An upsurge of violence in Syria has further exacerbated the already severe refugee crisis in the Middle East. More than 3.2 million Syrians have fled their country since the conflict began, and neither a cessation of hostilities nor an imminent return of refugees to their homes appears likely. The most recent spate of fighting and its effects on the civilian population serve as a sobering reminder that the humanitarian community and its partners need to establish a comprehensive set of long-term solutions and support systems to provide effective healthcare services for Syrian refugees.
Fleeing the violence of the civil war, Syrian refugees have hit Jordan and Lebanon particularly hard. Both countries have relatively small populations and less robust public healthcare systems in comparison to regional neighbors like Turkey. They are therefore less capable of absorbing large numbers of new patients with a multitude of needs. Nevertheless, Jordan is currently home to approximately 619,376 Syrian refugees. About 79,229 and 14,493 refugees live in the Za’atari and Azraq refugee camps respectively. Health services for refugees living in camps are the responsibility of United Nations High Commissioner for Refugees. The remaining 521,000 refugees reside throughout the country’s urban areas, with more than half living in the Amman and Irbid governorates. These refugees rely on the either the Jordanian Ministry of Health public clinics or on a network of private providers that provide services for a fee. Lebanon, for its part, has registered 1,133,934 Syrian refugees. Close to 700,000 live in North Lebanon and the Bekaa Valley in host communities, and the remainder live in Beirut and South Lebanon. Service provision is the responsibility of the Lebanese Ministry of Health.
The scope of the problem encompasses more than the number of refugees: it also involves their health status. The Syrian refugee population has a wide age distribution and exhibits high rates of both chronic and communicable diseases. In many cases, children have not received immunizations or are significantly behind schedule. Women, and sometimes children, have been the victims of domestic or sexual violence. Elderly Syrians often suffer from chronic diseases such as hypertension, heart disease, and diabetes. These issues require large-scale, ongoing, or complex responses that strain the capacity of the primary care systems of Jordan and Lebanon. The physical infrastructure, equipment, human and financial resources, and sometimes the technical capacity to provide quality care for an extended period of time are insufficient.
The development community has learned a tremendous amount since the Syrian conflict began nearly four years ago. To ensure that these best practices become long-term solutions, three critical steps are needed that will serve not only Syrians but also vulnerable Jordanians and Lebanese who have been placed at risk by the ongoing civil war.
First, local governments and stakeholders should implement solutions under the assumption that refugees will not be returning to Syria, or at least not anytime soon. Anecdotal evidence suggests that while many Syrians plan to return home, the number that will return and when they will do so are unclear. Refugee health interventions must therefore be designed from the outset with a long-term view. This means that the development community needs to focus more on building the capacity of (and in many ways reorienting) local health service systems and providers to meet the needs of these new patients. Facility renovations and equipment upgrades can help accommodate the needs of an expanded patient load. Additional human resources, mainly clinicians, are needed in public sector primary care clinics. Clinic staff need training in new skills areas such as organizing rapid mass-vaccination campaigns, identifying and treating domestic violence and other women’s health issues, and treating stress and other causes of cardiovascular and related chronic diseases.
Second, the development community must adopt a policy orientation toward public health that focuses more robustly on prevention, patient education, and self-care rather than on addressing health issues after they arise. Central to this shift away from a curative-only approach is engaging and empowering refugees to participate in managing their own healthcare. To do that, refugees and other high-risk populations will need more information about the prevention of illness, especially communicable diseases, presented in ways they can easily absorb. This education often begins in the community with information and training about basic hygiene, nutrition, immunization, and disease prevention. From there, it moves to essential information about available healthcare services ranging from doctors and clinics to women’s shelters.
The need to support positive behavior change accompanies the creation of an environment that disseminates information. Community-based referral systems are critical to providing critical information to refugees and maintaining access for refugees to the health system. Refugees need both the knowledge and reassurance that qualified, trustworthy doctors and clinics are available, supportive, and have the capacity to address their wide-ranging needs. Recruiting and training Syrian volunteers as community referral agents has proven to be an invaluable component of this approach in Jordan.
Third and finally, health services and other types of support for Syrian refugees in both Jordan and Lebanon need to be viewed not only as a form of assistance for Syrians but as a way of improving access for marginalized Jordanians and Lebanese as well. While Syrian refugees have been largely welcomed in both countries, they still face discrimination. A key message of education campaigns should thus be directed at the nation’s own citizens, including healthcare workers. That message must be clear: threats to refugees’ health are also threats to Jordanians and Lebanese citizens’ health and wellbeing. An obvious example of this threat is communicable disease. Overcoming attitudes that drive sick people underground is not easy and will take sustained effort. But it is essential to the success of a preventive public health campaign.
The challenge of providing health services to Syrian refugees in both Jordan and Lebanon continues to test governments and the international development community. While we in the development community have learned much about what works, we lack consistency in our approach, in applying what we already know, and—perhaps more importantly—in providing sufficient resources to allow local stakeholders to implement these approaches themselves.