Protecting Non-communicable Diseases Patients during Pandemics:

Fundamental Rules for Engagement and the Case of Lebanon

Luna El Bizri

and Nabil Georges Badr

Higher Institute of Public Health, Saint Joseph University, Beirut, Lebanon

Keywords: Non-Communicable Diseases, Patient Journey, Digital Health, Universal Health Coverage, COVID-19,

Lebanon, Sendai Framework, Disasters.

Abstract: Non-communicable diseases (NCDs) are still the number one killer in the world. Their economic burden is

heavy, notably in low-and-middle-income countries. Lebanon is a middle-income country in the Eastern

Mediterranean region. The arising COVID-19 pandemic, political and economic instability, inadequate

funding, and deteriorated infrastructure have rendered the country a fragile setting, significantly affecting

persons with non-communicable diseases. Improving the patient journey during the COVID-19 pandemic and

a comprehensive approach to NCD management is important during emergencies.This paper used a quantitate

literature review to provide a theoretical framework touching NCDs patients in their journey during

emergencies and crisis. It further adopted the Sendai Framework to draw the road for these patients in

Lebanon. The ultimate goal is better preparedness and response in case of emergencies and disasters. It calls

for a clear and coordinated action plan addressing the challenges posed by NCDs to a resilient country's

response. This paper provides an overview of the situation of NCD patients in Lebanon during the COVID-

19 pandemic. It suggests strategies to address non- communicable diseases guided by the Sendai Framework's

four priorities, based on previous experiences.

INTRODUCTION

Non-communicable diseases (NCDs) kill 41 million

people each year, equivalent to 71% of all deaths

globally

. The World Health Organization (WHO)

reports that each year, more than 15 million people die

from a NCD between the ages of 30 and 69 years;

85% of these premature deaths occur in low- and

middle-income countries. Non- communicable

diseases such as cardiovascular diseases account for

most NCD deaths, or 17.9 million people annually,

followed by cancer (9.3 million), respiratory disease

(4.1 million), and diabetes (1.5 million).

The COVID -19 pandemic has accentuated the

vulnerability of NCD patients and weakened that

resilience of the public health system. Diabetes,

hypertension, and cholesterol levels are among the

comorbidity factors that increase the severity of

https://orcid.org/0000-0001-9317-2132

https://orcid.org/0000-0001-7110-3718

https://www.who.int/news-room/fact-

sheets/detail/noncommu nicable-diseases

COVID-19 infection (Zaki et al, 2020), placing a

higher risk (Chan et al, 2020) on NCD patients. This

risk increase with the lack of appropriate care due to

the sudden shift in priorities of the healthcare system

and providers, infrastructure disruption, degraded

living conditions, inability to operate safely and offer

quality care to all patients. Evidently, NCD diagnosis

and treatment services were partially or completely

disrupted worldwide - Hypertension (-50% decrease),

cancer treatment (-45%), and cardiovascular

emergencies (-30%)

The patient journey for NCDs is depicted in five

broad touchpoints: awareness, screening, diagnosis,

treatment, and adherence with integration of

palliative care along the care continuum pathway (Fig

1.). These phases require the development of

interventions and policies tailored to the patient’s

need at these different phases (Devi et al, 2020),

which, if disrupted may be fatal to the patients, or

NCD department (May 2020): final results: rapid

assessment for NCDs during the COVID-19 pandemic.

WHO (2020). The impact of the COVID-19 pandemic

on non-communicable disease resources and services:

results of a rapid assessment.

306

El Bizri, L. and Badr, N.

Protecting Non-communicable Diseases Patients during Pandemics: Fundamental Rules for Engagement and the Case of Lebanon.

DOI: 10.5220/0010742300003123

In Proceedings of the 15th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2022) - Volume 5: HEALTHINF, pages 306-315

ISBN: 978-989-758-552-4; ISSN: 2184-4305

introduce risks that yield to an unpredictable

outcome. Essentially, the COVID-19 and NCD

pandemics exert a combined effect, leaving NCD

patients at a higher risk of developing severe COVID-

19 complications, and more likely to develop long-

term chronic conditions (Nassereddine, 2021).

Figure 1: Key Stages - NCD patient journey (adapted from

Devi et al, 2020).

1.1 Motivation

The context of our paper is the country of Lebanon.

A middle-income country located in the Eastern

Mediterranean region, where NCDs account for

approximately 91% of all deaths

. The economic

growth was slowing since 2011, following the Arab

Springs, and the influx of 1.5 million Syrian refugees

to Lebanon, abruptly raising the population by 25%.

