COPENHAGEN –  In Lebanon, international donors are supporting a network of public primary health care centers to test for diabetes and other noncommunicable diseases (NCDs), offering treatment equally to Lebanese nationals and Syrian refugees who are unlikely to return anytime soon to their war-torn homeland. 

In Kenya, a new national insurance law aims to make health insurance mandatory and accessible both to unemployed Kenyans as well as to the estimated 625,000 refugees that have been living in the country for 30 years or more. And a much-touted “Shirika” initiative aims to integrate refugee communities into the health workforce, as well as the broader economy. 

In both Moldova and Jordan, refugees fleeing war-torn Ukraine and Syria were immediately brought into the national health systems of their respective host countries at the height of the crisis.  That allowed international aid to be targeted to supporting refugee’s direct medical costs and even expanding national health system capacity, rather than building up a parallel system for the refugee communities.   

As humanitarian crises become more complex and more protracted, extending not years but decades, host governments, as well as United Nations aid agencies and major donor groups, are shifting tactics in an effort to extend to refugees a more holistic range of health services. The effort is particularly relevant when it comes to NCDs, which are often more expensive to diagnose and treat. And such services are not always widely available yet in many low- and middle-income countries that also host tens of millions of the world’s refugees. 

As such, policies and funding plans that simultaneously bolster NCD services for refugees as well as in national health services available to all citizens, may be particularly effective in closing multiple gaps simultaneously. 

The issue of integration was a key theme on the closing day of a three day meeting in Copenhagen on Noncommunicable diseases in Humanitarian Settings; Building Resilient Health Systems, co-organized by the World Health Organization (WHO) and UNHCR, the UN refugee agency.

“It’s paramount when you start a humanitarian response to look at the end system setting for the long term answers,” said WHO’s Director of Health and Migration, Dr. Santino Severoni, speaking Thursday in the closing hours of the event. 

“We see that all in those countries where there is a political commitment, where the political sensitivities about refugees have been diffused and the country is moving on with a rational approach, what is important is to provide support in order to converge efforts, expanding domestic capacity to finance access.  

“Every time we keep the situation in a protracted emergency. Every time we keep funding operations, not directly funding the country’s financial capacity, we are actually postponing the capacity of the country to be more effective.”

Extending Kenya’s social health insurance system to refugees means better NCD coverage

In Kenya, such an approach has led the government to extend the benefits of a new social health insurance fund intended to cover jobless Kenyan citizens to the country’s 625,000 refugees, who hail mainly from Somalia and Uganda, as well as South Sudan.

After overcoming several court challenges, this year’s plan rollout will extend coverage to tens of thousands of refugees living for decades in the Dadaab and Kakuma camps in the country’s remote northern and northwest regions. It also coincides with the government’s launch of the Shirika Plan, which calls for transitioning the sprawling camps into more open settlements.

“Shirika is an acronym which means social, economic hubs for integrated refugee inclusion,” said Elizabeth Onyango, who heads NCD Prevention and Control at the Kenyan Ministry of Health. “It also is a Swahili word that means coming together.

“So what does the government of Kenya envision? It envisions a situation where the refugee and host communities get together; they can work, play, and even love together. It is multi-agency and multi-sector” – including the health sector as part of the coordinating secretariat.

“For health, the Shirika plan wants to focus on enhancing access to comprehensive health services, including services for NCDs. Secondly, we also want to focus on building or improving the capacity or human resources to deliver the services, including the refugee and the host population, into the country’s social health insurance funding structure,” she said. “And lastly, we focus on preventing people from promoting health, preventing disease and disease surveillance in these regions.”

Integration of refugees will be enabled by the extension of the new Kenyan Social Health Insurance programme to all of the country’s residents.

The new initiative will ensure that primary health care is “free to anyone in Kenya, including refugees,” said Onyango. At secondary and tertiary levels, refugees will be able to obtain a social insurance card for a nominal payment on the same basis as Kenyan citizens, granting them free access to services.

In terms of health facility infrastructure in and around refugee communities, the emerging model is a hybrid with UNHCR, Kenyan county governments and NGOs working in partnership to ensure that health facilities in refugee communities can “provide a wide range of services from preventive promotive of primary health care all the way to tertiary and tertiary care,” Onyango said.

Refugees as part of the health workforce solution 

Experts have applauded another critical element of the Kenyan plan: capacity-building in the refugee communities – to train a new generation of health workers.

This shifts refugees from being victims and recipients of aid from their host country to being an integral part of the solution. And it addresses the common problem of health worker migration from rural areas, where the most prominent camps are located, to the cities.

“We want to support [refugee] students with scholarships so they can get into medical training colleges,” said Onyango.

“Because one of the things we suffer is the retention of health worker staff; most staff are from other regions. Conversely, if more refugees from the far-flung camps are educated as health workers, she said it’s more likely they’d be willing to return to work in their home communities. She added that bolstering local capacity can help ensure that a full spectrum of NCD services are available in the communities.

“We want to ensure that we have the specialists who can go and mentor the healthcare workers, and at the same time, support groups established by people with lived experience, who can empower people to take charge of their health and ensure better management of their conditions,” she said.

Jordan – health enabling policies and programmes for everyone   

Jordan, host to one of the largest refugee populations in the world, is another country that has prioritised the integration of refugee health into the mainstream health services of the country.  

The country of 11 million people hosts nearly 760,000 refugees and asylum seekers registered with UNHCR. These are mostly Syrians who fled the country since the beginning of the civil war in 2011, but also Iraqi, Yemeni and Sudanese.  And that is not including some 2.3 million Palestinian refugees from the 1948 and 1967 Arab-Israeli wars, who hold Jordanian citizenship but are also registered with the UN refugee agency for Palestinians, UNRWA.  

