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NCDs and their social determinants in Mediterranean partner countries: building sustainable research capacity for effective policy intervention

Final Report Summary - RESCAP-MED (NCDs and their social determinants in Mediterranean partner countries: building sustainable research capacity for effective policy intervention)

Executive Summary:
NCDs and their social determinants in Mediterranean partner countries:
building sustainable research capacity for effective policy intervention

Partners (11)
• 4 in EU: UK (Newcastle University (coordinator), Liverpool University, and St. Georges London University); Ireland (Trinity College Dublin)
• 6 non-EU: Turkey (Dokuz Eylul University, Izmir); Jordan (Jordan University of Science & Technology, Irbid); Lebanon (American University of Beirut); Syria (Syrian Center for Tobacco Studies, Aleppo); Palestine (Birzeit University, West Bank); Tunisia (Faculte de Medicine de Tunis)
• 1 International Organisation: World Health Organisation – East Mediterranean Regional Office, Cairo
Objectives
RESCAP-MED has been a research capacity-building project (2012-2014) in public health in six non-EU countries of the Eastern Mediterranean, focused on the challenge of non-communicable disease (NCDs) and their social determinants. The project aimed to create a network of partners to organise: (a) a series of training events and activities to consolidate research skills in several academic disciplines and collaborative links; and (b) academic e-resources for independent use and skills development. The longer term goal has been the sustainability of viable collaborative research networks beyond project funding.
Political Context in the Middle East and North Africa
RESCAP-MED has taken place at a time of profound political turmoil in the Middle East, affecting all partners in the region. The scale and consequences of this crisis were unimaginable when the project was first planned. We cannot over-emphasise the significance of the turbulent and unstable political context within which RESCAP-MED has worked. The network has therefore needed to be unusually adaptable.
Results
RESCAP-MED has met its key objectives, and has created a cohesive and sustainable NCD research network. In that it built on the success of its predecessor project, MedCHAMPS.
• Training Workshops: Delivered 10 workshops (197 participants)
o 6 discipline-based workshops (Health Economics, Health Policy Evaluation, Health Inequalities, Medical Anthropology, Environmental Health, Advanced Epidemiology)
o 3 Writing Workshops (Writing for Academic Journal publication)
o 1 Training Needs Assessment Workshop
• International Symposia: Held two major 2-day Symposia
o On the social determinants of NCDs in Mediterranean Countries (Istanbul 2013; 96 participants from 10 countries)
o On Socio-political challenges in the Mediterranean Region: implications for NCD Prevention and Control (Beirut 2014; 185 participants from over 12 countries)
• Fellowships: Run a Visiting Fellowship programme (13 people making 18 visits) to build methodological skills and promote publication in peer-reviewed journals to help build careers
• NETPH: Created an e-learning website with significant impact: NETPH (North Africa, Eastern Mediterranean and Turkey Public Health Network) http://www.netph.org/
• Dissemination: Wide dissemination to policy makers and academics.

Project Context and Objectives:
1. Overview of Objectives in Context
RESCAP-MED has been a research capacity building project. Its purpose was to enhance research capacity in disciplines relevant to public health research on non-communicable diseases (NCDs) and their social determinants in southern and eastern Mediterranean countries. However, the project has taken place at a time of extraordinary turmoil in the region, including in all of the Mediterranean partner countries. When the grant application was submitted to the EC in 2010 the events which were to engulf the region had not started and formed no part of our proposal. By the time the project actually started in 2012 the political landscape was already transformed; and by the time the project ended in 2014, those initial assessments made in 2010 bore little relation to current circumstances, so profound have been the political, demographic and social repercussions of the last four years. This project must be evaluated in relation to these changed circumstances in the region.
The project aims were to enhance and, where needed, build research capacity in the eastern and southern Mediterranean region for health, its social and environmental determinants and their complex interactions, in order to inform policy development and implementation. We focussed on strengthening both the disciplinary capacity necessary to understand and explain the social and environmental factors causing the rise in NCDs, and equally the disciplinary capacity necessary to identify achievable policy outcomes and interventions. We prioritised five disciplines in this context: epidemiology, health economics, environmental health, medical anthropology, and health policy evaluation. We also attached particular importance to fostering South-South research cooperation for the long-term through this process. RECAP-MED’s objectives were achievable because the project developed out of a preceding FP7-funded research collaboration (MedCHAMPS, Grant number 223075) in several countries of the region, each of which was a partner in RESCAP-MED. The timescale of the two projects overlapped by 9 months.
RESCAP-MED has brought together six Mediterranean research partners – from Izmir (Turkey), Aleppo (Syria), Beirut (Lebanon), Irbid (Jordan), Ramallah (Palestine) and Tunis (Tunisia). A seventh partner is the World Health Organization’s East Mediterranean Regional Office (WHO-EMRO) in Cairo. EU partners come from Liverpool, London and Newcastle Universities (UK) and Trinity College Dublin (Ireland). Newcastle University has coordinated RESCAP-MED.
Non-communicable diseases (NCDs) – particularly cardiovascular diseases (CVD), diabetes, and cancers – have been increasing dramatically in low and middle income countries (LMICs), including in eastern Mediterranean countries. The rising trends in urbanization and ageing of societies represent the driving force behind the continuing rise of the burden of NCDs in developing countries. On a more immediate level, the main reasons for the increase in these chronic diseases lie in the increase in major risk factors that are closely linked to socio-economic and environmental causes, which impact differentially across the population. While LMICs are bearing most of the brunt of NCDs, they are currently the least-equipped to address this looming epidemic. Governments in LMICs already have their resources stretched to the limit, and struggle with the economic and institutional challenges posed by these chronic conditions. However, the ongoing political turmoil and violence in the region, and the associated mass movements of population fleeing violence or the fear of violence, have intensified these underlying problems greatly – indeed to breaking point. While promising initiatives to address the burden of NCDs in the Middle East have emerged, there remains a serious shortage of trained personnel to monitor public health trends and the workings of the health system in each country. That is what this project sought to assist and promote.
A crucial feature of this project has been to build research capacity to investigate the social determinants of health focusing on NCDs. That not only reflects a broad view of the remit of public health and health policy, first stressed internationally in the Alma Ata Declaration of 1978; it also requires a combination of academic disciplines, working together in dialogue. Over the last two decades it has become increasingly well recognised that a social model of health encompasses not only the behaviour and social characteristics of individuals, but the broader contexts which shape and constrain that individual behaviour. That places emphasis on the material resources people have at their disposal, such as disparities in income or housing. But it also goes beyond the individual altogether, to include the quality of the built environment in which lives are led, including what we often think of as environmental factors, such as access to clean water and air. That is why we placed emphasis on building research capacity across the region in five disciplines vital for increasing knowledge of the social and environmental determinants of NCDs. Public health and epidemiology capacity in the region was largely medical-model based in most participating countries, with limited integration of other disciplines, such as sociology, medical anthropology, and urban planning.

2. Specific Project Objectives
As a research capacity-building project, RESCAP-MED set the following objectives:
1. To identify and appraise training needs and achievable priorities in specified disciplines in each partner country and institution.
2. To provide training opportunities to meet the gaps identified, aimed at both academic and operational researchers.
3. To strengthen capacity for within-country and cross-country interdisciplinary research on NCDs and their social and environmental determinants.
4. To initiate specific ‘south-south’ research collaboration on NCDs through this network, alongside further developing south-north collaboration.
5. To organise two international symposia on NCDs and their social determinants, to provide a platform for regional research, to enhance its profile, and to strengthen dialogue with key international researchers in the field.
6. To strengthen capacity for operational research on policy evaluation within government ministries and NGOs.
7. To create a model for research capacity building which would be self-sustaining after the period of the grant.
8. To develop research capacity going beyond a medical model of public health, towards a social model, by integrating the contributions of other professionals and disciplines.
9. To enhance existing dialogue between academic and policy making sectors about the implications of rising NCD levels and the burdens placed on health systems.
Overall, RESCAP-MED was designed to:
• enhance capability in disciplines with an established presence in the region (i.e. epidemiology);
• build capability where key disciplines are patchily represented (i.e. health economics) or almost non-existent (medical anthropology, environmental health);
• create research links to foster future inter-disciplinary research collaboration; and
• foster recognition and awareness of the vital importance of inter-disciplinary research of this kind among national policy makers.

3. Framework to achieve these objectives
To achieve these objectives, RESCAP-MED set out to create the following framework:
1. The creation of a Mediterranean regional network for NCD researchers which would:
a. Organise four training workshops in partner countries to enhance methodological skills, of five days’ duration.
b. Organise three training workshops in partner countries to foster grant-writing, and research manuscript writing skills, of two to three days’ duration.
c. Organise two international symposia on the social and environmental determinants of NCDs and implications for policy.
d. Create an online depository of training materials and research resources.
e. Develop an e-learning website to pilot the utility of a web-based learning system for RESCAP-MED, and subsequently for a wider academic community of NCD researchers in the region.
f. Foster cross-disciplinary research grant applications and collaborative research in partner countries.
g. Link with, cooperate with, and where appropriate draw on the expertise of existing professional networks in the region.
h. Create a pool of ‘critical experts’ to provide advice on all stages of collaborative research design, conduct and publication.

2. The establishment of a competitive, funded visiting fellowship programme, to be organised through the network outlined above, which would:
a. Involve exchanges of personnel both for mentoring junior researchers and for pursuing research collaborations and advanced training for mid-career researchers.
b. Facilitate each stage of the research process, from scoping work and literature review to research design and grant application, and through to publication and dissemination.
c. Operate on both a south-south and south-north basis.
d. Last for shorter or longer duration (typically 4 weeks to 3 months), depending on the task(s) to be achieved.
e. Apply to both academic and operational (i.e. Ministry of Health personnel) researchers.

4. Expected Outputs
By the end of three years, RESCAP-MED aimed to have greatly extended research capacity and research networks on NCDs and their social determinants in the eastern and southern Mediterranean. The important outputs were to ensure the forward momentum beyond this three-year timeframe. We identify seven key outputs in this connection.
1. A website with newly developed e-learning resources which will be available not only to partner institutions but to a wider academic, policy and practitioner community.
2. An organisational framework for ongoing academic exchanges through a short-term Visiting Fellowship programme to facilitate intra-regional collaboration.
3. An organisational framework among partners for making collaborative grant applications for new empirical research or analytical reviews in the region.
4. An enhanced number of high quality grant applications.
5. Increased numbers of presentations at academic and policy conferences, and an increase in publications in internationally-recognised peer-reviewed journals.
6. A framework to give impetus to continuing dialogue with policy makers, not only in international organisations, but more especially those in national ministries.
7. Integration of research findings and evidence within the curricula of formal academic programs (i.e. Masters of public health) and other training courses offered by partners.

5. Planned Management Framework
RESCAP-MED’s decision-making body was its Project Management Committee (PMC). This body, made up of leads from all partners, met annually (as well as through electronic means as necessary). The PMC was supported and overseen by a Project Monitoring and Advisory Committee (ProMAC), made up of relevant policy expertise. RESCAP-MED was coordinated by a secretariat at Newcastle University, UK, the coordinating partner.

