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The Response to Syrian Refugee Women’s Health Needs in Lebanon, Turkey and Jordan and Recommendations for Improved Practice

Goleen Samari wrote "The Response to Syrian Refugee Women’s Health Needs in Lebanon, Turkey and Jordan and Recommendations for Improved Practice" as part of the 2014 Humanity in Action Diplomacy and Diversity Fellowship

Abstract

Since 2011, there have been an estimated three million Syrian refugees to neighboring countries. In times of conflict, women’s health disproportionately suffers, and Syrian women are no different. A vast majority of Syrian refugees are hosted in Lebanon, Turkey and Jordan. While each country has approached the refugee crisis in a different way, similar women’s health problems have arisen, and Syrian women’s health and reproductive health has been compromised. Syrian women experience sexual harassment, rape, violence, early age at marriage, early age at pregnancy and complications during pregnancy. Because Syrian refugees reside in multiple countries, international and diplomatic efforts are required to address their health and well-being. The continued presence of Syrian refugee women’s health disparities requires action to remedy the disparities. Creating health programs and policies for Syrian women refugees’ health requires operating at the intersection of diversity and diplomacy and is essential to post-conflict reconstruction and recovery. This paper explores the current health needs of Syrian refugee women in Lebanon, Turkey and Jordan and recommendations to address Syrian women’s health in the region moving forward. 

Introduction

The United Nations has declared the Syrian crisis the worst humanitarian crisis of the 21st century. The Syrian crisis provides another example of modern warfare wherein civilians are the primary victims, and the conflict in Syria is also rapidly becoming a public health disaster. More than three years after the start of the war in Syria, since 2011, there have been an estimated 2,999,091 Syrian refugees to neighboring countries, primarily Lebanon, Jordan, and Turkey. (1) Of all the Syrian refugees, 50.5% are women and 49.5% are men. (2) Seventy-five percent of Syrian refugees are women and children, and 716,492 are women and girls of reproductive age. (3) While some Syrian refugees have gone to Iraq (primarily the Iraqi Kurdistan Region), North Africa and Egypt, Morocco and Algeria, the vast majority of refugees are hosted by Jordan, Lebanon and Turkey. Lebanon, Jordan and Turkey’s hosting capacities are overstretched, thus transforming the Syrian crisis into a regional and global crisis. The Syrian crisis has become a Lebanese, Jordanian, Turkish and Syrian crisis.

Syrian refugees put pressure on the economy and health care systems of hosting countries, and Lebanon, Turkey and Jordan have all approached handling the integration of and the health needs of Syrian refugees differently, resulting in diverse social and health issues. Being away from home and facing uncertainty about the future affects Syrian refugees psychologically, socially and physically. The escalated conflict also has direct effects on the provision of medical resources and the operation of medical staff. (4) In addition to general health issues, due to lack of services, prioritizing other family members, gender dynamics and fear of seeking services, Syrian women’s health and reproductive health disproportionately suffers. Small-scale needs assessments show high levels of sexual and gender-based violence including rape, assault, harassment and intimate partner violence, early marriage, early age at pregnancy, frequent UTIs, complications during pregnancy and prostitution among refugees. (5) Gender-based violence and sexual exploitation are of primary concern. 

The difficulties that refugee women encounter are not a new phenomenon, yet work in this area remains limited. Reports from international NGOs thoroughly document the humanitarian crisis in general. However, Syrian refugee women’s health issues in the contexts of Lebanon, Jordan and Turkey could be further assessed, evaluated and documented. Escaping Syria was only the beginning for Syrian refugee women. Escaping a horrific circumstance is only part of the trauma that exists. Addressing refugee women’s health and well-being is both a diplomatic and humanitarian effort, integral to long term strategies and rebuilding. While food aid, water and sanitation are vital responses in humanitarian crises, comprehensive women’s health and reproductive health service provision is also crucial. There is an urgent need to make sure Syrian refugee women’s health needs are met and, to date, the public health response to address their needs is lacking. Women’s health needs to be fully integrated into the overall response strategy.

This paper explores the vulnerabilities of women and girls in times of conflict, how Lebanon, Jordan and Turkey responded to Syrian refugee health needs and provides a set of recommendations for improved health provision for Syrian refugee women. Based on an assessment of academic literature and international policy and development reports on the current refugee situations in Lebanon, Jordan and Turkey, these recommendations can guide how to best address Syrian refugee women’s health needs in the region moving forward. 

