syrian refugee crisis case study

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• Published: 11 May 2018

The Syrian conflict: a case study of the challenges and acute need for medical humanitarian operations for women and children internally displaced persons

• Rahma Aburas 1 ,
• Amina Najeeb 2 ,
• Laila Baageel 3 &
• Tim K. Mackey   ORCID: orcid.org/0000-0002-2191-7833 3 , 4 , 5  

BMC Medicine volume  16 , Article number:  65 ( 2018 ) Cite this article

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After 7 years of increasing conflict and violence, the Syrian civil war now constitutes the largest displacement crisis in the world, with more than 6 million people who have been internally displaced. Among this already-vulnerable population group, women and children face significant challenges associated with lack of adequate access to maternal and child health (MCH) services, threatening their lives along with their immediate and long-term health outcomes.

While several health and humanitarian aid organizations are working to improve the health and welfare of internally displaced Syrian women and children, there is an immediate need for local medical humanitarian interventions. Responding to this need, we describe the case study of the Brotherhood Medical Center (the “Center”), a local clinic that was initially established by private donors and later partnered with the Syrian Expatriate Medical Association to provide free MCH services to internally displaced Syrian women and children in the small Syrian border town of Atimah.

Conclusions

The Center provides a unique contribution to the Syrian health and humanitarian crisis by focusing on providing MCH services to a targeted vulnerable population locally and through an established clinic. Hence, the Center complements efforts by larger international, regional, and local organizations that also are attempting to alleviate the suffering of Syrians victimized by this ongoing civil war. However, the long-term success of organizations like the Center relies on many factors including strategic partnership building, adjusting to logistical difficulties, and seeking sustainable sources of funding. Importantly, the lessons learned by the Center should serve as important principles in the design of future medical humanitarian interventions working directly in conflict zones, and should emphasize the need for better international cooperation and coordination to support local initiatives that serve victims where and when they need it the most.

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The Syrian civil war is the epitome of a health and humanitarian crisis, as highlighted by recent chemical attacks in a Damascus suburb, impacting millions of people across Syria and leading to a mass migration of refugees seeking to escape this protracted and devastating conflict. After 7 long years of war, more than 6 million people are internally displaced within Syria — the largest displacement crisis in the world — and more than 5 million registered Syrian refugees have been relocated to neighboring countries [ 1 , 2 ]. In total, this equates to an estimated six in ten Syrians who are now displaced from their homes [ 3 ].

Syrian internally displaced persons (IDPs) are individuals who continue to reside in a fractured Syrian state now comprising a patchwork of government- and opposition-held areas suffering from a breakdown in governance [ 4 ]. As the Syrian conflict continues, the number of IDPs and Syrian refugees continues to grow according to data from the United Nations High Commissioner for Refugees (UNHCR). This growth is continuing despite some borders surrounding Syria being closed and in part due to a rising birth rate in refugee camps [ 5 , 6 ]. This creates acute challenges for neighboring/receiving countries in terms of ensuring adequate capacity to offer essential services such as food, water, housing, security, and specifically healthcare [ 4 , 7 , 8 ].

Though Syrian refugees and IDPs face similar difficulties in relation to healthcare access in a time of conflict and displacement, their specific challenges and health needs are distinctly different, as IDPs lack the same rights guaranteed under international law as refugees, and refugees have variations in access depending on their circumstances. Specifically, there are gaps in access to medical care and medicines for both the internally displaced and refugees, whether it be in Syria, in transit countries (including services for refugees living in camps versus those living near urban cities), or in eventual resettlement countries. In particular, treatment of chronic diseases and accessing of hospital care can be difficult, exacerbated by Syrian families depleting their savings, increased levels of debt, and a rise in those living in poverty (e.g., more than 50% of registered Syrian refugees in Jordan are burdened with debt) [ 9 ].

Despite ongoing actions of international humanitarian organizations and non-governmental organizations (NGOs) to alleviate these conditions, healthcare access and coverage for displaced Syrians and refugees is getting worse as the conflict continues [ 4 , 10 ]. Although Syria operated a strong public health system and was experiencing improved population health outcomes pre-crisis, the ongoing conflict, violence, and political destabilization have led to its collapse [ 11 , 12 , 13 ]. Specifically, campaigns of violence against healthcare infrastructure and workers have led to the dismantling of the Syrian public health system, particularly in opposition-held areas, where access to even basic preventive services has been severely compromised [ 14 , 15 , 16 , 17 ].

Collectively, these dire conditions leave millions of already-vulnerable Syrians without access to essential healthcare services, a fundamental human right and one purportedly guaranteed to all Syrian citizens under its constitution [ 4 ]. Importantly, at the nexus of this health and humanitarian crisis are the most vulnerable: internally displaced Syrian women and children. Hence, this opinion piece first describes the unique challenges and needs faced by this vulnerable population and then describes the case study of the Brotherhood Medical Center (the “Center”), an organization established to provide free and accessible maternal and child health (MCH) services for Syrian IDPs, and how it represents lessons regarding the successes and ongoing challenges of a local medical humanitarian intervention.

Syria: a health crisis of the vulnerable

Critically, women and children represent the majority of all Syrian IDPs and refugees, which directly impacts their need for essential MCH services [ 18 ]. Refugee and internally displaced women and children face similar health challenges in conflict situations, as they are often more vulnerable than other patient populations, with pregnant women and children at particularly high risk for poor health outcomes that can have significant short-term, long-term, and inter-generational health consequences [ 10 ]. Shared challenges include a lack of access to healthcare and MCH services, inadequate vaccination coverage, risk of malnutrition and starvation, increased burden of mental health issues due to exposure to trauma, and other forms of exploitation and violence such as early marriage, abuse, discrimination, and gender-based violence [ 4 , 10 , 19 , 20 ]. Further, scarce medical resources are often focused on patients suffering from acute and severe injury and trauma, leading to de-prioritization of other critical services like MCH [ 4 ].

Risks for women

A 2016 United Nations Population Fund (UNFPA) report estimated that 360,000 Syrian IDPs are pregnant, yet many do not receive any antenatal or postnatal care [ 21 , 22 ]. According to estimates by the UNFPA in 2015, without adequate international funding, 70,000 pregnant Syrian women faced the risk of giving birth in unsafe conditions if access to maternal health services was not improved [ 23 ]. For example, many women cannot access a safe place with an expert attendant for delivery and also may lack access to emergency obstetric care, family planning services, and birth control [ 4 , 19 , 24 , 25 , 26 , 27 , 28 ]. By contrast, during pre-conflict periods, Syrian women enjoyed access to standard antenatal care, and 96% of deliveries (whether at home or in hospitals) were assisted by a skilled birth attendant [ 13 ]. This coverage equated to improving population health outcomes, including data from the Syrian Ministry of Health reporting significant gains in life expectancy at birth (from 56 to 73.1 years), reductions in infant mortality (decrease from 132 per 1000 to 17.9 per 1000 live births), reductions in under-five mortality (from 164 to 21.4 per 1000 live births), and declines in maternal mortality (from 482 to 52 per 100,000 live births) between 1970 and 2009, respectively [ 13 ].

Post-conflict, Syrian women now have higher rates of poor pregnancy outcomes, including increased fetal mortality, low birth weights, premature labor, antenatal complications, and an increase in puerperal infections, as compared to pre-conflict periods [ 10 , 13 , 25 , 26 ]. In general, standards for antenatal care are not being met [ 29 ]. Syrian IDPs therefore experience further childbirth complications such as hemorrhage and delivery/abortion complications and low utilization of family planning services [ 25 , 28 ]. Another example of potential maternal risk is an alarming increase in births by caesarean section near armed conflict zones, as women elect for scheduled caesareans to avoid rushing to the hospital during unpredictable and often dangerous circumstances [ 10 ]. There is similar evidence from Syrian refugees in Lebanon, where rates of caesarean sections were 35% (of 6366 deliveries assessed) compared to approximately 15% as previously recorded in Syria and Lebanon [ 30 ].

Risks for children

Similar to the risks experienced by Syrian women, children are as vulnerable or potentially at higher risk during conflict and health and humanitarian crises. According to the UNHCR, there are 2.8 million children displaced in Syria out of a total of 6.5 million persons, and just under half (48%) of Syrian registered refugees are under 18 years old [ 1 ]. The United Nations Children’s Fund (UNICEF) further estimates that 6 million children still living in Syria are in need of humanitarian assistance and 420,000 children in besieged areas lack access to vital humanitarian aid [ 31 ].

For most Syrian internally displaced and refugee children, the consequences of facing lack of access to essential healthcare combined with the risk of malnutrition (including cases of severe malnutrition and death among children in besieged areas) represent a life-threatening challenge (though some studies have positively found low levels of global acute malnutrition in Syrian children refugee populations) [ 24 , 32 , 33 , 34 ]. Additionally, UNICEF reports that pre-crisis 90% of Syrian children received routine vaccination, with this coverage now experiencing a dramatic decline to approximately 60% (though estimating vaccine coverage in Syrian IDP and refugee populations can be extremely difficult) [ 35 ]. A consequence of lack of adequate vaccine coverage is the rise of deadly preventable infectious diseases such as meningitis, measles, and even polio, which was eradicated in Syria in 1995, but has recently re-emerged [ 36 , 37 , 38 ]. Syrian refugee children are also showing symptoms of psychological trauma as a result of witnessing the war [ 4 , 39 ].

A local response: the Brotherhood Medical Center

In direct response to the acute needs faced by Syrian internally displaced women and children, we describe the establishment, services provided, and challenges faced by the Brotherhood Medical Center (recently renamed the Brotherhood Women and Children Specialist Center and hereinafter referred to as the “Center”), which opened its doors to patients in September 2014. The Center was the brainchild of a group of Syrian and Saudi physicians and donors who had the aim of building a medical facility to address the acute need for medical humanitarian assistance in the village of Atimah (Idlib Governorate, Syria), which is also home to a Syrian displacement camp.

Atimah (Idlib Governorate, Syria) is located on the Syrian side of the Syrian-Turkish border. Its population consisted of 250,000 people pre-conflict in an area of approximately 65 km 2 . Atimah and its adjacent areas are currently generally safe from the conflict, with both Atimah and the entire Idlib Governorate outside the control of the Syrian government and instead governed by the local government. However, continued displacement of Syrians seeking to flee the conflict has led to a continuous flow of Syrian families into the area, with the population of the town growing to approximately a million people.

In addition to the Center, there are multiple healthcare centers and field hospitals serving Atimah and surrounding areas that cover most medical specialties. These facilities are largely run by local and international health agencies including Medecins Sans Frontieres (MSF), Medical Relief for Syria, and Hand in Hand for Syria, among others. Despite the presence of these organizations, the health needs of IDPs exceeds the current availability of healthcare services, especially for MCH services, as the majority of the IDPs belong to this patient group. This acute need formed the basis for the project plan establishing the Center to serve the unique needs of Syrian internally displaced women and children.

Operation of the Center

The Center’s construction and furnishing took approximately 1 year after land was purchased for its facility, a fact underlining the urgency of building a permanent local physical infrastructure to meet healthcare needs during the midst of a conflict. Funds to support its construction originated from individual donors, Saudi business men, and a group of physicians. In this sense, the Center represents an externally funded humanitarian delivery model focused on serving a local population, with no official government, NGO, or international organization support for its initial establishment.

The facility’s primary focus is to serve Syrian women and children, but since its inception in 2014, the facility has grown to cater for an increasing number of IDPs and their diverse needs. When it opened, facility services were limited to offering only essential outpatient, gynecology, and obstetrics services, as well as operating a pediatric clinic. The staffing at the launch consisted of only three doctors, a midwife, a nurse, an administrative aid, and a housekeeper, but there now exist more than eight times this initial staff count. The staff operating the Center are all Syrians; some of them are from Atimah, but many also come from other places in Syria. The Center’s staff are qualified to a large extent, but still need further training and continuing medical education to most effectively provide services.

Though staffing and service provision has increased, the Center’s primary focus is on its unique contribution to internally displaced women and children. Expanded services includes a dental clinic 1 day per week, which is run by a dentist with the Health Affairs in Idlib Governorate, and has been delegated to cover the dental needs for the hospital patients . Importantly, the Center facility has no specific policy on patient eligibility, its desired patient catchment population/area, or patient admission, instead opting to accept all women and children patients, whether seeking routine or urgent medical care, and providing its services free of charge.

Instead of relying on patient-generated fees (which may be economically prohibitive given the high levels of debt experienced by IDPs) or government funding, the Center relies on its existing donor base for financing the salaries for its physicians and other staff as well as the facility operating costs. More than an estimated 300 patients per day have sought medical attention since its first day of operation, with the number of patients steadily increasing as the clinic has scaled up its services.

Initially the Center started with outpatient (OPD) cases only, and after its partnership with the Syrian Expatriate Medical Association (SEMA) (discussed below), inpatient care for both women and children began to be offered. Patients’ statistics for September 2017 reported 3993 OPD and emergency room visits and 315 inpatient admissions including 159 normal deliveries and 72 caesarean sections, 9 neonatal intensive care unit cases, and 75 admissions for other healthcare services. To better communicate the clinic’s efforts, the Center also operates a Facebook page highlighting its activities (in Arabic at https://www.facebook.com/مشفى-الإخاء-التخصصي-129966417490365/ ).

Challenges faced by the Center and its evolution

The first phase of the Center involved its launch and initial operation in 2014 supported by a small group of donors who self-funded the startup costs needed to operationalize the Center facility’s core clinical services. Less than 2 years later, the Center faced a growing demand for its services, a direct product of both its success in serving its targeted community and the protracted nature of the Syrian conflict. In other words, the Center facility has continuously needed to grow in the scope of its service delivery as increasing numbers of families, women, and children rely on the Center as their primary healthcare facility and access point.

Meeting this increasing need has been difficult given pragmatic operational challenges emblematic of conflict-driven zones, including difficulties in securing qualified and trained medical professionals for clinical services, financing problems involving securing funding due to the shutdown of banking and money transferring services to and from Syria, and macro political factors (such as the poor bilateral relationship between Syria and its neighboring countries) that adversely affect the clinic’s ability to procure medical and humanitarian support and supplies [ 40 ]. Specifically, the Center as a local healthcare facility originally had sufficient manpower and funding provided by its initial funders for its core operations and construction in its first year of operation. However, maintaining this support became difficult with the closure of the Syrian-Turkish border and obstacles in receiving remittances, necessitating the need for broader strategic partnership with a larger organization.

Collectively, these challenges required the management committee and leadership of the Center to shift its focus to securing long-term sustainability and scale-up of services by seeking out external forms of cooperation and support. Borne from this need was a strategic partnership with SEMA, designed to carry forward the next phase of the Center’s operation and development. SEMA, established in 2011, is a non-profit relief organization that works to provide and improve medical services in Syria without discrimination regarding gender, ethnic, or political affiliation — a mission that aligns with the institutional goals of the Center. Selection of SEMA as a partner was based on its activity in the region; SEMA plays an active role in healthcare provision in Idlib and surrounding areas. Some other organizations were also approached at the same time of this organization change, with SEMA being the most responsive.

Since the Center-SEMA partnership was consummated, the Center has received critical support in increasing its personnel capacity and access to medicines, supplies, and equipment, resulting in a gradual scale-up and improvement in its clinical services. This now includes expanded pediatric services and the dental clinic (as previously mentioned and important, as oral health is a concern for many Syrian parents and children). The Center also now offers caesarean deliveries [ 41 ]. However, the Center, similar to other medical humanitarian operations in the region, continues to face many financial and operational challenges, including shortage of medical supplies, lack of qualified medical personnel, and needs for staff development.

Challenges experienced by the Center and other humanitarian operations continue to be exacerbated by the ongoing threat of violence and instability emanating from the conflict that is often targeted at local organizations and international NGOs providing health aid. For example, MSF has previously been forced to suspend its operations in other parts of Syria, has evacuated its facilities after staff have been abducted and its facilities bombed, and it has also been subject to threats from terrorist groups like the Islamic State (IS) [ 42 ].

The case study of the Center, which evolved from a rudimentary medical tent originally located directly in the Atimah displacement camp to the establishment of a local medical facility now serving thousands of Syrian IDPs, is just one example of several approaches aimed at alleviating the suffering of Syrian women and children who have been disproportionately victimized by this devastating health and humanitarian crisis. Importantly, the Center represents the maturation of a privately funded local operation designed to meet an acute community need for MCH services, but one that has necessitated continuous change and evolution as the Syrian conflict continues and conditions worsen. Despite certain successes, a number of challenges remain that limit the potential of the Center and other health humanitarian operations to fully serve the needs of Syrian IDPs, all of which should serve as cautionary principles for future local medical interventions in conflict situations.

A primary challenge is the myriad of logistical difficulties faced by local medical humanitarian organizations operating in conflict zones. Specifically, the Center continues to experience barriers in securing a reliable and consistent supply of medical equipment and materials needed to ensure continued operation of its clinical services, such as its blood bank, laboratory services, operating rooms, and intensive care units. Another challenge is securing the necessary funding to make improvements to physical infrastructure and hire additional staff to increase clinical capacity. Hence, though local initiatives like the Center may have initial success getting off the ground, scale-up and ensuring sustainability of services to meet the increasing needs of patients who remain in a perilous conflict-driven environment with few alternative means of access remain extremely challenging.

Despite these challenges, it is clear that different types of medical humanitarian interventions deployed in the midst of health crises have their own unique roles and contributions. This includes a broad scope of activities now focused on improving health outcomes for Syrian women and children that are being delivered by international aid agencies located outside of the country, international or local NGOs, multilateral health and development agencies, and forms of bilateral humanitarian assistance. The Center contributes to this health and humanitarian ecosystem by providing an intervention focused on the needs of Syrian women and children IDPs where they need it most, close to home.

However, the success of the Center and other initiatives working to end the suffering of Syrians ultimately relies on macro organizational and political issues outside Atimah’s border. This includes better coordination and cooperation of aid and humanitarian stakeholders and increased pressure from the international community to finally put an end to a civil war that has no winners — only victims — many of whom are unfortunately women and children.

Abbreviations

the Brotherhood Women and Children Specialist Center

Internally displaced persons

Maternal and child health

Medecins Sans Frontieres

Non-governmental organizations

Outpatient department

Syrian Expatriate Medical Association

United Nations Population Fund

the United Nations High Commissioner for Refugees

The United Nations Children’s Fund

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Joint Masters Program in Health Policy and Law, University of California - California Western School of Law, San Diego, CA, USA

Rahma Aburas

Brotherhood Medical Center for Women and Children, Atimah, Syria

Amina Najeeb

Department of Anesthesiology, University of California, San Diego School of Medicine, San Diego, CA, USA

Laila Baageel & Tim K. Mackey

Department of Medicine, Division of Global Public Health, University of California, San Diego School of Medicine, San Diego, CA, USA

Tim K. Mackey

Global Health Policy Institute, San Diego, CA, USA

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We note that with respect to author contributions, all authors jointly collected the data, designed the study, conducted the data analyses, and wrote the manuscript. All authors contributed to the formulation, drafting, completion, and approval of the final manuscript.

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This community case study did not involve the direct participation of human subjects and did not include any personally identifiable health information. Hence, the study did not require ethics approval.

Competing interests

Amina Najeeb and Laila Baageel, two co-authors of this paper, were part of the foundation of the Center, remain active in its operation, and have a personal interest in the success of the operation of the clinic. The remaining authors declare that they have no competing interests.

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Aburas, R., Najeeb, A., Baageel, L. et al. The Syrian conflict: a case study of the challenges and acute need for medical humanitarian operations for women and children internally displaced persons. BMC Med 16 , 65 (2018). https://doi.org/10.1186/s12916-018-1041-7

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Examining the politics of responses by the main host states of first asylum in the Syrian refugee crisis

Over 4 million refugees have fled Syria since the outbreak of the crisis and the armed conflicts in 2011. The overwhelming majority of these people have been hosted by Lebanon, Jordan and Turkey in what has been described by the UN High Commissioner for Refugees as “the biggest humanitarian emergency of our era ” . The crisis has created a set of fundamental policy challenges, including how to ensure ongoing protection in host countries with overwhelmed response capacities.

There has been a growing body of research on refugees from Syria. What has been lacking, however, is a focus on understanding the politics of responses by the main host states of first asylum: Lebanon, Jordan, and Turkey. Although we already know a lot about those governments’ basic positions at the capital city level, there is a lot more to understand at the local level. For example, how do municipal or district level authorities shape responses, and what potential opportunities does this open up?

If we can better understand the layers of decision-making, and the gatekeepers that shape policy at local, national, and regional levels, then this in turn will point to new policy levers available to donor governments and the international community. Understanding how interests and power relations have played out at a micro-political level can open up new diplomatic channels to enhance protection space.

To take an example, in Jordan, in the governorate of Mafraq a series of opportunities to integrate Syrian refugees into local labour markets have emerged as a result of local political dynamics. Conversely, in Turkey, pressure on municipal authorities in Bodrum has created pressure on central government protection responses. Understanding these politics within the main host countries of first asylum is the key to unlocking protection space.

In this one-year project, we conducted fieldwork across the three main host countries. Methodologically, the research focused on undertaking qualitative interviews in each of the capital cities and a selection of local sites outside the capital city. The over-arching objective of the project is to inform policies that can enhance protection space for displaced Syrians within the region of origin.

A key output is the report  Local Politics and the Syrian Refugee Crisis: Exploring Responses in Turkey, Lebanon, and Jordan

Alexander Betts

Leopold Muller Professor of Forced Migration and International Affairs

Selected publications

Alexander Betts, Ali Ali, Fulya Memişoğlu, (2017)

March 13, 2024

Syria Refugee Crisis Explained

Here's What You Need to Know:

1. when did the syrian refugee crisis begin, 2. how are the türkiye-syria earthquakes impacting syrians, 3.   where do syrian refugees live do all syrian refugees live in refugee camps, 4. what are syrian’s greatest challenges, 5. how are syrian children impacted by this crisis, 6. what is the un refugee agency doing to help syrians, when did the syrian refugee crisis begin.