Project Results:
Table of Contents

1. RESCAP-MED Achievements: An Overview of Results

2. The development of a framework and timescale

3. Initial activities: Training Needs Assessment

4. Discipline-based Workshops

5. Writing Workshops

6. International Symposia

7. NETPH

8. Fellowship Programme

9. Other Capacity Building Activities

10. Dissemination

11. Publications facilitated through RESCAP-MED

12. Successes and Failures of RESCAP-MED

13. Challenges Faced in Current Political Situation

14. Sustaining Momentum

15. Overall Lessons and Conclusions

16. Appendices (as Attachments)


1. RESCAP-MED Achievements: An Overview of Results
RESCAP-MED has been a 3-year (2012-14) research capacity-building project in public health in six non-EU countries of the Eastern Mediterranean at a time of profound political turmoil, whose scale and consequences were unimaginable when the project was first planned. Mediterranean partners in RESCAP-MED come from Jordan, Lebanon, Palestine, Syria, Tunisia and Turkey. To list these countries is to make evident that RESCAP-MED has taken place against a background of multiple challenges unparalleled in recent decades. The repercussions of the humanitarian catastrophe taking place in Syria have affected neighbouring countries – Jordan, Lebanon and Turkey – to an extraordinary degree. Both Tunisia, with its revolution in 2011, and Palestine, also witnessed extraordinarily turbulent political times. We cannot over-emphasise the significance of the turbulent and unstable political context within which RESCAP-MED has worked, in which only the events in Tunisia have given reason for much optimism. (See section 13 for a fuller discussion.)
As a network, RESCAP-MED has therefore needed to be particularly flexible, adaptable and resourceful to respond to changing national situations which have necessitated changes to plans.
RESCAP-MED has brought together 11 partners in total in a research capacity building project with a particular focus on non-communicable disease (NCDs). The project has created a network of partners to organise: (a) a series of training events and activities to consolidate research skills and collaborative links; and (b) academic resources for independent use and skills development. The longer term goal has been the sustainability of viable collaborative research networks beyond project funding. The project has been organised through nine work packages (WP).
In order to provide a basis in evidence for the workshops (to define the level of skill and perceived need among academics and policy makers at different levels), RESCAP-MED started with an assessment of training needs. This was the project’s first activity, and covered the first nine months of the project. It was led by Birzeit University (Palestine).

1.1 Training Events and Activities
The following training events and activities were held (grouped by type):
Training Needs Assessment
• Workshop to fine-tune methodology for initial Training Needs Assessment (TNA), and to train researchers in skills to undertake the TNA (Dead Sea, Jordan, 19-20 May 2012, hosted by JUST, Jordan). *
Discipline-based or subject-based Workshops
• Workshop on Health Economics (Cairo, Egypt, 16-18 December 2012, hosted by WHO-EMRO).
• Workshop on Social Inequalities in Health (Istanbul, 8-9 May 2013, organised by DEU with Universitat Pompeu Fabra (Barcelona).**
• Workshop on Health Policy Evaluation (Amman, Jordan, 3-6 June 2013, hosted by JUST, Jordan).
• Workshop on Medical Anthropology (Cesme, Izmir, Turkey, 9-13 December 2013, hosted by DEU, Turkey).
• Workshop on Environmental Health (Amman, Jordan, 5-9 April 2014, hosted by JUST, Jordan).
• Workshop on Advanced Epidemiological Methods and Modelling (Cesme, Izmir, Turkey, 22-26 September 2014, hosted by DEU, Turkey).
Writing Workshops
• Writing Workshop 1: Peer Reviewed Journal Articles & Grant Writing Skills (Dublin, 16-18 September 2013, hosted by TCD, Ireland).
• Writing Workshop 2: Writing for peer reviewed journals (Hammamet, Tunisia, 3-5 June 2014, hosted by CAVEPLA, Tunis).
• Writing Workshops 3: Writing for peer reviewed journals, country-specific workshops in:
o Dead Sea, Jordan, 9-10 December 2014
o Izmir, Turkey, 20-22 August, and 22-24 December 2014
o Tunis, Tunisia, 25-27 December 2014.

TABLE 1: Summary of RECAP-MED Workshops
Workshop Dates Location Participant
numbers No. of countries In original project plan
Training Needs 19-20 May 2012 Dead Sea, Jordan 7 6 No*
Health Economics 16-18 Dec 2012 Cairo 13 5 Yes
Health inequalities 8-9 May 2013 Istanbul 7 5 No**
Health Policy 3-6 June 2013 Amman 21 6 Yes
Writing 1 16-18 Sept 2013 Dublin 9 4 Yes
Med Anthropology 9-13 Dec 2013 Izmir 23 5 Yes
Environ Health 5-9 April 2014 Amman 18 5 Yes
Writing 2 3-5 June 2014 Hammamet 19 5 Yes
Epidemiology 22-26 Sept 2014 Izmir 24 5 Yes
Writing 3a 9-10 Dec 2014 Dead Sea 20 1 Yes
Writing 3b
20-22 Aug 2014
22-24 Dec 2014 Izmir
Izmir 8
8 1
1 Yes
Yes
Writing 3c 25-27 Dec 2014 Tunis 20 1 Yes

* This event was designed and created for a limited number of staff, one per Mediterranean partner, to finalise the research design for the TNA. The Syrian participation was by Skype from Aleppo. A few months later that communication itself would become impossible.
**This event was organised by DEU Turkey with their academic partners in Barcelona, and made available to RESCAP-MED partners. It thus provided an additional training opportunity. ‘Participant numbers’ refers to RESCAP-MED participants.

1.2 Major Regional and International Symposia
RESCAP-MED organised two major symposia, in Istanbul (hosted by partners at DEU in Turkey) and in Beirut (hosted by partners at AUB in Lebanon).
• 1st RESCAP-MED International Symposium, ‘The Social Determinants of Non-communicable Diseases in Mediterranean Countries’ (hosted by DEU Izmir, Istanbul, 6-7 May 2013).
• 2nd RESCAP-MED Regional Symposium, ‘Socio-political challenges in the Mediterranean Region: implications for NCD prevention and control’ (hosted by AUB Beirut, 3-4 December 2014).

1.3 Fellowship Programme
In total, 18 research visits were made by 13 research fellows under the project’s Fellowship Programme. This part of the project was managed by Trinity College Dublin. The majority of these fellowships involved short visits of 1-2 weeks; however, in several cases there were repeated visits by the same research fellows to the same host institute, increasing the total duration to 4-6 weeks for some individuals. No single visit lasted for longer than 18 days. All Mediterranean partners but one were able to identify potential fellows: four from Lebanon, three from Turkey, and two each from Jordan, Palestine and Tunisia. The exception was Syria, afflicted by escalating conflict and extreme violence since March 2011.

1.4 NETPH (North Africa, Eastern Mediterranean and Turkey Public Health Network) and RESCAP-MED Facebook Page
As part of the RESCAP-MED commitment to create a sustainable e-learning environment The North Africa, Eastern Mediterranean and Turkey Public Health Network (NETPH) website went live in September 2013. It has since then steadily built up its reach and scope. In addition, a Facebook page has also provided another means of dissemination to new audiences.

2. The development of a framework and timescale
In the project plan, we identified three overlapping phases to RESCAP-MED:
• an initial phase to finalise the project framework and agree the guidelines for the capacity building, and to initiate the project website;
• a main phase which brought all the main activities into play and continued till the end;
• and a final phase which brought our activities to completion but also linked together our final review of what we had achieved. This was built around the three work packages which considered our dissemination strategy, evaluation and sustainability.
In practice, the steadily worsening political crises in Syria and Tunisia, which already had momentum several months before the project started, complicated our efforts to set a timetable. But in the event, our first PMC in January 2012 committed us to an ambitious Training Needs Assessment. That took longer to complete than we had expected, both because of its ambition and also because it was hard to undertake in the circumstances developing in partner countries (after initial efforts, it proved impossible to undertake in Syria).
Thus, the Training Needs Assessment occupied the first 10 months of the project. Only as that ended did we embark on our Workshops. We started with one on Health Economics which we decided was a clear priority need identified by stakeholders and younger researchers alike. Our WHO-EMRO partner hosted this workshop in Cairo in December 2012. The year-by-year sequence of events is shown here:
• 2012: Training Needs Assessment; Health Economics Workshop.
• 2013: Health Policy Evaluation Workshop; 1st Symposium (Istanbul); Workshop on Social Determinants & Inequalities; First Writing Workshop; Medical Anthropology Workshop.
• 2014: Environmental Health Workshop; Second Writing Workshop; Advanced Epidemiology Workshop; 2nd Symposium; Third Writing Workshops.

3. Initial activities: Training Needs Assessment (TNA)
The TNA has been the pivot of the first phase of RESCAP-MED. It was led by Palestinian partners at Birzeit University’s ICPH. It was the only part of this project to necessitate collection of original data. That has resulted in an extremely detailed report to the EC (Deliverable 3.1). This WP was completed in the first nine months, and the scope, methods, results and lessons were presented in Report 3.1. The TNA carried out for this project was ambitious, and may have had no previous parallels in the majority of the six partner countries participating.
The approach taken to the needs assessment integrated three components conducted in parallel by researchers in each partner country, under the guidance and coordination of the Palestinian team leading the TNA. First, a mapping phase, based on a literature search and interviews with selected stake-holders, aimed to identify institutions within each country engaged in health-related research. Second, development of a training needs assessment tool took place (which was refined at a workshop in Jordan in June 2012). And third, data collection followed. This used the TNA tool, which included quantitative and qualitative components. A considerable amount of data were collected and analysed (see Report 3.1).
The need for training in general research skills for young researchers varied between the five countries. Palestine and Turkey reported high levels of training needs for writing policy paper, qualitative report and qualitative data analysis. Jordan and Tunisia reported high levels of training needs for questionnaire development, statistical analysis and routine data use. Lebanon, on the other hand, reported high levels of training needs for policy writing and data analysis in addition to writing academic papers and research proposals. The lowest training needs levels reported in the five countries were for conducting literature reviews.
The three phases of this needs assessment were completed in five countries (Turkey, Jordan, Lebanon, Tunisia and Palestine). The Syrian counterparts completed the first phase (Mapping of health institutions). However, the other two phases could not be completed because of the political context of Syria which deteriorated rapidly as time passed, making it impossible for the Syrians to complete the rest of this study. However, given the consistent and similar results obtained in the other five countries, we anticipated that similar findings might have been found in Syria prior to the crisis that started in 2011.
Health economics and health policy evaluation were the main two disciplines reported as a priority for training. Health economics is a focus of some international aid agencies, such as the World Bank, and the further focus on efficiency and cost effectiveness. This may explain the finding of a high priority for health economics training. Some young researchers could not rank certain disciplines or competencies and this might be partially explained by the fact that they do not understand what it means or they are not familiar with them. This applies to medical anthropology and some health policy, environmental health sub-competencies.