Vulnerabilities of Women and Girls in Times of Conflict

There are several known health risks that women and girls face in conflict and displacement settings. First, armed conflict disrupts access to essential services and distribution of health care, which includes the provision of women’s health care. (6) Prolonged emergencies can weaken health systems, with long-lasting effect on women’s health care. (7) Second, aspects of women’s health that suffer in war, conflict and displacement include access to family planning, safe motherhood, sexual and gender-based violence and disproportionate risk for STDs, including HIV. (8) Female refugees and displaced women are at daily risk of safety and security as well as sexual, physical and mental abuses as they attempt to survive.

The question then becomes why do women face such health risks. Conflict and the resulting forced displacement creates an environment that increases the vulnerability of women and girls. Women and girls remain refugees or displaced for longer periods of time without status and are more vulnerable at every stage of displacement compared to men. (9) One must recognize that vulnerability to a disaster is a social dynamic rooted in the interaction between gender and class, culture, nationality, age and other power relations. (10) For example, in terms of culture, patriarchy is entrenched in cultures throughout the world, and in a refugee situation it amplifies the difficulties female refugees already face. (11) These conceptual intersections and social dynamics shape refugee women’s health status and access to health services. 

While each receiving context shapes women’s health vulnerabilities in context-specific socio-ecological ways, in the Syrian conflict the intersection between gender and violence and gender and age, and the gendered division of labor have consistently emerged as determinants of women’s health vulnerabilities. Syrian refugee life is particularly conducive to gender-based and sexual violence at all stages of the conflict. At the early stages, the armies used rape as a weapon of war, and now the prevalence of violence perpetrated by intimate partners continues to rise. Types of violence against women in a displacement settings include mass rape, military sexual slavery, forced prostitution, forced marriage, trafficking, forced pregnancy, gang rape, sexual assault, physical assault, resurgence of female genital mutilation and forced sex for survival, food, shelter and protection. (12) Importantly, violence against women is not a side effect of political conflict. It appears in societies with deep-rooted gender disparities, and Syrian society is a patriarchal society. The proliferation of violence is due to the challenges to the gendered identity of individuals. The WHO reports that the Eastern Mediterranean region already had a high prevalence of intimate partner violence with 37% of women suffering from intimate partner violence in the region. The Syrian crisis has only further exacerbated this problem. 

Young Syrian girls experience double marginalization due to both age and gender. This intersection is most easily visible through the rising numbers of early ages at marriage among Syrian refugees. Early marriage is used as a coping strategy for young girls in abusive home environments and poor living conditions. Sexual exploitation and violence also contributes to early marriage. Families marry off their daughters with the idea that they are providing protection for young girls, continuing family traditions, alleviating poverty or helping daughters escape the environment. (13) Islam forbids sexual relations outside of marriage, yet in the camp setting, rape, prostitution and underage forced marriages are rampant. Hundreds of women and girls have been sold under the guise of “temporary marriage.” As economic resources are depleted in a camp setting, girls are married off at younger and younger ages. Survival sex becomes the only way to support themselves and their families. (14) Preservation of family honor serves as a justification for marrying off young girls to their perpetrators. It is also an avenue into human trafficking. Preservation of this family honor often prevents women from reporting sexual assault and violence. In general, girls under 18 are more likely to experience obstetric and neonatal complications.

For the gendered division of labor, armed conflict inevitably deprives households of their males and increases the prevalence of women- and child-headed households. Displaced women bear acute care responsibilities and disproportionately bear communal and familial responsibilities. Coupled with this added responsibility are their disparate social and legal status and less access to capital, social goods and legal means of protection. The dual role of women as caregivers and resource providers makes it more difficult to adapt to a new environment, causing further isolation and marginalization. In urban settings, without recognized legal status, women and girls resort to an underground economy where they are vulnerable to exploitation. Their work as low-wage laborers force them to live in squalid conditions. They may have very limited ability to move freely, and they might have to obtain permission to travel or get medical care through a male relative. In urban areas, forcibly displaced women and girls live in substandard conditions and lack access to fundamental services, such as education and health care. Social bonds may be broken as women isolate themselves or are isolated by their families and communities. This isolation can contribute to higher incidences of violence against women. Often without adequate financial resources for rent, women risk sexual exploitation by landlords. Many Syrian women in Lebanon are involved in sex work to obtain necessary financial resources. 

