Lebanon currently has the highest proportion of Syrian refugees in the world relative to the number of citizens,
with 855,172 registered Syrian refugees according to the United Nations High Commissioner for Refugees (UNHCR) office in Lebanon (1).
The disruption in the formation of the government over several non-consecutive years affected the Lebanese
health care system, which was already suffering from many challenges even before hosting refugees and led to
more difficulties. According to the Vulnerability Assessment of Syrian Refugees in Lebanon (VASyR)(2),
the poverty rate among Syrian refugees has risen to 75 percent. Moreover, their purchasing power has decreased due to the deterioration of the Lebanese currency exchange rate. The demand for health-care services among Syrian refugees has declined since 2019 because of various factors associated with the Lebanese economic crisis(3), which has led to an unprecedented increase in prices, including high fees for hospitals and doctors, drug prices and transportation costs, and has therefore affected the extent to which refugees consider their health needs a priority.
The Lebanese situation and the current healthcare realities means that the state is losing the capacity to provide healthcare services on its own due to its limited financial means and strategic planning to meet the needs of the population, including refugees. Healthcare in Lebanon is mostly executed by the private sector, making it more expensive for the vast majority of refugees, less able to accommodate them, and inaccessible to the majority of the population. Most secondary and tertiary health care institutions (specialized and highly specialized) are private, making the high financial cost of medical services a major challenge to Syrian refugees in Lebanon.(4). Lebanon’s health care system is also heavily dependent on international funding for refugee health care, making it more vulnerable to economic and increased donor burdens. The system has become heavier and increasingly unable to cope with the situation, especially as a result of the current build-up of crises in the country (5). Several actors have responded jointly to the health needs of Syrian refugees in Lebanon over the past eight years. These actors consist of the network of primary healthcare centers of the Ministry of Public Health (MOFH), UNHCR, local NGOs, (6) other international NGOs and humanitarian agencies such as WHO. (7)
The UNHCR in Lebanon covers approximately 85% of primary health care expenses for refugees in some cases that need urgent interventions, as UNHCR contracts annually with medical institutions to provide medical services for free or at low cost in primary health care centers and Lebanese hospitals. In addition to UNHCR, the World Bank and several NGOs play active roles in providing healthcare services to Syrian refugees in Lebanon, by establishing health centers and providing free medical consultations and medicines. (8)
Main healthcare Challenges Faced by Syrian
Refugees in Lebanon:
According to more than 15 academic studies on the health needs of Syrian refugees in Lebanon women’s
health care is the most prevalent health need, followed by mental health, infectious diseases, and vaccinations(7).
General Difficulties and Challenges:
The difficulties preventing access to health care services include several factors such as the complex healthcare system in Lebanon; geographical barriers such as the high cost of moving between areas; the high cost of obtaining medical services; structural barriers such as the complex medical referral system;(8) a lack of necessary crises awareness and knowledge about symptoms of diseases, treatment, available services and how the system works; prejudice against refugees; discrimination from health
care providers;(8)and finally the perceived lack of attention and care from service providers.(7)
Nonexistence of Identification Documents:
Some primary health care centers and hospitals ask Syrian refugees for their identity documents in exchange
for the health service, which is difficult to obtain by refugees who have lost or not issued their identity documents and/or cannot return to Syria to extract an alternative. (10)
Challenges Facing Syrian Healthcare Workers:
The path to the official employment of Syrian healthcare workers in the health sector is not available in the first
place. As the Ministry of Labor has prohibited foreigners, including Syrians, from undertaking their liberal professions, which include medicine and pharmacy related sectors, and limited these professions, in addition to businesses, professions, as well as job and trades in administration, banking, insurance, and education to the
Lebanese, and only excluded Syrian workers from the ban on work in the agricultural, construction and
environmental sectors (11). Refugees also face numerous organizational, administrative, legal, and professional barriers to formal practice. For example, Syrian doctors in Lebanon face difficulties in obtaining legal work permits, inability to secure licenses to practice without incurring unusual costs, and other related challenges that prevent entry into the labourmarket. (12)
Random Costs of treating Refugees:
Hospitals and health centers are taking on additional costs due to higher prices for medical equipment without
a change in the pricing of various medical procedures, (12) by the official Ministry of Health, which led to the
imposition of random prices and charging additional prices, especially on Syrian refugees who may not be aware enough of the financial details of their treatment bills. Hospitals do not hand over an invoice in case the UNHCR contributes to part of the cost and are therefore able to increase the prices charged without bringing it to
the attention of the patient or even the contributor.
Syrian Refugees and the COVID-19 Pandemic:
Although Syrians constitute approximately 20% of the population in Lebanon, and the registration process on
the electronic platform to receive vaccine doses does not base an assumption on nationality at all, the percentage of Syrians registered, according to the data of the Ministry of Health vaccine platform, does not exceed 97.611 (4.3%) people, compared to 2,227,427registered
from all nationalities on the platform as of August 9th, 2021. (14)
Relevant Laws and Policies:
Article 12 of the International Covenant on Economic, Social and Cultural Rights indicates that the right to health is not limited to the right to medical care, but rather considers the right in its broadest sense, which guarantees the enjoyment of the highest attainable standard of physical and mental health. Indeed, it embraces many social and economic factors that determine what is healthy, including food and nutrition, housing, access to drinking water and sanitation, healthy and safe working conditions, as well as a clean environment.
