as beneficial at the administrative and clinical levels; however, various financial and non-financial resources, in addition to establishing a strong referral system with secondary care settings and further arrangements with MOPH, are necessary for PHCs to pursue a stronger preventive role. The generated results denote needed changes within the healthcare system's governance, financing and delivery. They involve empowering PHCs and increasing their breadth of services, allocating a greater portion of national budget to health and preventive care, and equipping PHCs with personnel skilled in conducting community-wide preventive activities. Copyright © 2013 John Wiley & Sons, Ltd.

INTRODUCTION

The multiple burdens faced by Lebanon, at both the economic and health levels, have been and continue to amass, threatening its stability and potential to prosper. Unemployment and the country's national debt have been increasing and currently subsist at 9% and 137.1% of gross domestic product, respectively (CIA, 2012; The World Bank, 2012). Simultaneously, non-communicable diseases (NCDs) are increasing in prevalence (WHO, 2010a), along with the excruciating costs needed for their treatment, and continue to be the nation's main burden of disease. The World Health Organization (WHO) asserted that in 2008, Lebanon had 21,600 mortalities caused by NCD alone, where 45% of the mortalities among men and 38.7% of those among women were in persons less than 70 years of age (WHO, 2011a). At the financial level, the situation is just as burdensome with local studies having confirmed that the government alone is spending hundreds of millions of dollars per year to provide curative care (Chaaban et al., 2010).

To add depth to breadth, risk factors for NCD are widespread with overweight/obesity affecting 60% of men and 53% of women, 47% being the proportion of those not engaging in adequate physical activity, and prevalence of smoking is 34.7% among Lebanese more than 18 years of age (Khatib, 2004; Chaaban et al., 2010). Even more, the increase in NCD has been affecting the principle working force of the country since two decades ago, where local studies confirmed that 48.21% of cases related to colorectal cancer were among people 19–60 years of age (Harb, 2004).

A viable solution to the aforementioned health issues has been under development for the past two decades. Lebanon's primary health care network (PHCN) has been developing in accessibility and quality, with an increase from 29 centers in 1996 to 144 in 2012 (Ammar, 2009), and is currently in the process of accreditation (MOPH, 2012). The recent accreditation efforts in primary healthcare have been under development since 2009 with the aim of improving the quality of delivered services (El-Jardali et al., 2013). However, investment in Lebanon's primary healthcare is not new; for over the past four decades the Ministry of Public Health (MOPH) has been attempting to enhance the influence and quality of primary care services through provision of medicines, equipment, information, education and communication products, trainings, and health information software and products (Ammar, 2009).

The role and the involvement of primary health care centers (PHCs) in promoting health awareness and carrying out related prevention programs, distributing essential drugs, caring for wounds and encouraging patients in adopting healthier lifestyles (Roemer and Montoya-Aguilar, 1988), along with their established success in facilitating accessibility of patients to needed care, maintaining the price of care within affordable limits and emphasis on the prevention of diseases in the first place; and in addition, their ability to avoid secondary, specialized services and the associated costs of such services (Starfield et al., 2005), all render investment in PHCs a financially attractive and health enhancing option, especially when considering Lebanon's limited financial resources and current economic situation.

With the aforementioned in mind, this study aims to assess the degree of responsiveness of primary healthcare services in PHCs to the growing burden of NCD, identify additional healthcare arrangements needed by PHCs to fulfill a more preventive role toward NCD and establish the responsibilities of PHCs, the MOPH and other entities in the healthcare system, to better respond to NCD health needs. In turn, this is expected to contribute to enhancing the role of PHCs within the Lebanese healthcare system, thus enhancing the health of Lebanese and attenuating the health and financial burdens imposed by the growing prevalence of NCD.

METHODOLOGY

The study was conducted at the national level and involved PHCs within the Lebanese PHCN. Prior to commencing the study, the MOPH was approached for permission to access the PHCs, and approval to conduct the study was obtained from the Institutional Review Board of the American University of Beirut. The PHCs were contacted first by telephone to determine their willingness to participate, upon which PHCs that were willing to participate were approached at their premises.