Syrian refugees live in close contact with the host

community, and their living conditions are favourable

for the epidemic spread to the Lebanese public at

large. Inadequate access to health care, and

inadequate community awareness levels are

vulnerability factors. The relatively high prevalence

of non-communicable diseases in this population

could also affect the severity of the disease among

those infected. Poverty, stigma, and fear of legal

consequences are contextual factors that further

exacerbate this vulnerability (Fouad, 2021).

Adding to the already failing health sector, the

disruptions of the COVID-19 pandemic, and the

stressful economic situation, was a massive explosion

in Beirut that rendered three major hospitals

www.who.int/nmh/countries/lbn_en.pdf.

https://www.who.int/publications-detail-

redirect/9789240029682

inoperable, and other hospitals severely damaged,

with more than 300,000 people left without shelter.

Consequently, there was a significant decrease in

scheduled mammograms, screening colonoscopies,

and elective surgeries and follow-up visits. This led

to delay in diagnoses or treatments in chronically ill

and cancer patients (El Karak, 2021). In fact, 29% of

NCD patients had interrupted or rationed their

medication before the explosion due to financial

problems and medicine shortage (Medecins sans

frontieres, 2021).

Components of health ecosystems, encompassing

collaborations between health and other sectors must

work in synergy to meet the demands imposed by

health emergencies

. Targeted investments and policy

reforms in building the capacity of health systems to

effectively manage routine demands can help

countries strengthen the effectiveness and coverage

of routine health care provision for NCD during

pandemics (Rentschler, 2021) and strengthen the

resilience of health systems to shocks and pressures.

The Ministry of Public Health (MoPH) have not been

able to meet the challenges, albeit having developed

the national NCD prevention and control plan (NCD-

PCP) back in 2016

With this work, we intend to summarize

Lebanon’s response to the pandemic and the

disruption of the NCD journey. Then, using guidance

from the extant literature, we outline a call to action

for the Lebanese communities that draw attention to

the case of NCD patients during a Pandemic.

Therefore, we try to answer the question What does

the literature recommend as principle strategies that

would help address the needs of NCD patients during

a pandemic emergency?

APPROACH

This effort was conducted between March 2021 and

August 2021, completing a literature search to

identify articles within the scope of the NCD journey

in Lebanon during the COVID Pandemic. The search

included databases such as PubMed, and Google

Scholar to look for papers that cover all three contexts

and published during and after the year of the

COVID-19 pandemic. Searches included keywords

such as "COVID-19" AND "Lebanon" AND "Non

communicable Diseases" to yield 101 papers;

https://www.moph.gov.lb/en/DynamicPages/index/2/

3687/non-%20communicable-diseases#/en/view/3691/

non-communicable-dis eases-prevention-and-control-plan-

ncd-pcp-lebanon-2016-2020.

Protecting Non-communicable Diseases Patients during Pandemics: Fundamental Rules for Engagement and the Case of Lebanon

307

"COVID-19" AND "Lebanon" AND "Non

communicable Disease", to produce 326 papers and,

"COVID-19" AND "Lebanon" AND "NCD", to

identify 118 sources. Papers eligible for review

included research studies, review articles, policy

papers, opinion articles, and legal briefs. There were

no limitations in term of times and languages. In

parallel we retrieve secondary sources of data: the

first author includes media stories and articles, blog

postings, and magazine articles from the grey

literature in the study (e.g., secondary sources from the

Ministry of Public Health - MoPH), only when

necessary to bridge the information gap in the

literature and triangulate authors concepts. Both

authors reduced the duplicate articles and review them

independently. After isolating 68 articles, they read

them in full, then checked for relevance, rejecting

patents and citations and restricting the review to

papers relevant to the study, which resulted in the

retention of 46 articles. That is, authors have found a

few entries in the literature discussing the Lebanon

context in general (23 papers). Citing Lebanon

example, sixteen articles were found to address NCD

in Emergencies (Covid-19 Pandemic specifically).

