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).

A 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:

1. The refugees arrived in waves and were spread over a large area so the administrative and health authorities were not overwhelmed.
2. Many refugees were culturally related to the host population with whom they had contacts before arrival.
3. 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.

Reference

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