|Medical Assistance to Self-settled Refugees (Institut Tropical - Tropical Institute, Antwerp, Belgium, 1998)|
|6. Health services for refugees: between primary health care & emergency medical assistance|
The refugee crisis in Guinea definitely was not an acute disaster, but neither was it a situation where a pure PHC could be followed, as if there were no emergency. Before the arrival of the refugees in Guinea, MOH and its field partners were developing a comprehensive PHC programme and setting up district health systems. When the first refugees arrived in Guinea, the same actors launched the medical part of the Programme d'Assistance aux Réfugiés Libériens et Sierra-Léonais (PARLS). PARLS' basic option was to use the facilities and infrastructure of the PHC programme where possible, and to reinforce and expand these where necessary. But PARLS also developed new parallel services on an ad hoc basis, such as mobile vaccination teams and feeding centres. The PHC infrastructure was undoubtedly a great asset for PARLS, but sometimes it was a stumbling block. PARLS was undoubtedly a boost for the PHC programme, but sometimes PARLS hindered the development of PHC.
During the period reviewed, 1990-96, these two types of logic, the PHC logic - developing a sustainable health system - and the PARLS logic - assisting the refugees in their plight - were permanently present. At times the PHC logic and the PARLS logic coexisted in harmony, at times in parallel, at times in conflict.
To illustrate this, the remainder of this chapter describes and analyses the health services for refugees in Guinea. Not all aspects developed in the previous section are systematically analysed. Only those aspects that illustrate the difficulties PARLS faced in combining aspects from EMA with aspects from PHC are developed in depth. Characteristics of care and of services are only developed marginally. This does not reflect a judgement on the relative importance of these aspects, but a choice to deal mainly with decision making and strategic issues, which most clearly illustrate the differing types of logic. The analysis is organised around the framework provided by Figure 41, and covers four aspects.
First, the section on management (page 161) analyses the role of MOH and its field partners in PARLS. During the initial months of 1990, the PHC programme and PARLS were fully integrated. However, the balance of power between the actors shifted away from MOH to foreign agencies, and PARLS evolved more as a parallel programme. Between 1992 and 1996, PARLS was again progressively integrated in the PHC programme. This process evolved differently in the 5 refugee-affected prefectures.
The following section (page 163) describes how PARLS supplied health services to the refugees: first line services, referral services and ancillary services. PARLS used the pre-existing health centres and district hospitals, but also established many new provisional health posts with a limited package of activities. Later, most of these health posts were upgraded and became permanent MOH facilities: integrated health posts or health centres. PARLS also established mobile vaccination teams, a rural hospital, feeding centres, and ancillary services.
A next section (page 174) describes the resources used for this fast and massive extension of the health system. The ambiguities and frictions between PARLS logic and PHC logic were most obvious in staff management and in user fees.