Others covered disaster risk reduction (DRR),

Universal Healthcare (UHC), and the NCD journey in

low and medium-income countries (LMIC) inferring

to the Lebanese context (seven publications). Next,

both authors proceeded with the paper to synthesize

the findings. Two steps were followed: First, a

summary of Lebanon’s reaction to the pandemic and

the NCD Population was produced (section 3.1). As a

second step, the authors identified components of

Health EDRM and SENDAI Priorities for Action to

provide a basis for a roadmap to strengthening the

resilience of health systems (Aitsi- Selmi et al, 2015)

and connect the recommendations from EDRM and

Sendai in the context of the NCD journey to

summarize a call to action in the Lebanese context

(section 3.2). Therefore, using these frameworks as a

backdrop to our paper, we pave the way to learn from

the extant literature and augment actionable examples

into these frameworks that would contextually apply

to the Lebanese case. We explicate the frameworks’

prescriptive nature to connect it to the NCD patient

journey. We identify gaps in the Lebanese handling

of the NCD journey and develop calls to action based

on the frameworks for (section 3.2.). Therefore, we

propose a vision under the guidelines of these

frameworks to shift focus from disaster response to

fundamentals of planning and preparedness. This new

lens may be helpful to focus the frameworks on

https://datareportal.com/reports/digital-2020-lebanon

addressing the risks of NCD in a pandemic (Hung et

al, 2021). In a contextual framework, we try to

compensate for the lack of evidence by suggesting

priorities for action that map to the NCD patient

journey. Then, we aim to use learnings from the

extant literature, raise public awareness, and provide

guidance from DRR frameworks (Health EDRM,

SENDAI).

PERSPECTIVES FROM THE

LITERATURE

COVID-19 response in Lebanon was meager,

burdened by compromised healthcare systems,

prolonged political unrest, conflict, and humanitarian

crisis, poor vital registration systems, suboptimal

reporting, and dearth of publicly available data

(Nassereddine, 2021). To set the stage for our work in

this paper and after consulting a few documents and

materials from the MoPH, we summarize the

response as follows:

At the onset of the COVID-19 pandemic (Jan

2020), Lebanon saw an increase of 6.8% of social

media compared to April 2019, and 68% of the total

population were using mobile Apps

. The MoPH set

up COVID-19 dashboards, for information diffusion

and provisioned resources for collecting information

required to guide all aspects of the operations

. That

included communications, risk and needs assessment,

priority setting, planning, information management,

health operations, and health logistics. Formalizing

their pandemic response, the MoPH put in place a

regional preparedness and response plan for COVID-

19, developed to establish a national plan of action to

scale up preparedness and response capacities in

Lebanon for prevention, early detection, and rapid

response to coronavirus disease 2019. The plan called

for screening at Points of Entry (POE) of coming from

outbreak countries, provision of PPEs at the health

facility level, the designation of additional referral

hospitals national coordination mechanisms, and

assessment of capacities and gaps for potential local

spread and outbreak.

Lebanon has managed to control the virus spread

through an initial strict lockdown and confinement

measures amid an already struggling economy (Fouad

et al, 2021). Nevertheless, the healthcare system has

been seriously affected and, the scarce resources have

been diverted from the primary healthcare centres

(PHCs) supported by the government to the COVID-

https://covid19.mohp.gov.np/

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19 emergency systems. The result was the interruption

of the provision of basic services such as procurement

of vaccines, chronic and essential medicines (Rosita di

Peri et al, 2020; Hamadeh et al, 2021).

3.1 Lebanon’s Reaction to the

Pandemic and the NCD Journey

Only a handful of publications studied and reported

the impact of the pandemic on the NCD patient

journey in Lebanon. Namely, Hamadeh et al (2020),

discuss the low level of readiness of the Lebanese

primary healthcare centres during the COVID-19

pandemic to address non-pandemic related diseases.

During COVID-19, visits to primary healthcare

centers (PHCs) waned to a minimum, and access to

essential chronic health services was interrupted.

Visits to PHCs for essential services declined by up

to 70%. As a result, the most vulnerable NCD

population was more likely to defer and postpone

care until their condition becomes critical, most

often requiring hospitalization (Hamadeh et al,

2021). Elsewhere, Zablith et al (2021) document the

complex dynamics of NCD management worsened

by lack of governance, the scarcity of financial and

human resources, perceptions of care quality, and

community trust in services. The COVID-19

pandemic dealt a heavy blow to the country’s health-

care system that has been buckling under

consecutive politico-economic and security events

(Zablith et al, 2021). Karak et al (2021) explain the

disruption in terms of lack of rapid access to

medications and the need for dedicated care centres

for cancer patients to ensure continued treatment and

care.

