1. Health needs assessment of vulnerable older Lebanese
populations and older Syrian Refugees
(Lebanon – February 2015)
Picture by HelpAge International
Final report

2. Table of Contents
Introduction ............................................................................................................................................3
Acknowledgments: .................................................................................................................................3
Section 1 Scope and Methodology ........................................................................................................4
1. Scope of the assessment.............................................................................................................4
2. Assessment methodology...........................................................................................................5
Section 2: Assessment limitations ........................................................................................................11
Section 3: Key findings and health priorities ........................................................................................14
1. 40 + and 60+ years old population estimates...........................................................................14
2. Population estimates in PHC catchment areas.........................................................................14
3. Household profile......................................................................................................................15
4. Analysis of the household vulnerability criteria .......................................................................19
5. Mental health status.................................................................................................................25
6. Key findings on Access to health...............................................................................................27
7. Health priorities-Programmatic recommendations based on household survey key findings 29
8. Key findings on PHC analysis.....................................................................................................31

3. Introduction:
With over 1.1 million of Syrian Refugees representing around 20% of the population and a poverty
level of 28.6% for nationals; Lebanon faces great challenges for granting the basic human right of
universal access to health. Moreover, 75% of health facilities are private while the two main
ministries in charge of health services, Ministry of Public Health (MoPH) and Ministry of Social Affairs
(MoSA), have limited capacities and often need to rely on local charity organizations and
international aid for ensuring a minimal level of access to vulnerable communities.
In general terms, the health situation in Lebanon is surprising when speaking about a middle income
country with a population of 4+ million people. However, the lack of access to basic services, not
only health, is structural and enrooted with the recent history of the country.
Despite several international initiatives, as the EUR 20 million pilot project of the European Union
Stability funding for Lebanon focusing on enhancing MoPH and MoSA health capacities, the level of
needs are not fully covered yet and its sustainability over time is not ensured.
Whereas Lebanon is the MENA region country with the highest prevalence of NCD (63.8%); the lack
of granted access to health care provokes a direct negative impact on older people and people
affected by chronic diseases from both communities, vulnerable Lebanese and Syrian Refugees.
Often, the absence of a sustainable income for ensuring NCD long-term treatments leads to negative
coping mechanisms such as not accessing to health facilities or not following the prescribed
treatments regularly. Furthermore, there is very little knowledge about the levels of psychological
distress and disability within older Lebanese and Syrian so far due the lack of specific interventions
addressing these problems.
HelpAge International has a developed a strategy for ensuring the access to NCDs treatment working
in collaboration with health partners in Lebanon. On regards to this strategy, the need of a) feeding
the current intervention with evidence-based findings; b) ensuring that the programmatic
interventions are tailored to the specific needs of older people and c) targeting the most vulnerable
population within both communities, justified the implementation of a health focus needs
assessment in four of the country governorates. The needs assessment was carried out between
January 19th
to February 13th
2015 covering Mount Lebanon, South Lebanon, West and North Beeka.
The analysis, findings and operational recommendations reflected in this report are result of this
exercise.
Acknowledgments:
The assessment team would like to thank the continuous and effective support of all the staff
involved during the implementation of this exercise. In particular, we would like to thank HelpAge
staff in London and Lebanon, Amel Association, Imam Sadr Foundation and Makassed for their help
and facilitation. Without their contributions and dedication, the final results of this assessment
wouldn’t reach the level of accuracy and quality required.
Most importantly however HelpAge would like to thank all the older people and key informants who
took part in the assessment and provided the rich evidence and experience on which this report is
based.

4. Section 1 Scope and Methodology
1. Scope of the assessment
Scope of the assessment and teams’ composition
During the decision –making process of the operational arrangements phase, the geographical scope
of the assessment was divided into four regions corresponding to the governorates political division
in Lebanon: Beirut-Mount Lebanon, South Lebanon, North and West Bekaa. In Beirut - Mount
Lebanon and in the South, one focal point was in charge of two teams of 2 enumerators. For the
Beeka regions, the focal point was supervising 4 teams of 2 enumerators. The gender balance was
respected in all the teams.
Each team of 2 enumerators (1 female, 1 male) was supposed to collect 36 interviews during the 6
days of data collection such that the objective was to collect up to 288 household interviews.
The total number of staff involved in the needs assessment was 23, their division by role and
responsibility was:
1 Assessment Coordinator; 2 Health Advisers; 1 Data Analyst; 3 Focal Points; 16 Enumerators
Scope of the Household Survey data collection
The following table provides the planning of the interviews by region and a type of area subdivision.
The last column presents the number of interviews that were validated and uploaded into the
dataset.
Table 1: Planning of the interviews
Region Type of area
Interviews
planned
Valid interviews uploaded
into the dataset
Beirut and Mount
Lebanon
100% of
Urban/periurban
72 79
South
25% ITSs
60% Rural
13% Urban
72 75
West and North
Bekaa
100% Rural 144 135
Grand total: 288 289

