The conflict ravaging Syria is an ever worsening public health tragedy for the country and the region. The United Nations High Commissioner for Refugees (UNHCR) Executive Committee in their recent “Solidarity and Burden Sharing” statement called for urgent donor assistance to meet the enormous social and economic strains placed upon neighbouring countries.
The World Bank estimates that in Lebanon alone the crisis has cost $7.5bn in lost revenue with hundreds of millions of dollars required to stabilise public services. In Jordan, there is a major discrepancy in these figures with the government estimating the cost at $850m by the end of 2013, while independent Jordanian economists put these costs at $3bn.
In addition to out-of-control costs and demands, the humanitarian response remains under-funded and poorly coordinated. The focus of the international community on chemical weapons and their removal from Syria has diverted attention away from the humanitarian disaster and massive demographic changes which are enveloping the region. These pose long-term health and security risks that threaten to destabilise the economies and social fabric of host communities.
Rising number of refugees
Escalating hostilities over the past months have led to a dramatic rise in refugee numbers and Internally Displaced People (IDPs). Over a third of the Syrian population is now effectively homeless. There are over 6 million IDPs and 8 million in urgent need of humanitarian assistance within the country. The total number of the externally displaced is set to reach 3.5 million by December. Within Lebanon and Jordan, these figures are officially estimated to be around 1 million and 650,000, although local NGOs report these figures at 1.5 million and 1.3 million.
Research indicates that the cost barrier has become so great that over the past two months increasing numbers of refugees are returning to Syria in order to access secondary care services, particularly for childbirth and reproductive health needs.
Within Syria the humanitarian and health situation continues to deteriorate. Civilian casualties are estimated to be over 115,000, with over 600,000 seriously injured. Some 5,000 people died in September alone.
Research by the authors found that in one field hospital in northern Syria there were over 4,000 conflict related injuries in August. Medical workers report that the multitude of infectious diseases continues to increase among IDPs due to overcrowding and poor sanitation. Over the past month there have been increasing incidences of malnutrition among children. Chronic conditions and Non-Communicable Diseases remain untreated due to the lack of qualified staff and access to pharmaceuticals. Data collected by the authors estimate that prior to the crisis, 6,000 Syrians per year died of cancer and 37,500 of Cardiovascular Diseases. The World Bank in their recent report “The Global Burden of Disease: Generating Evidence, Guiding Policy” note that prior to the conflict Syria had the highest percentage (76 percent) of Disability-Adjusted Life Years in the Middle East due to NCDs. Given the collapse of the country’s health system all these figures are surely now far higher.
Medical workers themselves continue to be targeted by the warring factions. As a result, very little coherent health and disease information is emerging from opposition areas. Humanitarian assessments have become infrequent and unreliable with the only official statistics available from the Syrian Ministry of Health and the World Health Organization via their Early Warning and Response Network system whose coverage is limited to government-controlled areas and regions.
Within Lebanon and Jordan, which host the largest numbers of refugees, the pressure on public services has gone beyond a tipping point. Primary healthcare services in both countries are experiencing severe strains and overcrowding. Secondary health-care services are available to Syrians but they continue to face large out-of-pocket payments in a system dominated by the private healthcare industry. Research by the authors indicates that the cost barrier has become so great that over the past two months increasing numbers of refugees are returning to Syria in order to access secondary care services, particularly for childbirth and reproductive health needs.
Refugee health needs continue to increase particularly with the appearance of informal tented settlements across Lebanon. It is reported that there are between 364 and 450 hosting 14 percent of registered Syrian refugees, with news ones emerging each week. Field visits by the authors shows that the health and sanitation conditions in these settlements are dire and look set to worsen with the onset of winter and the arrival of other refugees.
Communicable diseases are rising with the Lebanese Ministry of Health (MoH) reporting measles outbreaks increased from 9 in 2012, to 1,456 in 2013. Discrepancies or under-reporting in health statistics are also apparent. The Lebanese MoH recently recorded 420 cases of Leishmaniasis whereas a local NGO that operates throughout Lebanon – the AMEL association stated they had found over 40,000 cases of skin diseases.