Sampling

The sampling frame was the list of 23 PHCs that were part of the pilot accreditation conducted by the MOPH. This particular list was chosen because of the increased likelihood that PHCs within it will be better able to relate to and comprehend the questions more fully, thereby providing more insight and policy impacting feedback as to what can be done to improve the Lebanese PHCN. The 10 PHCs selected for the study were chosen on the basis of convenient sampling, because of issues of accessibility related to national security, the short period available to conduct the research and the limited financial resources required for transportation. Nevertheless, all districts were covered with four PHCs chosen from the Beirut district, three PHCs from the Mount Lebanon district and one center from each of the remaining districts: the North, Bekaa and South.

Study population

The study population included PHCs' directors, and/or different members of the primary healthcare team (such as physicians, nurses, social workers and medical lab specialists). PHCs' directors were chosen because of their knowledge of the logistical aspects and processes and their administrative capacity to make the necessary changes once results are disseminated, and policies and guidelines proposed. The primary healthcare team was chosen as they are better acquainted with the delivery process than PHCs' directors, because of their direct involvement in the provided services.

Study tool

The study involved conducting both single and group interviews with members of the primary healthcare team using an anonymous, semi-structured questionnaire that was completed by the research team. The total number of interviewees was 23 (Table 1). The participants (PHCs' employees) that were available and not preoccupied with patients at the time of the meeting were the ones included in the single and group interviews.

Table 1. Number of interviewees and surveying mode
Primary health care center #IntervieweesSurveying modeTotal
  1. PHC, primary health care center.

1Medical social worker, in-charge nurse and registered nurseGroup interviews3
2PHC director, medical lab specialist and registered nurseGroup interviews including PHC director and medical lab specialist. Interview with the registered nurse.3
3Midwife, physician, pharmacist, school health educator and accreditation “officer”Group interviews5
4Registered nurse, social worker and PHC directorGroup interviews3
5Public health officer and social workerGroup interviews2
6PHC directorInterview1
7PHC directorInterview1
8PHC director and President of the organizationGroup interviews2
9PHC directorInterview1
10Executive secretary and nurseSeparate interviews with each2
Total23

The quantitative part of the analysis was designed to assess the current responsiveness of PHCs toward NCD in Lebanon. It included a series of yes/no questions and was developed in reliance on the WHO report, “PEN Disease Interventions for Primary Care in Low-Resource Settings”, which is a collection of prioritized and cost-effective interventions representing an important step for integrating NCD into PHCs (WHO, 2010b), along with another WHO paper on the “Prevention and Control of NCD: Priorities for Investment” (WHO, 2011b); and a study entitled, “Accessibility and Continuity of Health Services: A Study on Primary Care in Quebec” (Pineault et al., 2006). The qualitative part facilitated the exploration of the centers' needs, because it enabled PHCs to reveal more in-depth information. The questions mainly revolved around the governance, financing and delivery aspects of care. Participants' answers to the questions remained confidential whereby the results represent the aggregated data collected with no identifiers. Single and group interviews lasted for a period ranging between 30 and 60 min each, whereby seven were voice-recorded upon approval of participants; moreover, the recordings were transcribed directly in translated form by the researchers. Additionally, to verify the accuracy of the transcriptions, they were internally validated by having each transcription read by another research group member.

Data analysis

The quantitative data were entered and analyzed using Microsoft Office Excel 2007. The qualitative data analysis involved thematic analysis of the open-ended questions to derive the main needs of PHCs for the provision of responsive and NCD-targeted primary care services.

RESULTS

The study's results elucidated the responsiveness of the PHCN and exposed additional healthcare arrangements necessary for enhancing the network's capacities to meet the growing burden of NCD.

At the administrative and human resources level, PHCs are less equipped with general practitioners (GP), ranging from 0 to 5, than specialists that ranged from 5 to 42. The vast discrepancy in availability of specialists among PHCs is also evident in the availability of helpers/assistants in each center that ranged from 3 to 28. Overall, PHCs are serving about 575 patients per month and are quite knowledgeable regarding the comprehensive services within PHCs' scope of care, in which each center provides around 28 different types of health services; however, because of the scarcity of information pertaining to this variable (only 50% of PHCs gave broad estimates), such a figure is unreliable (Table 2).

