 And the first speaker, David Baran, who is a researcher that – as you can see from the bio, really specializes in diabetes primarily in developing countries, from a health systems perspective in particular. And he's based at Geneva University Hospitals, also known as HUGE events, or HUGE, and the University of Geneva in the Division of Tropical and Humanitarian Medicine. Thank you. Thank you. Thank you. Thank Pablo, Kieran, Philippa, and Bayarfa for inviting me and giving me the opportunity to go through, in a sense, the assessments of NCD health services and humanitarian settings, what is needed. And I think just before starting on the assessments, I think we talk about NCDs and people with NCDs as if they were this sort of whole. But I think we have to remember that NCDs is a continuum from the general population to, unfortunately, death. And how people at risk, people with overweight or obesity, people with high blood pressure, high blood glucose, non-diagnosed NCD, or people with actual NCDs or NCD-related complications are part of the spectrum and have different needs and have different requirements from the response, be it from a humanitarian actor or the health system. I think what's also important is the different information needs at different stages. A lot of my work has been in health systems in low- and middle-income countries, not in humanitarian settings. And one of my first introductions to this was a discussion with a colleague from the IFRC saying, what do I need to know if I get that call at 2 in the morning on Sunday saying we have a typhoon that's hit somewhere else, a new conflict that's come out? For NCDs, what do I need to know? I know how many tents I need, I know how many vaccines I might need, but for NCDs, I don't know. The next is arriving on the scene, so to speak. What information needs to be gathered? What background information do the first responders need? And then the planning phase, the medicines that are needed, the diagnostic tools and everything else. And then finally, health professionals, the doctors, the nurses, the pharmacists that are sent by MSF, by other organizations, what information needs do they need or do they need to provide to their colleagues who are planning logistics or the response in order to ensure this continuity of care and an appropriate response for the people that they're treating. And then finally, the individual that is being cared for, be it for diabetes, hypertension or anything else, what information needs on the individual are needed, age, weights, BMI, blood glucose, blood pressure, et cetera, et cetera, again, to best manage this individual but recognizing that managing individuals has implications in terms of human resource needs, in terms of medicine needs, in terms of the overall response. And then also in thinking about the information is how does the information needed evolve as the situation evolves. Again, from preparedness, what information is needed, what is needed in the sort of initial hours, minutes of the humanitarian emergency, and then a week, a month, beyond one month, we've talked a lot about the protracted situations that are present in the Middle East, and then also phasing out. So what background information do we have? We heard a lot about that a lot of NCD data is estimates or guesstimates at best. What information do we need that is country-specific, region-specific, disease-specific, or others? And then also the sources as the reviews presented by James, by Bayar, and Pablo show there's very little out there in terms of published literature. So what secondary data can be used from global reports, local sources, and the literature? And if we're going to collect data, what data are we going to collect and how are we going to collect it? Is it going to be quantitative? Is it going to be qualitative? Are we looking for objective information? Are we looking for opinion? And also how can observations be used in this whole process? And then, again, as an academic, we can spend a lot of time thinking about the how and who data will be collected. We have that luxury. But recognizing that in an emergency situation there is not that luxury, that you need information right away. So again, how can existing information be used? What tools do you use currently and how can NCDs be integrated? How can they be adapted to each setting? Again, the DRC is not the same as Lebanon, and so what tools need to be developed and adapted to each of these settings? The who is also important? Looking at cultural issues, gender issues, language, sensitive issues in situations. Do you really want to speak about access to medicines for hypertension when people have lost their families, have lost their livelihoods? What types of questions do we ask? Do we need to ask? What issues do we need to look at? And again, quantitative versus qualitative. Different sets of skills in terms of who will collect this data and also how it can be collected. And also data analysis. We're lucky as academics because our analysis can take forever. And if you're preparing a response and you need to provide care within the next few hours or the next few days, how do we analyze that data in a meaningful way but also in a timely way? And it's really important to think then about what data is collected and needed that allows prompt analysis. And also what purpose is the data being used for? Is it preparation? Is it planning for something that will be protracted? Is it for how many medicines, tablets, vials of insulin we need? And also who will analyze and the detail that's needed in that analysis to then prepare a response? And then the reporting, who, how, and when. Again, thinking about these different phases and how this data analysis can evolve over that period of time in the sense that at the beginning, the preparedness, the 72 hours in the one week, it's a very, well, the information is needed very quickly. Whereas if this is a protracted situation, such as the onerous situation, the analysis is needed but not as quickly. So one thing that I was asked to discuss is really needs assessments and what do we assess when we think about needs assessments. And really what it is is looking at different levels of a given system. So this can be the provision of care within a refugee camp. It can be the health system of a given country. This includes laws, resources, the opportunities and constraints that occur. But also values and cultural factors in terms of some of the things that were discussed this morning in terms of alcohol use, for example, or lifestyle modification. And then how these different factors impact how the actual system works. And again, the system can be a refugee camp or it can be the health system of Lebanon or Jordan. And so what resources exist in the system? The service providers, the service receivers, and those also left out of the system. I think it's important. I think I can't remember which slide showed that in some circumstances the full proportion of those in need are actually not being reached. And so those not being reached, what factors lead them to