Non-communicable diseases (NCDs) including cardiovascular diseases, diabetes, chronic respiratory diseases and cancer are the leading causes of mortality worldwide (1). In Lebanon, NCDs contribute to 91% of all deaths and cardiovascular diseases alone account for almost half of NCDs mortality (2). The majority of premature deaths due to NCDs occur in low and middle-income countries (LMICs) (3). LMICs disproportionately suffer from NCDs, especially that those countries are hosting the greatest proportion of conflicts in the world (4). Patients in conflict and post-conflict settings are often more vulnerable to NCDs due to the increase in negative coping mechanisms, which often constitute NCDs risk factors, such as smoking and alcohol consumption. The growing burden of NCDs in LMICs aggravates existing health threats and worsens poverty and presents substantive challenges to the equitable delivery of affordable care (4, 5).

Fragility is commonly defined as “the combination of exposure to risk and insufficient coping capacity of the state, system and/or communities to manage, absorb or mitigate those risks” (2). Hence, fragility exposes populations to a range of threats including poverty, insecurity, as well as social and economic inequality (6). There is a huge gap in access to health services in countries experiencing fragility (7). Around 1.3 billion people globally have no access to effective and affordable health care, and among the latter, about 170 million spend more than 40% of their income on health expenditure (8).

The management of chronic diseases represents a major challenge for healthcare systems globally, given that they often require a long period of supervision and observation or care (9). Inadequate management of chronic diseases represents an important factor in the development of adverse outcomes, including hospitalizations (10). Factors that contribute to the poor management of chronic diseases include low educational and income levels among patients, strained patient-provider relationships, limited or non-existent health insurance or health coverage. Patients suffering from chronic diseases face increased healthcare utilization costs, decreased self-reported health status, and reduced functional capacity (11).

There is a dearth of data on care quality in LMICs, particularly in areas such as system competence, confidence in the system, and user experience and wellbeing, including patient-reported health outcomes (12). Health systems often produce inadequate insight on what matters most to people, such as competent care, user experience, health outcomes, and confidence in the system (12). Furthermore, few studies have investigated the associations between self-reported patient satisfaction scores and health outcomes (e.g., physical health, hospital utilization, and expenditures) while accounting for baseline patient-level characteristics (e.g., gender, education level, SES) (13).

The current study received ethical approval from the Institutional Review Board (IRB) for Social and Behavioral studies at the American University of Beirut—Protocol number SBS-2018-0514. It also received ethical approval from the IRB committee at the Queen Margaret University (Protocol number REP 0201).

This is the first of its kind study in Lebanon examining the quality of the clinical management of diabetic and hypertensive patients at PHCCs in the fragile context of Lebanon. The study found that a significantly higher clinical management index score was associated with patients: living in the semi-urban/rural areas (setting 2/Beqaa), with health coverage, aged above 60, having primary and secondary educational levels, and making partial or full payment for their treatment. In contrast, significantly poorer quality of clinical management index scores were associated with Syrian nationality (compared to Lebanese) and with patients suffering from diabetes or hypertension (compared to comorbid patients).

Clinical management index scores ranged from 5.15/10 ± 1.94 for hypertensive patients to 6.62/10 ± 1.7 for comorbid patients, with the average among all patients being 5.7/10. This flags a general lack of compliance with the international and national guidelines for diabetes and hypertension care and highlights a clear opportunity for improving the quality of care delivered to diabetic and hypertensive patients. This finding is particularly disconcerting in that it suggests a suboptimal control of diabetes and hypertension which increases substantively the risks of costly complications within the target population. This not only has consequences for patients and the course of their disease, but also threatens the capacities of a health system with already very scarce resources. The most critical areas of non-compliance indicated by the clinical management index were the referral to an ophthalmologist (only 16.9% of all patients referred), receiving most to all prescribed medications (only 15.7% patients reporting), and receiving smoking cessation advice (advised to only 44.2% of patients). It is also of concern that only three out of each five patients attended two GP visits per year as per the clinical management guidelines. These findings call for a deeper analysis of the root causes for non-compliance with the established guidelines and whether they relate to patients, care providers or the delivery system at large.

