Vaccinating Refugees: Lessons from the Inclusive Lebanon Vaccine Roll-Out Experience

^{_{Authors: Naila Ahmed, Nour Aoun, Noushig Kaloustian, Farah Asfahani, Ronald Eduardo Gomez Suarez, Sherin Varkey}}

Countries hosting refugees in the Mashreq region face a daunting challenge. The Mashreq region continues to experience a cascade of forced displacement crises spurred by conflict, violence and political turmoil in Iraq, Syria, and Lebanon, compounded now by COVID-19 and economic shocks. In the last ten years, approximately 12 million Syrians have been displaced, more than half of them to neighboring countries, and in late 2019 there were new waves of Syrian Kurds leaving North East Syria for Iraq. In addition, an estimated six million Iraqis were internally displaced, with an estimated 4.8 million having recently returned to their place of origin while 1.2 million remain as Internally Displaced People (IDPs). While the long-standing Palestinian displacement continues and Syria and Iraq remain volatile, there is little reason to expect that the scope or impact of forced displacement in the Mashreq will be reduced in the near term.

While COVID-19 has led to multifaceted challenges for all in the region, vulnerable populations in Lebanon (both Lebanese and non-Lebanese) are at a particular disadvantage as the country has been assailed by compounded crises — specifically, an economic and financial crisis, followed by the COVID-19 pandemic and, lastly, the explosion at the Port of Beirut on August 4, 2020 — which have significantly exacerbated vulnerabilities among specific groups.

Home to the highest number of refugees per capita in the world, Lebanon hosts 855,172 registered Syrian refugees in addition to 600,000 Syrian refugees informally residing in the country, bringing the estimated total to about 1.5 million, equivalent to over 20% of the overall population. There are also approximately 225,000 Palestinian refugee and 30,000 Palestinian refugees from Syria in Lebanon, 15,800 refugees of Ethiopian, Iraqi, Sudanese, and other origins, in addition to 400,000 migrant workers.

Refugees face difficulties in access and are hesitant to receive vaccination. Following the launch of the COVID-19 vaccination campaign in Lebanon in February 2021, Lebanon adopted an inclusive approach and officially confirmed that its national plan covers all those residing in the country based on priority categories (such as morbidity, age, essential worker status, etc.), regardless of their nationality or residency status. However, despite an inclusive approach and vaccines being made available through public and private sources, several obstacles have emerged, which are particular to refugees and migrant workers living in Lebanon.

One of the platforms established by the World Bank to explore and address such issues is the Joint Monitoring Committee, constituted by the World Bank and UN agencies (WHO, UNICEF, UNRWA, UNHCR and IOM). The objective of this committee is to join efforts to advocate for a fair, transparent, and inclusive vaccination campaign. The World Bank financed Third-Party Monitoring mechanism of the vaccination rollout implemented by the International Federation of the Red Cross and Red Crescent societies (IFRC), has been successful in detecting and reporting violations of the National Deployment and Vaccination Plan.

The World Bank has also established robust communication channels to share the monitoring findings with the Lebanese authorities (the Ministry of Public Health, the National Vaccination Committee, the Vaccine Executive Committee) for prompt action. As the Government of Lebanon (GoL), the private sector, World Bank, UN agencies and NGOs come together to support an inclusive vaccine roll out for all residents of Lebanon, what is interesting to note is that legacy issues which range from mis-trust in the Government, high levels of poverty, to lack of documentation are emerging as impediments. There are concerns that requirement for formal documentation for online registration may lead refugees to refrain from registering out of fear of harassment, arrest or detention.

Furthermore, given the fact that mobility is often a barrier for refugees, vaccination centers need to be opened in areas with a high concentration of refugee populations. For example, the largest concentration of refugees is in Bekaa and Baalbeck-El Hermel region (39%) followed by Akkar (27%). While the establishment of a national online platform for pre-registration has been crucial in ensuring a fair and transparent rollout of the vaccination campaign, low levels of literacy and digital literacy might limit the ability of refugees to register online.

Alternative methods of registration exist (through municipalities or national call center), however they require additional support to boost their capacity. The high levels of vaccine hesitancy across refugee groups is well documented, mainly related to concerns on vaccine safety and potential side effects, similar to Lebanese communities residing in the same regions.

