Improving healthcare at the intersection of gender and protracted displacement amongst Somali and Congolese refugees and IDPs

Lead Research Organisation: University of Edinburgh
Department Name: Sch of Social and Political Science

Abstract

This project aims to help displaced people to access appropriate healthcare for long-term physical and mental health conditions associated with protracted displacement, conflict, and gendered violence. The category of Sexual and Gender-Based Violence (SGBV) receives a great deal of attention. However, there is limited research on how gendered violence, including violence relating to sexuality, is experienced in displacement contexts. There is also limited understanding of how gender, sexuality, and related violence affect access to healthcare, and how that can result in neglected chronic health conditions, particularly mental ill-health. Similarly, much attention is devoted to immediate healthcare needs following SGBV, but longer-term physical and mental health conditions are not adequately addressed. Displaced people face multiple barriers when seeking healthcare in protracted displacement settings, with the result that long-term health conditions are often misdiagnosed and mistreated or undiagnosed and untreated.

This project examines access to care and the responsiveness of healthcare providers for displaced Congolese and Somalis in Eastern Democratic Republic of Congo (DRC), Somali, Kenya, and South Africa. Eastern DRC and Somalia have both experienced long-term conflict and displacement since the early 1990s, leading to large populations of Internally Displaced People (IDPs) within these countries and large refugee populations across the region. Conflict and displacement in Eastern DRC and Somalia are characterised by high rates of sexual and gender-based violence, and victims are stigmatised through prevailing gender and sexual norms. Existing health research tends to focus on the immediate aftermath of violence rather than on long-term mental and physical health conditions. The project has eight field sites in four countries. The four IDP field sites are one formal camp and one informal settlement each in Eastern DRC and Somalia, both of which have weak health systems. The four refugee field sites are Congolese and Somali settlements in Kenya and South Africa, which have different health systems and different refugee laws and policies.

The project brings together researchers and practitioners from international development, migration studies, gender studies, medical anthropology, public health and health policy, and medical sciences to undertake interdisciplinary empirical research in these protracted displacement contexts. Panzi Foundation (DRC) and War Trauma Foundation (Netherlands) will guide teams of researchers based at the University of Edinburgh (UK), the University of Kinshasa (DRC), the Somali Institute for Development and Research (Somalia), Amref International University (Kenya), and the University of Witwatersrand (South Africa). Project activities are designed to: 1) enhance the capacity of partner organisations; 2) support the inclusion of displaced people in healthcare systems; 3) foster international networks.

Planned Impact

This project aims to have a direct impact on the health of those affected by displacement in Eastern DRC, Somalia, Kenya, and South Africa. It will:
* improve diagnosis, provision, and accessibility of healthcare for neglected chronic physical and mental ill-health conditions amongst displaced populations.
* help develop resilient, responsive, inclusive health systems which ultimately contribute to strong and welcoming societies.
* support the development of mechanisms and organisations that empower displaced communities when they seek healthcare.

Through interactive knowledge exchange with key stakeholders, this project will influence working practices in health systems and among those who organise and/or support displaced people in protracted situations. In-country and cross-country workshops during the initial and final stages of the project will foster dialogue and knowledge exchange between key knowledge users (activists, health practitioners, academics, policy-makers, and displaced people). Phase I workshops will also allow us to better identify the stakeholders' priorities and willingness to implement change, which are relevant for the refined research design and maximisation of research uptake. Finally, the workshops will improve our mapping of the key stakeholders, including (grassroots) groups and the private sector that are less visible to us at the moment. The project will impact upon three main user categories:

A. Internally Displaced Persons (IDPs) in Somalia and Eastern DRC and refugees and asylum seekers in Nairobi and Johannesburg, and the wider public living in the region. The project will generate positive health and societal impacts, including:
* developing displaced peoples' (and medical personnel's) awareness of neglected chronical health conditions in their communities. This increases the chances of proper diagnosis, and then treatment.
* improving the understanding of chronic health issues affecting displaced communities amongst the wider public and civic society (through dissemination events and social media), which is key to building a coalition for increasing displaced people's rights and access to healthcare services.