Syrian women’s health risks are largely shaped by the interactions between gender and violence, age and divisions of labor. As a result, Syrian women have faced a range of health issues from sexual harassment to maternal mortality and extreme violence in Lebanon, Turkey and Jordan. An understanding of the increased vulnerabilities of women and girls in conflict settings fueled the creation of the Minimum Initial Service Package (MISP) designed by the Inter-Agency Working Group on reproductive health. MISP is intended to save lives and prevent illness among women, newborns and girls. MISP is only the first step toward comprehensive reproductive health care for women and girls, and it has been deployed in Lebanon and Jordan. Each country, Lebanon, Turkey and Jordan, has its own policy on integration of refugees and distribution of health care and has begun to respond to the needs of Syrian women within these constraints.

Response to Crisis: Lebanon

Refugee Response

Lebanon has not ratified the 1951 Convention Relating to the Status of Refugees (the Refugee Convention) or its additional protocol in 1967, but Lebanon has largely maintained an open-border policy for Syrian refugees. The massive influx of refugees has strained an already resource poor Lebanon. In 2013, the government committed not to forcibly return any Syrian refugees to Syria. However, the government is also adamant that Lebanon cannot be a permanent country of asylum. In Lebanon, the model of working with refugees is highly integrative. 

There are 1,176,971 Syrian refugees, which amounts to one quarter of the entire Lebanese population. (15) The number of Syrians in Lebanon is thought to be higher than the reported numbers as many have not registered. Official figures indicate that there are 33,793 Syrian refugees awaiting registration. (16) At least 2,000 to 3,000 people are estimated to be entering Lebanon every day. (17) The Lebanese government estimates that it is hosting a million more refugees than those who are registered and 25% of the Lebanese population is now comprised of Syrian refugees. (18) Of these refugees, 52.3% are women and the largest proportion of women and girls of reproductive age are in Lebanon (273,823). (19)

In Lebanon, the model of working with refugees is highly integrative. Syrian refugees are living within host communities and in settlements, but they are mostly not residing in camps. Many Syrian refugees have lost their homes and family members. An increasing number of refugees are gathered in tented settlements in Eastern Lebanon. Those who manage to register receive assistance from UNHCR, NGOs and the Lebanese government. Although there is solidarity between populations, Syrian refugees put pressure on the Lebanese health care system and economy, and Lebanon’s hosting capacities are overstretched. (20)

Health Care System

Lebanon has a fragmented and uncoordinated health care system. Lebanon has ratified a number of treaties that guarantee the right to health, including the international Covenant on Economic, Social, and Cultural Rights (ICESCR), the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and the Convention on the Rights of the Child (CRC). However, ratification of these treaties does not mean that they are implemented across sectors. Between 2005 and 2011, in the public sector the ability to deliver health care declined by 45%. (21) The system is highly privatized and largely based on user fees. 

In Lebanon a public-private partnership makes it difficult to enroll marginalized groups in medical insurance schemes. Uninsured Lebanese citizens obtain care through the Ministry of Health through public hospitals and cover up to 85% of hospital care and 100% of medication costs for high-risk diseases. The Syrian refugee crisis has further exacerbated this situation as there were further lags in payments for treatment to hospitals, a 50% increase in the patient caseload at health clinics in Lebanon and an increase in ambulance wait times because of high transport demands. The influx of Syrian refugees exacerbates the challenges faced by Lebanese citizens seeking access to public health care.

Lebanon does not have a national strategy for coping with the health care needs of the Syrian refugee population. In Lebanon, UNHCR coordinates support with relevant ministries and non-governmental organizations. For refugees, the high cost of referral care in Lebanon, up to 75% of the cost, is covered by UNHCR. (22) Lebanon does not allow the establishment of formal refugee camps or field hospitals by humanitarian organizations. When field hospitals are not allowed, this places all refugee medical needs on the existing Lebanese health care infrastructure. There are three mobile clinics and 24 medical centers throughout Lebanon that provide health care for Syrian refugees. (23) 

Women’s Health

There is limited data on women’s reproductive health outcomes for the entire Syrian refugee population in Lebanon. A rapid assessment in clinics in Lebanon found that Syrian refugees report gynecologic problems such as menstrual irregularity, reproductive tract infection, severe pelvic pain or dysmenorrhea and some combination of the above conditions. (24) Importantly, many Syrian women are pregnant and need proper care through pregnancy and delivery. Close to 100 babies are delivered each month. (25) However, UNICEF reports that number is much higher and one baby is born from a Syrian woman every hour. While close to 60% of the general population of Syrian women reported using contraceptives prior to the conflict, only 34.5% report using family planning during displacement. (26) This contributes to the high fecundity. 

