Out of the spotlight and hard to reach: Syrian refugees in Jordan's cities

The conflict in Syria has had very significant repercussions in neighbouring countries, including Jordan. Between July and December 2012, the number of Syrians registered as having sought refuge in Jordan quadrupled, from 38,000 to 133,000; in the subsequent six months it quadrupled again, bringing the total to just under 506,000. The government of Jordan estimates that there are now over 600,000 Syrians in the country.

Médecins Sans Frontières (MSF) has been present in Jordan since 2006, principally as a rear base for missions in Iraq. The organisation has a specialised reconstructive surgical and physiotherapy project for victims of conflict in the Middle East, based at the Jordanian Red Crescent hospital in Amman. Syrian patients currently comprise 60% of the total caseload in this project; an outpatient clinic has also been established for Syrian refugees in Amman. As the numbers of refugees increased in the second half of 2012, and responding to a request from the Jordanian Ministry of Health, MSF established a paediatric inpatient and outpatient facility at the Zaatari refugee camp in March 2013. A surgical project for war-wounded coming across the Syrian border was established in Ramtha in August 2013, and negotiations are now under way for a maternal and child health project focused on Syrian refugee families in the northern city of Irbid. Some support is also being provided to Syrian medical networks in Jordan and inside Syria.

This article assesses the humanitarian response to the refugee crisis in Jordan. It is based on fieldwork conducted by the authors, including visits to MSF medical projects in the country and interviews with international and national humanitarian agency representatives and Syrian and Jordanian medical staff.

The national response is increasingly overwhelmed

The attitude of the Jordanian authorities, and of the Jordanian population, to the influx of Syrian refugees has been largely welcoming. Despite the fact that Jordan is not a signatory to the 1951 Refugee Convention, the border has been largely open to arrivals; Syrians have been able to register for refugee status; Syrian refugees have been allowed to settle in Jordan’s cities; and registered refugees have been allowed to access government services on much the same terms as Jordanian citizens.

As the refugee influx has grown in scale, Jordanian capacities have become increasingly strained. Syrians now account for 7% of the country’s population. The continued provision of open access to public services for Syrian refugees has been particularly difficult to maintain. For example, the Jordanian health system is formally free of charge at primary level for Jordanians and for registered Syrian refugees. According to the World Health Organisation (WHO) and the Jordanian Ministry of Health, the number of Syrians in public hospitals has increased by almost 250% over the five months to June, while the number requiring surgical operations in Jordanian government facilities has increased by almost 600%. Bed occupancy rates in hospitals in the north are now higher than 95%, while reserve medicine stocks (normally at 100% of demand) are now at 30%. ECHO estimates a 40% increase in activity in the health sector. There are numerous anecdotal reports of people being turned away from health facilities. The refugee influx has reportedly put similar pressure on schools, housing and civil infrastructure such as water.

Needs covered in the camps, but not in the cities

In order to reduce the impact of the refugee influx in Jordan’s cities, in July 2012 the government approved the establishment of a large refugee camp at Zaatari (and has approved another to be opened at Azraq). The humanitarian response has focused overwhelmingly on Zaatari camp, which houses a third of all refugees in Jordan (close to 150,000 in May 2013). The camp’s first months were extremely difficult, with refugees sleeping in tents in the snow over winter. Rates of malnutrition and crude and under-five mortality are now very low, and water and sanitation, shelter and food provision are all above Sphere standards. While protection and security are still major concerns, basic needs for assistance are being met.

The majority of the refugee caseload, however, has sought shelter in urban areas. An estimated 60–80% of refugees (up to 400,000) live outside the camps, the majority in towns and cities near the border. Although levels of mortality and malnutrition among urban refugees are not known, levels of hardship, vulnerability and destitution are high and rising. CARE found that some 34% of refugees in four cities and towns in the north of country reported having no income at all. Humanitarian assistance is insufficient. Of 80,000 families in host communities, only 12,000 receive cash assistance from UNHCR of 100 Jordanian dinars (approximately €105) a month, a third of a refugee household’s average monthly expenditure of 303 dinars. Coverage of food vouchers, worth 40–45 dinars per month, is higher: the World Food Programme (WFP) estimates that it had reached 94% of registered refugee families in cities by March 2013, although this proportion is probably lower now due to the rapid growth in refugee numbers. Levels of assistance and coverage for urban refugees are significantly lower than for camp residents for other forms of humanitarian assistance too, including school enrolments, medical consultations, mental health consultations, distributions of blankets and assistance with water supply and sanitation.

Why the imbalance?

