Support of humanitarian organisations to refugees in developing countries may inadvertently be creating a two-tier health system

A study from Uganda in this week’s issue of THE LANCET highlights how the support of humanitarian organisations to refugees in developing countries may inadvertently be creating a two-tier health system - with the host population having to cope with poorer health facilities than that provided by aid agencies to refugees.

Since 1990, Uganda has hosted an estimated 200,000 refugees in postemergency settlements interspersed within host communities. Christopher Garimoi Orach and Vincent De Brouwere (Makerere University Institute of Public Health, Kampala, Uganda and the Institute of Tropical Medicine, Antwerp, Belgium) investigated the extent to which obstetric needs were met in the refugee and host populations during 1999–2002.

The investigators found that the rates of major obstetric interventions were greater for refugees (around 1%) than for the host population (0·45%) who lived in the same rural areas as refugees; the intervention rate was slightly lower for the host population living in areas where there were no refugees (0·4%). Maternal mortality was 2·5 times greater in the host population (322 deaths per 100,000 births) than in the refugee population.

Dr Garimoi Orach comments: “Although our findings give credit to humanitarian organisations that provide health services to refugees, they also reveal wide disparities with respect to access to health care between refugee and host communities living in the same regions. The disparities raise important concerns about equity...In the developing countries, which host most of the world’s refugees, living conditions are precarious and maternal health remains poor. Several factors related to poor socioeconomic conditions, including inadequate access to reproductive health services, contribute to weakness of host health services. In such settings, therefore, humanitarian organisations should not neglect host communities that are also disadvantaged and which reside in refugee-affected areas. Rather, they should support and strengthen the capacity of local health services. An integrated health system designed to cater for refugee and host populations should be considered to enhance equity and promote harmonious coexistence between refugees and the host population”.

In an accompanying commentary (p 562), Shona Wynd and David N Durrheim (James Cook University, Townsville, Australia) discuss refugee and host populations health within the framework of the millennium development goals for improving global health. They conclude: ‘If we are to achieve the spirit and the letter of the MDGs, we cannot neglect refugee and IDP [internally displaced people] populations. We must identify and improve links between relief and development work through local integrated plans that include refugees’ needs in the national development strategy of the host country. Nor should we gloss over inequities within host countries. Hard-to-reach communities cannot be treated as too difficult. As demanded by the recent global Chronic Poverty Report, “the right to development should not be selectively applied, targeting only those who are the easiest and cheapest to assist.”’.