Table 2. Primary healthcare center (PHC) administrative characteristics
  Primary health center (unit of analysis)    
#VariablesPHC 1PHC 2PHC 3PHC 4PHC 5PHC 6PHC 7PHC 8PHC 9PHC 10TotalMeanSD% CV
  1. SD: Standard Deviation; % CV, the coefficient of variation: it is employed to join the average/arithmetic mean and the SD (% CV = SD/Average ∗ 100). It allows for comparing various samples with different means.

  2. Variable 6 “Awareness of Breadth of Primary Healthcare”1: Yes (aware); 2: No (unaware).

  3. Certain PHC could not provide reliable answers to the presented questions, which is denoted by NA.

  4. Variable 2 “No. of Medical Specialists (Full and Part Time)”: here the Average, SD and % CV were calculated considering the nine PHC that answered only.

Administrative
1No. of general practitioners (GPs—full and part time)5340412241262.61.663.3
2No. of medical specialists (Full and part time)9NA2874222511311517018.912.767.0
3No. of helpers/assistants421592839579100108.151.5
4No. of beneficiaries (Monthly average)4801100800300250NA6003509004005180575.5296.75.5
5No. of procedures/services providedNA6020NANA40NANA16814428.821.073.1
6Awareness of breadth of primary healthcare11101111119   

Regarding the responsiveness of PHCs to the growing burden of NCD, interviewed PHCs are functioning well at the level of services for Diabetes Type I and II with the majority of PHCs providing the recommended services. However, interviewed PHCs are lacking in their responsiveness to health needs pertaining to cardiovascular diseases (CVD), respiratory diseases and cancer, where aside from the availability and analysis of electrocardiograms (ECG) for CVD, providing inhaled short-acting β2 agonists for respiratory diseases, and conducting clinical breast-examination and pap smear/cervical examination for cancer, none of the services are being provided by more than 80% of the PHCs assessed, with certain services being provided by only 40% of PHCs. Furthermore, the study revealed that even though all PHCs are providing ECG testing and analysis, 90% of the interviewed PHCs do not provide a basic smoking cessation program that calls to question how preventive Lebanon's PHCs are (Table 3).

Table 3. Basic primary health services related to NCD
Basic NCD serviceTotal No. of PHC providing the ServiceBasic NCD serviceTotal No. of PHC providing the ServiceBasic NCD serviceTotal no. of PHC providing the service
  1. NCD, non-communicable disease; PHC, primary health care center; CVD, cardiovascular disease.

CVDDiabetes IICancer
Tobacco/smoking cessation program1Educational material—physical activity—glycemic patients9Clinical breast examinations9
Electrocardiograms available10Educational material—physical activity—diabetes type II9Hepatitis B vaccination6
Analysis of electrocardiograms10Metformin/anti-hyperglycemic drugs—overweight Persons8Pap smears—cervical examination9
Educational material—physical activity—CVD8Oral hypoglycemic agents—diabetes type II10Final-needle aspiration biopsies to test lumps4
Educational material—dietary habits—CVD7Respiratory diseasesEvidence-based guidelines—cancer4
Aspirin/statin/anti-hypertensive provision for CVD10Oral short-acting β2 agonists7Referral process—specifically cancer8
Anti-hypertensives for constant blood pressure > 160/1004Inhaled short-acting β2 agonists9 
Anti-hypertensives for constant blood pressure >140/904Steroid inhalation for bronchial asthma6
Diabetes IShort-acting bronchodilators to relieve breathlessness6
Capillary glycaemia tests10 
Insulin injections: type I diabetes9

The previous results reflect the current situation of PHCs; however, the qualitative results of the study allowed for identifying the healthcare arrangements needed by PHCs to follow a more effective role in responding to NCD.

Regarding the question about the centers' relationship with MOPH, all 10 PHCs reported having a good working relationship, with the main theme being “collaboration and communication” whereby five PHCs described it in terms of active and continuous efforts in trainings, development in work processes and participation in all meetings and activities. Six PHCs focused on the importance of the provision of medication and vaccinations by MOPH. Finally, two PHCs mentioned the pilot accreditation as a good indicator of the collaboration with MOPH. In fact, one center asserted: “They taught us a lot” when referring to the accreditation surveyors.

When PHCs were asked about what additional arrangements are needed with the MOPH, two main themes emerged. The first theme was “contracts that ensure sustainable provision of drugs”, whereby nine out of 10 PHCs focused on the need to have a relationship that ensures sustainability in provision of drugs.