Our findings also flagged the sociodemographic characteristics of those in the target population receiving significantly poorer clinical management of their conditions. Those characteristics include being a Syrian refugee, a patient under 60 years of age, those who live in the urban setting of Beirut, those who have no formal schooling and those who benefit from free care.

Patients aged above 60 reported receiving better clinical management of their conditions compared to those belonging to younger age groups. One explanation for this could be that patients older than 60 become relieved from the financial burdens of healthcare access because they either move in with, or otherwise depend on, their children with higher current income or become eligible for health coverage (35). In Lebanon, a law was approved to extend the provision of health care to the entire population above the age of 64 through the National Social Security Fund (NSSF). This covers 90 per cent of hospitalization costs and 80 per cent of medical consultations and medication excluding dental care, while for Syrian refugees, the United Nations High Commissioner for Refugees (UNHCR) covers 85% of primary healthcare costs (36, 37).

Our results also illustrated the discrepancies on health outcomes by nationality. The health systems of countries receiving refugees are placed under tremendous pressure. Such systems often struggle to meet the urgent and acute health needs of the refugees, and as a result often neglect the care for patients with NCDs (38, 39). Refugees are specifically vulnerable to NCDs owing to several factors (38). The stress which results from fleeing one's home renders refugees susceptible to many chronic diseases such as hypertension, diabetes and many types of cancer (40, 41). In addition, refugees go through lifestyle changes which influence their dietary intake and activity levels and may as a result increase the risk of NCDs (38, 42). Earlier studies reported underutilization of NCDs services among Syrian refugees compared to Lebanese community members and showed that host community members had better access to care and fewer reports of medication interruption compared to refugees (43, 44). Study findings suggest that providing Syrian refugees with access to free or highly subsidized NCDs services is a necessary but not sufficient condition for them to be able to attain proper disease control. Many other determinants of health (e.g., income, education, employment, etc.) will negatively influence their health outcomes compared to their host communities.

Our results are also in accordance with other studies in demonstrating ties between socioeconomic status and health outcomes (35). People who belong to lower economic classes and who have less education are more likely to suffer from diseases, experience loss of functioning and experience higher mortality rates (35, 45). Education is a key determinant of health given that it influences both access to a range of resources such as income, safe neighborhoods, or healthier lifestyles (46). It also influences the attitudes and behaviors that lead to better health (35). People belonging to different socioeconomic groups lead different lifestyles in many aspects of life (e.g., childhood, educational experiences, work careers, marriage and family experiences, and health care) (47, 48).

Patients with health coverage received significantly better clinical management of their conditions compared to those with no health coverage. Given that health insurance is mostly provided by employers, people who lack health coverage are typically unemployed or have lower incomes (48, 49). Such socially disadvantaged patients have multiple risk factors (50). It is important to note that despite the presence of health coverage, patients would still be expected to make full or partial payment for some aspects of their care (e.g., drugs, lab tests). For example, patients covered by the NSSF still need to cover 20% of the cost of drugs and ambulatory care services. Our results demonstrated that patients that make partial or full payment for their medical expenses receive better quality of clinical care compared to patients who receive free healthcare. Patients benefiting from free care are usually the poorest and the most disadvantaged and, in the settings considered here, were primarily Syrian refugees and their families. In Lebanon, Syrian refugees benefit from free care through the 25 mobile medical units established by the Lebanese Ministry of Public Health in collaboration with UNHCR, NGOs and humanitarian agencies, which provide free consultations and medication to Syrian refugees. If access to a primary healthcare facility is unavailable, UNHCR covers 85% of primary healthcare (37). Disadvantaged Lebanese citizens with no health insurance resort to public hospitals or contracted private hospitals, where the Ministry of Public Health covers 95% and 85% of hospital care costs and 100% of medication costs for chronic and high-risk diseases (18, 51). While the provision of free healthcare is welcome and would improve accessibility to health service to NCDs patients, our findings suggest that a poorer quality of clinical management is reported by NCDs patients who are receiving free services. The results call on agencies providing free services to systematically monitor and evaluate the quality of such services since the subsidization of cost is a necessary but not sufficient condition for the equitable access to quality services by the vulnerable NCDs patients.

