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Abstract

Background:

This study examines the health security of both Lebanese citizens and Syrian refugees in Lebanon. It also assesses the readiness and resilience of the healthcare system in response to the multi-layered crisis that began in late 2019.

Methods:

A qualitative case study design was employed, utilizing 2 unstructured interviews with health experts/hospital staff, semi-structured interviews with 20 Lebanese participants and a document review. Thematic analysis was used to analyze the data.

Results:

The study found that Syrian refugees have access to health services under terms, conditions and restrictions including out-of-pocket (OOP) payment. In contrast, Lebanese citizens find traditional health guarantor systems largely ineffective, leading to high OOP costs for most healthcare services, with few exceptions. This study reveals a paradox in healthcare access within Lebanon’s fragile environment. Syrian refugees have greater access to health services, with minimal out-of-pocket (OOP) costs to a certain extent, compared to Lebanese citizens themselves who remain entrenched in inadequate health support services and poor public administration.

Conclusion:

To address this, targeted interventions and policies are crucial for policymakers and stakeholders, including the private and public sectors, local non-governmental organizations (NGOs), and the international community. Reforms are needed, spearheaded by the Ministry of Public Health (MoPH), other relevant ministries, and government payers, to refinance the traditional guarantor system and restore Lebanese citizens’ health security. Additionally, unifying health coverage across all government payers is vital.

Keywords

Health refugees Lebanon crisis services integration

Introduction

Throughout history, humanity has been in constant motion, driven by a complex interplay of economic opportunity, social upheaval, legal constraints, and the ever-present need for security. Today, 2.3% of the world’s population finds itself outside their country of origin.¹ This mass movement presents a significant challenge to global healthcare systems. Migrants and refugees often face an uncertain landscape of health services, struggling with availability, access, and the long-term sustainability of care. For those already battling chronic illness, the journey itself can be particularly disruptive. Interrupting established medical routines and therapies becomes a stark reality, further compounded by the frequent lack of accessible medical records or documentation for their current medications.² Syria provides a stark example. The ongoing civil war, raging since 2011, has displaced over 6 million people, making it the fifth-highest source of refugees worldwide.³

Despite its own struggles with instability and crisis, Lebanon, alongside regional neighbors like Türkiye, Jordan, Egypt, and Iraq, has opened its doors to a significant number of Syrian refugees and migrants. However, this humanitarian effort has coincided with a period of immense internal strain for Lebanon. Since the 2019 uprisings, the country has grappled with a multi-faceted crisis that has stretched public services to the breaking point and threatened the very foundation of its healthcare system. The current situation in Lebanon paints a grim picture: a crippling economic, financial, and banking crisis; a skyrocketing poverty rate; social unrest; severe food insecurity; the lingering effects of the Beirut port explosion; civil unrest; and the long-term impacts of the COVID-19 pandemic.⁴ These daunting challenges are further compounded by the weight of the decade-long Syrian refugee crisis.⁴ As a result, Lebanon’s healthcare system, already burdened and fragmented, struggles to deliver even basic services to its own citizens. The lack of adequate resources and infrastructure creates a system riddled with inconsistencies, leaving many Lebanese without access to quality healthcare.

A refugee crisis can exert immense pressure on a host country’s healthcare system. Already strained by high demand, escalating costs, staffing shortages, and a fragile infrastructure, such an influx can exacerbate existing weaknesses, impacting both the host community and the refugees themselves. In Lebanon, for example, refugees often face significant hurdles in accessing healthcare. Compounding this issue is the fact that public health services are not free, and many refugees lack essential medical records. The overall financial situation further complicates matters. The net result? A dramatic decline in healthcare access for all, jeopardizing the fulfillment of international commitments to both refugees and host citizens. These commitments encompass the fundamental right to health enshrined in Article 25 of the Universal Declaration of Human Rights, along with the principles of non-discrimination (Article 5 of CEDAW), fair trial (Article 7 of ICCPR), and access to essential social services (Article 12 of ICESCR). Additionally, it undermines progress toward Sustainable Development Goals 3 (Good Health and Well-being) and 10 (Reduced Inequalities).^5-11

In crisis settings, the importance of health management and provision of healthcare cannot be overstated. Crisis often exacerbates existing health vulnerabilities and create new challenges, placing immense strain on already fragile healthcare systems.^12,13 Effective health management becomes crucial for mitigating the spread of diseases, preventing outbreaks, and ensuring the well-being of affected populations.^14-16 Accessible and efficient healthcare services not only save lives but also foster resilience and stability in communities facing adversity^17-20 Moreover, prioritizing health management in crisis settings facilitates the delivery of essential medical aid, promotes coordination among responders, and strengthens the overall response efforts.^17-20

Against this backdrop, this paper aims to explore how the healthcare landscape for Syrian refugees and Lebanese citizens in Lebanon contributes to broader and nuanced understandings of health security, as viewed through the lens of resilience theory, amidst the multi-layered crisis that commenced in late 2019.

