Forced migration and healthcare systems

Assessment and surveillance

A fundamental role of public health is to assess the current and future health needs of refugees and IDPs to help allocate resources and to design, implement, and evaluate health services and systems to meet those needs. This is based upon the collection of timely and valid quantitative and qualitative data. Of particular importance are epidemiological studies. Epidemiology is the study of the distribution, frequency, and determinants of health-related events in human populations. It is less concerned with events affecting a single individual than it is with the patterns of events in populations, and is based on the premise that adverse health outcomes do not occur randomly within a population but rather occur in somewhat predictable patterns. Such patterns may be manifested as clusters of disease, or other health outcomes in location, time, or amongst certain groups of people.

The overall objective of assessment and epidemiological surveillance is to understand the needs of displaced populations, match available resources to needs, prevent further adverse health effects, evaluate the quality and quantity of services provided, and facilitate improved performance in the planning, services, and management by individuals, organizations, and health systems. Such studies may address the following:

• Vulnerability analysis of the population at risk.
• Evaluation of the public health impact of disasters or complex emergencies.
• Analysis of risk factors for adverse health effects.
• Clinical and economic investigations of the efficacy and effectiveness of particular approaches to prevention, diagnosis and treatment of healthcare interventions.

Essential to the effective measurement of such studies is a surveillance system that integrates epidemiologic, behavioural, laboratory, demographic, vital statistical, economic, medical, anthropological, and other types of information for programme development and action. To support preparedness, WHO has established a ‘Health Intelligence Network for Advanced Contingency Planning’, which provides rapid access to up-to-date information on particular countries and their health indices, as well as guidance on best practices and data on disease surveillance.

However, surveillance studies are often imprecise in identifying etiologic factors associated with increased morbidity and mortality. Such studies take place in what are generally extremely difficult situations characterized by insecurity, political involvement, restricted access to areas of conflict and sources of information, public fear and mistrust, lack of infrastructure, rapid movement of large populations, and lack of trained people to carry out the survey. Many poor countries also lack reliable health registration systems, making it particularly difficult to get baseline demographic and health data and denominators to determine the proportions of deaths, diseases, and disabilities that are related to conflict and settlement in refugee and IDP settings.

Whilst progress has been made, there remain calls to further standardize and co-ordinate the protocols, procedures, and indicators for the gathering of information, and to ensure that data is available, intelligible, useful, and appropriate. A further challenge to the medical research profession lies in the fact that there remains limited protection for refugees and IDPs when participating in medical research. This is particularly important given their lack of power and control.

Data limitations can be partially overcome through ‘quick and dirty’ surveys which aim to ensure simplicity, speed of use, and operational feasibility. These rapid assessment and surveillance methods use data from existing/temporary medical facilities, sentinel surveillance, community questionnaires, verbal autopsies, structured and semi-structured interviews, and focus group discussions. However, one of the greatest challenges is that no matter how accurate, timely, or relevant the information for policy- and programme-making, other issues come in to play involving political and personal values. This is particularly the case in the intensified environment of the complex emergency.

A large number of health assessment tools have been developed. These include the following:

• WHO: Rapid Health Assessment Protocols for Emergencies, 1999 http://www.who.int/disasters/
• UNHCR: Operations Management Handbook, 2003 http://www.unhcr.org/cgi-bin/texis/vtx/publ
• The International Federation of Red Cross and Red Crescent Societies: Disaster Preparedness Training Manual, 1997 http://www.ifrc.org/WHAT/disasters/dp/manual.asp
• Sphere project, Sphere Project Handbook, 2004 http://www.sphereproject.org
• Johns Hopkins University School of Public Health: Rapid Assessment Procedures (RAP): Addressing the Perceived Needs of Refugees & Internally Displaced Persons Through Participatory Learning and Action, 2000 http://www.jhsph.edu/refugee/images/tmb_rap_docs/rap_section1_profile.pdf
• Médecins Sans Frontières (MSF), Refugee Health: An Approach to Emergency Situations, 1997 http://www.msf.org/source/refbooks/msf_docs/en/Refugee_Health/RH1.pdf
• MSF - Rapid Health Assessment of Refugee or Displaced Populations, 1999 http://www.msf.org/source/refbooks/index.htm

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Relief, rehabilitation, and development

A healthcare system may be defined as the resources, organization, financing, and management that go into the delivery of health services to the population in a designated geographic entity: country, province, district, or the like. Conflict and forced migration exert direct and indirect effects on health status and health systems, and the needs of forced migrants pose significant challenges to the healthcare systems in the areas in which they arrive. The nature of these challenges varies enormously depending on the cause of displacement, the socio-economic and political conditions in the source and host countries, the capacity of local health systems, and the health needs of the displaced and host population.

