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Rethinking How Refugees Get Medical Care

Refugees can be a benefit rather than a burden to health services in countries where they live, says refugee health expert Paul Spiegel. He explains that when refugees are integrated into national health systems and allowed to work to pay for care, everyone wins.

Written by Charlotte Alfred Published on Read time Approx. 6 minutes
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A boy looks in through a window of a makeshift clinic at the port of Piraeus, near Athens, on March 26, 2016. AP/Yorgos Karahalis

The record number of refugees around the world, and the increasing amount of time they remain displaced, is testing the capacity of aid organizations and host countries to meet refugees’ basic needs, including food, shelter and medical care.

But it doesn’t have to be this way, says Paul Spiegel, a doctor who has spent decades working in the field of refugee health, including with Médecins Sans Frontières, the U.S. Centers for Disease Control and Prevention and the U.N. refugee agency (UNHCR).

If refugees are integrated into the national health systems of their host countries instead of being provided with separate medical services, this would both benefit refugees and strengthen host countries’ health services, Spiegel said at a meeting on refugee health at the U.N. summit last month.

Spiegel recently joined the Johns Hopkins Bloomberg School of Public Health as a professor of international health and director of the Center for Refugee and Disaster Response, which provides research, training and technical assistance to international organizations, governments and humanitarian groups.

Refugees Deeply spoke with Spiegel about his experiences in the field and his hopes for more research and innovation on refugee health.

Refugees Deeply: Most refugees live in developing countries, where public health provision is pretty limited even for their own population, let alone refugees. How can refugees be a benefit rather than a strain on the health systems of developing countries?

Paul Spiegel: The key is allowing refugees to work. If you match the skills that are needed in a community with refugees that have those skills, it should expand the economy. It should also allow refugees to be able to pay for services. When you have more people using and paying for services, they should expand and become cheaper.

If refugees cannot work and are totally dependent on international aid, and over time that aid is not enough, this could be problematic. In the past there was a knee-jerk reaction of putting refugees in camps in remote areas and providing parallel services, so the local services are not benefiting [from the refugees’ presence].

But if the money from the international community that would normally would go into a parallel system can instead be put into an existing system for both the refugees and the locals, this could be to everyone’s advantage – both the host communities and the refugees.

Refugees Deeply: Are there examples of this working well in practice?

Spiegel: One of the older examples is Uganda. In more rural areas they allowed the refugees to develop settlements, and everyone – both refugees and local populations – had access to the clinics. It’s worked extremely well over time.

Another example is in Iran, where you have at least 950,000 registered refugees and many others that are not registered. Last year, the Iranian government agreed to allow refugees to join the national health insurance scheme at the same rates as Iranians. Some refugees who were allowed to work in the country paid for their own insurance, and UNHCR paid for the most vulnerable people.

Refugees Deeply: Has there been any studies on how that benefits a health system in the long run?

Spiegel: No, it’s been more anecdotal. Now that I’ve moved from UNHCR to Johns Hopkins, I hope that we can look openly and objectively at some of the negatives and positives. It’s not always positive – I’m sure there’s going to be negative aspects in many situations as markets are going to have to respond, so there needs to be sufficient flexibility. In the Iranian case, they did the math that they currently were paying for a lot of refugees in their hospitals, so in their view, this was a way to save money, as well as to provide some benefits to the refugees.

Refugees Deeply: People are remaining displaced for longer periods of time due to protracted conflicts in countries like Somalia and Afghanistan. How does this change how healthcare services should be delivered to refugees?

One of the problems is that many host governments understandably don’t want to say that something is going to be long term. For the first year at least, everything is always considered temporary. But from a financial point of view, if you can do better up-front investment in things like healthcare and sanitation, it will pay off in the longer run, five to 10 years down the road.

Another aspect is that in the acute emergency phase, it will take time for refugees to get some money and be stable. So at the beginning, someone’s going to be paying for the refugees. There should be a way to consider a funding mechanism to make sure that during that initial process, an already fragile health system is not brought to its knees.

We should also look at a country’s development plans, or how their population is going to grow, and make sure the services we are providing are going to those areas, so we can also develop infrastructure that will be useful for the future. If you put refugees in inhospitable areas, the money that goes into that will not be useful for the future for the nationals.

Refugees Deeply: At the U.N. side event, you mentioned the idea of a travel health passport for refugees to make sure that critical health data doesn’t get lost across borders. How would that work?

Spiegel: This doesn’t even have to be just for refugees, it could be for anyone on the move – for migrants, or people moving within a country. One of the main issues is to make sure there is continuity of care. There needs to be a minimal amount of data available, and we would need to make sure protection and data confidentiality are dealt with. With cloud technology, I’m pretty sure there are ways to do this. It doesn’t have to be a physical card. The organization best placed to do this would be the World Health Organization. Similar initiatives such as vaccination cards are already being done on a small scale. There have been some discussions, but it’s still in a very preliminary phase.

Refugees Deeply: You worked for a long time within the U.N. system. What are the most urgent ways you’d like to see the U.N. and humanitarian agencies change how they deal with refugee health?

I think to look broader. In situations where it is possible, we should integrate into existing systems, and look at how this can be done in a cost-effective manner. There’s a tremendous amount of responses where there is not enough data, both in terms of their effectiveness as well as the cost-effectiveness.

With UNHCR, for a long time the knee-jerk reaction to refugees was to set up camps. Now the policy within UNHCR is to avoid camps whenever possible, and if you cannot, then at least try to look at integrating services. But this is not the case in the wider U.N. community and NGO community and the governments.

Refugees Deeply: What would you like to see included in the global compacts on refugees and migrants in 2018, to make sure all refugees get access to healthcare?

Spiegel: It’s important for governments to recognize that, unfortunately, refugees often do not come on to their land for a short period of time, and they need to think about the infrastructure to deal with this for a longer period of time. That could help alleviate some of the political pressure on them.

Secondly, we need to have a holistic view, while also recognizing the important differences between groups. Everyone who needs healthcare should get healthcare. Like any community, you have a wide variation in a refugee community. In some situations, nationals or displaced persons might be worse off than a refugee community, and donors need to recognize this. In the past, UNHCR and others have been criticized for providing better services to refugees than others, as donors earmarked money for that.

Yet there are some unique aspects of a refugee that are not the same as a national, an internally displaced citizen or economic migrant. First, refugees might not have the coping mechanisms and community support that a national has. Second, they may not be able to work and therefore pay for services. And third, they’ve often gone through experiences such as gender-based violence or mental health issues, and may require different services to nationals.

This interview has been edited for clarity and length.

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