While each of the above-mentioned categories require targeted programming and attention, we argue that highest priority needs to be given to individuals with compounded vulnerability. For example, while being a Syrian refugee appears to negatively and significantly affect the quality of chronic care received, being an illiterate refugee seeking free care in Beirut will entail multiple layers of vulnerability and will require additional attention to ensure proper and equitable care for all patients. The findings thus call on donor agencies, NGOs and provider institutions to design targeted programs and activities that will ensure equitable delivery of services to diabetic and hypertensive patients with particular attention to patients with compounded vulnerability. While the context of Lebanon may be unique in some aspects, many of the recommendations in this paper would likely apply to other countries hosting a large number of refugees. The authors argue that the significant elements of vulnerability for NCD patients, including refugee status, literacy rate, and having health coverage, would apply to other contexts and recommend the carrying of studies similar to this one to validate the elements of vulnerability specific to each context.

The study has a number of shortcomings that are important to report. First, the QoC index, despite being grounded on the guidelines of multiple agencies (WHO, World Bank), best practice guidelines and the guidelines of the Ministry of Public Health, was never validated before and may need to be modified based on expert validation in the future. Despite strong assurances to the participating patients that their responses would not affect the care and/or aid they are receiving, it cannot be ascertained whether the study is free of bias toward poorer care and outcomes in anticipation of higher subsidies and continued support. The research team was not able to recruit equally from the two fragility contexts. The presence of a large number of refugees in fragility setting 2 have resulted in a larger number of responses from that setting. The fact that the study was planned and ethically approved prior to the COVID-19 pandemic, while data collection took place at the peak of the pandemic in Lebanon, did not allow the research team to systematically capture the effect of the pandemic on the quality of provided NCDs services to the target population. The pandemic also introduced a bias since people were reluctant to visit primary healthcare centers out of fear of contracting the virus. This may have caused a delay in seeking care and generally resulted in poor compliance to NCD protocols.

The study identified a wide margin for improving quality of NCDs care in fragile contexts with particular gaps identified in referral to ophthalmology, accessing all prescribed medication and receiving counseling for smoking cessation. Additionally, findings indicate a number of predictors of comparatively poor quality of care that warrant attention, notably with regard to Syrian nationality/legal status, lack of health coverage, seeking free health provision and lower educational attachment. Although these are all relevant risk factors, the findings call on donor agencies, NGOs and provider institutions to design targeted programs and activities that especially ensure equitable delivery of services to diabetic and hypertensive patients with compounded vulnerability as a result of a number of these factors.

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/supplementary material.

The study protocol was reviewed and approved by the Ethics Research Panel of Queen Margaret University, Edinburgh (Protocol number QMU: REP 0201) and the Ethics Review Committee of the American University Beirut (protocol number AUB: SBS-2018-0514). The patients/participants provided their written informed consent to participate in this study.

SS has made substantial contributions to the analysis, interpretation of the data, write up, and revising the manuscript. DM has made substantial contributions to the acquisition, analysis, interpretation of the data, drafting the original manuscript, and revising it. RH and AA have made substantial contributions to the interpretation of the data and the revision of the manuscript. HD has made substantial contributions to the analysis, interpretation of the data, and revising the manuscript. KD has made substantial contributions to the conception and design of the work, analysis, interpretation of the data, and revising the manuscript. SA has made substantial contributions to the analysis, interpretation of the data, and the revision of the manuscript. MA has made substantial contributions to the conception and design, supervision of the work, write up, and revision of the manuscript. All authors have read and approved the submitted version of the manuscript.

This research was funded by the National Institute for Health Research (NIHR) Global Health Research program 16/136/100.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health and Social Care.