Gudrun Svavarsdottir
Final paper
Health and Human Rights, Fall 2016
Syrian Refugees in Jordan
Access to health care for Syrian Refugees in Jordan, especially maternal care
Introduction
The aim of this report is mainly directed at violations of the rights of pregnant women amongst the Syrian refugee population in Jordan, although problems that all refugees, living outside refugee camps, face will also be addressed. The reason for the report is increased populations of Syrian refugees in Jordan which has put a lot of pressure on the health care system, as well as the introduction of user fees for Syrian refugees in September 2014.
Before proceeding, it should be stated that I recognize that the Hashemite Kingdom of Jordan, due to its geographical situation, has had to sacrifice immense resources to help the Syrians fleeing the devastating civil war, when compared to other nations. That, on the other hand, does not excuse the human rights violations happening, although it might be seen as a reason for the Jordanian authorities’ decision to allocate scarce resources. That shows that it is not only the Jordanian government that has failed, but the whole international community.
Background
The Syrian Civil War has forced millions of people to leave their homes. There are over 4.8 million registered Syrian refugees outside Syria, but the UN has estimated that the total number of refugees is between 6.1 and 6.4 million. Most refugees flee to neighboring countries, most to Turkey, but also to Iraq, Lebanon and Jordan. On December 19th 2016 there were 655,675 registered Syrian refugees in Jordan but the Jordanian Government has estimated that they host around 1.4 million Syrians, which includes those that lived in Jordan before the war. This means that Syrian refugees make up between 8-17% of the Jordanian population.
Officially, all people fleeing from Syria are sent to refugee camps on arrival to Jordan. The UNHCR issues a ‘Proof of Registration’ document to all refugees in camps. Nevertheless, only 20% of registered refugees live in these designated refugee camps. Although unfeasible for anyone to live for a long period of time in a confined camp as the refugee camps are, the benefits are insured access to food and water, as well as health care and other services that are available in all camps. For refugees outside camps the UNHCR issues an ‘Asylum Seeker Certificate’(ASC). The ASC assures those registered on the document, normally a whole family, the legal status of refugees, and lists them as ‘persons of concern.’
Many refugees want to leave camps, e.g. to reunite with family or seek employment opportunities, and those that do face difficulties in leaving because of strict rules concerning the ASC. Before, refugees were able to leave camps with the ASC. However, in July 2014, the protocols concerning providing ASC to Syrians leaving camps where made stricter, which meant that refugees could leave with their AMC, only if they went through a ‘bailout process,’ which required a married male Jordanian relative over 35 years old to submit a direct as well as a $400-600 payment (300-600 JOD). In January 2015, Jordanian authorities stopped the UNCHR altogether from providing ASC to anyone leaving the camps. In August the same year, the UNHCR estimated that over 160,000 Syrians left Zaatari, the biggest refugee camp in Jordan, without papers.
The Jordanian government requires all Syrian refugees living outside camps to register with the Ministry of Interior and receive a card. The MoI-card is required to access subsidized public services, such as health care services. Without that card refugees are viewed as being ‘foreign citizens,’ who have no relevant rights concerning public services, irrespective of them having the AMC or not. Although the MoI-card is a crucial document for Syrian refugees to have, it can be hard to obtain and even if one has all the right documents it can take months to get the card itself. The MoI-card is only valid while people live in the same area. If they move, which is often the case due to instable housing and employment, they are required to re-register with the local police to apply for a new card. The waiting time after the application has been filed can be months. Furthermore, all Syrians over the age of 12 need to have a health certificate from the Ministry of Health, to be able to apply for the MoI-card. The certificate costs $7 (5 JOD). According to Amnesty International only approximately 299,000 MoI-cards had been issued at the end of February 2016, that means that the remaining registered refugees, over 350,000, did not have the relevant card to be able to access public health services.
Before the Syrian Civil War, the Jordanian Health System was one of the best in the region. 88% of Jordanians have access to health care through insurance. All Jordanian women get free pre- and ante-natal care. But with increasing numbers of Syrians coming into the country, the health care system has had difficulties coping with the increase in demand. The Jordanian government has increased the expenditures towards the health care immensely, but still in 2015 they were only able to fund 26% of what was needed to keep the health care system adequate. The Jordanian government has repeatedly sought assistance to the UN and the international community in vain. To help support the health care system the UN and Doctors Without Borders, amongst others, have opened clinics and hospitals in the biggest cities. They are open to everyone, with or without the MoI-card, but due to limited resources they are unable to help everyone they want to. For example, according to Amnesty International, one of Jordan Health Aid Society’s (JHAS) clinics frequently has over 300 people waiting outside when they open in the morning, but they are only able to help 120, which means that 180 have to be turned away.
