Refugee perceptions of the quality of healthcare: findings from a participatory assessment in Ngara, Tanzania

This article describes the findings of a participatory assessment of Burundian and Rwandan refugees' perceptions of the quality of health services in camps in Ngara, Tanzania. Taking a beneficiary-centred approach, it examines a collaborative effort by several agencies to develop a generic field guide to analyse refugees' views of healthcare services. The objective was to gather information that would contribute to significant improvements in the care offered in the camps. Although the primary focus was on healthcare, several broader questions considered other general apprehensions that might influence the way refugees perceive their healthcare. Findings indicated that while refugees in Ngara were generally satisfied with the quality of healthcare provided and healthcare promotion activities, recognition of some key refugee concerns would assist healthcare providers in enhancing services. With increasing need for refugee community participation in evaluating humanitarian assistance, this assessment has relevance both in the context of Ngara and beyond.     

Refugee Density and Dependence: Practical Implications of Camp Size

Different refugee camps may have widely differing morbidity and mortality rates. Some of these differences are ascribed to environmental factors. This paper reviews the key issues relating to one environmental factor: the size of the refugee camp, and provides a tentative theoretical framework for examining the effect of camp size on refugees. This effect may not be considered because aid workers chronically underestimate the value of the refugees' contribution to their own survival. Large camps settle great numbers of refugees to the hinterland of the camp and limit their access to resources available there. This may increase refugee dependency and vulnerability. There is some slight evidence from the analysis of data provided by Mercer (1992) that child mortality rates (aged 0–4 years) are positively correlated with camp size (as inferred from child populations). If other factors allow, it might be wise for camp planners to try to limit camps to a size which allows refugees reasonable access to local resources.     

Planning STI/HIV prevention among refugees and mobile populations: situation assessment of Sudanese refugees

This article reflects an investigation of knowledge, attitudes and behaviours and HIV/STI prevalence of Sudanese refugees and Ethiopian sex workers in 1992. It represents one of the earliest such investigations within an African refugee population. The investigation took place in the Dimma refugee settlement in south-western Ethiopia and study participants included Sudanese refugee men and women and Ethiopian female sex workers. Methods used for this investigation included focus group discussions, behavioural surveys and serologic testing. The main outcome measures of the investigation were HIV/STI knowledge, attitudes and behaviours and biological markers for HIV, syphilis and herpes simplex 2. The study findings indicate that in the early 1990s, knowledge about AIDS and condom use was low among Sudanese refugee women and not one reported having ever used a condom. Furthermore, sexual contact between refugee men and sex workers was frequent during the time of this study and the prevalence of HIV and other STIs was high. The results confirm a widely held assumption that highly mobile and transient populations in Africa are susceptible to STIs and HIV, in large part due to their knowledge, attitudes and behaviours.     

Reproductive health services for refugees by refugees: an example from Guinea

The need to involve refugees in their own reproductive health (RH) services has long been recognised, but there is a lack of published examples describing how this can be achieved collaboratively between refugee initiatives, UNHCR, bilateral development organisations and international relief agencies. This paper outlines the work, outputs and lessons learnt of the Reproductive Health Group (RHG), an organisation of Liberian and Sierra Leonean refugee midwives and laywomen providing RH services to fellow refugees in Guinea's Forest Region between 1996 and 2000. Working as part of the Guinean health system, RHG midwives and community facilitators helped make the RH services in their region the most effective in Guinea at the time. Looking at RHG's achievements, the challenges it faced and partly overcame, it is argued that refugee organisations can plan and implement RH services for refugees where UNHCR and its international partners ensure that they receive funding and technical assistance.     

Training Community Health Workers in refugee camps: A case study from Pakistan

In October 1983 a training programme for refugee community health workers was begun as the major part of a primary health care programme for Afghan refugees in Pakistan. The programme began with a pilot period in Badaber camp, situated near to Peshawar. The general issues involved in training auxiliary health personnel were answered by the use of a "knowledge, attitudes and practices survey" and involvement of the refugees from the beginning of the programme. The development of the training programme is discussed with reference to these issues and the constraints arising from the special circumstances of the refugees, in addition to those common to most national training programmes, are reviewed.     