In refugee settings, the government authorities of the host country delegate the responsibility for the health care of refugees either to their own representatives or to a humanitarian agency or consortium of UN and NGO agencies, depending on the government’s capacity for health financing and provision. The delegation of responsibility for IDPs is more complex and problematic, with local powers often reluctant to directly provide services or allow external agencies to do so.

Those responsible for healthcare services need to decide the most effective system for their provision. Criteria which need to be addressed include, firstly, ensuring accessibility and equity of care. This includes geographic, financial, political, and sociocultural access, and must address issues of discrimination based upon gender, age, ethnicity, or political affiliation. Secondly, the quality and humanity of care, including participation by the target population in the nature and range of health services provided, must be addressed. Thirdly, co-ordination must be ensured between the types of services offered, the needs of the target population, and the various administrative and implementing bodies involved. Lastly, it is essential that the needs of the host population are fully taken into account and not marginalized in this process.

These decisions are generally based on findings from local assessments and surveillance (see above), negotiations with local authorities, agency policies, operational guidelines and specialist experience. The strong involvement of local entities in the initial assessments has also proven to be beneficial. A key difficulty faced in assessing the most effective provision of health services to refugees and IDPs is the lack of systematic data and research. Whilst the WHO and the Macfarlane Burnet Institute for Medical Research and Public Health have begun to document studies that will build the foundation of research, no foundation of applied health research exists for complex emergencies, as it does for natural and technological disasters or for conventional cross-border wars.

In emergencies, humanitarian organizations try in the first instance to prevent loss of life and subsequently to re-establish an environment where health promotion is possible. Many relief organizations see their primary role in providing these Emergency Medical Health Interventions (EMHIs) to save lives and have an impact upon health outcomes within a couple of weeks. Their health measures are largely decided by humanitarian agencies (justified by the urgency of meeting vital needs), and are not necessarily concerned whether their activities can be replicated or sustained over the longer term.

In contrast, agencies such as UNHCR have adopted a specifically development-related, primary health care (PHC)-based perspective that attempts early on to take into account issues such as efficiency, sustainability, equity, and local involvement and ownership. PHC activities include:

• Promotion of good nutrition.
• Adequate provision of safe water and basic sanitation measures.
• Shelter and housing.
• Immunization programmes.
• Prevention and control of local endemics through communicable disease and vector control programmes.
• Reproductive health care and preventative care for mothers, infants and children.
• Treatment of common diseases and injuries.
• Provision of essential drugs.
• Health promotion and education about health problems.

EMHIs are criticized for foregoing sustainability by becoming too isolated from longer-term PHC initiatives, and for not recognizing that the needs of refugee populations are not essentially different from the everyday health needs in developing countries. However, the development/PHC approach is criticized for failing to address the unique, immediate challenge of acute morbidity and mortality. It is said that the objectives of emergency interventions must be differentiated from other forms of intervention, with specific tools developed, and a more context-specific and flexible appreciation of vulnerability ( Davis 1996 ).

However, a synthesis of the two approaches is possible. Both use a similar strategy of aiming to ensure the widest possible access to health services and emphasising preventative measures. The varying causes of forced migration and changes over time will also effect the nature of the healthcare needs and thereby the appropriateness of different approaches. This includes shifts from casualty and acute patient care management towards provision of primary health services. Co-ordination between EMHI and PHC, including the participation of the target population in planning and implementation, would help emergency activities gain a ‘developmental’ dimension ( Macrae et al. 1998 ).

