Lebanon remains at the forefront of the Syrian crisis, with over 1.5 million refugees (including both registered and unregistered) out of the 6.6 million who fled Syria since 2011 currently residing in the country. Escaping the severe war conditions in Syria, refugees in Lebanon were confronted by conditions of other nature, ones that in the last year only, included: an unprecedented economic deterioration, a sharp devaluation in the local currency, a pandemic and the Beirut blast. The multi-layered crises that have struck the country since 2019 have fomented the vulnerability of refugees across multiple areas, increasing their poverty and significantly decreasing their access to essential services – most notably those related to healthcare. And while various local and international organizations aim to meet the needs of refugees against all odds, the situation and conditions of Syrian refugees in Lebanon remain increasingly difficult.
Health coverage of Syrian refugees in Lebanon
The large number of refugees that has arrived in the country post 2011 has substantially increased the demand for health services and overstretched the already struggling system. Additionally, the structure of the Lebanese healthcare system, which is renowned by being highly privatized and majorly reliant on user fees, has made it harder for vulnerable communities, including refugees, to access essential services. These factors have highlighted the urgency of improving health-service availability for Syrian refugees, and paved the way for collaboration between the various stakeholders – most importantly between the United Nation Agency for Refugees (UNHCR) and the Ministry of Public Health (MoPH), in addition to a number of other humanitarian actors.  As a result of this collaboration, Syrian refugees in Lebanon can access essential health services through: local primary healthcare centers (PHCCs), hospitals, and some mobile medical units (MMUs). Through the 218 nationwide PHCCs and 25 MMUs, Syrian refugees are able to attain subsidized basic health services including: general medical consultations, mental health services, reproductive health and family planning, medications and free vaccinations. Here, it is worthy to note that UNHCR does not support out-patient screenings, i.e. expensive radiological examinations (MRI, CT, PET-scans) and laboratory tests. Additionally when it comes to hospitals, UNHCR only supports deliveries and critical emergencies, covering 75-90% of the hospital fees, while a lot of severe conditions remain wholly uncovered such as: cancers, chronic haematological, immunological, neurological and endocrinological conditions.
UNHCR’s COVID-19 Response
According to UNHCR, up until mid-January 2021, 2,734 COVID-19 cases were recorded among Syrian refugees in Lebanon, out of which 228 live in informal settlements.  Responding to the escalating pandemic, UNHCR has devised a trifold rescue plan to fight COVID-19, such that:
Prevention – “community engagement and awareness-raising” constitutes the first level. UNHCR has joined efforts with the United Nations Children’s Fund (UNICEF) to launch awareness campaigns among refugees through different communication channels. As a result, UNHCR estimates that around 93% of refugees are aware of the preventative measures against COVID-19.  Moreover, hygiene kits such as: soaps, antiseptics, and bleach, were also delivered to refugees, but only those residing in congested settings.
Containing Transmission – “isolation procedures in overcrowded settings” comprises the second level of action. Hand in hand, UNHCR along with the World Health Organization (WHO) and concerned authorities have developed guidance and regulations on self-isolation in case of detection within overcrowded refugee communities. The agency has also supported the inauguration of specialized isolation shelters with informal settlements, and other isolation facilities in urban settings with the collaboration of the local municipalities. To that end, UNHCR reports the establishment and readiness of 577 sites across Lebanon to be used for isolation at the community level. .
Treatment and Case Management represents the third and last level of action, by which UNHCR is ensuring the availability of testing and hospitalization services for refugees through supporting the expansion of the already existing facilities and equipment. According to UNHCR, by mid-January 2021, an additional 197 hospital beds and 25 Intensive Care Unit (ICU) beds were ready to use. 
Nonetheless, the comprehensive COVID-19 response plan retains some gaps that cannot be overlooked. First, the distributed hygiene kits target not only registered refugees, who in essence do not constitute the majority of Syrian refugees in Lebanon, but also those who live in crowded settings. This fact raises question marks regarding the sanitation and hygiene needs of those who are neither registered, nor live in crowded settings. This must be particularly regarded, in light of the deteriorating purchasing power of Syrian refugees in tandem with the great market inflation, and the prioritization of “more essential needs” like food and shelter over hygiene products. Second, when it comes to the newly established isolation sites, the number of dedicated beds remains far beyond the current and projected needs of refugees, especially as the toll of cases is still on the rise amid the lack of serious interventions.These conditions apply as well when it comes to the newly added hospital and ICU beds.
Refugees amid the great economic descent
Three years into its worst recession since the Civil War, Lebanon is facing a severe economic depression. Exacerbated by re-emerging political instability, and fueled by a raging pandemic, the economic and financial situation has worsened the living conditions of the vulnerable communities in Lebanon and refugees are not an exception. The Lebanese currency value has dropped by 80% between October 2019 and the end of 2020, reflecting the currency’s real worth and most importantly the Purchasing Power Parity (PPP).* According to recent World Bank estimates, 45% of the Lebanese citizens will live below the poverty line, while 22% others will fall below the food poverty line. While these figures reflect a tint of the situation, they are still far off of the living conditions of refugees, and the vulnerabilities that they endure.
According to the latest vulnerability assessment of Syrian refugees (VASyR), 89% of the Syrian refugees in Lebanon live on less than LBP 308,000 per person per month which is less than half of the Lebanese minimum wage. More dangerously, nine out of ten Syrian refugees are now living in extreme poverty. VASyR has also highlighted the increasing rate of debt that the Syrian households are accumulating denoting that 9 out of 10 households continue to be in debt for reasons that range from food acquisition (93%), to paying rent (48%), and buying medicine (34%). The severity of the financial situation will definitely have a debilitating effect on refugees’ access to healthcare, especially during the global pandemic and the needs that arise. “Medical fees have also become prohibitive for vulnerable groups in the country,” suggests the Deputy Medical Coordinator for Lebanon at Doctors Without Borders (MSF), adding that “This context is expected to worsen people’s health conditions and access to care, and our teams [at MSF] on the ground have already started to witness signs of deterioration”.
Escaping the enduring war in Syria, Syrian refugees in Lebanon were confronted, in the last year only, with an unprecedented economic recession, a critical socio-political situation, and a raging pandemic. These conditions among others have detrimental effects on the overall health status of refugees, affecting their access to services at multiple occasions. It is the acute financial downturn, however, that has had the most significant impact. Receiving their cash assistance in Lebanese Pounds, in-line with being insufficiently covered for adequate health services, Syrian refugees are forced to weigh and decide between the various essential needs. The gravity of the situation dictates prompt corrective measures that include but are not restricted to: 1) the reformation of the cash assistance programs in a way that caters to the current situation and needs, and 2) the re-evaluation of the current health coverage system in an attempt to address some of the most prominent gaps in service delivery.
* Purchasing Power Parity refers to the currency exchange rate which equalizes the purchasing power of different countries.
: Research Assistant, Global Health Institute, American University of Beirut
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