The Syrian refugee crisis began in March 2011 as a result of a violent government crackdown on public demonstrations in support of teenagers who were arrested for anti-government graffiti in the southern town of Daraa. The arrests sparked public demonstrations throughout Syria which were violently suppressed by government security forces. The conflict quickly escalated and the country descended into a civil war that forced millions of Syrian families to flee their homes. Thirteen years later, the conflict is ongoing with Syrians continuing to pay the price—more than 16.7 million people in Syria are in need of humanitarian assistance, accounting for 70 percent of the population.

How are the Türkiye-Syria Earthquakes impacting Syrians?

On February 6, 2023,  two powerful earthquakes  struck south-eastern Türkiye and northern Syria, claiming thousands of lives and causing untold destruction to homes and infrastructure across the region. This is a crisis on top of existing crises already impacting internally displaced Syrians and Syrian refugees.

In Türkiye, the heavily impacted areas are regions where Syrian refugees live in high numbers. Syrian refugees were already vulnerable, living with protection risks and economic insecurity. For people inside Syria, the earthquake has only brought on more misery and pain and catapulted some of the most in need communities in the country into utter desperation. 

As of March 2024, the earthquake has impacted 8.8 million people across Syria, uprooting tens of thousands—many of whom had already been displaced. The earthquake claimed 60,000 lives, with tens of thousands injured and entire neighborhoods reduced to rubble. In north-west Syria alone, more than 40,000 people remain displaced by the earthquake and are living in temporary reception centers.  

The immediate impact of the earthquake has been devastating, but the full extent of the damage is yet to be seen. The long-term impacts of the earthquakes pose serious challenges for Syrians and will require a robust response on multiple fronts.

Where do Syrian refugees live? Do all Syrian refugees live in refugee camps?     

Syrian refugees have sought asylum in more than 130 countries, but the vast majority live in neighboring countries within the region, such as Türkiye, Lebanon, Jordan, Iraq and Egypt. Türkiye alone hosts the largest population of Syrian refugees: 3.3 million. Approximately 92 percent of refugees who have fled to neighboring countries live in rural and urban settings, with only roughly five percent living in refugee camps . However, living outside refugee camps does not necessarily mean success or stability. More than 70 percent of Syrian refugees are living in poverty, with limited access to basic services, education or job opportunities and few prospects of returning home.

What are Syrians' greatest challenges?

Protracted displacement, the war in Ukraine, global inflation and the earthquakes that struck south-eastern Türkiye and northern Syria are some of the biggest challenges Syrians currently face. 

Poverty and unemployment are widespread within Syria, with over 90 percent of the population in Syria living below the poverty line. By October 2023, the cost of the food basket had doubled compared to January and quadrupled in the last two years. An estimated 12.9 million people are food insecure as a result of the economic crisis. 

The situation for Syrian refugees living in neighboring host countries has deteriorated as well. Economic challenges in neighboring countries like Lebanon have pushed Syrians in the country into poverty with more than 90 percent of Syrian refugees reliant on humanitarian assistance to survive. In Jordan, more than 93 percent of Syrian households reported being in debt to cover basic needs. Ninety percent of Syrian refugees living in Türkiye cannot fully cover their monthly expenses or basic needs. 

Millions of refugees have lost their livelihoods and are increasingly unable to meet their basic needs - including accessing clean water, electricity, food, medicine and paying rent. The economic downturn has also exposed them to multiple protection risks, such as child labor, gender-based violence, early marriage and other forms of exploitation.

How are Syrian children impacted by this crisis?

Thirteen years of crisis have had a profound impact on Syrian children. They have been exposed to violence and indiscriminate attacks, losing their loved ones, their homes, their possessions and everything they once knew. They have grown up knowing nothing but the crisis. Today, over 47 percent of Syrian refugees in the region are under 18 years old and more than a third of them do not have access to education. In Syria, more than 2.4 million children are out of school and 1.6 million children are at risk of dropping out.

Children’s rights during the crisis are undermined on a daily basis. An increasing number of Syrian children have fallen victim to child labor, with cases in Lebanon almost doubling in just one year.

Read some of their stories

What is the UN Refugee Agency doing to help Syrians?

The UN Refugee Agency has been on the ground since the start of the crisis providing shelter, lifesaving supplies, clean water, hot meals and medical care to families who have been forced to flee their homes. UNHCR has also helped repair civilian infrastructure – including homes, school facilities and recreation centers, supported educational activities for children and provided psycho-social support.

UNHCR and humanitarian partners are responding to the Türkiye-Syria Earthquakes by stepping up their assistance in the two countries. In Syria, UNHCR has delivered protection assistance, including psychosocial support, to more than 311,000 people affected by the earthquakes. UNHCR is also providing shelter support, cash assistance and other aid to those affected. In Türkiye, UNHCR has provided over 3 million relief items including tents, containers, hygiene kits, bedding and warm clothing for refugees and local residents in temporary accommodation centers. UNCHR is also supporting protection activities for more than 500,000 people – including legal counseling, identification and referral of people with specific needs, psychosocial support and cash assistance. 

Help protect Syrian refugees...

Monthly giving is the most convenient, effective and efficient way you can help people fleeing conflict. Start making a lifesaving difference today. Please become USA for UNHCR’s newest monthly donor.

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Article Contents

Introduction, investigating the politics of host states’ forced migration management, theorizing refugee rentier states, methodology and case selection, foreign policy and the refugee rentier state in jordan, lebanon, and turkey, the syrian refugee crisis in regional perspective, acknowledgements.

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The Syrian Refugee Crisis and Foreign Policy Decision-Making in Jordan, Lebanon, and Turkey

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Gerasimos Tsourapas, The Syrian Refugee Crisis and Foreign Policy Decision-Making in Jordan, Lebanon, and Turkey, Journal of Global Security Studies , Volume 4, Issue 4, October 2019, Pages 464–481, https://doi.org/10.1093/jogss/ogz016

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How does forced migration affect the politics of host states and, in particular, how does it impact states’ foreign policy decision-making? The relevant literature on refugee politics has yet to fully explore how forced migration affects host states’ behavior. One possibility is that they will employ their position in order to extract revenue from other state or nonstate actors for maintaining refugee groups within their borders. This article explores the workings of these refugee rentier states , namely states seeking to leverage their position as host states of displaced communities for material gain. It focuses on the Syrian refugee crisis, examining the foreign policy responses of three major host states—Jordan, Lebanon, and Turkey. While all three engaged in post-2011 refugee rent-seeking behavior , Jordan and Lebanon deployed a back-scratching strategy based on bargains, while Turkey deployed a blackmailing strategy based on threats. Drawing upon primary sources in English and Arabic, the article inductively examines the choice of strategy and argues that it depended on the size of the host state's refugee community and domestic elites’ perception of their geostrategic importance vis-à-vis the target. The article concludes with a discussion of these findings’ significance for understanding the international dimension of the Syrian refugee crisis and argues that they also pave the way for future research on the effects of forced displacement on host states’ political development.

“We can open the doors to Greece and Bulgaria anytime and we can put the refugees on buses,” Turkish President Recep Tayyip Erdoğan declared to a group of European Union (EU) senior officials in February 2016. “So how will you deal with refugees if you don't get a deal? Kill the refugees?” ( Reuters 2016a ). A year before this, the Greek Minister of Defense Panos Kammenos threatened that “we cannot keep ISIS out if the EU keeps bullying us” ( Aldrick and Carassava 2015 ). Other host states in the region—namely Lebanon and Jordan—have also repeatedly voiced their need for international economic assistance albeit by promising to continue supporting refugee populations within their borders. Indeed, forced migration often generates tensions in global politics and varied reactions by host states, most strikingly in the responses to the post-2011 displacement of Syrians across the Middle East and beyond. Existing theorization of host states’ engagement with forced migration flows indicates that they may aim to benefit from such outflows in an aggressive manner, even if they played no part in generating them. But this does not account for the full gamut of host states’ foreign policy choices or some states’ abstention from the use of coercion. This article aims to expand our understanding of the interplay between forced migration and power politics within the context of the Syrian refugee crisis, in order to address how refugee flows affect host states’ foreign policy.

I argue that a host state's domestic elites often approach refugee communities as potential sources of revenue. I introduce the term refugee rentier states to describe states that employ their position as host states of forcibly displaced populations to extract revenue, or refugee rent , from other state or nonstate actors in order to maintain these populations within their borders. Building on international relations literature on issue-linkage strategies, I identify two strategies through which a host state may exercise refugee rent-seeking behavior in its foreign policy: via blackmailing —threatening to flood a target state(s) with refugee populations within its borders, unless compensated—or via back-scratching —promising to maintain refugee populations within its borders, if compensated. Recognizing that a state's policy choice is rarely a simple binary between coercion and cooperation, I operationalize the two strategies with regard to specific patterns that allows to distinguish specific behavior patterns in host states’ policies. Using a three-case-study approach to examine the foreign policy behavior of the main host states of displaced Syrian communities since 2011, my data suggests that a host state's choice between blackmailing or back-scratching depends on domestic elites’ perception vis-à-vis the target state(s). Drawing on data collected in Jordan, Lebanon, and Turkey, I argue that a strategy of blackmailing is adopted when domestic elites believe that their state is geopolitically important vis-a-vis the target state(s) and they host a significant number of refugees. Otherwise, they are more likely to employ a strategy of back-scratching.

The article proceeds as follows. I review the relevant literature and present my theoretical model. I then introduce three case studies that will allow for further theory development via covariation and within-case analysis. Turkey, Lebanon, and Jordan are selected for they constitute the largest host states of displaced Syrians in the post-2011 Middle East. I demonstrate how Lebanon and Jordan adopted a strategy of back-scratching in their foreign policy because, even though they believed they hosted large communities of Syrian refugees, they did not consider themselves geopolitically important vis-à-vis the European Union (EU). In sharp contrast, Turkey adopted a blackmailing strategy that can be explained by state elites’ perception of Turkey's geopolitical importance and the large size of Syrian refugees residing within its borders. I continue by explicitly discounting alternative explanations that may account for the three states’ foreign policy-making. I conclude with a note of how additional research may shed light on how forced displacement affects refugee rentier states’ domestic political development, particularly with regard to encouraging opportunities for state corruption, autocracy, and other pathologies associated with rentierism.

How does forced migration affect the politics of host states, and, in particular, how do the latter employ the presence of refugees in their foreign policy decision-making? A long line of international relations scholars has attempted to address these questions, albeit not systematically. As Betts and Loescher argue, “only relatively isolated pockets of theoretically informed literature have emerged on the international politics of forced migration,” while the study of refugee politics has yet to form part of mainstream international relations ( Betts and Loescher 2011 , 12–13). This is not to undermine the work of international politics scholars who critically examined the emergence of the international refugee regime, and who pioneered empirical work on the politics of forced migration ( Gordenker 1987 ; Zolberg 1989 ), primarily within the context of interstate conflict. During the Cold War, superpower rivalry resulted in forced displacement across developing states of the Third World ( Zolberg, Suhrke, and Aguayo 1989 ). It also shaped the refugee policy of American policy-makers, with Washington considering refugees “a weapon in the cold war” ( Zolberg 1988 , 661; Loescher and Scanlan 1986 ; Munz and Weiner 1997 ; Adamson 2006 , 190). Beyond the United States’ aiding of “lone individuals crossing borders to seek political freedom in the West” ( Stedman and Tanner 2004 , 5), host states also used refugees instrumentally in military conflicts, while numerous states sought to “embarrass or discredit adversary nations” by allowing refugee flows or to use them against an “adversarial neighboring regime” ( Teitelbaum 1984 ). In the Middle East, the status of Palestinian refugees served as a strategic asset for Arab states’ ongoing struggle against Israel ( Hinnebusch 2003 , 157); in the Rwandan and Pakistani contexts, humanitarian aid to refugee camps fueled violence by providing legitimacy and support to militants ( Lischer 2003 ). In fact, research has demonstrated the wide impact of refugees in the diffusion and exacerbation of conflict ( Lischer 2015 ), with Kaldor including displacement as a form of post-1989 “new wars” in the Balkans, sub-Saharan Africa, and elsewhere ( Kaldor 2013 ).

At the same time, the socioeconomic and political risks perceived to be associated with hosting large numbers of refugees has led to lukewarm responses in tackling the problem of forced migration ( Zolberg 1989 , 415; Loescher 1996 , 8). This also highlights some of the main problems behind the development of a functional global refugee regime ( Betts 2011 ), as “states have a legal obligation to support refugees on their own territory, [but] they have no legal obligation to support refugees on the territory of other states” ( Betts and Loescher 2011 , 19). Tackling this dichotomy lies at the heart of host states’ political engagement with forced migration. For historical and structural reasons, states across the Global South feature the large majority of refugee populations, which creates a power asymmetry with seemingly unaffected Global North states. Yet, Global North states continue to provide economic support for the governments of refugee host states in the Global South in an act of “calculated kindness” ( Loescher and Scanlan 1986 ; cf. Arar 2017b ). From a security perspective, they do so aiming to prevent the diffusion of forced displacement into their own territory, be it North America ( Weiner 1992 , 101) or Europe ( Huysmans 2000 ; Greenhill 2016 ). In attempting to examine how the North-South asymmetry may be perceived from the point of view of refugee host states, forcibly displaced populations arguably become a source of revenue, particularly given Western states’ tendency to offer “charity” in order to outsource refugee problems to the Global South (cf. Loescher 1996 ). Empirical examples attest to this: for instance, the influx of Afghani refugees into Pakistan paved the way for a five-year $3.2 billion aid package by the Reagan administration in 1981 ( Loescher 1992 ). More recently, between 2001 and 2007, Nauru received $30 million from the Australian government in order to host refugees and asylum seekers within the Nauru Regional Processing Centre, in addition to Australia covering its operating costs, at $72 million for 2001–2002 alone ( Oxfam 2002 ). 1 This is not to suggest that host states consciously encourage inflows of forcibly displaced populations—rather, that an inflow of refugees may constitute a strategic resource for these states’ governments.

How does the strategic importance of these forcibly displaced populations affect refugee host states’ foreign policy decision-making? Two research agendas are relevant in this regard: firstly, a small group of researchers examines issue-linkage processes, suggesting that “win-win” strategies may convince Global North states to continue providing support for protecting refugees in the South (cf. Hollifield 2012 ). As Betts argues, “in the absence of altruistic commitment by Northern states to support refugees in the South, issue-linkage has been integral in achieving international cooperation on refugees” ( Betts and Loescher 2011 , 20; Betts 2017 ). Secondly, work on leverage suggests that host states are also able to proceed unilaterally, aiming at extracting resources from target states that fear being overwhelmed by migrants or refugees; Greenhill demonstrates that host states may employ deportation in order to create targeted migrant or refugee “crises” in target countries that, in fear of being “capacity-swamped,” are likely to comply with these states’ demands ( Greenhill 2003 , 2010 ). As a result, Afghanistan, Sudan, Libya, and Jordan have been able to pursue issue-linkage strategies that manipulate “migration interdependence” by linking the management of cross-border population mobility to extracting foreign policy and economic benefits from Western and non-Western actors ( Tsourapas 2017 , 2018 ).

Two questions remain unresolved in existing theorizations of refugee host states’ policy-making: firstly, what is the full gamut of foreign policies that these states may employ in seeking to exploit the presence of a refugee population group on their soil, beyond encouraging generations of outflows? Greenhill argues for three types of refugee host states, namely “generators,” “ agent provocateurs ,” and “opportunists”—which do not consider states that aim to profit from forced displacement without resorting to coercion. A second, related question is the following: why do some refugee host states have more aggressive foreign policy preferences, while others develop strategies of policy coordination rather than coercion? In other words, when do refugee host states adopt a more coercive stance—reminiscent of Fidel Castro's use of the 1980 Mariel boatlift to exert pressure on the Carter administration—and when will they employ a more cooperative one, as in the case of Pakistan or Nauru? In addressing these questions, this article contributes to the literature by presenting a more complete picture of refugee host states’ foreign policy decision-making, as well as the rationale behind it.

reward—income or wealth—is not related to work and risk bearing, rather to chance or situation. For a rentier [state], reward becomes a windfall gain, an isolated fact, situational or accidental as against the conventional outlook where reward is integrated in a process as the end result of a long, systematic, and organized production circuit. The contradiction between production and rentier ethics is, thus, glaring. ( Beblawi 1987 , 385–86)

While rentier state theorists do not discuss cross-border population mobility, I introduce this framework into international refugee politics. I argue that refugee host states may adopt characteristics of a rentier state with regard to their management of forced migration, given that their governments are able to derive similar forms of unearned external income from a specific resource—namely, the presence of refugee populations within a state's borders. For the purposes of this analysis, a refugee rentier state is a state that hosts forcibly displaced population group(s) and relies financially on external income linked to its treatment of these group(s). Refugee rent may come from international organizations or third states in a variety of forms, including direct economic aid or grants, debt relief, preferential trade treatment, and so on. As per the expectations of rentier state theory, refugee host state actors are not engaged in the generation of such rent, but on its distribution or utilization, which may or may not directly relate to the domestic management of forcibly displaced population group(s). Finally, a refugee rentier state's government remains the principal recipient of this rent.

Some empirical examples allow the clarification of the refugee-rentier-state concept: Libya's reliance upon European economic aid under Colonel Gaddafi in order to prevent the outflow of sub-Saharan African refugees into the Mediterranean suggests that it is a refugee rentier state. the Libyan state was not involved in the creation of these refugee flows out of sub-Saharan Africa, and the Libyan government was the primary recipient of substantial European economic aid. In contrast, the 1923 population exchange between Turkey and Greece generated more than two million forcibly displaced persons and significant international economic support; yet, given the involvement of both states’ governments in the refugee-generation process, neither Turkey nor Greece qualify as refugee rentier states. Since 1948, Israel has witnessed the inflow of millions of Jewish refugees, notably from the Arab world and the Soviet Union; yet, it does not constitute a refugee rentier state, for Israeli governments do not receive any external income with regard to their treatment of these refugees. In contrast, the significant economic aid afforded to the Pakistani government in response to the influx of six million Afghan refugees since 1979 renders it a refugee rentier state.

As discussed in the previous section, the argument that refugee host states may seek material gains from the presence of displaced communities within their borders is not novel. In fact, already in 1984, Weiner had asserted that international migration may constitute a kind of “national resource” (quoted in Teitelbaum 1984 , 447). In this line of thought, the rentier state framework allows us a better understanding of states’ foreign policy decision-making and the rationale behind it, if examined via the prism of refugee rent-seeking behavior. I introduce two key terms from the literature on interdependence: blackmailing and back-scratching. For Oye, a central aspect of contemporary diplomacy within a world of asymmetrical power distribution involves the use of cross-issue linkage, via two forms. Firstly, blackmailing involves “threats to do something one does not believe to be in one's interest, unless compensated, and promises to refrain from doing something one does not believe to be in one's own interest, if compensated.” A main example is the Organisation of Arab Petroleum Exporting Countries’ (OAPEC) oil embargo against the United States in 1973, which was not in the interests of its member states. On the other hand, back-scratching involves “promises to refrain from doing something one believes to be in one's interest, if compensated, and threats to do something one believes to be in one's interest, unless compensated.” One example of this is the post-1973 tacit agreement between Washington and Saudi Arabia to maintain oil production in excess of Saudi financial needs ( Oye 1979 , 14; cf. Haas 1980 ). Keohane and Nye summarize the difference between blackmailing and back-scratching by arguing that the first involves “making a threat one does not wish to carry out,” while the second refers to “offering a quid pro quo bargain” ( Keohane and Nye 1987 , 735).

Importing this model into refugee studies, I argue that there are two ways through which a host state may exercise rent-seeking behavior in its foreign policy: via blackmailing—threatening to flood target states with refugee populations within its borders, unless compensated—or via back-scratching—promising to refrain from taking unilateral action against refugee populations within its borders, if compensated. Although back-scratching and blackmailing may be considered as two sides of the same coin and the choice made by refugee rentier states may often be less clear-cut, there is value in understanding how the two policies may differ. I operationalize them as follows: on the one hand, a blackmailing strategy often includes threats of unilateral actions to be taken by a refugee host state. Blackmailers often frame their actions around potential losses that a target state(s) may incur and show little interest in international laws or norms. On the other hand, a back-scratching strategy is usually framed around common benefits accrued by cooperation. Back-scratchers tend to value multilateral negotiations rather than bilateral ones, and they believe that references to international laws or norms strengthen their case.

In order to understand whether a refugee rentier state will adopt a blackmailing or back-scratching strategy, I proceed inductively via an exploratory three-case study research design of the three main states hosting Syrian refugees in the aftermath of the 2011 Syrian conflict, namely Jordan, Lebanon, and Turkey. In choosing a foreign policy strategy, I expect states to make a rational calculation based on their relative position and strength vis-à-vis their target state(s). This is not a structural variable based on geography alone: the relative position of Egypt vis-à-vis Great Britain, for instance, diminished in the aftermath of World War II once ensuring a safe passage to India became less important to London. The relative position of Pakistan vis-à-vis the United States increased exponentially in the aftermath of the Iranian Revolution and the Soviet Union's invasion of Afghanistan. A second expectation of refugee host-state foreign policy decision-making also involves an evaluation of itself vis-à-vis its target state(s). State strength may be calculated in numerous ways, but I expect the strength of a refugee host state to lie in the size of refugee communities it hosts, given that target states tend to estimate the significance of accepting refugees based on their numbers, rather than any other indicator such as age, sex, or educational status. As Teitelbaum and Weiner argue, the post–Cold War realities suggest that the United States and other Western states see migration flows less as instruments that “could both weaken our adversaries and strengthen our friends” and more as an imposition of “unacceptably high costs” and security threats ( Teitelbaum and Weiner 1995 , 17; Weiner 1996 , 17). The following section offers a brief discussion of the article's methodology before proceeding to the analysis of the three case studies in more detail.

I employ exploratory case-study methodology for the purposes of theory development through induction, and I rely on covariation and within-case analysis ( Bennett and Checkel 2015 ). Turkey, Lebanon, and Jordan have been selected for they constitute the largest host states of Syrian refugees. As of September 2018, more than 3.56 million Syrian refugees have registered in Turkey, which currently constitutes the largest host state of Syrian refugees. Syrians enjoyed visa-free entry into Turkey, as part of a 2009 bilateral mobility agreement, until Turkey closed border crossing points in 2015. Estimates for Lebanon and Jordan vary, but they are acknowledged to be the second and third largest host states of Syrian refugees, with 1 to 2.2 million and 660,000 to 1.26 million Syrians, respectively. Jordan initially allowed Syrians free entry, albeit with restrictions on employment. Controls were gradually put in place, coinciding with the opening of the Za'atari refugee camp in July 2012, until border closures became more prominent since mid-2013. Syrians in Lebanon enjoyed similar freedom of entry but were also eligible to work based on the 1991 and 1993 bilateral agreements between the two countries. From October 2014 onward, the Lebanese government adopted the “October Policy” that tightened restrictions on entry and residency for Syrian refugees.

