The four primary research themes for R4HC-MENA

Dr Preeti Patel and Prof Richard Sullivan speak with ecancer at the September 2018 R4HC Executive Board Meeting, which brought together regional collaborators to discuss programme updates and activities at the end of the programme’s first year.

This work stream brings together complementary strengths at KCL (Conflict and Health Research Group) and American University Beirut (AUB Lebanon) to build regional capacity on conflict and health. Our published work so far has focused on broader thematic issues around contemporary armed conflict and health, such as measuring the direct and indirect effects of war on population health outcomes and health systems, causes of contemporary conflict, humanitarian principles and ethical dilemmas, civil-military relations, challenges of aid-effectiveness and trends in ODA for health, changing humanitarian landscape and new humanitarian donors, and evidence-based interventions for health. 

The aim of this work stream is to provide systematic and empirically grounded research capacity in the political economy of health in conflict in MENA countries, particularly around methods to examine the historical development and policies of their health systems, and the current role of government, the private sector, international donors and humanitarian agencies.

The Syrian conflict and humanitarian crisis has affected almost all countries of the MENA region but has had particularly profound effects on immediate neighbours. This new context of crisis requires deepened knowledge about the political economy in the region, guiding the formation of new health policies particularly in NCDs such as cancer and mental health. A recent analysis of health in the MENA region highlights the key problems of ignoring political economy approaches in understanding health concerns. In addition to the increasing NCD burden, the region has long suffered from a sustained under-investment in both public health systems and health research. Powerful actors with vested interests—governments, donors, NGOs and the private sector — shape national health agendas, including the formation of social protection systems. However, the research capacity to conduct programs that can inform evidence-based policies is severely lacking. There is an urgent need to design and build multi-sectoral responses based on evidence generated within the MENA region. The project will incorporate multidisciplinary research capacity approaches across policy sectors, such as ministries of development, labour, social affairs and public health.

Cancer is a growing problem in all MENA countries, currently ranking as the fourth leading cause of death in the region. The incidence of cancer in this region is expected to experience the highest increase among all WHO regions in the next 20 years, posing a major burden to health and development in MENA. In the period just prior to the spread of conflict, regional healthcare systems had begun to take preliminary steps in prioritizing cancer care within national systems. However, much of this progress has been stymied or even reversed as recent conflicts have presented unprecedented challenges.

The Syrian and Iraqi conflicts, and the massive forced migration of populations across borders, have led to the fragmentation of cancer care in affected countries in the region. It has also presented the healthcare systems of neighbouring host countries, such as Turkey, Jordan, and Lebanon, with an unforeseen additional cancer burden. This burden comprises the large number of refugees seeking cancer care who are not covered by insurance or by
humanitarian packages, as well as therapeutic migrants seeking cancer care across therapeutic geographies in the region. In the context of demographic upheaval, political instability and the fragmentation and regionalization of care, there is a need for vital, multidisciplinary research in order to better understand the complex dynamics that influence health-seeking behavior among this patient population. This includes research into the patients’ different therapeutic geographies of cancer care, including their communities, the health system of their host countries, post-conflict reconstruction of highly fragmented health systems, and assessing the effectiveness of existing humanitarian and development aid on cancer prevention, treatment and outcomes.

As war changes the biospheres in which these cancer patients live, the political and economic context of this biosphere reshapes oncology and its diagnosis and treatment through surgery and palliative care. Cancer care
represents a complex, highly expensive, multi-modal challenge to MENA health systems and there is an urgent need to develop research to understand the new onco-landscape of delivering affordable and equitable care in health systems in areas of conflict.

Palliative care has been identified by WHO and partner countries as one of the major gaps in research. Through R4HC, research capacity will be built around health systems research methods to inform policy, cancer surgery and palliative care. Specific research will also be undertaken on implementation of outcome measures, as a means to scale up quality, access, influence individual assessment and treatment plans for palliative care.

