Our findings indicate that access to NCD services in the capital of Lebanon is inequitable, with Syrian refugees experiencing more barriers to care seeking compared to host community members. Principal factors that affect health seeking and service accessibility include refugee status, poor socio-economic status and absence of health coverage. Findings indicate that the two communities seek care from different sources: Syrian refugees rely primarily on primary care centres and dispensaries, compared to Lebanese host community members who primarily seek care from specialists. Pharmacies were also identified as an important source of health service provision.

Primary barriers to care seeking were the same among both communities and relate to financial challenges to care access. For Lebanese persons, health coverage, gender and employment were important influences on access to care; for Syrian refugees, socio-economic status only is statistically significantly associated with this. Health status among both communities was poor overall: approx. 5 in 10 Lebanese community members reported being in good health, compared to 4 in 10 for Syrian refugees.

Perceptions of the care model significantly differ by community. Lebanese community members generally have more positive perceptions compared to Syrian refugees. Among Lebanese participants this can be partly attributed to presence of health coverage and level of education, even when accounting for barriers to care seeking. However, for this group of participants, positive perceptions correlated with the type of health care provider accessed: those accessing specialists and private clinics were likeliest to have positive perceptions. For Syrian refugees, health care coverage, level of education and socio-economic status also influenced perceptions of the care model, but barriers to care negatively influenced perceptions. There were no differences in perceptions depending on whether care was sought from private providers.

Trust in the health system was higher among Syrian compared to Lebanese participants, but differences in scores were notable by item. For example, approx. half of Lebanese participants perceived the system as fair in its care provision to disadvantaged and vulnerable groups, compared to almost three quarters of Syrian refugees. Trust was significantly influenced by the care model score and barriers to care seeking.

Evidence on inequitable access to health services is high in LMIC even with the implementation of health reforms and interventions.²³ Levesque et al. (2013) conceptualised access to care by integrating factors from both supply and demand sides and the context (e.g. urban areas), and summarized them in five concepts: approachability; acceptability; availability and accommodation; affordability; and appropriateness.²⁴ Our study findings showed gaps in all those dimensions and validated that reducing inequities in access to care should tackle different elements such as cultural and psychological barriers (affecting acceptability), and financial barriers to care affecting the capacity of people to use health services.

Our findings identified disparities in terms of services provided to different community members by exploring how different communities perceived the NCD care received. Empirical research in other LMIC settings also investigated perceptions and attributes of the care model and explored inequities in the distribution of primary care services. For instance, Pongpirul et al. (2009) reported satisfactory but inequitable features of primary care between different regions in Thailand and therefore identified pitfalls in the PHC policy of the country that need to be addressed.²⁵ Our study also highlighted more positive perceptions – likely associated with better care features – within the private sector. Similar findings were reported by a study in Hong Kong where primary care experiences were better when received from private providers,²⁶ showing the importance of such approaches to understand the differences in primary care quality of services in the case of multiple providers. In terms of the specialty of providers, a study in Taiwan showed that patients visiting primary care physicians reported better experiences in relation with several domains such as continuity, coordination and comprehensiveness of services, compared to those seeking care from specialists.²⁷ These findings from a setting where there is no restriction on physician choice such as Lebanon contradict the findings of our study, suggesting that more support is needed for the primary care workforce in Lebanon to take the lead on providing essential services and have the power to be gatekeepers of the health system.

This survey offered insights on the complexity of trust in healthcare and its determinants. The first observation is that community members identified gaps in different aspects of trust – related to both interpersonal trust and institutional trust, confirming the dynamic and multi-dimensional characteristics of this concept.²⁸ Of major importance were the lower scores on the reliability and fairness of the system (elements of institutional trust) and the fidelity of providers to work beyond self-gain (element of interpersonal trust), compared to other dimensions such as competence of providers and confidentiality. This difference in perceptions between domains may relate to general perceptions of commercialization of healthcare in Lebanon,¹⁶ and confirms that structural reforms in the system towards universal health coverage would contribute to increasing trust of communities in the health system.

Our findings also validated hypotheses from previous research studies on the impact of accessibility of care, primary care features of provided services and the type of providers on people’s trust in healthcare.^17-18 However, an unexpected observation was the negative association between receiving pharmacist consultations and trust in healthcare, even though this same variable of pharmacist consultations was associated with more positive perceptions of care. A reasonable explanation is that community members view accessing pharmacists as easier compared to physicians but acquire negative perceptions on the health system because of the need to find such alternatives. Therefore, the discussion about the role of different providers within the health system in Lebanon and in other fragile contexts should take into account providers contribution to the delivery of quality services and also the impact on community trust in the system and its implications of their relationship with the system.