Article 12 also affirms the state’s obligations towards individuals under its jurisdiction in terms of securing a health protection system that provides equal opportunities for all to obtain the highest attainable standard of health. Accordingly, the state bears the first and primary responsibility in this, and in the second place comes its duty to resort to and allow organizations and other bodies to carry out part of these responsibilities when the state is not able to fulfil its obligations, with the state’s continuing responsibility for organizing and supervising these processes to ensure the maximum extent possible of the protection of individual rights in this context. Moreover, a state cannot be sustainably unable to fulfil its obligations, as the International Covenant requires states to permanently and/or gradually endeavour to meet these obligations. States must ensure “the right of the entire population to the enjoyment of the highest achievable standard of physical and mental health,” and states must ensure “the establishment of conditions that secure ‘for all’ medical services and medical attention in case of illness.”(10) Consequently, the state bears the responsibility to provide the appropriate and required conditions to spare the population, to the maximum extent possible, the lack of standards of physical and mental health. Here, the right to adequate housing, adequate sanitation and access to clean water and food cannot be separated from this right, and therefore the state must take care of fulfilling its obligations towards those rights in the context of fulfilling its obligations regarding the right to enjoy the highest possible standards of mental and physical health (15). Depriving some Syrians of their right to health for reasons related to identification papers, for example, is not considered a legal justification, as the state’s inability to fulfill other rights that lead to such conditions does not place responsibility on the refugees themselves. The duty of the Lebanese state to respect the right to health of Syrian refugees within its jurisdiction requires not to deny or limit their equal access to the health services available in the country. The state’s duty to protect this right also dictates that it prevents non-state actors from prohibiting Syrian refugees from having equal access to these services, especially if this prohibition is on discriminatory grounds. As for the state’s duty to fulfill the right to health, it must provide everyone without discrimination with healthcare, especially in the time of epidemics, when it must secure access to immunization and awareness programs as well as measures to contain the pandemic.
References:
- Situation Syria regional refugee response [Internet].Unhcr.org. [cited 2021 Aug 9]. Available from: https://data2.unhcr.org/en/situations/syria/location/71
- Lyons A, Kass-Hanna J, Montoya Castano A, Greenlee A. A multidimensional approach to measuring vulnerability to poverty of Syrian refugees in Lebanon. Available at SSRN 3787795. 2021.
- Rischke R, Talebi N. Lebanon at a critical conjuncture-Perspectives of Syrians and Lebanese in
Lebanon 2019-2021. Available at SSRN 3848223. 2021 - El-Jardali F, Hammoud R, Fouad F, Bou K. K2P Briefing Note: Promoting Access to Essential Health
Care Services for Syrian Refugees in Lebanon.Beirut: Knowledge to Policy (K2P) Center Beirut.2014:6. - Karasapan O. The challenges in providing health care to Syrian refugees [Internet]. Brookings. 2018 [cited2021Aug9].Available from: https://www.brookings.edu/blog/future-development/2018/11/15/the-challenges-in-providing-health-care-to-syrian-refugees/
- Trovato MG, Al-Akl N, Ali D. Displaced Syrians in Lebanon: Protection amidst Crises AUB final report.
- El Arnaout N, Rutherford S, Zreik T, Nabulsi D, Yassin N, Saleh S. Assessment of the health needs of Syrian refugees in Lebanon and Syria’s neighboring countries. Conflict and Health. 2019;13(1):31.
- Nabulsi D, Ismail H, Abou Hassan F, Sacca L,Honein-AbouHaidar G, Jomaa L. Voices of the
vulnerable: Exploring the livelihood strategies,coping mechanisms and their impact on food insecurity, health, and access to health care among Syrian refugees in the Beqaa region of Lebanon. PloS one. 2020 Dec 2;15(12): e0242421. - FAWAZ M. BARRIERS FACED BY SYRIAN REFUGEES IN ACCESSING HEALTHCARE IN URBAN AREAS IN LEBANON. BAU Journal- Health and Wellbeing. 2018;1(3):32.
- Documentation and access to healthcare for refugees in Lebanon [Internet]. Nrc.no. 2020 [cited 2021 Aug
9].Available from: https://www.nrc.no/globalassets/pdf/briefing-notes/documentation-and-access-to-healthcare-for-refugees-in-lebanon/icla_briefing-note_documentation-and-access-to-healthcare_may2020.pdf - A decision regarding the professions and crafts that should be restricted to the Lebanese [Internet].
Gov.lb. 2017 [cited 2021 Aug 9]. Available from: https://www.labor.gov.lb/Temp/Files/4bff7fea-2cfa-
497f-bbec-f1c804fbbaf9.pdf - Ismail S, Coutts AP, Rayes D, Roborgh S, Abbara A,Orcutt M, et al. Refugees, healthcare and crises:
informal Syrian health workers in Lebanon. 2018. - [Internet] نطالموا ىلع تاحر” عالواقو”.التهديد نيب …ياتالمستشف يف ةفالتعر فعبر ةبلاطم Annahar.com. [cited 2021 Aug 9]. Available from: https://www.annahar.com/arabic/section/5-%D8%B5%D8%AD%D8%A9/17022021043205125
- COVID-19 Coronavirus Lebanon Cases [Internet]. Gov.lb. [cited 2021 Aug 9]. Available from: https://www.moph.gov.lb/maps/covid19.php
- CESCR General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 12)
[Internet]. Refworld.org. 2000 [cited 2021 Aug 9]. Available from: https://www.refworld.org/pdfid/4538838d0.pdf