4. Discipline-based Workshops
Training events were led by Turkish partners at DEU Izmir. Five RESCAP-MED workshops took place based on specific academic disciplines, plus one further workshop to which RESCAP-MED was linked. The medium of these events was English. These workshops were:
1. Workshop on Health Economics (Cairo, Egypt, 16-18 December 2012, hosted by WHO-EMRO).
a. Academic leads: Dr Awad Maataria (WHO-EMRO) & Dr Kaan Sozmen (DEU).
b. 13 participants (from Jordan, Lebanon, Palestine, Tunisia, Turkey)

2. Workshop on Social Inequalities in health (Istanbul, 8-9 May 2013, organised by DEU with Universitat Pompeu Fabra (Barcelona).**
a. Academic Lead: Prof. Joan Benach (Universitat Pompeu Fabra, Barcelona)

3. Workshop on Health Policy Evaluation (Amman, Jordan, 3-6 June 2013, hosted by JUST, Jordan).
a. Academic Leads: Dr Shahaduz Zaman (UNEW), Prof. Abdullatif Husseini (ICPH-BZU), Dr Fouad Fouad (SCTS/ AUB)
b. 21 participants (from Jordan, Lebanon, Palestine, Tunisia, Turkey)

4. Workshop on Medical Anthropology (Cesme, Izmir, Turkey, 9-13 December 2013, hosted by DEU, Turkey).
a. Academic Lead: Dr Shahaduz Zaman (UNEW)
b. 23 participants (from Jordan, Lebanon, Palestine, Tunisia, Turkey)

5. Workshop on Environmental Health (Amman, Jordan, 5-9 April 2014, hosted by JUST, Jordan).
a. Academic Leads: Dr Balsam Ahmad, Prof. Tanj Pless-Mulloli (UNEW)
b. 18 participants (from Jordan, Lebanon, Syria, Palestine, Turkey)

6. Workshop on Advanced Epidemiological Methods and Modelling (Cesme, Izmir, Turkey, 22-26 September 2014, hosted by DEU, Turkey).
a. Academic Leads: Prof. Belgin Unal, Prof. Gul Ergor, Dr Kaan Sozmen (DEU), Prof. Julia Critchley, Dr Fiona Pearson (SGUL), Dr Kath Bennett (TCD), Dr Maria Guzman-Castillo (UoL)
b. 24 participants (from Jordan, Lebanon, Palestine, Tunisia, Turkey)
A full account of these workshops is provided in the WP4 Report.
The RESCAP-MED project plan had identified the anticipated topics of discipline-based workshops, and these were what we duly delivered. The Training Needs Assessment then provided us with additional valuable insights into the level of awareness or perceived importance about each topic. The order in which we held workshops was largely dictated by practical considerations of availability at a particular time. However, we started with Health Economics because it was evident that this was considered a high priority across the network. Conversely, we did not hold the Epidemiology workshop until later. This gave us time to consider the best level to pitch training on a topic where most partners reported basic skills existed. In hindsight, the Health Economics workshop suffered by being our trail-blazer. Too much of the delivery was left to two individuals, and we had not at that relatively early stage perfected our methods of reaching out to attract participants. Had a no cost extension been granted we anticipated holding a further health economics workshop early in 2015, reflecting demand.
The intention was that each workshop would have participants from each Mediterranean partner. That did not always prove possible. The political situation usually precluded Syrian participation, though both the Medical Anthropology and the Environmental Health workshops were attended by a single Syrian participant (in addition to the Syrian joint lead partner). Visa delays also made it impossible at the last minute for Tunisian participants to attend the Environmental Health workshop (see visa issues as a wider problem also in section 12).
A vital part of the discipline-specific workshops was the introduction of expertise from outside our own network. While we ran the first and last workshops, on Health Economics and Advanced Epidemiology, relying on our own teams’ expertise, three workshops – Health Policy Evaluation, Medical Anthropology, and Environmental Health – benefitted greatly from outside contributors. These contributors are listed here:
Health Policy Evaluation:
• Dr Motasem Hamdan (Al-Quds University, Jerusalem)
• Dr. Riyad Amin Okour (Ministry of Health, Jordan)
• Dr. Jamal Abu Saif (Ministry of Health, Jordan)
• Dr. Musa Ajlouni (Philadelphia University, Jordan)
Medical Anthropology
• Professor Sjaak Van der Geest (University of Amsterdam)
• Dr Inci User (Marmara University, Istanbul)
• Bahar Taymaz (Yeditepe University, Istanbul)
Environmental Health
• Dr. Jarrah Al-Zu’bi (AlBalqa Applied University, Salt, Jordan)
• Dr. Saad Al-Kharabsheh (former Minister of Environment, Jordan)
• Dr. Munjed Al-Sharif (German Jordan University; Coordinator and Chief Tech. Advisor, UN Joint Prog., Jordan)
• Professor Ziad Al-Ghazawi (Jordan University of Science & Technology)
• Dr. Muna Abu Dalo (Queen Rania Al-Abdullah Center for Environmental Science & Technology, Jordan University of Science & Technology)
• Dr. Reem Musleh (Environmental Consultant Palestine).
As this list makes apparent, RESCAP-MED was able to benefit enormously from the stature of the lead Mediterranean partners. They were in a position to attract contributions from figures with considerable expertise and experience, whether as ministers, senior policy advisers and administrators, or in science and technology.
A critical ingredient to all such workshops is how easily they foster open and comfortable discussion among all who are present. We anticipated that we might need to work hard to ensure that everyone could take part and no-one felt excluded. In the event, we were delighted with the liveliness of participation. The one inhibiting factor seemed to be the level of confidence in speaking English. That was a problem to varying degrees at one or other workshop for participants from Turkey, and occasionally from Jordan and Tunisia also.

5. Writing Workshops
RESCAP-MED planned to hold three workshops devoted to developing writing skills. In the event, two such workshops were held which were open to all partners, while three partners held in-country writing workshops in the final month of the project, as indicated below.
1. Writing Workshop 1: Peer Reviewed Journal Articles & Grant Writing Skills (Dublin, 16-18 September 2013, hosted by TCD, Ireland).
a. Academic Leads: Dr Kath Bennett (TCD), Prof. Julia Critchley (SGUL), Prof. Simon Capewell, Dr Martin O’Flaherty (UoL), Prof. Abla Sibai (AUB), Prof. Peter Phillimore (UNEW)
b. 9 participants (from Jordan, Lebanon, Palestine, Turkey)

c. Writing Workshop 2: Writing for peer reviewed journals (Hammamet, Tunisia, 3-5 June 2015, hosted by CAVEPLA, Tunis).

d. Academic Leads: Dr Kath Bennett (TCD), Prof. Julia Critchley (SGUL), Prof. Belgin Unal, Prof. Gul Ergor (DEU), Dr Martin O’Flaherty (UoL), Prof. Peter Phillimore, Dr Cathrine Degnen (UNEW)
e. 19 participants (from Jordan, Lebanon, Palestine, Tunisia, Turkey)

2. Writing Workshops 3: Writing for peer reviewed journals, country-specific workshops in:
o Dead Sea, Jordan, 9-10 December 2014
 Academic Lead: Prof. Yusuf Khader (JUST); 20 participants
o Izmir, Turkey, 20-22 August 2014
 Academic Leads: Profs Belgin Unal & Gul Ergor (DEU); 8 participants
o Izmir, Turkey, 22-24 December 2014
 Academic Leads: Profs Belgin Unal & Gul Ergor (DEU); 8 participants
o Tunis, Tunisia, 25-27 December 2014.
 Academic Lead: Prof. Habiba Ben Romdhane (CAVEPLA); 20 participants
Our Writing Workshops did not need to draw in outside expertise, as for discipline-based workshops, as there was no additional benefit to doing so. However, it will be apparent that writing workshops involved several senior staff from within partner teams, because of the intensive one-to-one work required in assisting the development of draft texts.
An essential part of long-term impact of RESCAP-MED has been to increase research capacity not only for conducting of research, but also for taking research data to the final, crucial stages of data analysis and data reporting. This is the hardest part of the research continuum, and the most critical for junior researchers in order to build research careers and credibility. The intention in the RESCAP-MED project plan had been to combine support for grant-writing with support on writing papers for academic journals, and the process of handling the process from submission to a journal to revision and then on to resubmission and eventual publication. In the event, we decided after the first Writing Workshop in Dublin that the greater need (and demand) was for supporting writing for publication. Few of those attending were at a career stage of seeking grants (and those who were interested could, we decided, be better supported through the Fellowship programme). Therefore the 2nd Writing Workshop concentrated on writing papers.
A key learning point from the writing workshops was that in hindsight we could have run more of them. For most participants, considerable existing competence in report writing has not yet been matched by an understanding of the very high standards required for successful publication in peer reviewed journals – and what that means for the framing and presentation of empirical research. It was also apparent that the whole process of journal selection, the need to address the editor with carefully crafted covering letters, and the appropriate way to respond to referees, etc. were skills that were relatively under-developed for many researchers.

6. International Symposia

In the RESCAP-MED plan, two major symposia were envisaged. Our stated intention was:
• to profile the most exciting recent work from various disciplines on NCDs and their social determinants;
• to attract keynote speakers from within and beyond the consortium, in order to foster dialogue with a wider academic and policy- making community;
• to bring the social determinants of NCDs on the agenda in the region;
• to improve partner institutions’ reputation/visibility in the field of NCD epidemiology at national and international levels; and
• to improve the organizational capacity of partner institutions, by exchanging knowledge and experience of NCD research on LMICs within the wider academic/public health community.

RESCAP-MED successfully fulfilled this aim with two major events, these taking place as planned in Istanbul and Beirut. For full programmes, see Appendices. In summary:

1st RESCAP-MED International Symposium
Social Determinants of NCDs in Mediterranean Countries, 6-7 May 2013, Istanbul, Turkey
Websites:
http://research.ncl.ac.uk/rescap-med/activities/symposia/istanbulsymposium2013/

http://www.netph.sgul.ac.uk/events/international-symposium-on-social-determinants-of-ncds-in-mediterranean-countries#.VNC6G8tyY5s

• 96 participants
• 4 keynote speakers (2 from within RESCAP-MED, 2 invited external speakers)
• 2 special sessions
• 6 country reports presented on inequalities in NCDs
• 64 accepted abstracts (16 oral presentations)
• 25 participants then attended the post symposium course taking place on social determinants of health inequalities – facilitated by Prof. Joan Benach (University of Pompeu Fabra, Barcelona), and taking place 8-9 May 2013.

2nd RESCAP-MED Regional Symposium
Socio-political Challenges in the Mediterranean Region: Implications for NCD Prevention and Control, 3-4 December 2014, Beirut, Lebanon.
http://research.ncl.ac.uk/rescap-med/activities/symposia/beirutsymposium2014/

• 185 participants
• 4 keynote speakers (2 from within RESCAP-MED, 2 invited external speakers)
• 4 keynote lectures, 15 oral presentations and 23 poster presentations
• 86 submitted abstracts
• 58 people coming from abroad – 13 countries (Palestine, Jordan, Iraq, Tunisia, Kuwait, Libya, Algeria, Sudan, Spain, Turkey, UK, USA, Barbados) in addition to those attending from Lebanon
Predictably, these were the RESCAP-MED events with the greatest visibility and impact. One major benefit of the Istanbul Symposium was that it was followed by a training workshop on broadly the same theme as the symposium itself – the social determinants of health – which facilitated the development of skills in this area of work. Moreover, the symposium also helped us recruit potential participants for subsequent workshops and fellowships. One additional major benefit of the Beirut symposium was that it was also linked to a second event, in this case the 60th anniversary conference held by the Faculty of Health Sciences immediately after our own event, the AUB conference being titled ‘Public Health in Contexts of Uncertainty’. The two events thus reinforced each other to mutual benefit, with a proportion of participants coming in order to attend both events.
The title and scope of the first Symposium in Istanbul was anticipated in the original project plan, and followed closely the project title itself. The title and scope of the second Symposium in Beirut was an example of the determination within the network that RESCAP-MED should be responsive to emerging realities (discussed more fully in section 13).