5. Scope of the PHC Facilities assessment
There were 9 facility assessed in the four covered regions. The interviews were made by the focal
points or the assessment coordination team.
Table 2: List of facility assessed by geographical area
Name of the facility Qaza Region
Al Ain Amel Association PHC Baalbeck North Bekaa
Al Sader foundation Aita Chaab centre Bint Jbeil South Lebanon
Tyre Amel Association PHC Sour South Lebanon
Al Sadr Foundation Siddiqine Sour South Lebanon
Al Sadr Foundation Kfarhata Saida South Lebanon
Al Bashura Beirut Beirut / Mount Lebanon
Al Harash medical centre Beirut Beirut / Mount Lebanon
Kamed el Loz Amel PHC West Bekaa West Bekaa
Hay el sellom Amel PHC Mount Lebanon Beirut / Mount Lebanon
2. Assessment methodology
The 2015 HelpAge International health needs assessment with focus on older vulnerable Lebanese
and Syrian refugees was carried out in Lebanon for a period of 21 working days between January
19th
to February 13th
.
The assessment objective was twofold;
a) Analysis in 4 country regions of the Primary Health Centres (PHCs) facilities following WHO
criteria of Access, Accessibility/Availability and Quality of health services with the intention
of obtaining a profile of the current PHCs status and;
b) A purposive sample at household level. The main objective of this sample was to collect
enough relevant information regarding the access to health of the vulnerable Lebanese and
Syrian Refugees in any of the regions assessed during the exercise.
The combination of both exercises allowed to HelpAge International to draw an evidence-based
analysis that can be used for future planning and prioritization of its response programmes. This
methodology section details all the staggered phases and methodological approaches applied during
the assessment considering as timeline the agreed planning between the assessment team, HelpAge
International and their partners in Lebanon:

6. Figure: Assessment timeline
Week starting on
January February
19 26 2 9
Definition of Primary Data tools and assessment
methodology
Focal Points Training
Enumerators Training
Primary data collection
Data uploading
secondary data review & analysis
Analysis workshop and submission of inception report
Reporting
The components and actions taken during each of these phases are as follows:
1. Definition of Primary Data tools and assessment methodology (3 days)
The first three days of the assessment were focused on defining 1) scope of the assessment; 2)
Primary data tools and 3) assessment methodology for ensuring the planned objectives. The scope
of the assessment is already detailed in the above section, regarding the primary data and
methodology:
a. Primary Data rationale:
Rationale:
During the internal discussions before starting the data collection exercise, it was defined to proceed
with a Household Survey sample combining random and purposive modalities.
Random: Each of the four assessed areas followed a “snowball” process for identifying the
households. The first interviewed household was identified by the social workers of the PHCs.
Afterwards; the enumerators together with the support of the focal points identified other
households within the selected categories asking the neighbourhood.
Purposive: This kind of sample was the best one adapted to the assessment objectives. Purposive
modality selects the sample based on certain knowledge of the population and the purpose of the
needs assessment. The selection is based on one or more specific characteristics explained in the
sections below. The following graphic shows how this assessment followed the standard criteria for
a purposive sample modality:

7. Representative sampling
Precision
Purposive sampling
Convenience sampling
Methodology
Phase I Phase II Phase III & IV
Time and Cost
Source: ACAPS.
b. Data collection tools:
Household Survey Questionnaire: Designed with a combination of HelpAge International expertise
on health needs assessment with tools successfully tested in the region. The format takes some of
the components from the 2013 urban Refugee profile in Southern Turkey (UNHCR) and 2014 SAMI
MSNA for Syria (SAMI). This tool, to be used by the enumerators and area focal points, was
produced in English and Arabic versions.
Health Facilities Questionnaire: The tool was designed for assessing the existing capacities and gaps
on each of the 3 organizations participating in the assessment PHCs following the analysis criteria of:
Access, Availability/Accessibility and Quality of the primary health services. The objective of the
facility assessment was not to evaluate the centres having as reference these three criteria, but to
obtain a better understanding of their capacities and how upcoming programmes would enhance
their current situation. The questionnaire, designed for being used by the assessment coordination
team and focal points, was produced on English version only.
c. Analysis tools:
In addition, two analysis tools were produced with the objectives of a) providing a framework for the
joint analysis phase and b) defining pre-established criteria for ranking and prioritizing responses.
These tools are:
Health Severity Scale: Using the same rationale applied during the SIMA-MSNA and OCHA-HNO1
&
AoO2
; the Health Severity Scale template was adapted for the purpose of this exercise. Applying logic
1
HNO: Humanitarian Needs Overview
2
AoO: Area of Origin

8. of WHO standards and thresholds on access, availability and quality of health services; the
assessment team was able to rank and prioritize the needs and potential responses during the joint
analysis phase.
Households and facilities criteria: Complementing the Severity Scale the questions included in the
Household and Facility questionnaires were grouped on access, availability and quality sections with
the same intention of easing the joint analysis.
d. Categories vulnerable groups:
The assessment team together with HelpAge team, pre-defined a list of categories of the potentially
most vulnerable groups expected to be identified within the sample considering socio-economic
determinants. These determinants are expected to make direct impact in their levels of vulnerability
and coping mechanisms for accessing to health services. Moreover, the division by categories
allowed the identification of the prevalence of each of them and fostered ranking the priorities.
The six selected vulnerable categories were:
. 40+ years old with chronic diseases
. Older People Head of Household (Female /Male)
. Older People living alone (Female /Male)
. Older People no receiving any assistance or HH unregistered by UNHCR
. OP living in HH with + 5 members
. Disabled
The identification at household level of any of these categories was done by the enumerators and
Focal Points once the interview was, not during it, in order ensuring the accuracy.
Figure: Profile of the vulnerable categories assessed.
Affected
population
40+ years old
with chronic
diseases
Older People
Head of
Household
(Female /Male)
Older People
living alone
(Female /Male)
Older People no
receiving
assistance
OP living in HH
with + 5
members
Disabled
Vulnerable
Lebanese
Syrian Refugees
Non affected
population