The second theme revolved around “increased support from the MOPH”, whereby, one center mentioned the need for MOPH to specify the catchment area so PHCs can be more proactive in targeting their surrounding community. Moreover, the need for MOPH to support PHCs by demonstrating confidence in them and giving them priority to admit patients to public hospitals was identified by one center. Another important role MOPH can fulfill is influencing and prohibiting the media's part in tarnishing the reputation of generic drugs being distributed to patients in PHCs.

One center recommended enhancement of policies and procedures: “The policies in PHCs, the bigger they get the less effective they become. And this is the problem, we are given these policies that are copy/paste… the policy should be very simple, very brief, and straight to the point”. Moreover, many PHCs would like MOPH to support them with more staff training on use of guidelines, equipment and technology. Also, more support is needed by diminishing inequity in drug distribution to different centers, whereby some are given a larger supply than others. Another dimension of inequity is between MOSA-sponsored and MOPH-sponsored PHCs, whereby the former receives monthly salaries for each of the PHCs' director, physician and housekeeping personnel.

When PHCs were asked about additional needs and resources, four main themes emerged. First, “medication and vaccines”, nine out of 10 PHCs expressed concern regarding the deficiency in provision of drugs. One center expressed the following concern: “I need Glucophage 8000 pills, they give me 3000”. The second theme was “human resources” where nine out of 10 PHCs reported a shortage. An accreditation officer, a person appointed to developing health indicators, physiotherapists, nurses, pharmacists and information technology personnel were among the needed personnel identified. As for the third theme, “equipment”, six out of 10 PHCs also reported shortages. One center stated that none of the equipment available is from the MOPH; all are from donations: “now we are in desperate need for an X-Ray machine and we have to wait for a donor to acquire it.”

As for the last theme, “financial resources”, six out of 10 PHCs perceived a need for more resources to open longer hours. For example, one center expressed concern for men who are not able to visit PHCs during opening hours: “The man who is working till 3–4 pm; he would have to take a vacation just to come to the center”.

When PHCs were asked whether they conduct needs assessment (NA) studies, nine out of 10 PHCs responded that they do, via their information technology department, community assessments with patient feedback forms, in collaboration with American University of Beirut, screening campaigns throughout the year, household visits, in-house analysis of patients, awareness sessions, free-check-ups, patient surveys or local committees consisting of prominent community members that discuss community needs. However, regarding how centers respond to NA studies, four main themes appeared. Certain centers “reestablish contact with patients”, whereas others provide “special discounts on clinical services (offers)” to attract patients to seek needed services, and some respond by “recruitment of needed specialties”; on the other hand, some reported “no action taken”.

When asked about the additional needs for acting on results of NA studies, two recurrent themes emerged: “increased credibility and confidence granted to PHCs” and “more human and financial resources”.

In regard to the question about the impact of the pilot accreditation on PHCs' performance, three major themes emerged. The first theme was that the “pilot accreditation improved the quality of PHCs' services”. Administratively, it helped PHCs develop a vision and strategic plans and establish more comprehensive policies and procedures. One center reported that it standardized among PHCs the understanding of quality, strategy and objectives. Also, accreditation guided work organization and coordination and improved the quality of documentation. Two PHCs reported that accreditation resulted in the increased availability of specialists, medications and patient follow-ups, thus improving care. One center perceived that the pilot accreditation resulted in reduced patient complaints and therefore improved clinical practice. Overall, accreditation was a learning process for PHCs that improved community involvement, health human resources management, patient care, staff and patient safety; it further enhanced patients' trust in PHCs, instigated a client-focus approach and teamwork and allowed PHCs to pursue a leadership role. The second theme was the “lack of a monitoring and evaluation system”, because all PHCs reported not having health and performance indicators. In fact, one center expressed the need to incorporate the accreditation process as part of a continuous monitoring and evaluation system for PHCs' performance improvement.

It is worth noting that some PHCs mentioned the need to contextualize the accreditation process to Lebanon, as one respondent noted, “Accreditation needs to be less rigid, more gradual, and contextualized to Lebanon”.

In regard to the question about methods of risk factor identification, one revealed theme was the “lack of a standard mechanism for risk identification”, whereby PHCs reported various yet limited methods such as filling a questionnaire within the patient's medical file, whereas others reported following the risk assessment approach of MOPH and WHO. Only one center conducted community assessment studies strictly for diabetes and hypertension.