be left out of the system. And again, the system can be for something that could be considered closed, a refugee camp, as well as something that's more open, for example, Lebanon, and looking at refugees in that setting, but as well as local populations. And how can we disaggregate these elements to better gain an understanding of a specific impact on one of these elements versus another. And again, looking at specialized care versus primary health care, how can that be disaggregated, or services for children versus adults if we look at, for example, asthma or COPD. And so one specific example is rapid assessment protocols, which many of you are probably familiar with. So they have been used extensively to assess services for a variety of diseases. And really the idea behind this assessment and the purists, the epidemiologist, not to point out, will challenge this as valid research because of its rapid nature, the fact that sample size is not important. And really what you're getting is a perspective more so than something with a confidence interval in terms of helping you develop a specific intervention. They have been used in humanitarian settings. And the WHO states that RAPs are an essential tool throughout the data collection process during humanitarian emergencies. And an example of that is a tool I'm sure many of you are familiar with, which is the multi-cluster sector initial rapid assessment or MIRRA. And really the main principles of this type of assessment are the speed. They collect information quickly. You're not looking at a statistically significant sample. What you're looking at is to gain information from key individuals, be it individuals with a given disease or health care workers or pharmacists on a given issue. You're using multiple data sources and triangulating between these, so you're not giving more or less value to a peer reviewed publication in a high impact journal or a report from an NGO or the perspective of someone with diabetes in a refugee camp. You're taking all of those pretty much as equivalent and trying to match them up to get this view of what the challenge is. And therefore, it's really a pragmatic approach and also relatively cost-effective. And the idea is it's done to quickly develop a preliminary understanding of a situation where specific research techniques can or cannot be used and give you a wide range of options on what could be done. And really, I think what's most important is taking this system perspective. And I'll show you in the next slide what really is this system perspective. Again, as I mentioned previously, it's this triangulation of data collection and data sources. So as you collect data, you may discover new things that need to be asked in terms of access to medicines or the cost of care or the availability of certain treatments. So therefore, the data collection and data analysis becomes an iterative process rather than a linear process. And again, it's a convergence of research and implementation, which is interesting for humanitarian settings in that the idea of doing this research is not to just have a nice peer-reviewed publication, but is actually to implement change and implement change very quickly. And so the experience I have with this tool, again, is in low and middle-income countries. It's not in conflict settings. But really, the idea behind this is to study the two paths, really the path of medicines, the path of care, and how they reach or don't reach the person with diabetes and how other problems may impact this. And so really, it's looking in a very simplistic way at two complex systems, delivery of care, delivery of medicines, and how other problems may impact that, and focusing on the person at the end. And so this is the system. This is a health system going from the Ministry of Finance all the way down to traditional healers and the links that exist between these parts of the system and understanding the interactions between these elements to then see where there are barriers or blockages to then develop specific interventions. And so the data in these tools is collected through interviews with convenience samples rather than random sampling discussions, observations, document reviews of existing statistics, government reports, et cetera. And so the work that has been done really looks at these different elements of a system ranging, again, from data collection tools, how data is collected within the system, the policy environment, drug procurement, and supply, adherence issues. And what this allows really is, and this is just showing visually the results from a study in Mozambique in 2003, what it allows you to do, and Mozambique maybe isn't the best example because everything is a weakness or needs improvement, is to say where could we target certain interventions, recognizing that these 11 elements and coming back to Pablo's presentation, they're integrated in the sense you can't change healthcare worker training if you don't improve the availability of diagnostic tools and access to medicines, for example. And so really just some concluding thoughts in thinking about needs assessments, data collection for NCDs in these complex situations is that NCDs are complex and have complex causes. There are multiple actors in and outside these health-related activities. A lot of the discussion this morning has been on clinical care, but there are a wide range of other issues around the delivery of healthcare. And also we're looking at people that have wider needs than just NCDs. What about shelter? What about food? And how does that impact their management of their chronic disease? When we're thinking about humanitarian emergencies, there are data needs at different stages and there are also dynamic situations in the sense that this isn't something that is running smoothly. There can be changes in population movement, in a conflict, or in these complex situations. And really I think in thinking about needs assessments or developing tools to respond to this is not giving another tool or adding more data collection to teams on the ground, but how could a tool be integrated into the data that you're already collecting? That it collects useful information that it enables action, that it's easy for data collection and analysis, and it's also flexible in the sense not having multiple tools for multiple settings, but having a tool that can be adapted to Syria to DRC to other contexts and really that this data is used for action. So I've just included, you saw some references mentioned, I've included these references. I think the presentations will be shared so some of these references might be of use and interest. So thank you very much. Thank you very much. Thank you very much. Thank you very much. Thank you very much. Great, just a little bit of time for clarification questions. Anything from our remotely dialed colleagues? Okay, any clarification questions from the audience before we move on? Or David? Don't see any raised hands, which is okay, because we can gain a little bit of time and we'll return to this issue I think in the main discussion.