Theoretical Framework

This paper aims to understand health security through resilience theory.²¹ Resilience theory offers a lens through which to understand the dynamics of health security amidst complex and protracted crises such as the one experienced by Lebanese citizens and Syrian refugees in Lebanon. This theory posits that individuals, communities, and systems possess inherent capacities to withstand, adapt to, and recover from adversity.²¹ In the context of healthcare systems, resilience is reflected in their ability to maintain essential functions, provide equitable access to services, and respond effectively to evolving challenges.^22,23

The findings of this study underscore the differential experiences of health security between Lebanese citizens and Syrian refugees, highlighting the resilience and vulnerabilities within the healthcare system. Syrian refugees, despite facing numerous barriers, including displacement and restricted access to formal employment, demonstrate a degree of resilience in accessing healthcare services.^24-27 This resilience is partly facilitated by humanitarian aid and international support, which mitigate financial burdens through subsidized or free healthcare provisions^12,28-30 Conversely, Lebanese citizens navigate a fragmented and ineffective traditional health guarantor system, which fails to adequately protect them from high out-of-pocket costs and limited access to essential healthcare services.^31-34 This system’s inadequacies are exacerbated by poor public administration and governance structures, contributing to systemic vulnerabilities and undermining health security.^35-37

Resilience theory suggests that interventions aimed at enhancing health security should focus on building adaptive capacities within the healthcare system and addressing underlying vulnerabilities.^35-37 Targeted policies and reforms are essential to strengthen the resilience of both the system and the communities it serves. This includes efforts to improve governance, enhance coordination between stakeholders, and mobilize resources to ensure equitable access to healthcare for all populations, regardless of nationality or status. Moreover, resilience theory emphasizes the importance of learning from past experiences and adapting strategies in response to changing circumstances. The findings of this study underscore the need for adaptive governance mechanisms that can anticipate and respond to evolving health challenges, such as pandemics, conflicts, and humanitarian crises. By fostering a culture of resilience within the healthcare system, policymakers and stakeholders can better prepare for future shocks and safeguard the health security of all populations.

Health, Conflict and Displacement in the Literature

As multiple studies underscore, despite access to healthcare being a fundamental human right, it remains a significant challenge for refugees and host communities in developing and conflict-affected settings and beyond.^38-44 The barriers to accessing healthcare faced by these populations are multifaceted and deeply rooted in the challenges of displacement, limited resources, and systemic inequalities.^45-47 Financial constraints often prevent both refugees and host communities from accessing healthcare services, exacerbated by the lack of insurance coverage or the inability to afford OOP expenses.^48-51 Moreover, legal and administrative hurdles, such as restrictive residency requirements or documentation challenges, have been found to impede refugees’ access to healthcare, while host communities may encounter bureaucratic obstacles in navigating healthcare systems.^52-54 Language and cultural barriers further complicate the situation, as refugees have been found to struggle to communicate effectively with healthcare providers, leading to misunderstandings and inadequate care.^55-57 Similarly, cultural differences can influence perceptions of healthcare and willingness to seek medical assistance, affecting both refugees and host communities.^58-60

In conflict settings, geographical inaccessibility compounds the challenges of accessing healthcare, as violence, displacement, and poor infrastructure limit the availability of healthcare facilities.^12,61-63 Remote locations exacerbate this issue, making it difficult for both refugees and hosts to access essential medical services (Ibid). Stigma and discrimination within healthcare settings also deter refugees and host communities from seeking necessary care, perpetuating marginalization and exacerbating health disparities.^58,63-66 Discriminatory practices based on ethnicity, nationality, or refugee status further alienate vulnerable populations, hindering their access to healthcare services.^31,67-73 Additionally, the limited healthcare infrastructure and resources in developing and conflict-affected settings pose significant barriers to access, including shortages of medical personnel, equipment, and medication.^31,67-73

Despite these challenges, various interventions and strategies have been implemented to improve access to healthcare for refugees and host communities.^62,63,74-76 Integrating healthcare services and coordinating efforts between humanitarian organizations, local healthcare providers, and government agencies have been found to enhance efficiency and comprehensiveness of care delivery.^77-79 Deploying community health workers within refugee and host communities has further been known to bridge gaps in healthcare access by providing culturally sensitive care, health education, and referrals to formal healthcare services.^80-84 Mobile health clinics offer flexible and accessible healthcare delivery, particularly in remote or conflict-affected areas, overcoming geographical barriers to access. Language and cultural competency training for healthcare providers enhances communication and understanding with refugee populations, fostering trust and encouraging healthcare-seeking behavior.^85-88 As such, studies have found that advocating for policy reforms, increased funding, and collaborative partnerships between governments, humanitarian organizations, NGOs, and local communities remains essential to address legal barriers, reduce stigma, and prioritize healthcare investments in developing and conflict settings.⁸⁹

While numerous studies have delved into the intricacies of healthcare accessibility in conflict and developing regions, along with the pivotal role of humanitarian responses, our paper seeks to illuminate a significant case study. Specifically, one where conventional notions of health access between refugees and host communities are challenged due to diminishing gaps in vulnerability. Although Syrian refugees in Lebanon face myriad challenges in accessing healthcare, our examination of a hospital in Saida offers a nuanced exploration of the intersecting factors influencing health access for both Syrian refugees and vulnerable host populations.

Methods

This study employed a qualitative research approach, integrating interviews and a comprehensive examination of hospital records. The investigation centered on a private hospital situated in Saida, South Lebanon—a renowned center for healthcare provision serving Syrian refugees and the local population alike. We selected this specific hospital for the study because it treats both Syrian and Lebanese citizens in roughly equal proportions. Additionally, it is located in a Lebanese city with a high concentration of refugees, and benefits significantly from humanitarian aid, which has been crucial for its ongoing operation since 2019.

Purposive sampling was implored in the selection of participants. The main sample comprised Lebanese adults, both male and female, aged 18 years and above, seeking healthcare services at the selected hospital. These services encompassed both inpatient care (hospital admissions) and outpatient services (including laboratory tests, radiology, and various clinics). Two interviewing methodologies were employed to gather data. Initially, an unstructured approach was utilized to interview 2 senior staff members from the hospital. This method involved posing open-ended questions alongside an aide-memoire to steer the discussion. Each staff member underwent a single interview session, with durations spanning 30 minutes and 2 hours, respectively. Subsequently, a semi-structured approach was adopted to interview 20 Lebanese study participants. This approach incorporated a set of predetermined questions supplemented by probe questions. Participants included individuals seeking either inpatient or outpatient healthcare services for themselves or their family members. Notably, all interview participants were of Lebanese nationality. Due to their vulnerable status and the associated challenges in obtaining necessary ethical approvals, Syrian refugees were excluded from participation in this study.

