Module 1: Healthcare in Refugee Camps and Settlements

Introduction

As of 2015, there were 65.3 million forcibly displaced persons worldwide.(1) Forcibly displaced persons include refugees, internally displaced persons (IDPs), and asylum-seekers. The UN General Assembly defines the term “refugee” as any person who “is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion.”(2) There were 21.3 million refugees in 2015, and more than half of all refugees came from just three countries: Syria, Afghanistan, and Somalia. These registered refugees are faced with three options: repatriation, local integration, or resettlement. Like refugees, IDPs have been forcibly removed from their homes due to violence or conflict; however, they remain within their own country. This category also includes refugees who have returned to their country of origin but who find that the country remains too dangerous to live in independently. In 2015, there were 40.8 million IDPs, with the largest numbers coming from Yemen, Iraq, Ukraine, Sudan, the Democratic Republic of the Congo, and Afghanistan. Finally, asylum-seekers, of which there were 3.2 million in 2015, are those who have applied to become a registered refugee but whose status is currently undetermined.

86% of the world’s refugees are being hosted by developing regions. In 2015, the countries that hosted the greatest number of refugees were Turkey, Pakistan, and Lebanon. Children composed half of the total refugee population, and 98,400 of these children were unaccompanied or separated from their parents.(3) Providing healthcare to refugees comes with its own unique challenges due to the extreme poverty, limited resources, over-crowdedness and remote settings of refugee camps.

Health in Refugee Camps

Refugee populations tend to have poorer health indicators than the communities from which they came.(4) Refugees usually have the highest risk of mortality immediately after reaching their country of asylum, as they frequently arrive in poor health and are completely dependent on foreign aid. During this time, the most commonly reported causes of death include diarrheal diseases, measles, acute respiratory infections, malaria, malnutrition and other infectious diseases.(5) There are also higher rates of STIs and increased rates of HIV transmission found in refugee camps due to engagement with sex workers, rape, and insufficient access to reproductive health services.(6) However, these trends are highly variable and dependent on the services of the particular camp, for some UNHCR refugee camps provide more extensive medical attention than in the refugees’ home countries and are thus able to reduce HIV infection rates as well as regional diseases with a more universal standard of health care imposed by the United Nations.(7)

Barriers to Care

Refugee camps present even greater barriers to care than most other settings in the developing world because they tend to be remote, poorly accessible by road, and have a limited power supply.(8) In addition, the limited amount of resources that camps have, combined with growing populations, puts great strain on basic resources such as food and water. The high mobility of the refugee setting, with the constant inflow and outflow of people, presents a unique challenge because it is difficult to provide sustained care over a period of time.(9) See Clinic Challenges in Resource-Poor Settings for more in depth explanations of these barriers.

Innovations

Though there are significant barriers that must be overcome to provide effective healthcare to refugee populations, a number of innovative techniques have worked to improve the health of refugees living in camps.

Case Study: Ultrasound in Lugufu Refugee Camp in Tanzania

A study conducted in Lugufu refugee camp in Kigoma District, Tanzania showed that ultrasound can be effectively implemented in refugee camp settings. In 2005, a group of physicians traveled to Lugufu and conducted an intensive four day training session for healthcare providers in the camp on how to correctly use ultrasound. Over the two year study period, healthcare providers in the camp used ultrasound to perform exams on women of childbearing age to diagnose female pelvic and obstetric issues, as well as to diagnose several tropical infectious diseases, such as echinococcosis. The healthcare providers subsequently stated that the use of ultrasound improved their ability to care for their patients.(10) In addition, ultrasound was shown to be used effectively in a refugee camp on the Thai-Burmese border by locally-trained health workers for gestational age estimation.(11)

Case Study: Reproductive Health Group in Guinea

The Reproductive Health Group developed an innovative technique that greatly improved education and access to reproductive healthcare in refugee camps. The program was developed through the efforts of Sierra Leonean and Liberian refugees in Guinea who were nurses and midwives. Aware of the lack of health resources, the limited number of health facilities, and the language barrier between the Guinean health workers and the refugees, these refugees decided to form a group that would provide information and advice to refugees about family planning and reproductive health. The group recruited nurses and midwives from the refugee community itself, trained refugee lay women to provide contraceptives and health education, and created drama groups in an attempt to reach male adolescents and educate the population. The group was so successful that it obtained official NGO status in 1996, and it soon became the most effective provider of reproductive health services in Guinea.(12) The group was instrumental at disseminating information and educating the community. Both men and women who said they received their source of information from Reproductive Health Group facilitators were more likely to name key STI symptoms. In addition, the UN estimates that the use of current contraceptives for Sierra Leone and Guinea was at 3.9% and 4.1% respectively, while the Reproductive Health Group’s contraceptive coverage for Sierra Leonean and Guinean refugees was 17%.(13) This statistic supports the value of the Reproductive Health Group’s work, and the success of this innovation shows the importance of community engagement to improve the health of a population.

