Lebanon’s healthcare is under strain over Syrian crisis

This blog was originally published in the Fair Observer on 20 April 2015. It was informed by interviews conducted in Lebanon, where Lana spoke with staff and patients at health centres across the country.

With the Syrian crisis entering its fifth year, Lebanon currently hosts over 1.1 million Syrian refugees. This high intake of refugees has increased political tension but also vastly strained the already limited resources and infrastructures of a country with approximately 4.5 million people.

In January, Lebanese authorities announced new visa restrictions for Syrians crossing the border into Lebanon, making it practically impossible for refugees to enter the country.

International organizations and United Nations agencies have been delivering humanitarian assistance and attempting to fill gaps where possible. That includes providing food and cash assistance for refugees, as well as supporting the Lebanese government to respond to increased demand in the several sectors such as health care.

The capacity of the Lebanese health care sector to deal with the demand is vastly overstretched. Today, several years into the Syrian refugee crisis, conflicts around health care provision are visibly surfacing, most notably in health clinics.

With a large part of the international assistance directly targeted at Syrians, many Lebanese feel unfairly treated and left behind, since they also often struggle to cover the rising rent, utilities and health care costs.

These rapid developments over a short time-span have brought about a number of changes and challenges for health workers across Lebanon.

Juggling tensions and workload

“Since the Syrian refugee crisis started, the stress levels at work have increased a lot,” says Safa, a receptionist and administrative assistant at the Makhzoumi Foundation’s health clinic in Beirut. “Instead of arguing with ten patients a day, I now argue with 30.”

As clinics across Lebanon have seen an increase in the number of Syrian refugee patients, frontline staff such as receptionists and nurses have often found themselves exposed to a new set of challenges in the workplace.

“The number of patients we get has increased over the past few years. I often don’t get a break during the day anymore,” says Safa.

But aside from the increased workload, health care workers are also faced with tension between Syrians and Lebanese.

“As we were getting more Syrian patients, the waiting rooms would fill up quickly. When our Lebanese patients would step in and find no place to sit or stand, they would often leave,” mentions Safa. “Lebanese don’t always want to wait with Syrians.”

A common solution adopted by health clinics is to segregate Syrian and Lebanese patients. Safa says this used to happen at her clinic until she came up with a new system: “Syrian patients would come and accuse me of letting Lebanese jump the queue, and the latter would come and accuse me of favoring Syrians over them. To avoid more tension, I developed a new numbering system. Now everyone knows whose turn it is to see the doctor.”

Nonetheless, she admits this has not solved all problems. Lebanese patients often call and take appointments in advance, to avoid waiting with fellow Syrian patients.

The most significant point of contention, however, is the specific targeting of assistance toward Syrians. Syrian refugees registered with the UN Refugee Agency (UNHCR) pay three to four times less for a consultation fee at health clinics than Lebanese patients. Mirna, a certified nurse and colleague of Safa, explains: “A lot of issues happen around the differences in fees. Our Lebanese patients get upset and ask us why they don’t receive support as well.”

While health workers explain that the UNHCR covers part of the fee for Syrian refugees, they are often left vulnerable to patients’ frustrated comments and questions.

“Lebanese seem to think that Syrians get everything for free but while that is not true, some Syrian refugees also think that and then accuse us of taking advantage of them,” adds Mirna. “Most of my energy is spent explaining, clarifying and mediating between both sides.”

Finding ways to deal with tensions

So far, frontline health care workers have had to cope with these new challenges in a mostly improvised manner. As it seems unlikely that those Syrian refugees already in Lebanon will be able leave the country anytime soon, an urgency exists to solve some of the pressing issues in the health care sector. While some short-term solutions are, to some extent, being used across Lebanese health clinics — such as segregation or prioritizing Lebanese patients — they may harm long-term cohesion between host and refugee communities. Health care workers as frontline staff play a pivotal role in bridging gaps and alleviating tension between both sets of people.

“For a good while I was chronically stressed,” says Safa. “I would get home after work and not want to speak to my family. I became very snappy and avoided going out to meet friends. I then realized that the constant interaction with people at work has tired me out and the stress was affecting my private life.”

Mirna has found another way of dealing with the difficult working conditions. She says: “I have started blocking my emotions toward the stress and conflict and am using humor to get me through the day. I laugh a lot and even sing at work, my colleagues find it amusing.”

Some organizations have included stress management in their technical trainings for medical staff. International Alert, however, is the only organization that has focused on tension arising from the presence of Syrian refugees in Lebanon.

As part of three-day trainings for health care staff held across Lebanon, over 120 nurses, receptionists and social workers met and discussed the issues they face at work. Using discussions and role-plays, health care staff learned and practiced how to communicate better with their Lebanese and Syrian refugee patients and prevent escalation.

Safa was very positive about her participation. “I was surprised to see that everyone is facing the same challenges,” she says. “I now feel much more confident in taking the responsibility away from myself when it really is not my fault. We cannot change the structure of things, but I can change my attitude in communicating better with patients and in not letting stress at work affect me. We really need more practical assistance to help us deal better with the changed working conditions.”

Photo: Nadim Kamel/International Alert