The potential pitfalls of the case-study method have been extensively examined in the literature ( Geddes 1990 ; Collier and Mahoney 1996 ), particularly if cases are selected on the dependent variable. Yet, a sizeable body of political science research also identifies how “in the early stages of a research program, selection on the dependent variable can serve the heuristic purpose of identifying the potential causes and pathways leading to the dependent variable of interest” ( George and Bennett 2005 , 23). Covariation is employed to substantiate the study's theoretical claims ( Gerring 2016 ), while within-case analysis is well suited to the “systematic examination of diagnostic evidence selected and analyzed” ( Collier 2011 , 823). The combination of the two methods enables the use of qualitative tools to assess the causal claims and mechanisms outlined in the previous section (for comparison, Beach and Pedersen 2013 ).

A final note on data collection: field research in the Global South contexts presents unique challenges ( Kapiszewski, MacLean, and Read 2015 , 218), particularly in light of the fact that regional migration is traditionally considered a security issue for ruling elites in broader Middle East. At the same time, research is plagued by a lack of detailed, publicly available statistical data on intra-Arab flows, a manipulation of statistics for economic and political gain, as well as by the fact that migration management is handled at the highest levels of the executive ( Tsourapas 2019 , 24–30). As Brand (2013 , 8) wrote on seeking statistical data on the Jordanian political economy, “one works under the assumption that such documents will probably never be released or may never have existed in the first place.” To overcome these issues, I rely upon a meticulous collection of primary sources, including Arabic and non-Arabic media reports collected during fieldwork in Amman and Beirut (2017 and 2018). For the purposes of triangulation, I also employ elite interviews, reports, briefs, and communications by international organizations and nongovernmental organizations (NGOs) with regard to Syrian refugees in all three states.

Jordan and the February 2016 Compact

To what extent does Jordan constitute a refugee rentier state, and how has that influenced its foreign policy decision-making? With regard to the Syrian refugee crisis, the emergence of the Jordanian refugee rentier state occurred gradually, from 2013 onward. This is primarily evident in policy-makers’ attempt to render Syrian refugees as visible as possible to the international community, while also aiming to inflate their numbers. Despite a welcoming policy between 2011 and 2013, Jordan created the Directorate of Security Affairs for the Syrian Refugee Camps in March 2013 and, two months later, closed its border crossings with Syria, even to those carrying valid passports (Syrians do not need a visa for entry into Jordan). Palestinian Syrians, in particular, had been denied entry since April 2012 and officially since January 2013 ( Human Rights Watch 2014 ). A number of security reasons have been identified for these border closures that highlight the potential risks for sociopolitical unrest that a large influx of Palestinian-Syrians into the country might entail. A state security rationale does not, however, adequately account for the fact that Jordanian border officers prompted Syrians to enter the country via informal crossings, instead; at numerous times in the first three years of the Syrian conflict, the country's formal borders were closed to Syrian passport-holders, who were encouraged to use informal border crossings along the eastern border, instead.

While state security concerns were important for domestic policy-makers, the shift in Jordan's policy on border crossings was primarily aimed at increasing the international visibility of the Syrian refugee issue. Those entering the country through informal crossing points are automatically recognized as prima facie refugees, according to the 1998 Memorandum of Understanding (MoU) signed between Jordan and the United Nations High Commissioner for Refugees (UNHCR). As a result, with the contribution of aid workers, local authorities were able to classify all Syrians entering into Jordan as refugees, rather than visitors. Syrians entering through informal crossing points were directly sent to the Za'atari refugee camp, near Mafraq. Whereas, in November 2012, Za'atari hosted some forty-five thousand Syrians, by February 2013 it was home to more than seventy-six thousand Syrians, a number that reached 156,000 refugees by March 11, 2013. This strategy enabled the Jordanian state to highlight that it was facing a clearly enumerated influx of Syrian refugees and to strengthen its appeals for international aid. The Jordanian security official in charge of the Azraq refugee camp, which was constructed in May 2014, notes that “if we hadn't built the camps, then the world would not understand that we were going through a crisis” ( Betts, Ali, and Memişoğlu 2017 , 9). As Turner argues, “part of the reason why Jordan built camps for Syrians is that it used encampment strategically to enable it to raise the profile of, and receive funds for, Syrian refugees on its territory” ( Turner 2015 , 393). In fact, Jordan insists that the number of Syrians inside its territory well exceeds the number of those formally registered; whereas the UNHCR puts forth approximately 655,500 Syrians registered with the United Nations inside Jordan, the government argues that Jordan hosted 1.3 million Syrians in 2017.

A strong indication of Jordan's refugee rent-seeking behavior lies in its treatment of earlier forced displacement, particularly Iraqi refugees that had entered its territory after 2003. By 2007, UNHCR estimated that Jordan hosted approximately fifty thousand registered Iraqis, but officials would claim that the number was between 750,000 and one million. This would cost the Jordanian state $1 billion annually. An independent report by Fafo, a Norwegian research institute commissioned by Jordan to establish an accurate estimate, produced a figure of 161,000 Iraqis, but the Jordanian government continued to inflate this figure. “We used to exaggerate the numbers with the Iraqis, but we do not do that anymore,” one high-ranking Jordanian official admitted, carefully noting that “we are not exaggerating the Syrian numbers” ( Arar 2017a , 14). At the same time, Jordan did not place Iraqis into camps, which has been identified as working “strongly against Jordan's attempts to secure increased financial aid” ( Turner 2015 , 393). Camps can turn refugees into a visible and “spatially legible population” ( Peteet 2011 , 18) and facilitate the counting of refugees, which in turn can facilitate fundraising ( Black 1998 ); in Jordan's case, the Iraqis were less visible to the international community, something that Jordanians sought to address with their management of Syrian refugees.

A number of domestic responses to Syrian refugees have been developed under a refugee rent-seeking rationale, particularly the July 2014 “bail out” process. According to this policy, Syrian refugees are permitted to exit their assigned camps only when they are able to secure a sponsorship from a Jordanian citizen, who has to be more than thirty-five years of age, married, and employed in a stable position. The Jordanian sponsor should also be able to prove a family relationship with the applicant and not have a criminal record ( Amnesty International 2013 ). While reliable data on this is not available, the Jordanian state's adoption of a bail-out process has encouraged phenomena of corruption and greed in the dealings between Syrian refugees and the Jordanian social body; numerous instances have been recorded of well-off Syrians that have been able to “buy” their way out of Jordanian refugee camps, for hefty prices. At the same time, the UNHCR has recorded instances of Syrians paying middlemen around $500 in order to be bailed out by unknown Jordanian citizens ( United Nations High Commissioner for Refugees 2013 , 8). The fact that Jordan cancelled this scheme in 2016, arguably once camp-enclosed Syrians who have been able to afford a Jordanian sponsor concluded such transactions, speaks to the state's refugee rent-seeking behavior.

Turning the Syrian refugee crisis into a development opportunity that attracts new investments and opens up the EU market with simplified rules of origin, creating jobs for Jordanians and Syrian refugees while supporting the postconflict Syrian economy;

Rebuilding Jordanian host communities by adequately financing through grants to the Jordan Response Plan 2016–2018, in particular the resilience of host communities; and

Mobilizing sufficient grants and concessionary financing to support the macroeconomic framework and address Jordan's financing needs over the next three years, as part of Jordan entering into a new Extended Fund Facility program with the International Monetary Fund ( Government of Jordan 2016 ).

The contribution to the Jordan Response Plan referred to a funding package that aimed to support Jordanian capacity to host refugees that, by 2016, had only reached 30 percent of its target. In London, $700 million of grants were raised with the expectation that additional pledges would provide an additional $700 million in 2017 and 2018. At the same time, the World Bank adopted the Concessional Financing Facility (CFF), which provided $147 million in low-interest loans, available only to middle-income refugee-hosting countries. Interestingly, although drafted within the context of the donor conference on Syria, the compact identified that “a new paradigm is necessary, promoting economic development and opportunities in Jordan to the benefit of Jordanians and Syrian refugees” (ibid.). In particular, Jordan secured support for its wish to boost its manufacturing sector by integrating refugees into Special Economic Zones: “[b]y allowing refugees to work in the SEZs [special economic zones], Jordan hopes to attract the additional support needed to make its own national development strategy work” ( Betts et al. 2017 , 10). This was possible via tariff-free access to the European Union market for goods produced within SEZs with a certain degree of Syrian participation (15 percent) and provided that Jordan issues two hundred thousand work permits to Syrians.

It is critical that today we begin to finance projects to support vulnerable populations in Jordan and Lebanon . . . [T]hese countries have made enormous sacrifices to meet the global responsibility of providing refuge from conflict, and it is vital that the international community unite to provide the long-term support that will help them both withstand shocks and continue to develop and prosper. ( World Bank 2016 )

This narrative was immediately picked up by local elites and policy-makers, shaping expectations and attitudes on the ground. Jordan understands how “the idea of turning the challenge of refugees into an economic opportunity is based on the protracted nature of the crisis,” according to Imad Fakhoury, Jordanian Minister of Planning and International Cooperation ( Reed 2017 ). In mid-2016, as the EU relaxed trade rules with Jordan in order to create jobs for Syrian refugees, Fakhoury hailed this as “an opportunity to transform the Syrian refugee crisis to an economic opportunity” ( Reuters 2016b ). As Saleh Kharabsheh, Secretary General at the Jordanian Ministry of Planning and International Cooperation, argued, “[the CSS] will play a significant role in contributing to building the resilience of Jordan's host communities and boost economic growth so that we are able to provide basic services and economic opportunities to both Jordanians and Syrian refugees” ( World Bank 2016 ). By February 2016, once Jordanian policy-makers perceived international economic aid as serving the country's broader developmental goals rather than merely addressing the Syrian refugee crisis, Jordan embodied a refugee rentier state.

[Western states] realize that if they don't help Jordan it is going to make it more difficult for them to be able to deal with the refugee crisis. And, to be honest, all the leaders that we talk to know that, by helping Jordan, they are actually helping themselves more. So, it is in their vested interests . . . I think the leaders of the international community have the spirit to help us. ( BBC 2016a )

At the same time, the Jordanian monarch addressed his appeals toward the international community and adopted cooperative language: “the international community, we've always stood shoulder to shoulder by your side,” he declared in February 2016. “We're now asking for your help. You can't say no this time,” he said ( BBC 2016b ). Abdullah aimed to highlight the plight of Jordan, rather than raise threats against other states: in a September 2016 television interview, Abdullah argued how “unemployment is skyrocketing. Our health sector is saturated. Our schools are really going through difficult times. It's extremely, extremely difficult. And Jordanians just have had it up to here. I mean we just can't take it anymore” ( CBS News 2016 ). Ahead of a donor conference on Syria in February 2016, Abdullah became more blunt: “I think it's gotten to a boiling point . . . sooner or later, I think, the dam is going to burst,” he warned. “We can't do it anymore” ( BBC 2016b ).

When asked whether a more assertive foreign policy strategy would have been preferable, my respondents appeared reticent. Most frequently highlighted was the country's relative position vis-à-vis the West. One source in the Ministry of Planning and International Cooperation laughed it off—“Send [the Syrian refugees] where? Israel?” While no one disputed that the Syrian refugee community in Jordan represented a sizeable force, the fact that Jordan is landlocked with no pathway to Europe was also frequently mentioned. As Arar also notes, quoting a Jordanian official she interviewed, “we should have blackmailed the EU like Turkey did” ( Arar 2017b , 25). An official interviewed in the Ministry of Foreign Affairs and Expatriates also doubted that a different policy would bring results; he argued that the influx of Iraqi refugees into Jordan following the 2003 invasion went largely unnoticed by the United States. In fact, back then, King Abdullah had famously declared that Jordan is stuck between “Iraq and a hard place.”

Finally, the domestic repercussions of the Jordan Compact merit analysis: the negotiations leading to the Jordan Compact were based on the expectation that two hundred thousand employment opportunities will be provided for Syrian refugees, as a way of reducing their dependence on aid. In practice, this has been difficult given a slower-than-expected economic growth since 2016, high unemployment, as well as a lack of interest in investing in Jordan's business sector. By July 2017, only sixty thousand work permits had been issued. This has resulted in significant tension between Jordan and the international donors, which was further fueled by the Jordanian Ministry of Labor decision to allow each Syrian to carry more than one work permit. In an attempt to reach the two-hundred-thousand mark, the Jordanian government argued that work permits do not represent individuals: “the permits are work opportunities,” explained one Ministry official. “It is possible for a Syrian to have more than one permit in a year if he has more than one job” ( Betts et al. 2017 , 11).

If Egyptian workers were already vulnerable and living in precarious situations, the Jordanian government's resolution at the international donors conference in London to issue work permits to [two hundred thousand] Syrians (at no cost to employers) within two years further exacerbated the situation. (ibid.)

Lebanon and the February 2016 Compact

In contrast to Jordan, Lebanon did not develop a policy of placing Syrians into refugee camps, a decision linked to its long background of enduring sociopolitical issues arising from its construction of Palestinian refugee camps ( Shami 1999 ). Yet, Lebanon adopted a refugee-rentier-state mentality that bears similarities to Jordan. In matters of enumeration, the two countries share the pattern of statistical inaccuracy in reporting Syrian refugee stocks estimates: UNHCR reported 1,001,051 registered Syrian refugees, but the organization was ordered to suspend registrations as of May 2015. “The government took a decision last October [2014] that included new border measures for all Syrians and also asked [UNHCR] to stop registering refugees unless in very exceptional humanitarian cases,” an adviser to the Interior Minister Nohad Machnouk reported to al-Jazeera . “Since the beginning of this year, UNHCR has registered thousands of new Syrians, which is basically in contradiction with the Lebanese decision” ( Gallart 2015 ). As a result, the Lebanese government has been able to put forth a wide range of estimates, going as high as 2.2 million refugees.

My boss makes me work more than [twelve] hours a day at his shop. Sometimes I complain but then he threatens to cancel my sponsorship. What can I do? I have to do whatever he says. I feel like his slave. ( Human Rights Watch 2016 )

According to a December 2014 directive by the General Security Directorate, Lebanese contractors would be forced to bear the cost of sponsoring each Syrian worker—estimated at $2,000 annually—and would include the “cost of work and residence permits, health insurance, and notary contracts” ( Shoufi 2015 ). As Lebanese officials aimed to extract rent in the form of permits by the private sector, this created a rift with the domestic construction industry, which was already able to profit from the influx of cheap Syrian labor. At the same time, there have been frequent reports of Syrian refugees getting arrested on a regular basis (in most cases exclusively because of lack of legal residency, which is a criminal misdemeanor under Lebanese law). Exact data on this is unavailable; however, NGO representatives have confirmed that, in most instances, the actual criminal case neither reaches the courts nor results in a formal conviction by a judge; this suggests that the various fees that Syrians’ families end up paying actually constitute unofficial bribes to the administrators of police detention facilities—or, in this article's argumentation, another dimension of refugee rent.

things are changing, and now the army is going in and arresting people in their homes, not waiting for them to come to checkpoints . . . When they came to take everyone, they took [twenty-seven] people. They took every male above the age of [fourteen] for four days. And they took all our documents and gave us one week to sort out our residency . . . It would have required going back to Syria . . . So none of us could do anything, [and] now we're all illegal in the country . . . My only hope is to get out of Lebanon, to get somewhere where I can educate my children. ( Alabaster 2016 )

Ensure the protection of vulnerable populations;

Provide immediate assistance to vulnerable populations;

Support service provision through national systems;

Reinforce Lebanon's economic, social, and environmental stability.

Dealing with long-term displacement crises requires innovative responses. Humanitarian support and development assistance need to be coordinated in order to increase the capacity of host communities and institutions from day one. Through close coordination and collaboration with the World Bank and other partners and donors, important concessional development assistance will be available for Lebanon to improve economic conditions, create jobs, and transform the crisis into new opportunities.

€15 million to boost Lebanon's productivity and competitiveness in the agribusiness and wood sectors . . . €13 million for the implementation of the National Plan to Safeguard Children and Women in Lebanon across the country . . . €1.5 million to reinforce the capacity of the Ministry of Youth and Sports to better address youth issues, including a €800,000 [program] addressing drug abuse . . . €48 million for solid waste management [programs] in addition to €5 million for the construction and equipment of [one] solid waste treatment facility and [one] sanitary landfill . . . €2 million to support the Lebanese Parliament, resulting in reactivation of the Legislative Tracking System in the Lebanese Parliament ( European Commission 2016 ).

Yeah, 4.5 million, so you can imagine the burden, and how much it is difficult. And we believe Lebanon is doing a public service for the entire world, and I believe Lebanon should be also compensated for that, because if those refugees didn't come to Lebanon, they would be everywhere in the world . . . The international community needs to help Lebanon, especially the refugees because with 1 percent growth in Lebanon, we cannot manage to have jobs for the Lebanese and the Syrians. ( Glasser 2017 )

Officials approached for comment in Beirut highlighted the fact that Lebanon did not have a functioning government between March 2013 and December 2016, following the resignation of Prime Minister Mikati. The general perception was that Lebanon did not have strong international allies or bargaining chips. “ Ce n'est pas nous qui dictent les règles du jeu” (“It is not us that call the shots”), according to an official interviewed in the Ministry of the Interior, which is tasked with responding to the Syrian refugee crisis. The point of whether Lebanon's proximity to Cyprus, an EU member state, may be important was also dismissed. Despite hosting the most refugees per capita of any country, Lebanon is not considered a gateway to Europe; despite a waterway to an EU member state (Cyprus), Syrian refugees have avoided the island because it offers neither an easy way into the rest of the continent ( Reuters 2017b ), nor a simple asylum process, with only 3 percent of asylum seekers granted refugee status: “[Cypriot officials] want to give refugees the message: [d]on't come to Cyprus because if you do, you won't get refugee status,” according to Doros Polykarpou, executive director of KISA, a Cypriot nonprofit, “and it works” ( Karas 2015 ).

Turkey and the March 2016 EU-Turkey Statement

[t]he fulfilment of the visa liberalization roadmap will be accelerated with a view to lifting the visa requirements for Turkish citizens at the latest by the end of June 2016. Turkey will take all the necessary steps to fulfil the remaining requirements . . . The EU will, in close cooperation with Turkey, further speed up the disbursement of the initially allocated €3 billion under the Facility for Refugees in Turkey. Once these resources are about to be used in full, the EU will mobilize additional funding for the [f]acility up to an additional €3 billion to the end of 2018 . . . The EU and Turkey welcomed the ongoing work on the upgrading of the Customs Union. ( European Council 2016b )

The European Commission agreed to provide €1 billion in funding, with €2 billion of additional funding from member states ( European Council 2016a ). The administration of the €3 billion support was organized through the EU Facility for Refugees in Turkey, which focuses on six priority areas: humanitarian assistance, migration management, education, health, municipal infrastructure, and socioeconomic support ( European Commission 2017a ). As of June 2017, forty-eight projects have been contracted worth more than €1.6 billion, out of which €811 million has been disbursed. As its one-year report states, “projects will notably ensure that [five hundred thousand] Syrian children have access to formal education; [seventy] new schools are built; 2,081 teachers and other education personnel have received training and two million refugees will get access to primary healthcare services” (European Commission 2017b). Similar to Jordan and Lebanon, the concessions that Turkey gained involved issues that were not immediately linked to the Syrian refugee crisis—the most evident one being the visa-liberalization process. The promise to reenergize the accession process exclusively benefitted the Turkish state and had no impact upon the country's non-Turkish population.

Unlike Jordan and Lebanon, Turkey developed a blackmailing strategy in its foreign policy decision-making with regard to its international management of the Syrian refugee crisis. This is evident in the threatening discourse that Ankara elite engaged in, targeting Brussels and EU member states. Minutes of a February 2016 meeting between Erdogan, Tusk, and Juncker (later confirmed by Erdogan) have the Turkish prime minister openly threatening to flood Europe with displaced Syrians ( Reuters 2016a ). The discussion included the amount of capital Turkey had spent on hosting displaced Syrian refugees: in October 2015, for instance, the Turkish Interior Ministry announced that Turkey had spent more $8 billion to support Syrians, “surpassing the Turkish Interior Ministry's budget” ( Kızıkoyun, 2015 ). But Turkey's rationale was better served by a blackmailing strategy: “we want this human tragedy to end,” Prime Minister Ahmet Davutoglu declared in 2016, detailing how Turkey wanted “our citizens to travel visa free, and the customs union to be updated” ( Associated Press 2016 ).

Interestingly, the outflow of refugees via the Aegean Sea into Greece and, subsequently, the rest of Europe, effectively ceased in the aftermath of signing the EU-Turkey deal. Until early 2016, the large flows of irregular migrants from Syria into Europe via Turkey allowed the enrichment of a wide number of Turkish nationals associated with smuggling via the Aegean Sea, which immediately stopped in March 2016; in Istanbul, one of these smugglers, interviewed by the New York Times , boasted more than $800,000 in profits, and having “more than [eighty thousand] missed calls from prospective customers” ( Kingsley 2017 ). In Izmir, al-Jazeera identifies how $1,000 would allow a smuggler to “launch boats unmolested by police or gendarmes for a day” ( Reidy 2016 ). Following the EU-Turkey deal, all smuggling business stopped; the smuggler identified by the New York Times is now considering opening a seaside café, instead.

Turkey's blackmailing strategy continued following the signing of the 2016 deal. One day after the European Parliament called for a pause in the country's EU accession talks over the Turkish government's repressive response to a July 2016 coup attempt, Erdogan declared that “we are the ones who feed 3–3.5 million refugees in this country . . . You have betrayed your promises. If you go any further those border gates will be opened” ( Pitel and Beesley 2016 ). This raises an important point with regard to the domestic political repercussions of refugee rent-seeking, particularly with regard to refugee host states’ governments attempts at consolidating authoritarian rule. The European Parliament's decisions are not binding for individual member states; however, observers were keen to note that Erdogan's warnings had come a few days in advance of the second round of the Austrian 2016 presidential elections. Brussels’ response was rather lackluster: “rhetorical threats are absolutely unhelpful and should not be the standard tone between partners,” one senior EU official noted on the record. “This will not help Turkey's credibility in the eyes of European citizens. Europe will not be blackmailed” (ibid.).