Whilst, touching on the digitalization of mental

health services, Fouad et al (2021a) described how

Tele-mental health was introduced as a viable

solution in times of pandemic especially in low-

income settings. The delay in diagnosis and early

treatment has a relevant impact and subsequently

increases the burden of NCDs. Teleconsultation had

become the norm for both Lebanese and Syrian

populations as less and less direct in-person services

and resources were available (Saleh et al, 2018). The

majority of Lebanese physicians increased their use

of WhatsApp (80%), phone calls (67%), and email

(63%) for their telehealth activities. These activities

include reading test results, discussing the patient's

case, prescribing medication, and providing public

awareness (Helou et al, 2020). The burden of the

pandemic had its toll on the NCD journey at all

stages (Table 1).

Table 1: NCD Journey in Lebanon – During COVID – 19.

Key Stages - NCD in Lebanon, during COVID – 19

Awareness

MOPH - WhatsApp and Facebook broadcast educational videos

(Sacca et al, 2020); Individual initiative – APP for weight control

and fitness (Bardus et al, 2019); breast cancer awareness (Sacca et

al, 2020);

Screening

Access to information for screening via mobile devices (Manca,

2015) and EMR systems (Saleh et al. 2018). Tele-mental health a

viable solution (Fouad et al, 2021a)

Diagnosis

Physicians relied on telehealth activities for diagnosis and

treatment (Helou et al, 2020); Teleconsultation had become norm

in both the Lebanese and Syrian populations as less and less direct

in person services and resources were available (Saleh et al, 2018).

Treatment

Physicians relied on telehealth activities for diagnosis and

treatment (Helou et al, 2020); lack of rapid access to medications

and care center resources (Karak et al, 2021); Low level of

readiness of the Lebanese primary healthcare centres (Hamadeh et

al, 2020)

Adherence

Lack of interoperability between healthcare stakeholders’ systems

(FIP, 2019). Lack of rapid access to medications and care center

resources (Karak et al, 2021); Learn new supply chain and/or

dispensing approaches for NCD medicines (Khoury, 2020); most

vulnerable NCD population likely to defer and postpone care

(Hamadeh et al, 2021)

Awareness - As the MoPH and the health

ecosystem in the country reacted to the pandemic, the

NCD population was left unattended, served only by

a few individual initiatives, trying to close the gap in

awareness and self-care interventions in NCD

patients through the promotion of training and

education. WhatsApp and Facebook broadcast

educational videos raising cancer awareness and the

importance of screening (Sacca et al, 2020). By

individual initiative, community members have

developed applications to help weight control

application - WaznApp (Bardus et al, 2019), help

individuals achieve their fitness goals

and raising

breast cancer awareness and the importance of

screening (Sacca et al, 2020).

Exceptionally, in this case, to curb the mental

health issues that resulted from the pandemic, the

MoPH developed an extension to the plan that aimed

at comprehensively addressing the mental health and

psychosocial support (MHPSS) aspects of the

COVID-19 outbreak in the country, including

Protecting Non-communicable Diseases Patients during Pandemics: Fundamental Rules for Engagement and the Case of Lebanon

309

Palestinian and Syrians refugees

. Components of this

action plan were to: (1) Promote mental health and

mitigate COVID-19 related stressors; (2) Support to

the quarantined; caregivers, first responders, and

mental health patients. However, the plan did not

include special provisions for resources to maintain

the services for the non- pandemic related chronic

diseases. The action plan mainly focused on multiple

scenarios for strengthening surveillance and response

to COVID-19 and missed the requirements of the

primary healthcare activities regarding the vulnerable

NCD populations' needs; dynamics of NCD

management were worsened by lack of governance,

scarcity of financial and human resources,

perceptions of care quality, and shaken community

trust (Zablith et al, 2021).

Screening and Diagnosis - Telehealth activities

took to the mainstream. These activities include

reading test results, discussing the patient's case,

prescribing medication, and providing public

awareness (Helou et al, 2020). Almost half of the

Syrian households have a member with an NCD

(Sethi et al, 2017). Over 90% of Syrian refugees’

households in Lebanon have access to a mobile phone

and use it widely (Manca, 2015). A cloud-based EHR

system (Sijilli) – meaning "my record" in Arabic,

launched in 2018 to gather and maintain medical data

for displaced Syrian refugees – which became an

essential source of information to care for the needs

of the refugees during the pandemic – some of which

were NCD patients. Another project (the e-Sahha

project) offered the Palestinian refugees the facility to

capture information on diabetic and hypertensive care

seekers. The project included a weekly diffusion of

personalized, educational text messages, providing

health information on lifestyle, dietary habits, body

weight, smoking, medications, and symptoms of

hypertension and diabetes (Saleh, S. et al. 2018).