Despite a high birth rate, Syrian refugee women have reported that they do not access antenatal care visits because of high out-of-pocket costs associated with these services. A majority of Syrian women do not visit a gynecologist except when they are pregnant. Only a quarter of the women reported visiting a gynecologist in the past six months, and only a third felt as though reproductive health services were easily accessible. (27) Many women experience complications during labor and delivery including abortion and hemorrhage. Some women also report difficulty breastfeeding due to constant displacement. (28) 

As for gender-based violence, there are reports of sexual violence perpetrated by armed individuals; however, underreporting is common due to shame or fear of stigmatization. There are numerous anecdotal reports of violence against women, but assessments and data on the actual prevalence of violence against women is scarce. Fifty-three percent of women report never once feeling safe in Lebanon, and 41% of young women have thought of ending their lives. (29) In Lebanon, all victims of torture or survivors of sexual and gender-based violence will be covered for up to 100% after the incident; however, this requires victims of gender-based violence to come forward, and Syrian refugee women do not report incidents. These facts and figures only provide cross sectional snapshots of Syrian refugee women’s health issues in Lebanon, as there is no available longitudinal data on Syrian refugee women’s health status over time. 

Response to the Crisis: Turkey

Refugee Response

Turkey is home to the second largest population of Syrian refugees. The government of Turkey takes the lead role for determining and implementing assistance provided to the 832,508 Syrian refugees, through the Prime Ministry Disaster and Emergency Management Presidency (AFAD). (30) The Turkish government aims to prevent the interference of UNHCR or other international bodies in Turkish control over the Syrian migrant situation. (31) Turkey is hosting refugees in 22 government-run refugee camps across 10 provinces. The Turkish government has registered an estimated 300,000 Syrians living outside camps in urban areas. Of all Syrian refugees in Turkey, 49.2% are female. (32) Between 17% and 22% of heads of households are women. (33) Roughly half a million refugees live in and around the camps. Their basic needs such as shelter, food and water are provided as much as possible. Health care, education and employment opportunities come next and are often lacking. A very small number of Syrians have returned to Syria from Turkey. Three-quarters of Syrian refugees choose Turkey over another country because of ease of transportation. (34) 

Turkey is a signatory of the 1951 Convention on the Status of Refugees; however, Turkey’s asylum policy is characterized by “geographic limitations” and only grants the right to asylum to persons who are refugees as a result of events occurring in Europe. With this geographic limitation, Syrians in Turkey are recognized as “guests” and not as “refugees.” (35) Due to this policy, in Turkey, the refugee model consists of local hosting or working with refugee integration without assimilation. This creates camps that are in contrast to the local community. Turkey has refused additional help from UNHCR and is handling the situation internally. Turkey has already spent $3.5 billion on the Syrian Refugee Response, and there is an increased burden on the health care system. The estimated number of women and girls is 250,000 with an estimated 40,000 pregnant women. (36) Turkey is particularly vulnerable because its community and humanitarian services are negatively affected by continuous conflict in areas close to border regions with Syria and Iraq. The increased number of displaced persons from Iraq who are in high need of humanitarian aid further affects Turkey’s ability to provide for all refugees.

Health Care System

As of 2013, Turkey had successfully introduced health system changes and brought universal health coverage to its citizens. (37) In Turkey, health care services are provided through primary health care centers, 112 medical emergency stations and tent hospitals. Universal health coverage has led to expansion of health insurance and health services, which has improved key maternal and child health services including a reduction in infant mortality. However, despite improvements in access to women’s health services and maternal mortality ratios, women still face inequalities. (38) 

In Turkey, there was a big effort to provide field hospitals within the camps, which promotes service utilization with over 90% of refugees in camps reporting access to services. (39) Additionally despite the government’s resistance to working with multilateral organizations, in the last few months, the Ministry of Health has been working with international organizations to construct 10 prefabricated clinics. These clinics should be available to deliver refugee health care in September of 2014. This is important for refugee care as more than 1.2 million patient consultations for Syrian refugees were registered in outpatient settings. In Turkey, health care workers providing services to this vulnerable population are also affected as doctors also often face a language barrier and a shortage of resources. However, a government report notes that 90% of Syrian refugees in camps and 60% of those outside of camps used health services in Turkey and were satisfied with them. (40) 