7. NETPH (North Africa, Eastern Mediterranean and Turkey Public Health Network)
As part of the RESCAP-MED commitment to create a sustainable e-learning environment The North Africa, Eastern Mediterranean and Turkey Public Health Network (NETPH) website went live in September 2013. It has steadily built up its reach and scope since it started. Initially, NETPH was hosted by partners St Georges London University, who led the work package. The website continues to benefit from technical assistance and support (free of charge) from the St George’s University IT team: http://www.netph.org/.
In many ways, NETPH has achieved even more than we had hoped. We undertook to deliver a pilot website and e-learning facility, one that would be largely a ‘proof-of-concept’ exercise. In practice, we have been able to create an operational website that fills a niche like no other in the region. It provides a growing range of training materials across several disciplines (reflective of RECAP-MED’s interdisciplinary approach), a publications section, and news updates.
Both of NETPH’s ostensible comparator websites – Middle East and North Africa Health Policy Forum (MENAHPF) and Eastern Mediterranean Public Health Network (EMPHNET) – have different priorities and orientations, and neither is currently as consistently updated as NETPH. However, that issue of being up-to-date is precisely the issue we face with the ending of RESCAP-MED: how to sustain NETPH beyond current funding. The St George’s partner has been able to find temporary funding to allow NETPH to continue for a few more months (into the second half of 2015). But a secure solution is required. The NETPH website address http://www.netph.org/ was purchased under a three year license which will expire early in 2016.. However, the most pressing need is for staff time to continue to update and maintain relevance to the website. The time commitment for this task cannot be underestimated and requires several different skills including technical skills (website development, graphic design, texting editing), administrative skills, as well as knowledge of NCDs in the region. The site has recently been supported by one key researcher with excellent technical and graphic designs skills, as well as some experience working on NCDs in LMICs. A “steering group” for NETPH, consisting of one or more key researchers from each project country, has provided the regional context and more in-depth knowledge of NCDs and public health. This steering group is mainly virtual and has met through Skype conversations on a regular basis, supplemented by meetings during RESCAP-MED symposia and other key workshops. Motivation to continue this is high but this commitment cannot be assured on a long term basis without external funding.
One option under discussion is whether to pursue some kind of link and association with MENAHPF. This has arisen as a result of initial overtures from individuals on the MENAHPF Executive Committee, and testifies to the wider perceived impact of NETPH. We return to this topic, and the options we are considering, in section 14. Part of our broader effort to capitalize on available regional resources in order to increase the visibility of RESCAP, as well as foster connectedness around NCD issues and public health research more generally in the region, was through linking to Public Health in the Arab World (PHAW) – http://www.aub.edu.lb/fhs/phaw/Pages/index.aspx . This is a site hosted by our Lebanese partners at the American University of Beirut. As mentioned above, even at the time of submission of this report, discussions are ongoing as to how we may liaise and collaborate with one of these sites (MENAHPF).

8. Fellowship Programme
In total, 18 research visits were made under the project’s Fellowship Programme by 13 research fellows. This part of the project was managed by Trinity College Dublin. The majority of these fellowships involved short visits of 1-2 weeks. However, some of the research fellows visited the same host institute on several occasions, which meant the overall time spent on any particular fellowship was longer than 2 weeks, and in some cases 4-6 weeks in total (for reasons discussed in section 12). All Mediterranean partners except for Syria were able to identify potential fellows: four from Lebanon, three from Turkey, and two each from Jordan, Palestine and Tunisia. Two of these fellows made two visits under the programme; two made three visits. Host partners were Liverpool, hosting 8 separate visits by 4 fellows; Newcastle, hosting 6 visits by 5 fellows; Dublin hosting 2 visits by 2 fellows; St George’s London 2 visits by one fellow; and Izmir hosting one visit by one fellow. The majority of fellowships were undertaken by early career researchers (two thirds), with around one third undertaken by those consolidating research careers at a mid-career level.
The sequence of fellowships – none in the first year (2012), six in the second (2013), with the first in March 2013, and twelve in the third (2014) – reflects several factors. First, it took the PMC time to develop the procedures for applications and monitoring of fellowships. Second, it took time for requests from potential fellows to build up. In several instances, the interest was sparked by attendance at one of the project workshops. Thirdly, once the interest was apparent partner leads had still to plan when best to release their own staff for a fellowship. It thus took time for this part of the project to gain momentum. Ideally, these fellowships would have been spread more equally. In practice, interest and enthusiasm built up through word of mouth by those returning from a fellowship. We had not initially envisaged that visiting fellows would make more than one visit. But as it became evident that fellowships of longer duration (1-3 months) would be unrealistic, the clear benefits of two (or even three) separate visits became the preferred solution. The ease with which it was possible for mentors and fellows to stay connected after or between visits ensured that fellowships were productive. Most fellowships contained both a training and research element. Details of individual fellowships are summarised below. It is worth stating that all fellows were keenly motivated (for one powerful example, reflecting back at the end of the project, see Appendix 3).

Table 2: Training& Research during fellowship and 3-6 months after fellowship
Fellow Name Training
Research
Eren Korkmaz
(TR to UNEW) Global health module; Qualitative research; medical anthropology; Designing qualitative research; social representations. Designed a qualitative research project on barriers to self-care behaviour in diabetes.
Duygu Islek
(TR to UoL) Turkish stroke epidemiological modelling methods; applying food policy scenarios to the model for prevention of CHD and stroke mortality in Turkey. Food policy scenarios on prevention applied to the Turkish stroke and CHD epidemiological model. Draft paper in preparation.
Ceyda Sahan
(TR to SGUL) CHD epidemiological modelling methods; Developing scenario and policy analyses; probability sensitivity analyses; preparation of abstract and paper for publication. CHD epidemiological model and application of scenario and policy analyses; probability sensitivity analyses; preparation of abstract and paper for publication.
Niveen Abu-Rmeileh
(P to UoL) Diabetes epidemiological model ; UKPDS model Building and completion of diabetes epidemiological model for projected prevalence in Palestine; Source data from UKPDS model.
Dooa Hammoudeh
(P to UNEW) Writing for academic publication Analysis of infertility data conducted in ICPU; the data will be used to develop a paper.
Faten Tlili
(TN to UNEW) Questions for data collection in qualitative research; analysis of qualitative data; paper writing and revision. Completed data collection and analysis; Writing an article on traditional healing and mental illness in Tunisia.
Olfa Saidi
(TN to UoL) Stroke epidemiological model; monte carlo methods and sensitivity analysis. Stroke epidemiological model for Tunisia, Abstract written and presented.
Dr Khaled Abu Hammour
(J to DEU) Planning and writing a proposal on “Association Between Herbal Medicines Use and type II Diabetes Control in Jordan”. Planning and writing a proposal on “Association Between Herbal Medicines Use and type II Diabetes Control in Jordan”. Including study design, sample size, randomisation methods, data collection and analysis.
Dr Sayer I. Al-Azzam
(J to TCD) Using large prescribing databases of complex data; SPSS statistical software; literature reviewing. Literature review completed on drugs that interact with anti-diabetic medications. Estimate of the prevalence of these interacting drugs in an Irish population. To be written for publication.
Sibel Labban
(L to UoL) Food policy models; population projection models for the Lebanese population. Forecasted deaths prevented or postponed from food policy intervention in the Lebanese population. Including salt reduction, saturated fat. Also deaths prevented by introducing policies in smoking, physical activity etc. Abstract presented at RESCAP-MED conference Dec 2014.
Hala Kerbage
(L to UNEW) Writing research proposals; qualitative training in interviewing and sampling; Research Proposal on ‘exposing experience of Syrian refugees with mental health and psychosocial support’ completed; application made for funding.
Christy Costanian
(L to TCD) Writing for academic publication; completing a paper for submission Analysis conducted mainly in Lebanon and during fellowship; publication prepared and submitted.
Anthony Rizk
(L to UNEW) Drafting research proposals; anthropological methods; public health NCDs Worked on research proposal; Paper on Knowledge into action drafted ; another publication submitted to BMC implementation science

9. Other Capacity Building Activities

Because of the difficulty, if not impossibility, of other partners entering Palestine, in March 2014 Prof. Peter Phillimore visited partners in Birzeit University’s ICPH for a 9 day visit. Prof. Phillimore’s visit involved the following activities at Birzeit University:
• Running a one day qualitative methods training day for ICPH researchers
• Presenting a research seminar
• Discussion and mentoring with each individual research team on the qualitative dimension of recent and ongoing research projects, with a view to assisting analysis and writing articles for publication in academic journals.
• Discussion of the range of potential journals that might be considered for qualitative research analyses, consistent with ICPH’s publication policy.
Several training workshops were conducted in association with other regional events and in collaboration with partners inside and outside RESCAP-MED to increase capacity in chronic disease research regionally. For example, Prof. Maziak (SCTS) organized and led two such training workshops during the 1st and 2nd International Conference on Waterpipe Smoking (Abu Dhabi 2013 Qatar 2014 http://icws.hamad.qa/en/program/25_october/25_october.aspx These workshops were attended by more than 70 junior researchers from across the region and focused on building research and grant writing skills that will enable those researchers to compete for funding and conduct high quality research.

10. Dissemination
Dissemination has been aimed primarily at two categories of people. First, we have sought to engage with national Ministries of Health and senior administrative or policy-making staff; at international organisations; at relevant NGOs; and at academic peers more widely. Second, we have sought (particularly through NETPH, and the project Facebook page) to engage with the rising generation of public health researchers in the MENA region.
Attracting attention for NCD research capacity-building in a time of such massive political turbulence is no easy matter. That said, through our activities we confidently claim that the acronym RESCAP-MED has now become familiar around much of the region to academics and policy-makers, most especially in those countries where Mediterranean partners are based.
We consider Dissemination more fully under the Impact section of the final report (and see Template A2). However, our Dissemination strategy has had eight main components, which link the activities of several work packages.
a. The involvement of key individuals on the Project Monitoring & Advisory Committee (ProMAC) (discussed more fully under Impact).
b. The project website (managed by the Newcastle office): http://research.ncl.ac.uk/rescap-med/
c. The NETPH website (managed by St Georges London): http://www.netph.org/ , including active Twitter site https://twitter.com/netphn
d. Facebook page “Eastern Mediterranean Network for NCD Research” https://www.facebook.com/groups/100218610103673/
e. Regular Project Newsletters (produced by Jordan partners at JUST), available on the RESCAP-MED website: http://research.ncl.ac.uk/rescap-med/news/newsletters.html
f. Three Policy Briefs for stakeholders in the region (produced by Jordan partners at JUST), available on the project website:
http://research.ncl.ac.uk/rescap-med/activities/engagement/
g. Country meetings with stakeholders, held in 2013 and late 2014
a. Jordan 11th Dec 2014
b. Turkey (17-20 Dec 2014)
h. The two major Symposia held in Istanbul and Beirut
The Facebook page “Eastern Mediterranean Network for NCD Research” now has 300+ members representing different countries in the region and sectors involved in chronic disease research and health care; academia, health delivery, NGOs, and international health organizations. The Facebook page has been actively utilized by our team members as well as those involved in chronic disease research and care in the region and internationally. The page is witnessing daily traffic and postings, and is mostly used to share research data, training opportunities, research funding opportunities, and articles and news pieces that deal with the important issues related to chronic disease in the region. It thus supplements NETPH. .

