1. Introduction
Since the onset of the civil war in Syria, people have fled to neighboring countries. By September 2016, 1,017,433 Syrian refugees have been registered with UNHCR Lebanon. Refugees are living predominantly in urban settings. Lebanon also hosts around 22,007 refugees mainly from Iraq, Sudan, and Somalia.
According to the 2013 UNHCR Public Health Operational Guidance Document, UNHCR’s responsibility towards the population under its mandate is to facilitate and advocate for access through existing services and health service providers and to monitor access to health care services. While the primary health care strategy is the core of all interventions; referral care is an essential part of access to comprehensive health services.
These standard operating procedures (SOPs) outline the policy and procedures for referral care applicable to all UNHCR registered refugees and persons of concern in Lebanon.
2. Definition of Referral Care
Referral health care is here defined as care that is too advanced for primary health care facilities and therefore needs to be provided at health care facilities of secondary or higher level i.e. in provincial, regional or central hospitals. Normally it requires admission of the patient.
3. Persons Eligible for Referral Care Support
Anyone residing in Lebanon who is recognized by UNHCR as a refugee or a person of concern (PoC) is eligible for supported referral care. This includes children born in Lebanon whose fathers are refugees, even though their mothers are not.
The following are not eligible for UNHCR supported referral care:
- Palestinians (fall under mandate of UNRWA)
- Lebanese or Palestinian spouses of refugees
- Migrants
4. Provision of Referral Care Support
UNHCR contracts a third party administrator (TPA) who in turn contracts hospitals throughout the country where refugees can access care. The hospitals under contract are a mix of private and public and form the so called UNHCR hospital network. Inclusion in this network depends mainly on proximity to beneficiaries and availability of services. The network is subject to continuous review according to the changing needs of the refugee population. As a general rule UNHCR does not support care given in hospitals outside of the network.
UNHCR supports provision of referral care to refugees through a cost-sharing mechanism. The TPA agrees with the contracted hospital upon standardized fees following Ministry of Public Health (MoPH) fixed rates. When care has been provided, UNHCR contributes by paying a certain proportion of the charges for the care given. The proportion covered is a function of socio-economic vulnerability of the beneficiary as well as type and cost of the treatment given.
The TPA is responsible for the medical and financial audit of referral care and is in turn audited by UNHCR.
5. Guiding Principles
The below principles are based on UNHCR’s Principles and Guidance for Referral Health Care for Refugees and Other Persons of Concern (2009):
1. Equity of care and access between PoCs and host population
UNHCR aims ultimately to provide refugees with access to and quality of referral care at similar levels as received by Lebanese citizens in government health facilities.
2. Prioritizations should be based on prognosis and cost
Since funds are limited, prioritizations need to be done in order to deliver the most necessary care to the highest number of people. The two most important factors determining whether to make treatments available are therefore prognosis and cost. Due to current budget restraints the referral care supported by UNHCR is either for deliveries, potentially life threatening conditions or conditions that might lead to severe permanent disability. Very expensive treatments are beyond UNHCRs capacity to support, even if they are potentially lifesaving (i.e. chemotherapy for cancer).
3. The decision to provide referral care is medical
The medical aspect should always remain central in the decision making about what treatment should be available for whom and the responsibility for final decisions should lie with a medical doctor.
4. The decision making procedure should be consistent and transparent
Decisions should be made following available SOPs and guidelines and involve qualified experts according to the nature of the different cases.
5. Medical confidentiality is ensured throughout the referral care process
Please refer to Annex 1