Women’s Health

There is significantly less data on the health outcomes of Syrian refugees in Turkey. In contrast to Lebanon and Jordan, very few NGOs are working to deliver refugee health care in Turkey. Turkish authorizes have been very strict about not allowing any independent observers, journalists, NGOs, national or international humanitarian relief organizations to enter the camps, so it is difficult to have an independent assessment of women’s status within the camps. (41) In general, for women in camp settings, factors that contribute to poor reproductive health are women’s lack of access to amenities for basic hygiene, including lack of drinking water, access to feminine hygiene products, washing water, soap and bathing facilities. (42)

There is very limited data on women’s health and reproductive health issues among Syrian refugees in Turkey, particularly for women who are not married or information on sexual and gender-based violence. The Turkish government reports that 96% of pregnant women report delivering in a health care setting. (43) This seems very high, but it is hard to assess the accuracy of this figure without independent assessment. A third of pregnant Syrian women were registered with complications and in need of reproductive health services. (44) Turkish women report not having a preference on the gender of their gynecologist; however, Syrian women in Turkey prefer female physicians. (45) 

Beyond the clinical, physical manifestations, there is an emotional burden too. Many Syrian women in Turkey report distress over their “guest” status and unpredictability about their presence in Turkey. (46) The Turkish government indicates that 55% of refugees are in need of psychological services, and close to half of the Syrian refugees think they or their family members need psychological support. (47) On July 24, 2014, the Ministry of Health in Turkey finally signed a memorandum of understanding with UNFPA to coordinate delivery of essential women’s health services. This will bring to light the current health status of Syrian women in Turkey. 

Response to the Crisis: Jordan

Refugee Response

Jordan shares a history, culture and long open border with Syria. In Jordan, there are an estimated 613,252 Syrian refugees. (48) Over 70% of Syrian refugees are residing among host Jordanian communities. (49) Only 30% of the refugees in Jordan reside in camps. (50) The largest refugee camp in Jordan is the Za’atri camp, with an estimated population of 120,000. This makes it the fifth largest city in Jordan. Several hundred Syrians cross the border illegally each day. The government of Jordan also estimates that the number of refugees is much higher than what is reported. 

Females, ages 18 to 35 years, represent the majority of new arrivals (at nearly 30% of the total registered) with females of all ages comprising 53% of those registered. Syrians and Jordanians are vastly different, which has created some social problems. (51) For example, Syrian women are sometimes seen as being willing to accept a smaller dowry in order to marry a Jordanian man who maybe cannot provide quite as much. This results in social tensions and some resentment towards the women. There are also tensions between the existing Palestinian refugees and incoming Syrian refugees. Additionally, the gendered division of labor is a factor, as Syrian men cannot work in Jordan so women must invent ways to financially provide for their families. Prior to being displaced, their primary responsibility was to take care of the home and children, so this is a very new burden for them. If they had not been forced to leave Syria, these women would have never worked outside the home.

Health Care System

Similar to Lebanon and Turkey, Syrians in Jordan are straining the Jordanian health care system, creating supply and bed shortages. Jordan prides itself on providing good access to health services to its citizens. There are 12 health centers per 100,000 persons, with an average travel time of 30 minutes to the nearest health center. The Ministry of Health provides free primary health care, which includes maternal and child health, immunizations and school health services. (52) The Jordanian government has established policies around the provision of reproductive health education and services, and there are some reproductive and family planning services integrated within the health system, but only to married individuals. (53) Jordan also has clinical guidelines around the implementation and delivery of maternal and newborn care for antenatal care (ANC), high-risk pregnancy, postnatal care and post-abortion care. All pregnant women in Jordan receive ANC and have skilled medical personnel present at their births. 

In the camps, similar to Lebanon, UNHCR with the support of the Ministry of Health provide health and humanitarian support. However, for the larger portion of refugees outside the camps, not all needs are adequately addressed. Refugees access health care services within camps, but the hundreds of thousands who live in cities face the same costs as Jordanians. Most of the refugee needs are located in the four northern governorates in Jordan, and the capital of Amman provides most of the specialty health care services. (54) 

In Jordan, UNHCR pays for 100% of the cost of patients referred from the Za’atari camp or for those who are unregistered. However, UNHCR has strict criteria for hospital care. To qualify for treatment, where 75% of treatment costs are covered with the remaining 25% covered by the individual unless they meet UNHCR’s vulnerability criteria or are victims of torture or sexual and gender-based violence (where 100% of the cases are covered). Subsidized care is only provided for conditions that are immediate, life threatening emergencies. Conditions that are not covered include treatment for chronic diseases that require hospitalization like cancer treatment or kidney dialysis, low birth weight babies and blood diseases. Due to lack of treatment, negligible conditions become progressively more life threatening over time. Furthermore, the eligibility criteria is confusing for refugees and when coupled with a lack of access in general, results add further anxiety about medical care. 