Case Study: Youth-Friendly Centers for Bhutanese Refugees in Nepal

In 2006, UNHCR camps in Nepal implemented Youth-Friendly Centers (YFCs) to address risk behaviors associated with high rates of HIV and substance abuse among young Bhutanese refugees. Run by local youth who are elected by YFC members, the centers are open to all refugees ages 18-25. The YFCs serve to not only foster leadership skills but also raise awareness about health-related issues. Youth are trained as peer educators to spread information about STI testing and services. These peer educators also lead reproductive health and substance abuse awareness campaigns throughout the year, many of which are centered around street dramas. This community-based engagement with youth has brought important health information to a wider audience in an innovative and interactive way.(14)

Case Study: Efforts to Improve Health Care and Health Education in Meheba Refugee Settlement in the Northwest Province of Zambia

Meheba Refugee Settlement in Zambia is one of the positive examples of a concerted effort on the part of the UNHCR and other local NGOs to spread awareness of sexual health, STIs such as HIV, and to promote health education more broadly. Pamphlets in Meheba are distributed camp-wide in French, Swahili, Lingala, Lunda, and many other local dialects to educate refugees on the truths of HIV/AIDS and other diseases, the symptoms associated, and preventative measures. Free HIV testing takes place weekly in the communal marketplace of the settlement, as do health talks. As a result of these efforts, Meheba Refugee Camp has a much lower HIV infection rate than its surrounding Zambian northwest province. Higher international health standards and UNHCR’s accountability to the world stage increases health standards as well as follow-up to health procedures. On top of this, World Refugee Day, which is celebrated every summer, features short plays, information sessions, and songs that cover issues such as HIV/AIDS, marital abuse, alcoholism, and the mental ramifications from violence, which further promotes awareness.(15)

Footnotes

(1) UNHCR. “Global Trends: Forced Displacement in 2015.” https://s3.amazonaws.com/unhcrsharedmedia/2016/2016-06-20-global-trends/2016-06-14-Global-Trends-2015.pdf.

(2) “Convention and Protocol Relating to the Status of Refugees.” http://www.unhcr.org/protect/PROTECTION/3b66c2aa10.pdfhttp://pdfserve.informaworld.com/690 908_731193368_725786965.pdf.

(3) UNHCR. “Global Trends: Forced Displacement in 2015.” https://s3.amazonaws.com/unhcrsharedmedia/2016/2016-06-20-global-trends/2016-06-14-Global-Trends-2015.pdf.

(4) Adler, D., Mgalula, K., Price, D., and Taylor, O. “Introduction of a portable ultrasound unit into the health services of the Lugufu refugee camp, Kigoma District, Tanzania.” Int J Emerg Med 1 (2008): 261-266.

(5) Toole, M.J., and Waldman, R.J. “The Public Health Aspects of Complex Emergencies and Refugee Situations.” Annual Review of Public Health 18 (1997); 283-312.

(6) Chen, M.,et al. “Reproductive health for refugees by refugees in Guinea II: sexually transmitted infections.” Conflict and Health. 2.14 (2008)..

(7) UNHCR the UN Refugee Agency, Figures at a Glance.

(8) Adler, D., Mgalula, K., Price, D., & Taylor, O. (2008). Introduction of a portable ultrasound unit into the health services of the Lugufu refugee camp, Kigoma District, Tanzania. International journal of emergency medicine, 1(4), 261-266.

(9) Rutta, E., et. al. “Prevention of mother-to-child transmission of HIV in a refugee camp setting in Tanzania.” Global Public Health. 3.1. (2008): 62-76.

(10) Adler, D., Mgalula, K., Price, D., & Taylor, O. (2008). Introduction of a portable ultrasound unit into the health services of the Lugufu refugee camp, Kigoma District, Tanzania. International journal of emergency medicine, 1(4), 261-266.

(11) Rijken, M., et. Al. “Obstetric ultrasound scanning by local health workers in a refugee camp on the Thai-Burmese border.” Ultrasound in Obstetrics and Gynecology 34.4 (2009); 395-403.

(12) Von Roenne, A.,et al. “Reproductive health services for refugees by refugees: an example from Guinea.” Disasters. 34.1 (2010): 16-29.

(13) Chen, M. I., von Roenne, A., Souare, Y., von Roenne, F., Ekirapa, A., Howard, N., & Borchert, M. (2008). Reproductive health for refugees by refugees in Guinea II: sexually transmitted infections. Conflict and health, 2(1), 14.

(14) The UN Refugee Agency. “Establishment of Multi-purpose Youth-Friendly Centres for Young Refugees in Nepal.” http://www.unhcr.org/4c5fdf326.pdf.

(15) UNHCR "Zambia." http://www.unhcr.org/pages/49e485ba6.html.