All three states examined above fall under the category of refugee rentier states, given the fact that they received external economic aid that was dependent on their status as hosting forcibly displaced populations and that they came to rely on substantial external rent linked to their continuous hosting of these refugee populations. This refugee rent is encapsulated in the three agreements negotiated between these refugee rentier states and the international community—the February 2016 Jordan Compact, the February 2016 Lebanon Compact, and the March 2016 EU-Turkey Statement, respectively. At the same time, as per the paper's theoretical framework, their foreign policy with regard to the refugee issue falls under the broad strategies of back-scratching and blackmailing. Jordan and Lebanon broadly employed a back-scratching strategy: although domestic elites made urgent pleas for help, they highlighted multilateralism, tended to approach the matter with reference to the responsibility of the international community to help, and praised the positive-sum value of interstate cooperation. Turkey, on the other hand, employed a different strategy that came closer to blackmailing: elites made little reference to cooperation or multilateralism and put forth distinct threats that aimed to coerce their target audience, rather than ensure cooperation.

What accounts for this variation in policy-making? The data collected suggests that Lebanon and Jordan were not able to employ a blackmailing strategy, even though there was a desire to follow Turkey's example. While the sizeable community of Syrian refugees was deemed important, the two countries’ relative positions and elites’ doubts on their countries’ strategic importance appeared to rule out a more forceful or aggressive policy. In the Turkish case, however, elites’ perceptions of the country's geopolitical importance—particularly with regard to the proximity to Greece—appeared to have enabled the government's blackmailing strategy. The geopolitical importance of the host state appears to matter with regard to Jordanian and Turkish strategy historically: back in the late 1960s, King Hussein did not hesitate to use Jordan's hosting of thousands of Palestinian refugees in order to blackmail the United States for a solution to their status. This can be explained by the significant geopolitical importance of Jordan in the late 1960s as the major United States ally in the region, a status that the country has since lost. Similarly, Turkey's behavior post–Gulf War—when, in 1991, it successfully blackmailed the United States on the fate of Kurdish refugees within its borders—was also predicated on its strategic importance for Washington at the time (details on both cases: Greenhill 2010 , 296–97, 316–17).

A number of alternative explanations of the three refugee rentier states’ behaviors are unconvincing. What about the argument that Jordan genuinely sought a cooperative solution to the Syrian refugee crisis or that it would not consider the deportation of Syrians for humanitarian reasons? This is discounted by two policies that Jordan developed domestically: firstly, the “bail out” process strongly suggests that Jordan aimed to employ the Syrian refugee issue for economic gain. Furthermore, Jordan did engage in the marginalization and deportation of migrant populations—that of Egyptians, which undermines the argument that state policy was driven by a humanitarian rationale. With regard to Lebanon, a number of policies discount the potential counterargument that Lebanese back-scratching policy resulted from its human rights protection record or, put differently, that officials would not consider deporting Syrian refugees for humanitarian reasons. For one, not only did Lebanon order UNHCR to stop registering new refugees, but, in January 2015, the government put forth legislation detailing a novel process regulating Syrians’ residency. More importantly, however, Lebanon has not hesitated to deport Syrian refugees back to their home country. Could the Turkish policy of blackmailing be accounted for via alternative explanations? One such explanation could be that Turkey was unable to control its European borders and, therefore, was forced to a policy of confrontation rather than accommodation with the EU. Yet, empirical facts discount this argument, particularly given the impressive decrease in crossings across the Aegean Sea since the signing of the EU-Turkey deal. Turkish state officials, in other words, were more than able to secure its European borders when they had the incentive to do so.

This article has examined how forced displacement affects the foreign policy decision-making of refugee host states. In doing so, it has attempted to move beyond discussion of coercion and to highlight the range of strategies available to host states of the Global South by drawing on the literature on rentier states and issue-linkage strategies. Through an exploratory, three case-study design, it has introduced the concept of the refugee rentier state and identified strategies of blackmailing and back-scratching in these states’ refugee rent-seeking behavior . Through a within-case analysis of Jordanian, Lebanese, and Turkish responses to the post-2011 Syrian refugee crisis, it has theorized how international aid to refugee host states constitutes a form of rent. In response, refugee host states’ refugee rent-seeking behavior appears to result in a blackmailing strategy when it contains a large number of refugees and when states’ elites perceive of their country as having geopolitical importance vis-à-vis the target state(s)—as in Turkey. Alternatively, state elites are more likely to opt for a back-scratching one—as in Lebanon and Jordan.

To what extent do the strategies of back-scratching and blackmailing apply beyond the three cases outlined here? The article findings appear to apply to both current and historical cases. One could argue that states that find themselves in a geo-strategically-important position and face an influx of refugee populations are historically prone to strategies of blackmailing. Back in 2002, Belarussian President Aleksandr Lukashenko aimed to employ Belarus’ status as a refugee rentier state of Chechnya's refugees when he “threatened to flood the European Union with drugs and illegal migrants” unless he was allowed entry into a November 2002 NATO summit ( Shepherd 2002 ; Greenhill 2010 , 327). Libya's proximity to Europe and its status as a host state for sub-Saharan African refugees had also led Gaddafi to demand an annual payment of €5 billion by the EU in order to prevent it from “turning black” with refugees back in 2009 ( Paoletti 2010 ; Tsourapas 2017 ). More recently, in 2015, Greek foreign minister Nikos Kotzias warned that, if Greece was forced out of the Eurozone, “there will be tens of millions of immigrants and thousands of jihadists” into Europe ( Waterfield 2015 ). It appears that, when refugee rentier states host a sufficient number of refugees and enjoy an important geostrategic location vis-à-vis their targets, they are likely to develop a foreign policy strategy of blackmailing.

Beyond blackmailing, refugee rentier states are also engaging with back-scratching strategies. Ethiopia's negotiating strategy resulting in the 2019 “Jobs Compact,” a $500 million program that aims to create one hundred thousand jobs for Ethiopians and refugees, is one example ( Reuters 2019 ). In the Middle East context, the EU has concluded a number of “Mobility Partnerships” with Morocco in June 2013, Tunisia in March 2014, and Jordan in October 2014 that offer certain perks to these states in return for their management of irregular migration and refugee flows ( Collyer 2012 ). While these countries may be considered geostrategically important for Europe, they lack large numbers of Syrian refugees that would allow them to pursue a blackmailing policy. Historically, Pakistan relied on extensive American economic support for hosting more than one million displaced Afghans in the aftermath of the 1979 Soviet invasion of Afghanistan—while Pakistan contained a large number of refugees, relations with the United States were tense and it had yet to become the geopolitically important state it is today.

The article advances a research agenda that explores how forced displacement affects states outside the Global North by identifying the ingenuity of governments that are dependent on extracting resources from the international system. It identifies numerous paths for further scholarly and policy debate on how to understand the behavior of refugee host states: for one, moving beyond foreign policy decision-making processes, what are the effects of refugee rent on states’ domestic political development? Anecdotal evidence from the article's three case studies suggest that forced migration increases opportunities for state corruption, which would be consistent with the pathologies associated with rentier states. More broadly, given that refugee rent is, by default, awarded to governments, what effects does this produce in terms of instances of violence or the durability of autocratic rule? The well-established literature on rentier states opens up a novel dimension of exploring the effects of forced displacement within the subfield of comparative politics. The mechanisms and dynamics of host-state use of refugee populations in their international relations constitute an important, underexplored field of inquiry in the study of world politics.

Beyond academic work on international relations and comparative politics, the phenomenon of refugee rents carries important policy-level repercussions with regard to the ethical and normative dimension associated with Western states’ decision to link economic aid to the management of refugee populations in the Global South. There is a palpable risk that encouraging overburdened states to treat forcibly displaced populations as sources of economic rent leads to refugee commodification. Should refugee host states’ governments be condemned for developing coercive foreign policy strategies to cope with forced displacement? Do such strategies constitute an exploitation of Western states’ vulnerabilities and the deficiencies of the international system, or are they merely a skillful way of “playing a bad hand?” At the same time, to what extent is a migration management system based on refugee rents sustainable in the long run? Identifying the perils of refugee commodification is not a moral condemnation of host states across the Global South, particularly given the disproportionate share of refugees they are tasked with managing. Rather, it highlights how the encouragement of refugee rent-seeking behavior as a solution to refugee burden-sharing problems and the absence of multilateral cooperation may produce unintended effects for the future of global migration governance.

Indicatively, Nauru's 2001 gross domestic product was $19 million.

Beblawi's canonical text on rentier states does not define what a “significant” amount may be. I adopt this approach here, given that it allows for maximum flexibility in understanding states’ behavior.

Research for this research article was funded by the Council for British Research in the Levant (2017–2019 Pilot Study Grant). Earlier versions of this article were presented at the 2018 International Studies Association Junior Scholar Symposium, the 2018 Annual Conference of the British International Studies Association, as well as at seminars and workshops at the University of Birmingham, University of Malta, Utrecht University, and Warwick University. Many thanks to Hannah Betyna for excellent research assistance. Filippo Dionigi, Giuditta Fontana, James F. Hollifield, Maja Janmyr, Anna Khakee, Dina Kiwan, Audie Klotz, Maria Koinova, Scott Lucas, Isobel McVey, Zeynep Şahin Mencütek, Nikola Mirilovic, Daniel Naujoks, Kamal Sadiq, Asaf Siniver, and Stefan Wolff provided invaluable feedback and comments.

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Syrian Crisis, Syrian Refugees

• First Online: 19 December 2019

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• Juline Beaujouan 6 , 7 &
• Amjed Rasheed 8  

Part of the book series: Mobility & Politics ((MPP))

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This chapter opens up on the premises of the Syrian refugee crisis, situating it within the Middle East and North Africa (MENA) regional order. Doing so, it offers an overview of the socio-economic and political factors that led to the Syrian civil war and the massive displacements of populations beyond the Syrian borders. It argues that the crisis is the fruit of the regional turmoil and Syrian domestic politics, mainly the authoritarian regime of Assad. The silence of the regional actors, symptomatic of the regional disorder, led Jordan and Lebanon to cope alone with the refugee influx. Although exhibiting different domestic policies, both countries became largely reliant on the humanitarian support offered by the international community. Yet, humanitarian aid contributed to the burden of Syrian refugees, failing to strengthen the resilience of host communities.

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Sylvia Westall, “Syria refugees set to exceed a third of Lebanon’s population,” Reuters , July 3, 2014, https://www.reuters.com/article/us-syria-crisis-lebanon- idUSKBN0F818T20140703 .

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Beaujouan, J., Rasheed, A. (2020). Syrian Crisis, Syrian Refugees. In: Beaujouan, J., Rasheed, A. (eds) Syrian Crisis, Syrian Refugees. Mobility & Politics. Palgrave Pivot, Cham. https://doi.org/10.1007/978-3-030-35016-1_2

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Explaining refugee flows. Understanding the 2015 European refugee crisis through a real options lens

Roles Data curation, Investigation, Methodology, Writing – original draft

Affiliation Statistics Netherlands (CBS), The Hague, The Netherlands

Roles Conceptualization, Data curation, Formal analysis, Methodology, Software, Writing – original draft, Writing – review & editing

Affiliations Faculty of Business and Economics, University of Antwerp, Antwerp, Belgium, School of Economics, Utrecht University, Utrecht, The Netherlands

Roles Conceptualization, Formal analysis, Methodology, Validation, Writing – review & editing

* E-mail: [email protected]

Affiliation Institute of Development Policy (IOB), University of Antwerp, Antwerp, Belgium

• Linda Peters, 
• Peter-Jan Engelen, 
• Danny Cassimon

• Published: April 20, 2023
• https://doi.org/10.1371/journal.pone.0284390
• Peer Review
• Reader Comments

In 2015 the unprecedented arrival of refugees in Europe posed serious challenges for the EU and its member countries on how to deal with such an influx. A key element in better managing refugee flows is to understand what drives these flows in a certain direction. A refugee who comes to Europe has to make trade-offs in terms of cost and benefits, duration, uncertainty and the multi-staged character of the journey. Real options models are a suitable tool for modelling these kind of decision dynamics. On the basis of a case-study, that compares three routes from Syria to Europe, we demonstrate how well the real options analysis is in line with the development of the refugee flows.

Citation: Peters L, Engelen P-J, Cassimon D (2023) Explaining refugee flows. Understanding the 2015 European refugee crisis through a real options lens. PLoS ONE 18(4): e0284390. https://doi.org/10.1371/journal.pone.0284390

Editor: Adetayo Olorunlana, Caleb University, NIGERIA

Received: November 11, 2022; Accepted: March 29, 2023; Published: April 20, 2023

Copyright: © 2023 Peters et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

1. Introduction

In 2015 the European refugee crisis began when the flow of migrants increased dramatically from 153,000 in 2008 to more than 1 million in 2015 [ 1 ]. This was mainly due to the growing number of Syrians, Iraqis, Libyans, Afghans and Eritreans fleeing war, ethnic conflict or economic hardship. With the exceptional volumes of new arrivals, an adequate response from Europe as one union was required, because the magnitude of the crisis was too large to solve for individual member states. For example, frontline states such as Greece and Italy bore a disproportionate responsibility for receiving new arrivals, transit countries such as Hungary and Croatia suddenly faced enormous pressure at their borders and the wealthier EU countries such as Germany and Sweden cope with the huge influx of refugees, because these are favored final destinations for migrants.

A major question that arises here is how the EU, individual countries and other stakeholders should address and manage this problem. A starting point for answering this question is to be able to better predict refugee flows. An assessment framework that allows to better understand the ways in which individuals process information, think through their options, and select courses of action is a key prediction tool. This is important, because we would like to know why migration movements progress the way they flow and try to understand why certain routes are more preferred by refugees to take than other routes.

The flows themselves are extremely complex and driven by a broad range of conditions in the countries of origin, transit and destination, and in the relationships between them [ 2 ]. The flows consist of a variety of individuals and families such as asylum seekers, war refugees, climate refugees, stateless persons, labor migrants and economic migrants, who come to Europe through authorized as well as irregular channels for various reasons. The identification and the legal differences and consequences are outside the confines of this article. In this article, we use refugees and migrants as a generic term for all groups. The basic idea here is that refugees or migrants are coming to Europe and that these individuals have to make trade-offs in terms of costs and benefits, uncertainty, the duration and the the multi-stage character of the journey in order to make a decision on the best route to travel to Europe. A potential refugee has to make a careful deliberation whether or not to make the crossing, at which time it happens, in what way, according to which route, etc. Nowadays, migrants keep themselves informed of the developments that could have an impact on their journey and adjust their decisions on a real-time basis [ 1 ]. Especially, when the refugee journey takes place in several phases, and the refugee does not arrive straight away on the desired final destination, they have several decision options at their disposal. In that case they make the actual decision at the moment they arrive at a transit point, based on the particular situation of that specific moment.

These dynamics could be captured in a real options framework, which is illustrated on the basis of a case-study. This case-study will investigate whether the predictions of the real options framework match with the refugee volume data. We assess three important routes, the Central Mediterranean Route, the Eastern Mediterranean Route by land and the Eastern Mediterranean Route by sea, to Europe in the years 2014 and 2015 and verify whether the model’s predictions follow the same pattern as the volumes. Our starting point of the case study is the situation of a Syrian migrant that already has taken the decision to leave Syria. The refugee needs guidance for the decision between the different routes available through several countries to the desired final destination and which routes it is best to take. The main objective of this paper is a first attempt to model the dynamics of the decision-making process of the average refugee using the real options framework. We try to understand why certain routes are more interesting for the migrant to take than other routes.

The article is structure as follows. In section 2, we discuss refugee routes as a real option and section 3 presents the value drivers of those routes. Section 4 provides an application of real options to the 2015 refugee crisis. This case-study provides a comparison of three routes from Syria to Europe that investigates how well the real option logic is in line with the evolution of the observed refugee flows at the time. Finally, section 5 contains the conclusions.

2. Modeling refugee flows

Refugees coming to Europe have to make trade-offs in terms of cost and benefits, duration, uncertainty and the multi-staged character of the journey. The choice for the best route between alternative paths by the refugee is analogous to make a selection between several potential investments. The decision of the refugee indeed shows similarities to that of an investment decision under uncertainty. Hence, a real options framework is a suitable tool for modelling these kind of dynamics.

Early work along these lines focuses on labor migration. Sjaastad [ 3 ] is the first to acknowledge that it could be viewed as an investment. Todaro [ 4 ] focuses on the wage differential between the host country and the country of origin as the main variable affecting labor migration. Burda [ 5 , 6 ] models migration as an investment decision under uncertainty, which is built on the ideas of Dixit and Pindyck [ 7 ]. His work refers to the fact that a migration decision will also depend on the value of waiting and found that when a migration decision is postponed, it generates a positive value if there is uncertainty about the future wage differences. Locher [ 8 ] explores a similar concept in a two-period framework, using data on ethnic German migration from CIS countries (Russian Commonwealth). Khwaja [ 9 ] has extended the framework of Burda [ 5 , 6 ] by describing the role of uncertainty in the migration decision, while Bayer and Juessen [ 10 ] model internal migration decisions in the United States.

The above-mentioned literature models a migration decision as a simple call option, where the labor migrant has the possibility, but does not have the obligation to migrate. The migrant has the option to wait if relevant information can be expected to reveal itself over time to take a better informed decision. For example, it could be profitable to postpone the migration decision, because the migrant is expecting ‘bad news’, or because the sunk cost could be decreasing. Most of the existing literature models migration decisions as a simple call option for straight one-off moves. One exception where labor migration is modeled as a compound option is provided by Artuc and Ozden [ 11 ]. The authors construct a multi-period model of dynamic transitory migration decisions, where the utility of living in a particular destination is linked to the option value to migrate further. In their model the value of the option to wait is derived from the underlying volatility of the economic environment. Even though the dynamic discrete choice model of migration is a multi-period model, it assumes that a migrant travels through legal channels, where the decision is voluntarily and based on the option to wait.

However, current models do not meet the requirements to model the decision-making process of a refugee during the 2015 European crisis. A journey of such a refugee contains a mix of involuntary and voluntary decisions, involves multiple stages, through several countries, and proceeds either through regular or irregular channels or both, where at each stage the refugee has to make a trade-off between the costs and benefits, uncertainty and duration, in order to choose the best route for reaching the desired destination. A multiphase real options framework is therefore needed in order to model the multistage character of refugee routes, where each leg of the specific route is a phase of the model. Therefore, in this article we model the dynamics of the multiphase decision-making process of the average refugee through the use of a sequential real option model. In contrast to the aforementioned models, where the labor migrant could choose to postpone the decision to migrate, we assume that the refugee has already decided to flee, but has to choose between different routes through which to reach its final destination.

We model the choice of a refugee for certain routes as the choice between multiple costly decisions. Most refugees are able to make a reasonably rational choice based on the information available to them on characteristics of the various routes. We expect refugees to consider information on particular factors, such as the desired final destination, the expected costs and benefits, the time and the risk of reaching their final migration destination. Even in case of war refugees, where the first stages of the journey often have a forced character and where consecutive stages are characterized by a more voluntary character, refugees can still actively make choices regarding routes [ 12 ]. For example, on a number of Facebook pages, refugees are able to find precise information on smuggler services revealing concrete prices and departure points. In addition, the Facebook pages also include the facilitation on organizing the logistics needed for the travel [ 1 ].

The objective of our article is to ‘value’ migration routes, which is analogous to the valuation of an investment decision under uncertainty with irreversible investment costs, and takes into account the various factors that have an impact on the decision of the migrant. To value the attractiveness of a certain route we use the multi-phase compound options framework by Cassimon et al. [ 13 ].

Compound options have been widely used in the financial literature to evaluate sequential investment opportunities. Such an investment process consists of a sequence of investment phases, in which each phase creates an option for moving to the next phase. If a previous-stage turns out to be successful, the next one will be initialized; otherwise the investment process is discontinued. This process goes on until the final stage ( Fig 1 ). Let us consider an investor who wants to invest in a project whose commercial phase cannot be launched upon the successful competition of previous k investment stages. Let T k +1 be the time of the market launch, when, upon paying the commercialization cost I k +1 , the firm earns the project value V . The project payoff at time T k +1 is max[ V − I k +1 , 0]. Let C k +1 ( V , t ) denote the value at time t of this 1-fold compound option or single stage investment opportunity. We assume that the commercialization phase is reached upon investing an amount I k , at time period T k , with T k +1 ≥ T k ≥⋯ T 2 ≥ T 1 ≥0. The project starts with I 1 as the startup costs, while T k and I k are maturities of intermediate phases that lead up to the commercialization phase and the respective investment costs. At any stage k the investor can decide to abandon the project or to enter the next stage, hence, the optional nature of the investment project. Each stage therefore creates an option on the next stage. In this way the investment problem becomes a chain of options. Compound options typically capture the value of such a multi-stage investment project well.

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Source: Authors’ own elaboration.

https://doi.org/10.1371/journal.pone.0284390.g001

Cassimon et al. [ 13 ] develop a generalized N -fold compound option model that explicitly incorporates both commercial (market) and technical uncertainty to value sequential multi-stage investment projects. Technical uncertainty refers to technical success of each investment stage by multiplying the options value at each decision point with the probability of technical success at that stage. In this model, the project has a commercial risk σ and technical success probabilities p 1 , p 2 ,…, p k +1 at each investment stage. The project value is unknown and is denoted by V t at time t . It is described by a Geometric Brownian motion dV t = μV t dt + σV t dW t , where μ and σ represent the growth rate and the standard deviation of the project value.