In both Lebanon and Jordan, the pressure on domestic health systems is widespread. For example, there are bed shortages because of the strain on the Jordanian health system. Currently, the WHO and the Jordanian Ministry of Health are conducting a joint rapid health assessment to better determine the facility capacity and service utilization patterns in most affected governorates. The disease burden among the Jordanians already strained the Ministry of Health budget, and the added burden from the Syrian refugees strains the workforce and the public hospital system. (55)

Women’s Health 

Rapid assessments of women’s health in the refugee camps indicate that 23% of women were unaware about reproductive health services, 28% had experienced unplanned pregnancies and 17% did not access antenatal care for pregnancy. (56) In the Za’atari camp, UNFPA is supporting a reproductive health clinic with a female gynecologist. The clinic is run by the Jordan Health Aid Society, and Syrian women feel comfortable seeking services because of the presence of a female gynecologist. The clinic sees 200 women a week, and there is a great need to expand the services to reach more women. (57) 

Reproductive health coverage has improved with 100% of deliveries in Za’atari in the first quarter of 2014 attended by a skilled attendant (compared to 92% on average throughout 2013). A majority of Syrian refugee deliveries are in a health facility (96.9%) and a third are in private facilities. (58) This could be due to a lack of female doctors in the public sector. Complete antenatal care coverage (at least four visits) also needs improvement. (59) A limiting factor to Syrian refugee reproductive care is that Jordanian law states that refugees who are HIV positive can be deported. This reduces HIV testing and availability of treatment among refugee populations. (60) The Jordanian government does however promote testing among its citizens and offers ARVs for both men and woman. 

There is no policy in Jordan to handle gender-based violence or to care for survivors of sexual violence. There are a few policies and programs to help survivors of domestic violence. (61) In 2000, the National Committee for Family Safety and the Unit of Family Protection was created to monitor and protect vulnerable family members who experience domestic violence. (62) The lack of security in refugee camps naturally lends itself to increased instances of violence. There is little to no protection for women. Some women fear that if they report abuse or violence, their husbands will send them back to Syria. UNFPA and the Ministry of Health have worked to improve the clinical care for sexual assault survivors through development of guidelines, trainings and distribution of post-rape kits; however, messaging on gender-based violence is limited and community and provider knowledge continues to be limited. (63) 

In Jordan, early age at marriage and child marriage is a significant issue with health implications for young girls. One in three marriages among Syrian refugees involved a person under 18. (64) This is in response to poverty and fear of sexual violence, and this proportion keeps rising. In Jordan, some clerics have issued fatwas against these temporary marriages and the justifications used to support them. Despite this effort, in the first quarter of 2014, the proportion of deliveries in girls under the age of 18 was 11%, which represents a significant increase compared to the average for 2013 of 5%. As mentioned, these girls are at greater risk for neonatal complications. 

Recommendations for Improved Practice

Lebanon, Jordan and Turkey have all approached the refugee challenge in different ways resulting in a variety of challenges, yet women and girls are particularly vulnerable in all three contexts. Based on current data and reports, similar women’s health problems have arisen in all three countries and merit prioritization. In all settings, early age at marriage, sexual and gender-based violence, access to family planning and antenatal and obstetric care for women are ongoing issues. In order to better address these issues, international health and development organizations should conduct a thorough needs assessment, continue to directly address women’s health and reproductive health at multiple levels and create policy and programmatic solutions that establish long term sustainable care for this displaced population. 

When looking at Syrian refugee women’s health outcomes, across all three countries, there is a clear lack of data. It is important to conduct needs assessments to clarify what additional risks refugee populations face that host populations do not face. An understanding of the ways that refugee women’s reproductive health problems are both similar to, and different from, those of women in settled populations can help policymakers and programmers address refugees’ specific health needs. (65) While small scale needs assessments have been conducted, there is room for greater understanding of the risks that this population faces, particularly gender-specific and reproductive health risks. Currently, research on this and the implications for women’s health are limited. 

