A Ministry of Public Health-supported health facility in Beqaa, Lebanon
Refugee health in Lebanon: a new facade on old practices
7 December 2023
In this article, Rouham Yamout of American University of Beirut discusses refugee health in Lebanon, critiquing its provision from the arrival of Syrian refugees in 2011 to today’s informal parallel sector. She considers access to care, cost effectiveness, the focus on profitability, and the impact on quality of care and equity of access, noting that healthcare for refugees has fallen victim to problems already embedded in the health system.
NB All links open new tabs.
Since 2011, Lebanon has been home to Syrian refugees fleeing their country. By 2015 this reached a peak of one in four residents. However, the political and economic landscape for refugees in Lebanon has been marked by restrictions on refugee camps, unemployment, high fees for residency permits, and ambiguous enforcement, creating a challenging environment for the refugees. A directive from the Lebanese government to UNHCR in 2015 to stop registering Syrians as refugees further complicated the situation, creating a new category of individuals deprived of their refugee status and having even less access to services.
In response, the international community allocated substantial resources to the refugees, with UNHCR mandated to coordinate their organization and distribution. Under the Lebanon Crisis Response Plan, UNHCR leads a multi-stakeholder, multi-faceted response to the refugee crisis, in conjunction with the government of Lebanon and local implementing partners. It covers all aspects of refugees’ lives, including healthcare. The plan has already utilized USD 8.2 billion of humanitarian funds since 2015 and has been appealing for USD 3.6 billion per year since 2022 (UNHCR 2022).
However, despite the wealth of funds dedicated to refugee health, Lebanon’s response has failed to meet their needs, and the host country’s power dynamics have limited the political space to create resilience-building programs (Aoun and Koubar, 2020).
Lebanon’s response to the healthcare needs of Syrian refugees
The Ministry of Public Health (MoPH) in Lebanon rejected the idea of directing refugees to a parallel, refugee-specific health system, operating basic and emergency healthcare services. Instead, the ministry opted to integrate refugee health into the existing civil sector for ambulatory healthcare (i.e. a visit to a doctor or clinic) and the hospital sector for hospitalizations, redirecting funds to subsidize those services (Anholt, 2020).
The civil sector for primary and ambulatory care in Lebanon comprises approximately 1,100 health centres, of which 220 are contracted and supported by the MoPH since 2000. This network, mostly run by charities, political, and civil society organizations, operates on a fees-for-services basis and provides consultations, vaccinations, diagnostic services and drug dispensing at a lower price, resembling more a “low-cost private sector” than a “public sector” (El-Arnaout, et al., 2019).
Before the refugee influx these centres were poorly attended and operated at a break-even point. This was due to little trust in the quality of services, a chaotic referral system, regular shortages of subsidized drugs, and a profit-centred approach which relied on MoPH support for survival. (El-Arnaout, et al., 2019).
In order to offer health care to refugees, UNHCR selected a number of the low-cost ambulatory centres where they subsidised services and installed a monitoring and reporting mechanism. After an initial period of full subsidy, co-payments were introduced in 2013 to limit abuse of services and maintain service quality, with refugees required to make an out-of-pocket payment for every health service received. Since 2020, UNHCR has contracted a third party to manage and coordinate the hospitalisation of Syrian refugees; facilitating admissions and managing subsidies. However, this has not reduced out-of-pocket costs for patients.
The commercialisation of refugee health
The decision by the MoPH to integrate refugee health into the existing health system is questionable, particularly in light of the fees-for-services system practiced by institutions providing healthcare services. Was this decision appropriate and were these centres equipped to handle the massive increase in demand for healthcare services?
The MoPH justified its decision by citing the need to bolster the “resilience of the local civil sector” (Ammar et al., 2016). This is understandable since the civil sector is an important stakeholder in the country’s healthcare ‘establishment’, partnering with the MoPH, delivering many population health programs at nominal fees, and providing the MoPH with valuable health data. The MoPH had already invested a lot of resources and energy in supporting this sector and seized the opportunity to provide it with more. However, the MoPH’s prioritisation of the interests of health institutions, rather than equity of access and quality of service, opened the door to the commercialisation of refugees’ health.
The willingness of the UNHCR and its partners to subsidise refugee health services on such terms confirmed the commercialisation of refugee healthcare. The ‘refugee health business’ had truly emerged on the healthcare landscape. Since then, healthcare services for refugees have been plagued by overpriced services of questionable quality, raising concerns about their suitability. Regions with high refugee density saw a proliferation of health centres, probably driven more by the desire to access humanitarian funds than by a motivation to respond to refugees’ needs. This raised important ethical and practical concerns.