9. 2. Focal Points Training (1 day)
The Focal Points of each of the regions included in the assessment were trained during one day on a
quick inception on needs assessments & information needs; primary data collection techniques;
questionnaires and operational arrangements required for the data collection phase.
Training materials for this phase are available upon request.
3. Enumerators Training (1 day)
Focal Points trained their teams partially replicating the Focal Points’ training and focusing on the
scope and use of tools for the data collection. Moreover, all the 16 enumerators read and signed
HelpAge International Protection Policy and Code of Conduct before their deployment and as pre-
condition for being considered part of the assessment team.
4. Primary data collection, data uploading and secondary data review & analysis (7 days)
Data collection: The primary data collection lasted for six days and according to the aspects detailed
in the scope of the assessment section. The coordination team visited each of the areas on daily
basis and kept constant communication with the Focal Points in order to solve any problem or
discuss their doubts and suggestions.
Data uploading: Simultaneously to the data collection, the assessment team uploaded the
household and facilities interviews on daily for ensuring a smooth implementation. While the
responsibility mainly relied on the assessment team, HelpAge implementing partners supported this
task providing temporal data clerks. Data upload included a quality control check of the
questionnaires submitted; those ones not having an optimal level of reliability were rejected.
Secondary data review & analysis: Having as main focus the production of population estimates of
vulnerable Lebanese and Syrian refugees for Lebanon and the regions covered by the assessment;
the assessment team made a review and analysis of the secondary data of the already existing
reliable sources. The final results of this process are core part of this report while the full
methodology and supporting documents as included as report annexes
5. Analysis workshop and submission of inception report (2 days)
Analysis Workshop: HelpAge team, Focal Points and partners participated in the analysis workshop.
The one-day session was divided into two different sections:
. Briefings on Household and PHC assessment results.
. Analysis using the tools designed (Severity Scale and criteria)
The analysis session brought as result a prioritization and ranking of the initial findings which defined
the main recommendations reflected in this report. The importance of the analysis session relies on
the need of joint package of conclusions endorsed by all stakeholders involved in the assessment
ensuring that the final profile, identification of needs and programmatic recommendations will be
followed by a programme and strategic design in the coming period.

10. Inception report: Looking for the endorsement and recommendations from HelpAge International in
London, an inception report was submitted a day after the analysis session showing the initial
findings and recommendations agreed at field level.
6. Reporting (7 days)
Last days of the deployment were focus on producing the final version of the assessment report
ensuring all findings and conclusion were evidence-based and aligned to the initial objectives and
goals defined.

11. Section 2: Assessment limitations
In order to avoid the risk of misusing the results, several limitations need to be taken in c
consideration
when using this assessment figures.
Population figures: Out of the household sample, population figures are based on estimations either
for national level or catchment areas not accurate data. However, the methodology applied
including the triangulation of reliable sources and already tested methodologies can be perfectly
consider by health stakeholders as starting point for programme planning purposes.
Sampling: As explained in the methodology section, the sampling methodology chosen was
purposive limiting the scope to the population of interest of this exercise. Therefore, the
percentages and figures showing the health status at household level are corresponding to the
sample itself only; they cannot be projected for analysing the health status of the overall population
of the two assessed groups.
Data on mental health and disability: The information collected for these two sections relied on the
enumerators’ responsibility without having a particular expertise for professionally screening for any
of them. While the resulted figures can be used for highlighting the metal health and disability status
of the households assessed, they cannot be considered neither for the identification of patients nor
for health referral purposes.

12. Age and gender breakdown in our sample
Syrian above 40 with NCD or Syrian above 60 Lebanese above 40 with NCD or Lebanese above 60 Sample composition including all HH members
Sex and age disaggregating data
Syrian population Lebanese population
Female Male Total Female Male Total
60+ yo: 2.8% 2.9% 5.7% 5.4% 5.8% 11.2%
40+ yo: 10.3% 10.5% 20.8% 17.9% 17.1% 35%
Physical health and access to health care
Republic of Lebanon: Health Needs assessment dashboard for 289 households in 4 assessed governorates
Among the people
suffering from NCDs,
9 out of 10 people
have at least 2
diseases
1 out of 3 Syrian suffering
from NCDs is not taking
regular medication
90% of the people not
taking medication cannot
afford it
This dashboard highlights the findings and recommendations, product of the collation and analysis of secondary and primary data. The
assessment findings identify the most important needs of the targeted groups and their underlying factors.

13. Almost half of the population
in South Lebanon reports
signs of distress
70% of the host community
reports some level of
disability
Facility assessment results
Quality: moderate problem
Case management is not up to date or
accurate
Information management tools are
not standardised or computerised
Some essential non-medical
equipment is missing
Operational recommendations:
Providing the PHCs with the essential
non-medical equipment
Standardising tools for information
management
Availability: moderate to major
6 out of the 9 centres experience
shortages most of the time
Operational recommendations:
Building contingency stock at PHC
level
Accreditation of the centres by
YMCA’s chronic disease medication
programme
Access: major problem
Centres comply with 58% of the
recommendations on information
provision
55% of the centre have a mobile unit
Centres comply with 58% the
guidance on age-friendliness
Operational recommendations:
Long-term: outreach activities;
Short-term: increasing the use of the
mobile clinics
Organise age-friendly hours to avoid
Improve information display in the
centre on NCD services and
prevention
Refurbish the centres to increase the
physical access