11. Publications facilitated through RESCAP-MED
Publication has been another facet of dissemination, aimed at academic and policy-making audiences, through contributing to major debates concerning NCD epidemiology and the challenge posed by NCD for health systems. However, publication clearly warrants a section in its own right. Much of RESCAP-MED’s publication track record builds on the success of MedCHAMPS, its predecessor project, as will become apparent. Herein lies a big problem with APCs. Many of the publications being drafted in writing workshops will not come out until after the end of RESCAP-MED. Yet the EC want them published in open access journals and this makes sense for the region. But each open access paper may cost around $2000-$3000. So the question arises: how are we supposed to pay for this when the grant has run out?
There has so far been one country-specific publication (from Turkey) focused on RESCAP-MED: that has analysed the Turkish Training Needs Assessment undertaken as part of the larger comparative TNA.
1. Kilic B. et al. 2014. Research capacity and training needs for non-communicable diseases in the public health arena in Turkey. BMC Health Services Research 2014 14:373. doi:10.1186/1472-6963-14-373
More typically, the RESCAP-MED Writing Workshops and Fellowships have provided the framework for mentoring that led to subsequent peer reviewed papers. These can be divided into two categories: papers which are based on MedCHAMPS research, brought to publication through RESCAP-MED; and papers which are entirely separate from MedCHAMPS.
An essential art of sustainability of our efforts through RESCAP-MED has been to increase research capacity not only for the conduct of research, but also for taking research data to the final stages of data analysis and data reporting. This is the hardest part in the research continuum, and the most critical for junior researchers in order to build research careers and credibility. As a result, WP9 led the organization of a Supplement in the International Journal of Public Health under the title “The rising burden of non-communicable diseases in four Mediterranean countries and potential solutions”. The supplement was planned to allow junior researchers to publish their research under the mentorship of senior RESCAP-MED academics. The supplement preparation and organization was led by Prof. Maziak (SCTS director), and 3 RESCAP-MED project members acted as guest editors (Maziak, Critchley, and Zaman). The supplement was published in January 2015 and has 9 papers from the 4 project partner countries, mostly led by relatively early career researchers.
MedCHAMPS publications facilitated through RESCAP-MED:
2. International Journal of Public Health, Vol. 60, Supplement 1, 2015: The rising burden of noncommunicable diseases in four Mediterranean countries and potential solutions. Editors, Wasim Maziak, Julia Critchley & Shahaduz Zaman.
(a) Rula Ghandour, Azza Shoaibi, Rana Khatib, Niveen Abu Rmeileh, Belgin Unal, Kaan Sözmen, Bülent Kılıç, Fouad Fouad, Radwan Al Ali, Habiba Ben Romdhane et al. Priority setting for the prevention and control of cardiovascular diseases: multi-criteria decision analysis in four eastern Mediterranean countries. International Journal of Public Health 2015, Volume 60, Issue 1 Suppl. pp 73-81.
(b) Kaan Sözmen, Belgin Ünal, Olfa Saidi, Habiba Ben Romdhane, Niveen M. E. Abu-Rmeileh, Abdullatif Husseini, Fouad Fouad, Wasim Maziak, Kathleen Bennett, Martin O’Flaherty et al. Cardiovascular risk factor trends in the Eastern Mediterranean region: evidence from four countries is alarming. International Journal of Public Health 2015, Volume 60, Issue 1 Suppl. pp 3-11.
(c) Kaan Sözmen, Belgin Unal, Simon Capewell, Julia Critchley, Martin Flaherty. Estimating diabetes prevalence in Turkey in 2025 with and without possible interventions to reduce obesity and smoking prevalence, using a modelling approach. International Journal of Public Health 2015, Volume 60, Issue 1 Suppl. pp 13-21.
(d) Bulent Kilic, Sibel Kalaca, Belgin Unal, Peter Phillimore, Shahaduz Zaman: Health policy analysis for prevention and control of cardiovascular diseases and diabetes mellitus in Turkey. International Journal of Public Health 2015: DOI 10.1007/s00038-014-0557-7
(e) Faten Tlili, Francine Tinsa, Afef Skhiri, Shahaduz Zaman, Peter Phillimore & Habiba Ben Romdhane: Living with diabetes and hypertension in Tunisia: popular perspectives on biomedical treatment. International Journal of Public Health 2015: DOI 10.1007/s00038-014-0572-8
(f) Habiba Ben Romdhane, Faten Tlili, Afef Skhiri, Shahaduz Zaman, Peter Phillimore: Health system challenges of NCDs in Tunisia. International Journal of Public Health 2015: S39–S46 DOI 10.1007/s00038-014-0616-0
(g) Balsam Ahmad, Fouad M. Fouad, Madonna Elias, Shahaduz Zaman, Peter Phillimore & Wasim Maziak: Health System Challenges for the management of cardiovascular disease and diabetes: an empirical qualitative study from Syria. International Journal of Public Health 2015: DOI 10.1007/s00038-014-0594-2

3. Rastam S, Al Ali R, Maziak W, Mzayek F, Fouad F, O'Flaherty M, Capewell S. 2012. Explaining the increase in coronary heart disease mortality in Syria between 1996 and 2006. BMC Public Health 12:754. doi:10.1186/1471-2458-12-754. [Highly Accessed]
4. Saidi O, Ben Mansour N, O’Flaherty M, Capewell S, Critchley JA, et al. 2013. Analyzing Recent Coronary Heart Disease Mortality Trends in Tunisia between 1997 and 2009. PLoS ONE 8(5): e63202. doi:10.1371/journal.pone.0063202. 2013.
5. Al Ali R, Mzayek F, Rastam S, Fouad F, O’Flaherty M, Capewell S, Maziak W. 2013 Forecasting future prevalence of type 2 diabetes mellitus in Syria. BMC Public Health 13:507. doi:10.1186/1471-2458-13-507 [Highly Accessed]
6. Unal B. et al. 2013. Explaining the decline in coronary heart disease mortality in Turkey between 1995 and 2008. BMC Public Health 13(1):1135. doi:10.1186/1471-2458-13-1135.
7. Ben Romdhane H. et al. 2014 Prevalence of diabetes in Northern African countries: the case of Tunisia. BMC Public Health 14:86. doi:10.1186/1471-2458-14-86 [Highly Accessed]
8. Mason H et al. the MedCHAMPS project team. 2014 A Cost Effectiveness Analysis of Salt Reduction Policies to Reduce Coronary Heart Disease in Four Eastern Mediterranean Countries. PLoS ONE: DOI: 10.1371/journal.pone.0084445.
9. Saidi O, O'Flaherty M, Ben Mansour N, Aissi W, Lassoued O, Capewell S, Critchley J, Malouche D, Ben Romdhane H. In press 2015. Forecasting Tunisian Type 2 Diabetes Prevalence to 2027: validation of a Simple Model BMC Public Health.
10. Critchley J. et al. In press 2015. Contrasting cardiovascular mortality trends in Eastern Mediterranean populations: contributions from risk factor changes and treatments. Lancet Global Health.

Additional Papers not related to MedCHAMPS but facilitated through RESCAP-MED
1. Coutts A & Fouad F. 2013 Response to Syria's health crisis—poor and uncoordinated. The Lancet 381, No. 9885, p2242–2243, 29 June 2013 http://dx.doi.org/10.1016/S0140-6736(13)61421-X
2. Islek D, Sozmen K, Unal B , Guzman Castillo M, Vaartjes I, Capewell S, O'Flaherty M. 2014 Modelling the effect of potential interventions for prevention of stroke and cardiovascular deaths among Turkish population for year 2012-2022. 2014 Eur J Public Health 24 (suppl 2). DOI: http://dx.doi.org/10.1093/eurpub/cku166.035 First published online: 31 October 2014.
3. Sahan C, Sozmen K, Unal B, Critchley J. 2014 Impact Of Risk Factor Modifications On Coronary Heart Disease Mortality In Turkish Adults For 2025. Eur J Public Health 24 (suppl 2): DOI:http://dx.doi.org/10.1093/eurpub/cku165.091 First published online: 31October 2014.
4. Costanian C, Bennett K, Hwalla N, Assaad S, Sibai AM. Prevalence, correlates and management of type 2 diabetes mellitus in Lebanon: findings from a national population-based study. Diabetes Res Clin Pract. 2014 105(3):408-15. doi:10.1016/j.diabres.2014.06.005. Epub 2014 Jun 23 2014.
5. Faten Tlili et al. On post-revolution resurgence in visibility of ‘traditional’ or religious healers. In prep.
6. Anthony Rizk, Abla Sibai et al. Knowledge-to-Action pathway on ageing in the Arab world: the role of institutional arrangements. In prep.


12. Successes and Limitations of RESCAP-MED
We believe we are justified in calling RESCAP-MED a very successful project. We have fulfilled our key objectives, and we have built a cohesive and supportive network.

We have fulfilled our key objectives. In brief, we have:
• Delivered all workshops as planned.
• Organised two major 2-day Symposia in Istanbul and Beirut as planned.
• Run a visiting fellowship programme as planned.
• Created an effective e-learning website as planned.
• Fulfilled our dissemination targets.

We have done so in an extraordinarily demanding context, which we could not have anticipated when the grant proposal was first submitted (discussed further in section 13). Moreover, these activities have not been separate, disconnected tasks but have worked together. The symposia have been a part of our dissemination activities, while the first symposium helped lead us to recruits for workshops in the second half of the project. Likewise, NETPH has been a major element in our dissemination to wider audiences of researcher and policy makers. The fellowship programme has for some researchers provided a vital and valuable follow-on to the workshops. Those attending workshops have been able build upon their efforts to make progress on publications through the fellowship programme, some going on more than one fellowship visit for this purpose. And NETPH backs up the workshops by providing a repository for training materials. Our initial survey results suggest that those who use the survey have mostly been to workshops or have colleagues who have attended.

We have built a cohesive and mutually supportive RESCAP-MED network. The second sense in which the project has been a success is less easily expressed in terms of stated objectives but relates to the cohesion and mutual supportiveness of the RESCAP-MED network. In this, we have built upon the work started in our predecessor FP7 project, MedCHAMPS. RESCAP-MED is a network of eleven partners who take pleasure in working together. In some cases it was prior research relationships that helped to create the network (some of these pre-dated MedCHAMPS). In other cases the relationships have been created through the network. In all cases these ties have been strengthened as a result of our collaboration. This project has thereby nurtured a vehicle for subsequent collaborative research in the region, among highly capable partners, helping to sustain and extend the work started through MedCHAMPS. Thus, the EC can consider this as having been an investment in building a cohesive network of NCD researchers in the region, one which is well-placed to undertake future collaborative and comparative research.

However, alongside our successes, we also acknowledge the importance of reflecting self-critically on the ways in which we have been less successful than we had hoped. We will start to address limitations in what we have achieved by referring back to our initial project framework detailing the tasks we set ourselves, and the degree to which we have been successful.

1. Organise four training workshops in partner countries to enhance methodological skills (both face-to-face and through on-line training). SIX COMPLETED.
2. Organise three training workshops in partner countries to foster grant-writing, and research manuscript writing skills. TWO COMPLETED FOR ALL, THREE FOR SOME.
3. Organise two international symposia on the social and environmental determinants of NCDs and implications for policy, with keynote speakers, in order to foster dialogue with a wider academic and policy-making community. BOTH COMPLETED.
4. Create an online depository of training materials, and research resources. COMPLETED.
5. Develop an e-learning website to pilot the utility of a web-based learning system for RESCAP-MED, and subsequently for a wider academic community of NCD researchers in the region. NETPH COMPLETED.
6. Foster cross-disciplinary research grant applications and collaborative research in partner countries. SOME PROGRESS.
7. Link with, cooperate with, and where appropriate draw on the expertise of existing professional networks in the region. LIMITED SUCCESS, RELATIONSHIPS AND WORK ONGOING.
8. Create a pool of ‘critical experts’ to provide advice on all stages of collaborative research design, conduct and publication. PROGRESS.
9. Organise in-country dissemination workshops to key stakeholders at the end of the project. COMPLETED IN ALL CASES EXCEPT FOR SYRIA.
10. The establishment of a competitive, funded visiting fellowship programme, to be organised through the network outlined above. FULFILLED. GIVEN NUMBERS INVOLVED NOT NEEDED ON COMPETITIVE BASIS.
11. Involve exchanges of personnel both for mentoring junior researchers and for pursuing research collaborations and advanced training for mid-career researchers. FULFILLED.
12. Facilitate each stage of the research process, from scoping work and literature review to research design and grant application, and through to publication and dissemination. FULFILLED.
13. Operate on both a south-south and south-north basis. SUCCESSFUL ON SOUTH-NORTH; SOUTH-SOUTH TO DEVELOP FURTHER.
14. Last for shorter or longer duration (typically 4 weeks to 3 months), depending on the task(s) to be achieved. SHORTER FELLOWSHIPS IDEAL & FULFILLED.
15. Apply to both academic and operational (i.e. Ministry of Health personnel) researchers. SUCCESSFUL FOR ACADEMIC RESEARCHERS. OPERATIONAL FOR DEVELOPMENT IN MORE PROPITIOUS POLITICAL CONTEXT.

On this basis, it is clear that while we were successful in the events we held, we found it harder to make progress to ‘reach’ policy-makers or embed NCD research in health policy-making, particularly at this time of multiple upheavals. We consider the limitations identified above under the following headings:
• Research Mentoring and Training Needs
• Fostering Research Collaboration between partners
• Engaging policy makers and operational research in ministries.

