REfugees in Africa ClusTer (REACT): humanitarian health policy, gender and health economics

Lead Research Organisation: University of York
Department Name: Centre for Health Economics


There are over 25 million refugees globally, the highest number since the end of the Second World War. ODA-eligible countries, many in Africa, host the majority of the refugee population; Uganda alone hosts 1.36 million refugees and is the third largest refugee-hosting country in the world. The vast majority of refugees are in long-term, protracted displacement situations. At a population level, there can often be stark social and health inequities between host and refugee populations, as well as within the refugee community itself. For example, refugee (and internally displaced) women and girls are less likely than men and boys to have secure access to food, health care, shelter, nationality and documentation, and are more vulnerable to sexual violence and exploitation.

The response to protracted displacement settings has commonly been the development of separate parallel health responses in which international donor funding is directed largely towards international NGOs, and less so towards host governments; even where there are efforts to integrate refugee populations within host communities. While helping to address needs in the short-term, this approach risks weakening the public health system response and community cohesion over the longer term. For example, it can cause poorly coordinated and inefficient responses by government and NGOs, fragment national governance mechanisms, divert financing and expertise away from government, and undermine national strategic plans. Parallel approaches also mean that the opportunity to address issues of social and health inequity are limited, through the siloed application of numerous advocacy and development programmes. Overall, the current nature of humanitarian response is unsustainable as it fails to build long term national capacity to respond effectively and equitably as needs arise.

The REfugees in Africa ClusTer (REACT) aims to respond to this situation by partnering specialist researchers - in the areas of health governance, political economy, refugee health needs, health economics and gender analysis - with policymakers from the east, central and southern Africa region - comprising Eswatini, Kenya, Lesotho, Malawi, Mauritius, Tanzania, Uganda, Zambia and Zimbabwe; represented collectively by the ECSA Health Community. REACT will cluster two existing large GCRF programmes - Thanzi la Onse (Health of All), led by the University of York, focused on health economics and related research to inform resource allocation in the ECSA region; and RECAP, led by the London School of Hygiene and Tropical Medicine (LHSTM), focused on health in humanitarian crises. It will include partnership of two major research institutes in the ECSA region, based in countries with amongst the largest refugee populations globally - Makerere University, School of Public Health, in Uganda; and KEMRI-Wellcome Trust, in Kenya. The partnership will also benefit from participation of other research groups with major potential to generate knowledge to contribute to designing suitable responses to refugee health needs - the University of Addis Ababa, Ethopia; University of Bergen, Norway; and the Overseas Development Institute in the UK.

Following an initial stakeholder mapping, the REACT Cluster team will support the convening of a workshop by the ECSA-HC comprising key specialists and stakeholders from the region; representing affected populations; academia and policy-makers. 4 distinct research themes will be investigated, in work packages led by REACT Co-Investigators; collectively leading to a Working Group report. A full submission to the GCFR Clusters Phase 2 call - highlighting areas for research, ways to strengthen capacity and research-to-policy partnerships - will be developed out of the Working Group report.

Planned Impact

REACT will utilise both Thanzi la Onse and RECAP's existing pathways to impact and further expand upon these. The REACT project is initially focused around research, capacity strengthening and partnership building to inform health care provision for refugees in the east, central and southern Africa (ECSA) region; which is the same geographical focus as Thanzi la Onse (TLO), hence will initially follow similar pathways to TLO. However, it is envisaged a successful GCRF Clusters Phase 2 project would assist in evidence generation even outside of the ECSA region, so REACT will build upon RECAP's pathways aimed upon informing government and humanitarian organisations more globally as the issues addressed in REACT also apply to a number of other protracted refugee settings in other regions (most notably Syrian refugees in the Middle-East).

A central partnership for TLO is with the East Central and Southern Africa Health Secretariat (ECSA-HC). ECSA-HC has been in existence for 45 years, fostering and strengthening regional cooperation and capacity to address needs of member states. The member states are: Eswatini, Kenya, Lesotho, Malawi, Mauritius, Tanzania, Uganda, Zambia and Zimabwe. The mandate of ECSA-HC is to promote and encourage efficiency and relevance in the provision of health services in the region. Its highest governing body is the Ministers Council, comprising the 9 Ministers of Health from the region, who meet annually to agree regional health resolutions. These resolutions are around defined policy priorities. They also respond and feed up to global level policies, particularly through the Commonwealth Secretariat and the World Health Assembly (e.g. at the World Health Assembly).

With the support of and funding through Thanzi la Onse, an ECSA Community of Practice in Health Economics was launched in January 2019. Its aim is to build capability for health economics research and its use within policy in the region. So far, it comprises approximately 30 senior government and academic health economists and receives training and research support through TLO.