14. Section 3: Key findings and health priorities
This section describes the key findings and priorities identified during the assessment process. Profile,
conclusions and recommendations reflected in the following paragraphs are product of a staggered
three levels of analysis; 1st
) Secondary and Primary Data collation and ranking; 2nd
)Database
comparative analysis and 3rd
) Joint analysis exercise.
1. 40 + and 60+ years old population estimates.
There is no precise census providing sex and age disaggregated data for both Syrian and Lebanese
population. However, having a clear idea on the number of older people in the population is critical to
ensure their effective inclusion in aid programmes.
As an alternative, a secondary data review and analysis was done to estimate the population. Several
sources were used for triangulation. They included the Multi-Indicator Cluster Survey (2009) elaborated
by UNICEF and the government of Lebanon, estimations made by HelpAge International (2013),
estimations provided by UNDESA (2010) and the UNHCR data (2015).
Details of the methodology are provided in the Secondary Data Review annex. The final estimation gives
the following results for the Lebanese population:
40+ yo: at least 35% (of which 45.4% female and 54.6% male)
60+ yo: at least 11.2% (of which 48% female and 52%male)
Following the conservative assumption that 11.2% of the Lebanese population is aged above 60, we can
estimate that there are 486,202 older Lebanese in the country.
The final estimation for the Syrian population gives:
40+ yo: at least 20.8% (49.6% female/50.4% male)
60+ yo: at least 5.7 % (49.1% female/50.8%male)
On the contrary to the Lebanese population, there is no certain figure on the number of Syrian refugee
population in Lebanon. As a result, the assessment team does not consider suitable to estimate a total
number for older Syrian currently residing in Lebanon. However, if considering other similar previous
analysis either inside Syria or neighboring countries and the displacement trends of all family members
moving together; it seems likely that in terms of percentages it will be close to the 5.7% from the total
refugee population.
2. Population estimates in PHC catchment areas
A key element of the access to health services is the catchment areas of the facilities in order to be able
of prioritize intervention areas and actions. This variable is hard to estimate as the facilities usually do

15. not have a clear estimation of the population they serve. In addition, the population of Lebanon is
estimated and the number of refugees is uncertain.
To at least provide a rough estimate of the catchment population in the assessed regions, it was
considered the total Lebanese population estimated for each municipality (Qaza), added the number of
refugees and divided this number by the number of PHCs in the Qaza. In some cases (Baalbek, Bint Jbeil)
the estimations didn’t provide any result. The table below provides the details of the estimation:
Name of the PHC Qaza
Lebanese
population
Refugee
population
Number of
facilities
Catchment
areas
Al Ain Amel Association PHC Baalbek 231648 130366
Not
available
Not
available
Al Sader foundation Aita
Chaab centre
Bint Jbeil 82345 8359
Not
available
Not
available
Tyre Amel Association PHC Sour 221040 32400 30 8448
Al Sadr Foundation Siddiqine Sour 221040 32400 30 8448
Al Sadr Foundation Kfarhata Saida 224624 48408 52 5251
Al Bashura Beirut 390238 30354 48 8762
Al Harash medical centre Beirut 390238 30354 48 8762
Kamed el Loz Amel PHC
West
Bekaa
78916 68405 21 7015
Hay el sellom Amel PHC
Mount
Lebanon
483777 94499 34 17008
3. Household profile
As explained in the methodology section, the sample was not representative of the whole host
community and refugee population as the households interviewed were selected according to two
criteria:
- Including a member aged above 60
- Including a member suffering from an NCD and aged above 40
Consequently, the paragraphs and graphs below provide an overview of the 289 assessed households
only.
Gender and Age composition
In our sample, there are overall 52% of women and 48% of men. In all regions appear to have a slight
higher of female;

16. Regarding age, as the figure below shows the age composition of our sample the proportion of people
aged above 60 is a lot higher (18%) than what is found in the SADD population estimates. This
percentage is mostly explained due the sampling selection criteria; however it provides a good picture of
the composition of the assessed households. It highlights a notable percentage of mid-age (22% 40-60
years old) and older people (3rd
age group) at risk or already suffering from NCDs and facing access
difficulties to treatments due their socio-economic vulnerability.
Figure 2: Age composition of the sample, including family members
Source: HelpAge International needs assessment data
Figure 1: Gender balance of the sample (289 HHs)

17. SADD sample composition of the targeted population (40+ with Chronic Diseases and 60+ years old)
Figure 3: Age and gender disaggregation
Lebanese households Syrian households
In our sample of interest represents 40% of the total household members, the proportion of people
aged above 60 years old reaches 80% for the Lebanese and 55% for the Syrian. The population aged
between 40 and 59 represent 20% of the Lebanese and 45% of the Syrian.
Country of origin of the interviewees
The figure below presents the composition of the sample grouped by citizenship. The key findings for
this section are:
- Mixed Lebanese and Syrians households represent a small minority of the sample (1 to 4%)
- Whereas in Mount Lebanon the sample is balanced between Syrian and Lebanese, in the South,
there were less Syrian than Lebanese probably due to the lower of Syrian refugees in the South
if compared if other regions of the country.
Figure 4: Origin of the households
Refugee household profile