Furthermore, when asked about the additional needs to better fulfill a preventive role, PHCs mentioned the need for more lectures, campaigns and advertisements, affordable campaign prices and free screenings.

With regard to the last question about the referral system, the main theme identified was the “lack of an integrated, accurate and reliable referral system”. None of the PHCs reported having a comprehensive (two-way) referral system, and variations have been noted in the method of updating patient medical records post-referral. Many PHCs reported referring services to other centers or hospitals; however, a limited capacity in the number of referrals to public hospitals was also expressed.

Moreover, the only consistent two-way referral mechanism identified was limited to laboratory results, and most PHCs reported that unless the patient returns to the center, there is no form of contact or coordination with hospitals. A main factor for the lack of a referral system was claimed to be hospitals postponing the establishment of one. Finally, the need to gain patient trust and encourage them to return to PHCs after visiting hospitals was voiced.

DISCUSSION

Discussion of results

Overall, the study elucidated the positive impact of the accreditation efforts and adequate responsiveness of the interviewed PHCs to the growing burden of NCD; however, deficiencies persist and additional arrangements are necessary (refer to Table 4 for summary of findings).

Table 4. Study's key findings
  • GP, gross product; PHC, primary health care center; CVD, cardiovascular disease.

  • *

    Figures based on absolute number count and not on full-time equivalent.

PHCs are less equipped with GP than specialists*
Availability of helpers/assistants is not proportional to the number of beneficiaries served among PHCs*
Overall, PHCs are responding well to Diabetes Type I and II
PHCs' responsiveness to CVD, respiratory diseases and cancer is insufficient
Additional findings and needed arrangements identified by PHCs
More contracts are needed for sustainable provision of drugs
MOPH needs to provide more support: define catchment area, increase publics' confidence in PHCs, provide additional financial resources, equipment, technology and trainings and guidelines
More equity in resource allocation among centers
No standard mechanism for identification of risk factors—a standard method needs to be developed
PHC lack in conducting sufficient community based needs assessments and more human and financial resources are needed for such activities
Pilot accreditation improved quality of services (administratively, defined strategies and objectives, improved quality of documentation and increased patient follow-up)
PHCs lack an integrated, accurate and reliable referral system (Centers have no comprehensive two-way referral system, except for medical lab results)

One interesting finding was the variation across PHCs in administrative aspects, whereby the number of helpers/assistants within a center is not proportional to the number of beneficiaries being served. An example comes from one center that with 28 helpers provides services for about 250 beneficiaries/month, whereas another center has seven helpers available to serve about 900 beneficiaries/month. Insufficient allied healthcare professionals and medical personnel, such as nurses, are common in our part of the world, where only 25% of the health labor force is operating as support staff and the density of nurses and midwives for every 10,000 persons in Lebanon is only 13, much less than the average for Arab countries of 25 (El-Jardali et al., 2012). Another study reveals that low nurse densities pose critical impacts on health outcomes in middle-to-high income countries, in which Lebanon is a part of (El-Jardali et al., 2007). Moreover, variation is also noted at the clinical level, whereby coefficient of variations of approximately 63% for GP and 67% for specialists clearly indicate variation in the number of physicians across PHCs.

These variations may be attributed to the multiple owners (Ammar, 2009) that, depending on their fiscal capacity, influence the availability of centers' resources. This lack of equal distribution in resources translates into inequitable provision of health services that contradicts the principles of primary care and undermines PHCN's capacity to address NCD.

A second key finding of the study is the significant gap between the number of GP and specialists, whereby on average, each center has only three GP in contrast to 19 specialists. Such a feature of PHCs is expected, yet not justifiable, considering that the proportion of specialists out of total physicians in Lebanon exceeds 70% (Ammar, 2009). Although, it must be noted that the previous findings and interpretations relied on figures regarding the number and profession of the primary health care centers' personnel that were based on absolute number, rather than on a full-time equivalent count, which would have been more accurate to assess the availability of different types of healthcare personnel within and among the primary healthcare centers interviewed.

