BEIRUT – The night Walaa’s daughter was born turned out to be the most terrifying night of her life.
The girl, Aseel, arrived in February, one month premature, with infections in her blood and lungs. But despite being born in Lebanon – a middle-income country with a relatively advanced healthcare system, and just outside Beirut, home to a high concentration of hospitals – her family’s status as Syrian refugees raised a huge hurdle to proper care: in this case, access to a neonatal incubator.
In Lebanon, the United Nations refugee agency, UNHCR, covers 75 percent of Syrian refugees’ delivery costs, along with care for newborn babies. Refugees must pay the rest. Many hospitals, wary of being short-changed, reject refugee patients outright or demand a 25 percent deposit up front.
Minutes after she gave birth in one overcrowded hospital, Walaa and her husband were frantically calling others to locate a neonatal incubator for Aseel. After five rejections, a sixth hospital said it would accept their case if they paid $800 upon admittance. Relatives and neighbors pitched in to cover the fee.
“I was going crazy,” said 27-year-old Walaa, who is from Idlib, cradling her still-underweight baby in late May, as they waited to see a pediatrician at a suburban Beirut health clinic. “I just gave birth and everyone was yelling at me to sit down. How could I sit down when I didn’t know if we would find another hospital to save my daughter?”
‘It Could All Collapse’
Lebanon, a tiny country of roughly 4 million citizens, is host to at least 1.5 million Syrian refugees – the world’s highest rate of refugees per capita. This has strained Lebanon’s infrastructure, education and healthcare.
“We’re seeing depletion of our [hospital] infrastructure and overuse of machines,” said Randa Hamadeh, head of the primary healthcare department for Lebanon’s Public Health Ministry. “In emergency rooms, we’ve seen delays because of overcrowding. Patients are being turned away.
“At some point, our services won’t be able to handle the strain,” she continued. “It could all collapse.”
Donor aid for Syrian refugees has brought some benefits to the Lebanese healthcare system, particularly in primary health. There are now 230 primary health clinics spread across the country, compared with 180 before the Syrian war. All serve Lebanese citizens as well. Many are located in poorer, rural areas that previously did not have health clinics at all.
But the benefits are not spread evenly in Lebanon’s highly privatized healthcare system, which is difficult to access even for Lebanese citizens – half of whom have no private health insurance.
“We should be building more public hospitals instead of paying billions in aid money to private systems,” said Dr. Fouad M. Fouad, a Syrian professor of health sciences at the American University of Beirut and head of its refugee health program.
UNHCR’s ‘Highest Health Budget in History’
The UNHCR covers primary care for Syrian refugees – such as doctor visits, immunizations, prescriptions, and prenatal care including ultrasounds for pregnant women – at subsidized rates through health clinics run by local and international NGOs or charities.
But when it comes to more serious issues, the UNHCR covers only life-saving care, leaving very few options for those with health conditions such as cancer, thalassemia, kidney disease and even some births deemed too premature.
Yet it is increasingly difficult for refugees to pay. Six years of crisis have depleted their savings, and the Lebanese government forbids most of them from working legally.
“Clearly, cost is the number one, two, and three reason refugees can’t access healthcare,” said Dr. Michael Woodman, the UNHCR’s senior public health officer in Lebanon.
The organization contracts a combination of 50 public and private hospitals in Lebanon to care for Syrian refugees. But, as in Walaa’s case, even contracted hospitals sometimes turn away refugee patients: complex emergencies, including premature births, can quickly hit the UNHCR’s $10,000 coverage ceiling per case. Private hospitals, which are more expensive, have more leeway to reject patients at the door.
Meanwhile, public hospitals, which comprise just a tiny percentage of hospital beds in Lebanon, have accumulated a $15 million deficit since the Syrian crisis began in 2011, according to the Ministry of Health, partly from Lebanese and refugee patients who are unable to pay their portion of the bill.
The UNHCR paid $50 million into the Lebanese healthcare system last year. It’s the biggest health budget in the organization’s history, Woodman said, due to Lebanon’s high cost of care.
“It’s totally unsustainable,” he added. “We’re looking hard at efficiency and better ways of financing care of refugees. The reality is, their ability to pay is linked to their livelihoods. So they can only contribute more to their healthcare bills if they’re able to work.”
