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FMR 34


Urban refugee health:

meeting the challenges
Paul Spiegel and the Public Health and HIV Section at UNHCR

Many of the accepted health strategies, policies and to integrate health-care treatment
interventions for refugees are based on past experiences into existing public services and
to augment the capacity of these
where refugees are in camp settings and in poor systems, directly when funding
countries. Rethinking of these to take account of the many is available and indirectly by
urban and middle-income refugees is underway. encouraging the engagement of
various donors and other actors.
More than half of the worlds same and different countries, have
refugees now reside in non-camp been an important and controversial Initially, UNHCR and partners (such
settings, including urban areas, topic for many years and are as WHO, UNICEF and medical or
and a larger proportion of them particularly relevant in urban refugee health NGOs) will assess whether
than before are now fleeing from situations.2 In most situations, existing services need help to
middle-income countries where policies and treatments should follow expand their capacity, and how to
the demographic and disease the host countrys health ministrys manage any such expansion. This
epidemiologic profiles are those of guidelines and protocols. However, if approach has the added benefit of
an older population with chronic these are incorrect or inappropriate, encouraging the authorities and
diseases. Furthermore, refugees in UNHCR and its partners will prefer the local population to recognise
urban areas often face numerous to use internationally recognised the fact that refugees can bring
disadvantages compared with low- guidelines, and in the meantime additional resources to the towns
income city dwellers disadvantages work with the national authorities to and cities where they have settled.
such as lack of community support improve the guidelines and protocols. These benefits may have the indirect
systems, exclusion from social effect of improving the protection
security systems or health insurance Given the need to prioritise efforts space for refugees and others.
schemes, and insufficient disposable and allocation of resources,
income (e.g. to pay for transport to and while priorities will
IRIN/Jaspreet Kindra

access such services and for user fees vary from one situation to
and other health-care costs). Stigma another, they will usually
and discrimination may also reduce include safeguarding the
access to already overstretched well-being of pregnant
government health services. and lactating women,
children under five years
In response to the publication in of age, unaccompanied
2009 of UNHCRs Policy on Refugee and separated children,
Protection and Solutions in Urban orphans, older people and
Areas, UNHCRs Public Health those who are seriously ill,
and HIV Section has adopted a including those with HIV
three-pronged strategy focusing and tuberculosis. Other
on advocacy, support of existing priorities include providing
capacities and monitoring of delivery care and counselling to
to work with its partners to increase people with specific needs,
access to affordable and good quality especially people with
health services for urban refugees disabilities, those who are
and other persons of concern.1 traumatised or mentally
ill, victims of torture
Advocacy and sexual and gender-
UNHCR will advocate with the based violence, and those
authorities on behalf of refugees to with complex diseases
ensure that public services such as requiring specialised care.
health care, nutrition programmes
and water and sanitation services Support
are made available to these Integration of refugees
populations at a limited or no cost. into such health systems
in urban environments
Ethical issues of equity of access is a more efficient use
and quality of care, both between of limited resources
refugees and host populations as well than setting up separate
as between refugees living in the facilities. So it makes sense
Residents of the Boa Vista informal settlement
queue for water, Luanda, Angola.

As a general rule, when working cannot be integrated into existing provide sufficient data to allow for
in urban areas, UNHCR will avoid government food and nutrition prioritisation of activities or to allow
setting up separate and parallel programmes for local populations, for proper monitoring and evaluation.
services for its beneficiaries, and will as is desirable, new programmes
instead seek to reinforce existing may indeed need to be created. Besides the difficulty in profiling
delivery systems, whether they urban refugee populations, urban
are public, private, not-for-profit Similarly important parts of the health information systems are
or community-based. If refugees strategy include a) advocacy for more complicated than camp-
cannot afford user fees for health refugees to be included in any local based systems because of the
services, agencies may need to cover (government) social safety nets, b) number of facilities at different
certain costs for the more vulnerable support to local water and sanitation levels (i.e. community-based,
refugees to ensure that all have access authorities to improve the existing primary health care, secondary
to good quality health services. infrastructure to cope with the care and tertiary care facilities)
additional burden placed on existing and different providers (e.g. public,
Community health outreach systems by the arrival of displaced private, NGO) involved in such a
programmes that reach out to populations and c) outreach through system. The health information
refugees as well as the host existing hygiene promotion activities. system must also take into account
community are essential to ensure or be linked to budget monitoring
communication of the rules and Minimising the number of partners to allow for the evaluation of the
regulations of whatever services and facilities/institutions while trying costs of a programme and relate
there are, improve access to all to ensure sufficient access to services the costs to services rendered.
levels of care, provide health has many advantages in terms
education and help ensure effective of establishing agreements, securing In non-camp settings, population-
delivery of preventive services. protection and confidentiality, based sample surveys have proved
Outreach workers may even monitoring the quality of care difficult, politically controversial
deliver home-based health-care and rationalising and monitoring and bias-prone, and some of their
services when appropriate. the costs. methods still require validation.
Other surveillance methods such
Given that poverty and food Monitoring as sentinel sites or prospective,
security are often present among Monitoring the public health and community-based surveillance
refugees in urban areas, if refugees nutritional status of urban refugees may be more useful approaches
is important for ensuring in many situations but are rarely
that these do not fall below used, perhaps reflecting a failure of
acceptable standards imagination and funding rather than
and to provide sufficient insurmountable technical problems.
information to advocate
effectively and support In promoting access to affordable
health services for urban health services for urban refugees,
refugees. The challenges, UNHCR will follow its Public
however, are increased Health and HIV Guiding Principles.4
by the populations being Among these principles, issues
dispersed, often in wide relating to integration, partnership,
and multiple geographic quality of services (i.e. availability,
areas, and in some accessibility, equity, appropriateness,
cases not wishing to be acceptability, effectiveness and
registered.3 Integrating efficiency) and sustainability
refugees into existing are of particular relevance to
health systems generally the urban refugee situation.
includes using existing
health information Paul Spiegel ( is
systems. This can be Chief, Public Health and HIV Section
problematic as some in UNHCRs Division of Programme
systems are not sufficiently and Support Management. This
flexible to allow for article was written in collaboration
essential modifications with other colleagues in the
to disaggregate data Public Health and HIV Section.
according to nationals and
1. For the remainder of this article the term refugees
refugees, or to add certain should be understood to refer to other categories of
disease categories that persons of concern to UNHCR, such as asylum seekers,
internally displaced persons, stateless persons and
may be more predominant returnees.
among a particular group 2. UNHCR. Public health equity in refugee settings.
Geneva, 2009.
of refugees. Furthermore,
3. See Davies and Jacobsen article pp13-15.
many health information
systems do not function
well anyway and may not