Treatment - Lebanese primary healthcare centres

were taken by surprise, as the COVID-19 pandemic

came to exacerbate the already stressed systems

(Hamadeh et al, 2020). NCD patients tended to defer

and care, at the risk of complications (Hamadeh et al,

2021), before admission to care centres, that

dedicated their resources to address COVID-19

patients. Some instances spawned the need for

dedicated care centres to treat cancer patients and

ensure their continuum of care (Karak et al, 2021).

MoPH Action Plan MHPSS response to the COVID-19

outbreak in Lebanon-V1.0 (2020, March).

Adherence - In Lebanon, the lack of

interoperability between different healthcare

stakeholders’ systems is a major concern (FIP, 2019).

Barriers are multiple: finding "common languages"

between medical records in different hospitals, a

significant cost of implementation, ensuring patients’

confidentiality, and care coordination between

different healthcare providers. NCD patients had to

learn new ways to manage their care, and their

caregivers were pushed to adopt telemedicine, learn

new supply chain and/or dispensing approaches for

NCD medicines, adapt new triaging protocols to

identify priorities and to care for the most vulnerable,

and often redirect their NCDs to alternate health care

facilities (Khoury, 2020).

In sum, from the initial stages of awareness,

prevention, and screening to the subsequent stages of

diagnosis and treatment and ongoing management,

the NCD population fought hard to gain access to

proper care. NCD patients had to learn new ways to

manage their care, and their caregivers were pushed

to adopt telemedicine, learn new supply chain and/or

dispensing approaches for NCD medicines, adapt new

triaging protocols to identify priorities and to care

for the most vulnerable, and often redirect their NCDs

to alternate health care facilities (Khoury, 2020). It

was not until a year later, in February 2021, when the

vaccination campaign took hold that the NCD

population received some attention. NCD patients

took "high priority".

3.2 Preparing the NCD Patient

Journey for Disaster Resilience

We start the conversation about disaster risk

reduction by referencing the Health Emergency and

Disaster Risk Management (EDRM) Framework,

published in 2019 by the WHO. The EDRM

framework prescribes fundamental components and

an approach for all actors in health and other sectors

who are working to reduce health risks and

consequences of emergencies and disasters (Hung et

al, 2021). Extended from the UN Sendai Framework

for Disaster Risk Reduction 2015–2030, the EDRM

places human health at the centre of disaster risk

reduction. The Sendai Framework stipulates that the

disaster management cycle is a continuing process

with three ultimate goals: mitigating the present

disaster effects, achieving a rapid and effective

recovery, and acting during the post-disaster phase

(Bullock et al, 2013). Disaster planners draw the

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roadmap for strengthening the resilience of their

health systems, while relying on the effective

implementation of such framework, which require

local, national, regional, and global actions and

cooperation between all stakeholders (Aitsi-Selmi et

al, 2015). A clear and coordinated action plan

addressing the challenges faced by NCD patients

before, during, and after disasters will help to mitigate

the heightened burden of risks, especially in the

context of low and middle- income countries

(LMICs) and among their vulnerable populations

(Gnanapragasam et al, 2016). Moreover, in 2018, the

WHO issued guidance on integrating NCD

management in emergency response preparedness

(ERP) plans

. In the preparedness phase, the guidance

emphasized the identification of priority conditions

for inclusion in emergency response that outline the

pre-emergency profile of NCDs and assess the

readiness of the concerned Health Facilities.

Coordination plans would be put in place for

contingencies, with individualized emergency plans,

ensuring the availability of resources, essential

medicines, and technologies. At the onset of the

emergency, coined as the emergency response phase,

the WHO working groups propose integrating NCDs

in initial rapid assessments, mapping the service

provisioned, and organizing the service delivery that

focuses on their care. Finally, a post-emergency phase

is recommended to debrief on lessons learned from

the crises, strengthen health ecosystem response to

the needs of NCD patients with a continuous loop of

monitoring and evaluation. In Table 2, we adapt the

works of Bullock et al, (2013) et Hung et al (2021), to

frame the EDRM context and the priorities for action

of Sendai Framework and provide insight into the

activities required in the NCD patient journey, during

an active disaster.