Many women do not even feel comfortable coming forward with their issues. There is an irrefutable cultural patriarchy among Syrian refugees, which creates difficulties for all women. The first step of providing refugee women and girls with more control or autonomy over their lives is to make known a number of underreported difficulties that they face every day. There is a need for better analysis and understanding of the ways in which sexuality and sexual violence, pregnancy, childbirth, HIV and AIDS and gendered power relations take on whole new meanings – and help give meaning to – situations of armed conflict and disaster. While these meanings will be specific to each country and the integration policies of that country, a thorough needs assessment is a good place to start to understand the landscape of Syrian women’s health.

Population survey research is often used to inform needs assessments. International health and development organizations, including WHO and the World Bank, have been constrained by their reliance on governments to collect information about health and development in the region. Population health statistics from the Arab world tell us little about the health status of the least advantaged residents. Few countries in the region report any consistent information about the state of their non-citizen populations, including refugees. When government services are weak, and in order to achieve better measures of health and ensure the delivery of health services, it is necessary for international stakeholders to liaise with civil society, activists and, in some cases, political parties and revolutionary governments to measure the health of all people living in the Arab world, not just citizens. 

It is hard to fully assess the health and well being of Syrian women in Lebanon, Turkey and Jordan without adequate data and health statistics. Additionally, there is often a male bias in identifying channels by which data and information is sought. International stakeholders can provide support to measure the health of those left outside the political process, the quality of health care delivery and the nature of inequality in health care delivery. These measurements, done over time, can become a core part of assessing need, operationalizing accountability and informing solutions. (66) 

Beyond a more thorough needs assessment, greater provision and awareness of existing health services, while also addressing barriers that prevent Syrian women from accessing them, can extend the reach of current efforts. Despite the country setting – Lebanon, Turkey or Jordan – or the refugee setting – urban, rural or camp environment – there are some consistent individual level and system-level barriers to Syrian women’s reproductive health care. These barriers include cost, distance, transportation issues, fear of mistreatment, shame, unavailability of female doctors and insufficient provision of services. (67) Additional barriers include scarcity of knowledge and lack of free services. Addressing some or all of these barriers will enable women to access health care.

At the individual level, Syrian refugee young women should be equipped with knowledge, skills and approaches to deal with their current situation, including areas related to gender-based violence. Importantly, individual efforts cannot just target women, and programmatic solutions must include men and households. For example, the lack of use of contraceptive methods is possibly linked to lack of awareness. However, there may also be a gap between knowledge of reproductive services and desire to use them. Among Syrian refugees, contraceptive decisions are viewed as couple decisions and not a decision to be made by an individual woman. This indicates that reproductive health education should not merely target women, but also needs to be directed towards men. The Syrian refugee men need to be involved in the contraceptive decision-making process so that they do not serve as a barrier to access.

At the health system level, in terms of health care delivery, there need to be clear standard operating procedures for medical services that are distributed to partners and refugees. While this is done sometimes, this needs to be the standard protocol. In addition, to avoid confusion and frustration among refugees and health providers, these operating procedures should not change frequently. For hospital referrals, UNHCR should ensure regular reviews of vulnerability criteria, which would allow for reassessments of eligibility for assistance in cases where a family member has a medical condition. (68) In order to truly understand limitations to health care delivery systems or the effectiveness of care coordination systems, UNHCR should also enforce an accessible and reliable complaint system for refugees who are not able to obtain health care.

The relationship between violence and mental and reproductive health in all three countries also points to the need to integrate mental health and reproductive health services. (69) Many Syrian refugees are in great need of psychosocial assessments. (70) Syrian women report health conditions related to stress like nerve issues, depression, unusual pain and fatigue, loss of appetite or sleep, repeated vomiting and migraines. (71) If adequate psychosocial services are not in place, then women face long-term mental health consequences and will not seek care for other health issues. There is also a shortage of mental health professionals dealing with the psychological damages of prolonged war and displacement. Provision of mental health care needs to be done ethically and not serve as a distressing reminder of the trauma the refugees have been through. (72) 

At the very least, for service provision, refugee entitlements to health care needs to be clearly communicated to both refugees and service providers. Even though Syrian refugees in some settings, like Jordan, are familiar with services, they are not using them or are afraid to use them. Syrian women refugees need increased awareness of the importance of reproductive and antenatal care. Of particular importance for women’s health are female service providers, and a concerted effort to make sure there are enough female service providers in Lebanon, Turkey and Jordan is needed. Increased availability of female physicians will provide women’s health services in a culturally appropriate manner. Whether programs are implemented to increase individual knowledge and awareness or implemented system wide to address barriers like transportation and shortages of female physicians, all such interventions need to be tailored to be appropriate for the specific country and undergo process and impact evaluations. A monitoring and evaluation system will better assess the impact of such programs and contribute to data shortages in the region. (73) 