Research Mentoring and Training Needs.
(a) One major lesson from the workshops was the need for mentoring in academic writing. The researchers who attended workshops typically had some skills as empirical researchers, and considerable competence in report-writing. But they also had limited familiarity with writing for peer-reviewed journals. In hindsight, and for future capacity-building projects, we conclude that greater emphasis should be given to fostering these skills. The first writing workshop incorporated a day on grant-writing skills after two days on academic paper-writing. However, the majority of those attending were not at the career stage to be envisaging grant-writing, which was why later writing workshops focused solely on paper-writing. Three-day workshops were also probably too short for developing these writing skills; in hindsight at least one five-day writing workshop would have been beneficial.
(b) We designed the fellowship programme to offer the possibility for both short and longer visits. In practice, no longer fellowships took place. None of the Mediterranean partners could afford the luxury of sending staff or potential trainees for periods of a month or more. As a result, all fellowships have been short ones, typically of 7-14 days. These worked well, and concentrated on developing papers for publication or on developing skills in new epidemiological techniques. Crucial was the mentoring before and after the fellowship.
(c) It proved unnecessary to implement our intended plan to make these fellowships competitive. Numbers did not warrant it. In a context where it proved difficult enough for partner institutions to release staff, we sought to maximise fellowships on the basis of a proposal that was endorsed by the director of the partner institution, the academic lead administering the fellowship programme (Dr Bennett at TCD) and the proposed host. That allowed sufficiently for a realistic assessment of quality and feasibility of achievement.
(d) We were not successful in attracting operational researchers for fellowship visits. In hindsight this was probably an unrealistic aspiration in the current political context.

Fostering Research Collaboration between Partners.
(a) Translating our collaboration into grant applications (and grant success) takes longer to show results. The RESCAP-MED network can certainly point to efforts in this regard: 4 grant applications were submitted which drew upon the opportunities provided by our network:
• Award by NIH 2012-2016: Principal Investigator: Ghada El Hajj Fuleihan. Co-Investigators: Abla Sibai, Robert Habib, Huda Heijer, Nahla Hwalla. Title of Project: Capacity building in chronic non-communicable diseases at the American University of Beirut. Total: $863,147
• Application to Wellcome/ DFID (2013). ‘Assessing the mental and psychosocial health of Syrian refugees in Lebanon’. AUB (Coutts, Fouad, Sibai, Phillimore) Outline submission, Unsuccessful, but a resubmission in 2014 awaiting result.
• Award by Tubitak (Turkish Science and Technology Council) to DEU Izmir to fund Duygu İşlek to work on sugar consumption modelling with Prof. Capewell and Dr O’Flaherty at Liverpool University (Award Duration: 6 months; Award, 2015). Funding was a direct outcome of the RESCAP-MED Fellowship programme.
• Application to Trinity College Dublin for a visiting fellowship for Hendia Amir Abunab’a, a research fellow in Palestine. For analysis of her own data from Palestine around transitions into adulthood among Palestinian youth, and postpartum depression in Palestinian women. (Value: 1000 euros. 50% funding awarded.)

(b) The task of creating a pool of ‘critical experts’ (task 8 above) to provide advice on all stages of collaborative research that goes beyond our own network is also an area where we have some success, but not as much as we might have hoped. As the workshops developed we drew in outside experts to present sessions to great effect. These individuals (from government, academia, NGOs and private consultancies) enlarged both the scope and the relevance of the training we were able to offer (see section 4 above). The next step is to draw on these networks to create a pool of critical expertise for research design and grant applications. That has proved to be too ambitious a step in the time available.

(c) We were only able to achieve one fellowship exchange between Mediterranean partners (see task 13 above). This was a disappointment.

Engaging policy makers and operational research in ministries.
(a) RESCAP-MED has worked hard to foster this aspect of our work, through several avenues: through having EMRO as research partners; through involvement of national policy makers and senior administrators in the Training Needs Assessment; through participation of policy makers as visiting speakers in workshops; through regular Newsletters and specific Policy Briefs; through invitations to the two major Symposia; through NETPH; and through national meetings with policy makers. Despite this deliberately extensive list of avenues for dialogue, we concede that this task is not straightforward, and policy makers often have limited interest in the work of individual research projects, especially at a time of such huge political turmoil.
(b) RESCAP-MED’s own research partners provide extensive connections to government and policy in their own countries. In that sense, RESCAP-MED was for most one facet of ongoing dialogues all are having with their governments or with relevant international organisations and NGOs concerning health policy priorities. Moreover, our ProMAC provided us with an additional level of connection to policy-making at a variety of levels – NGOs, national government and WHO.
In our efforts to meet our objectives, the political turmoil in the region complicated our efforts greatly. We now consider these factors in more detail.

13. Challenges Faced in Current Political Situation
It is important to remember that RESCAP-MED was designed prior to the political turmoil that started in January 2011. When we submitted our proposal to the EC for capacity building in the six Mediterranean partner countries, no one could have anticipated what dramatic changes there would be in the circumstances which form the wider context to our work. For example, when the EC awarded this grant, we could not then know:
a. That it would prove impossible to hold any events in Syria.
b. That it would prove impossible for academic colleagues or potential trainees living in Syria to participate in our events.
c. That sanctions against Syria would make it impossible for the Syrian partners to hold their budget in Syria.
d. That the Syrian partners, SCTS, would have their staff scattered by the crisis (to Lebanon, Jordan, Egypt, and the USA, with two of those employed by SCTS at the start of RESCAP-MED still resident in Aleppo at the end of the project).
e. That the deteriorating political situation in both Lebanon and Tunisia at certain points would prove sufficiently insecure to necessitate rearranging planned events in both countries at fairly short notice (with events moved to Turkey and Jordan respectively).
f. That as the political situation worsened, obtaining visas also became an increasing problem, with unpredictable delays. We ruled out a workshop in the UK because we knew that visa difficulties would present us with many problems. (To give two other examples of visa difficulties: Tunisian participants could not get visas in time for the 1st Writing Workshop in Dublin; and Palestinian participants were only able to attend the 2nd Writing workshop in Tunisia after high level interventions, including by the Palestinian Ambassador to Tunisia). Visa delays on occasions also complicated the fellowship programme.
All these issues greatly complicated our work. For a coordination and support action built around a set of events (training needs assessment, training workshops, symposia, visiting fellowships) the practical task of delivering our commitments inevitably proved much more challenging than we were anticipating. In our Project Management Periodic Report after 18 months we described the situation as it appeared to us then in mid-2013. We briefly quote this here to highlights graphically the circumstances we faced:
“At one level, the wider political situation complicates decision-making about where to hold our planned events. We knew we could not hold events in Palestine, as only Turkish colleagues among our Mediterranean partners would be able to attend. For obvious reasons, Syria is impossible. Planning events in Jordan, Lebanon and Tunisia is possible, but in each case we have to be prepared to rearrange these should the situation on the ground change. At the time of writing this report, for instance, we would not hold an event in Tunisia because of the volatile situation there at present; and the Turkish Government call for their citizens to leave Lebanon or to avoid travel there, in the wake of kidnap in Beirut of two Turkish Airlines pilots this month puts a question mark over potential Turkish participation in any event held in Beirut. Rearranging a workshop at 2 months’ notice is one thing; having to rearrange a symposium would be quite another.”

Taking those events (symposia and workshops) involving the whole network, four were hosted by DEU in Turkey, and four were hosted by JUST in Jordan. Partners in Beirut, Cairo, Tunis and Dublin each hosted one event. That uneven distribution of our main events is telling in itself.

Moreover, the focus of the project on the social determinants of NCDs had to be widened to reflect the new circumstances. Standard depictions of social determinants would have done no justice to the complexity of the situations developing very rapidly in these countries. To give an example, in designing both the Health Policy Evaluation workshop and the Environmental Health Workshop we decided that it was essential to have sessions which considered the magnitude of the task created by forced migration and the enormous scale of refugees in Jordan, Lebanon, Tunisia and Turkey. We also added a section to NETPH on “NCDs in displaced populations” in response to the situation that had developed and perceived need on the ground.

The title of our second symposium, held in Beirut in the final month of the project, also reflected our collective response to the new situation, and our appreciation that we had to think of social determinants of NCDs in a way that encompassed the scale of the crisis engulfing the health systems in partner countries. The title was decided at our PMC in Jordan in April 2013. Syria at that point had endured two years of intensifying conflict and misery; Tunisia was still in a state of great uncertainty; and four of our partner countries (Jordan, Lebanon, Turkey and Tunisia) were each grappling with accommodating hundreds of thousands of refugees. As the planning for it started we concluded that if we neglected the particular implications of the current crisis for NCD care and health systems we would be guilty of ignoring the biggest single pressing public health concern in these countries. Thus, as we wrote in the handbook for the Beirut Symposium:
“These developments in population health are taking place against a background of political upheaval unanticipated even a few years ago, and in countries most challenged by scarcity of resources. These countries have been profoundly affected by these seismic events, with massive and growing population movements as people flee violence or its threat. The consequences for physical and mental health of extreme insecurity and hardship, and the repercussions for fragile health systems now additionally overwhelmed by the crisis, have scarcely begun to be evaluated. This symposium brings together these two powerful dynamics – the epidemiological and demographic on the one hand and the political and social on the other – to assist this vital process of evaluation.”
The very positive feedback from participants at the Beirut symposium – expressing how valuable it was to provide a forum for researchers, practitioners and policy makers to address NCDs in the current tumultuous context – confirmed our hopes in that regard.

Against this background we are relieved and very grateful that the EC kept faith with this project. For our part, we believe that we have delivered on our undertaking – to the EC as funders and to our partners’ stakeholders in their countries – to put together a considered capacity-building programme. We return to this in the final section (no.14) to consider the pros and cons of such capacity-building projects, and some of the factors that may assist effectiveness. Before that, however, we look at the question of sustaining momentum within the network.

14. Sustaining Momentum
Our objectives in terms of long term sustainability have focused around the following:
• To increase the visibility of the RESCAP-MED network.
• To reemphasise the urgency of developing research capability in the NCD field.
• To facilitate networking and communication between researchers in the region and their regional and international counterparts.
• To provide resources and mentorship for junior researchers in the region in order to conduct high quality research and enhance their career prospects as independent researchers.
• To identify research capacity needs and conduct training activities in conjunction with other regional events and in collaboration with regional partners.
The partners in this network do not see RESCAP-MED as an ending. We intend to work towards future activities and grant applications (to the EC and/or other funders) involving different combinations of partners. While we cannot anticipate exactly where this will lead, there are specific events planned to take place, in 2015,using resources outside the RESCAP-MED funds. We note here that the Tunisian partners, CAVEPLA, will be using their own funds to organise three events for Maghreb participants in the first 6 months of 2015 which draw on the networks established through first MedCHAMPS and then RESCAP-MED:
• A workshop on qualitative research methods (26-29 January 2015)
• A workshop on medical anthropology (22-25 March 2015)
• A conference for Maghreb policy-makers on the lessons of a research capacity project such as RESCAP-MED (28-29 May 2015).
While the first two of these events follow the RESCAP-MED workshop format, the last follows a format the Tunisian team adopted to disseminate the findings and lessons from MedCHAMPS.

In parallel, the last of our PMC meetings, to finalise this document and the key messages from this project, also provided an opportunity for our Syrian joint-lead (Dr Fouad) to speak about the public health implications of the Syrian crisis in presentations at the London School of Hygiene & Tropical Medicine (12 February 2015) and Cambridge University (16 February 2015). Moreover, the two Scientific Coordinators of MedCHAMPS and RESCAP-MED will present in Brussels on the policy lessons from looking jointly at these two projects (30 April 2015).