Before November 2014, the MoI-card was the golden ticket for Syrian refugees. With that card all public services were free. During that time a person with the MoI-card was viewed as being an insured Jordanian citizen. In November 2014, the Jordanian authorities, in response to the financial difficulties the health care system faced, changed the regulations concerning MoI-cards from viewing card-holders the same as insured to uninsured Jordanian citizens. That means that now, if a refugee is lucky enough to have the MoI-card, he is still required to pay 30-65% of the user fee. All other refugees have to pay the whole user fee, the ‘foreigner’s rate’.
It is estimated that 86% of Syrian refugees live under the Jordan poverty line. This means that the introduction of the user fees has an inevitable influence on people access to health care. Even though the user fees are not high, for a person living under the poverty line, just one dollar can make a life-changing difference. As mentioned before there are some facilities available for refugees without the MoI-card. But these facilities are limited, both in ability to accommodate and help everyone that is in need, but also they are only located in the biggest cities, so transportation costs are high. The fact that people are turned away makes people reluctant to seek the care they need in the places they can afford. According to a survey by the UNHCR performed in May 2015, half a year after the introduction of the user fees, combined with both perceived and real obstacles, there was an obvious decrease in access to health care services.
Pregnant Syrian Refugees
Pregnant women are part of the medically vulnerable population of Syrian refugees in Jordan. According to a report from the UNHCR 16.9% of Syrian women between the age 14-49, living outside camps, were pregnant at least once in 2013 and 2014. Deliveries in girls younger than 18 increased from 5% to 8,5% from 2013 to 2014. The reason is that Syrian girls are married younger than before the Civil War.
Only 38,2% of Syrian women living outside camps visited a clinic or hospital for antenatal care four or more times, which is the World Health Organization (WHO) minimum recommendation. 11,3% did not get any antenatal care. 50% of women told the UNCHR that the reason for them not seeking care was their inability to access relevant services because they didn’t afford fees or transportation costs. Long waiting times in the facilities available was also listed as a reason for their reluctance to seek care. It is important to note that these are the women registered as refugees, but as noted above, it is likely that up to 800,000 Syrian refugees are unregistered. This means that it is likely, based on the numbers from the UNCHR, that there are up to 35,000 pregnant women amongst unregistered refugees. Furthermore, if these numbers are compared this to Jordanian women, nearly 95% of pregnant women had at least four antenatal care visits in 2012. This is mainly due to the fact that the care is free of charge for Jordanian citizens.
Although antenatal care is wanting, 96.9% of deliveries amongst Syrian refugees were in a health facility. Thereof 30.2% in a private clinic. Many reasons are for women not seeking care in public clinics. The most obvious reasons were barriers in registering and obtaining the MoI-card, but also lack of knowledge of were relevant services were available, as well as shortage of female doctors in the public sector. Paying for a delivery can be very expensive. An example of fees for a normal delivery in a public hospital (a private clinic delivery is much more expensive) is $70-80 for women with a MoI-card, but $300-420 for a C-section. Compared to the fees for women without a MoI-card, which is the majority, a normal delivery costs $200-30 but a C-section $560-700. The reader should be reminded that 86% of registered refugees live under the Jordanian poverty line (it is very likely that at least as high of a percentage, if not higher, of unregistered refugees also live under the poverty line). It is also quite clear why the percentage of deliveries in health facilities is so high compared to antenatal care, it is simply because it is a very clear necessity to seek care when delivering a baby, while the need is not as clear while pregnant.
A further impact that has been detected as a result of the difficulties refugees have obtaining the relevant documents is that up to 40% of children born to Syrian parents in Jordan don’t get a birth certificate because the mother didn’t have the documents needed. This can have detrimental effects on the future of the children. For a child, being without a birth certificate can nearly mean that they don’t exist. Accessing education can be nearly impossible, as well as accessing health care can be difficult. The fact that it is hard for Syrian women to obtain the right documents therefore can have a horrible chain-reaction for future generations that are born without citizenship.
The Legal Status of Syrian Refugees in Jordan
Although Jordan has not ratified the Convention Relating to the Status of Refugees (CRSR) of 1951 or its 1967 Protocol, the Jordanian government and the UNHCR signed a memorandum of understanding (MOU) in 1998, which allows the UNHCR to provide international protection to people within the country. After the signing of the MOU, the definition of a refugee, as articulated in the CRSR, has become a part of the legal framework in Jordan. Furthermore, by signing the memorandum, Jordanian authorities agreed to treat refugees and asylum seekers in accordance to international standards. This means that although Jordan has not ratified the CRSR, the government holds at least a minimum core obligation towards refugees. According to the Convention and Protocol Relating to the Status of Refugees (CRSR) a refugee is a person who
[…] owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable, or owing to such fear, is unwilling to return to it.
