Sharif A Ismail, Adam P Coutts, Diana Rayes, Sophie Roborgh, Aula Abbara, Miriam Orcutt, Fouad M Fouad, Gladys Honein, Nour El Arnaout, Aya Noubani, Hana Nimer, Spencer Rutherford
Summary
The impact of nearly seven years of conflict on the Syrian health system has been catastrophic. Thousands of qualified doctors and health workers have left the country since 2011, and Syria today is one of the most dangerous countries in the world in which to practise as a healthcare worker.
Although an emerging phenomenon of informal employment among displaced Syrian health workers is broadly acknowledged in some countries neighbouring Syria, the scale, scope and nature of this workforce is poorly documented. A key aim of this research was to detail both the scale of this activity and the challenges that Syrian healthcare workers (HCWs) face in Lebanon. The research also gathered data on the strategies that Syrian health workers have developed to work in the informal economy.
Findings from this work indicate the presence of a diverse, qualified workforce of Syrian health professionals currently practising informally in Lebanon, including physicians, nurses, midwives, psychologists, and health administrators. These health professionals practice overwhelmingly in primary care clinics and although Syrian refugees account for the majority of their caseloads, they do provide limited services to Lebanese citizens in addition to community members from other neighbouring countries.
In the case of Lebanon, the informal employment of Syrian healthcare workers is primarily a peri-urban phenomenon. The humanitarian crisis in Lebanon and Jordan is often referred to as an urban issue, but demand for informal health workers seems to have emerged in peri-urban areas outside the major cities where the cost of living is cheaper for both refugees and HCWs, existing healthcare coverage is more limited, and where it may be easier to operate informally in the labour market away from the scrutiny of central state authorities.
The lived reality of working in these environments for many Syrian HCWs remains extremely challenging. Besides well-recognised barriers to formal labour market entry (residency status, professional registration, accreditation), health workers interviewed for this working paper identified persistent fear and distress (including the threat of deportation), ethical challenges in practice, and discrimination both in terms of pay and attitudes from host populations among the daily challenges of practising informally in Lebanon.
There is little evidence from our research that providing informal healthcare services offers a viable and sustainable source of living for individuals engaged in the system. It is evident that Syrian HCWs deliver services either on a voluntary basis or for minimal financial remuneration.
At policy level, there is an urgent need to address legal barriers to registration to practise for Syrian HCWs – possibly through limited registration. Recommendations for the Lebanese government must, however, be tempered by recognition of the immense challenges to labour market integration for a Syrian refugee population that now accounts for over 25 per cent of all residents of Lebanon.
There are, however, key roles for donors in expanding financial support for training and development programmes for Syrian HCWs, and for educational institutions in developing and implementing materials for these.
Key research needs include further mapping work on health worker numbers, specialties and geographical distribution to support workforce planning as well as information gathering and analysis on current and potential educational initiatives to support Syrian healthcare worker training and development (drawing on evidence from other contexts).