Cover Image
close this bookMedical Assistance to Self-settled Refugees (Tropical Institute Antwerp, 1998)
View the document(introduction...)
View the documentPreface
View the documentIntroduction
close this folder1. Guinea, Liberia & Sierra Leone
View the documentThree poor countries
View the documentDifferent histories, different economies
View the documentA patchwork of ethnic groups
View the documentThe Forest Region of Guinea
View the documentThe influx of refugees between 1990 and 1995
close this folder2. The health system in Guinea, 1988-96
View the document(introduction...)
View the documentThe Bamako Initiative at the health centres
View the documentHospitals: rationalisation, cost recovery... but low utilisation
View the documentThe administrative structure of the health system
View the documentHuman resources in the health sector
View the documentCost and funding of the health system
View the documentThe Guinean health care system and PARLS
close this folder3. The refugee-crisis: between self-reliance and pragmatic assistance
close this folderWave 1: rural refugees from Nimba county, January-March, 1990
View the document(introduction...)
View the documentThe Initial Assistance
View the documentMore Refugees
close this folderWave 2: urban refugees or returnees? May-June, 1990
View the document(introduction...)
View the documentThe same assistance .....
View the document... But not for everybody
View the documentWave 3: rural refugees from Loffa county, June-August, 1990
close this folderWave 4: refugees from Sierra Leone, March-April, 1991
View the document(introduction...)
View the documentMore active interventions
View the documentA period of relative tranquillity: the refugees remain and PARLS is consolidated
close this folderLate arrivals: the subsequent minor waves, 1992-95
View the documentCross-border movements in both directions
View the documentEarly versus late arrivals
View the documentNew agencies and changes in PARLS
close this folderSettlement patterns of refugees
View the documentThe number and distribution of refugees*
View the document'Integration' of urban refugees
View the documentRural refugees: between 'integration' and 'segregation'
View the document'Refugees live in camps'
close this folder4. Food aid
View the document(introduction...)
View the documentA rational basis for deciding on food aid?
View the documentRefugee registration
close this folderAssessing the nutritional situation
View the document(introduction...)
View the documentMonitoring of market prices
View the documentPMC monitoring
View the documentAnthropometric surveys
View the documentThe limitations of anthropometric surveys
close this folderDelivering food aid
View the documentA major issue right from the start
View the documentOn counting calories (1991-95)*
View the document1996: Better supply and less fraud
close this folderOf evidence and pressure
View the documentExpert opinion versus anthropometry
View the documentDecision making in food aid
close this folder5. Control of epidemics
View the document(introduction...)
View the documentEpidemics: bio-demographic burden & psychological impact
View the documentControl of epidemics
close this folderEpidemics and forced migration
View the document(introduction...)
View the documentWhy does forced migration result in excess mortality?
View the documentReducing excess mortality in forced migration
close this folderEpidemics in the Forest Region
View the document(introduction...)
View the documentBio-demographic burden of epidemics in the Forest Region
View the documentMeasuring control of epidemics
View the documentControl of cholera, measles, meningococcal meningitis & beriberi
View the documentControl measures in the forest region
close this folderCosts and effects of controlling epidemics in the Forest Region
View the document(introduction...)
View the documentCholera
View the documentMeasles
View the documentMeningococcal meningitis
View the document'Routine' vs. 'Intervention'
close this folderEpidemics in context
View the documentDeaths in 'natural' situation vs. 'Routine' & 'Intervention'
View the documentCost of 'Interventions' vs. Cost of the health system
View the documentIs cost per death averted an adequate measure?
View the documentManaging epidemics: balancing response to burden and fear
close this folder6. Health services for refugees: between primary health care & emergency medical assistance
View the document(introduction...)
close this folderHealth services organisation in development & emergency*
View the document(introduction...)
View the documentDevelopment, disaster & emergency
View the documentParadigms of PHC & EMA
View the documentCharacteristics of PHC and EMA health services
View the documentStrategic aspects
View the documentBetween development and emergency
View the documentHealth services for refugees in Guinea
close this folderManagement: MOH & its field partners
View the document(introduction...)
View the documentEffective decentralisation or foreign substitution?
View the documentN'Zérékoré, Yomou & Lola
View the documentMacenta & Guéckédou
close this folderHealth services supplied
View the document(introduction...)
View the documentFirst line health services (FLHS)
View the documentReferral health services
View the documentAncillary services
close this folderResources used
View the document(introduction...)
View the documentHuman resources
View the documentSupplies
View the documentUser fees vs. Free access
View the documentTotal cost
close this folderHealth care provided
View the document(introduction...)
View the documentFirst Line Health Services
View the documentReferral services
View the documentThe host population benefited from PARLS
View the documentWhy health care utilisation by the refugees remained low
View the documentWas PARLS the best solution possible?
close this folder7. Towards a more balanced refugee policy
View the document(introduction...)
close this folderFrom saving lives to promoting health
View the documentThe bio-medical approach to refugee health
View the documentRefugees as a product of a disrupted society
View the documentThe determinants of health status & coping ability
View the documentA theory of human need: health & autonomy
View the documentBecoming a refugee as a way of coping
View the documentThe central role of settlement patterns
close this folderRefugee policy as a balance between self-reliance & assistance
View the documentAssistance in lieu of self-reliance
View the documentAssistance in support of self-reliance
close this folderReferences
View the documentPreface & introduction
View the documentChapter 1
View the documentChapter 2
View the documentChapter 3
View the documentChapter 4
View the documentChapter 5
View the documentChapter 6
View the documentChapter 7
View the documentAbbreviations & Acronyms

New agencies and changes in PARLS

The three examples described above show that the results of the 'new relief approach' were quite different from one place to another. In Guu, the new relief approach was reasonably effective, though undoubtedly more expensive than the previous one. In Noonah in Yomou, it was a complete failure (Box 1). In Forriah, resettling refugees in camps was unnecessary and costly.

