Multi-purpose cash transfers and health among vulnerable Syrian refugees in Lebanon: a prospective cohort study

Emily Lyles, Jakob Arhem, Ghada El Khoury, Antonio Trujillo, Paul Spiegel, Ann Burton, and Shannon Doocy

BMC Public Health, Volume 21, Article number 1176 (2021)


This paper evaluates the impact of multipurpose cash transfers (MPCs) on health-seeking behavior, health service utilization, and health expenditures by Syrian refugees in Lebanon. At the beginning of 2020, there were nearly 1 million registered refugees in Lebanon, although government estimates the actual number closer to 1.5 million.

Syrian refugees, regardless of whether they have been registered, can access primary health care at subsidized rates at more than 100 health facilities across Lebanon. Secondary and tertiary health care for refugees is supported through a UNHCR cost-sharing program. Approximately a quarter of refugee households receive MPCs from either or both UNHCR (monthly cash transfers of US$173.5) or WFP (US$27 per person for food). Due to funding constraints, not all economically vulnerable households receive MPCs.

Data was collected from a sample of households from UNHCR’s registration lists from May 2018 to July 2019. Households receiving MPCs from UNHCR (intervention group) were compared to households not receiving MPCs from UNHCR or WFP (control group).

Main results:

  • MPC households reported needing health care more frequently. While baseline levels of care-seeking for child illness and acute adult illness were high for all households, MPC households reported needing care more frequently for child illness, acute adult illness, and chronic adult illness at baseline and endline. However, adjusted differences in change in care-seeking rates over time were not statistically significant for child illness and only marginally significant for acute adult illness.
  • For both MPC and control households, cost was the primary barrier to seeking care or receiving all recommended care. An increasing proportion of both MPC and control households that sought care reported not receiving all recommended care due to cost. Among adults with chronic health conditions, MPCs were marginally associated with an increased ability to afford all recommended services.
  • MPC recipients reported fewer hospitalizations for child illness. Receipt of MPC was associated with consistent hospitalization rates for child illness compared to an increasing rate of hospitalization among controls. No significant differences in change in emergency room visits or hospitalizations were observed for acute or chronic adult illnesses.
  • MPCs did not enhance household ability to obtain all needed medications for child and acute adult illnesses, but they may have been beneficial for obtaining medications for chronic adult illness. Among adults with chronic health conditions, MPCs were marginally associated with fewer difficulties in obtaining and affording medication for chronic disease.
  • MPC recipients reported higher monthly household expenditures on health care. The proportion of MPC recipients reporting expenses for the most recent child and acute adult illness increased significantly, as did the total visit cost.
  • MPCs did not protect recipients from resorting to borrowing and asset sales to pay for health expenses, despite the relatively large transfer size (38 percent of monthly household expenditures on average). Both MPC and control households reported significant increases in borrowing to pay for health expenses over the study period. Differences between the two groups in change in borrowing or asset sales were not significant.

The authors conclude that unconditional cash transfers may improve access to health services and medication for chronic diseases and reduce hospitalizations among children but may be insufficient on their own to address health utilization and expenditures. They suggest that transfer values may not have been sufficiently large to increase access to more costly services or reduce the economic impacts on households of larger health expenses given increasingly high poverty levels.


Cash Transfers | Health


Lebanon | Syria