Health facilities for refugees in Islamic Republic of Iran - H. Salmanmanesh

1. Background

Towards the end of 1979 the first refugees from Islamic State of Afghanistan started to spill over the border into Islamic Republic of Iran. Within a year their number rose to 2-3 million. Since 1987 many Kurdish refugees have come to Islamic Republic of Iran from beyond the western border. Thus the country has borne the second heaviest case-load of refugees in the world.

There is little variety of occupational background among the Afghan refugees. A few were petty tradesmen, a few more were subsistence farmers or even landless tenants but the majority were nomads or semi-nomads, with small or large flocks of sheep or camel herds.

However, according to the official figures in the Ministry of the Interior, the total number of Afghan refugees was reported as 2.29 million, spread over 21 out of the 24 provinces of Islamic Republic of Iran; only three provinces, namely Kurdistan, Ham and West Azarbaijan, did not have Afghan refugees although they have Kurdish ones. The largest number is in Khorasan, the second largest in Isfahan, followed by an equal number in each of Teheran and Sistan-Baluchistan provinces.

A table showing distribution of refugees by province and percentage of total population of each province is attached as Appendix 1.

In Appendix 2, map No. 1 shows the areas of major refugee presence.

2. Health organization and policies

The national health policy rests on the following principles: the Government is fully committed to the primary health care (PHC) approach; this is being adapted to provide health care services to all population groups, with special emphasis on rural areas. Most of the provinces and districts of the country have well developed PHC systems.

The ongoing PHC network system in Islamic Republic of Iran is as follows:

2.1 Rural settlement health services

Different levels exist for rural settlements.

The first level is for delivery of health and basic sanitation services, given in “health houses” (or health posts for refugees) by community health workers (CHWs), who can easily solve basic health and sanitation problems and treat common diseases. More serious cases can be referred to the second level, where medical facilities are available and a physician and environmental health technician are working (Rural Health Centre). Even more serious cases are referred to district hospitals. Environmental health cases are referred to the environmental health engineer in the district health centre.

2.2 Urban health services

The people as well as the refugees inhabiting cities or their suburbs have access to urban health centres where they can receive primary health care as well as environmental health services.

3. Categories of refugees according to health facilities

According to their refugee settlements, refugees are grouped into three different categories:

(a) The first category consists of those settled in the temporary registered camps; it comprises a population of about 100 000. These refugees have access to the health facilities available in these camps and, through the establishment of an active referral system, they also benefit from improved services.

(b) The second group of refugees, consisting of about 300 000, are those who have been settled spontaneously either in the rural areas (but separate from the Iranian villages) or around some large cities mixed with local people (e.g. in Zahedan). These groups are engaged in their own agriculture and animal husbandry.

(c) The third group, which forms the majority of refugees (about 1.9-2 million), comprises those dispersed among the villages and towns, either through registered camps or directly across the border. These refugees use the health facilities available in the area for the Iranian population.

4. Health facilities for refugees

In 1986, a PHC programme was proposed for refugees on the basis of the national PHC network, in order to establish and strengthen first- and second-level delivery of health services to Afghan refugees living in the spontaneous settlements. Refugees in the urban and rural areas will benefit from the health facilities available there for Iranians.

Based upon this recommendation, the Ministry of Health and Medical Education formulated a Master Plan according to which PHC networks were established in Afghan refugees’ spontaneous settlements. These networks were strengthened by provision of needed materials as well as development of sanitary and water supply facilities, with cooperation of UNHCR.

In 1987, according to this Master Plan, 28 health posts out of 48 were installed in the spontaneous settlements at Qaen and Birjand. Meanwhile, 43 Afghan refugees (male and female) were trained through three-month CHW courses.

Map No. 2 in Appendix 2 shows distribution and location of 28 health posts in Burjand and Qaen districts of Khorasan province. In 1989 fifteen more health posts were added to those in the above-mentioned districts, plus five health posts in Khaf district in the same province (see Appendix 2, map No. 3). Eighteen Rural Health prefabricated clinics have also been provided to strengthen the system (see Appendix 2, map No. 4).

Afghan refugees were being trained in CHW courses; in 1988 many female refugees took TBA (Trained Birth Attendant) courses in Sistan-Baluchistan and Khorasan Provinces.

5. Water supply and sanitation

Several environmental sanitation projects have been implemented for refugees in spontaneous settlements. Six water supply projects have been carried out by the General Department of Environmental Health, with financial support from UNHCR, in Sistan-Baluchistan and Khorasan Provinces.

Three water supply and one sewage project for Kurdish refugees in the west of the country as well as three water supply and sanitation projects for Afghan refugees in the east, were to be implemented in 1991 in spontaneous settlements. In addition, a major water supply project has already been started; it will cover 830 villages in the east in which many Afghan refugees (a percentage of about 30-40% of the total in the country) are living. In other areas, they will use the water and sanitation facilities available for the Iranian population.

Appendix 1

TABLE 1. Distribution of Afghan refugees (AR) by province as of January 1988

NB

1. Total population of each province extracted from 1986 public census results. Total population in 1988 calculated based on approximately 4% yearly natural increase.

2. Official statistics (number of refugees) provided by Commissionerate for Afghan Refugees, Ministry of Interior.

Appendix 2

Map No. 1

Major locations of Afghan refugees Islamic Republic of Iran

Map No. 2

Major Afghan refugee concentration Locations of 28 health posts in Birjand and Qaen districts of Khorasan Province

Map No. 3

Proposed locations of 20 health posts in Birland and Qaen districts, 1989

Note: Five of the 20 health posts will be relocated in Khaf sub-district according to the MOH priorities

Map No. 4

Locations of prefabricated clinics, Islamic Republic of Iran