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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

Rural refugees: between 'integration' and 'segregation'

SETTLEMENT PATTERNS AND SELF-SUFFICIENCY. In the rural areas, different settlement patterns can be distinguished (Figure 15). Many refugees lived within Guinean villages. For an outsider it was very difficult to distinguish them from Guineans. This pattern can be called 'spatial integration'. Other refugees lived in 'paired villages': the refugees created a settlement close to an existing village with which they enjoyed good relations. This can be called 'peaceful cohabitation'. Other refugees lived in 'new villages', situated rather close to an existing village with the possibility of social and economic relations, but with a distinct identity ('spatial separation'). At the extreme of the spectrum, some refugees were living in 'real camps'. Although not intended as such, this situation could be qualified as 'spatial segregation'.*

[* In the particular case of Kouloumba, the camp came into existence due to 'takeover': the concentration of refugees was so high - 26,000 refugees for some 1,000 Guineans - that the local village was almost absorbed in the refugee settlement.]

Figure 15: Settlement pattern and self-sufficiency of the rural refugees, Guinea, 1990-95

RELATIVE IMPORTANCE OF THE DIFFERENT SETTLEMENT PATTERNS. Guu was the prefecture with the highest density of refugees, and the highest number of real camps. A detailed analysis of the situation in Guu at the end of 1995 clarified the quantitative importance of the different settlement patterns.

According to the data of the health animators 90,790 (33%) of the 273,388 refugees officially registered in Guu at the end of 1995 were living in 45 'camps'. In the nine largest camps 60,647 refugees were living, 24,434 in Kouloumba camp alone. The remaining 30,143 refugees were registered in 36 camps with a population ranging between 2,788 and 273. However, many of these 'camps' were rather new or paired villages. This means that in Guu prefecture two-thirds of the refugees were not living in camps, but among the local population or in settlements with less than 300 inhabitants. In other prefectures, the proportion of refugees living in camps was even lower.

[ One of the roles of the health animators was to estimate the number of people effectively living ill the refugee settlement in which they worked (as this was often very different from the number of refugees registered there). This was done by visual inspection of the houses. If a house was inhabited or maintained normally, it was considered that all members of the family registered there were effectively residing in it. This was probably a very sensitive criterion.]

Moreover, refugees officially registered in camps were often not residing there, but settled among the Guineans. They returned to the camp when food distributions took place. This phenomenon was especially important during the rainy season, when agricultural labour was in high demand. Camps were then often largely abandoned with only few people present, the remainder having settled on a semi-permanent basis in villages outside the camp. With many houses closed or collapsing, and vegetation growing wildly, these camps were called 'ghost camps'.

One can roughly estimate that less than 20% of the refugees of the Forest Region were living in real camps, some 25% in new or paired villages, and over half were fully integrated in Guinean villages and towns. The degree of homogeneity of the refugees within these different situations varied considerably. 'Spatial integration' and 'peaceful cohabitation' were usually rather homogeneous situations: refugees with close kinship relations to the Guineans settled freely among their kin. 'Spatial separation' and 'spatial segregation' situations were often more heterogeneous, constituted of a mix of different ethnic groups distinct from the host population.

DETERMINANTS OF SETTLEMENT PATTERN. These different settlement patterns resulted from the interaction of factors such as (1) ethnic and kinship relations between the refugees and the ethnically diverse host population; (2) the time of arrival and duration of stay of the refugees in Guinea; (3) the degree of laisser-faire or steering of the situation by UNHCR, and the degree of freedom the refugees had to self-settle; (4) the concentration of refugees and speed of arrival; (5) the pattern of land use and possibilities of access to land for the refugees; and (6) the intensity of social and economic relations between the refugees and the host population (Figure 15).

CONSEQUENCES FOR SELF-SUFFICIENCY. Most rural refugees were farmers. In Guinea, most became landless. The local communities own the land, even if it is not in use. Not only for land, but also for common property resources, such as wood or even thatch for their houses, the refugees needed permission from the Guineans. The refugees depended thus to a large degree on good relations with the host communities. The refugees were often employed on a daily basis by the Guineans to work as agricultural labourers. Others got access to land that normally would have been left fallow. Initially the refugees were allowed to use such land for one year, as an exceptional measure. The Guineans perceived the presence of refugees as a temporary phenomenon. Only few refugees got the permission to clear forest and cultivate new land.

The main untapped economic resource in the Forest Region was, however, its swamps. They were fertile and well suited for lowland rice. Few Guineans, with the exception of the Kissi, ever used them. But, many refugees had experience growing swamp rice in Liberia and Sierra Leone, and some got access to these swamps in Guinea. However, to lay out unused swamps is hard labour. Removing trees, digging canals and constructing dikes is an important investment, which is not worthwhile for one single harvest. Since 1995, UNHCR negotiated with local communities access to unused swamps for the refugees communities. UNHCR paid refugee labour and technical assistance for the initial works, and the local communities allowed refugees to use the land for five years. This approach marked an important shift in perspective for UNHCR, the refugees and the local communities.

The self-sufficiency of the refugees depended thus not only on the agricultural resources available in the area, but also on the access granted by the Guineans. This depended strongly on the settlement pattern (Figure 15). The refugees who could integrate in local communities enjoyed a higher degree of self-sufficiency. Their means of livelihood were intertwined with these of the host community. They shared the lives of the Guineans, worked on their farms and participated fully in the rural subsistence economy. The refugees living in peaceful cohabitation in paired villages or separated in the new villages over time also developed a high degree of economic self-sufficiency. As they settled freely, they usually spread themselves well enough to have access to economic opportunities. Those living segregated in camps faced the most serious problems. Both their density and their isolation from the host society made their economic integration difficult. They often moved out of the camps to live in a more integrated way.