As a first priority, it is vital to enhance risk

governance and better understand disaster risk to

reduce the frequency and effects of disasters (Aitsi-

Selmi et al, 2015). Ultimately current risks are

reduced and, the development of new ones is

minimized (Mizutori, March 2020). Developing risk

communication improvement strategies can help

planners and managers design and implement

effective risk management programs (Fathollahzadeh

et al, 2021). Effective Risk Communication is critical

for health and other sectors, government authorities,

the media, and the public. A consistent collection of

reliable, strong data from past and present inform

projections to build good strategies and interventions

https://apps.who.int/iris/handle/10665/272964

for the future; the ultimate result is to reduce disaster

risks and improve the safety and functionality of

critical infrastructure (Mizutori and March, 2020).

Operative information and knowledge management

include risk assessment, surveillance, early warning,

information management, technical guidance, and

research.

Table 2: Four Priorities for action for NCD – Adapted from

(Bullock et al, 2013 & Hung et al, 2021) and our literature

review.

Priority 1. Understanding disaster risk:

Effective Risk Communication (health and other sectors,

government, media, and the public)

Operative information and knowledge management (risk

assessment, surveillance, early warning, information

management, technical guidance and research)



Patient engagement (identify priority conditions for

inclusion in emergency response, outline pre- emergency

profile of NCDs and assess readiness of health facilities).



Leveraging technologies: Encourage community-based

screening for NCDs w/ digital tools to scale level of care.

Priority 2. Strengthening disaster risk governance:

Policies, strategies and legislation that define structures,

roles and responsibilities of governments and other actors that

strengthen capacities (incl. care costs for NCDs)



Patient engagement with care providers and other

stakeholders in planning and crisis management.

Priority 3. Investing in disaster reduction for resilience:

Human resource plans (staffing, education training).

Financial resources to supports implementation of Health

EDRM activities, capacity development and contingency

funding for emergency response and recovery.



Include contribution from the whole care team,

(pharmacists, etc.) to provide focused interventions,

specialised counselling and care coordination



Health infrastructure and Logistics that includes supply

chain of essential NCD medicines.



Patient engagement and coordination for contingencies,

with individualized emergency plans (NCD patient profiles),



Leveraging technologies: “care anywhere” concepts

Priority 4. Enhancing disaster preparedness:

Strengthen the capacity of local health workforce and

inclusive community-centered planning and action –

Establish monitoring and evaluation to constantly assess

progress and provide feedback for managing risks and

capacities and fine-tuning of strategies.



Patient engagement in Post Emergency Debrief to

strengthen response to needs of NCD patients



Integrate NCD patients in initial rapid assessments and

organizing the service delivery that focus on their care.

As an example, community-based screening for

Protecting Non-communicable Diseases Patients during Pandemics: Fundamental Rules for Engagement and the Case of Lebanon

311

diabetes and hypertension that leverage digital tools

may advance the level of care and avail these services

at scale, for NCD patients screening (Saleh et al,

2018) even during disasters. Here we echo the

recommendations of Devi et al (2020) that patients

and care providers ought to collaboratively design

their care pathways with the inclusion of “care

anywhere” concepts leveraging advancements in

technology; among those, the support of home

monitoring, optimized accurate diagnosis,

personalized care plans, and facilitated timely

intervention through mobile devices and integration

of digital portals. The resilience of services away

from the traditional setting would bring continuity of

care in the face of emergent disruption.

Priority two calls for strengthening disaster risk

governance. It is critical to invite all stakeholders to

partner together, with the ultimate goal of using and

implementing all instruments to mitigate disaster risk

(UN Office for DRR, 2015). NCD stakeholders are

part of this planning and crisis management group.

Aside from risk reduction, the target of this group is

to improve economic, social, health, and

environmental durability. Agencies must implement

policies, strategies, and legislation that define the

structures, roles, and responsibilities of governments

and other actors including strategies for strengthening

Health EDRM capacities and related services.

Priority 3 calls on investing in disaster reduction

for resilience. I Integration of primary, secondary,

and tertiary healthcare systems into disaster risk

management becomes vital for NCD patients to shift

towards alternate, well-prepared and well-resourced

healthcare services since the essential healthcare

systems and their workers are more engaged in the

containment of disaster, as happened during the

COVID-19 pandemic. This includes Data collection

and assessment for NCD patient profiles, as well as

reviewing the national essential medicines list to

maintain fluidity in the drug supply chain (Slama S et

al, 2017).

