By Catarina Hanna-Amodio
Since 2011, more than a million refugees from Syria have arrived to Lebanon. With a population of just over four million, today Lebanon has the highest number of refugees per capita in the world. The Lebanese population has grown by up to 25% since the beginning of the Syrian crisis, and this sharp increase in levels has put pressure on Lebanese facilities, facilities already weakened by a long-lasting internal crisis, and exacerbated by current political unrest and economic uncertainty.
The protracted nature of the Syrian refugee crisis has created serious difficulties in its neighbour, and the Lebanese government's response to the influx of people into the country has been, at best, lackluster. The Lebanese political system is beset by constant power struggles between different political parties and religious sects, and such factionalism has inhibited a coordinated response. International aid efforts have also been challenging; one pivotal refugee organization there, the United Nations Relief and Work Agency (UNRWA), recently had its funding cut by some $300 million. The financial crisis in the country has also devalued the national currency causing further problems.
Availability and Access
The structure and nature of Lebanon's healthcare system does not help. It is highly privatised and involves many actors. While both private and public providers exist, political agendas and lack of transparency within government means that Lebanon's healthcare system is fragmented, with private providers wielding significant influence and power. The Lebanese Civil War helped fuel the growth of the private sector, allowing it to dominate over a weakened public sector in many fields, including healthcare. These dynamics are still in place today. In the post war period, where an even larger number of actors have emerged, it is private healthcare facilities, international donors and NGOs that have significantly shaped local activities and refugee response.
Attempts to improve the availability of healthcare for Syrian refugees in Lebanon have mainly been a collaborative effort between the Lebanese Ministry of Public Health, UNHCR, NGOs and humanitarian agencies. The establishment of 25 Mobile Medical Units operated by NGOs, for instance, provide free consultations and medication to refugees if access to a primary healthcare facility is unavailable. There exist more than 200 primary healthcare facilities in Lebanon where Syrian refugees are able to receive subsidised treatment, while medication and vaccinations are often free and widely available.
UNHCR have even suggested that healthcare in Lebanon has actually improved since the influx of refugees from Syria beginning in 2011. An increase in the amount health centres and staff has led to more specialised treatment becoming available. For example, psychological help has reportedly increased, and is increasingly recognised as a legitimate and pressing health concern. Nevertheless, there remain significant barriers to Syrian refugees accessing healthcare in Lebanon, especially owing to economic and geographic factors.
Lebanon's highly privatised healthcare system means that healthcare is 'expensive and inaccessible to a large proportion of the population', with the majority of even local Lebanese not having expensive health insurance. Despite the Lebanese Ministry of Public Health's efforts to support and increase availability of primary and secondary healthcare for refugees, the cost of consultations, laboratory tests, and medication remains a significant barrier.
Doctor's appointments cost between 8,000 and 16,000 LBP, or about USD $ 4- 9, a price that is difficult for refugees to afford, bearing in mind that 70% of Syrian refugees live below the poverty line. The 2017 Vulnerability Assessment Report conducted by UNHCR, Unicef and the World Food Programme (WFP) found that the main reasons that households did not receive required care were because of the cost of drugs (33%), consultation fees (33%), uncertainty about where to go (17%), and not being accepted at the facility (14%).
There have even been reports of some people travelling back to Syria to receive treatment, due to the cost in Lebanon, illustrating how dire the situation is. Another significant cost is for antenatal and maternal care, as well as childcare and baby milk.
Some responses to this economic barrier have been made. For example, UNHCR covers 85% of primary healthcare costs for refugees in an attempt to increase accessibility.
This has had an impact: one survey conducted by UNHCR, Unicef and (WFP) found that many refugees that required primary health care services were able to access them (89%). However, given that the survey only reached households with a landline, only surveyed registered refugees and relied on partner health-care providing organisations to carry out fieldwork, it is likely that the least vulnerable of refugees were surveyed. For example, 591 cases were removed from the random sample due to safety or security concerns -- it is possible these cases had safety and security concerns that meant they were also less likely to have access to healthcare. Reporting suggests a greater number than 11% cannot access healthcare.
In any case, there also remains a geographic disparity in access.
**Geographical barriers\ **Crucially, there exists a distinction between availability and access. While healthcare might be available, there are other barriers to access, such as geographical location. Unlike other countries in the region, such as Jordan, Lebanon has not established formal refugee camps for Syrians, leaving communities dispersed among villages across the country. The dense distribution of refugees in low-resource areas makes it difficult to access healthcare because of distance and isolation.
The map below shows how many refugees reside in Bekaa Valley, the highland region on the border with Syria, on the Eastern side of the country. Other refugees settled around Mount Lebanon, or further North or South across the country. However, this map doesn't cover unregistered refugees, who are more likely to be closer to the Syrian border and in areas of even lower-resource.
A Lebanon-specific study conducted by Conflict and Health into the health needs of Syrian refugees found that ‘geographical barriers and lack of necessary awareness and education’, remained the most significant barriers to accessing healthcare faces by Syrian refugees in Lebanon.
There also exists significant geographic disparity in terms of access; the 2017 Vulnerability Assessment found that 25% of households did not receive required healthcare in Mount Lebanon. This is below the national level of 11% of households that do not receive required healthcare, and is due to the fact that there exist fewer Primary Healthcare Centres in the areas surrounding Beirut and Mount Lebanon, making treatment more difficult to access for locals and refugees alike.
Importantly, lack of access to healthcare is not exclusively a refugee problem in Lebanon; it is and has long been difficult to access for local Lebanese populations.
Of note, too is that the barriers to access to healthcare that exist to refugees, like economic costs and geographical location, also cause barriers to accessing a range of other facilities, such as schools or vocational training.
While progress in terms of Syrian refugee healthcare in Lebanon from various NGOs, the Ministry of Public Health and other organisations can seem promising, the picture today remains far from positive. Current political unrest has dramatically impacted local endeavors. Years of donor fatigue over the refugee issue has not been helped by a profound lack of transparency from the Lebanese government, which makes it difficult for organisations to demonstrate impact and rally support for funding.Road closures during periods of unrest have made already hard-to-reach communities even more isolated and have made it more difficult for food provisions to be provided.On top of this, the financial crisis has affected exchange rates, meaning that cash provisions to refugees in Lebanese Pounds, now buys even less. It is so bad that essentials like bread and medicine are actually cheaper in Syria, causing some to return despite the risk.
For refugees being forced to return back to the places from where they fled just to survive is an indication of just how bad things are. And it is fair to say that today, in Lebanon the potential for things to get better no longer feels to be on the horizon, but almost out of sight.