Building a primary healthcare centre in challenging times

Your work supports the establishment of an accredited Primary Healthcare Centre (PHC) in Al Mohammara to improve medical care for residents as well as Syrian and Palestinian refugees. How long have you been working there and what is your exact task?

Ramia Assaad: I have been working in Mohammara since the beginning of July 2022. I applied to the job through a well-known job advertisement platform in my country.

After being selected for the job position as a health expert, I was introduced to the different programs and in the first few months I received a general orientation on the working strategy and on the principles of relationship between the different bodies BMZ, GIZ, SKEW and EG and the scope of their intervention.

In September, I received an invitation to Germany to attend the annual experts meeting and to meet our German partner team as well in Opfenbach municipality. This visit gave me a good push and constitute a big support for my mission, as it contributed to consolidating the relationship and facilitating the communication process.

According to the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA), Mohammara is identified one of the most vulnerable villages in Lebanon and lacks local development to provide basic services to citizens. The country's economic, political and health crisis has placed an additional burden on the resources and infrastructure of the small municipality of 2,300 residents that hosts an additional 4,500 Lebanese from neighboring villages, 10,000 Syrian refugees and 35,000 Palestinian refugees.

Please describe the social and economic situation during which the project is being built.

Ramia Assaad: Lebanon as a whole is in a crisis. It is a political crisis. It is also an economic crisis. It is a health crisis. There are many factors that have contributed to reaching this stage.

One of these factors is the impact of the refugees coming to Lebanon, for whom we are not prepared in terms of infrastructure. There is not enough sewerage, electricity and fuel.

The government has been supporting the Lebanese and the Syrians. The government's support for fuel, electricity, food, medicine, bread, etc. has put a huge strain on the Lebanese government's cash reserves. And after more than ten years of hosting refugees, the economy collapsed. Inflation set in and salaries dropped. For example, average wages for most people were around US$1,000 per month. Now it is less than 100 US dollars. This puts a strain on the Lebanese system as a whole and in Mohammara in particular, because Mohammara is a very small community with only 2300 inhabitants. Therefore, the amount it receives from the government to take care of these people is very small. However, it is home to more than 50,000 citizens.

How did the initiative to build a primary healthcare centre come about?

Ramia Assaad: There is a need for a health center because people cannot afford the fees of private doctors and the prices of medicines in the pharmacies. The high prices for transport are another hurdle.

The health sector has been identified as a priority based on the results of a health needs assessment conducted by a local healthcare consulting firm. The study shows that women, children, and the elderly have limited access to primary health care services, especially immunization, counseling, medication, and diagnostic tests. The need to establish a health center was also highlighted through similar studies and focus group discussions conducted by UNICEF, UNDP and others.

To respond to this need, the municipality of Mohammara has established the building of a health center consisting of two floors. Then, the economic crisis began, and the local currency exchange rate collapsed, so the municipality was no longer able to complete the final constructions touches of the first floor neither to equip it.

As a result of the discussions, consultations and workshops that had been conducted between the municipality of Opfenbach and the municipality of Mohammara, it was agreed to support the municipality of Mohammara to establish, equip and operate the health center, and I was appointed to provide technical support to the municipality within this framework and to coordinate between the various parties.

With the help of the joint fund of KfW and the Norwegian Refugee Council, it was possible to continue the construction of the building. My main task at this stage was to ensure that the construction and rehabilitation works are carried out according to the requirements of the Lebanese Ministry of Health. The infrastructure, maps, administrative departments, diagnostic departments and service delivery units to comply with the accreditation standards.

Can you give me an idea of the size of the centre?

Ramia Assaad: It is considered a great centre. I think it will be one of the biggest and most ideal centres in the governorate because all the expertise and many resources have been put into it. The building is two-storey and each floor is about 500 square metres and has 15 rooms. We have a laboratory, radiology, physiotherapy, paediatric consultation, a room for pregnant women, an immunisation room, an emergency room, a mental health room. And we are trying to make it child-friendly. And for mothers, it will be baby-friendly. We will have a special room where mothers can breastfeed their babies. We have also put in a lift so that people with disabilities can reach the two floors. There are about seven counselling rooms. It is also equipped with an emergency exit, a fire alarm system and a solar energy system. To ensure that the center limits the spread of infectious diseases, it has been designed with an external entrance, an isolation unit, a sterilization unit, and a space for medical waste collection.

What are the next steps?

Beside the construction work, we have been working on strengthening the Community Health Committee and networking with local committees, INGOs, local authorities and the government to get everyone involved in the project.