Supporting primary healthcare professionals and

training them is important to achieve this shift.

Planning of human resources is necessary, which

includes staffing, education, and training across the

spectrum of capacities at all levels, and the

occupational health and safety of personnel. Some

recommend increasing the involvement from the

whole care team, including pharmacists that build on

the key roles they already play as primary healthcare

professionals in the community to provide focused

interventions, specialized counselling, and care

coordination, improving patient engagement to

achieve better outcomes (Pinto et al, 2020). Financial

resources to supports implementation of NCD

support activities, capacity development, and

contingency funding for emergency response and

recovery. Investments are also required for health

infrastructure and logistics that focus on safe,

sustainable, secure, and prepared health facilities,

critical infrastructure (e.g. water, power), and supply

systems to sustain the care ecosystem for NCD

patients, in continuity without compromise.

Considerations for NCD patient-centered care

include the best practices to ensure management

sustainability in the most collaborative and

productive ways between healthcare stakeholders and

patients.

Priority 4 emphasizes on improving preparedness

for effective response and on "Building Back Better"

in recovery, rehabilitation, and reconstruction. The

post- disaster phase evaluation of emergency response

to NCDs is critical to "Building Back Better".. This

evaluation will "build" the road to strengthening the

NCD surveillance system, implementing strategies to

prepare better in case of new emergencies, and

incorporating NCDs into government budgeting and

plans (WHO, 2018). To alleviate the disaster’s effects

on NCD patients, it is essential to strengthening the

Lebanese national good governance to include NCDs

in national disaster plans. A robust public health

surveillance system will spot indicators that identify

vulnerable groups (NCD patients in the case of the

COVID-19 pandemic, among others), for further

Emergency and Disaster Risk Management (EDRM),

planning (Law, 2019). Further, a focus on a systemic

approach to strengthening the capacity of the local

health workforce and inclusive community-centred

planning and action for the wellbeing of the

vulnerable NCD population in a pandemic situation.

3.3 NCD Patient Engagements in

Disaster Planning

A comprehensive response to NCD management in

emergencies that may place a large demand on

resources is not trivial. Often, NCD patients find

themselves at the lower priority as aspects of non-

communicable disease control become inadequate to

reduce the potential risk of morbidity and mortality.

Findings from our review have stressed the

engagement of NCD patients in the planning and

preparedness for disasters. We, therefore, stress the

importance for policymakers, communities, and

individuals to give adequate attention to disaster risk

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reduction (DDR), specifically to include the needs of

NCD patients. During a pandemic, it is critical to

focus the resources available on the containment of

the pandemic while also continuing to support the

NCD patient journey. The strengthening of health

infrastructure and logistics are important to build that

focus on safe, sustainable, secure, and prepared health

facilities, critical infrastructure (e.g. water, power),

and supply systems to support the complete Health

ecosystem. However, this must include, for

instance,reviewing the national essential medicines

list to maintain fluidity in the drug supply chain for

NCD patient journey support.

NCD patients and care providers are stakeholders

in the planning and management of the crisis. Patient

engagement in the coordination for contingencies,

with individualized emergency plans (NCD patient

profiles) ensures that adequate resources, essential

medicines, and technologies are available upon need.

NCD patients must participate in the elaboration of a

clear and coordinated action plan addressing the

challenges faced by NCD patients before, during, and

after disasters. This planning effort identifies priority

conditions for inclusion in emergency response that

outline the pre-emergency profile of NCDs and assess

the readiness of the concerned health facilities.

Further, the finding of this study reinforces a

recommendation that NCD patients engage in post-

emergency debrief activities on lessons learned to

strengthen the response to the needs of NCD patients

in the next emergency events with a continuous loop

of monitoring and evaluation.

3.4 Leveraging Technology Tools

The development of an action plan for NCD patients

must leverage solid tools for collecting reliable data,

such as electronic medical records (EMR / EHR),

strengthening national healthcare and policies, in

addition to the capacity of the medical body and

institutions. Technologies that provide for the concept

of “care anywhere” leveraging advancements in

telemedicine, for instance, become necessary tools in

the success of the NCD journey continuum. Namely,

the support of home monitoring, optimized accurate

diagnosis, personalized care plans, and facilitated

timely intervention through mobile devices and

integration of digital portals. Additionally,

community-based screening for diabetes and

hypertension that leverage digital tools may advance

the level of care and avail these services at scale, for

NCD patients ‘screening and early detection. This

further contributes to reducing the demand for acute

care. Additionally, empowering individuals through

educating them about different self-care interventions

can mitigate the effect of the disaster on their health.