Regarding responsiveness to NCD, findings revealed that preventive services are lacking for CVD, respiratory diseases and cancer; such is the case specifically at the level of CVD with only one PHC targeting smoking as a risk factor, despite all PHCs being equipped with advanced ECG imaging and analysis, which clearly supports the long-debated issue of the Lebanese healthcare system's over dependence on advanced technology and curative care oriented services, while undermining low-resource consuming yet highly impacting primary and preventive care services.

This is a critical finding when in 2010, the MOPH alone was financially burdened with 37,476 hospitalizations for circulatory system health problems, 27,834 for respiratory diseases and 25,803 for hospital inpatient cases (MOPH, 2010); in addition to that, smoking, inadequate physical activity and a poor diet are well-established risk factors and are estimated to be the causes of 75% of NCD (Khatib, 2004).

In regard to diabetes and its preventive measures, PHCs are functioning well by providing almost all recommended services; however, the lack of provision of metformin decreases the effectiveness of care. Studies assert that metformin, along with behavioral modifications, avert the development of diabetes, and are established as cost-effective initiatives (Beaglehole et al., 2008).

Primary health care centers reported distinct requirements for a better working relationship between them and the MOPH, signaling a lack of a standardized approach from the MOPH. This may be the case because every center operates individually, caters for a specific community and may have different agreements with the MOPH. Another reason for the MOPH failing to provide similar services to all PHCs could be explained by the fact that 25% of MOPH's personnel have retired in the past decade without being replaced (Ammar, 2009).

The lack of MOPH support to PHCs may lead to repercussions, as health system entities left to work independently, without guidance, deviate from their responsibility of achieving favorable health outcomes and respecting the values of equity and social justice. Such repercussions can set a trend for an increased focus on curative care with minimal resources devoted to prevention (WHO, 2008).

Additionally, all PHCs reported shortages in resources. This may be due to MOPH being allocated only 3% of the total government budget. Another factor is half of the population being uninsured coerces MOPH to allocate 85% of its budget to hospitalization of uninsured citizens, thus depleting the meager amounts of resources available for preventive care (Ammar, 2009). This overwhelming financial burden faced by MOPH will impact the capacity of PHCs to pursue an effective role in attenuating the burden of NCD by decreasing the quality of care, which in turn negatively affects patients' trust and confidence in PHCs, thereby indirectly leading people to seek curative care.

In regard to the pilot accreditation, one of the major impacts was the shift from a “management unit” to one that “follows patients and diseases processes”, a finding that is validated in international studies (WHO, 2003). Furthermore, the perceived improvement in service quality correlates with existing literature on the positive impact of accreditation in healthcare (Nicklin & Dickson, 2008). Results suggest that implementing accreditation across all PHCs would assist the MOPH in controlling NCD-related health expenditures and strengthening confidence in PHCs' services.

Moreover, findings from this study and others allude to the importance of ensuring that processes for accreditation are contextualized to Lebanon (Tabrizi et al., 2011), because placing high standards of performance on PHCs' professionals with limited resources may create a resistance to change among PHC staff.

With regard to enhancing PHCs' preventive role, the absence of a standard, proactive and sustainable approach to identifying populations at risk of NCD means that the burden of NCD may remain the same, if not, escalate. This calls for the development and institutionalization of a standard strategy, such as the “WHO NCD Surveillance” strategy across PHCs (WHO, 2013a).

The study also identified a lack of multi-sector collaboration in raising awareness about NCD, which correlates with findings from previous studies in Lebanon that the consumer is often uninformed and misguided, thereby depriving the health system of a significant driver for better quality (Ammar, 2009).

One major indicator of a health delivery system is the use of a comprehensive two-way referral system (USAID, 2012.). The lack of an effective counter-referral process is not unique to Lebanon, and international research studies indicate that failures in coordinated care are common and raise serious concerns about service quality (Bodenheimer, 2008) as they may result in patients missing the necessary advanced care, either for reasons of perceived poor quality of public hospitals or the high cost of referred services; hence, they are at risk of ill-health and impoverishment. Alternatively, some may perceive better quality at a secondary level, and may continue purchasing secondary health care services and discontinue follow-up with PHCs. This is not unusual considering that in Lebanon, bypassing PHCs and directly seeking specialist care is a common practice (Ammar, 2009). Other studies have in fact indicated that although referral guidelines may exist, their implementation may not be effective; with the most complex aspect of referral care often being the patient's acceptance of, and compliance with, the recommended referral (Samb, 2010). If left unchecked, this may further burden the health system with unnecessary and costly higher level care, and concomitantly delay access to higher level facilities for patients who truly need more specialized treatment. Overall, the lack of an effective and integrated referral system jeopardizes the use and popularity of PHCs among the served population (WHO, 2013b).

