In the fifth year of the Syrian refugee crisis, donors and humanitarian agencies still remain unsure about which policies and interventions have been most effective, and continue to rely on a largely reactive response, say a group of researchers, aid workers and Syrian medical professionals.
Response approaches to date have often been short-termist, sometimes duplicating work and have very little evidence of effectiveness or impact, they say.
As national leaders and UN delegates gather in London this week for the Support Syria Donor Conference, members of the Syrian Public Health Network warn that unless aid is provided on condition of evidence-gathering and transparency so funding can be directed to interventions that work, the health, education and livelihoods of refugees will continue to deteriorate.
They caution that Syrians in neighbouring countries such as Lebanon and Jordan – where services are stretched to breaking point – will suffer the most from ineffective interventions unless governments and NGOs of wealthy nations to do more to link allocation of donor funds to evidence.
"A focus on health and health services is notably absent in the donor conference agenda yet it is a fundamental determinant on the success of education and livelihoods policies," said Dr Adam Coutts, Cambridge University researcher and member of the Syria Public Health Network.
"What funding there is for refugee healthcare risks disappearing unless governments insist on an evidence basis for aid allocation, similar to that expected in domestic policy-making.
"It is estimated that there are now over 4.3 million Syrian refugees in neighbouring frontline countries, and over half these people are under the age of 18. This level of displacement is unprecedented and given how short funds are, we need to be sure that programmes work," said Coutts.
"New ideas and approaches need to be adopted in order to reduce the massive burdens on neighbouring frontline states."
Researchers say that the health response should do more to address the so-called 'non-communicable diseases' which ultimately cause more deaths: slow, silent killers such as diabetes, heart disease and, in particular, mental disorders. This means moving towards the development of universal health care systems in the region and building new public health services.
The calls for more evidence come on the back of an article published last week in the Journal of the Royal Society of Medicine, in which members of the Syria Public Health Network (SPHN) address the response to mental disorders among displaced Syrians.
Clinics in some camps in Turkey and Lebanon report almost half of occupants suffering from high levels of psychological distress. However, many Syrians in neighbouring countries live outside the camps – up to 80% in Jordan, for example – which means cases are unreported.
In Lebanon, despite political commitment to mental health, there are just 71 psychiatrists, mostly in Beirut.
"The implementation of short-term mental health interventions which often lack culturally relevant or practically feasible assessment tools risk diverting funds away from longer term, evidence based solutions," said Coutts.
Moreover, a shortage of Syrian mental health professionals – less than 100 prior to the conflict has now fallen to less than 60 – is worsened by some neighbouring countries preventing Syrian doctors of any specialism from practising. Along with Physicians for Human Rights, SPHN members are calling for restrictions to be lifted on practising licenses for displaced Syrian health professionals.
"To date Syrian medical workers in Lebanon and Jordan are a largely untapped workforce who are ready to work and help with the response. However, due to labour laws and the dominance of private health service providers it is very difficult if not impossible for them to work legally," said SPHN member Dr Aula Abbara.
Emerging evidence from the Syrian crisis, as well as evidence from previous conflicts, is pointing to psychological treatments which show some effectiveness:
Pilot studies with refugees in Turkish camps using 'telemental' projects, the delivery of psychiatric care through telecommunications, suggest that such techniques are effective in supporting healthcare professionals on the ground.
The 'teaching recovery techniques' method is designed to boost children's capacity to cope with the psychological aftermath of war. These techniques have been used in communities in the aftermath of major natural disasters and conflicts, and have shown promise.
While SPHN members caution that adequate testing of these interventions is required, they argue that this is precisely the point: more evidence of what works.
Added Coutts: "A more scientific approach is needed so that precious and increasingly scarce financial aid is put to the most effective use possible. At the moment, NGOs and governments are not making sufficient reference to evidence in determining health, education and labour market policies for the largest displacement of people since World War II."
The Syria Public Health Network was established in early 2015 in response to calls for an independent and critical assessment of the humanitarian and health response to the crisis, from colleagues working in Syria and the wider region. It aims to create an independent and neutral space for discussion, analysis and to generate policy proposals for the types of health interventions and research that might help to address current and future health needs in Syria and the region. A key function of the network is to improve understanding of the types of research and interventions that are taking place within the health response, and their political and social determinants. Workshops organised by the network incorporate key people working for UN agencies, donors, iNGOs, NGOs as well as academic researchers, journalists and those working on the ground in Syria and neighbouring countries.