Lebanon’s Refugee Mothers
In Lebanon, one-third of UNHCR health expenditures go to maternity care. And 74 percent of UNHCR hospital referrals are for women, reflecting Syrians’ high birth rates. About 40,000 Syrian babies were born in Lebanon last year, according to UNHCR and Lebanese government data, compared with about 71,000 babies born to Lebanese parents.
Even with UNHCR support, pregnant and new Syrian mothers struggle in Lebanon. UNHCR and most NGOs only cover two of the four recommended ultrasounds throughout a pregnancy, and many women do not go in for enough checkups particularly in the critical first trimester, according to International Medical Corps. When it comes to giving birth, refugee women pay up to $100 for a normal delivery and up to $200 for cesareans after UNHCR subsidies.
Most refugees in Lebanon live outside Beirut, in rural areas where they can only access health centers by taxi. Families must also grapple with ever-changing government policies on their residence permits. Lack of legal status is grounds for arrest at checkpoints on main roads across the country.
“For a pregnant woman, they would let her pass,” said Dr. Youssef Almeslimani, an obstetrician-gynecologist who works for an Amel Association clinic in El Ain, in Lebanon’s Bekaa Valley. “But for a man, he would get arrested if he doesn’t have a residence permit and thrown in jail for a few days.”
As he spoke, a long hallway packed with patients awaited him – pregnant women and new mothers who had traveled to see him from informal tented settlements or crowded apartments in the area. Most were extremely poor. Some patients turn to makeshift, unlicensed field health clinics, often run by refugee doctors and nurses not permitted to work in Lebanon, Almeslimani said.
Even in cities, where transport is easier and clinics are more plentiful, the labyrinth of restrictions and bureaucracy for refugees mean some women simply don’t know where to get help.
At the suburban Beirut health clinic where Walaa took her premature baby, another mother said she had been covering all her health bills on her own because she was unable to register with the UNHCR. While the UNHCR stopped registering Syrian refugees in 2015 on the Lebanese government’s orders, the clinic does cover life-saving and obstetric care for unregistered refugees.
In some cases, hospital staffs have fought their administrations to admit and save refugee patients.
“I’ve paid the bill myself so that a baby wouldn’t die,” Almeslimani said. “Sometimes the hospital staff contributes, or anyone who happens to be at the hospital contributes.”
At the other extreme, four doctors and aid workers told Refugees Deeply that some Lebanese hospitals have confiscated identity documents or detained newborn babies until bills are paid – practices the Ministry of Health considers illegal.
When it comes to refugee health, Lebanon is trapped in an unforgiving spiral: the refugee population is increasing as healthcare costs skyrocket and foreign donors’ interest wanes, and tensions between the government and NGOs grow over healthcare delivery.
For pregnant Syrian mothers, the only organization providing free deliveries is Doctors Without Borders/Medecins sans Frontieres (MSF), which operates three mother-and-child health clinics in Lebanon: one in Beirut, one in the north and one in the Bekaa Valley. More than 300 babies are born at MSF clinics each month.
This spring, the Ministry of Public Health ordered the organization to stop deliveries in clinics, citing its regulations that deliveries cannot take place outside hospitals. The action is part of Lebanon’s general tightening of rules surrounding NGOs and medical practices since President Michel Aoun took office in October following a two-year political vacuum.
“MSF is currently in discussion with the Ministry of Public Health to look at possibilities to adapt our maternal health service in order to comply with [their] requirements,” communications manager Jinane Saad said in a statement to Refugees Deeply. The clinics are still operating fully – including delivering babies – as they search for a solution.
Meanwhile, some women take grave risks to give birth. Sitting beside Walaa at the Beirut clinic was 40 year-old Asma Najjar, who went back to her home of Latakia, Syria in 2013 to deliver her daughter, Leen. Though Syria’s healthcare system is in disarray, its public services meant Leen – who has cognitive delays and very weak muscles – would be born at very little cost despite complications at birth.
While Najjar gave birth four years ago, the midwife at the clinic, Ghada Gabriel, said several patients still illegally cross the border back into Syria to give birth.
The high cost of giving birth in Lebanon will continue to pose daunting risks for refugees as long as war rages in neighboring Syria and beyond.
“We are in a region facing several crises that are all protracted in nature,” said Fouad, the AUB professor. “The Syrian crisis isn’t a new one, and it won’t be the last one.”