Both sets of interviews were conducted with the aim of addressing key research sub-questions, including the response of the healthcare system to the significant influx of Syrian refugees in Lebanon, and the extent to which health needs are met for both Syrian refugees and the local host community. Participants were interviewed privately, either in patient rooms or at the outpatient clinic, with interview durations ranging from 15 to 25 minutes. Data collection was undertaken in June 2022 with no audio or video recordings made. Documentation relied solely on written notes. All interviews were conducted in Arabic and subsequently translated into English during the transcription process. Interview quotes presented in this publication were edited for grammatical accuracy, and names were omitted to ensure confidentiality and privacy.

The semi-structured interview guide utilized in this study drew inspiration from a questionnaire featured in a study by Lyles et al. Seeking permission to adapt portions of this questionnaire, we reached out to the corresponding author, Dr. Shannon Doocy, via email in March 2022. Fortunately, Dr. Doocy granted full approval for the incorporation of the questionnaire’s content into the development of our interview guide. With meticulous attention to clarity and accessibility, the interview guide was crafted using simple, non-technical language to address our research inquiries. Prior to finalization, a pilot test identified 3 redundant questions, prompting their removal from the guide. Subsequent to Institutional Review Board (IRB) approval, another pilot test confirmed the tool’s compliance with criteria and requirements.

After conducting 20 qualitative in-depth interviews, data saturation was unequivocally reached, indicated by the recurring emergence of themes throughout the analysis. Familiar patterns and narratives surfaced consistently, signaling thorough exploration of the research topic and validating the robustness of identified themes. This recurrent nature of emerging themes across diverse participants and contexts affirms the depth of collected data, providing a solid basis for insightful interpretations. Thematic analysis followed a consistent, pre-defined approach aligned with the research sub-questions. Through this approach, we familiarized ourselves with the data through repeated readings, gaining a holistic understanding of the content. Next, initial codes were generated to label segments of data relevant to the research questions. These codes were then organized into potential themes, grouping together similar codes that represented overarching concepts or ideas.

Throughout this process, we maintained transparency by documenting the decisions made at each step, including the rationale behind code generation and theme development. To validate the identified themes, we employed inter-coder reliability checks, where multiple researchers independently analyzed the data to ensure consistency in theme identification. Additionally, transparently reporting the process of theme validation, including any discrepancies or challenges encountered, contributed to the credibility and reproducibility of the study findings, enabling other researchers to assess the trustworthiness of the analysis. Ethical approval was obtained from the Institutional Review Board (IRB) of the Lebanese American University under LAU.SAS.JD4.6/June 2022. Characteristics of study participants is unpacked below (Tables 1 and 2):

Table 1.

Characteristics of participants in semi-structured interviews, inpatients.

No.	Age	Sex	Type of service	Type of health coverage
1	55	F	Inpatient	Islamic Health Committee (IHC)
2	29	F	Inpatient	No health coverage
3	58	M	Inpatient	Civil Servant Cooperative (COOP)
4	49	F	Inpatient	Ministry of Public Health (MoPH)
5	63	M	Inpatient	Internal Security Forces (ISF)
6	59	M	Inpatient	Lebanese Army Forces (LAF)
7	29	F	Inpatient	National Social Security Fund (NSSF)
8	87	M	inpatient	LAF
9	61	F	Inpatient	No Health coverage
10	27	F	Inpatient	No health coverage
11	25	F	Inpatient	NSSF

Table 2.

Characteristics of participants in semi-structured interviews, outpatients.

No.	Age	Sex	Type of service	Type of health coverage
1	35	F	Outpatient	NSSF & Private insurance
2	43	F	Outpatient	ISF
3	60	F	Outpatient	No health coverage
4	40	F	Outpatient	Private insurance
5	69	F	Outpatient	IHC
6	35	F	Outpatient	Public Security (PS)
7	31	F	Outpatient	No health coverage
8	36	F	Outpatient	PS
9	27	M	Outpatient	NSSF

Results

The healthcare conundrum in Lebanon, affecting both Syrian refugees and Lebanese hosts, cannot be fully comprehended without delving into the socio-political and economic landscapes that underpin it. Lebanon’s complex socio-political dynamics, compounded by economic challenges, play a pivotal role in shaping healthcare access and exacerbating disparities.^90,91 Lebanon’s intricate sectarian politics and historical context significantly influence healthcare dynamics.⁹² The country’s sectarian power-sharing system has led to fragmented governance and weak public institutions, impacting healthcare delivery and accessibility.⁹² Moreover, political instability and frequent governance crises further strain an already fragile healthcare system, leaving vulnerable populations, including Syrian refugees and marginalized Lebanese citizens, particularly exposed.^92,93

Lebanon’s economic woes, including high unemployment, inflation, and currency devaluation, have deepened healthcare disparities. Lebanese citizens, grappling with economic hardships, often face insurmountable barriers to accessing affordable healthcare.^32,94-98 For many, OOP expenses become prohibitive, resulting in delayed or forgone care.^32,94-98 Syrian refugees, while also affected by economic hardships, may have comparatively better access to healthcare due to international aid programs and NGO support, albeit still facing significant challenges.^30,58,99-102 Furthermore, international aid plays a crucial role in mitigating healthcare disparities in Lebanon.^103,104 Humanitarian organizations and donor countries provide essential funding and support for healthcare services, particularly for Syrian refugees.^103,104 However, aid dependency poses challenges, as it has been known to perpetuate a temporary fix rather than addressing systemic issues.^105,106 As such, fluctuations in aid disbursement, shifting donor priorities and donor fatigue, can destabilize healthcare provision, underscoring the need for sustainable, long-term solutions.^105,107-109

Against this backdrop, various stakeholders, including NGOs and government bodies, shape healthcare access dynamics in Lebanon. NGOs often fill gaps in service delivery, providing essential healthcare services to underserved populations.^110-112 However, their efforts have been constrained by limited resources and dependence on donor funding. Government bodies, including the Ministry of Public Health, bear responsibility for healthcare governance and policy formulation. Effective collaboration between government entities, NGOs, and international partners albeit essential for addressing healthcare disparities and building a resilient healthcare system that serves all populations equitably, remains largely absent.⁹⁴ Findings from interviews conducted with the hospital’s senior staff and patients largely fall in line with these realities, and corroborate the aforementioned.