The problem with this definition of refugees is that people fleeing their homes don’t automatically fall into the legal category of refugees. This means that there is a disanalogy between the colloquial term ‘refugee’ and the legal term. According to Jordanian law, only refugees that are registered either with a ‘Proof of Registration’ or ‘Asylum Seeker Certificate’ can claim the rights of refugees.
Furthermore, the International Labor Organization states in a report that “[i]n practice, Jordan avoids the official recognition of refugees under its domestic laws and prefers to refer to Syrian refugees as ‘visitors’, ‘irregular guests’, ‘Arab brothers’ or simply ‘guests’, which has no legal meaning under domestic laws.” Under Jordanian law, Syrian citizens are free to enter the country, and by doing so and not claiming to be a refugee, they are legally viewed as ‘foreign citizens’ not refugees. This helps Jordanian authorities avoid the obligation they have towards the Syrians, that really are refugees. This does not change the fact that the government has obligation towards those unregistered people, but because they are not registered as ‘people of concern,’ as other refugees are, the legal obligation is less clear.
Human Rights Violations
Jordan
As stated above Jordan has not ratified the Convention Regarding the Status of Refugees, but still has acknowledged the international definition of refugee. It is clear that not every Syrian that has fled to Jordan has the official status of being a refugee. In light of that fact, the human rights violations Jordan has committed will be looked at from the perspective of non-discrimination, in recognizing that by doing so the report can encompass the problems of every Syrian in need of protection in Jordan, and not be limited to registered refugees.
Jordan ratified the International Covenant on Economic, Social and Cultural Rights (ICESCR) in 1975, and therefore “recognize[s] the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” (ICESCR Art. 12.1). The principle of accessibility, as articulated in General Comment 14 to the ICESCR, states that the Jordanian government has a duty to ensure that health care is accessible to all, “especially the most vulnerable or marginalized sections of the population” and that “health facilities, goods and services must be affordable for all.” The Jordanian government has a duty towards everyone, regardless of their nationality or legal status, to not discriminate against them. As stated in General Comment 20, to the ICESCR, paragraph 30, “[t]he Covenant rights apply to everyone including non-nationals, such as refugees, asylum seekers, [etc.], regardless of legal status and documentation.” By introducing user fees for refugees with the MoI-card the Jordanian Government has failed its duty to ensure the affordability of health care. Furthermore, the fact that it is extremely hard, and even impossible for some, to obtain the MoI-card to ensure a reduced fee shows that the government has not ensured non-discrimination.
In recognizing that the situation in Jordan is difficult and the strain under which the health care system is under, it is still obvious that the government failed to uphold its minimum core obligations. The UN Committee on Economic, Social and Cultural Rights has stated in General Comment 14 to the ICESCR, that “States parties have a core obligation to ensure the satisfaction of, at the very least, minimum essential levels of each of the rights enunciated in the Covenant, including essential primary health care.” Furthermore, “[t]o ensure the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups.”
The fact that Syrian women, who are regarded as a vulnerable group, do not have the same rights as Jordanian women in accessing antenatal care shows that the Jordanian government has failed to uphold its duty to fulfil their right to health. While recognizing that there might be resource constraints on the Jordanian government, General Comment No. 3, paragraph 12, articulates “that even in times of severe resources constraints whether caused by a process of adjustment, of economic recession, or by other factors the vulnerable members of society can and indeed must be protected by the adoption of relatively low-cost targeted programmes.” Furthermore, the Jordanian government has failed to “ensure reproductive, maternal (pre-natal as well as post-natal) and child health care,” as well as “ensure equitable distribution of all health facilities, goods and services” since Jordanian women have free access to these services but not Syrian women. Moreover, 95% of Jordanian women access what the WHO regards as essential antenatal care, while only 38.2% of Syrian women that are registered as refugees.
Furthermore, the fact that up to 40% of children born to Syrian mothers in Jordan do not obtain a birth certificate, whatever the reason is for that, is a violation of the article 7 of the Convention on the Rights of the Child, which Jordan has ratified, where it says that a “child shall be registered immediately after birth and shall have the right from birth to a name, the right to acquire a nationality and, as far as possible, the right to know and be cared for by his or her parents.” The Jordanian government has therefore failed to protect the fundamental rights of the most vulnerable population, newborns.