As such, each of the parameters of the compound option model determines the value of a migration route. The expected benefits at desired destination V are the benefits which the migrant expects to obtain when he or she reaches the desired final destination. These benefits in the destination country might include the right to work and live in the host country and, therefore, to receive access to education, private housing, healthcare, employment opportunities and social assistance, in addition to the basic support. Alongside the benefits and costs at the desired destination, there are also benefits and costs for the intermediate locations. In the neighboring and transit countries the benefits serve the basic needs such as food and shelter. The costs include the costs of traveling to the next destination point. The next parameters of an intermediate phase are T i , the time horizon in days, which refers to the time that a refugee needs to move to the next phase and the probability p i the refugee will be able to make it to the next phase. For instance, the placing of a border fence has an impact on the probability of not arriving at the next phase. The parameter σ represents the uncertainty of benefits at the desired destination, which for example depends on the changing asylum policy in a given country.

3. Case study of the 2015 European refugee crisis

This section will illustrate our model by focusing on a case study, since there is no data on a large sample available. This case-study demonstrates the modelling of refugee decision-making through a real options framework. The objective of this case study is to illustrate that the popularity of the different routes runs parallel with their real options values, i.e. to show that a route becomes more popular as soon as the real options value of that route increases relative to other routes, and that a route becomes less popular when the real options value decreases relative to other routes. This is performed on the basis of the situation of the average Syrian adult male migrant who fled to Europe and had to choose between three main routes: Central Mediterranean Route (CMR), Eastern Mediterranean Route by sea (EMR by sea) and Eastern Mediterranean Route by land (EMR by land). In 2013 and 2014, the CMR was slightly favored. However, during the European refugee crisis of 2015, Syrians avoided the CMR and the EMR by sea became by far the most popular one, dwarfing the migrant volumes of the other routes. We will demonstrate that this turning point is clearly visible in the real options value of the routes.

3.1. Description of the main routes from Syria to Europe

As a consequence of the Arabic Spring in December 2010 in countries such as Tunisia, Egypt and Libya, a revolt started in Syria in March 2011. In September 2016, about 11 million Syrians had been displaced from their homes since the start of the Syrian war. More than half of them, about 6.6 million, were internally displaced within Syria. Furthermore, 4.8 million refugees have fled to Turkey, Lebanon, Jordan, Egypt and Iraq. In addition, about 1 million Syrians crossed into Europe to seek asylum. The most popular destinations within the EU were Germany with 300,000 asylum applications and Sweden with 100,000 asylum applications.

Syrian refugees have mainly used three routes for their journey to Europe: Eastern Mediterranean route by land (EMR by land), Eastern Mediterranean route by sea (EMR by sea) and Central Mediterranean route (CMR). The three routes are presented in Fig 2 .

Source: Authors’ own elaboration based on USGS National Map Viewer.

https://doi.org/10.1371/journal.pone.0284390.g002

The refugees using the EMR by sea arrived on several Greek islands, most on Lesbos, while others have entered Greece via the land border, or else exited Turkey directly into southern Bulgaria (EMR by land). Most of the refugees continued their journeys north, leaving Greece and Bulgaria through its border with the former Yugoslav Republic of Macedonia via Serbia into Hungary and Croatia and then towards Western Europe. This is the so-called Western Balkan route. The CMR is the route over sea from North Africa, mostly from Libya, to Italy and Malta. Although the crossing of the CMR was long, Italy remained a preferred destination over Greece until 2014 because migrants arriving in Greece had to pass through the Balkans to get to Germany. However, this changed in 2015. Syrians started to avoid Libya due to the deteriorating political and security situation in Libya, increasingly poor conditions in transit countries and the perception that the EMR was relatively safer [ 14 ]. Furthermore, Egypt had blocked the border to Libya from mid-2014 on, and Algeria removed visa free travel arrangements at the end of 2014 [ 15 ]. Due to the construction of border fences by Greece in 2012 and Bulgaria in 2014 along their borders with Turkey [ 16 ], the EMR by sea was more popular than the route by land. This is shown in Fig 3 . For example, one can see that in 2014, 50% of the Syrians took the CMR. However, in 2015 this changes drastically, only 1% is taking the CMR, whereas 82% are taking the EMR by sea to Greece.

Central Mediterranean Route (grey), Eastern Mediterranean Route by sea (orange) and Eastern Mediterranean Route by land (blue). Source: [ 17 ].

https://doi.org/10.1371/journal.pone.0284390.g003

3.2. The real option value of each route

Each route is modeled as a multistage compound option as the (Syrian) refugee has to travel through several countries (geographical legs) before arriving in Germany (final destination). Fig 4 represents a refugee route as a (k+1)-stage compound option. Each geographical leg describes the phase between two geographical locations, for example between the starting point and the first transit point, or between the last transit point and the final destination. A geographical leg begins at the moment a refugee departs from the start location of that leg and ends with the stay at the final location of that leg. In Germany the refugee has to apply for asylum and therefore ends up in the asylum procedure; here, we refer to both “asylum”according to the German constitution as well as „refugee status”according to the 1951 Convention. The asylum procedure is modelled as an additional fourth phase as it is uncertain whether or not the refugee can stay in Germany. Finally, once the asylum has been granted, the refugee is able to build a life in Germany during this final phase. For this final phase, we need the expected benefits and its uncertainty. In order to estimate the value for these value drivers, we make use of publications from Destatis , the Federal Statistical Office of Germany [ 18 ]. For the asylum procedure phase, we use the data from the Asylum Information Database (AIDA) [ 19 ]. For the geographical legs we take as a proxy for the value of the benefits of the leg the available monthly financial allowance/vouchers granted to asylum seekers at the final location of a leg from the country reports on the AIDA. It is not always clear whether or not refugees actually do receive these benefits (in cash or kind), but we believe this is a reasonable proxy of the possible benefits of a particular leg.

Source: Author’s own elaboration.

https://doi.org/10.1371/journal.pone.0284390.g004

In order to estimate the probability of arrival, we use volume figures of AIDA [ 19 ], International Organization for Migration (IOM), UNHCR [ 20 ] and Frontex [ 17 ]. Because of the often clandestine character of refugees, there are very few comprehensive sources available for the other value drivers. Therefore, we rely on information available through press, Facebook and other social media. An important aspect to consider here is the length of a leg: the time needed for a refugee in order to bridge the leg. In the public anecdotal information, often the net travel time is denoted. In case we would use this travel time for the length of a leg, we assume that the refugee is able to travel without any obstacles or delays whereas the refugee has to find the way to a new place or has to find the route to the next transit stop. Since this is not very likely to be the case, we correct for this and use for the length of a leg twice the travel time that is reported in the public anecdotal information. In this way, we are not only trying to provide realistic durations for each specific leg, but also consider the duration of the journey as a whole (see for example [ 21 ]).

3.2.1. Route 1 –The Central Mediterranean Route.

In Table 1 the values of the parameters for the Central Mediterranean Route in 2014 and 2015 are presented, i.e. before and after Libya became less popular as a transit country, for the Syrian refugee who flees to Germany; for converting the values from dollar to euro we have used the OECD yearly average exchange rates [ 22 ]. Firstly, the route consists of three geographic legs: from Syria to Libya, from Libya to Italy and from Italy to Germany. Upon arrival in Germany, the refugee enters the asylum procedure by applying for asylum. Finally, the final phase is the temporary (3-year) stay of the refugee in the desired destination country Germany.

https://doi.org/10.1371/journal.pone.0284390.t001

In 2014 the journey from Syria to Libya was mostly travelled by road. The route passes through Jordan, across the Sinai desert and ends in the Egyptian border town of El Salloum [ 23 ]. A refugee payd almost 400 euro per person to the smuggler for this 5-day journey. This is the irreversible cost or exercise price in our model to reach the next phase. (See variable K_1 in Table 1 ). In Libya, Syrians were in general well-received and regarded as fellow-Arabs. Most of the times they searched for a job or tried to travel directly to the next destination. Since Syrians might have to wait a few days up to several weeks [ 24 ] to search for a smuggler who could assist them with the crossing to Italy, we set the length of travel at 24 days for both 2014 and 2015 (see variable T_1 in Table 1 ). We put the benefits that Syrians receive during their stay in Libya to zero. The powerlessness of the Libyan government to secure its borders and the presence of a vast desert territory made it easy for Syrians to enter the country through the use of smugglers. As a reasonable approximation for this, we set the probability of arrival to 85% in 2014 (see variable p_1 in Table 1 ). At the end of 2014, the situation in Libya deteriorated and Algeria and Egypt closed their borders with Libya. Syrians were still able to enter Libya by catching a plane to Algeria and consecutively cross the border by using a smuggler at a price of 300 euro [ 25 ]. However, there are not many Syrians who did this. The UNHCR Statistical Database indicates that in 2014 18,653 Syrian refugees resided in Libya, whereas in 2015 there were only 97 refugees [ 26 ]. Therefore, we set the probability of arrival for 2015 at a very low value, 2%.

The journey continued by sea to Italy. In 2014 smugglers asked 2,000 euro for this journey [ 1 ] and in 2015 they asked between 800 and 3,600 euro [ 27 ]. According to the IOM, there were 2,892 fatalities in 2015 on the Central Mediterranean Route [ 28 ] and 153,842 arrivals in Italy [ 29 ]. The survival rate of the crossing will be 153842 / (153842+2892) = 98%. However, this is not the same as the probability of arrival, since for example it is not taken into account how many persons have been sent back or were not able to obtain a spot on a boat. Therefore, we set the probability of arrival in Italy at 75%. Since there is no different data on 2014, we set this in the base case equal to 2015. As a proxy for the benefits that the refugees receive in Italy, we need to take the financial allowances/vouchers to asylum seekers in Italy. These benefits are not present, therefore we set their benefits to 0 euro [ 30 , 31 ]. The boat journey usually takes two to six days [ 24 ]. By law, asylum-seekers can be held for up to a maximum of a month in an accommodation center for asylum seekers [ 32 ]. Therefore, as an approximation we set the duration to 18 days for crossing the Mediterranean Sea and the waiting time in Italy.

The final ‘geographic’ leg is the leg to Germany. In 2014, for example, an amount of 4,000 euro was paid in order to travel with a transporter for eight people to Germany, which comes down to 500 euro per person, and in 2015 amounts between 500 and 1,000 euro per person were generally accepted [ 33 ]. Therefore, we set it equal to 750 euro. The duration for this journey by car, including the search of a smuggler, is estimated to take seven days. As a proxy for the benefits, we take the financial allowances to asylum seekers in Austria, which comes down to 332 euro per month [ 34 ], in other words 332 x 7 / 30 = 77.47 euro for four days. It is not always clear whether or not refugees actually did receive these benefits (in cash or kind), but we believe this is a reasonable estimation of the possible benefits of a leg. Finally, we set the probability of arrival to 70%.

During the asylum procedure in Germany, the allowance in the reception center including food amounted to 143 euro per month [ 35 ]. The average duration of the asylum procedure for Syrian asylum seekers in Germany was 4.2 months in 2014 and 3.2 months in 2015 [ 36 ], therefore the benefits for Syrian refugees to travel to Germany equal 4.2 x 143 = 600.60 euro in 2014 and 3.2 x 143 = 457.60 euro in 2015. We have taken the Existenzminimum (single person), the minimum payment for survival such as for accommodation and heating, as an indication for the costs that asylum seekers have to pay by themselves. However, the amount that an asylum seeker needed is lower in comparison to the Existenzminimum due to the following two reasons: Firstly, we assume that the asylum seeker stays in an asylum seekers center, which results in lower costs. Secondly, the asylum seeker received several benefits, such as food and shelter. We correct the minimum level of subsistence for both factors and take the figures from 2015 as a proxy for 2014 and 2015.

In 2015, the Existenzminimum was 8,472 euro per year [ 37 ], or 8472/12 = 706 euro per month. The monthly allowance for a single adult was 143 euro for staying in an accommodation center and 359 euro for staying outside an accommodation center [ 38 ]. We apply this ratio in order to correct the minimum level of subsistence for staying in an accommodation center: 706 x (143/359) = 281 euro. Since the refugee received 143 euro per month for food, accommodation etc., the costs at the expense of the refugee were equal to 281–143 = 138 euro per month. For 2014, this will be equal to 138 x (126/30) = 580 euro for 4.2 months (= 126 days) and for 2015 this will be 138 x (96/30) = 442 euro. Finally, the probability of entitlement to asylum is based on country reports of Germany [ 38 , 39 ]. From this we find that the refugee rate for Syrians, i.e. the percentage of applicants who receive the refugee status, was 85.9% in 2014 and 99.5% in 2015.

Once asylum has been granted to the refugee, Germany had to incorporate expenses for education, private housing, health and employment opportunities and social assistance [ 18 , 40 ]). The individual federal states bore the majority of these costs [ 40 ] and we take these costs [ 18 ] as a proxy for the benefits that the refugee receives in Germany. We also assume that the differences in the costs per person within a federal state is limited and that the volatility of these costs for a major part is caused by the differences between the federal states. Based on this we derive that in 2014 the annual expected benefits for a refugee in Germany were equal to an annual amount of 6,570 euro with a volatility of 22% [ 18 ]. When we perform this calculation for 2015, we arrive at annual benefits of 5,414 euro with a volatility of 25% [ 18 ]. However, there is a complicating factor at play here. The benefits for the refugee, which are equal to the costs of the federal states, appear to decrease in 2015 when compared to 2014, whereas in fact they did the opposite: they increased. A large part of the costs for the federal states in 2015 have been booked in 2016, which results in annual benefits of 30,139 euro in 2016 [ 18 ]. In order to provide a realistic picture, we take as a proxy for the annual benefits in 2014 and 2015, the average value over the years 2014, 2015 and 2016: (6570 + 5414 + 30139) / 3 = 14,041 euro. In addition to the benefits that the refugee received, he or she also has to incur certain expenses. These total necessary expenses are estimated on the basis of the minimum wage. The minimum wage in Germany was 1,440 euro per month in 2014 and 2016. From this we could note that the additional annual costs for a refugee were equal to 1440 x 12–14041 = 3,239 euro per year. In case a refugee is entitled to asylum, then he or she received a residence permit for three years. For this reason, we assume that the refugee could count on to receive expected benefits in Germany for three years.

We notice that mainly because there is a lower probability of arriving in Libya (p_1) the real options value of the CMR decreased from 10,388 in 2014 to -113 in 2015. Besides this lower probability also the irreversible cost of the different stages went up. For instance, the cost of stage 2 increased from 2000 to 2500 euro, while the cost of stage 3 went up from 500 to 750 euro. One can simulate the effects in isolation. If we increase the irreversible costs from 2014 to 2015, but keep the probabilities in 2015 at the previous year level, the real options value drops to 9,934. If we decrease the probability in 2015, but keep the irreversible costs at the 2014 levels, then the real options value drops to -80 euro. If both variables change simultaneously, the real option value drops to -113 euro.

3.2.2. Route 2 –The Eastern Mediterranean Route by sea.

The values of the parameters for the EMR by sea in 2014 and 2015 are presented in Table 2 . This route is also divided in three geographical legs: from Syria to Turkey, from Turkey to Greece and from Greece to Germany, and in addition there is the phase of the asylum procedure and the phase after the asylum has been granted to the refugee. In this case-study we only discuss the first three legs, as the values of the value drivers during and after the asylum procedure in the desired destination Germany are similar to those of the CMR. In Turkey, asylum seekers only received an allowance when needed [ 41 , 42 ], for this reason we set the benefits to zero. In 2014, the amount that smugglers received from the refugees in order to travel to Turkey equaled 189 euro [ 43 ] and in 2015 it was 361 euro [ 44 ]. Since the refugees reportedly travelled though territory controlled by armed groups, we estimate the duration of the travel at 14 days. Since 2011 Turkey maintained a generous open door policy to Syrian refugees [ 45 , 46 ]. Therefore, we set the probability of arrival at 85%.

https://doi.org/10.1371/journal.pone.0284390.t002

Consecutively the route continued by sea to Greece. In Greece refugees did not receive any financial allowances [ 47 , 48 ]. For the sea travel itself, the refugees paid about 1,600 euro in 2014 [ 49 ] and about 1,350 euro in 2015 [ 27 ]. The journey itself just took a few hours, but since the refugees also needed to make sure to have a seat on the boat and this journey could fail a couple of times we estimate a duration of 14 days. In 2014 there were 72,632 arrivals in Greece [ 28 ] and 59 casualties [ 50 ] on this route, for which we estimate the survival rate on 72632 / (72632 + 59) = 99.9%. In 2015 there were 853,650 arrivals in Greece [ 29 ] and 806 casualties [ 28 ], which also results in a survival rate of 99.9%. Like for the CMR, we set the value at 75%. Finally, there is the leg from Greece to Germany. This route goes through Serbia and Hungary towards Germany. We estimated its duration to be 24 days, the costs of travelling to average 160 euro and the benefits to amount to 109 euro, while there is a probability of successfully moving to the next leg of 25%. With these values for the different parameters, the real options value of the EMR by sea equals 3,149 in 2014 and 3,809 in 2015.

3.2.3. Route 3 –The Eastern Mediterranean Route by land.

Finally, Table 3 provides the values of the parameters for the EMR by land in 2014 and 2015. Again, this route is divided in three geographical legs: from Syria to Turkey, from Turkey to Bulgaria and from Bulgaria to Germany, and in addition, the phase of the asylum procedure and the phase after granting the asylum. We only discuss the leg from Turkey to Bulgaria of this route. As a proxy for the journey from Bulgaria to Germany, we take the journey from Greece to Germany, as was discussed before. The only deviation is the duration of the journey, which we set at 22 days instead of 24 days. For the other legs we refer to the other routes earlier discussed in this case study.

https://doi.org/10.1371/journal.pone.0284390.t003

The crossing from Turkey to Bulgaria by land was difficult, because in response to the refugee flows, Bulgaria had started to place fences along its border with Turkey since 2014. Therefore, we assume that the leg from Turkey to Bulgaria took 14 days. For this leg, refugees paid 500 euro [ 51 ] in 2014, whereas this has increased to 1,000 euro [ 52 ] in 2015. In 2014 about 38,500 people attempted to cross irregularly the Bulgaria-Turkey border, of which some 6,000 of them indeed have reached Bulgaria [ 53 ]. Therefore, we estimate the probability of arrival in Bulgaria to 6000 / 38500 = 16%. We also use this value for 2015. Once having arrived in Bulgaria, refugees received a financial allowance of 33.23 euro per month [ 54 ], however, this was reduced to zero in 2015 [ 55 ]. In 2014, we set the benefits of travel equal to 33.23 x 14/30 = 15.51 euro, whereas this is zero in 2015.

With these values for the value drivers the real options value of the EMR by land equals 674 in 2014 and 577 in 2015.

3.3. Discussion

The objective of this case study was to illustrate that the popularity of the different routes runs parallel with their real options value. A route becomes more popular as soon as the real options value of that route increases relative to other routes, and that a route becomes less popular when the real options value decreases relative to other routes. This was performed on the basis of the situation of the average Syrian adult male refugee who fled to Europe and had to choose between three main routes: Central Mediterranean Route (CMR), Eastern Mediterranean Route by sea (EMR by sea) and Eastern Mediterranean Route by land (EMR by land). We have seen that in 2014, the CMR was slightly the favorite one. However, during the European refugee crisis of 2015, Syrians avoided the CMR and the EMR by sea became by far the most popular, overshadowing the refugee volumes of the other routes.

Table 4 illustrates this with the results from this case study. In this table we present the real options values for the three main routes (CMR, EMR by sea, EMR by land) for 2014 and 2015 (see columns 3 resp. 5 in Table 4 ). These values were calculated above in Tables 1 to 3. For instance, the real option value of the EMR by sea route goes up from 3,179 euro in 2014 to 3,809 in 2015. The real option model indicates that the most valuable route in 2014 is the CMR route, while in 2015 it is the EMR by sea (indicated in bold in Table 4 ). We also collected data on the actual amount of Syrian refugees per route as detected by Frontex, the European Border and Coast Guard Agency in the years 2014 and 2015. The most popular route in 2014 was the CMR route which accounted for 50% of the Syrian refugees, while this changed to the EMR by sea route in 2015 (82% of Syrian refugees) (See columns 3 resp. 5 in Table 4 ). One can observe that the relative attractiveness between the routes is reflected in the real options values. We could for example see that the CMR has the highest real option value in 2014, which is consistent with the fact that this was the most popular route. In 2015 the highest option value shifts towards the EMR by sea route, which is again the most popular route on the field in that year, accounting for 82% of the illegal crossings.

https://doi.org/10.1371/journal.pone.0284390.t004

As the real option value captures the attractiveness of a certain route, policy makers can also focus on one of more value-drivers of the real option model to actively manage refugee flows. Our model shows that the attractiveness of a route depends on the value-drivers of the real option model, such as the benefits of travel, the cost of travel, the length of travel, and the probability of travel, among others (see, for instance, the value-drivers in Table 1 ). By altering the value of one of the value drivers, policy makers have the ability to influence the real option value of a particular route. Put differently, they have the ability to influence the attractiveness of this route and they are able to steer the route choice of the refugee. This active management can occur both at the supranational EU level as well at the individual country level.

At the supranational level, the EU has the ability to make one route more or less attractive than another in order to better allocate the migrants throughout Europe and reduce the pressure on the frontline states. To change the real options value, the EU policy level has to focus on certain value-drivers of the real option model that impact the options value, and hence change the attractiveness of a certain route. For instance, if the strategy is aimed at reducing the attractiveness, a potential value-driver is to increase the travel costs, while the opposite is true if one would like to increase the attractiveness of a certain route. To achieve the latter, Frontex could decrease the costs of travel by organizing free transport to the assigned country in the context of the EU Relocation plan. Relocation refers to the transfer of refugees who are in clear need of international protection from one EU state to another EU state. By lowering the travel costs for refugees, a particular route will become more attractive, while another route will become less attractive. In this way, Frontex can actively try to manage to divert refugee flows from member states under too much pressure to member states with more capacity to handle a certain amount of refugees.

At the individual country level, many countries do not have the capacity and resources to host a large amount of refugees. Therefore, these countries try to decrease the attractiveness of the routes to and through their territories. For instance, individual countries have the possibility to decrease the real option value by lowering the probability of arrival. A country can achieve this by introducing border checks or by building border fences.

As policy actions to impact one or more value-drivers of the real options model can occur both at the EU level and at the level of individual countries, such actions can reinforce or counteract with each other. It is important to note here that this is not a shortcoming of the model, but merely the consequence of political choices with the different EU member states. Hence, on the contrary, our real options model is well-suited to provide further insights in the anticipated (joint) effects of different policy actions.