The themes and findings presented below are derived from a combination of unstructured and semi-structured interviews conducted with participants and experts. Unstructured interviews allowed for open-ended exploration of experiences, perspectives, and challenges related to healthcare access in Lebanon. These interviews provided rich qualitative data, capturing the nuances and complexities of lived experiences. Semi-structured interviews, on the other hand, followed a predefined set of questions while still allowing for flexibility and probing into specific areas of interest. These interviews facilitated a deeper understanding of key topics and ensured consistency in data collection across participants. By integrating both approaches, a comprehensive picture of healthcare access issues in Lebanon emerged. Together, these methods enabled the identification of common patterns, perspectives, and challenges experienced by both Syrian refugees and Lebanese citizens in accessing healthcare services.

Guarantors and schemes providing access to health services for Syrian refugees and hosts

During our data collection period in June 2022, Syrian refugees in Lebanon had access to a conditional health coverage program, “NEXtCARE,” offered by UNHCR’s insurance partner. This program provided limited coverage (75%) and primarily focused on essential services like maternal health, child health, and emergency care. However, even unregistered refugees were not entirely without options. UNHCR, through third-party administrators, could still offer prompt access to healthcare for specific life-threatening situations, such as trauma (excluding childbirth). Furthermore, various local and international organizations stepped in to bridge the gaps in health access, assistance, and coverage for the Syrian refugee community. This included instances where refugees provided financial assistance to one another within their community. Perhaps the most striking finding was that some refugees, despite facing ongoing security concerns and the risk of persecution, chose to return to Syria to access necessary healthcare services.

Health guarantors in Lebanon, such as NSSF, COOP, ISF, PS, and MoPH, are government-affiliated. Before the 2019 crisis, these guarantors typically covered 85% of the total medical bill. However, during the data collection period (June 2022), their usefulness was largely limited. This is because they continued to provide coverage based on an exchange rate of LBP 1500 for each 1 USD billed, which was significantly lower than the market rate. This resulted in a substantial OOP expense for patients. Lebanese citizens covered by the Lebanese Armed Forces (LAF) health insurance enjoyed a distinct advantage. LAF was the only government-connected guarantor that did not require OOP payments, and their coverage even extended to medical equipment. However, we also observed instances of “wasta,” an Arabic term for clientelism or favoritism, playing a significant role, particularly with government-connected guarantors. This practice gave certain individuals priority access to health services, sometimes at the expense of other beneficiaries.

On a different note, both LAF and the Islamic Health Coverage (IHC) offered comprehensive health coverage. While some expressed gratitude for IHC, others voiced reservations due to concerns over potential humiliation when seeking support from Lebanese government funds. Regarding IHC, their network of primary healthcare centers (PHCs) remained a robust system for accessing basic medical services. Lebanese citizens typically accessed healthcare services through various channels, including private clinics, PHCs, hospital emergency departments, private military clinics, and the United Nations Relief and Works Agency for Palestinian Refugees (UNRWA) if their spouse was Palestinian. Notably, those seeking services at military clinics often did so to obtain approval for regular hospital admission. However, some challenges persist: 1 respondent lamented the need to procure their own medical supplies at military hospitals, while another highlighted the heavy patient burden on physicians at these clinics. Additionally, the utilization rate of primary healthcare services remained comparatively low.

Both Syrian refugees and Lebanese citizens reportedly followed the same criteria for admission and billing at hospitals. However, variations in bills arose due to factors such as physician fees, hospital stay charges, and the cost of medical supplies. Several interviewees expressed dissatisfaction with the healthcare system. One respondent offered a scathing critique, stating, “[. . .] the hospitals’ goal is to earn money only.” Another lamented the perceived unfairness, remarking, “[. . .] the healthcare system is unfair for Lebanese citizens.” Another participant voiced a sense of abandonment, noting, “[. . .] if I were Palestinian or Syrian [. . .] I might have had UN coverage.” This sentiment was echoed by another interviewee who observed, “Lebanese citizens are treated like refugees, while Syrians seem to be treated better here.” The frustration was palpable. One respondent questioned, “Is it normal for this country to prioritize Syrians over us?” Another expressed feelings of worthlessness, stating, “[. . .] we, Lebanese citizens, are nothing—we are just garbage.” Perhaps the most poignant remark came from an interviewee who said, “I wish we were born Syrians.”

Role of accreditation in structuring the Lebanese healthcare system

The accreditation process in Lebanon, overseen by the Ministry of Public Health (MoPH), has been in place since 1990; this was followed by the revision of the Lebanese Hospital Accreditation Standards in 2012. These standards are influenced by the International Society for Quality in Healthcare (ISQua) requirements. Regardless, participation in the accreditation process remains voluntary. Hospitals that choose to participate conduct self-assessments based on the standards, followed by on-site evaluations by external surveyors from the MoPH. Accreditation is granted or denied based on compliance with the standards and remains valid for 3 years with follow-up visits.