REACT will facilitate the translation of research into regional policy debates in partnership with ECSA. In Phase 2 it will also deliver extensive and well-considered capacity strengthening initiatives; potentially including delivery of short courses and supporting university training curricula so raise priority of considering the organisation of refugee health care. Our ultimate ambition is that the suitability of the current financing and governance systems of provision for refugee health care can be better understood and supported to strengthen more efficient, equitable and sustainable responses.
Description One of the main objectives for REACT (stage 1) was to refine and expand upon its original three research themes, and develop a series of research questions that can be investigated as part of a longer-term programme of research. These questions have been informed by the three REACT reports setting-out the policy priority and research and capability building demands to address healthcare challenges for refugee and host populations in Kenya and Uganda. The reports reveal a need to better integrate health services for both populations in addition to, indirectly, related sectors (e.g. food security, social protection and education), as well as build gender factors into implementation decisions (e.g. ensuring consistent sexual and reproductive health initiatives for refugee populations). Mental health provision has also been identified in the stage 1 work as an important priority for refugee populations, with further research required on how specialist care can be delivered most effectively.

A stakeholder mapping exercise during REACT-1 helped to identify the key national and regional stakeholders to engage for longer-term work who bring expertise in specific disciplines and services; the project team has made good progress in building a collaborative partnership with these organisations in preparing for REACT stage 2. For example: Tutapona mental health service; the UN Food and Agriculture Organization; BRAC-Uganda; the International Rescue Committee; and World Bank. This broader partnership builds upon the strong interdisciplinary relationship established under REACT-1, which brought together previously disparate areas of research to focus on refugee health (i.e. economics, law and governance, gender studies); a series of literature reviews and research prioritisation reports are currently being developed for each of these discipline areas to inform the REACT stage 2 application (due for publication in the next 3-5 months).

A REACT led a webinar with the East Central and Southern Africa Health Community's health economics community of practice in late 2020, which brought the issue of refugee health to senior regional health policy-makers (i.e. Ministry of Health officials and others from prominent funding and health care delivery organisations). The webinar recording has been made freely available on the Global Health Economics Hub ( as a reference aid for policy-makers responsible for refugee health issues in their contexts.
Exploitation Route The context in which REACT is being delivered has experienced a significant change in recent years; the number of refugees hosted in LMICs has increased globally (with large populations living in Africa), however, the global resources set aside to address the health and social service needs of these communities is decreasing. The national health systems of refugee host countries are increasingly taking on a more prominent role to fill this gap, however, these systems have severe resource constraints making management of refugee health an additional burden on already stretched health services. Supporting better integration of host and refugee population health services has been identified as a potential solution to this challenge, although questions still remain on how funding can be sourced and allocated efficiently.

REACT is developing long-term research plans which will help to answer these questions, through developing plans for excellent research in collaboration between universities and national-level ministries of health in Kenya, Uganda and across the East and Southern Africa region, as well as international partners responsible for global refugee strategies (World Bank, IRC, UNFAO). In the immediate term, the REACT team has been producing policy-friendly papers and webinars on the topic, as well as striving to raise the profile of refugee health among national research and policy institutes to encourage further research. REACT's outputs to date have been shared at the regional and international level via the Global Health Economics Hub, with the aim that these materials will help to inform refugee health policy in other contexts outside of Africa too.
Sectors Communities and Social Services/Policy,Healthcare

Description While the work undertaken so far in REACT is still in its early stages, the reports published and webinar with the ECSA-HC COP in 2020 have contributed towards highlighting the complex issue of resourcing and implementing refugee health services in Africa. Should the second stage phase of REACT be awarded in 2021, the team plans to work with policy-makers, refugee service providers and community groups to inform a new approach to managing refugee health in the region. Instead of implementing 'emergency' type responses to refugee populations, a more strategically planned and developmental type approach may be deemed more appropriate given the average length of stay a refugee will spend in a camp (more than 15 years). We hope that REACT stage 2 project will detail how such a transition can take effect, considering governance, legal, economic/resourcing and gender/equity concerns.
First Year Of Impact 2020
Sector Communities and Social Services/Policy,Healthcare
Impact Types Policy & public services

Description Webinar on "refugee health" delivered to the ECSA-HC health economics community of practice 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Webinar hosted by the East Central and Southern Africa Health Community (ECSA-HC) in collaboration with REACT researchers, delivered to the ECSA-HC Health Economics Community of Practice (including Ministry of Health and senior academics from ECSA-HC nine member countries). Webinar included presentations by Chrispus Mayora and Fred Matovu (Makerere School of Public Health), Julie Jemutai, Kui Muraya, Primous Chi (KEMRI), Stephen Mulupi (Liverpool School of Tropical Medicine) and Federica Margini (associate of the Centre for Health Economics, UOY). The presenters discussed the refugee context in East Central and Southern Africa, and summarised their work to date examining the health needs and services for refugee and host populations in Kenya and Uganda. A Q&A session allowed attendees to share experiences from their contexts and interrogate the presenters'' findings. A recording of the webinar has now been made freely available on the Global Health Economics Hub for access by the ECSA-HC COP at any time.
Year(s) Of Engagement Activity 2020