While there are some health clinics run by UNHCR, UNRWA or affiliated charities, most are served in Jordan’s national system “available to all registered refugees from all nationalities at the non-insured Jordanian rate at public health centres and governmental hospitals”, according to UNHCR. 

“When the Syrian refugee crisis came, and they are our neighbors by the way, the services were provided free of charge for several years,” said Dr Anas Almohtaseb director of the NCD Directorate in Jordan’s Ministry of Health, speaking at the conference, which was co-sponsored by the Hasemite Kingdom, as well as Kenya and Denmark. 

Particularly in terms of NCD-related policies, many government initiatives “related to strengthening the healthcare system, will also strengthen the services provided for refugees,” Almohtaseb stressed, and vice versa. 

As an example, he cited tobacco cessation clinics – which are free and available to everyone, regardless of nationality.  Similarly, in terms of nutrition, Jordanian government plans to supplement basic goods like flour with critical vitamins would benefit the micronutrient status of everyone.   

Jordan also is in the process of updating its guidelines on cardiovascular disease prevention, diagnosis and care to align with the WHO HEARTS protocol, released in 2020. 

“Once we have these unified guidelines, this will help improve the services for every patient, whatever his nationality, said Almohtaseb. “And also we have the implementation of community engagement programmes, such as mental health care clinics, which will be inclusive for the whole population,” he said. 

Finally, digitisation of healthcare services, including better tracking of patients’ diagnoses and treatment, can help improve NCD coverage for refugees, who may be more mobile as they seek work and better living conditions, he pointed out. 

“Ultimately, the refugees affect the whole healthcare system. And for this reason, while NGOs are very important, we have to also be dependent on the public health system – that is crucial to the sustainability of the healthcare system in Jordan.”

New direction for the international health and development community 

Strategies that advance the integration of refugee health services with national health systems of host governments represent a “significant improvement” to the traditional approach to health emergencies, said Bent Lautrup-Nielsen, head of global advocacy for the World Diabetes Foundation (WDF).

“This is relatively new to the international health and development community,” Lautrup-Nielsen observed, noting that historically, institutional and funding drivers tended to foster more siloed approaches.

“For many years, the international system of humanitarian response has had its own mechanisms of funding – for example, through appeals by UNHCR, the Red Cross and many others,” and that led to focused emergency health efforts, more siloed approaches, he observes.

Over a decade ago, however, some organisations, including the World Diabetes Foundation, began to see that refugee health issues, with all of the urgency those often implied, could also be an essential entry point for boosting capacity for sorely needed NCD services in affected host countries.

“What we’re saying is that if you’ve got a refugee situation, then the donors should target the whole NCD population – not only refugees but also the host communities. If you start distinguishing between the refugee population and the local population, you risk creating uneven health access and inequities.”

In Lebanon – the refugee crisis led to new primary healthcare investments

Lautrup-Nielsen cites the Foundation’s experience supporting refugees in Lebanon, who fled to the country in the first phases of the Syrian civil war, as one example.

Public health clinics have traditionally played a relatively minor role in Lebanon’s largely privatised health services. However, these clinics became more critical due to the domestic economic crisis and the refugee inflow.

The new healthcare demands stimulated by the refugee crisis ultimately prompted a group of donor organisations, including WDF, the Danish Red Cross and Novo Nordisk Foundation, to support the expansion of NCD services in over 200 public primary health clinics nationwide, serving refugee and host populations. They are rolling out services for cardiovascular disease, diabetes and other conditions, including mental health.

“Building that as an integrated, basic package that wasn’t there before was a benefit to both Lebanese and refugees living in Lebanon,” Lautrup-Nielsen said.

But he notes that integration cannot be a one-size-fits-all approach. “Of course, there are acute emergencies at times that demand a dedicated humanitarian approach. We have a lot of that right now.

“But that cannot be separated from a long-term perspective,” he added. “And the COVID-19 pandemic crisis, which was considered a health emergency, showed that those who suffer the most are people living with NCDs.

“What came out of COVID was that realisation that you have to build resilient health systems that are meaningful in any context and serve everybody.”

Convergence instead of silos 

“Many [high-income] governments and private sector donors and foundations have willingly supported dedicated health services in response to humanitarian crises and emergencies – and for good reason. But this can also create imbalances or a lack of equity in a protracted situation.”

The inequities may also go both ways. In some low-income host countries, UNHCR-provided health services in refugee camps might even be regarded as “better” than what might be available in the local communities, Lautrup-Nielsen pointed out.

“But governments also wish to build equitable health systems, whether for refugees or local communities.

“Amongst the more than 150 countries represented at the conference, many are hosting refugees, and they are also appealing for a balanced international system, combining humanitarian response support in acute emergencies with protracted, long-term national health system strengthening.

“At the same time, most premature deaths from NCDs, before the age of 70, now occur in low- and middle-income countries of Asia, the Americas, the Middle East and Africa – and the disease burden is huge and growing fast.

“Five or ten years ago, this conference probably would not have been possible. But the thinking has matured a lot due to COVID and other things, not the least, because of the NCD agenda,” said Lautrup-Nielsen.

“To put things in a positive light, we are seeing a convergence within the health and development space and with other spaces like humanitarian response.”

Image Credits: UNHCR/Sala Lewis, UNHCR/Mia Bulow-Olsen , E. Fletcher/Health Policy Watch , E Fletcher/Health Policy Watch , UNHCR , Jesper Westley.