According to a recent survey from IMC at MoPH, almost 37% non-Lebanese respondents stated that they do not think the COVID-19 vaccine is safe, while almost 31% non-Lebanese expressed that they do not have enough information about the COVID-19 vaccine and how it works. Only 23% of non-Lebanese respondents stated that they are willing to take the vaccine when available. As of June 17, 2021, only 38,957 Palestinians and 45,195 Syrians had pre-registered on the national platform. The low levels of confidence in COVID-19 vaccination amongst refugees is evident as only 3.0% of the total estimated Syrian refugee population have pre-registered for vaccination.

Supporting refugees for COVID-19 vaccination

UN agencies such as UNHCR and UNICEF who support Syrians and other refugees, UNRWA whose mandate is to support the Palestinian refugees, International Organization for Migration (IOM) who supports the migrant works as well as relevant NGOs with strong field presence have launched several initiatives to increase awareness, address vaccine hesitancy and support registration. Despite such efforts, the unmet needs are significant. Faced with the magnitude of the multiple crises in the country including the Syrian refugee crisis, new ways and means to mobilize financing to support activities targeting all vulnerable groups and adopting the One Refugee Approach are urgently required.

The World Bank has approved the re-allocation of US$34 million from the existing Lebanon Health Resilience project, which received funding from the Global Concessional Financing Facility (GCFF), to support vaccines for all residents of Lebanon. Launched in 2016, the GCFF provides concessional financing to middle income countries hosting large numbers of refugees at rates usually reserved for the poorest countries. It is the World Bank’s primary instrument to engage on the displacement response in countries such as Lebanon. In addition, the World Bank is currently mobilizing resources from the Health Emergency Preparedness and Response Multi-Donor Trust Fund for refugee vaccination deployment. This initiative aims to deliver a series of interventions intended at understanding and addressing gaps in COVID-19 vaccine preparedness and implementation and COVID-19 response in Lebanon for vulnerable populations, particularly refugees and host communities.

In addition to procuring and financing the costs for vaccines and their deployment for refugees, the Lebanon experience shows that the following approaches are critical for country plans to support vaccination of refugees in any country.

1. Ensure priority groups as defined by a country’s national vaccination plan amongst refugees are clearly identified and supported as part of the implementation of this plan. The COVAX humanitarian buffer can also be accessed as a measure of ‘last resort’ to ensure access to COVID-19 vaccines for high-risk and vulnerable populations where there are unavoidable gaps in coverage in national vaccination plans and micro-plans, despite advocacy efforts.
2. Build vaccine confidence amongst refugee population. Engaging refugee families through an evidence based targeted communication approach using mass media, social media platforms and interpersonal communication through field mobilizers, community influencers, and relevant NGOs would be critical in understanding and addressing the various factors which influence vaccine hesitancy. Having a systematic feedback mechanism with accessible uptake channels in this regard would be important to obtain real time and active feedback from the refugees, which can serve as a critical monitoring tool to identify main areas of concern.
3. Address bottlenecks faced by refugees in registration for vaccination. This will include supporting refugees to access the registration platforms with special focus on those who do not own or are not comfortable with the use of mobile phones and online applications as well as relaxation in the requirements for ID documents for registration. Innovative approaches such as group registrations facilitated by UN or NGOs, mass vaccination outreach campaigns tailored to reach the different groups, working through embassies in the case of migrant workers should also be explored. A good example is the first “vaccination marathon” launched by the Ministry of Public Health in Lebanon on May 29th, 2021 where more than 10,000 individuals received the COVID-19 vaccine, of which around 40% were non-Lebanese.
4. Implement special measures for underserved areas. Governments should collaborate with partner agencies and civil society to improve access to immunization in areas with large proportion of refugee population. This would require opening additional vaccination sites or using outreach approaches such as mobile vaccination units and exploring ways to decentralize efforts by working with municipalities in regions which host large numbers of refugees.
5. Consider the security concerns faced by refugees. Refugees will need assurance of their data being protected and free from misuse by state security authorities or agencies. Refugees will also need to feel safe and confident to access vaccination sites.

In addition to the above, initiatives to support vaccination of refugees must recognize the complex dynamics of the local context. Lebanon, for example, is currently seeing over 55% of its own population fall below the poverty line due to the economic crisis. It is critical to remain sensitive to the sentiments of the host communities and ensure that there is no privileged access or improper targeting or prioritization of one population over another. The ultimate goal for countries is to ensure fair and equitable access to vaccines for all with the understanding that no one is safe until everyone is safe.