3.4. Limitations

While our case study shows preliminary evidence for the fitness of a compound real options framework to model refugee routes, this section points towards some limitations. A first limitation is related to the case study approach as we focus on the average Syrian male refugee as the focal decision-maker [ 44 ]. It is unclear whether our conclusion can be transposed to other refugees which are non-Syrian or non-male. Although we conjecture that the model could also be applied to different situations and therefore allowing for heterogeneity among the refugee population, future research needs to confirm our model in different contexts. For instance, family members who travel together and also have a mutual interdependence: if one of the family members does not want or is not able to travel, this could also affect the choices of the other family members. Another example could be an individual refugee who chooses to stay in a transit country instead of traveling to the desired final destination. Although we did not consider these situations, the compound option model could easily incorporate such features. Furthermore, the country of origin could affect the decision of the refugee regarding choice of the final destination. During the refugee crisis, Germany declared an open-door policy for Syrian refugees, while its policy might not be so generous to refugees from countries that are not at war. We invite researchers to replicate our study for refugees from other countries or continents. Analyzing different type of refugees could lead to different input values for the model, such as duration of the journey, probability of arrival, costs and benefits and uncertainty in benefits, which in turn would deliver a different option value in comparison to that of the case of the Syrian male refugee.

Second, it is challenging to determine the exact value for certain input parameters, because data is not available, unreliable or not quantifiable. For example, in case it is unknown how many refugees travel from one to another country, it would be hard to determine the probability of arrival. Furthermore, there is also little information available about people who have made the trip multiple times, which prevents to take into account issues with double counting. More reliable microdata would lead to better results, therefore it would be very helpful to have access to better finer-grained data sources.

A third potential limitation is the idea that it may not be realistic to expect a refugee, whose major concern is survival, to perform a rational cost and benefit analysis in case of forced migration. However, even though socio-economic actors do not always conduct an explicit cost-benefit analysis, the framework accurately predicts human behavior. A good example is criminal behavior. Even though not all criminal perform an explicit analysis, economic models accurately predict criminal behavior [ 56 ]. The forced character of refugees also poses potential problems with regard to compound option analogy in case of “timing”. According to real options logic, the more time there is to make a decision, the more the option is worth. In case of involuntary migration, such as during the first part of the journey of the Syrian refugee, option logic is applicable to a lesser extent.

A fourth and final limitation is the feasibility of using the real options analysis in monitoring and steering policy measures. While the impact of policy makers on the attractiveness of certain routes by leveraging one or more value-drivers of the real option model seems straight-forward in theory, one can imagine numerous challenges in practice. Many times precise data might be missing, making it more difficult to calculate the precise real option value. However, we conjecture that in many case applying the real option logic to route choice of refugees is often more important than the exact valuation of such routes. To gain better insight in the pros and cons of implementing our model in practice, a study using our model to retrospectively assess the policies implemented in Europe following the 2015 Syrian refugee flows could be very useful. This will be left for future research. At this stage, we invite Frontex to start collecting data on the different value-drivers of the real option model to assist more efficient future decision-making.

4. Conclusion

During the refugee crisis the unprecedented number of refugee arrivals in Europe has created new and complex challenges for the EU, member states, and the international community at large. This calls for a tool to analyze refugee flows. In this article we have used compound real options analysis to model refugee flows. A refugee has to cope with many uncertainties, such as for example the changing unilateral and EU-wide legislation, and in more concrete terms, the uncertainty regarding the possibility to obtain a seat on a boat. At the same time, the refugee still has the possibility to make an informed decision regarding factors such as the desired final destination, the expected costs and benefits, the travel time and the uncertainty of reaching their final destination. Through modern channels, such as Facebook, a refugee still could have the possibility to make a reasonably informed decision and to opt for one route over another.

In order to be able to model refugee flows we have used a compound real option model. We have illustrated on the basis of a case-study how refugee flows could be modeled through the use of a compound option models by quantifying the attractiveness of a refugee route relative to other routes. In this case-study we have demonstrated that the popularity of different routes, and thereby the dynamics of the decision-making process of the average refugee, runs parallel with their real options values. The effects of the changing conditions in the countries of origin, transit and destination could be calculated through a real options framework. For example, we have noticed that the closure of Libya, translated to an enormous decrease of the probability of arrival from Syria to Libya, indeed had a strong negative impact on the real options value. This in turn corresponds to the enormous decrease in refugee volumes to Libya. Policy makers could use this framework prior to the implementation of policy measures. Real options analysis offers the possibility to provide an ex-ante estimation of the effects on refugee volumes of policy measures. Moreover, (near) real-time refugee data would also provide the possibility to monitor and steer the influence of policy measures accordingly.

In general, there are obviously more players involved than just the policy maker. Measures by an EU policy maker call for reactions by the other actors, such as the refugees, individual countries and the smuggler, who plays an important role as a facilitator of the migration. In order to present a complete picture of effective refugee policy, it is also important to take into account this interaction into the analysis. Otherwise, there could be the risk that a policy measure works counter-productive and outdrives the intended objectives, such as that persons will disappear into illegality, but still do come to Europe. After all, refugee flows are said to be unstoppable [ 12 ], with (more stringent) policy measures merely diverting flows, possibly causing additional unintended negative effects.

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The Syrian refugee crisis and global security threats a case study of Germany

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In recent times, various governments have increasingly regarded both newly arrived and well-established refugee groups as potential sources of concern, posing challenges to the internal stability of the state, regional security, and even global security. The concerns of European host states encompass a range of issues, including the inadvertent provision of a safe haven for foreign combatants, as well as the potential for affiliates of ISIS and other Islamist groups to exploit the hosting nation as a platform for carrying out terrorist activities. However, the academic community currently faces a dearth of theoretical frameworks and empirical investigations that establish a connection between the influx of refugees and instances of criminal behaviour or acts of terrorism. The objective of this study is to evaluate the assertion that Syrian refugees provide a potential risk to global security. This will be accomplished by a focused analysis of crime and terrorism rates inside Germany, a nation that had a significant influx of refugees from Syria during the period spanning from 2015 to 2020. This study posits and substantiates, via the utilisation of descriptive statistical analysis, the absence of a direct correlation between Syrian refugees and crime rates or instances of terrorism. Drawing upon primary German, English and Arabic sources, the study makes the conclusion that the increase in the number of Syrian refugees was not necessarily accompanied by an increasing threat to security.

Keywords: Syrian refugees, Global security, Terrorism, Threat, ISIS

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Ahmad Barakat, Department of Political Science and International Studies, University of Birmingham

Ahmad Barakat is a visiting lecturer in Middle East politics at the University of Birmingham. His research examines the political economy in the Middle East. and in the politics and diplomacy of the Middle East. He completed his PhD in political science and international studies at the University of Birmingham. He is a former Syrian diplomat and human rights expert.

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The Syrian conflict: a case study of the challenges and acute need for medical humanitarian operations for women and children internally displaced persons

Rahma aburas.

1 Joint Masters Program in Health Policy and Law, University of California - California Western School of Law, San Diego, CA USA

Amina Najeeb

2 Brotherhood Medical Center for Women and Children, Atimah, Syria

Laila Baageel

3 Department of Anesthesiology, University of California, San Diego School of Medicine, San Diego, CA USA

Tim K. Mackey

4 Department of Medicine, Division of Global Public Health, University of California, San Diego School of Medicine, San Diego, CA USA

5 Global Health Policy Institute, San Diego, CA USA

After 7 years of increasing conflict and violence, the Syrian civil war now constitutes the largest displacement crisis in the world, with more than 6 million people who have been internally displaced. Among this already-vulnerable population group, women and children face significant challenges associated with lack of adequate access to maternal and child health (MCH) services, threatening their lives along with their immediate and long-term health outcomes.

While several health and humanitarian aid organizations are working to improve the health and welfare of internally displaced Syrian women and children, there is an immediate need for local medical humanitarian interventions. Responding to this need, we describe the case study of the Brotherhood Medical Center (the “Center”), a local clinic that was initially established by private donors and later partnered with the Syrian Expatriate Medical Association to provide free MCH services to internally displaced Syrian women and children in the small Syrian border town of Atimah.

Conclusions

The Center provides a unique contribution to the Syrian health and humanitarian crisis by focusing on providing MCH services to a targeted vulnerable population locally and through an established clinic. Hence, the Center complements efforts by larger international, regional, and local organizations that also are attempting to alleviate the suffering of Syrians victimized by this ongoing civil war. However, the long-term success of organizations like the Center relies on many factors including strategic partnership building, adjusting to logistical difficulties, and seeking sustainable sources of funding. Importantly, the lessons learned by the Center should serve as important principles in the design of future medical humanitarian interventions working directly in conflict zones, and should emphasize the need for better international cooperation and coordination to support local initiatives that serve victims where and when they need it the most.

The Syrian civil war is the epitome of a health and humanitarian crisis, as highlighted by recent chemical attacks in a Damascus suburb, impacting millions of people across Syria and leading to a mass migration of refugees seeking to escape this protracted and devastating conflict. After 7 long years of war, more than 6 million people are internally displaced within Syria — the largest displacement crisis in the world — and more than 5 million registered Syrian refugees have been relocated to neighboring countries [ 1 , 2 ]. In total, this equates to an estimated six in ten Syrians who are now displaced from their homes [ 3 ].

Syrian internally displaced persons (IDPs) are individuals who continue to reside in a fractured Syrian state now comprising a patchwork of government- and opposition-held areas suffering from a breakdown in governance [ 4 ]. As the Syrian conflict continues, the number of IDPs and Syrian refugees continues to grow according to data from the United Nations High Commissioner for Refugees (UNHCR). This growth is continuing despite some borders surrounding Syria being closed and in part due to a rising birth rate in refugee camps [ 5 , 6 ]. This creates acute challenges for neighboring/receiving countries in terms of ensuring adequate capacity to offer essential services such as food, water, housing, security, and specifically healthcare [ 4 , 7 , 8 ].

Though Syrian refugees and IDPs face similar difficulties in relation to healthcare access in a time of conflict and displacement, their specific challenges and health needs are distinctly different, as IDPs lack the same rights guaranteed under international law as refugees, and refugees have variations in access depending on their circumstances. Specifically, there are gaps in access to medical care and medicines for both the internally displaced and refugees, whether it be in Syria, in transit countries (including services for refugees living in camps versus those living near urban cities), or in eventual resettlement countries. In particular, treatment of chronic diseases and accessing of hospital care can be difficult, exacerbated by Syrian families depleting their savings, increased levels of debt, and a rise in those living in poverty (e.g., more than 50% of registered Syrian refugees in Jordan are burdened with debt) [ 9 ].

Despite ongoing actions of international humanitarian organizations and non-governmental organizations (NGOs) to alleviate these conditions, healthcare access and coverage for displaced Syrians and refugees is getting worse as the conflict continues [ 4 , 10 ]. Although Syria operated a strong public health system and was experiencing improved population health outcomes pre-crisis, the ongoing conflict, violence, and political destabilization have led to its collapse [ 11 – 13 ]. Specifically, campaigns of violence against healthcare infrastructure and workers have led to the dismantling of the Syrian public health system, particularly in opposition-held areas, where access to even basic preventive services has been severely compromised [ 14 – 17 ].

Collectively, these dire conditions leave millions of already-vulnerable Syrians without access to essential healthcare services, a fundamental human right and one purportedly guaranteed to all Syrian citizens under its constitution [ 4 ]. Importantly, at the nexus of this health and humanitarian crisis are the most vulnerable: internally displaced Syrian women and children. Hence, this opinion piece first describes the unique challenges and needs faced by this vulnerable population and then describes the case study of the Brotherhood Medical Center (the “Center”), an organization established to provide free and accessible maternal and child health (MCH) services for Syrian IDPs, and how it represents lessons regarding the successes and ongoing challenges of a local medical humanitarian intervention.

Syria: a health crisis of the vulnerable

Critically, women and children represent the majority of all Syrian IDPs and refugees, which directly impacts their need for essential MCH services [ 18 ]. Refugee and internally displaced women and children face similar health challenges in conflict situations, as they are often more vulnerable than other patient populations, with pregnant women and children at particularly high risk for poor health outcomes that can have significant short-term, long-term, and inter-generational health consequences [ 10 ]. Shared challenges include a lack of access to healthcare and MCH services, inadequate vaccination coverage, risk of malnutrition and starvation, increased burden of mental health issues due to exposure to trauma, and other forms of exploitation and violence such as early marriage, abuse, discrimination, and gender-based violence [ 4 , 10 , 19 , 20 ]. Further, scarce medical resources are often focused on patients suffering from acute and severe injury and trauma, leading to de-prioritization of other critical services like MCH [ 4 ].

Risks for women

A 2016 United Nations Population Fund (UNFPA) report estimated that 360,000 Syrian IDPs are pregnant, yet many do not receive any antenatal or postnatal care [ 21 , 22 ]. According to estimates by the UNFPA in 2015, without adequate international funding, 70,000 pregnant Syrian women faced the risk of giving birth in unsafe conditions if access to maternal health services was not improved [ 23 ]. For example, many women cannot access a safe place with an expert attendant for delivery and also may lack access to emergency obstetric care, family planning services, and birth control [ 4 , 19 , 24 – 28 ]. By contrast, during pre-conflict periods, Syrian women enjoyed access to standard antenatal care, and 96% of deliveries (whether at home or in hospitals) were assisted by a skilled birth attendant [ 13 ]. This coverage equated to improving population health outcomes, including data from the Syrian Ministry of Health reporting significant gains in life expectancy at birth (from 56 to 73.1 years), reductions in infant mortality (decrease from 132 per 1000 to 17.9 per 1000 live births), reductions in under-five mortality (from 164 to 21.4 per 1000 live births), and declines in maternal mortality (from 482 to 52 per 100,000 live births) between 1970 and 2009, respectively [ 13 ].

Post-conflict, Syrian women now have higher rates of poor pregnancy outcomes, including increased fetal mortality, low birth weights, premature labor, antenatal complications, and an increase in puerperal infections, as compared to pre-conflict periods [ 10 , 13 , 25 , 26 ]. In general, standards for antenatal care are not being met [ 29 ]. Syrian IDPs therefore experience further childbirth complications such as hemorrhage and delivery/abortion complications and low utilization of family planning services [ 25 , 28 ]. Another example of potential maternal risk is an alarming increase in births by caesarean section near armed conflict zones, as women elect for scheduled caesareans to avoid rushing to the hospital during unpredictable and often dangerous circumstances [ 10 ]. There is similar evidence from Syrian refugees in Lebanon, where rates of caesarean sections were 35% (of 6366 deliveries assessed) compared to approximately 15% as previously recorded in Syria and Lebanon [ 30 ].

Risks for children

Similar to the risks experienced by Syrian women, children are as vulnerable or potentially at higher risk during conflict and health and humanitarian crises. According to the UNHCR, there are 2.8 million children displaced in Syria out of a total of 6.5 million persons, and just under half (48%) of Syrian registered refugees are under 18 years old [ 1 ]. The United Nations Children’s Fund (UNICEF) further estimates that 6 million children still living in Syria are in need of humanitarian assistance and 420,000 children in besieged areas lack access to vital humanitarian aid [ 31 ].

For most Syrian internally displaced and refugee children, the consequences of facing lack of access to essential healthcare combined with the risk of malnutrition (including cases of severe malnutrition and death among children in besieged areas) represent a life-threatening challenge (though some studies have positively found low levels of global acute malnutrition in Syrian children refugee populations) [ 24 , 32 – 34 ]. Additionally, UNICEF reports that pre-crisis 90% of Syrian children received routine vaccination, with this coverage now experiencing a dramatic decline to approximately 60% (though estimating vaccine coverage in Syrian IDP and refugee populations can be extremely difficult) [ 35 ]. A consequence of lack of adequate vaccine coverage is the rise of deadly preventable infectious diseases such as meningitis, measles, and even polio, which was eradicated in Syria in 1995, but has recently re-emerged [ 36 – 38 ]. Syrian refugee children are also showing symptoms of psychological trauma as a result of witnessing the war [ 4 , 39 ].

A local response: the Brotherhood Medical Center

In direct response to the acute needs faced by Syrian internally displaced women and children, we describe the establishment, services provided, and challenges faced by the Brotherhood Medical Center (recently renamed the Brotherhood Women and Children Specialist Center and hereinafter referred to as the “Center”), which opened its doors to patients in September 2014. The Center was the brainchild of a group of Syrian and Saudi physicians and donors who had the aim of building a medical facility to address the acute need for medical humanitarian assistance in the village of Atimah (Idlib Governorate, Syria), which is also home to a Syrian displacement camp.

Atimah (Idlib Governorate, Syria) is located on the Syrian side of the Syrian-Turkish border. Its population consisted of 250,000 people pre-conflict in an area of approximately 65 km 2 . Atimah and its adjacent areas are currently generally safe from the conflict, with both Atimah and the entire Idlib Governorate outside the control of the Syrian government and instead governed by the local government. However, continued displacement of Syrians seeking to flee the conflict has led to a continuous flow of Syrian families into the area, with the population of the town growing to approximately a million people.

In addition to the Center, there are multiple healthcare centers and field hospitals serving Atimah and surrounding areas that cover most medical specialties. These facilities are largely run by local and international health agencies including Medecins Sans Frontieres (MSF), Medical Relief for Syria, and Hand in Hand for Syria, among others. Despite the presence of these organizations, the health needs of IDPs exceeds the current availability of healthcare services, especially for MCH services, as the majority of the IDPs belong to this patient group. This acute need formed the basis for the project plan establishing the Center to serve the unique needs of Syrian internally displaced women and children.

Operation of the Center

The Center’s construction and furnishing took approximately 1 year after land was purchased for its facility, a fact underlining the urgency of building a permanent local physical infrastructure to meet healthcare needs during the midst of a conflict. Funds to support its construction originated from individual donors, Saudi business men, and a group of physicians. In this sense, the Center represents an externally funded humanitarian delivery model focused on serving a local population, with no official government, NGO, or international organization support for its initial establishment.

The facility’s primary focus is to serve Syrian women and children, but since its inception in 2014, the facility has grown to cater for an increasing number of IDPs and their diverse needs. When it opened, facility services were limited to offering only essential outpatient, gynecology, and obstetrics services, as well as operating a pediatric clinic. The staffing at the launch consisted of only three doctors, a midwife, a nurse, an administrative aid, and a housekeeper, but there now exist more than eight times this initial staff count. The staff operating the Center are all Syrians; some of them are from Atimah, but many also come from other places in Syria. The Center’s staff are qualified to a large extent, but still need further training and continuing medical education to most effectively provide services.

Though staffing and service provision has increased, the Center’s primary focus is on its unique contribution to internally displaced women and children. Expanded services includes a dental clinic 1 day per week, which is run by a dentist with the Health Affairs in Idlib Governorate, and has been delegated to cover the dental needs for the hospital patients . Importantly, the Center facility has no specific policy on patient eligibility, its desired patient catchment population/area, or patient admission, instead opting to accept all women and children patients, whether seeking routine or urgent medical care, and providing its services free of charge.

Instead of relying on patient-generated fees (which may be economically prohibitive given the high levels of debt experienced by IDPs) or government funding, the Center relies on its existing donor base for financing the salaries for its physicians and other staff as well as the facility operating costs. More than an estimated 300 patients per day have sought medical attention since its first day of operation, with the number of patients steadily increasing as the clinic has scaled up its services.

Initially the Center started with outpatient (OPD) cases only, and after its partnership with the Syrian Expatriate Medical Association (SEMA) (discussed below), inpatient care for both women and children began to be offered. Patients’ statistics for September 2017 reported 3993 OPD and emergency room visits and 315 inpatient admissions including 159 normal deliveries and 72 caesarean sections, 9 neonatal intensive care unit cases, and 75 admissions for other healthcare services. To better communicate the clinic’s efforts, the Center also operates a Facebook page highlighting its activities (in Arabic at https://www.facebook.com/مشفى-الإخاء-التخصصي-129966417490365/ ).

Challenges faced by the Center and its evolution

The first phase of the Center involved its launch and initial operation in 2014 supported by a small group of donors who self-funded the startup costs needed to operationalize the Center facility’s core clinical services. Less than 2 years later, the Center faced a growing demand for its services, a direct product of both its success in serving its targeted community and the protracted nature of the Syrian conflict. In other words, the Center facility has continuously needed to grow in the scope of its service delivery as increasing numbers of families, women, and children rely on the Center as their primary healthcare facility and access point.

Meeting this increasing need has been difficult given pragmatic operational challenges emblematic of conflict-driven zones, including difficulties in securing qualified and trained medical professionals for clinical services, financing problems involving securing funding due to the shutdown of banking and money transferring services to and from Syria, and macro political factors (such as the poor bilateral relationship between Syria and its neighboring countries) that adversely affect the clinic’s ability to procure medical and humanitarian support and supplies [ 40 ]. Specifically, the Center as a local healthcare facility originally had sufficient manpower and funding provided by its initial funders for its core operations and construction in its first year of operation. However, maintaining this support became difficult with the closure of the Syrian-Turkish border and obstacles in receiving remittances, necessitating the need for broader strategic partnership with a larger organization.

Collectively, these challenges required the management committee and leadership of the Center to shift its focus to securing long-term sustainability and scale-up of services by seeking out external forms of cooperation and support. Borne from this need was a strategic partnership with SEMA, designed to carry forward the next phase of the Center’s operation and development. SEMA, established in 2011, is a non-profit relief organization that works to provide and improve medical services in Syria without discrimination regarding gender, ethnic, or political affiliation — a mission that aligns with the institutional goals of the Center. Selection of SEMA as a partner was based on its activity in the region; SEMA plays an active role in healthcare provision in Idlib and surrounding areas. Some other organizations were also approached at the same time of this organization change, with SEMA being the most responsive.

Since the Center-SEMA partnership was consummated, the Center has received critical support in increasing its personnel capacity and access to medicines, supplies, and equipment, resulting in a gradual scale-up and improvement in its clinical services. This now includes expanded pediatric services and the dental clinic (as previously mentioned and important, as oral health is a concern for many Syrian parents and children). The Center also now offers caesarean deliveries [ 41 ]. However, the Center, similar to other medical humanitarian operations in the region, continues to face many financial and operational challenges, including shortage of medical supplies, lack of qualified medical personnel, and needs for staff development.