18. Majority of the interviewed refugees are from Rural Damascus (15.6%) or Aleppo (14.2%). More
precisely, 27% the refugees interviewed in Mount Lebanon and 16% in the South came from Aleppo. The
interviewees in West and North Bekaa came, for the majority, from Rural Damascus (30%). The
concentrations by area of origin can be partially justified with three non-exclusive explanations:
- Staggered phases of the refugees influxes over the time. The different influxes faced by Lebanon
during the Syrian crisis have been always related with the military offensives inside Syria;
- Pull factor within refugees from the same area of origin looking for re-establishing their social
networks;
- Political/religious affiliations between the Syrian refugees and the hosting communities in
Lebanon.
The figure below gives averages across Lebanon.
Registration status
Most of the sample was registered under UNHCR (94% registered against 6% unregistered). In the
South, all households interviewed were registered. In Mount Lebanon, 95% of the households were
registered. Registration rates dropped in the Bekaa Valley regions where only 91% of the households
were registered.
Figure 5: Area of origin of the Syrian refugees

19. 4. Analysis of the household vulnerability criteria
Picture by HelpAge International
As described in the methodology section, in order to foster a comprehensive analysis of the household
sampling; there were 6 pre-defined vulnerability criteria disaggregated by gender for the 40+ suffering
from a chronic disease and 60+ years old.
The following table provides an overview of the composition of the sample of the vulnerable groups
following these criteria by each of the areas assessed during the exercise in Lebanon. The percentages
highlighted in red, represents the highest percentage per category and area.
Table 1: proportion of household entering the vulnerability criteria by area
North and West
Bekaa
Mount
Lebanon
South
Lebanon
Head is older man 27% 53% 43%
Head is older woman 10% 22% 20%
Older woman alone 5% 4% 11%
Older man alone 0% 0% 0%
Person aged above 40 with NCD 95% 100% 99%
Disabled 48% 76% 52%
Older person living with 5 other household
members at least 18% 32% 9%
Older person not receiving assistance or not
registered to UNHCR 4% 27% 0%

21. Hereby there is a description of each of the vulnerability criteria categories:
Households headed by an older person:
North and West
Bekaa
Mount
Lebanon
South
Lebanon
Head is older man 27.4% 53.2% 42.7%
Head is older woman 10.4% 21.5% 20.0%
In some regions as Mount Lebanon, older man head of Household reaches over 50% of the assessed
sampling. It is easy to conclude on the particular challenges these households will face for ensuring a
sustainable income. Negative coping mechanisms practices are highly expected within this category.
One of them would be the interruption to their medical treatments due the costs.
Older person living alone:
North and West
Bekaa
Mount
Lebanon
South
Lebanon
Older woman alone 5% 4% 11%
Older man alone 0% 0% 0%
Interestingly, we identified no older man living alone in our sample. Older women living alone are not
very frequent but still represent 11% of the households interviewed in the South, 5% of the households
in North and West Bekaa and 4% in Mount Lebanon. Half of these women are Lebanese, 39% are Syrian
and 11% are from another country.
One of the reasons explaining the strong discrepancy between genders under this criterion lies in
cultural reasons. In both societies, older people are unlikely to be left alone. This could explain the
absence in our sample and the low frequency of older women living alone. The analysis group pointed
out that their current social status (widowed, single etc.) would justify their current situation. The higher
number of older women alone could be explained because older men can remarry younger women,
while older widows often do not remarry.
Despite the low frequency of these categories if compared with others, the level of vulnerability of these
women living alone is supposed to be high or very high. Lack of access to livelihoods or family support
will lead this group to high levels of vulnerability hampering their access to health in a context where
social services are very limited.

22. Person aged above 40 with NCD
North and West
Bekaa
Mount
Lebanon
South
Lebanon
Person aged above 40 with NCD 95% 100% 99%
The proportion of households including a member aged above 40 and suffering from a chronic disease is
very high. It is 100% in Mount Lebanon, 95% in North and West Bekaa and 99% in the South. This fact is
explained by two factors:
a) There is a very high rate of chronic diseases in the Lebanese and refugee population;
b) The methodology applied for the sampling was a purposive, therefore the enumerators were
selecting the household according to two criteria: HH that include members who are “over 60
years old” or “over 40 with chronic disease”. As a result, in our sample anyone interviewed who
is under 60 is suffering from an NCD.
However, among the older people, who were selected on their age and not on their health status, rates
remain high. In fact, it is 100% Mount Lebanon, 92% in North and West Bekaa and 98% in the South. In
terms of analysis, the prevalence of NCDs among the interviewed households can be considered as
evidence for the assessment purposes only; it cannot be extrapolated to the rest of the population as
total percentages.
In addition and as comparative analysis, the following figure highlights the rates of co-morbidity by
region.
Comparative analysis I: Prevalence of co-morbidity for chronic
diseases by region
The figure shows that among the people suffering from an NCD, 92% suffer from more than one in
Mount Lebanon. In North and West Bekaa, 60% of the people the chronically ill people have more than
one disease. In the South, this proportion is slightly lower but remains worryingly high: 50%.
Without surprise, the rate of co-morbidity is higher among older people (69%) than among the younger
cohort (63%). This can be due to the fact that chronic diseases are the result of a longer term life habits,
such that older people are more likely to develop them.

