Refugee Influx Can Improve Services for Locals
Summary of published paper
There has been debate
around the effects of service provision for refugees on host populations.
The level / quality of care provided by local services are taken into account when setting
standards for service provision in camps. Aiming at providing a level of
health, nutrition and general quality of life for refugees greater than that experienced among
host population has been seen by some as inappropriate. The following summary
illustrates that there can be a marked positive effect on the host population when
health facilities for refugees are integrated into, and supported by, existing
health care structures. There may be lessons here for those planning refugee
nutrition interventions (Eds).
recent paper published in the Lancet described the effects of a refugee
assistance programme in Guinea on the host population as measured by the
number of obstetric interventions carried out.
When refugees arrive in
a country in large numbers they are generally moved into camps where they
get relief assistance. Several studies have shown that such refugee assistance
may have a negative impact on the quality of health services offered to
the host population. Commonly, parallel refugee health services are organised
by foreign relief agencies to deliver a standard health package. Relief
organisations often recruit medical staff from the host country. This can
hamper the functioning of the health services with a scarcity of
such staff. The health authorities that are supposed to co-ordinate relief
agencies in the area can also be overwhelmed by new relief programmes,
further weakening the local health services.
Since 1990, half a million
people have fled from Liberia and Sierra Leone to Guinea, West Africa where
the government allowed them to settle freely and provided medical assistance.
Government/UNHCR and NGO policy was to give refugees free access to the
Guinean health services, which were reinforced and extended where necessary.
UNHCR covered the cost of refugee health care on a fee for services basis,
whereas native Guineans had to pay for most services themselves.
A research team from the Department of Public Health, Institute of Tropical
Medicine in Antwerp, set out to assess whether the host population gained
better access to hospital care during 1988-96. The research team looked
at data from Gueckedou prefecture on obstetric interventions performed
in district hospitals between January 1988-96 and estimated the expected
number of births to calculate the rate of major obstetric interventions
for the host population. They found that the rates increased significantly
in the area with high numbers of refugees compared with two other areas.
In areas with large numbers
of refugees the refugee assistance programme improved the health system
and transport infrastructure. The district hospital in Gueckedou was repaired,
staff were trained and supplies and equipment improved. The number of first
line health services including health centres and health posts in rural
areas increased from 3 in 1990 to 28 in 1995, mostly in areas with
large or moderate numbers of refugees. Transport infrastructure was
substantially improved. Roads and bridges were repaired mainly to allow
food aid to be transported to the refugee settlements. The presence of
refugees also led to economic changes and increased utilisation of services
by nationals. The presence of freely settled refugees meant cheap labour
and increased use of agricultural resources. Relief food was sometimes
resold, which substantially increased trade and circulation of money in
the area. Agencies assisting the refugees employed hundreds of staff and
introduced more money into the local economy. These changes seem to have
enabled better access to cash for the Guinean rural population for whom
lack of money was often a constraint when seeking emergency medical care.
The non-directive refugee
policy made such changes possible and could be a cost-effective alternative
to camps. Refugee assistance followed the refugees to where they settled
and supported the refugees own coping mechanisms. Several factors made
the situation conducive to this type of approach:
- The refugees arrived
in waves and were spread over a large area so the administrative and health
authorities were not overwhelmed.
- Many refugees were culturally
related to the host population with whom they had contacts before arrival.
- Conditions prevailing
in the existing health system were also favourable as the Ministry of Health
(MOH) had launched new integrated health centres and was upgrading
the hospital. With stocks of drugs and medical equipment readily available
locally new health facilities modelled on the national health policy could
be created overnight.
The situation of refugees
in Guinea was therefore different from that of many refugees who generally
arrive more quickly in larger numbers. In other countries, conditions for
an integrated approach to refugee assistance may be less favourable. However,
the positive effects for the host population documented in Guinea show
that such a strategy might be worthwhile for host governments' consideration
whenever possible. Relief agencies involved should adapt intervention methods
accordingly. An integrated approach to refugee assistance is probably also
more cost-effective. In Guinea the cost of medical assistance was estimated
at $4 per refugee per year . This is much lower than the average cost of
medical services in refugee camps of $20 per refugee per year.
The authors concluded that
a non-directive approach to refugees has the potential to avoid the negative
impact of emergency refugee relief on the health services of the host country
and to improve access to health care for the host population. Those conditions
which enable such an approach with appropriate intervention methods should
be studied in other refugee affected areas.
Damme, W.V, De Brouwere.
V, Boelaert. M and Lerberghe. W (1998): Effects of a Refugee-Assistance
Programme on Host Population in Guinea as Measure by Obstetric Interventions:
The Lancet , Vol 351, May 30th, pp 1609-1613
Taken from Field Exchange Issue 5, October 1998