|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|
Compromise: Finding of intermediate way between conflicting opinions, courses, &c, by modification of each.
Concise Oxford Dictionary
The organisation of health care nowadays invariably refers to the concept of primary health care (PHC).1-6 Although in developing countries PHC has often been restricted to 'selective primary health care',7-17 or to village health workers,18 it is now widely accepted that it calls for an equilibrium between technical ('rationalisation') and social dimensions ('participation & autonomy'). Most authors have described these principles in generic terms,19-21 while others focused on practical organisational issues,22 and particularly district health care.23-30 All implicitly refer to stable situations where there is a perspective for development - not to societies struck by disaster.
Whereas PHC has a well-developed conceptual substructure, the literature on emergency medical assistance (EMA) has concentrated on technical and logistic considerations.31,32 The few authors who addressed the issue highlighted the fundamental differences between PHC and EMA in cases of mass migration of refugees:33 "the emergency approach tends to be the antithesis of the primary health care approach".34
Typically refugees settle in camps, and a specific camp health care system is created to deliver EMA. Five types of camp health services are then usually put in place: health posts, health centres, home visitors, feeding centres and vaccination teams (Figure 39).35,36 These health services are usually set up in parallel to and with but few links with the health services in the host area. Setting up a system to deliver health care in a camp is straightforward, and can be done in a few days - although emergency assistance may meet with many logistic and political constraints and obstacles.37,38 Once the health system is established, access for refugees is usually good as all services are free of charge, well supplied and located within the camp. Moreover, as camps constitute a very unhealthy environment, there are many health needs. Utilisation of curative care is thus invariably high. Planning guidelines often refer to 4 visits per refugee per year,35 but sometimes utilisation is much higher, especially during the initial emergency phase (Table 50). Also, the coverage of preventive activities is often high: measles vaccination coverage of over 90% is common. Such results are facilitated by close follow-up by home visitors. Refugees living in camps constitute a 'captive population'; they are 'beneficiaries' of a hierarchic top-down relief system.39,40
Such a health care system concentrates on delivering life-saving measures such as basic curative care and measles vaccination. When the emergency phase is over, and the health needs of the refugees cease to be fundamentally different from these of their hosts, the range of activities is progressively widened to include vaccination with all EPI vaccines, antenatal care and family planning.41,42 However, the social dimension - participation & autonomy -is rarely given due consideration. In fact, as a camp moves from emergency towards chronicity few fundamental changes are introduced in the top-down approach. As for other aspects, refugee camp health care fosters dependence on assistance rather than autonomy, and refugees are more often considered as passive recipients than as active partners.43,44
Refugee camp health services usually are better supplied and organised than services for the host population. In the post-emergency phase, such inequality may fuel resentment between hosts and refugees.45,46 Some studies have documented how the efforts to run a refugee camp health care system resulted in weakening the health system of the host country by diverting human and financial resources towards the refugee health services.47,48
In Guinea, the refugees self-settled among the host population, and there was no dramatic emergency phase. The Programme d'Assistance aux Réfugiés Libériens et Sierra-léonais (PARLS) gave refugees free access to the pre-existing Guinean health facilities wherever possible, and reinforced the health centres and district hospitals to enable them to cope with the additional workload. But PARLS also created many new health services. Links between the pre-existing health services and the newly created PARLS health services were intense and complex.
Such an approach of the health problems of refugees is not new. It was common before refugee camps became the dominant approach,49,50 but it has not been well documented in the scientific literature nor was it clearly conceptualised. In the absence of documented precedents, the implementation of PARLS was far from straightforward, and more a matter of 'muddling through' than of planned rational intervention. Ad hoc decisions progressively shaped the health services for refugees. From its onset PARLS was a compromise between primary health care (PHC) and emergency medical assistance (EMA), and had to reconcile their conflicting types of logic.
The first part of this chapter spells out the conceptual, practical and strategic differences between PHC and EMA. PHC aims at promoting health in a society in development, while EMA concentrates on safeguarding survival in an emergency situation. This fundamental difference in objectives and time-frame results in different characteristics of health care and of health services, with important strategic implications. However, many situations are not clear-cut development or emergency situations, but remain in an in-between grey zone of non-development non-emergency situations.
The refugees in Guinea lived in such an intermediary situation: not a real emergency, but not a stable situation either where one could concentrate on long-term development alone. This had consequences for the organisation and development of health services for refugees. A key strategic choice was to develop one single health service for both refugees and Guineans. Many aspects of this complex and changing health system have been simplified for the sake of clarity and brevity. The description focuses mainly on the strategic and policy aspects.
The results indicate that PARLS' basic approach was the best option possible given the circumstances. PARLS was set up to solve the refugees' health problems, but at the same time it was used as an opportunity to strengthen and expand the Guinean health care system. This policy of compromises had implications for the effectiveness of PARLS as compared to more classical approaches of dealing with health care for refugees. In particular, it led to a balance of benefits between refugees and Guineans that is very different from what one usually finds in case of EMA. But the results also indicate that PARLS suffered from a series of imbalances and mistakes. First, choices systematically favoured expansion of geographical access over quality of care. Second, PARLS left little room for participation. Third, social accountability towards the refugee population was rarely taken into consideration. Lastly, certain strategic choices, such as the manpower policy, were initially short-sighted and proved difficult to reverse later. The PARLS experience thus points at a number of do's and don'ts in the organisation of health services in non-development non-emergency situations.