In parallel we have been working with our German partner in Opfenbach to apply for a fund through NAKOPA to equip the medical center. Lately we have received a verbal confirmation that the project is approved. Now we are preparing for the implementation phase of the project. Feasibility study, business plan, health needs assessment, budgeting, were already prepared.

Our Tasks during the next stage are mainly:

• To review and release the tenders.
• To purchase and install the equipment and furnishings.
• To start the recruitment process of the health center staff
• To provide training and orientation to the newly recruited staff
• To update the financial plan
• To install a medical and financial software
• To inform the community about the health center and the services provided.
• To prepare for the opening ceremony.

Opening will be in 2024, May, June, but we are not sure yet. It's based on the purchasing process, because some equipment needs to be shipped outside from Lebanon, for example, the x rays. We may start earlier with a smaller opening to offer simpler care services, for example, vaccinations, follow-up for pregnancy or screening for malnutrition and dispensing of medicines.

The health centre is supported within the framework of the project partnership between Opfenbach - Al Mohammara. What role does this partnership play in your work?

Ramia Assaad: The partnership between the two municipalities has been the cornerstone of the achieved success. Without the patience and support of our German partner in Opfenbach, the project would not have reached this stage.

I was appointed to work on the Medical Health Center project since July 2022, but the partnership relationship between Mohammara and Opfenbach was established before that in 2018 and has been closely maintained. The municipalities have implemented several joint projects and activities together such as setup of a neighborhood help and distribution aid packages to people affected by Covid19.

The Opfenbach municipality team and Mr. Christian Renn "Project Manager" were leading and coordinating with NAKOPA, EG, GIZ, SKEW, NRC. They were handling the application and all relevant studies and evaluations. They were communicating with the donor, responding to their feedback and comments, and making modifications to the application accordingly. They gave unlimited support and were so patient with all the paperwork and calculations that they would repeat over and over. Every time there were adjustments. The process was very complicated and time consuming but they didn't give up, they were very committed to helping vulnerable people in Mohammara. Their hard work was highly appreciated by the Mohammara Municipality residents.

Personally, I learned a lot from them during this journey. The sense of humanity, commitment and professionalism was impressive. They supported me during my work, encouraged me and listened to my concerns. My visit to Opfenbach gave me empowerment, everyone was showing sympathy and were very generous in their hospitality. Even though I come from different background, different religion, and different clothes, they treated me with respect and dignity.

During my stay in Opfenbach we visited many administrative, educational, health and other institutions. I gained a lot of knowledge and made sure to pass on the good impression I had to my country. It was good to know that things can work and that a well-designed and organized system can improve the well-being of individuals.

Together with our partner, we hope to reach a good end in our project and have new chapters in our partnership. This partnership is more than a programme, it is not only about communities in solidarity, but about connected people."

What are the biggest challenges at the moment and what have been the best successes or experiences in your work so far?

Ramia Assaad: One of the biggest challenges we faced was convincing the donor and proving the sustainability of the project. Since the project will be funded by German taxation, the donor has been very picky to ensure that this project is sustainable and will yield the best results. The economic crisis and the instability of the currency exchange rate, inflation forced us to fill the application several times because the prices were constantly changing which put an additional burden on the team and specifically the project manager Mr. Christian Renn.

The partnership itself is a great success. On a personal level, the trainings I attended, online and in-person workshops, visits to Germany, excursion - all contributed to building my capabilities and knowledge. Communicating with the GIZ, EG, SKEW and Opfenbach teams was an added value for me, I learned a lot from them.

The personal relationship that binds me to the people of Mohammara, the municipality team and the mayor was a great honor and pleasure.

The construction and rehabilitation work of the health center has been crowned with success. The approval to equip and operate the center is a big success. The biggest success we hope to celebrate with our partners is improving people's health and well-being by providing accessible, affordable and high-quality health services after the opening of the health center.

Do you think that this project is transferable to other cities in Lebanon, and if so, under what conditions?

We hope that we can transfer our experience to other cities. Al-Bawarej, a municipality in Lebanon within the program, is planning a smaller version of this project.

Although Lebanon is a very small country of 10,452 square kilometers with natural resources, strategic location, beautiful coastline, mountains and weather, its people have always been suffering. It was subjected to external attacks and civil war, and recently witnessed an influx of refugees that exceeded 1/3 of its population. All these factors added by COVID19 put additional pressure on the infrastructure and led to a multidimensional crisis including the health crisis. People can no longer access basic health services and medicines.

Strengthening the primary health care system to provide basic health services will contribute to reducing mortality and morbidity and preserving the right of children, women, youth, the elderly and adults to good health.

An interview by Burkhard Vielhaber