Armed conflict and organised violence cause and amplify psychosocial stressors (e.g. poverty, malnutrition, inadequate housing and social isolation), which adversely affect people’s mental health and wellbeing (Miller & Rasmussen, 2010). Conflict-affected populations have been shown to have a higher prevalence of both common and severe mental disorders compared to the general population (Tol et al., 2011). Treatment gaps are widened especially in conflict affected areas of the MENA region due to inadequate infrastructure and human resources (Colidron et al., 2013). A recent assessment of a refugee population in North and Bekaa region in Lebanon reported a significant 65% impairment in daily functioning due to untreated trauma experiences and feelings of hopelessness in the individuals. The situation has been shown to be particularly grave for refugees and internally displaced persons, with treatment gaps reaching over 90% in some areas (Llosa, 2014). At a systems level, there is limited government spending on mental health (Palestine: 2.5%; Lebanon: 5%); minimal inpatient facilities, day care or residential facilities; a severe lack of staff and no mental health law.

In line with the WHO’s Mental Health Action Plan 2013-2020, Palestine and Lebanon have begun to design and implement their nation’s own mental health strategy by investing in delivering affordable and equitable mental health care for both domestic and refugee populations. Unfortunately, there is a lack of systematic mental health research conducted in these regions, due to capacity issues. To address this research gap, this project aims to build interdisciplinary research capability for mental health in both Palestine and Lebanon.

The Mental Health workstream has produced a report, Training Needs Assessment for Mental Health Research in War and Conflict, which contains extremely interesting and important findings regarding training needs for mental health research in the West Bank, PalestineThe needs assessment was led by Prof Rita Giacaman, Institute of Community and Public Health, Birzeit University (ICPH/BZU) and her team Weeam Hammoudeh and Rawan Kafri, and supported by King’s College London colleagues, Hanna Kienzler, Alessandro Massazza and Nancy Tamimi.

Read further publications from the Institute of Community and Public Health at BZU here.


Across all four work streams, four common deliverables are embedded:

  • Curricula and courses will be co-developed and co-delivered in local contexts

  • Training will be focused on faculty leaders and will use a variety of pedagogical approaches (from certificate level modules to full Masters degrees tailor made for the MENA region)

  • Both UK and MENA partners will be strongly encouraged to co-publish in high impact journals to build academic depth and ensure the translation of research to policy

  • A focus on innovative learning technologies and informatics – such as blended learning, online and virtual learning

Additional areas of work and cross-cutting themes

Training & Capacity Building

The R4HC-MENA programme aims to build research and policy capacity in conflict affected areas focusing on health, political economy of health and complex non-communicable diseases (NCDs) such as mental health and cancer, by blending qualitative and quantitative methods and bridging social and clinical sciences.

This will be achieved in the UK and MENA partner countries through contextually sensitive activities including:

  • Co-development and delivery of accredited multi-disciplinary courses following a blended learning approach with faculty from the UK and MENA region. These courses are fundamentally inquiry based and will improve knowledge and expertise in classical and new research methods to grow capacity to generate much needed empirical data. To achieve this, lecturers and researchers will be specifically trained in innovative teaching methods, assessments and evaluation methods.
  • Mentoring senior leadership at national and global/multilateral institution levels in the translation of research to policy.
  • Developing targeted and innovative Learning Technologies and Informatics  platforms for distance learning and education (iTEL).
  • The AUB Global Health Institute Academy will be involved in the development and implementation of blended learning, including webinars and massive open online courses.

Additionally, the R4HC-MENA programme will develop new sustainable partnerships between organisations to build expertise and capacity in conflict and health research across the MENA region and globally. Activities include:

  • Bringing together academic, humanitarian and government sectors to develop education programs and build expertise in conflict and health research in both the UK and partner countries.
  • Engage with other countries in areas of conflict in the MENA region (e.g. Iraq, Yemen, Libya and Tunisia) in order to learn from their experiences and build new or strengthen existing South-South partnerships.

Medical Ethics Education

The Centre for Military Ethics at King’s College London is working to refine and expand the existing (and successful) Military Ethics Education Playing Cards and their linked online resources by researching and developing a new training and education resource specifically designed for health care professionals deployed in conflict, post conflict and humanitarian disaster relief environments.