A general assessment of the environmental impact of refugees in Somalia with attention to the refugee agricultural programme

This paper attempts to examine the broad features of Somalia's harsh physical environment into which several hundreds of thousands of refugees, with mainly a nomadic or semi-nomadic life style and culture, dramatically descended six years ago. The thirty-six rural camps in which at least half of them live are described as is the refugee agricultural programme which is training several thousand families so that they may be "self-supporting." The four regions where the camps are located are each briefly summarized in terms of their soils, their climates, their natural vegetation, and the type of agriculture which the refugee farmers practice. A more detailed analysis is then given on the following critical environmental concerns: Vegetation and erosion on refugee farms, the growing problem of refugee livestock, the destruction of trees, and irrigation practices and salinity on refugee farms. The paper concludes with an argument to preserve Somalia's environment from careless and destructive exploitation, which is leading towards desertification, and calls for an in-depth study of the situation.     

Training refugees as primary health care workers: Past imperfect, future conditional

Many problems have been encountered in the planning and implementation of health care in refugee camps, and more specifically in the training of refugees as primary health care workers. A review of the published literature and a "survey" of the opinions and experiences of refugee, national and international health personnel regarding training has therefore been undertaken to provide an overview of what has been done and to make recommendations for future work.
The review highlights the need to reallocate resources away from high visibility emergency aid to development activities, such as training, that will create an infrastructure for primary health care and promote self-reliance.     

Effects of social interaction between Afghan refugees and Iranians on reproductive health attitudes

Afghan refugees in Iran, like many Muslims around the world, think that using contraceptives is against their religious beliefs. The majority of Iranians also thought so until a decade ago. Since then an all-encompassing social movement has emerged in Iran in which women and young people have played decisive roles. This movement has led to an attitude shift towards acceptance of family planning across Iranian society. High-ranking clerics, responding to the social movement, issued progressive edicts indicating that poor families could practise family planning. This paper reports the findings of focus group studies carried out among Afghan refugee men in two communities in Iran. The findings indicate that exposure to Iranian life, especially the rulings of Iranian clerics, have influenced Afghans' views on family planning. The findings also indicate that a system of justification is needed to help people avoid both social sanctions and individual stresses resulting from a controversial practice regarded as a sin for centuries.     

Uncovering local perspectives on humanitarian assistance and its outcomes

This paper draws on a study of Angolan refugees in Zambia to suggest ways that the perspectives and interests of the local population can be included in the assessment of relief interventions. Taking an actor-oriented approach, the paper suggests stepping back from the categorisation of the situation as an emergency and particular groups of people as the beneficiaries. Such categories are imposed from outside and may not reflect local people's outlook on the situation. In the case of Angolans in Zambia, the category of refugees had dissolved in the border villages to the extent that it was practically impossible to distinguish between refugees and hosts. This was in contrast to the official settlements where people were marked out as refugees and the label was maintained and reproduced over many years. Investigating outcomes in the border villagers in terms of refugees and the refugee problem would have been futile. The paper calls for evaluations of humanitarian assistance in complex emergencies to look beyond the 'beneficiaries' and to investigate the wider context of 'normality'. Neglecting the life and world of local people will make it impossible to understand the process by which external interventions are mediated at the local level to give particular outcomes, and valuable lessons which could help alleviate suffering will be lost.     

An Ethiopian refugee village in Sudan: the question of employment

Abstract— There are some 460,000 Eritrean and Tigrean political refugees in Sudan. The numbers have increased dramatically since the mid-1970s, and as yet there are no convincing signs of peace which would allow the prospect of a speedy return home. Sudan is thus faced with one of the Third World's largest populations of long term refugees, and the capacity of the economy to absorb such numbers into its labour force is an acute and potentially violent issue. Discussion and planning has been hindered by a lack of specific information on the proportion of refugees who are of urban or rural origin and the proportion of those who might undertake skilled or unskilled employment. The following report of a census and survey of a refugee village in eastern Sudan offers some insight into the problem and suggests steps towards its solution.     