There is an issue of scale and rate of growth. Since March, numbers in the camps have been dropping, while they have approximately doubled in the cities. It is also relatively ‘easy’ to work in Zaatari. The work there is principally about establishing and managing camp infrastructure, such as hospitals and clinics (as MSF has done), water points and distributions. If there is relevant work to be done in Zaatari, and it is work which is well understood by implementing agencies, then why step outside? Zaatari camp is also possibly the most visible component of the humanitarian response to the world’s largest contemporary crisis – and therefore has no lack of attention from donor governments and international media. Indeed, in the week that we were there, there was a visit from the World Bank president; the week before, actor Angelina Jolie, High Commissioner for Refugees Antonio Guterres and the Norwegian foreign minister came for World Refugee Day. The week after we left, European Commissioner for Humanitarian Aid Kristalina Georgieva and the Italian foreign minister visited. The availability of large contracts from UN agencies and a high media profile have allowed many international NGOs to build very large programmes in the camp – but those camp programmes in turn appear to have absorbed much of their management and technical capacity (and perhaps also their willingness) to respond in Jordan.

In contrast, the more difficult the needs are to reach, the less they have been covered. This applies to the urban caseload as a whole, as we see in the coverage rates in Table 1. But it also applies to the most vulnerable Syrians in Jordan, the approximately 70,000 unregistered refugees. This category includes those who did not think they would be in Jordan long enough to register, those who choose not to register for fear of security or political repercussions, those who do not know how to register and those who have difficulties travelling to a registration centre. They currently receive almost no targeted humanitarian assistance of any kind, they are not eligible for food vouchers or cash distributions and they cannot freely access most Jordanian government services (including primary health, although they can access some preventative services such as vaccination).

Finding them will require extensive community-based work, including building relationships with Jordanian and Syrian civil society associations. According to representatives of both civil society associations and international agencies that we met, only a handful of humanitarian organisations are willing to do such work. While there are examples of ‘partnerships’ between international and local NGOs, these are mainly of the subcontractor kind. Syrian doctors working in an unofficial clinic providing medical care to unregistered Syrians told us that they cannot secure funding from UN agencies or INGOs because they are not officially registered (‘we’re too busy to do that’, one doctor told us).

Jordan’s status as a middle-income country also makes its needs more complex, requiring a more sophisticated and more expensive response. Although Jordan’s health system is of good quality, it is at serious threat of collapse and needs humanitarian actors to relieve the pressure on it. This would involve providing substitution services in urban centres (such as maternal and child clinics for Syrian families) as well as supporting existing hospitals. This is not only a very large job, but also a highly technical one. The programmes we visited seemed to only manage one factor (scale) or the other (technical complexity): for example, a Gulf-based Red Crescent society ran a large programme to pay hospitals for the medical bills of those who had undergone surgery (until the financial burden became too much due to ever-growing numbers of patients needing very high-cost care). MSF, meanwhile, has its surgical programme in Amman but it is targeted at a very specific group (victims of conflict in need of surgical follow-up or reconstructive surgery). It has expanded to cover Syrian patients, but the project is reaching its own capacity limits: in 2012, its budget was €7.7 million, for an average of just under 100 surgeries per month; the number of new arrivals each month and the bed occupancy rate (at 92% in 2012) have increased dramatically. Other planned MSF projects also address particular gaps: surgery and trauma for war-wounded at a public hospital on the border, and maternal and child health for Syrian refugees in a particular city.

Another factor is the inflexibility of the humanitarian system itself. The response has on the whole been moderately effective – assistance has been provided to more than 400,000 registered refugees to meet their most pressing needs, including food, shelter, water and sanitation and health. The government of Jordan, UNHCR and the humanitarian community deserve credit for this. But not only has the billion-dollar humanitarian machine in Jordan only really managed to do the ‘easy’ things, it has done so regardless of the desires or wishes of those leading it. UNHCR has been encouraging both donors and implementing agencies to focus more efforts outside the camps than inside for the last six months (and has a strong policy on urban refugees to back up such efforts); many major and influential humanitarian agencies have produced detailed reports showing that vulnerabilities are much higher outside the camps; the Jordanian government has been complaining of the strain on its social infrastructure. But none of those actors has managed to shift the direction of the aid machine. The focus instead has remained on the more visible, and easier to manage, aspects of the crisis.

Sean Healy and Sandrine Tiller are humanitarian advisers for Médecins Sans Frontières United Kingdom. This article represents their own views and not necessarily those of MSF. The authors gratefully acknowledge the assistance of the field teams in Jordan and of this article’s reviewers.