Programmatic and evaluation efforts require funding. One strategic priority must be to substantially increase the level of support available to host states and communities throughout the region, thereby mitigating the socioeconomic and political pressures generated by the refugee influx. Foreign aid is far lower than what is needed to respond effectively to this humanitarian crisis and cover the budget deficit. (74) This severely hampers any effective humanitarian and health response. There is an obvious need for additional funding for refugee care in Lebanon, Turkey and Jordan. In Lebanon, because health systems are largely privatized, the cost of refugee care is much higher and access to health services is more limited at all levels of care. (75) In Lebanon, due to a lack of funding, the UN High Commissioner for Refugees will reportedly cut their health care subsidies from 85% to 50%. (76) However, in all three countries, there is a funding deficit, and because food, shelter and emergency care are the priorities, women’s health care suffers. 

Beyond looking for additional funding, agencies should also carry out awareness-raising activities internally and among partner organizations and donors, strengthen internal organization and interagency collaboration and share expertise in order to maximize benefits and save resources at the local level. The academic community also needs to collaborate with humanitarian organizations and humanitarian organizations need to be more open to this collaboration. Incorporating thoughtfully designed interventions based on evidence and standardized outcome measures into routine humanitarian protocols may help conserve resources. (77) Multilateral organizations should also continue to collaborate with local partners. For example, UNFPA needs to continue to work with the Jordan Health Aid Society to increase capacity and resources to meet demands, and the health sector should work in conjunction with child protective services to strengthen interventions to reduce early marriage. The provision of health care is not specific to one agency. In fact, it should not even be thought of as confined to nation-state borders. The nature of the ongoing crisis in Syria and the developing crisis in Iraq demands for health care delivery that is beyond the nation-state border to a transnational geographic space. (78) 

Traditionally, health responses have focused on emergency and humanitarian needs. (79) However, in all three countries, in order to continue to provide refugee care, there needs to be a shift in response from short-term to long-term conflict response. The duration of the conflict now lends itself to a longer-term health delivery strategy. Syrian refugees cannot be confined to a state of UNHCR indefinitely. (80) Importantly, for this long-term response, resettlement beyond the neighboring region is essential to reconstruction in the region. Beyond this shift, there also needs to be proper synergistic integration of reproductive health and sexual and gender-based violence programs with all the related sectors of the response and recovery.

Conclusions

Continuing efforts to improve reproductive health care delivery for Syrian refugee women in Lebanon, Turkey and Jordan will demonstrate their political accountability to refugees and the larger international community. Women’s health and health care should be seen as fundamental pillars of the long-term policy response to the crisis in Syria in addition to that of economic, governance and rule of law issues. While tacit acknowledgement of this reality permeates discourses, the depth of the description often fails to fully grasp the gender harms and women’s health implications. As experts and policymakers calculate how best national and international communities should respond to the Syrian emergency, women and women’s health should be prioritized. Because a majority of the refugees are women and girls, without such thinking and planning, the situation is set to further undermine the reputation of the international community in the region. These women have the right to health care and social justice and are integral to the fabric of the rebuilding process. Women have an essential role in post-conflict reconstruction, and their basic needs should be met so they can emerge from this ongoing crisis as essential stakeholders in the recovery process.

 

 

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About the Author

Goleen Samari is a Ph.D. candidate in community health sciences at the University of California, Los Angeles (UCLA) Fielding School of Public Health. Her dissertation focuses on determinants of women’s autonomy over the last 15 years in Egypt and the subsequent impact on fertility. She also holds a master of public health and an MA in Islamic studies from UCLA and completed her undergraduate studies at the University of Texas at Austin. She is a Bixby Doctoral Fellow in Population and a pre-doctoral trainee with the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Recently, she worked with the International Organization on Migration in South Africa. Goleen serves as a National level judge for US Figure Skating. She grew up in Austin, Texas. She is a Humanity in Action Senior Fellow (Diplomacy and Diversity 2014).

Citation

Samari, Goleen. "The Response to Syrian Refugee Women’s Health Needs in Lebanon, Turkey and Jordan and Recommendations for Improved Practice." Article, "Knowledge & Action," Humanity in Action, 2015. Humanity in Action, Inc. 

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