Intended for healthcare professionals

Feature Humanitarian Aid

Healthcare for Syrian refugees

BMJ 2015; 351 doi: (Published 04 August 2015) Cite this as: BMJ 2015;351:h4150
  1. Jonathan Gornall, freelance journalist, Suffolk, UK
  1. jgornall{at}

As Syria’s civil war rages on, promised aid money has not materialised and the UN is struggling to provide healthcare for more than four million refugees. Jonathan Gornall reports

During a snow storm on New Year’s Day this year, triplets Riyadh, Ahmed, and Khalid were born in a refugee camp in Lebanon’s Bekaa Valley. Their mother developed heavy bleeding and died shortly after the births; the smallest of the boys died three weeks later.1 The UN High Commission for Refugees (UNHCR), which drew global attention to the family’s tragedy, could not confirm whether the births had taken place in the family’s tent or in a medical facility. But in June, the head of the agency, Antonio Guterres, warned that there are “70 000 pregnant women at risk of unsafe deliveries” because “life-saving health services are becoming too expensive for many.”2

In Lebanon, UNHCR covers 75% of the cost of life saving, obstetric, and emergency hospital care for refugees. But increasingly refugees cannot scrape together their 25%. The agency told The BMJ that it had spent $40.25m (£25.80m; €36.60m) subsidising healthcare costs for 55 000 refugees in Lebanon in 2014—approximately $727 a head. Given that in 90% of cases UNHCR pays only 75% of the costs, with the patient being left to find the balance, this suggests an average cost per patient of about $1000.

“We do our best to refer refugees to non-governmental organisations or charities who are able to assist them with the remaining fees as most have depleted whatever resources they had and are often unable to cover outstanding costs,” a spokesperson for UNHCR told The BMJ.

More than 142 000 Syrian children have been born refugees since the start of the crisis in 2011, but it is not known how many others have died because of lack of medical help or whether maternal or infant mortality among refugees is going up. A UNHCR spokesperson said, there are “no accurate overall data on mortality rates before and since the crisis to provide this information.”

Funding shortfall

At the same time, a lack of donor support for the Syrian crisis means the UN expects to have to stop subsidising some types of hospital care this winter. The ranks of refugees from the Syrian conflict are continuing to grow (4.01 million as of June, expected to reach 4.27m by the end of this year), but 26 of the 37 nations that agreed in March to contribute to the Regional Refugee and Resilience Plan 2015-16 have yet to give the money they promised. This means that only 27% of the $4.35bn needed for the Syrian crisis in 2015-16 is in place. “We are so dangerously low on funding that we risk not being able to meet even the most basic survival needs of millions of people over the coming six months,” Guterres said in June.2 The biggest refugee population from a single conflict in a generation deserves the support of the world, he said, but instead they were “living in dire conditions and sinking deeper into abject poverty.”

Already the value of food vouchers to 1.6 million refugees has been reduced by an average of 30% since January this year, with the decrease in Lebanon at 37%. Overall, only 1.82 million (76%) of the target population of 2.35 million individuals have received any kind of food assistance, whether in the form of vouchers, cash, or in kind.

The funding shortfall means that in Lebanon the UN has only 17% of the $369m it had estimated was needed for healthcare and cannot even subsidise all life saving, emergency, and obstetric care. It has had to exclude certain treatments such as “care for infants born before 26 weeks’ gestation, non-strangulated hernias, dialysis for chronic renal failure, and chemotherapy and radiotherapy for cancer,” the UNHCR said.

In June, the agency warned that, unless more funds materialise, by October around 10 000 people will not have access to life saving emergency healthcare.3

These figures do not take into account the unknown number of refugees who fled Syria without any identity documents and therefore cannot register as refugees and benefit from any UN support. The UNHCR estimated there were 275 000 such unregistered Syrian refugees in Lebanon in June 2014. All those who have arrived since 6 May, with or without their identity documents, have not been allowed to register as refugees because Lebanon is now refusing to take in more people.

Long term problems

A further problem is the high rate of chronic disease in the Syrian population. Humanitarian medical aid has traditionally focused on emergency care and communicable diseases, and there is no funding for long term care for diseases such as diabetes, hypertension, and cancer. Some 77% of all deaths among Syrians before the civil war began were due to non-communicable diseases,4 and managing diseases such as diabetes is much harder for refugees because of lack of access to medicines or suitable food. “Syrian refugees are not dying from pneumonia; they’re dying from diabetes and heart problems,” said Jon Gunnarsson, from the medical aid organisation Médecins sans Frontières (MSF), in May. Official figures for the numbers of Syrians who have died from treatable non-communicable diseases are not available, but MSF believes as many Syrians may be dying from these diseases as from the violence of war.5

Overburdened systems

The lack of funding will be keenly felt in Lebanon. A small country, with a pre-2011 population of 4.7 million, it now has over one million Syrian refugees. The UNHCR has warned of “rapidly depleting resources and a host community stretched to breaking point.”6

Lebanon’s health system is mainly private and expensive. It is also riddled with corruption, although UNHCR insists it has systems for avoiding any fraud.

The most recent breakdown of referral data shows that from January to June 2014 27 553 refugees had 30 073 referrals for secondary and tertiary healthcare in Lebanon to 99 hospitals across the country, with “the top 20 hospitals” accounting for 75% of referrals.7

Costs vary widely. Mean costs, adjusted for disease category, sex, and age, were highest ($833) in Mazloum hospital in Tripoli, on the northwest coast, and lowest ($361) in Hermel, a government hospital at the northern end of the Bekaa Valley and close to the border with Syria.

Although only 52% of the refugee population is female, 70% of patients referred between January and June were female, with referrals for obstetric care accounting for 47.6% of the total. Among obstetric referrals, the “main reasons for seeking care were deliveries [92%, of which 30% were Caesarean section], miscarriages and other pregnancy complications, and complications of labour and delivery.” Twenty four per cent of referred patients were children under 5 years old.

Marian Schilperood, chief of the public health section in UNHCR’s division of programme support and management, told The BMJ that one of the main consequences of underfunding would be that “more and more difficult decisions need to be taken on the access to healthcare and which kind of services people are still going to have access to. One of our health policies is that we will prioritise access to primary healthcare and so we will be [increasingly] restricted in providing access to referral care services.”

Crisis by numbers

  • The Syrian conflict has generated 4.1 million refugees, and the total is expected to rise to 4.27 by the end of 2015

  • Donors have provided only 17% of the $369m that the UN estimate is needed for healthcare in 2015-16

  • The UN covers 75% of hospital costs for life saving, obstetric, and emergency care

  • 70 000 pregnant women are at risk of unsafe deliveries because they are unable to pay the rest


Cite this as: BMJ 2015;351:h4150


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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