International Community
Article 3, paragraph 1 of the ICESCR, articulates that States have an obligation “to take steps, individually and through international assistance and co-operation, especially economic and technical, […] with a view to achieving progressively the full realization of the rights recognized.” The Jordan government had repeatedly tried to fulfill its duty by seeking assistance from the international community, in understanding that they needed help to fulfill their minimum core obligations. In September 2016, the New York Declaration for Refugees and Migrants was signed by the UN General Assembly. Paragraph 68 of the declaration reads:
We underline the centrality of international cooperation to the refugee protection regime. We recognize the burdens that large movements of refugees place on national resources […]. To address the needs of refugees and receiving States, we commit to a more equitable sharing of the burden and responsibility for hosting and supporting the world’s refugees, while taking account of existing contributions and the differing capacities and resources among States.”
It is therefore clear that the international community has failed to ensure the rights of Syrian refugees and especially those of pregnant women, as well as it has failed to help Jordanian authorities.
First of all, the international community has failed to help Jordan in coping with the increasing numbers of refugees in their country. The fact that Jordan has had to take emergency loans to finance the health care system, and even with that, only be able to fund 26% of what was needed for the year 2015 shows that the international community has failed to help the country in hosting and supporting refugees. Furthermore, the fact that refugees do not have secure access to essential health-care services, and that the New York declaration states that States “will work to ensure that the basic health needs of refugee communities are met,” helps show that the member States have not taken their job seriously enough.
Second of all, the declaration states that they “intend to expand the number and range of legal pathways available for refugees to be admitted to or resettled in third countries.” It is obvious that States have not been expanding available pathways, because the last few years, borders have been closing which makes legal pathways nearly impossible, as well as the fact that even if refugees are able to arrive in a third country by themselves, the Dublin Regulation is often used to send them back to the country the originally arrived to, for example Jordan. This hostility has likely caused many people to settle in countries that are already strained with new populations. This shows that the international community has failed to show the hospitality and solidarity needed in coping with the crises resulting from the Syrian Civil War.
Even the clinics that are free of charge for Syrians, for example the Doctors Without Borders maternity clinic in Irbid and the JHAS clinics, are not easily accessible, since they are often a long way away, which means that transportation costs can be high. Neither are they completely available, because of limited resources which results in not everyone that needs getting the treatment or help they need. This shows further that the even the efforts international organizations have already made, is not extensive enough to help Jordanians fulfil their duty.
Recommendations
Recommendations to Jordan:
♣ Jordan should ratify the Convention and Protocol Relating to the Status of Refugees.
♣ The government should make it easier for refugees to register and obtain the Asylum Seeker Certificate. This can be done by making it easier for people to leave camps with an ASC. It is obvious that the effort to prevent people from leaving camps by restricting who gets a ASC has not resulted in people staying in camps, but rather simply people that leave worse-off, by not being able to register and get the documents needed to get access to public services.
♣ The process of obtaining a Ministry of Interior card, the card that gives people access to public services, should be facilitated. People should not have to pay fees to obtain a health certificate from the Ministry of Health. The requirement that people re-register if they move in-between regions should be more lenient, for example, by allowing people to simply get verification of a new residence, instead of having to do the whole process again.
♣ The government should revoke the user fees that were introduced in 2014 and make an effort to make health care services affordable for everyone regardless of their legal status.
♣ Maternal care should be made free for everyone, not only Jordanian women.
♣ The organizations that run the maternal clinics available should try their best to make the clinics accessible, for example, by providing free transportation. They could also try to visit regions were refugees live and provide antenatal care there. That would greatly increase the number of women getting the care they need for themselves and their babies.
♣ The Jordanian government should issue a birth certificate for every child born, regardless of the mother’s legal status.
Recommendations to the International Community:
♣ The international community should honor their own declaration, the New York Declaration for Refugees and Migrants, and commit to providing real and considerable financial and technical assistance to countries such as Jordan.
♣ The UNHCR and governments, especially of countries in Europe and North-America, should make a real effort in increasing and facilitating resettlement of refugees. A priority should be made to resettle vulnerable groups, especially pregnant women and children. It is very important that children are not unnecessarily made the victims of the Syrian Civil War.
Conclusion
The concluding statement is that although the Jordanian government has violated the human rights of Syrian refugees it is not they who have failed, since they have shown admirable solidarity towards their neighbors. It is the whole world that has failed to uphold the human rights of the Syrian people, who are now entering the sixth year of a gruesome civil war. This, however, does not change the fact that people’s fundamental human rights have to be protected.