While some respondents credited this system with helping to structure the Lebanese healthcare system after the Civil War, challenges persisted. Low liquidity, lack of motivation to invest in high-tech equipment, delayed payments, and the migration of skilled healthcare professionals continued to hinder the system’s effectiveness. Additionally, the MoPH and the Syndicate of Hospitals had collaborated for several years to bolster medical tourism. Lebanon traditionally attracted patients from countries with weaker healthcare systems seeking even simple, non-invasive procedures, not just life-saving treatments. Unfortunately, the recent economic downturn has stalled these efforts.

Impact of the 2019 crisis on healthcare in Lebanon for Lebanese citizens

In the period immediately following the civil unrest and protests that began on October 17, 2019, hospitals in Lebanon experienced a significant decline in the number of patients seeking care. This drop can be attributed to several factors. One major reason was the financial strain placed on Lebanese citizens. With banks restricting access to deposits, many people simply could not afford hospital bills. Another contributing factor was the devaluation of the Lebanese pound. Even with medical insurance, patients were often required to pay OOP costs in fresh US dollars (a locally-adopted term loosely meaning readily available cash). This created a situation where even those with insurance felt insecure about their ability to access healthcare. To cope with rising costs, some Lebanese patients opted to seek laboratory tests outside of hospitals, hoping for lower fees. The economic crisis forced many to prioritize basic needs over preventative or non-critical medical care.

Coping strategies of the healthcare system

The 2019 economic crisis forced Lebanese citizens to adopt various coping strategies to access healthcare. Some relied on family support, as 1 participant poignantly expressed, “[. . .] it makes me feel bad that I have to take money from my brothers and sisters.” Others resorted to selling personal assets like gold jewelry to raise additional funds. To manage costs, some citizens reduced their visits to doctors, prioritizing only essential appointments. In some cases, patients were forced to decrease the dosage or even discontinue their regular medications. Drug shortages in Lebanon also led some individuals to seek medication from abroad, in countries like Canada, the USA, and Türkiye. Furthermore, the financial burden prompted some citizens to take on multiple jobs to generate enough income for healthcare needs.

Hospitals in Lebanon battled a complex crisis across 3 distinct fronts: the economic downturn, the COVID-19 pandemic, and the ongoing presence of Syrian refugees. Each challenge demanded a different coping strategy. The economic crisis was the most devastating. Many hospitals simply could not sustain themselves and were forced to close their doors. Others limped by with minimal operations, often relying on the financial support of NGOs, international organizations, or even political parties. The COVID-19 pandemic presented a new set of challenges. Hospitals had to divert resources and staff to manage the influx of COVID-19 patients, further straining their already limited capacity. The Syrian refugee crisis added another layer of complexity, but also opportunity, as some hospitals were initially funded by humanitarian actors to primarily serve refugees, but then expanded to include Lebanese citizens as well.

The hospital in Saida’s overall strategy focused on maximizing revenue by prioritizing patients with strong financial backing. This involved 2 main steps. First, they ranked all healthcare payers by their ability to pay in fresh USD. Syrian refugees covered by UNHCR, who paid in USD, became a key target demographic. This strategic focus was bolstered by the hospital’s existing contracts with UNHCR, as well as the Internal Committee of the Red Cross (ICRC) and UNRWA. Notably, 65% of the hospital’s patients were Syrian refugees paying in USD, with an additional 15% from UNRWA (partially paying in USD). This financial advantage contributed significantly to the hospital’s survival. Beyond financial considerations, the hospital made a strategic investment in its Neonatal Intensive Care Unit (NICU). Located near the maternity ward serving Syrian mothers, the expanded NICU allowed infants to remain close to their families. This department, boasting the highest number of NICU beds in Lebanon and a near-constant 95% occupancy rate, became a significant source of revenue while still providing high-quality care for newborns. Furthermore, the hospital distinguished itself by offering sub-specializations like pediatric urology and cardiology, unavailable elsewhere in South Lebanon. This ensured patients received the full spectrum of care they needed, further solidifying the hospital’s position as a leading healthcare provider.

Hospitals catering to Syrian refugees, similar to the 1 at the focus of this study, faced the necessity of physically segregating Syrian patients from Lebanese patients, primarily to maintain the hospital’s “image” as interviewed staff insisted. Despite this separation, both communities received equitable and comparable services. Notably, a key distinction was found in the expectations each community had from healthcare providers. Syrian refugees tended to exhibit lower expectations regarding service provision, resulting in notably high satisfaction rates. Conversely, Lebanese patients typically demanded superior quality healthcare services while seeking to minimize costs, often insisting on cutting-edge technology and highly specialized physicians, even for procedures that did not necessitate such expertise.

Moreover, the hospital significantly expanded its reach to Syrian refugees by increasing the number of patients covered by UNHCR’s program. This placed the hospital among the top 1 or 2 facilities providing services to the highest number of refugees each month. The partnership with UNHCR also motivated the hospital to continuously improve the quality of care it delivered according to testimonies from staff. As such, UNHCR, through its NEXtCARE program, implemented a 2-step verification process to ensure beneficiaries received efficient and effective services. This process included a financial check (through NEXtCARE funds) and a medical evaluation (conducted by both NEXtCARE and UNHCR). Throughout the contract period, the hospital received regular monitoring to confirm it was providing appropriate care. Additionally, UNHCR maintained a clear list of unacceptable practices, such as detaining patients due to unpaid bills or withholding lifesaving treatment in specific situations. The hospital was fully aware of these expectations and obliged.

