RESUMO
The humanitarian sector has often been criticised for its hierarchical power dynamics. Such dynamics often centre the priorities of 'international' actors, thereby marginalising the knowledge and expertise of those closest to the setting and play out in various fora, including coordination mechanisms. While guidance emphasises the importance of supporting local systems and government structures rather than creating parallel humanitarian structures, this approach is not consistently applied, creating challenges. We used a case study approach to explore how power relations influence the practice of the Mental Health and Psychosocial Support Taskforce in Lebanon, a nationally-led coordination mechanism chaired by the Ministry of Public Health with UN agencies as co-chairs. We conducted 34 semi-structured interviews with Taskforce members and other stakeholders coordinating with the Taskforce, including local non-governmental organisations (NGOs), international NGOs, United Nations agencies and government ministries. Interview transcripts were collaboratively analysed using Dedoose. We conducted feedback workshops with participants and integrated their feedback into analysis. We found that UN agencies and international NGOs are perceived as holding more decision-making power due to their access to funding and credibility-both shaped by the humanitarian system. Our findings also suggest that power dynamics arising mainly from differences in seniority, relations between 'local' and 'expat' staff, and language used in meetings may affect, to varying degrees, decision-making power and members' voices. We also show how the agenda/focus of meetings, meeting format, language, and existing relationships with Taskforce leaders can influence levels of participation and decision-making in Taskforce meetings, ranging from lack of participation through being informed or consulted about decisions to decisions made in partnership. Our findings have broader implications for coordinating service delivery within the humanitarian sector, emphasising the need to reflect upon power imbalances critically and continually and to ensure a shared understanding of decision-making processes.
RESUMO
Forcibly displaced populations experience an increased burden of mental illness. Scaling up mental health (MH) services places new resource demands on health systems in crises-affected settings and raises questions about how to provide equitable MH services for refugee and host populations. Our study investigates barriers, facilitators, and proposed solutions to MH financing and access for Lebanese populations and Syrian refugees in Lebanon, a protracted crisis setting. We collected qualitative data via 73 interviews and 3 focus group discussions. Participants were purposively selected from: (i) national, United Nations and NGO stakeholders; (ii) frontline MH service providers; (iii) insurance company representatives; (iv) Lebanese and Syrian adults and parents of children aged 12-17 years using MH services. Data were analysed using inductive and deductive approaches. Our results highlight challenges facing Lebanon's system of financing MH care in the face of ongoing multiple crises, including inequitable coverage, dependence on external humanitarian funds, and risks associated with short-term funding and their impact on sustainability of services. The built environment presents additional challenges to individuals trying to navigate, access and use existing MH services, and the social environment and service provider factors enable or hinder individuals accessing MH care. Registered Syrian refugees have better financial coverage to secondary MH care than Lebanese populations. However, given the economic crisis, both populations are facing similar challenges in paying for and accessing MH care at primary health care (PHC) level. Multiple crises in Lebanon have exacerbated challenges in financing MH care, dependence on external humanitarian funds, and risks and sustainability issues associated with short-term funding. Urgent reforms are needed to Lebanon's health financing system, working with government and external donors to equitably and efficiently finance and scale up MH care with a focus on PHC, and to reduce inequities in MH service coverage between Lebanese and Syrian refugee populations.
RESUMO
BACKGROUND: The use of feedback to address gaps and reinforce skills is a key component of successful competency-based mental health and psychosocial support intervention training approaches. Competency-based feedback during training and supervision for personnel delivering psychological interventions is vital for safe and effective care. AIMS: For non-specialists trained in low-resource settings, there is a lack of standardised feedback systems. This study explores perspectives on competency-based feedback, using structured role-plays that are featured on the Ensuring Quality in Psychosocial and Mental Health Care (EQUIP) platform developed by the World Health Organization and United Nations Children's Fund. METHOD: Qualitative data were collected from supervisors, trainers and trainees from multiple EQUIP training sites (Ethiopia, Kenya, Lebanon, Peru and Uganda), from 18 key informant interviews and five focus group discussions (N = 41 participants). Qualitative analysis was conducted in Dedoose, using a codebook with deductively and inductively developed themes. RESULTS: Four main themes demonstrated how a competency-based structure enhanced the feedback process: (a) competency-based feedback was personalised and goal-specific, (b) competency-based feedback supported a feedback loop, (c) competency-based feedback supported a comfortable and objective feedback environment, and (d) competency-based feedback created greater opportunities for flexibility in training and supervision. CONCLUSIONS: A better understanding of the role of feedback supports the implementation of competency-based training that is systematic and effective for trainers and supervisors, which ultimately benefits the learning process for trainees.
RESUMO
Health system governance has been recognized as critical to strengthening healthcare responses in settings with conflict-affected populations. The aim of this review was to examine existing evidence on health system governance in settings with conflict-affected populations globally. The specific objectives were (1) to describe the characteristics of the eligible studies; (2) to describe the principles of health system governance; (3) to examine evidence on barriers and facilitators for stronger health system governance; and (4) to analyse the quality of available evidence. A systematic review methodology was used following Preferred Reporting Items for Systematic Review and Meta-Analysis criteria. We searched six academic databases and used grey literature sources. We included papers reporting empirical findings on health system governance among populations affected by armed conflict, including refugees, asylum seekers, internally displaced populations, conflict-affected non-displaced populations and post-conflict populations. Data were analysed according to the study objectives and informed primarily by a governance framework from the literature. Quality appraisal was conducted using an adapted version of the Mixed Methods Appraisal Tool. Of the 6511 papers identified through database searches, 34 studies met eligibility criteria. Few studies provided a theoretical framework or definition for governance. The most frequently identifiable governance principles related to participation and coordination, followed by equity and inclusiveness and intelligence and information. The least frequently identifiable governance principles related to rule of law, ethics and responsiveness. Across studies, the most common facilitators of governance were collaboration between stakeholders, bottom-up and community-based governance structures, inclusive policies and longer-term vision. The most common barriers related to poor coordination, mistrust, lack of a harmonized health response, lack of clarity on stakeholder responsibilities, financial support and donor influence. This review highlights the need for more theoretically informed empirical research on health system governance in settings with conflict-affected populations that draws on existing frameworks for governance.