23. Disabled:
North and West
Bekaa
Mount
Lebanon
South
Lebanon
Disabled 48% 76% 52%
The proportion of households with an Older Person or 40+ years old with disability varies between 75%
and 48%. This is high compared with the 15% of Global Disability prevalence (World Disability Report,
WHO). As HelpAge and Handicap International report (2014)3
underlines: in that sample, the proportion
of people suffering from a physical or cognitive impairment is closer to 20% in Lebanon.
The definition of disability during the assessment was limited to “difficulties” to hear, see, speak, move
or learn without any further scoring. The rationale behind this approach was to follow WHO’s position
on ageing and disability for which is concluded that “the proportion of people with disabilities is higher
among older persons (60+), mainly due to decreasing mobility, and the prevalence of chronic health
conditions associated with disability (incl. diabetes, cardiovascular diseases, and mental illness)”4
.
Older people living in households with more than 5 members:
North and West
Bekaa
Mount
Lebanon
South
Lebanon
Older person living with 5 other household
members at least 18% 32% 9%
There are strong variations in the number of older people living in households with more than 5
members (32% in Mount Lebanon vs. 9% in the South). Importantly, 75% of the older people living with
more than 5 household members are Syrian in Mount Lebanon. Considering the scarce resources of
these households and the price of housing in urban areas, it is possible that different households
gathered under the same roof in Lebanon, resulting in more household members on average as coping
mechanism due the limited access to income. In terms of older people’s access to health, it is expected
these households residing in urban areas will prioritize other vulnerable groups (pregnant women,
children) or acute diseases. Therefore we can expect that this behavior is putting on risk regular access
to older people and their specific needs for long-term NCD treatments.
3
HelpAge International and Handicap International, Hidden Victims of the Syria crisis: disabled, injured and older
refugees, 2014
4
World Disability Report, WHO

24. Older person not receiving assistance:
North and West
Bekaa
Mount
Lebanon
South
Lebanon
Older person not receiving assistance or not
registered to UNHCR 4% 27% 0%
27% of the households interviewed in Mount Lebanon declared not receiving assistance. This figure is
high, both in absolute terms and relatively to the other regions. Within these households, 62% are
Lebanese, who may have a misperception of what is considered “assistance”. The figure may be
considered just as an indication of the level of assistance provided by the Ministry of Public Health
(MoPH) and Ministry of Social Affairs (MoSA). These Ministries are the key actors in terms of primary
health care provision for vulnerable Lebanese.
On the other hand, the 4% in Beeka Valley is probably connected to unregistered households or pitfalls
in the targeting selection criteria applied by the humanitarian actors in Lebanon due the lack of funding.
Comparative analysis II: Multiple vulnerability categories
Proportion of households entering in several vulnerability categories
The previous figure highlights the high proportion of households entering several vulnerability
categories. These rates are particularly high in Mount Lebanon with almost 8 out of 10 households
interviewed entering in 2 or more categories and 4 out of 10 entering 3 or more categories. In the other
regions, there is a high proportion of households fitting into 2 or more categories but he proportion of
households entering 3 or more categories are lower (under 10%).
The graph highlights the urgency of the situation, in particular in Mount Lebanon, in terms of access to
treatment and follow up for non-communicable diseases.

25. 5. Mental health status
Picture by HelpAge International
The household survey implemented did not aimed to be a professional Mental Health and Psychosocial
screening following the IASC MHPSS guidelines as our team of data collectors had no previous
experience in this field. The assessment aimed to at least draw some basic information about the
Mental Health status of the population interviewed.
Someone presents strong signs of psychosocial suffering if they answer “all of the time” to two or more
of these questions. Overall, the prevalence of psychosocial distress is high, with 37% of the population
presenting strong signs of it. The most common symptom is the restlessness, with almost a third of the
people interviewed declaring feeling restless all of the time. Sleeping problems and fear are the least
common symptoms, with 13% of the people reporting such problems all of the time over the past few
weeks.
Mont Lebanon
North and West
Bekaa
South Lebanon
People reporting serious signs of
psychological distress (2 out of 6 “All
the time” answers)
28% 38% 44.0%

26. The prevalence of psychological distress varies somewhat between regions. In Mount Lebanon, 28% of
the people report a sign of serious psychological distress. In North and West Bekaa, this prevalence is
higher, 38%, and in the South it reaches 44%.
Previous analysis performed by HelpAge International highlighted the correlation between psychological
distress and non-communicable disease. This correlation is also found here as people suffering from
NCDs are also 48% more likely to report strong signs of distress. This emphasizes the importance of
developing psychosocial activities targeted at people suffering from chronic diseases.

27. 6. Key findings on Access to health
Overall, 25% of the people suffering from an NCD do not take regular medication for it. Hypertension
and diabetes left untreated lead to severe, even deadly, complications. It is therefore important to
ensure access to regular medication for everyone. In this respect, Lebanese are twice as likely as Syrian
to take their medication. Also, the region of Beirut - Mount Lebanon is particularly vulnerable with half
of the cases of NCD reported left untreated. The following figure illustrates this fact.
Figure 1: Proportion of people suffering from NCD
not taking medication
Within the people declaring that they are not taking medication. The most common reason is the price
of the treatment. The following figure illustrates the reasons given and their frequency.
Figure 2: Proportion of people suffering from NCD not taking medication

28. Frequency of the visits to the health centre for NCDs:
Figure 3 : frequency of the visits to the health centre for NCD
The interpretation of the previous figure is not straightforward as the recommendations on the
frequency of the doctor’s visits vary according to the disease and to the phase of the treatment. We can
highlight three phases:
Diagnosis/screening: the doctor needs to see the patients very regularly to be able to monitor
the disease
Treatment definition: the doctors sees the patient regularly to monitor the effect of the
treatment and adjust the medication accordingly
Follow-up: the doctor needs to see the treatment occasionally (every 6 months) to be able to
see the longer term impact of the treatment and lifestyle changes made by the patient
As per YMCA and MOPH guidelines, the follow up visits should happen at least every 6 months in order
for the patients to access their medication. As a result, we consider here that people seeing their doctor
less than every 6 months are not followed up enough. In our sample, 1 out 5 people suffering from an
NCD is in this case. They are therefore at risk of following an inadequate treatment or of ignoring the
worsening of their condition. In both cases, there are live-threatening consequences such that action is
required.