Worthy of noting, Lebanon is currently setting upon initiatives and preliminary efforts to achieve some form of continuity of care by establishing health cards for the extremely poor. Such innovations as e-referrals and systematic referral agreements may also provide improvements in waiting times for specialty consultation, enhanced information flow between primary care and specialists, and timely response from specialty to primary care practice (Bodenheimer, 2008).

CONCLUSION

The study generated findings having nationwide implications at the level of governance, financing and delivery of healthcare. At the level of governance, the government ought to empower PHCs and increase their level of autonomy to be able to provide a broader array of services that fall under primary care, which are currently provided by secondary health institutions. In addition, there is a need to formulate a policy for establishing a referral system that delineates the mode of coordination between primary and secondary care settings. Another policy, with the potential of strengthening PHCs through quality assurance of their service delivery, is the expansion of the pilot accreditation initiative to encompass more centers within Lebanon's PHCN.

As for financing, the government needs to ensure that preventive care targeting NCD is properly budgeted for. This would entail an overall increase in the allocated budget to MOPH by proposing alternative methods for increasing the fiscal capacities of government, such as additional taxation of alcohol and tobacco. More specifically, MOPH must emphasize preventive care by proportioning a larger budget to primary care services.

Finally, to advance the delivery of care, PHCs should be equipped with more qualified allied healthcare professionals and develop the number of GP and Family medicine physicians to enhance efficiency and effectiveness and to fulfill the requirements of accreditation.

To strengthen the case for PHCs, additional research may be developed regarding the impact of accreditation, referral systems and the success of preventive care in attenuating the healthcare system's financial burden; however, political will and commitment are imperative to realizing any identified recommendations.

DISCUSSION OF LIMITATIONS AND STRENGTHS

Regarding the sample, because the number of PHCs surveyed was small and had variations in the number and type of participating healthcare professionals, the quantitative findings of the study may have been undermined. Moreover, the PHCs in this study represented a convenience sample that had undergone accreditation, and their opinions may not be reflective of the entire PHCN. PHCs that have not undergone the pilot accreditation may have even greater challenges and therefore greater needs to address, thereby limiting the generalizability of the study.

With regard to the questionnaire, it was not officially translated into Arabic, and therefore, the questions were not read out in the same and consistent manner. Three of the PHC interviews were not recorded, and researchers may not have accurately recalled responses; however, the fact that all three researchers were filling out the questionnaire allowed for recall, crosschecking and validation of the interviewees responses. Some responses may have been limited to the participants' recall ability. Moreover, an inherent limitation with recorded research is the provision of socially desirable responses, with some participants perhaps providing the researchers with responses that they believe are expected of them, particularly in the presence of physicians and directors in the group interviews that are of a higher authority in the professional/organizational hierarchy and may have a coercive effect on the respondents to provide what would be an expected, rather than an actual response. However, probing into the topics addressed in the qualitative questions enhanced the respondents' understanding of the questions, their ability to recall data, and the validity of their answers.

Despite the aforementioned limitations, this study has its strengths and represents a starting, not an end point. The study is original and the first of its kind in assessing the responsiveness of PHCs to the growing burden of NCD in Lebanon. Furthermore, the study identifies ongoing issues associated with the healthcare system as perceived by the primary healthcare professionals and focuses on their needs to provide better primary healthcare services. The study also comes at a critical time when major investments—such as the accreditation process—are being made in the Lebanese PHCN to assure service quality; and thus, it provides a preliminary assessment of the impact of such investments. As such, the information generated from this study is important in providing critical constructive data from which to develop further research and policy translation.

ACKNOWLEDGEMENTS

The authors would like to acknowledge the kind efforts of Diana Jamal, Nabil Natafgi and Maha Jaafar for the help they provided in developing the American University of Beirut Institutional Review Board application. All funds for transportation, data collection, analysis and documentation were provided for by the research team. No funds were provided by any outside party. The authors of the study identify no conflict of interests regarding any aspect of the study.

Ancillary