The nature of service provision and systems development also includes debate over the establishment of parallel services for displaced persons, or a more development approach by upgrading the existing health infrastructures to provide integrated services for host and displaced persons. Whilst the former may be more able to meet the specific needs of displaced persons, it may forego sustainability and also run the risk of alienating the host population if they perceive health services for displaced people as better than their own. An example of efforts to co-ordinate and integrate emergency health care with long-term health sector reform was led by WHO in Kosovo in 1999. This highlighted the importance of close inter-agency and cross-sectoral co-operation, and the need for a clear mandate, legitimacy, and leadership. These are clearly challenges in themselves.

Long-term planning, and ultimately legitimacy, of health services and systems also involves shifting responsibilities over time between humanitarian agencies and local or national authorities. Ensuring the extent and quality of services provided is a particular concern where doubts exist as to the capacity and/or willingness of the authorities to provide services to the displaced population. The risk is in maintenance of the socio-economic structural weaknesses that may have been a cause of the conflict or displacement itself. Rehabilitation must therefore take into account the needs of the previously under-served minority groups and ensure more equitable and appropriate access to health services.

Addressing the needs of displaced people also implies financially re-examining the conventional expectations of the national healthcare system. The potential expense and resources needed may require considerable international support, including ensuring sustainability through appropriate allocation of capital and recurrent costs ( Macrae 1997 ). Concerns over financial sustainability have also led to debate over the use of health-user fees. Although the general consensus is that health services should be provided for free to refugees, a number of cost-recovery schemes have been introduced in long-term, protracted situations, such as in Afghanistan and the Democratic Republic of Congo, in an attempt to improve the long-term financial viability and quality of health services. Studies on the use of user fees in complex emergencies have addressed issues of equity, including people’s willingness and ability to pay for health services and the impact that user fees and cost of medicines have upon purchase of other essential items and food such as food, education, and housing.

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Health, humanitarianism, and human rights

The provision of health services to refugees and IDPs is inevitably implicated in the ongoing debate within the humanitarian field between those favouring the traditional humanitarian principles of impartiality and neutrality, and those who feel humanitarian activities should include longer-term political, developmental, and human-rights goals. Critics of the former would argue that in many cases health workers are inadvertently assisting the very perpetrators of violence, and confer a degree of legitimacy on the perpetrators. Instead, humanitarian work should actively involve securing human rights and peace, even at the expense of neutrality and impartiality. Many agencies support this belief. Médecins Sans Frontières (MSF) was founded upon the importance of ‘bearing witness’ to human rights violations; and in extreme cases, services have been withdrawn from those suspected of being involved in violent activities, such as from refugee camps in Zaire in 1994. Staff of NGO have expressed their belief that humanitarian responses alone are often insufficient, and that without a commitment to human rights, humanitarian responses will only mitigate suffering, but not prevent a new generation of victims of human-rights violations ( Rieff 2002 ). Indeed, neutrality has almost become a dirty word among many of the UK’s leading aid agencies ( Slim 1997 ).

However, the reformist approach is marked with huge practical and ethical difficulties that potentially risk the significant gains made in humanitarianism over the past half century ( Fox 2001 ). How does one distinguish (and prioritize services between) the victims from the villains, refugees from fugitives, the deserving from the undeserving? Gerald Martone ( 2003 ) of IRC noted, "by withdrawing life-sustaining assistance from refugees of Hutu ethnicity, humanitarian agencies abandoned the principle of impartiality. Is this not precisely the sort of prejudice and ethnic generalization that had caused the slaughter in the first place?"

Critics of the development approach also express concerns that development-oriented aid interventions may be channelled through organs of the state, so that in situations where the state is a party to conflict, humanitarian aid may lose its fundamental elements of neutrality and impartiality ( White and Cliffe 2000 ). Making humanitarian aid political by linking it with human rights and longer-term development also runs the risk of combatants no longer recognizing or respecting the impartiality and neutrality of humanitarian agencies. As Hugo Slim noted, ‘agencies cannot expect immunity or “humanitarian space” if they are leaning towards solidarity’ ( Slim 1997 ).

The humanitarian principle is further clouded by the arguments for military intervention based upon humanitarian justifications, which have been supported by a number of aid agencies. The danger is a blurring of roles as military forces get involved in the provision of humanitarian relief, with aid agencies perceived as being aligned with the those same military forces and their governments. Attacks on UN, Red Cross, and NGO staff in Afghanistan and Iraq in 2003 testify to the increasing lack of respect for humanitarian principles by belligerents.

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