29. 7. Health priorities-Programmatic recommendations based on household survey key
findings
The key findings detailed in the previous points of this section, bring as general conclusion the need of
an intervention on health to support the effective inclusion of the targeted population in the primary
health care system of Lebanon. As result of the analysis of findings, it is possible to define a list of key
interventions which will immediately improve the current situation. This report groups the
recommendations identified during the process into the Access and Accessibility criteria without any
particular ranking as all of them are considered suitable for immediate implementation.
Recommendations on Access:
Better access to Information:
Design and implementation of Information campaigns on cost and availability of care. These
campaigns have to be age-friendly and able to reach the population in the catchment areas.
Awareness campaigns and enhanced communication between GPs / MMUs and the population to
build up the trust in the health system.
Increase prevention and health education. Not only to the population at risk, but all the household
members for ensuring impact and sustainability.
Better access to healthcare:
Free medication and follow-up visits. First consultation still should include a fee to ensure patient’s
commitment to start the treatment.
Training of health workers on special needs of older people and guidelines on chronic disease,
especially in the cases of co-morbidity.
The link between patient and PHC needs to be reinforced: focal points at PHC level to manage the
follow up of patients are recommended.
Better physical access to health:
Making the centres age-friendly following WHO guidance to easier physical access.
Enhance home visits methods and outreach activities from the PHCs such that they reach the most
vulnerable.
Use the Medical Mobile Unit (MMU) as a tool for follow up visits to reduce transportation costs. In
particular, the use of MMU is recommended as they can be recycled at the end of the programmes
into units specialised for older people and people with specific needs.
Recommendations on Accessibility/Availability:
Increase the provision of devices for special needs like wheelchairs, glasses etc.

30. Work towards the accreditation of the centres by the MOPH or the YMCA to secure sustainable
access to NCD medication.

31. 8. Key findings on PHC analysis
Picture by HelpAge International
Legend:
In the Summary tables the lowest value is highlighted in red font over pink background; the highest
value is highlighted in green over light green background.
The problem ranking tables are based on the Severity Scale criteria used during the assessment
annexed to this report.

32. Access to Primary Health Care facilities:
Access-Summary table
Accessible information on services provided, prices, opening hours etc.
The average score on information display within the assessed facilities is 58%, meaning that more than
40% is not offered. However, this average figure hides large variation between facilities. The scores go
from 20% of the required information available in Al Ain (N. Bekaa) to 100% in Al Bashura and Al Harash
(Beirut-Mount Lebanon) medical centres. There is margin for improvement in the display of
information in most centres.
Physical access, outreach and referral to secondary and tertiary care
The measure of physical access is based on the WHO guidelines on age-friendliness. Here again, the
average score of 58% hides large variations between centres. Hay el Sellom (Beirut-Mount Lebanon) and
Al Ain only complied with a third of the guidelines while Al Harash respected 90% of the WHO advice.
Physical access for older people can be improved in most centres.
Opening hours are not standardized; most centres are open 36 hours for 6 working days per week or
less. None of them has established age-friendly hours to avoid long waits during the peak hours.
Name of the centre Region
Information and
awareness
material
displayed
Compliance
with age-
friendly
guidelines
Mobile
unit
Distance to
secondary or
tertiary care
in km
Total
opening
hours
per
week
Al Ain Amel
Association PHC
North Bekaa 20% 30% Yes 0 33
Al Sader foundation South Lebanon 40% 80% No 14 36
Tyre Amel Association
PHC
South Lebanon
40% 80% Yes 3 36
Al Sadr
Foundation/Siddiqine
South Lebanon
60% 60% No 3 36
Al Sadr
Foundation/Kfarhata
South Lebanon
40% 50% No 20 36
Al Bashura
Mount
Lebanon
100% 60% Yes 3 51
Al Harash medical
centre
Mount
Lebanon
100% 90% Yes 1 51
Kamed el Loz PHC West Bekaa 60% 40% Yes 0.5 48
Hay el sellom
Mount
Lebanon
60% 30% No 5 36

33. Only five of the centres have a mobile unit available while these are key instruments to increase the
access to services for remote villages.
On average, the closest secondary health care centre is 5.5 km away. However, this Al Sadr foundation
centre in Kfarhata (South Lebanon) is 20 km away from the closest secondary or tertiary care provider
and does not have a mobile unit. A referral system is sometimes in place but the good monitoring of
patients is at risk in these centres. This level of monitoring is connected the Quality analysis of
information/case management of this same section.
Key findings on access to Primary Health Care facilities:
Major
problem
On average, centres comply with only 58% of the recommendations on information provision
and physical access to the centre.
Only 55% of the centre have a mobile unit
Centres are open 40 hours per week on average
No centre is further than 20 km away from the closest secondary or tertiary care provider
Consequences:
Non-communicable diseases are not being normally managed and access to medication is frequently
interrupted because clinics aren’t open for long enough or are far away. Complications requiring
secondary treatment are estimated to be frequent. Data on health is outdated or inaccurate. The
population cannot cope with the current situation without external aid.
Programmatic recommendations:
In the long run, training community health workers to ensure outreach activities is a solution to the
access problem. In the short run, increasing the use of the mobile clinics is recommended
In accordance with age friendly policies, organise age-friendly hours to avoid long wait for older people
Improve information display in the centre about the prices, the services available and prevention of
diabetes and hypertension
Refurbish the centres to increase the physical access