Challenges experienced by the Center and other humanitarian operations continue to be exacerbated by the ongoing threat of violence and instability emanating from the conflict that is often targeted at local organizations and international NGOs providing health aid. For example, MSF has previously been forced to suspend its operations in other parts of Syria, has evacuated its facilities after staff have been abducted and its facilities bombed, and it has also been subject to threats from terrorist groups like the Islamic State (IS) [ 42 ].

The case study of the Center, which evolved from a rudimentary medical tent originally located directly in the Atimah displacement camp to the establishment of a local medical facility now serving thousands of Syrian IDPs, is just one example of several approaches aimed at alleviating the suffering of Syrian women and children who have been disproportionately victimized by this devastating health and humanitarian crisis. Importantly, the Center represents the maturation of a privately funded local operation designed to meet an acute community need for MCH services, but one that has necessitated continuous change and evolution as the Syrian conflict continues and conditions worsen. Despite certain successes, a number of challenges remain that limit the potential of the Center and other health humanitarian operations to fully serve the needs of Syrian IDPs, all of which should serve as cautionary principles for future local medical interventions in conflict situations.

A primary challenge is the myriad of logistical difficulties faced by local medical humanitarian organizations operating in conflict zones. Specifically, the Center continues to experience barriers in securing a reliable and consistent supply of medical equipment and materials needed to ensure continued operation of its clinical services, such as its blood bank, laboratory services, operating rooms, and intensive care units. Another challenge is securing the necessary funding to make improvements to physical infrastructure and hire additional staff to increase clinical capacity. Hence, though local initiatives like the Center may have initial success getting off the ground, scale-up and ensuring sustainability of services to meet the increasing needs of patients who remain in a perilous conflict-driven environment with few alternative means of access remain extremely challenging.

Despite these challenges, it is clear that different types of medical humanitarian interventions deployed in the midst of health crises have their own unique roles and contributions. This includes a broad scope of activities now focused on improving health outcomes for Syrian women and children that are being delivered by international aid agencies located outside of the country, international or local NGOs, multilateral health and development agencies, and forms of bilateral humanitarian assistance. The Center contributes to this health and humanitarian ecosystem by providing an intervention focused on the needs of Syrian women and children IDPs where they need it most, close to home.

However, the success of the Center and other initiatives working to end the suffering of Syrians ultimately relies on macro organizational and political issues outside Atimah’s border. This includes better coordination and cooperation of aid and humanitarian stakeholders and increased pressure from the international community to finally put an end to a civil war that has no winners — only victims — many of whom are unfortunately women and children.

Abbreviations

Authors’ contributions.

We note that with respect to author contributions, all authors jointly collected the data, designed the study, conducted the data analyses, and wrote the manuscript. All authors contributed to the formulation, drafting, completion, and approval of the final manuscript.

Ethics approval and consent to participate

This community case study did not involve the direct participation of human subjects and did not include any personally identifiable health information. Hence, the study did not require ethics approval.

Competing interests

Amina Najeeb and Laila Baageel, two co-authors of this paper, were part of the foundation of the Center, remain active in its operation, and have a personal interest in the success of the operation of the clinic. The remaining authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• Research article
• Open access
• Published: 17 August 2023

Health aid displacement during a decade of conflict (2011–19) in Syria: an exploratory analysis

• Munzer Alkhalil   ORCID: orcid.org/0000-0003-2156-8802 1 , 2 , 3 , 4 ,
• Maher Alaref 1 , 5 ,
• Abdulkarim Ekzayez 2 , 6 ,
• Hala Mkhallalati 1 , 7 ,
• Nassim El Achi 6 ,
• Zedoun Alzoubi 1 , 8 ,
• Fouad Fouad 6 , 9 ,
• Muhammed Mansur Alatraş 10 ,
• Abdulhakim Ramadan 1 , 10 ,
• Sumit Mazumdar 11   na1 ,
• Josephine Borghi 12   na1 &
• Preeti Patel 6   na1  

BMC Public Health volume  23 , Article number:  1562 ( 2023 ) Cite this article

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Syria has been in continuous conflict since 2011, resulting in more than 874,000 deaths and 13.7 million internally displaced people (IDPs) and refugees. The health and humanitarian sectors have been severely affected by the protracted, complex conflict and have relied heavily on donor aid in the last decade. This study examines the extent and implications of health aid displacement in Syria during acute humanitarian health crises from 2011 to 2019.

We conducted a trend analysis on data related to humanitarian and health aid for Syria between 2011 and 2019 from the OECD’s Creditor Reporting System. We linked the data obtained for health aid displacement to four key dimensions of the Syrian conflict. The data were compared with other fragile states. We conducted a workshop in Turkey and key informants with experts, policy makers and aid practitioners involved in the humanitarian and health response in Syria between August and October 2021 to corroborate the quantitative data obtained by analysing aid repository data.

The findings suggest that there was health aid displacement in Syria during key periods of crisis by a few key donors, such as the EU, Germany, Norway and Canada supporting responses to certain humanitarian crises. However, considering that the value of humanitarian aid is 50 times that of health aid, this displacement cannot be considered as critical. Also, there was insufficient evidence of health displacement across all donors.

The results also showed that the value of health aid as a proportion of aggregate health and humanitarian aid is only 2% in Syria, compared to 22% for the combined average of fragile states, which further indicates the predominance of humanitarian aid over health aid in the Syrian crisis context.

This study highlights that in very complex conflict-affected contexts such as Syria, it is difficult to suggest the use of health aid displacement as an effective tool for aid-effectiveness for donors as it does not reflect domestic needs and priorities. Yet there seems to be evidence of slight displacement for individual donors. However, we can suggest that donors vastly prefer to focus their investment in the humanitarian sector rather than the health sector in conflict-affected areas. There is an urgent need to increase donors’ focus on Syria’s health development aid and adopt the humanitarian-development-peace nexus to improve aid effectiveness that aligns with the increasing health needs of local communities, including IDPs, in this protracted conflict.

Key messages

• Health aid displacement is not an effective tool for aid-effectiveness used by donors in Syria.

• Some health aid displacement is evident for some leading donors such as the EU, Germany, Norway and Canada.

• Donors prefer to fund humanitarian activities with humanitarian aid being 50 fold more than development health aid; this is largely because humanitarian projects are easier to implement with sanctions and highly dynamic borders.

• There is an urgent need to adopt the humanitarian-development-peace nexus, considering the localization agenda. This approach can bridge the gap between the humanitarian and development phases, thereby increasing aid effectiveness.

Peer Review reports

The unprecedented number of protracted humanitarian emergencies in the last decade, including armed conflicts, natural disasters, political violence, human rights violations, climate change and COVID-19, have contributed to the greatest humanitarian challenges since World War II, leading to more than 100 million forcibly displaced persons, including refugees and internally displaced persons (IDPs) in May 2022 [ 1 ].

Many conflict and crisis-affected countries depend on donor aid (both humanitarian and development), particularly during times of crisis. However, it is unclear where humanitarian aid is additional or displaces other aid and whether crises affect the quality of aid. Also, it is unclear how donors used needs’ assessment data for decisions to allocate funds [ 2 ]. Reallocation of domestic health funds due to receiving donor health aid by the recipient government to match other priorities is known as health aid fungibility [ 3 , 4 ], which has been long recognized with many studies showing donor aid is fungible in certain countries and sectors. For example, foreign aid is fungible in health, education, and agriculture, partially fungible in energy, but non-fungible in transport and communication [ 5 ]. Lu et al. found that between 1995 and 2006, there had been a decrease of almost US$0.43 in domestic health spending for each extra dollar of development assistance for health (DAH) [ 6 ]; so that health aid has a negative impact on domestic spending on health.

In comparison, very few studies have considered health aid displacement at the donor level, which refers to shifting funding from the health sector to other sectors, such as the humanitarian sector during crises to reflect the humanitarian needs and/or shifting priorities of donors; this displacement does not always consider domestic health needs during decision-making [ 7 ]. The limited existing evidence suggests that the flow of humanitarian aid during humanitarian crises was not at the cost of health aid. For instance, in Sierra Leone, South Sudan and Lebanon there was no evidence of health aid displacement during times of crisis [ 7 , 8 , 9 ].

However, there are no studies on health aid displacement in conflict settings in the MENA region. Syria offers a unique example of a protracted conflict for more than a decade, which has left a humanitarian crisis described as the worst of the twenty-first century [ 10 ]. With around 60% of Syrians (13.7 million) currently internally displaced or living as refugees [ 11 ]. Over 98% of individuals in Syria live in extreme poverty, living on less than $1.90 per person a day according to the Humanitarian Needs Assessment in September 2021 [ 12 ].

The main objectives of this paper are to analyse trends in humanitarian and health aid in Syria between 2011 and 2019 and their alignment with needs in terms of key dimensions of the Syrian conflict. We also examine whether there is evidence of health aid displacement across all donors, assess whether and how this differs between donors, and compare the volume of health and humanitarian aid in Syria to other fragile states.

Study setting

Syria has been in a state of continuous conflict since 2011, resulting in more than 874,000 – directly and indirectly deaths [ 13 , 14 ], The areas of military influence have changed dramatically in Syria between 2011 and 2019. The Syrian government control is limited to the red area in 2019 (Fig. 1 ) and has contested power with four de facto local governments that arose during different times [ 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 ].

Areas of control in Syria as of Jan 2019—Source: Live Universal Awareness Map (Liveuamap)

In 2014, UN Security Council Resolution 2165 was issued to allow donors to provide humanitarian aid through four border crossings: Bab al-Salam and Bab al-Hawa on the Syrian-Turkish border, Al-Yarubiyah on the Syrian-Iraqi border and Al-Ramtha on the Syrian-Jordanian border, which were all not under the control of the Syrian government. This Resolution is to support areas outside the control of the Syrian government and does therefore not require its approval [ 23 ]. At the same time, humanitarian aid continued to flow to the Syrian Governmental-held areas (GoHA) through many humanitarian agencies in collaboration with the Syrian Regime [ 24 ]. After that three of these border crossings were closed in 2020 due to further UN Security Council Resolutions, and only the Bab al-Hawa crossing is maintained thus far.

The humanitarian funding landscape

The ten most significant humanitarian donors according to OCHA in 2019 (the last year of our study) were: the USA, Germany, UK, EU, Canada, Norway, Denmark, Japan, France, and Sweden, respectively [ 25 ]. The sectors which received most of the humanitarian funding in 2019 were food security (not specified), health, multiple shared sectors, education, water sanitation and hygiene, emergency shelter/non-food items (NFI), and protection, respectively [ 25 ].

The humanitarian clustering model was established in Turkey for the humanitarian response in Syria across border in 2014 [ 26 ]. It is led by the Office for the Coordination of Humanitarian Affairs (OCHA), which is responsible for leading the Humanitarian Response Plans (HRPs) and Humanitarian Needs Overviews (HNOs) and documenting the development process [ 27 ]. Humanitarian intervention was carried out by the health cluster mechanisms through three leading platforms: Syria hub, Turkey Cross-border and Jordan Cross-border, the three platforms working together through the Whole of Syria approach (WoS) established in 2015 [ 28 ].

Moreover, another humanitarian hub emerged inside Syria in Al Hasaka governorate in 2017, coordinated by the North East Syria (NES) NGOs Forum. It manages several technical working groups and has loose links with the WoS approach in Amman, Jordan.

Study design

This is a mixed methods country case study that tracks aid trends and allocation from donor countries and organisations in response to the humanitarian crises in Syria. It is then combined with follow-up qualitative interviews with an expert panel of key informants and stakeholders in the humanitarian and health sectors in Syria to complete and corroborate results obtained by analysing aid repository data.

Quantitative data

The research team charted the crisis timeline based on four quantitative indicators after excluding many others due to their limitations in the Syrian context. These indicators were then tested in the expert panel to see if they were suitable or if they required adaptation. The relevant humanitarian indicators to explain key dimensions of the Syrian conflict include: 1) the number of IDPs; 2) the number of people in need of humanitarian assistance; 3) the number or frequency of internal movements (displacements) due to the conflict and violence only. As Syria did not witness significant natural disasters during this period, the number of internal movements due to natural disasters was at the most 2,300 until the beginning of 2017. It then increased to 27,000 in 2018 and dropped to 17,000 in 2019 [ 29 ]. 4) the decline in Syria’s population between 2011 and 2019. Although there are other important indicators that can trace humanitarian flow and conflict intensity, such as the number of civilian casualties, data are very scarce on such indicators.

For this study, we could not include casualty figures as an important indicator because when compared to refugee data, casualty data is of a lesser standard of validity for the period. The United Nations stopped counting fatalities in the conflict by January 2014, citing the difficulty in accurately recording the constantly increasing toll [ 30 ].

After expanded discussion with the experts in the panel, we concluded that, although there were limitations associated with each indicator individually, quantitatively, reading these four indicators together would best express the crisis timeline in Syria.

Data sources

Data on internal movements and IDPs were collected from the Internal Displacement Monitoring Centre (IDMC), which is a comprehensive source of data and analysis of internal displacement worldwide. The Centre was established as part of the Norwegian Refugee Council (NRC) in 1998 [ 29 ]. And data on the Syrian population were collected from United Nations – Department of Economic and Social Affairs / Population Division. Data on people in need of humanitarian assistant were collected from Syria Humanitarian Needs Overviews, Syrian Arab Republic Humanitarian Assistance Response Plans, Strategic Response Plans, and Syrian Arab Republic Humanitarian Response Plans issued by OCHA over the study period.

Data on humanitarian and health aid for Syria were collected from the OECD's Creditor Reporting System (CRS) [ 31 ]. Despite some limitations of the CRS, this database is the most comprehensive one for tracking health and humanitarian aid for conflict-affected countries; it enables analysis of different aid activities, multilateral and philanthropic donors, country donors and recipients, purpose, policies, and over years [ 7 , 32 ]. As per our knowledge, we did not find any other comprehensive sources that track aid in Syria.

The data, in the CRS, are reported by 42 multilateral donors (i.e., multilateral institutions such as UN agencies); 49 bilateral donors (i.e., country), and 36 private donors (i.e., entities such as the Bill and Melinda Gates Foundation).

The CRS provides financial data for 2002 -2021 with almost 200,000 – 300,000 data entries per year. Furthermore, it covers the specific economic or social programs that the aid seeks to support in a recipient country and classifies them into sectors. In addition, some contributions are not subject to sector-specific allocations and are reported as non-sector allocable aid [ 33 ]. Donors report which country is receiving aid and the purpose of aid. In addition, some descriptive information about the projects is also provided [ 34 ].

The CRS data used in this study are based on the 31 April 2021 update [ 31 ] and were downloaded to Excel sheets on 15 August 2021. The DAC and CRS list of codes were updated on 24 April 2021 [ 35 ].

The scope of the study is the whole of Syria whether the government- controlled area or the non-government-controlled territories.

Quantitative variables

Based on the databases mentioned earlier, we identified several variables representing crisis timelines, health aid and humanitarian aid. Table 1 provides a summary of the variables used in the quantitative analysis:

Quantitative data analysis

We collected information about the Syrian conflict's key dimensions from various sources annually between 2011 and 2019. Then we applied trend analysis techniques to trace their trajectories, which allowed us to comprehend the interrelations among them. Simultaneously, we explored the connections between the crisis timeline and the fluctuations in health and humanitarian aid trends.

We gathered financial data from the CRS and performed a trend analysis using Excel from 2011, the year the protests began in Syria, until 2019, the last year with available data at the CRS database at the moment of downloading the data. In this analysis, our definition of aid includes “Official Development Assistance”: “ODA grants” and “ODA loans” and “Private Development Finance” from the Bill & Melinda Gates Foundation (BMGF). In addition, aid excludes “Equity Investment” and “Other Official Flows” [ 7 , 31 , 40 ]. This combination is consistent with other recent analyses [ 7 ]. Data on regional and non-country-specific aid was not included in this analysis, and the focus was solely on aid flow to the Syrian territories.

We extracted data on gross disbursements rather than commitments because we were looking for “the actual international transfer of financial resources, or goods or services valued at the cost to the donor” [ 41 ]. To analyse aid trends over this long timeframe, we relied on constant 2019 US dollars rather than the current value to account for fluctuations in exchange rates and inflation. The Development Assistance Committee (DAC) deflator converts the amounts back to the value they held in a specific year. This means the expression of flows to multilateral donors and recipient countries is in terms of the purchasing power of the US dollar in each year of the study period [ 42 , 43 ]. The aid database includes the bilateral ODA of the DAC members and excludes their contributions to the regular budgets of multilateral institutions when accounting for bilateral aid [ 42 ].

We considered that a decrease in health aid while an increase in humanitarian aid in a given year as a sign of health aid displacement.

Qualitative data

We also conducted semi-structured interviews by constituting a panel of humanitarian sector experts, humanitarian practitioners, and public sector officials; this was a crucial step, especially in this setting where quantitative data alone is often not an entirely accurate reflection of what is happening on the ground.

We used purposive sampling followed by snowballing sampling approaches to identify the participants. The research team invited 31 humanitarian workers in senior positions from health NGOs and INGOs, local authorities, technical entities, and the Turkey Cross-border health cluster for Syria’s response to an Expert Panel in Turkey – Mersin in August 2021. Twenty-five out of 31 accepted and attended the panel, 88% of the participants were from a health and medical background with vast experience in humanitarian and health programs. The discussions were conducted in Arabic with 3 research assistants writing notes as the participants did not agree on recording the session.

We also followed up findings from the Expert Panel with four key informants interviews (KIIs) with representatives of the four leading donors in September–October 2021 to understand the key stakeholders’ perspectives. The feedback from these key informants aligned strongly with the areas discussed in the Expert Panel. The KIIs were conducted in English and recorded. They were later transcribed and anonymized using a unique identifier for each participant. Following a thematic analysis approach, data from the Expert Panel and interviews were extracted and categorised into different themes.

Qualitative data analysis

For qualitative data we used a thematic analysis approach, data from the Expert Panel and interviews were extracted and categorised into different themes. The qualitative approach was aimed at completing, interpreting, and understanding the quantitative data-related results, comprehensiveness of the aid databases, and scope of the humanitarian and health interventions (emergency and/or development).

Key dimensions of the Syrian conflict

It can be seen from Fig. 2 that the population of Syria is constantly decreasing, as the number dropped by about 4.7 million over the study period. The numbers of IDPs steadily rose until a peak in 2014 and then witnessed other increases in 2017 and 2019.

Crisis Timeline in Syria, 2011–2019 [ 38 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 ]

The volume of internal movements peaked in 2013 and in 2017. Finally, the number of people in need peaked in 2016 and 2017 with 13.5 million people in both years.

The four indicators reflect the severity of the humanitarian crises which showed an increase in the years 2013, 2014, 2016, 2017, and 2019. However, it seems that the year 2017 was worse due to the length of the crisis and the large number of violent incidents that occurred in 2016. A total of 338 attacks on health facilities were recorded across Syria, 38 attacks on education facilities and a quarter of the Syrian population lived in besieged or hard-to-reach areas [ 53 ]. Health aid displacement will be examined herein in response to the crisis timeline indicated in Fig. 2 .

Trends in aid flow concerning the key conflict and crises parameters

When considering aid trends against the crisis timeline, we notice a significant rise in health aid in 2017, which corresponds to the four indicators: the number of IDPs in Syria (6.78 m), number of internal movements (2.91 m), people in need (13.5 m), and the total population (17 m) (Fig. 3 -Chart A). Notably, there were two peaks in humanitarian aid in 2013 and 2016 which corresponds to the number of internal movements index in 2013 (3.5 m) and the people in need index in 2016 (6.8 m). However, in 2014 there was no clear parallel with the humanitarian crisis expressed through the number of IDPs in Syria indicator, which peaked in 2014 at 7.6 m. Moreover, in 2017, which represents the peak of the humanitarian crisis in Syria, humanitarian funding decreased by 159 million compared to 2016 (Fig. 3 -Chart B).

Humanitarian and health aid trends against the crisis timeline, 2011-2019

With reference to Fig. 3 , it seems that such indicators are not the major criteria for the allocation of humanitarian aid to Syria as none of them seem to strongly impact donor decisions for mobilization of funds.

Participants in the Expert Panel and interviews emphasized that there is no clear relationship between health and humanitarian funding allocations and the four indicators and that it is not clear that donors rely on need assessments before allocating funding. For example, the 2020 HRP, which was supposed to be released before the start of the year, was issued in December 2020, and the 2021 HRP was not released at the time of the workshop in Mersin in August 2021.

This raises an important question: Are HRPs developed after the projects are implemented?

• Health aid displacement

The trend in the volume of health aid vis-à-vis humanitarian aid evident from the CRS for all donors (except Turkey) indicates the latter to be about 50 times higher than health aid (Fig. 4 ). We excluded the Turkish donor from this analysis due to a classification error in their reporting on the CRS system; Turkish funds were spent on Syrian refugees in Turkey and not within Syrian territory [ 39 ].

Humanitarian and health aid trends in Syria, 2011-2019

It can be seen that health aid and humanitarian aid trends are, in fact, inversely correlated as health aid decreased by 7 $million, whereas humanitarian aid increased by 1.5 $billion between 2011 and 2013, and health aid increased when humanitarian aid decreased after 2016. However, the magnitude of financial flows is very different. The increase in humanitarian aid from 2011 to 2013 was far more significant in scale than the corresponding decrease in health aid, so this aid displacement is negligeable. Moreover, between 2013 and 2019, there was no health aid displacement at this aggregate level.

The Expert Panel and KIIs all stated that although CRS database is a great resource, they questioned the reliability of data presented in this work given funds from Gulf countries at the beginning of the crisis were not recorded, as well as other sources of private funding such as individual donations, therefore CRS misses an important source of funding. This finding is in accordance with the literature which also states that a major limitation in CRS is the omission of data from countries which do not report their aid disbursements to the CRS which includes China, Qatar, and Saudi Arabia [ 32 , 54 ].

The participants also stressed the importance of excluding Turkey as a donor and that the amounts registered as humanitarian aid within Syria are, in fact, aid that was disbursed to Syrian refugees within Turkey, also emphasizing that there are not many precise details on how these amounts were spent.