The politics of protection: aid, human rights discourse, and power relations in Kyaka II settlement, Uganda

This paper explores the conceptualisation and application of 'protection' by the United Nations High Commissioner (UNHCR), Ugandan government, and Congolese refugees in Kyaka II refugee settlement, Uganda. Analysing the origins and consequences of a demonstration against school fees, and drawing on other ethnographic data, it explores how different interpretations of this incident reflect different conceptions of, and approaches to, protection. Ugandan government officials viewed the demonstration as a security incident; Congolese and Ugandan adults responded with increased monitoring and 'sheltering' of children and young people; students justified the demonstration as a legitimate manifestation of their rights; while UNHCR promoted assistance and resettlement. The paper argues that prevailing protection responses, including 'sensitisation', sheltering, and resettlement, are de-contextualised from daily realities and fail to address the underlying power relations that undermine protection. It concludes with recommendations on how international refugee agencies can reorient assistance to address protection concerns in refugee contexts.     

Rural refugees in Africa: Past experience, future pointers

Rapid change In rural Africa raises new policy problems In dealing with mass influxes of rural refugees. Self-settlement in agriculture has become less feasible and is less acceptable now that Its disadvantages are better understood. Organized smallholder settlement can be a better solution where it is economically viable, refugees have freedom of movement, and staff are suitable. But growing land shortage means that Increasing proportions of refugees are being placed in camps. To offset this trend, more attention is suggested to programmes for groups of refugees, categorized by time of arrival, by ability to self-settle or to farm, and by skills and experience. Practically-oriented social science research can contribute to these and other approaches which will require imagination and ingenuity. Solutions to future rural refugee problems should be linked with programmes of social and economic development which will make easier the achievement of humanitarian objectives.     

Vulnerable groups*

As a rule, refugees arrive in their host country with a bare minimum of possessions; in this respect every refugee can be classified as vulnerable. However, a certain category is especially at risk, namely those persons who would be considered vulnerable in a "normal society." These people are doubly in need of assistance, firstly, inasmuch as they are refugees and secondly, insofar as they are vulnerable. If these refugees can be helped to overcome (or at least reduce) their handicaps, they can begin to become self-reliant and form an active, productive parts of their community, rather than remaining an extra burden to an already vulnerable part of the society in their country of asylum. Whilst their able-bodied companions work in the fields or the towns, part of this category can be trained and usefully employed in sectors of work that do not require great mobility or physical fitness (such as handicrafts, trade, teaching and services)..     

The impact of refugees on the health status and health services of host communities: Compounding bad with worse?

Although there have been a number of recent developments in our understanding of refugee health problems that have influenced policies and action, the effects of refugees on the health status and services of host communities remain relatively neglected. This article sets out to explain why this is an important issue with implications for policy, planning surveillance and evaluation, training and research.
The first sections outline some of the problems facing host governments and communities in Africa and discuss the changing rhetoric between the first and second International Conferences for Assistance to Refugees in Africa. A number of possible ways in which refugees could affect the individual, agent and environmental causes of disease are considered, as are the characteristics of the refugees, the host communities and the response which may all modify this impact.
Policy implications of the impact of the refugees, both negative and positive, are discussed, and detailed consideration is given to the pros and cons of integrated and parallel approaches to health care provision. The need to monitor carefully the health status and services of host communities is emphasized and recommendations are made for this and other essential developments relating to training and research.     