Perception surrounding access of health services

Lebanese participants expressed a perception of unequal access, with Syrian refugees in their view, reportedly receiving “higher quality and easier access” to services. Concerns arose that hospitals prioritized refugees due to perceived higher profit margins. However, other participants believed both communities received similar care. Furthermore, the common knowledge that Syrian refugees accessed healthcare “entirely free through organizations like UNHCR and Médecins Sans Frontières (MSF)” served as a significant contributor to rampant anti-refugee sentiments among Lebanese citizens. This was found to have led to feelings of humiliation among Lebanese citizens who lacked the necessary funds for healthcare. The impact of Syrian refugees on various sectors, including healthcare, sparked debate. Some participants felt the influx negatively affected access, while others believed refugees adapted better to the crisis, finding ways to access care with less effort compared to Lebanese citizens. Interestingly, participants mentioned Palestinian refugees also benefiting from improved healthcare access. While a detailed exploration falls outside this study’s scope, many participants noted the comparatively better access for Palestinian refugees who utilize UNRWA services, compared to access for Lebanese citizens through the national health systems. This suggests a potential disparity in healthcare systems themselves, rather than between individual groups.

Discussion

Disparities in access, options and coverage across Lebanon

The healthcare system in Lebanon relies on traditional health guarantors, many of which are nearly absent, with coverage often based on the standard rate of 1 USD equivalent to 1500 LBP. Additionally, “wasta” has become prevalent, granting priority access to some individuals at the expense of others, exacerbating the challenge for Lebanese citizens who must largely pay OOP for health services. This issue was particularly pronounced in 2017, coinciding with the prevalence of the Syrian refugee crisis before other crisis dimensions emerged in 2019. The burden of OOP expenses persisted long before 2019, as noted by Lyles et al. OOP payments remain the primary source of health financing in Lebanon, consistent with findings by Fouad et al and Kronfol.¹¹³ Despite increases in tariffs by the MoPH, private hospitals often do not meet their minimum financial obligations, leading to reduced or refused care for MoPH-covered patients. For example, the allocated budget at the time of this study in June 2022 was only LBP 150 000 000 per month, equivalent to USD 5000, highlighting the fragility and scarcity of resources in Lebanon’s public health sector.

While patients covered by the Lebanese Armed Forces (LAF) were found to enjoy full coverage at hospitals, in part, thanks to contributions made by hospitals to the military, interviews with Lebanese citizens suggest that military hospitals may be underequipped, with beneficiaries sometimes needing to provide their own medical supplies like cotton and disinfectant. A shortage of medical supplies poses a threat to the effectiveness of the primary healthcare system established for army force beneficiaries. Nevertheless, the LAF health system is perceived as efficient, ensuring the health security of its beneficiaries and mirroring the effectiveness of the primary healthcare network in Lebanon.

Regarding the National Social Security Fund (NSSF), its coverage scheme mirrors that of Lebanese guarantors discussed earlier, perceived as very fragile due to its low tariff. NSSF health coverage appears vulnerable in terms of medications and hospitalization, as patients covered by NSSF often need to pay a deposit for hospital admission. Other guarantors linked to the Lebanese government, such as the Internal Security Forces (ISF) and Cooperative of Government Employees (COOP), also require OOP, which we believe negatively impact the health access of their beneficiaries.

In contrast, health access through the Islamic Health Cooperative (IHC) appears highly effective, with minimal or no OOP expenses at hospitals. Interestingly, IHC operates 27 primary healthcare centers (PHCs) across the country, predominantly targeting its Shiite community in specific geographical locations. The strong presence of IHC-supported PHCs is highlighted by their affiliation with political groups, aligning with findings by Fouad et al regarding the role of confessional, sectarian, and politically affiliated providers in expanding political clientelism to facilitate health access for their target community. This entity has proven to be a successful model of communitarianism by ensuring the health security of its community and assuming an active role that should ideally be led by the government through its various funds. Thus, while other models of communitarianism exist in Lebanon, they are not as extensively involved in health assistance and are typically supported by political parties.

However, Lebanese citizens working with international organizations, including UN agencies, benefit from health insurance policies paid in fresh USD, facilitating payment for hospital coverage in the same currency. Consequently, health access in this scenario encounters no payment obstacles. Among Lebanese citizens, there are also “private payers” who cover the full bill out-of-pocket and lack any health coverage, typically perceived to be from high socioeconomic backgrounds with the means to afford such expenses. In terms of healthcare-seeking behavior within the host community, Lebanese citizens often visit private clinics, PHCs, hospital emergency departments, private military clinics, and UNRWA clinics. However, the utilization rate of PHC services among Lebanese citizens, especially those with middle to high incomes, is relatively low. Seeking PHC services is primarily observed among individuals from low socioeconomic backgrounds or those unable to access facilities provided by the private health sector. These findings align with research by Ibrahim & Daneshvar highlighting the high OOP expenses within the Lebanese healthcare system, posing a financial risk to individuals with low incomes when seeking medical services. This finding is consistent with previous research by Lyles et al, which indicates that only a small percentage (15%) of the host community of Syrian refugees in Lebanon utilizes PHC services.

Admissions, public sentiment, and preferences

Regarding admission criteria, both refugees and Lebanese citizens must meet the same requirements of being covered and providing necessary documents and payment or coverage. Additionally, both communities receive equal quality of health services regardless of their health guarantor. However, some Lebanese citizens experience discrimination and delays in hospital admission compared to Syrian refugees, leading to perceptions of prioritizing Syrians over Lebanese citizens. This discrepancy, according to testimonies, is exemplified by multiple incidents in which an admissions employee addressed a Syrian woman “courteously” while instructing a Lebanese woman to leave. Furthermore, perceptions among Lebanese participants surrounding a preferential treatment of refugees is rampant –ultimately inciting anti-refugee sentiments. Statements from participants included everything from insisting “[. . .] they [hospitals] prefer the Syrians over the Lebanese,” to suggesting that Lebanon feels more like the “home country of Syrian refugees,” leaving Lebanese citizens feeling “estranged in their own land.”