34. Availability of Primary Health Care facilities:
Availability-Summary table
Availability of services and medication
Five centres out of the nine assessed provide 50% or less than half of the services related to NCD
diagnosis, treatment and management as per YMCA and MOPH standards as well as important support
services, like a laboratory. In this index, we took into account the presence of 9 essential staff: 1 General
Practitioner, 1 trained nurse, 1 pharmacist, 1 cardiologist, 1 dentist, 1 endocrinologist, 1
ophthalmologist, 1 health educator and 1 laboratory technician.
All centres normally provide more than half of the types of NCD medication recommended by the
MoPH. However, two thirds of the centres declared that they ran out of medication more than half of
the time. The figure below illustrates the frequency of drug shortages:
Frequency of the shortages in the PHCs
Name of the centre Region
NCD
services
available in
house
NCD medication
normally
provided by the
facility
drug shortage
Al Ain Amel Association PHC North Bekaa 40% 57% Once every few months
Al Sader foundation South Lebanon 50% 86% 75% of the time or more
Tyre Amel Association PHC South Lebanon 50% 57% 75% of the time or more
Al Sadr Foundation/Siddiqine South Lebanon 90% 100% Once every few months
Al Sadr Foundation/Kfarhata South Lebanon 60% 57% 75% of the time or more
Al Bashura
Mount
Lebanon
80% 100% 50% of the time
Al Harash medical centre
Mount
Lebanon
80% 100% 50% of the time
Kamed el Loz PHC West Bekaa 40% 71% 75% of the time or more
Hay el sellom
Mount
Lebanon
30% 86% Only happened once

35. Key findings on availability of Primary Health Care facilities:
Moderate to
major
problem
On average, 58% of the services necessary to manage chronic disease and their
complications are available.
79% of the recommended medication to manage NCD are normally offered by the centres
However, 6 out of the 9 centres experience shortages most of the time
Consequences:
Non-communicable diseases are not being normally managed and access to medication is frequently
interrupted. Complications requiring secondary treatment are estimated to be frequent. Data on health is
outdated or inaccurate. The population cannot cope with the current situation without external aid.
Programmatic recommendations:
Building up contingency stocks of the centres in order to be able to fill in the gaps in the medication
provision.
Work towards the accreditation of the centres by YMCA to ensure sustainability of the medication
provision.

36. Quality of Primary Health Care facilities:
Quality-Summary table
Quality of the provision of primary health services
There was no significant variation in the level of medical equipment of the facilities. All facilities
complied with the standards. Broad variations appeared in the non-medical equipment with facilities
lacking essential infrastructure like toilets. In Al Bashura centre, half of the non-medical equipment was
missing.
This gap in terms of equipment may hamper the management of information on patients and drugs.
Indeed, three centres (Al Ain, Tyre and Kfarhata) had significant gaps in their information management
system. Systems are not standardized and not fully computerized. There is scope to improve the
equipment in order to have better management of the information and as a result, better
management of chronic diseases and the referral to secondary and tertiary care.
Drug storage conditions were mostly complying with the WHO guidelines. However, in some cases the
storage space was small such that it did not allow for increasing the stock of medication, keeping the
storage up to the standard. As the stock of medication is not sufficient to deal with the demand, more
storage equipment will be required to increase the stocks in good conditions.
Name of the centre Region
Score on patient
and drug
information
management
Score on
drug
storage
Quality of
premises (non-
medical
equipment)
Quality of
the medical
equipment
Al Ain Amel Association
PHC
North Bekaa 50% 83% 57% 100%
Al Sader foundation South Lebanon 100% 83% 86% 100%
Tyre Amel Association PHC South Lebanon 50% 100% 93% 85%
Al Sadr Foundation/
Siddiqine
South Lebanon 100% 100% 93% 100%
Al Sadr Foundation/
Kfarhata
South Lebanon 50% 100% 86% 100%
Al Bashura Mount Lebanon 100% 83% 50% 100%
Al Harash medical centre Mount Lebanon 100% 100% 100% 100%
Kamed el Loz PHC West Bekaa 100% 100% 57% 100%
Hay el sellom Mount Lebanon 100% 100% 79% 92%

37. Key findings on quality of Primary Health Care facilities:
Moderate
problem
On average, 83% of the information management tools are in place at least partially.
84% of the drug storage recommendations by WHO are respected
On average centres have 78% of the non-medical equipment available although in some
cases essential non-medical is missing.
Consequences:
Non-communicable diseases are not being normally managed and access to medication is frequently
interrupted. Complications requiring secondary treatment are estimated to be frequent. Data on health is
partially updated or accurate. The population can cope with the current situation without external aid.
Moderate actions are highly recommended in order to enhance quality of services
Programmatic recommendations:
Information management tools are not standardised, and not computerised. Reaching some level of
computerisation and standardisation would improve the management of the facility
Centres normally have a good level of non-medical equipment, including access to a phone, internet, a
computer etc. However, in some cases, some basic equipment is missing (for example, toilets). In this
instance, action is required.

38. List of annexes
1. Needs assessment dashboard
2. Health severity scale
3. Health facility and household criteria
4. Sex and Age Disaggregated Data estimates
4.b Supporting document: Needs Response and Gaps group (NRG) SADD estimation
5. Needs assessment covered areas
6. Household survey questionnaire (English)
7. Household survey questionnaire (Arabic)
8. Health facility questionnaire