The challenges and consequences of the current management of refugee health
It is no surprise that the integration of refugees’ healthcare into the pre-existing health system has failed to adequately meet refugee needs. There are several reasons.
Firstly, the fees charged for services quickly depleted the funds allocated to refugee health. This led to UNHCR and its partners restricting subsidies to an ever-shrinking list of services, and limiting full subsidies to life-threatening health conditions (Saleh and Fouad, 2022), to the point that some refugees resorted to travelling back to war-torn Syria to access healthcare for critical conditions not covered by available subsidies (Nabulsi et al., 2020).
Secondly, since 2015 the introduction of partial subsidies for healthcare has led to significant financial burdens on refugee families. This, coupled with the economic crisis in Lebanon, resulted in exorbitant out-of-pocket expenditure on ambulatory care and hospitalizations, as well as the costs of medications and transportation (there’s more on this issue in this article). This has left a growing number of families unable to afford even low-cost subsidised healthcare services (Nabulsi et al., 2020).
Discriminatory behaviour on the part of demotivated, overworked, and underpaid healthcare workers employed in the civil sector (Karaki et al., 2021) has also impacted on patients. Together with the cumbersome referral system for more specialised healthcare, and exclusion from national programs, such as COVID-19 vaccines (Kaloti and Fouad, 2022), it has further complicated refugees’ access to healthcare (Sousa et al., 2020).
As a result, after more than a decade and billions of dollars spent, Syrian refugees continue to experience poorer health outcomes than the host community. They are less likely to be able to afford the cost of their medicines and more likely to suffer from chronic diseases at a younger age. Fundamental indicators also reveal inequities in areas such as neonatal and maternal mortality rates (MoPH Vital Data Observatory, 2019; Dumit and Honein-AbouHaidar, 2019).
At the same time, the drive to strengthen the pre-existing civil sector did not pay dividends. Although the organisations running the low-cost ambulatory centres seized a financial opportunity to access humanitarian funds, the sector is witnessing a regression in the implementation of national programs, in the provision of quality services, and in coordination with both the MoPH and each other. At the same time, Lebanese patients deserted the sector, fleeing interminable waiting times and a deteriorated quality of service.
Criticisms and alternatives
Although academic and lay literature extensively criticises the current state of refugee health in Lebanon, its commercialisation is only briefly alluded to, often using the term “humanitarian business”. Criticism of the current refugee crisis management system primarily revolves around the fragmentation of the health system and the lack of coordination among different health actors (Blanchet et al., 2016). In contrast, certain literature commends the government’s response, attributing the fragmentation of the Lebanese health system to a dysfunctional humanitarian system.
Rather than regretting its decision not to support a parallel health system, the MoPH instead highlights its achievement of effectively managing international funds, contracting new donors, creating coordinating venues, and establishing an inclusive governance model (Ammar et al., 2016).
While academia focuses on efforts to limit health system fragmentation and systematise MoPH’s stewardship of all healthcare services, and its control of the system (Blanchet et al., 2017), communities have created alternatives routes to healthcare for refugees.
Refugees with medical backgrounds have joined forces to establish healthcare services in informal premises, securing important funding channels from international donors and the Syrian diaspora. This parallel system prioritises dignity over profitability. While not sanctioned or supported by the MoPH, observation of and comparison with ‘formal’ services leads to the conclusion that this model functions more effectively. The range and quality of services on offer has led to this system becoming popular with Syrians and Lebanese alike. (You can read a comparison of two such facilities here.) In other instances, there are attempts to activate local healthcare governance teams whose remit is to address the entire population’s health needs. For example, the Majdal Anjar Municipal Health Committee, which includes Syrian refugees alongside local Lebanese people, is an attempt to reduce fragmentation, improve cost effectiveness, and monitor and improve the quality of health services and programs for Lebanese and Syrians alike.
Video: From concept to reality: challenges of decentralising healthcare governance in Lebanon – Rouham Yamout speaks on Majdal Anjar’s Municipal Health Committee
Video: Navigating turbulence: an analysis of Lebanon’s healthcare system resilience during a multi-crisis situation – Fouad Fouad gives an overview of the challenges faced by the Lebanese health system in recent years