They must strive to learn how to use mHealth

applications and web-based technologies. Wearable

devices and teleconsultation are ways to maintain a

connection with their healthcare providers.

Resilience in disaster management helps the country

to respond to and to recover from it in a better way.

Investing in technology is an opportunity that can

optimize the country's response to future disasters.

Lebanon must learn from this pandemic to better

prepare for any future disaster and to establish strong

policies for the final target citizens and community.

4 RECOMMENDATIONS

The Lebanese government and community partners

should pay immediate attention to develop an action

plan and strategies where vulnerable populations

notably NCD patients are included in the response

and mitigation efforts. Planners and practitioners

must therefore:

1) Establish an overall coordinated approach to

develop effective risk assessment and

communication plans that include both public

and private sectors (MoPH, primary healthcare

providers, community and media) with the

consult and the participation of key stakeholders

in the NCD patient journey.

2) Provide means to collect and diffuse operative

information that aid in risk assessment,

surveillance, early warning, information

management, technical guidance, and research.

Emphasize transforming knowledge to policy to

strengthen the structures and response

mechanism to serve specific needs of NCD

patients throughout their journey.

3) Define clear roles and responsibilities with a

rapid response plan that includes contingencies

to care for NCD patients – for instance, plans that

encourage community-based screening for

NCDs w/ digital tools to scale the level of care

and set up the provisions necessary for continuity

of care in the time of stress on the health

ecosystem.

4) Strengthen capacities, in addition to funds and

resources set aside for the care of NCDs in their

journey. Education and training would be

included in the plan to make sure that the

readiness for response and care of the NCDs.

5) Augment diagnostics centres capabilities to take

on the added burden during emergencies,

Protecting Non-communicable Diseases Patients during Pandemics: Fundamental Rules for Engagement and the Case of Lebanon

313

through scalable resource planning – with the

ability for the government to unlock assistance in

funding and resources.

6) Equip treatment facilities with telehealth and

other scalable technologies, potentially, standing

up mobile clinics to increase access to care.

7) Develop the ability to muster other supportive

functions and volunteers in the health ecosystem,

such pharmacists and informal carers, to alleviate

the burden on the primary care function.

8) Optimize the logistics supply chain. The plans

must account for logistical support to provide an

adequate flow of medicines and required

treatment for the continuity of care for NCD

patients. Human, financial, and supply chain

resources must be ready to scale to the required

capacity.

9) Finally, establish monitoring and evaluation

cycles that integrate NCD patients in rapid

assessments and organizing the service delivery

that focuses on their care.

We, therefore, call on the responsibility of the

disaster planners to include NCD patients in response

and recovery planning. They are informed and pivotal

stakeholders. Leverage technology such as portals,

integration tools, mobile and telehealth, supply chain,

and tracing technology to facilitate the identification,

planning, communication, and delivery of care - as

“care anywhere”.

5 CONCLUSION

The Lebanese health system is fragile and lacks a

sustainable preparedness to build a strong future

considering the vulnerable populations. As we aim

for Universal Health Coverage while protecting the

vulnerable, it is crucial to accompany them during

their disease journey, in periods of peace and

disasters. NCD patients have been the most hit by the

COVID-19 pandemic then later on with the severe

shortage of medicines resulting from the economic

situation. Structured guidelines and considerations

under the Sendai framework priorities will build a

strong ground for preventing disruptions of the

different stages of the NCD patient journey. The

success of this action plan is the contribution of all

involved stakeholders under the umbrella of good

governance and the integration of the NCD care in

emergency preparedness and responses.

Our work reviews the extant literature and draws

the connection between theory and practice. We

summarize what is in the literature and identify a

serious gap in scientific studies that would improve

the NCD journey. Potentially, further research could

explore the level of resources required in order to

support the underserved NCD patients in an effective

response, given certain contexts, during abnormal

situations, as pandemics, etc.

In conclusion, our contribution is timely and

primarily targeted towards the practices of health

disaster planning and response. Moreover, our paper

suggests the broad lines of such response strategy and

identifies key initiatives that must become priorities

in emergency response that includes provisions for

protecting NCD patients during pandemics (Fig.2).

Figure 2: Key priorities for protecting NCD patients during

a pandemic (by the authors).

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