The success of NETPH in a short period emphasises RESCAP-MED’s achievements beyond the events we have held. We highlight here our intention to secure a sustainable future for our e-learning website, NETPH. This intention is reflected in the fact that the St Georges partner has levered additional funds to subsidise the continued management and updating of NETPH for the coming 6-8 months. This will help to buy further time to arrange a sustainable solution. At this point, two options for the future are under consideration. For the next year and more after the St Georges funding ends, CAVEPLA, the Tunisian partners, have offered (and have the funds) to administer NETPH. Alongside this, we are in discussion with MENAHPF about creating closer links and collaboration, on the basis that the complementarity of the two bodies offers valuable benefits to both.

A different long term initiative is underway through partners at WHO-EMRO. They have been developing plans for a greatly needed Health Economics training package, as a direct outcome of their stake in this project. WHO EMRO is working to develop a standalone course in Health Economics and Health Financing that can be packaged and shared with Member States and related academic institutions in support of efforts to build regional and national capacity.


15. Overall Lessons and Conclusions
While section 12 reviewed the successes and limitations of RESCAP-MED, we now step back to consider what has been its value as a capacity-building project. Drawing general lessons from a project which took place during such extraordinary circumstances may be hard. But these very circumstances also sharpen its relevance, at a time when multiple crises (the Middle East, Ebola) have ensured global attention on fragile health systems.
A key to RESCAP-MED’s effectiveness has been that this has not been an ad-hoc consortium but one based on established connections. That has been intrinsic to the trust between partners. As we have emphasised in this report, and as we stressed in our initial proposal, RESCAP-MED builds upon the successful collaboration in a predecessor FP7 project, MedCHAMPS. That connection has been crucial. We therefore suggest that a freestanding research capacity project would have much less chance of success than one following on directly from a research project, as here. This is partly because the Mediterranean MedCHAMPS partners then had data to work on in RESCAP-MED workshops, (both for discipline-specific workshops and for writing workshops). Moreover, the MedCHAMPS publication record has been greatly facilitated and strengthened by the work we subsequently mounted in RESCAP-MED. This has been vital in assisting a wide range of early career researchers to push their work all the way along the tough road to successful publication in peer-reviewed journals (see section 11 above).
We end this report by emphasising four points:
• The level of research experience and expertise within the RESCAP-MED network;
• The level of experience and expertise of realistic policy options within the RESCAP-MED network, highlighted most clearly by the presence of WHO-EMRO as partners;
• The importance of a strong network for the future in a troubled region;
• The capability of this network to take research to next stage/ level.

Potential Impact:
1. Original Objectives for Strategic Impact

1.1 Background
RESCAP-MED’s title was ‘NCDs and their social determinants in Mediterranean partner countries: building sustainable research capacity for effective policy intervention’. In our original plan, we defined our intended strategic impact in these terms:
NCDs pose a major public health challenge. RESCAP-MED intends to…create the capacity for more advanced knowledge of the increasing burden on health systems posed by NCDs, their social determinants, and the growing social differentials in both the distribution of disease and access to health care. We thus address ‘upstream’ causes and ‘downstream’ consequences in this capacity building plan.
The intended beneficiaries of this project are evidently the academic institutions of the region, and particularly those institutes engaged in public health research, as it is their capacity this project seeks to strengthen.
However, equally we regard as key beneficiaries those in government and NGOs engaged in making and implementing health policies to develop national health system infrastructure… research capacity is a means to a larger end, namely national health systems better equipped to cope with the challenge of NCDs.
This project will be only a step – but a crucial step nonetheless – towards filling this gap in the region. It envisages nothing less than building the methodological skills on which an evidence base for policy making can rely.
This project therefore presents an ambitious plan to achieve three overriding impacts:
(a) to build up the multi-disciplinary research capacity needed to address the public health challenge of NCDs;
(b) to assist in the long-term process of embedding such widened academic capacity through systematic engagement with relevant policy communities;
(c) eventually to make realistically possible the evidence base for improving health services’ planning, delivery, and the public health monitoring and evaluation of NCD trends.

1.2 Mechanisms for delivering impact
Seven main outputs were the mechanisms to achieve these intended impacts:
a. A website with newly developed e-learning resources available to a wider academic, policy and practitioner community throughout the region
b. An organisational framework for on-going academic exchanges through a short-term Visiting Fellowship programme to facilitate intra-regional collaboration.
c. An organisational framework among partners for making collaborative grant applications for new empirical research or analytical reviews in the region.
d. An enhanced number of high quality grant applications.
e. Increased numbers of presentations at academic and policy conferences, and an increase in publications in internationally-recognised peer-reviewed journals.
f. A framework to give impetus to continuing dialogue with policy makers, not only in international organisations, but more especially those in national ministries.
g. Integration of research findings and evidence within the curricula of formal academic programs such as the masters of public health and informal training courses offered by the partners.

1.3 Broader intended impacts
On the basis of these outputs, we summarised our intended impacts in four terms: capacity, collaboration, recognition, and communication.


2. The political context in which RESCAP-MED took place

Before we consider the impact we have been able to achieve against these initial intended objectives and ambitions, it is important to emphasise the extraordinary political context in which this capacity building project took place. We have discussed this in both the other parts of the Final Report: the Summary of Context & Objectives, and in the Description of Scientific Results. For clarity, we reiterate here what we stated under Scientific Results:
“RESCAP-MED has been a 3-year (2012-14) research capacity-building project in public health in six non-EU countries of the Eastern Mediterranean at a time of profound political turmoil, whose scale and consequences were unimaginable when the project was first planned. Mediterranean partners in RESCAP-MED come from Jordan, Lebanon, Palestine, Syria, Tunisia and Turkey. To list these countries is to make evident that RESCAP-MED has taken place against a background of multiple challenges unparalleled in recent decades. The repercussions of the humanitarian catastrophe taking place in Syria have affected neighbouring countries – Jordan, Lebanon and Turkey – to an extraordinary degree. Both Tunisia, with its revolution in 2011, and Palestine, also witnessed extraordinarily turbulent political times. We cannot over-emphasise the significance of the turbulent and unstable political context within which RESCAP-MED has worked, in which only the events in Tunisia have given reason for much optimism…
When we submitted our proposal to the EC for capacity building in the six Mediterranean partner countries, no one could have anticipated what dramatic changes there would be in the circumstances which form the wider context to our work. For example, when the EC awarded this grant, we could not then know:
a. That it would prove impossible to hold any events in Syria.
b. That it would prove impossible for academic colleagues or potential trainees living in Syria to participate in our events.
c. That sanctions against Syria would make it impossible for the Syrian partners to hold their budget in Syria.
d. That the Syrian partners, SCTS, would have their staff scattered by the crisis
e. That the deteriorating political situation in both Lebanon and Tunisia at certain points would prove sufficiently insecure to necessitate rearranging planned events in both countries at fairly short notice…
f. That as the political situation worsened, obtaining visas also became an increasing problem…Visa delays on occasions also complicated the fellowship programme.
All these issues greatly complicated our work. For a coordination and support action built around a set of events (training needs assessment, training workshops, symposia, visiting fellowships) the practical task of delivering our commitments inevitably proved much more challenging than we were anticipating.”


3. Main Dissemination Activities and Exploitation of Results

Dissemination about RESCAP-MED – and its central focus on the challenge of addressing NCDs by building up independent national research capacity – was undertaken at three main levels:
• Internal dissemination between RESCAP-MED partners
• Dissemination to the wider academic community within the partner countries involved.
• Dissemination to health policy makers/planners at national and international level.

Channels and Mechanisms of Disssemination. A variety of channels were used to disseminate information about the project activities. The main ones, reaching all three levels, were:
• NETPH http://www.netph.org/
• RESCAP-MED Newsletters (twice a year) http://research.ncl.ac.uk/rescap-med/news/newsletters.html
• RESCAP-MED Policy Briefs (once a year) http://research.ncl.ac.uk/rescap-med/activities/engagement/
• The RESCAP-MED project website, and the partner institution websites http://research.ncl.ac.uk/rescap-med/
• Facebook page " Eastern Mediterranean Network for NCD Research” https://www.facebook.com/groups/100218610103673/
• Participating and leading discussions with regional researchers through regional resources such as Public Health in the Arab World (PHAW)
• Regional networks such as The Eastern Mediterranean Public Health Network (EMPHNET)
• Research publications.
• Regional events, and training workshops
• Two major Symposia (in Istanbul 2013 and Beirut 2014) (See Appendices for programmes)
• One-to-one discussions during some workshops
• Dissemination Meetings with Policy Makers
• The Mass Media – Newspapers

RESCAP-MED Newsletters. A total of six concise newsletters were produced and distributed. The newsletters were publicized on the RESCAP-Med and NETPH websites and circulated by partner leads to wider national stakeholders. Mailbase lists were used to distribute the newsletters. The newsletters were used to disseminate diverse information including:
• the scope and aims of the project
• up-to-date information on RESCAP-MED activities
• announcements of future project events, training workshops, symposia, and fellowships
• project and individual achievements
• regular update on the progress of the fellowship programme
• updates on the progress and reach of NETPH, and case studies of individual fellows
• feedback from workshop participants

Policy Briefing. Three policy briefs were prepared to present and communicate the findings and recommendations of RESCAP-MED workshops, research, and symposia to policy makers. Topics, in chronological sequence, were:
1. National Health Research Systems and Training Needs Assessment in Six Mediterranean Countries (focused on the Training Needs Assessment)
2. Bridging the gap between health researchers and policy-makers in the Eastern Mediterranean Region (the challenges of sustaining dialogue between academic research and government and policy-making)
3. Socio-political Challenges in the Mediterranean Region: Implications for NCD Prevention and Control (a review of the scope and significance of the Beirut Symposium)

Policy expertise embedded within RESCAP-MED. Dialogue with policy makers in partner countries and in WHO-EMRO was established through RESCAP-MED. In many instances, good links to policy makers pre-dated RESCAP-MED, and in some instances these connections were utilised in setting up the Project Monitoring & Advisory Committee (ProMAC). For example:
• The initial ProMAC member representing Lebanon was Dr Walid Ammar (Director General, Ministry of Public Health, Lebanon).
• With Prof. Habiba Ben Romdhane as the Tunisian lead, RESCAP-MED had a recent (2011) Tunisian Health Minister playing a leading part in the project. Prof. Ben Romdhane has also been closely involved more recently in promoting and supporting the new Social Dialogue in Tunisia, concerning the creation of a responsive and publicly accountable health service, which has been supported by the WHO through the Universal Health Coverage Partnership http://www.who.int/features/2014/tunisia-citizens-jury-health/en/
• The presence of WHO-EMRO as a RESCAP-MED partner meant that senior international health policy expertise was further embedded in the project’s internal deliberations: through Dr Awad Mataria (Health Economist, WHO-EMRO) and Dr Ibtihal Fadhil (Regional Adviser, Noncommunicable Diseases, WHO/EMRO).
• One of the two Syrian leads, Dr Fouad Fouad, had in the past been a Director of Primary Health Care in Northern Syria.

Wider Engagement with Policy Makers & Advisors. Overall, mechanisms for wider engagement with policy makers and advisers or administrators were:
• Through the oversight committee, ProMAC, which met annually alongside and with the PMC.
• Through involvement of policy makers in the two international symposia.
• Through participation in some of the training workshops
• Through the twice-yearly RESCAP-MED Newsletters.
• Through a regular series of meetings between partners and significant national and regional policy makers.
• Policy Briefings
• National Dissemination Workshops (held in Jordan and Turkey)

National Dissemination Workshops in Jordan & Turkey. In Jordan, key policy makers from the Ministry of Health, and from Health Councils, attended the dissemination meeting in Jordan (11th December 2014). The Secretary Generals of the Health and Nursing Councils, the President of Jordan University of Science and Technology, and the Vice President attended the meeting. Nearly 40 participants attended the workshop. In Turkey, a national dissemination meeting was held during the meeting of National Strategies and Targets on Non-Communicable Diseases (NCDs) for Turkey in Elazig, Turkey (17-18 December 2014). Nearly 100 participants attended the workshop.