Pre-existing state neglect
The refugee crisis has exposed the fragile and long term neglect of health and social welfare systems particularly in Lebanon where 50 percent of the population have no health insurance and lack basic means of social protection. According to the World Bank’s recent assessment on Lebanon, $1.5bn (3.4 percent of Lebanon’s GDP) will be needed to restore services to pre-crisis levels of which $177m is for health services alone. In addition they estimate that by the end of 2014, an additional 170,000 Lebanese will be pushed into poverty. This is on top of the existing 1 million Lebanese who live below the poverty line equating to $4 per day; 300,000 of which exist on less than $2.5 per day.
In Jordan the government is transferring the responsibility of price hikes and increased austerity measures on to the refugee crisis. In December 2012, the government excused the removal of universal subsidies on water and electricity based on the pretense that non-Jordanians were benefiting from such subsidies. To cover the shortfall in welfare spending the government requested international NGOs to include Jordanians within their cash transfer programs.
The most efficient and effective policy option now is for new donor money to be conditional upon host countries undertaking radical reforms to their health and welfare systems. This will increase cost effectiveness of donor money but more importantly secure the much needed long term health gains and stabilisation of host communities.
Response is under-funded and scattered
In terms of the response, constrained budgets mean that UN organisations are set to reduce the number of registered refugees receiving aid in Lebanon. According to the Assessment Capacities Project, only 72 percent of registered refugees in Lebanon will receive food aid and non-food items over the next few months. Duplication of projects, lack of coordination and sharing of information and data between agencies remain common throughout Jordan and Lebanon. A major gap in Lebanon is the absence of reliable health data and monitoring systems to provide an accurate description of health conditions throughout the refugee community. The Health Information Systems (HIS) of the MoH and UNHCR struggle to generate a reliable account of the health status of the refugee community and therefore to determine where health needs will arise. This is glaringly apparent in terms of mental and psychosocial health and NCDs.
NGOs themselves have become conduits of tension between Syrians and host communities. The authors have found that NGOs in Jordan are responsible for inflating the costs of public services and goods such as water and non-food items thereby creating tensions between local suppliers and consumers who often blame Syrians. Recent opinion polls in both countries highlight mounting resentment against the presence of Syrians in local communities. In Jordan 73 percent of the host community recently polled in favour of closing border crossings with Syria. The increase in tensions between Syrians and their host communities has become a struggle between the poor over finite public resources and already inadequate services.
The UNHCR Executive committee announcement that the response will now adopt and combine long-term humanitarian and development polices is welcome. However, there remain major information gaps and inefficiencies in how this will be designed and delivered. The most practical and immediate proposal is to establish rigorous and national multi-layered needs assessments and surveys on refugee communities covering each sector from employment and health to education and shelter. In terms of health this will provide accurate, reliable and transparent baseline data on a range of conditions including mental health and NCDs which can be used for screening, modeling projections as well as directing and evaluating interventions over the next years. This can also form the basis of a monitoring system that can be updated on a regular basis and can be extended to cover host communities.
In addition existing interventions and programmes need to be evaluated using field trials. There is currently no data on which, why and for whom interventions have worked in Lebanon and Jordan. Given the rumoured failure of a number of donor-funded projects in Lebanon, it should now be a requirement that NGOs and the UN measure outcomes and implement evaluations of their interventions. This will not only increase accountability and transparency but also enhance long term cost effectiveness of donor funds.
Above all the current crisis should be used as an opportunity to reform the existing social protection and social safety nets of host communities. Over the past five years polices of Universal Health Care and social protection have been scaled back and abandoned in both Lebanon and Jordan as a result of political neglect, the dominance of the private healthcare industry and under the guise of austerity. The most efficient and effective policy option now is for new donor money to be conditional upon host countries undertaking radical reforms to their health and welfare systems. This will increase cost effectiveness of donor money but more importantly secure the much needed long term health gains and stabilisation of host communities.
Dr Adam Coutts is a UK and Lebanon-based policy consultant specialising in social welfare, employment and public health.
Dr Fouad is on the faculty of Health Sciences at American University of Beirut, Lebanon.
Dr Thamer Sartawi is a medical doctor and independent public health researcher.