Health aid displacement for individual donors

The following six charts show the health aid displacement at the level of the six largest donors in the health and humanitarian sectors in Syria between 2011 and 2019: the USA, Germany, the UK, EU, Norway, and Canada (Fig. 5 ).

Aid trends at individual donor's level, 2011–2019

The United States did not spend on health during the study period. Instead, it focused on humanitarian aid, so there is no displacement of health aid for this donor. For Germany, there was an apparent decrease in spending on health with $2.3 million per year between 2015 and 2017 and spending reached zero in 2018 and 2019; this was accompanied by an increase in spending on humanitarian aid with $545 million per year between 2015 and 2017, which, theoretically, could be considered a displacement of health aid.

The UK did not spend on health in the first six years, while its spending has increased steadily in the last three years; no evidence of health aid displacement from the UK.

In the first six years, European Union spending on health was close to zero, then increased in the following three years. In 2017 and 2019 there was a shift in EU investment in favour of health aid, while, in 2018, spending on health decreased by $4 million, and there was an increase in spending on humanitarian funding by approximately $2.3 million in the same year; this could be considered health aid displacement.

For Norway, in 2019, the decrease in health funding from $3.4 million to zero was accompanied by an increase in humanitarian funding by nearly $27 million, and this can be considered a health aid displacement.

Finally, for Canada, there was an apparent decrease in health funding after 2016 from almost $1.6 million per year until it reached 0 in 2019, and this was accompanied by an increase in humanitarian funding by almost $37.5 million per year during the same period, which can be considered health aid displacement.

A key takeaway is that although there is slight health aid displacement at the level of some donors in specific years especially after 2015 there is no consistent evidence of displacement over the study period. Also, by comparing the individual donors’ result with aggregate data in Fig. 3 , the health aid displacement was at individual donors’ level for some years but was not accompanied by health aid displacement across donors.

Comparison between health aid in Syria and other fragile states

Figure 6 shows that the proportion of health aid to the combined total of health and humanitarian aid in Syria is 2% compared to 22% in other highly fragile countries on average. This means that in the Syrian context, donors’ are prioritizing the humanitarian sector relative to health, and this was confirmed among our participants in the Expert Panel and KIIs.

The percentage of health aid out of the humanitarian and health aid in Syria compared to other fragile states (CRS), USD 2019, Millions

The reason for humanitarian aid favouritism between 2011 and 2019 mentioned by participants in the Expert Panel and KIIs is the weakness of a governance structure in opposition-led areas such as north west Syria and north east Syria. This might discourage funding health programs as a development investment. So, donors prefer funding emergency health programs defined as humanitarian through UN agencies because it is less risky in terms of aid diversion and tends to be less politicised.

Also, the participants in the Expert Panel and KIIs pointed out that the multiplicity of governments, the different areas of military control, and the governance complexity make donors more inclined towards humanitarian aid rather than health aid of a developmental nature. The dramatic change in military influence over the last decade was accompanied by significant changes at the level of governance and the management of humanitarian and health aid.

In addition, the participants in the Expert Panel and KIIs mentioned the “blurred lines” between humanitarian and development health aid. Most of the participants confirmed that many humanitarian actors provide health services in a development sense, and that could be because many local NGOs are led and managed by individuals from a health and medical background. The definition of health programs in humanitarian emergency and development settings is confusing, and the boundaries between the two scopes are unclear. In the same course, the participants questioned the standardised methodology and definitions used to classify health programs implemented inside Syria by donors in CRS database, and whether the mix between humanitarian and developmental activities on the ground also affects the reporting and thus the reliability of the distinction between humanitarian and health aid in CRS database.

To the best of our knowledge, this is the first study that provides an analysis of health and humanitarian aid trends and explores health aid displacement in a conflict-affected setting in the MENA region. It covers the Syrian crisis from its start in 2011 until the year 2019, the latest available information on the CRS database at the downloading data moment; we wanted to look at all the available conflict years to study the trends.

We present a crisis timeline while considering different criteria -number of IDPs, total population, number of internal movements, and number of people in need. However, it seems that none of these indicators strongly influenced donor aid allocation in Syria. This is consistent with other literature which identifies alternative criteria that donor countries take in their decision- making process such as perceived risk of investment, colonial/post-colonial links, nationalist policies, domestic concerns, dynamics of a conflict [ 55 , 56 ].

Although we observed reductions in health aid disbursements alongside increases in humanitarian aid among donors such as the EU, Germany, Norway and Canada, the scale of the increased humanitarian funding in all cases except the EU far exceeded that of reductions in health aid. This suggests that while health aid displacement may have occurred, most of the increase in humanitarian aid was additional, increasing the overall health and humanitarian aid envelope. In comparison, we observed in the literature a different pattern in other conflict settings such as South Sudan, Sierra Leone, and Lebanon where humanitarian aid was added to the health aid and did not replace it [ 7 , 8 , 9 ].

However, when comparing the ratio of humanitarian aid to health aid given to Syria to that of all other fragile states, there is a strong indication that donors prefer to fund humanitarian activities in Syria as the ratio is 2 to 98 in favor of humanitarian aid compared to 22 to 78 in the other fragile countries.

Humanitarian aid can include funding to the health sector, and sometimes donors label health aid as humanitarian aid in humanitarian crisis settings. According to OCHA, in 2019, 8,6% of Syria’s humanitarian aid was health-related [ 25 ]. This part includes, primarily, life-saving health aid and sometimes health aid of a developmental nature. A clear example of that, the German Donor / Federal Minister for Economic Cooperation and Development (BMZ) supported 8 health directorates in the area outside of the Syrian Regime’s control, which are health local authorities, between 2017 and 2019 through Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) in a development sense [ 57 ]. The GIZ mandate is “sustainable development and international education work” [ 58 ]. We see in Fig. 5 that Germany’s health aid to Syria in 2018 and 2019 was zero. That means even strengthening health system activities through development entities have been provided under the humanitarian, not health, umbrella.

One would also argue that given the protracted nature of the Syrian conflict, humanitarian aid would somehow cross with development health aid given that most humanitarian agencies, donors and INGOs try to adopt the humanitarian-development-peace nexus [ 59 ] which calls for using a holistic approach where coherence among the development, humanitarian and peace-related actors, policies and operations should be ensured. These “blurred lines” between humanitarian and development aid have been mentioned in the literature with more people speak of a humanitarian development “continuum” [ 60 , 61 , 62 ]. However, major challenges in implementing the nexus in other conflict settings like Uganda [ 63 ].

Preference for humanitarian aid was confirmed by the participants in the Expert Panel and KIIs due to the governance challenges and donors’ desire to avoid dealing with the Syrian Regime largely due to its involvement in war crimes and crimes against humanity. This is consistent with the literature on health governance in opposition-held areas that shows that although there is a form of quasi-governance in both NWS and NES, donors are hesitant to support health directorates as they believe they lack capacity. Donors also prefer to work through NGOs partially due to concerns about treating opposition-controlled health authorities as political substitutes for the Syrian regime [ 64 , 65 ]. Also, this can be because at the earlier stages of the Syrian crisis, many countries, including major donors, imposed unilateral sanctions [ 66 , 67 , 68 , 69 ] on the Assad regime which made it less likely for them to provide health aid. However, those sanctions were designed while ensuring that they would not affect humanitarian assistance [ 70 ], which made it much easier and more realistic to focus primarily on humanitarian aid.

The reason why the United States did not invest in health aid of a developmental nature is mostly its stance against the violations of the Syrian regime since the protests began. First, the US government imposed economic sanctions on officials in the Syrian regime less than a month after the protests began [ 71 ], then, followed by a series of sanctions against many officials, including the Syrian president [ 71 ], his wife [ 72 ], his foreign minister [ 73 ], and many businesspeople close to the Assad family [ 72 , 73 ].

Despite its limited amounts, health aid by most donors seems to be decreasing annually, except for UK and EU donors, at a faster pace than that of humanitarian aid. However, this is not the case with the overall trends where health aid is slightly increasing annually, contrary to humanitarian aid which is decreasing.

This slight increase in “interest” in health aid by UK and EU may be primarily due to a major change in the political climate in Syria: the international community has partially resigned to the fact that the Assad regime is going to stay in power, so a political transition is unlikely. A few of the European embassies and Arab countries have reopened in Damascus with Assad’s diplomatic visits on the rise [ 74 , 75 ].

Western countries are gradually easing restrictions on supporting and dealing with Syrian state institutions, so it is expected that development aid will increase in the coming years. Based on the Expert Panel and KIIs, this shift in the political environment would pose critical ethical challenges for the donors and the international community: How can donors support developmental health aid in light of a complex governmental reality in Syria? This is astounding given that the Syrian government has almost completely controlled state institutions for more than five decades.

The health cluster mechanism in Syria, operating under the WoS approach, primarily focused on providing life-saving services during the first decade of the Syrian crisis [ 76 ]. As a result, it did not significantly encourage donors to invest more in sustainable health interventions, including development health aid. This emphasis on immediate and critical healthcare needs reflects the humanitarian phase of the response. However, UN agencies have called recently for greater support and have taken steps toward increasing early recovery projects inside the country and thus re-adding development aid, including health aid, to major donors’ agendas. Indeed, in November 2021, the US Treasury Department’s Office of Foreign Assets Control (OFAC) announced its decision to expand authorizations for NGOs to engage in additional activities in Syria [ 77 ].

Estimates in this study may be incomplete as some donors, such as China, Qatar, and Saudi Arabia, also, other sources of private funding, do not report their aid disbursements to the CRS [ 32 , 54 , 78 , 79 ]. And some donors, such as Turkey, do not report their aid with complete accuracy [ 39 ].

The population indicator may not be an ideal indicator of the crisis timeline, but it has been used due to the lack of regular updates on the number of refugees, deaths, and new births.

Although the number of IDPs and internal movements are suitable indicators for expressing the fundamental crises, they cannot represent the entirety of all the crises in the Syrian context, as many areas have witnessed significant humanitarian crises due to the military siege. For example, a high-level UN investigation reported in 2018 that the more than five-year siege of Eastern Ghouta in a war-torn country is “barbaric and medieval” [ 80 ]. However, this disaster did not significantly affect the number of IDPs and internal movements over the years because 400,000 people, including wounded people, were prevented from leaving their homes due to the military blockade [ 81 ]. In addition, there are significant numbers of people who migrated outside Syria. According to the UNHCR, the number of the Syrian refugees worldwide was 6.8 million in 2022 [ 11 ]. This is in addition to more than 874,000 deaths since 2011 due to the conflict [ 82 ].

Recommendations

We highlighted above several challenges of aid that are faced in Syria, a highly complex conflict setting with multiple local, regional, and international players along with state and non-state actors and combatants. A few recommendations can be made which would help in improving aid at different levels: the OECD should do more to ensure having more inclusive databases that go beyond the current donors reported to CRS, such as including China and other so-called “emerging” donors that do not share comprehensive information about their aid funds. And there should be a clear distinction between humanitarian and health aid categories at the levels of the UN, OECD, donors, and recipient governments. Also, the OECD Secretariat should ensure quality and comparability by regularly reviewing donor input.

UN-OCHA should encourage donors to invest more in the health sector in Syria. It can prepare an annual response/development plan independent of the humanitarian response plan with more involvement for the local governance bodies in different areas.

In the humanitarian phase of the conflict in Syria, there was understandably limited engagement from humanitarian donors and organisations with local governments, considering the involvement of these governments in conflict atrocities. However, as we transition into the early recovery phase it becomes crucial to employ the humanitarian-development-peace nexus. This approach encourages simultaneous and synergistic efforts on humanitarian aid, sustainable development, and peacebuilding. The nexus becomes especially significant with the increased need to implement the localization agenda for sustainable humanitarian interventions and to pave the way for development, demanding more engagement with local actors.

It is essential to recognise that Syria now has new “de-facto borders” with different areas of control, a reality that has already been established by the 12 years of conflict. Therefore, a single approach to early recovery for the whole country is neither feasible nor best practice. The UN agencies and donors should prioritise efforts in enhancing health governance and development activities within each of the three main areas of control, including NWS and NES, to bridge the gap between the humanitarian and development phases.

To initiate development activities, it is important to assess the capability of each area and foster positive competition among them. At the central levels (NWS, NES and GoHA) donors should exert diplomatic pressure and engage in technical negotiations with the various central and local governments. This engagement facilitates meaningful involvement at the community and district levels, while harmonizing activities at the national level.

The lack of political engagement with governments involved in the conflict has provided them with opportunities to exploit humanitarian responses, evade public accountability, divert funds towards perpetuating violence and conflict, and exert control over aid distribution. The case of South Sudan serves as an example of these challenges [ 56 ].

Addressing these issues necessitates providing robust support to technical health bodies that play quasi-governmental or governmental roles at local and community levels based on human rights principles becomes imperative. This support can contribute to the formulation of comprehensive national needs strategies and plans, ultimately enhancing the effectiveness of health aid in Syria during the early recovery phase.

In this study, we realized that in contexts as complicated as that of Syria, there was insufficient evidence of health displacement across donors. Yet there seems to be evidence of slight displacement for individual donors.

There is a strong indication that donors prefer to fund humanitarian activities, including health, in favor of humanitarian aid in Syria compared to other fragile countries. Especially that humanitarian aid was 50 folds more than development health aid, as humanitarian projects are easier to implement with sanctions and highly dynamic borders. UN agencies and INGOs should work more on providing more inclusive and better-defined aid reporting systems to ensure that all the received aid to a given country is recorded and that there is a clear distinction between humanitarian and development aid. This will provide more reliable evidence for policymakers to advocate for more development projects, especially in protracted conflicts such as Syria, where humanitarian projects cannot meet local needs.

The humanitarian-development-peace nexus should also be implemented to bridge the gap between the humanitarian and development phases. This can be achieved through leading technical negotiations by UN agencies and donors with the various central and local governments to facilitate meaningful engagement at the community and district levels. This approach helps to reduce the politicization of aid, empowers local communities, and enhances their ownership of development plans until a political solution matures in Syria.

The data used for quantitative analysis herein are based on donor reporting and donors' inputs without results and achievement-based reflection. And therefore, future work should focus on aid effectiveness in reference to the five goals of the 2005 Paris Declaration: Alignment, Harmony, Ownership, Results and Mutual Accountability.

Availability of data and materials

The datasets generated and analysed through the FGDs and KIIs are not publicly available as they contain information that could compromise research participant confidentiality. All other data sources used in this study were publicly accessible.

Abbreviations

Governmental-held Areas

Internally Displaced People

Organisation for Economic Co-operation and Development

Creditor Reporting System

European Union

Coronavirus Disease 2019

Development Assistance for Health

Middle East and North Africa

United Nations

Office for the Coordination of Humanitarian Affairs

United States of America

United Kingdom

Non-Food Items

Humanitarian Response Plans

Humanitarian Needs Overviews

Whole of Syria

North East Syria

Non-Governmental Organizations

Internal Displacement Monitoring Centre

Norwegian Refugee Council

Development Assistance Committee

Official Development Assistance

Bill & Melinda Gates Foundation

International Non-Governmental Organizations

Key Informants Interviews

Federal Minister for Economic Cooperation and Development

Deutsche Gesellschaft für Internationale Zusammenarbeit

North West Syria

Office of Foreign Assets Control

United Nations High Commissioner for Refugees

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Acknowledgements

Not applicable.

This publication is funded through the National Institute for Health Research (NIHR) 131207, Research for Health Systems Strengthening in northern Syria (R4HSSS), using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and do not necessarily reflect those of the NIHR or the UK government.

Author information

Sumit Mazumdar, Josephine Borghi and Preeti Patel are last authors.

Authors and Affiliations

Research for Health System Strengthening in Northern Syria (R4HSSS), Union for Medical and Relief Organizations, Gaziantep, Turkey

Munzer Alkhalil, Maher Alaref, Hala Mkhallalati, Zedoun Alzoubi & Abdulhakim Ramadan

Syria Public Health Network, London, UK

Munzer Alkhalil & Abdulkarim Ekzayez

LSE IDEAS Conflict and Civicness Research Group, London School of Economics and Political Science, London, UK

Munzer Alkhalil

Nottingham, UK

Strategic Research Center SRC, Gaziantep, Turkey

Maher Alaref

The Centre for Conflict & Health Research (CCHR), Research for Health System Strengthening in Northern Syria (R4HSSS), King’s College London, London, UK

Abdulkarim Ekzayez, Nassim El Achi, Fouad Fouad & Preeti Patel

Syria Research Group (SyRG), Co-Hosted By the London School of Hygiene and Tropical Medicine and Saw Swee Hock School of Public Health, London, UK

Hala Mkhallalati

MEHAD, Paris, France

Zedoun Alzoubi

Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon

Fouad Fouad

Health Information System Unit, Gaziantep, Turkey

Muhammed Mansur Alatraş & Abdulhakim Ramadan

Centre for Health Economics, University of York, York, UK

Sumit Mazumdar

Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK

Josephine Borghi

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Contributions

The initial framing, outlines, literature review, and initial drafting of the piece, multiple rounds of edits, and producing the final manuscript were carried out by MAK. MAK, MAA, HM, ZZ, AE contributed to data collection and data analysis. All the authors contributed to further literature review, additional content, and a round of edits. SB, JB and PP contributed to the overall structuring and producing the final draft. All authors read, edited and approved the manuscript.

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Correspondence to Munzer Alkhalil .

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Ethics approval and consent to participate.

Ethical approval to conduct the Expert Panel was obtained from the Idlib Health Directorate in northwest Syria (16 June 2021, reference number 2307). Another ethical approval for the rest of the research, including KIIs, was sought from King’s College London (22 September 2021; MRA-21/22–26339). All participants were provided with informed consent information before study participation and consented to participate. The study has assured that all quotes of interviewees remain anonymous.

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Verbal consent was obtained from participants in the expert panel, and written consent was obtained from participants in the KIIs. Participants were informed that the findings might be shared and published in academic journals, conferences, or other scientific platforms. Their personal information and identity would remain confidential, and all necessary steps were taken to ensure anonymity and privacy. The results were presented in an aggregated and anonymised format to protect participant privacy. By providing consent, participants agreed to disseminate and publish the study findings while ensuring confidentiality and privacy.

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The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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Alkhalil, M., Alaref, M., Ekzayez, A. et al. Health aid displacement during a decade of conflict (2011–19) in Syria: an exploratory analysis. BMC Public Health 23 , 1562 (2023). https://doi.org/10.1186/s12889-023-16428-7

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Published : 17 August 2023

DOI : https://doi.org/10.1186/s12889-023-16428-7

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Supporting teachers to improve foundational learning for syrian refugee students in jordan, foundational learning case study.

Even before the extended COVID-19 school cloures, many of the 34,000 students in Jordan’s Syrian refugee camps faced difficulties acquiring foundational literacy and numeracy (FLN) skills. Upon schools reopening, UNICEF found that over three quarters of Grade 5 and 6 students in the camps were unable to read at a Grade 3 level. Without adequate reading skills, these children were unable to access the wider curriculum and therefore at increased risk of dropping out.

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Sweden launches war crimes trial against former Syrian officer

Mohammed Hamo is the first Syrian officer to face trial in Europe over military operations in the civil war.

Sweden has launched the trial of a former Syrian army officer over his alleged role in war crimes committed in 2012 during the country’s civil war.

The case against Brigadier General Mohammed Hamo, who resides in Sweden, opened on Monday. The trial is one of a very small number thus far against high-ranking Syrian government or military officials, despite efforts in Europe to implement justice against those responsible for human rights abuses during Syria’s 13-year civil war.

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Hamo is charged with aiding and abetting abuses of international law. The 65-year-old former military official is accused of participating in operations that “systematically included attacks carried out in violation of the principle of distinction, caution and proportionality”, during his time as brigadier general in the Syrian army between January and July 2012.

Prosecutor Karolina Wieslander read out the charges which were described as constituting “a serious crime”. Hamo contributed, through “advice and action”, to the Syrian army’s “indiscriminate” warfare, according to the case.

The prosecutor also said Hamo worked in the Syrian army’s 11th Division and was vital in making “strategic decisions and [implementing] military operations”.

Hamo’s defence lawyer said her client maintained his innocence, claiming he could not be held liable for the actions “as he had acted in a military context and had to follow orders”.

‘Complete impunity’

According to estimates, nearly half a million people have been killed in the Syrian civil war , which began after the government’s repression of pro-democracy protests spurred unrest between the regime of Bashar al-Assad and the opposition.

Since the war began in 2011 , half of the country’s pre-war population of 23 million have fled the country, igniting a wave of migration in the Middle East and Europe .

However, few Syrian officials have been brought to trial.

In November, France issued an international arrest warrant for Assad , accusing him of complicity in crimes against humanity and war crimes over chemical attacks in 2013.

Three other international warrants were also issued for the arrests of Assad’s brother Maher, the de facto chief of the army’s elite 4th Division and two generals.

In March, Swiss prosecutors charged an uncle of Bashir with war crimes and crimes against humanity. However, Rifaat al-Assad – who recently returned to Syria after 37 years in exile – is unlikely to show up for the trial, for which a date has yet to be set.

In January 2022, a German court sentenced former Colonel Anwar Raslan to life in jail for crimes against humanity in connection with “state-sponsored torture”.

Activists claim that the case against Hamo strikes a blow by putting the first military official on the stand over army operations.

“This trial is important because it’s the first time that anyone from the Syrian government or the Syrian army is actually put on trial for the attacks that took place,” claimed Aida Samani of the Stockholm-based Civil Rights Defenders human rights group.

“The attacks in and around Homs and Hama in 2012 resulted in widespread civilian harm and an immense destruction of civilian properties,” Samani added. “The same conduct has been repeated systematically by the Syrian army in other cities across Syria with complete impunity.”

If convicted, the former general faces up to 18 years in jail and even life imprisonment, the activist suggested.

Little is known about Hamo, who in July 2012 defected from the Syrian army and joined those fighting to remove President Bashar al-Assad from power.

Syrian opposition activists say he was involved in the fighting in the once rebel-held neighbourhood of Baba Amr in Homs, Syria’s third-largest city.

He lived in central Sweden until he was arrested over his supposed participation in war crimes in 2021, but he was swiftly released due to a lack of evidence.

Several plaintiffs are set to testify at the trial, including Syrians from the cities that were attacked and a British photographer who was injured during one strike.

The trial at the Stockholm District Court is planned to run for 18 days, with the last court session on May 21.