Moreover, Lebanese citizens express feelings of anger, resentment, and in many cases, envy toward Syrian refugees, with participants expressing exaggerated sentiments such as “[. . .] we [Lebanese citizens] became the minority,” and “[. . .] the Lebanese citizen is worthless.” This negative perception extends beyond healthcare access discussions. Participants note that Syrian refugees receive diapers and milk at PHCs “simply because of their refugee status.” These findings align with existing literature by Tan and reports by the Government of Lebanon (GoL) and the UN, highlighting the social tension that has evolved between Syrian refugees and their host communities since the onset of the Syrian refugee crisis—largely due to competition over access to aid and other forms of support.¹¹⁴

Management, Brain Drain, and Internal Administration

Collaborative efforts between the Ministry of Public Health (MoPH) and private hospitals have aimed to facilitate health access for Lebanese citizens without health guarantors. Prior to 2019, the MoPH covered 85% of the bill, leaving patients responsible for the remaining 15%. This finding aligns with Ibrahim and Daneshvar’s¹¹⁵ study, which highlights the efficiency of the healthcare system between 2006 and 2015 due to accreditation-related reforms. Conversely, the migration of healthcare professionals, including skilled physicians and nurses, due to limited opportunities and low income exacerbated by the depreciation of the Lebanese pound amidst the multidimensional crisis, adds further fragility to the healthcare system.¹¹⁶ This issue is prevalent among participants, with 1 mentioning frequent travels to consult with a physician who relocated abroad. Lebanese citizens are now unable to use their savings in banks to settle hospital bills, forcing them to seek alternative places for healthcare services. Moreover, this situation has disrupted cash flow in hospitals, prompting critical decisions about the sustainability of their healthcare operations.

In the context of the hospital under study, management made a strategic decision aimed at survival by securing contracts with organizations such as UNHCR, UNRWA, and ICRC. This move ensured a significant number of receivables in USD with minimal time wasted, leading to a shift in focus toward patients covered by these payers, primarily Syrian and Palestinian refugees. Partnerships with UNHCR and NEXtCARE compelled the hospital to adhere to rigorous standards to maintain its status as a contracted facility, thereby enhancing service quality, management, and governance for all communities they serve. Moreover, catering to the evolving clientele—predominantly refugees—proved to be relatively straightforward compared to satisfying the high expectations typically associated with the Lebanese community. Consequently, the hospital prioritized targeting Syrian refugees in Lebanon to generate USD revenues with minimal effort while delivering standard healthcare services. This strategy, perceived by some Lebanese citizens as prioritizing profit over humanitarian concerns, has sparked criticism, with 1 participant expressing, “[. . .] but the situation is catastrophic and the hospitals’ goal is to earn money only.”

Health insurance limitations and coping strategies

Given the unreliable state of health insurance providers, especially those associated with the Lebanese government, host communities with a high number of Syrian refugees in their regions have had to develop various strategies to cope with healthcare access challenges. These strategies include relying on support from family members, adjusting medication doses or discontinuing them altogether, switching to generic drugs, importing medications from abroad, liquidating assets, and minimizing visits to healthcare professionals. Notably, the need for some individuals to reduce or stop taking medications, either due to prohibitively high costs or unavailability in the Lebanese market, was found to be a significant and alarming risk to their health.

The instability of health insurance providers affiliated with the Lebanese government has prompted Lebanese citizens to reassess their employment choices, spanning from roles in local private enterprises to positions within the public sector, despite their tenure. This shift is fueled by the perceived inadequacy of health coverage provided by entities like the National Social Security Fund (NSSF), Internal Security Forces (ISF), and Cooperative of Government Employees (COOP). Instead, Lebanese citizens are increasingly drawn toward career opportunities with international organizations to secure comprehensive health insurance/coverage. Furthermore, some citizens are opting for career transitions or accepting lower-ranking positions specifically to secure improved health coverage and higher salaries, often paid in fresh USD to mitigate healthcare expenses. This multifaceted crisis profoundly impacts the career trajectories of skilled professionals, pushing them to contemplate migration, especially in the case of healthcare workers like physicians and nurses, or to pivot toward alternative professions to ensure better income, social benefits, and healthcare security. While such decisions may divert from their original career paths, they underscore the pervasive impact of the crisis on employment dynamics and healthcare accessibility for Lebanese citizens.

Even with conditional coverage from UNHCR and NGOs (MSF, Caritas) minimizing OOP expenses, some refugees reportedly felt compelled to return to Syria for critical care, essentially making a life-or-death decision despite facing an uncertain and potentially dangerous situation. This highlights the impossible choices Syrian refugees grapple with in Lebanon. The Lebanese government, seeking to ease the strain on its healthcare system and infrastructure, continues to push for refugee repatriation. However, this agenda raises serious legal concerns. Humanitarian organizations have documented ongoing armed violence, arbitrary arrests, persecution, and human rights abuses in Syria.¹¹⁷ Forcing refugees back to such conditions poses a significant legal and ethical challenge.¹¹⁷

Limitations

This research represents a pioneering effort in examining the healthcare access of Syrian refugees in Lebanon and its comparison with Lebanese citizens post-2019. Utilizing a qualitative approach, the study delves into the multifaceted dimensions of healthcare access during this crisis. However, certain limitations should be noted. Firstly, due to IRB constraints, Syrian refugees were not interviewed, thereby limiting the discussion to the perspective of Lebanese citizens, potentially overlooking the crisis’ impact on refugees while emphasizing its effects on the healthcare sector. Secondly, the study focuses on a specific subset of Lebanese citizens within a particular timeframe and location, making generalization difficult. Thirdly, the chosen case study reflects a conservative societal context, potentially biasing responses, particularly regarding socioeconomic status. Additionally, translation from Arabic to English may lead to nuances being lost, affecting the accuracy of interpretation. Moreover, the fluctuating value of the Lebanese Pound against the USD poses a challenge, impacting the reported financial data. To mitigate these limitations, future research could employ a more diverse sampling strategy that includes Syrian and Lebanese patients from multiple hospitals across different regions of Lebanon. This approach would enhance the representativeness of the sample and provide a more comprehensive understanding of the healthcare experiences and needs these groups.

