Table 2 Healthcare provision, referral policies, and financing schema for Syrian refugees in Lebanon, Jordan, and Turkey

Health Care Provision

The Ministry of Health, UNHCR and partner non-governmental organizations (NGOs) such as Jordan Health Aid Society (JHAS). [56].

The Ministry of Health provides full access to health services for Syrian refugees outside camps.

For camp refugees, primary and secondary healthcare is delivered inside camp through a host of NGO clinics, UNHCR and national organizations.

Around 100 primary healthcare centers (PHCs), that are under the umbrella of UNHCR, NGOs, and the Ministry of Social Affairs and the Ministry of Public Health. [39]

MoPH and YMCA are responsible for distributing medication and laboratory supplies [26].

The Disaster and Emergency Management Presidency of Turkey (AFAD).

Voluntary health centers run by non-governemntal organizations with special permission from the Ministry of Health also provide primary health care [29].

Community health centers provide primary health care services, while field hospitals and polyclinics provide secondary health services [28].

Refugee health centers work in alliance with community health centers to provide primary care health services to Syrian refugees [30].

Access to Healthcare

Refugees registered with UNHCR need to obtain a Ministry of Interior (MOI) service card to access primary, secondary and some tertiary healthcare at Ministry of Health (MOH) facilities [47].

Refugees registered with UNHCR obtain a registration card to access healthcare services at PHCs.

Refugees registered under the Temporary Protection Regime have the right to Social Security, subsidized by AFAD [29, 57].

Syrian refugees who reside in and out of the camps have free access to primary and secondary health care facilities [30, 57].

Financing Scheme

 Coverage of Costs

Access to primary and secondary care was free of charge for UNHCR registered refugees, until late 2014. Costs were not covered for medicines or private facilities. Due to a governmental policy change, refugees with a MOI service card are required to pay the same highly subsidized rate for care at PHC facilities as uninsured Jordanians at any healthcare facility attended [33, 47].

UNHCR Scheme:

- Refugees pay a subsidized fee of USD 2–3.33 per consultation at PHC centres.

-For refugees that are < 5 and > 60 years old, disabled people, pregnant and lactating women, 85% of diagnostic costs are covered. Other refugees pay 100% of these costs required for referral to hospital treatment or medicines [26].

-Those with chronic conditions pay USD 0.67 as handling fee for medication. Medications are free of charge through YMCA [42].

Other schemes:

Privately funded PHCs may be providing free primary health care to registered and unregistered refugees, in accordance with their own guidelines [26].

Access to healthcare through social security is free in the geographic area in which the refugee has registered his/her social security [29].

 Unregistered refugees

Refugees without the MOI service card pay a “foreigner rate” which is up to 60% higher than the rate of uninsured Jordanians [33, 47].

Unregistered refugees pay to access services, like Turkish citizens without Social Insurance, except in cases of emergency, preventive health services and communicable diseases [28, 29].

Referral System Policy

Cases requiring secondary or tertiary care are referred to a neighboring hospital. Referral from PHCs to government hospitals are possible only if the refugee is able to pay the remaining rate of the subsidized cost [32].

UNHCR works with JHAS clinics to cover the cost of treatment for patients through JHAS clinics if the patient is unable to pay for the treatment at PHCs and governmental hospitals and is deemed vulnerable. Patients are referred to private affiliated hospitals.

UNHCR’s mechanism for funding costly secondary and tertiary care for registered refugees is through the Exceptional Care Committees (ECC). The latter decides whether to finance or reject a refugee’s treatment based on criteria such as necessity of the treatment, financial need, disease prognosis and overall cost. The ECC finances a broad range of treatments [27].

Those requiring secondary or tertiary care need to be referred by a PHC center that works alongside the UNHCR except in the case of a life threatening circumstance [26].

UNHCR set guidelines for eligibility to subsidized secondary and tertiary care on life threatening conditions and likelihood of good prognosis. These include referrals for emergencies (obstetric, medical and surgical) and elective cases for complementary investigations and/or specific treatment [26].

If UNHCR’s criteria for hospital care are met, 75% of the treatment costs are covered, excluding cost of medicines, unless the patients meet UNHCR’s vulnerability criteria in which case 100% of costs are covered [26].

A private health care benefit management company assesses patients’ eligibility to access hospitals according to UNHCR guidelines. Cases that do not exactly fit eligibility criteria or where treatment costs over $1500 (with a cap of-$15,000) are submitted to the Exceptional Care Committee (ECC) that approves hospital admission [26, 39].

Refugees are covered only upon referral and for the first 24 h. After 24 h, refugees are responsible to seek approval for coverage.

Life-saving conditions covered during the 24 h include myocardial infarction and respiratory distress. Cases not covered include long term sustaining tertiary care such as treatment/rehabilitation of complications of chronic degenerative diseases [42].

Referral is not required to access secondary and tertiary health care services provided by MOH [28]. Referral is required from state hospitals to access Ministry of Health affiliated university hospitals [29].

Those requiring referrals to health centres located in a different city than where the social insurance was issued, should seek referral at a state hospital where the person lives or at emergency services in case of an emergency [29].