News Media. At any time, a research capacity building project would typically not produce the findings that attract media attention, and it would be unrealistic to expect that. However, RESCAP-MED has taken place at a phase in modern history that could by no stretch be called ‘any time’, making the likelihood of media attention even less realistic. News media (global and national) have been preoccupied with the impact of conflict and uncertainty, and the impact of massive population displacements from Syria (affecting Jordan, Lebanon and Turkey among RESCAP-MED partners) and Libya (affecting Tunisia). The damage being done to health, health care, and fragile health systems has received limited attention; the implications for NCD care even less. However, the New York Times has twice featured Dr Fouad Fouad, the Syrian co-lead, once in an article he co-authored:
Coutts A & Fouad F. Syria’s raging health crisis. New York Times 1.1.2014 http://www.nytimes.com/2014/01/02/opinion/syrias-raging-health-crisis.html?_r=0
http://www.nytimes.com/2014/03/18/world/middleeast/three-years-of-strife-and-cruelty-put-syria-in-tailspin.html?_r=0



4. Evaluating impact against objectives for impact.

We summarise the various impacts of RESCAP-MED under the following headings (used in our project plan):

Capacity
RESCAP-MED contributed to developing capacity and capability for multi-disciplinary NCD research through the following activities (see Box 3):
• By defining training needs in partner countries (as a proxy for the wider MENA region)
• By developing the knowledge and skill level of participants in several disciplines at training events (a total of 197 participants at 10 workshops)
• By creating new materials for training events, extending across several disciplines and fields relevant to NCD research
• By the RESCAP-MED Fellowship programme (for 13 participants making 18 fellowship visits)
• By individual mentoring for publications and presentations, grant applications, PhD applications, especially for researchers early in career
• By creating opportunities for early career researchers to undertake presentations at the two RESCAP-MED Symposia in Istanbul (2013) and Beirut (2014)
• By providing the collaborative framework within which a number of early career researchers have become lead authors, and others co-authors
• By creating an e-learning website with a depository of training materials for NCD researchers in the region (and beyond) (NETPH: http://www.netph.org/ )

Collaboration
RESCAP-MED contributed to collaboration within and beyond the East Mediterranean Region through the following mechanisms and activities:
• By collaboration between eleven partners
• By working with other institutions in same country and the creation of new partnerships
• By inter-disciplinary collaboration
• By organising that each of the two Symposia was associated with a linked event, immediately following the RESCAP-MED Symposium. (a) 1st RESCAP-MED Symposium, 2013, followed by a Workshop on Social Inequalities in health organised by Turkish partners DEU Izmir; (b) 2nd RESCAP-MED Symposium, 2014, followed by Conference ‘Public Health in Contexts of Uncertainty’ organised by Lebanese partners AUB
• NETPH’s success in filling a regional gap leading to discussions concerning future links and prospects for sustainability with two other websites: Public Health in the Arab World (PHAW), and Middle East & North Africa Health Policy Forum (MENAHPF)



Recognition
• As a project network, the name RESCAP-MED name has become increasingly well known in the MENA Region over the last three years
• Two major Symposia have assisted this. The first, in Istanbul (May 20113), attracted 96 participants from eleven countries (including the six Mediterranean partners in RESCP-MED). The second, in Beirut (December 2014) attracted 185 participants from over a dozen countries, including Algeria, Sudan and Iraq in addition to the six Mediterranean partners in RESCAP-MED. (See Appendices for full programmes.)
• The continuing stream of publications from the predecessor FP7 project, MedCHAMPS, has assisted this recognition (for full details see Scientific Results, section 11)
• NETPH has attracted growing recognition, most evident in the geographical spread of its users, and in the interest shown by MENAHPF in some form of link or collaboration
• Recognition for RESCAP-MED and its network has benefitted from the fact that all its Mediterranean lead partners have established and growing reputation and influence; these reputations have all grown over the years 2012-14, and RESCAP-MED has benefitted as a consequence (see Box 1 below)
• New partnerships reflect growing recognition
• The presence of WHO-EMRO as a RESCAP-MED partner has greatly enhanced the ability of RESCAP-MED to engage with policy makers and other stakeholders at national and international level

Communication
• Through NETPH: http://www.netph.org/ and Twitter: https://twitter.com/netphn
• Through the RESCAP-MED Project website: http://research.ncl.ac.uk/rescap-med/
• Through Facebook, Eastern Mediterranean Network for NCD Research (coordinated by Professor Wasim Maziak, SCTS Syria & Florida International University, USA)
• Through Three Annual Policy Briefs: http://research.ncl.ac.uk/rescap-med/activities/engagement/
• Through twice yearly Newsletters to Stakeholders: http://research.ncl.ac.uk/rescap-med/news/newsletters.html
• Through two major Symposia (Istanbul 2013, Beirut 2014) (See Appendices for Programmes). The information about the Istanbul Symposium was shared on the European Association of Public Health Newsletter: http://www.eupha.org/documents/newsletters/eupha_newsletter_november_2012.pdf
• Through participation of senior policymakers, administrators or other specialists in RESCAP-MED events (see Box 2 below)
Some of the Communications continue into 2015:
• Through a presentation in Brussels in EC Infopoint Series, combining lessons from MedCHAMPS and RESCAP-MED, by Scientific Coordinators of both projects (30th April 2015)
• Through a conference in Tunis hosted by CAVEPLA to reflect on lessons from RESCAP-MED to a policy audience from several countries of the MENA Region (28-29 May 2015)
5. The socio-economic impact and wider societal implications of RESCAP-MED
Getting attention for NCD research (epidemiology or health system) at a time of the biggest crisis in the region in decades is inevitably extremely difficult, notwithstanding the scale and severity of a rapidly growing NCD burden made worse by the present crisis. In Jordan and Lebanon, much of the policy-making attention among the project’s likely policy audience has been directed to the provision of services for Syrian refugees displaced by violence or the fear of violence and the impossibility of surviving economically in Syria at the present time. In Tunisia and Turkey, the same issues arise also (in relation to those displaced from Libya and Syria respectively). In the West Bank of Palestine it hardly needs stating that the circumstances are different, but the rising tension through 2013 and 2014, increased further after Israel’s assault on Gaza in 2014, has there also ensured that other pressing priorities make it difficult to attract sustained attention to the task of developing research capacity in relation to NCDs.
Moreover, the socio-economic impact of a capacity-building project like RESCAP-MED is not going to be realised in isolation, but as part of a web of activities and initiatives whose value will only become evident over the longer term.
Against this background, however, we note the following ways in which RESCAP-MED has contributed to developments and thinking in the region, and has also as a network reacted to wider societal developments.
• By highlighting the importance of the social determinants of NCDs, through our 1st Symposium in Istanbul (May 20113) on the ‘Social Determinants of NCDs in Mediterranean Countries’, RESCAP-MED was able to promote dialogue, debate and wider policy recognition about the critical importance of social determinants. DEU partners at Izmir have confirmed how their own exchanges with policy makers in Turkey have shown increasing recognition of this relationship.
Conference Themes:
o The social determinants of NCDs in Mediterranean countries
o The social and policy challenges of the growing NCD burden
o The latest evidence on health inequalities and NCDs by country
• By addressing the key preoccupations of the present time – the challenge to fragile health systems amidst political instability, violence and population displacement – RESCAP-MED’s 2nd Symposium in Beirut (December 2014) was able to remind an audience from many countries of the significance of NCDs in the present critical situation.
Conference Themes
o Displacement and migration
o War and conflict
o Capacity building, training and education
o Socio-political transformations
o National health systems and provision of care in times of crisis
• By creating a set of frameworks in which to keep reminding audiences of the importance of questions such as:
o How does public health operate when states are weak?
o How are Ministries of Health responding to these emerging problems?
o What different approaches are needed in a context of weak states?
o How should countries in the region adapt programs of research, education, and practice?

BOX 1
Examples of awards & recognition to RESCAP-MED lead partners during the project

Professor Habiba Ben Romdhane (CAVEPLA, Tunisia) was elected through Distinction as a Fellow in the Faculty of Public Health at the Royal College of Physicians in the UK, July 2013. http://www.sante-tn.com/psy-moi/psychose/item/1798-distinction-tunisienne-en-gb-habiba-ben-romdhane-membre-du-college-royal-de-medecine
In 2011, she was appointed as the first Minister of Health in Tunisia after the overthrow of the Ben Ali dictatorship.

Professor Abla Mehio Sibai (AUB, Lebanon) was awarded the esteemed Dr. A.T. Shousha Foundation Prize at the 60th Session of the World Health Organization (WHO) Regional Committee for the Eastern Mediterranean, held last October, 2014. The Dr A.T. Shousha Foundation prize is awarded to a person who has made significant contributions to the improvement of health in the Eastern Mediterranean Region (EMR). http://www.emphnet.net/MediaCenter/LatestNews/ViewNews/tabid/96/ArticleId/296/Professor-Abla-Mehio-Sibai-gains-the-esteemed-Dr-A-T-Shousha-Foundation-Prize.aspx

Dr Niveen Abu-Rmeileh (Birzeit, Palestine). “Rising star in the Middle East.” Perspective. The Lancet Volume 384, No. 9946, p847, 6 September 2014 . http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61477-X/fulltext


BOX 2
Examples of senior policy makers who have been involved in RESCAP-MED activities

Dr Walid Ammar (Director General, Ministry of Public Health, Lebanon)
Dr Samer Jabbour (Director - NCDs and Mental Health, WHO EMRO)
Dr Riyad Amin Okour (Ministry of Health, Jordan)
Dr Jamal Abu Saif (Ministry of Health, Jordan)
Dr Saad Al-Kharabsheh (former Minister of Environment, Jordan)
Dr Munjed Al-Sharif (Coordinator and Chief Tech. Advisor, UN Joint Prog., Jordan)
Dr Reem Musleh (Environmental Consultant; Adviser to Palestinian Authority, Palestine)
Dr Heidar Abu Ghosh (Director of Prevention Programs, Palestine Medical Relief Society, Palestine)
Dr Gauden Galea, (WHO Director of the Division of Noncommunicable Diseases and Life-course)
Dr Gojka Roglic, (WHO Diabetes Unit)


BOX 3
Text indicating scope of Beirut Symposium from Symposium Programme

The topic of this symposium is one of great importance to this region and beyond. It is made even more urgent because of the political and social turmoil overwhelming many of our countries. At the same time, this urgency is rarely reflected in political and policy debate: the long-term burden of managing the rapid growth of non-communicable diseases (NCDs) only occasionally makes headline news and is rarely part of humanitarian relief efforts. Yet, we start from the position that the Arab Region displays the highest worldwide levels on some key indicators of NCD burden and is projected to witness the second largest proportional increase in NCD mortality worldwide. Six of the countries with the highest rates of diabetes are in the region; obesity rates, notably among women, exceed those recorded in the developed world; and levels of physical activity are among the lowest. These developments in population health are taking place against a background of political turmoil, unanticipated even a few years ago, and in countries most challenged by scarcity of resources. These countries have been profoundly affected by these seismic events, with massive and growing population movements as people flee violence or its threat. The consequences for physical and mental health of extreme insecurity and hardship, and the repercussions for fragile health systems now additionally overwhelmed by these crises, have scarcely begun to be evaluated. This symposium brings together these two powerful dynamics – the epidemiological and demographic on the one hand and the political and social on the other – to assist this vital process of evaluation.

List of Websites:
http://research.ncl.ac.uk/rescap-med/

Principal Investigator: Professor Peter Phillimore
Project Secretary: Alexandra Smith
Telephone: +44 (0)191 222 7394

Institute of Health and Society, Newcastle University, UK

http://www.netph.org/