The absence of power sampling in this study can be attributed to several factors. Firstly, the resources and time required for power analysis might have been limited, leading to its exclusion from the methodology. Additionally, researchers might have relied on historical data or common practice within the field to determine the sample size, rather than conducting a formal power analysis. However, it’s crucial to acknowledge this as a limitation in the Discussion Section, emphasizing the potential impact on the study’s findings and the reliability of its conclusions. Moving forward, incorporating power analysis into future research endeavors would strengthen the methodological rigor and enhance the validity of the results.

Conclusion

This research exposes a paradoxical situation in fragile host countries regarding refugee and host healthcare access. Ultimately, this study highlights that in many instances, barriers to access for hosts are deeply entrenched and persistent due to systemic failures. Moreover, the adaptability of the humanitarian system, which is primarily designed to address deteriorating economic and conflict conditions, renders the healthcare support for refugees outstrip that provided for vulnerable Lebanese hosts in terms of efficiency. While refugees may sometimes face lower OOP expenses, this can exacerbate social tensions. These findings illuminate the Syrian refugee crisis’ strain on the already fragile healthcare system and offer significant contributions to both health and migration studies. More importantly, the research highlights a critical gap in access to healthcare when the central government stagnates. This stagnation manifests in the government’s inability to address its citizens’ health concerns, leaving them vulnerable and underserved. The study serves as a stark reminder of state abandonment, emphasizing the vacuum it creates in situations where both refugees and citizens face similar vulnerabilities. They become victims of a failing healthcare system and a detached public administration, forced to fend for themselves. These insights offer policymakers and stakeholders a foundation for targeted interventions and policy development.

Effective interventions should promote primary healthcare utilization (PHC). Public awareness campaigns in schools, workplaces, and with NGOs can encourage Lebanese citizens to register and leverage the MoPH’s PHC package (vaccinations, consultations, medications, etc.). Furthermore, strengthening PHC capacity requires joint efforts, funding, and adequate medication supplies. NGOs can fill service and medication gaps. However, a thriving private sector offering high-quality services remains crucial for affluent citizens. This public-private interplay is essential for universal healthcare access. Both sectors need resilience and adaptation. Collaboration is key to cater to diverse healthcare needs and financial capacities across Lebanese communities.

Further research is imperative to grasp the intricacies of healthcare access challenges faced by refugees and host communities in Lebanon. Key areas warranting investigation include the long-term health outcomes resulting from Lebanon’s enduring refugee crisis. Delving into the effects of displacement on chronic diseases, mental health, and preventive healthcare accessibility is crucial for informed intervention and resource allocation to meet future health demands effectively. Additionally, evaluating the efficacy of existing interventions is paramount. A comprehensive analysis is required to gage the success of various programs aimed at enhancing healthcare access for refugees, considering factors such as cultural relevance, outreach methodologies, and integration with local healthcare systems. Such insights will empower stakeholders to tailor sustainable and impactful healthcare solutions tailored to the unique Lebanese context. By addressing these targeted research areas, stakeholders can gain invaluable insights specific to Lebanon’s healthcare landscape. Understanding the long-term health repercussions of displacement and critically assessing the effectiveness of ongoing interventions will enable the design of more resilient and impactful healthcare solutions for both refugees and host communities in Lebanon.

In conclusion, addressing healthcare disparities and ensuring equitable access to services for Syrian refugees and Lebanese citizens in times of crisis like the COVID-19 pandemic requires structural interventions and robust health policies. One key recommendation is the enhancement of good governance practices, which can promote transparency, accountability, and effective decision-making within healthcare systems. By implementing policies that prioritize the needs of vulnerable populations, such as Syrian refugees, and ensuring their inclusion in healthcare planning and resource allocation, governments can mitigate disparities and foster a more equitable distribution of healthcare services. Moreover, investing in healthcare infrastructure, workforce training, and technology can strengthen the resilience of healthcare systems and improve their capacity to respond to crises. By prioritizing fair access to healthcare services and implementing evidence-based best practices in healthcare management, policymakers can work toward building more resilient and inclusive healthcare systems that address the needs of all individuals, regardless of their nationality or refugee status.

Supplemental Material

sj-docx-1-his-10.1177_11786329241263697 – Supplemental material for Health in Crisis: A Paradox of Access for Syrian Refugees and Lebanese Hosts

Supplemental material, sj-docx-1-his-10.1177_11786329241263697 for Health in Crisis: A Paradox of Access for Syrian Refugees and Lebanese Hosts by Yasmine Fakhry, Hussein F. Hassan and Jasmin Lilian Diab in Health Services Insights

Supplemental Material

sj-docx-2-his-10.1177_11786329241263697.docx – Supplemental material for Health in Crisis: A Paradox of Access for Syrian Refugees and Lebanese Hosts

Supplemental material, sj-docx-2-his-10.1177_11786329241263697.docx for Health in Crisis: A Paradox of Access for Syrian Refugees and Lebanese Hosts by Yasmine Fakhry, Hussein F. Hassan and Jasmin Lilian Diab in Health Services Insights

Footnotes

Author Contributions

Yasmine Fakhry conceptualized this study, led on data collection, analysis and writing. Jasmin Lilian Diab supervised this study, supported with analysis and led the writing of the paper. Hussein Hassan supported in drafting and led on submission. The final draft of the manuscript was read and authorized by all authors.

Declaration of conflicting interests:

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding:

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Consent to Publication

Not applicable.

ORCID iD

Jasmin Lilian Diab

Supplemental Material

Supplemental material for this article is available online.

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