But most of the new refugees needed more assistance and the relief system was ready to deliver it. Food aid and medical care quickly became available. All children were vaccinated against measles, anthropometric surveys were conducted and, when indicated, feeding centres were started. Clean water was also made available in all new settlement sites. During 1995, however, the relief system failed overall to supply reasonable quantities of food.18 Consequently, food insecurity increased and malnutrition among the refugees rose considerably. As an answer to this problem, UNHCR reinforced programmes for vulnerable refugees. Malnourished children were relatively easy to identify, but this was more difficult for female-headed families and unaccompanied elders within a highly mobile population. In an attempt to decrease irregularities during food distribution, food basket monitoring was started. At every distribution, checks were made to determine what were the real quantities of food received by the refugees. It soon became clear that even at the end of the distribution channel problems existed. UNHCR and WFP decided to change the 50-beneficiaries-ration-card system to a distribution at household level. This increased the reliability of the distributions for the refugees. Also, support for income-generating activities, mainly rice production, was stepped up. In previous years, this had consisted of distribution of agricultural tools and seeds. Later, improving access to land, mainly through exploitation of new swamps became the target, with better results.

This more interventionist relief approach also brought new actors on the scene. Up to 1993 PARLS was carried by UNHCR, WFP and NGOs already working in the Forest Region in the context of development programmes. Only the Red Cross, the Adventist Development and Relief Agency (ADRA) and the International Rescue Committee (IRC) had joined PARLS as new NGOs. During 1993-95, however, additional NGOs started operating, such as Action Contre la Faim, Jesuit Refugee Service and Eglise Protestante Evangque. Early 1996, GTZ took over PARLS from MSF in Guu, and from Oxfam in Forriah. GTZ later also replaced ADRA to transport food aid. In less than two years, GTZ became one of the main actors of PARLS.

Not only did the nature of the refugees evolve over time, so did the attitude of the hosts and the preparedness of the relief system. The role of the relief system increased. In terms of refugee livelihood, there was a shift from self-supporting to relying on assistance from outsiders. To a certain extent, this change in approach was an understandable response to the changing conditions of the refugees. But the change in policy was not necessarily appropriate, as illustrated earlier. Table 9 compares the response of the hosts and the relief system to the early and late arrivals.

Table 9: Response to the refugee waves, 1990-95

Early arrivals, 1990-91
Four major waves

Late arrivals, 1992-95
Subsequent minor waves

Attitude of the hosts and the relief system towards

Collective wishful thinking and generosity. Most people thought: 'This is a short-term problem, we have to help these refugees through this difficult period of a few months, after which they will return home'. Resources were pouring in from the donors to help the refugees.

Management approach. Many people thought: 'This problem is lasting longer than anyone could have expected', and 'Many refugees are misusing the aid system'. Donors started imposing conditions on better use of food aid. 'Old' refugees who had arrived in 1990-93 were assumed integrated and self-sufficient.

General approach of the relief system

Low-key approach: a limited relief system that followed the refugees. During the first wave, UNHCR was not yet present in Guinea. MOH and MSF took the lead with a low-key approach. UNHCR became fully operational only after 4 to 5 months.

The existing relief system led by UNHCR took the initiative, as the main actor. The relief system was already fully operational upon arrival of the refugees.

The registration system was lax during the first and second waves; and still quite liberal during the third and fourth waves. Distributions, once started, were poorly targeted. Large quantities of food were misappropriated. Food prices on the local market plummeted to an 'all-time low'.

Different actors had highlighted adverse effects of food aid. Consequently, UNHCR started control on registration and fraud. Food aid was decreased for old refugees. When new refugees arrived in the same areas, they seriously interfered with control and verification.

Not only the general attitude and approach to refugee assistance changed, also the technical content of the assistance evolved over time. Where the early arrivals had received a low-key slimmed assistance package, the late arrivals received a more comprehensive package (Table 10).

Table 10: Content of PARLS, 1990-95

Early arrivals, 1990-91
Four major waves

Late arrivals, 1992-95
Subsequent minor waves

Medical relief

At the onset basic curative care, measles vaccination, disease surveillance and nutritional monitoring were considered to be an appropriate package of relief activities.

Therapeutic feeding centres, a supplementary feeding programme and services by health animators were added to the package of relief activities.

Food aid

Refugees lived several weeks, even months without food aid, without serious consequences on their health.

Refugees received food aid rations from the first days or weeks on.

Water Supply

Improvements in village water supply (e.g. protection of existing shallow wells) were first attempted. New wells and boreholes with hand pumps were installed months later.

New wells and boreholes were dug very early in the camps.


Initially no assistance was given for the construction of shelter. Months later some plastic sheeting was distributed.

Assistance in the lay-out of camps and the construction of shelter was given from the onset.