Between international donors and local faith communities: Intermediaries in humanitarian assistance to Syrian refugees in Jordan and Lebanon

This paper explores the crucial part that faith‐based organisations (FBOs) play in acting as intermediaries between international donors and local faith communities (LFCs) implementing humanitarian relief projects for Syrian refugees. Humanitarian responses to the mounting Syrian refugee crisis have coincided with greater collaboration between international donors and LFCs. This cooperation often is facilitated by a complex web of non‐state intermediaries at the international, national, and local level. This study probes the breadth of roles of these intermediaries, drawing on primary data from case studies of two Christian intermediaries supporting Christian LFCs as they deliver aid primarily to Muslim Syrian refugees in Jordan and Lebanon. The results of the study are connected to the wider literature on LFCs in humanitarian response, revealing how intermediaries address issues of accountability, capacity‐building, impartiality, neutrality, and professionalism. The paper concludes by offering suggestions for further research on intermediaries as key actors in the localisation of humanitarian assistance.     

Quality design: a planning methodology for the integration of refugee and local health services,West Nile,Uganda

In an emergency, the international community responds to the immediate health needs of refugees through the establishment of action-oriented, life-saving services. Healthcare delivery is often managed with limited, if any, coordination with local health management structures. In situations where refugees remain in the host country for many years, sustainability issues inevitably arise. Refugee-hosting governments may ultimately be called upon to assume the management and funding of refugee services. Planning for service integration, while protecting against declines in service quality, is a challenge in the typically resource-poor host environments. This paper discusses these issues by presenting the experience of the West Nile districts in northern Uganda, and describes quality design as a relevant planning methodology. Quality design is a systematic planning approach that documents and directly incorporates the service users' self-defined expectations and needs.     

Surveillance of the Health and Nutritional Status of Rohingya Refugees in Bangladesh

Early in 1992, Bangladesh experienced an influx of Burmese refugees, reaching a total of 263,000 by May. As the health and nutritional status of the refugee population was reportedly poor, a need was felt to collect dependable data through epidemiological surveillance, on which interventions could be based. The nutritional and health status of children was dramatically poor in all camps surveyed and a deterioration was expected in the coming monsoon. Several problem areas could be identified. Based on these findings it was possible to undertake appropriate action and to avert threatening calamities. Epidemiological surveillance is an important monitoring tool to provide reliable data on the health and nutritional status of refugee populations and to help the organizations involved to prioritize and evaluate their actions.     

Cholera in Sudan: An account of an epidemic in a refugee camp in eastern Sudan, May-June 1985

In 1985 cholera has been a serious problem in the horn of Africa, particularly affecting the many famine victims and refugees in that region. In this paper the history of cholera in Africa is briefly summarized, as is the background to the current refugee situation in eastern Sudan. A cholera epidemic involving 1,175 cases in two adjacent refugee camps in eastern Sudan is described. In this epidemic there were thirteen inpatient deaths and thirty-eight known home deaths from cholera. The management of the epidemic is described in detail. Overall an average of 8 1. of intravenous fluid was used per case, a higher figure than was anticipated, probably because of the unexpected degree of vomiting and the shortage of trained nursing staff.
The relationship between cholera and malnutrition is explored and hypochlorhydria is suggested as the main reason for the increased susceptibility to cholera among malnourished populations. It was observed that severely malnourished adults and children appeared to nave less severe diarrhoea with their cholera, presumably because of reduced mucosal surface area and poor enterocyte function. Finally possible means of aborting cholera epidemics are discussed.     

Jockeying for position in the humanitarian field: Iraqi refugees and faith-based organisations in Damascus

The rise in the number of interventions by faith-based organisations in the humanitarian field has reignited debate about the role of religion in the public sphere. This paper presents a nuanced examination of the part played by religious institutions and networks in the strategies of forced migrants in urban contexts. Furthermore, it considers how such organisations work to integrate displaced populations into their new surroundings. Drawing on two case studies and ethnographic fieldwork and in-depth interviews with Iraqi refugees and refugee service providers in Damascus, Syria, carried out between March 2010 and March 2011, it evaluates how Iraqi refugees, as active social agents, utilise religious institutions and networks in conjunction with established international humanitarian organisations to produce a distinctive geography of exile. In addition, it draws attention to how the Syrian state exerts influence over religious actors and how ultimately this affects the decision-making of forced migrants.