B. NGOs, civil society, local organisations of displaced people and/or working on access to healthcare. The project's innovative methods of engagement will enhance the impact and effectiveness of support structures for displaced populations:
* the co-design and co-delivery of the project will enhance the research and advocacy capacity of the project partners and civil society organisations involved in our workshops. It will also help identify areas for further work, during and beyond the project, on chronic neglected conditions.
* long-lasting relationships amongst project collaborators will be fostered through the project's activities, thereby contributing to refining and circulating approaches that make healthcare services more responsive to the needs of displaced people during and beyond the project.

C. Policymakers including those responsible for governing and reforming health systems and/or IDP/refugee policies: Ministries of Health, United Nations agencies (particularly WHO, IOM and UNHCR), and influential patients/displaced people's groups and networks such as Refugees International or the People Health's Movement:
* dedicated outputs and policy engagement workshops will feed directly into national policies and national health plans, with clear proposals for accruing effective access to healthcare for displaced people. Health plans, which are developed every 4-6 years in our target countries, and WHO, IOM, and UNHCR strategies guide governmental and non-government interventions.
* engagement between country-based practitioners and transnational actors will enable networks with a lobbying remit to uptake our research insights into best practices on health and displacement and campaign for change outside our countries of focus.
 
Description Work Package 1:
a) Mental health in relation to refugees and migrants in is understood primarily as trauma and sexual violence. This means that mental health that is layered (i.e., trauma experienced at all stages of migration); complex and, shaped by specific socio-cultural experiences is ignored.
b) Mental health challenges are determined by structural violence: lack of documents, exclusion, poverty, poor access to housing, employment and support systems; discrimination, stigma and xenophobia; violence within healthcare.
c) Mental health challenges for refugees and migrants are felt through the body, which can be due to a link between body and mind and somatic experiences; visible/invisible pain, and/or a lack or inability of language to express pain.
d) Healthcare workers do not understand the needs of refugees and migrants: the system is over-whelmed and refugees and migrants with some of greatest mental health challenges are seen as a threat and burden to the system while also misunderstood. This is compounded by: a shortage of psychiatrists and psychologists and community-responses; lack of understanding and compassion; poor mental health literacy; healthcare workers themselves struggling with mental health problems.
e) Services work but there is limited to no access to mental health care for refugees and migrants: mental healthcare systems are under-resourced, over-burdened, and unable to respond to the needs of all and especially migrants.
f) Responses: "plugging the gaps" and responding to immediate needs to reduce mental stress. The starting point is that responding to immediate needs ie no food, no rent money, access to schools etc. is the central response needed to reduce stress created by structural violence. In recognition of specific needs and challenges faced by refugees and migrants, civil society creates "parallel systems" to bypass state services and reduce risks of stigma and discrimination.
These findings link to our aim to support the right to healthcare in contexts of protracted displacement and vulnerability (SDG3).

Work Package 2:
'Neglect' is a highly lucrative concept that attracted billions of US dollars and transformed global health prioritisation. WHO (2019) states that "mental health remains a neglected part of global efforts to improve health", but what (and who) is neglected and what should be done (and by whom) is debated. Our research on the 'neglect' of mental health conditions asked: whose mental health is neglected, why is this neglect considered to be problematic, and what are some of the effects of labelling mental health conditions as 'neglected'? Drawing on interviews with people with professional and/or lived experience of displacement, we made three key findings. First, in uneven and shifting medical landscapes, 'neglect' must be considered in the context of differential health priorities and health-seeking behaviours. Second, disruption to social care networks is often compounded in protracted displacement contexts. Third our respondents distinguished between overt bodily expressions of distress that are socially disruptive and more internalised expressions of distress that are more easily containable.
This finding links to our aim to support the right to healthcare in contexts of protracted displacement and vulnerability (SDG3).

Work Package 3:
a) For Congolese and Somali Migrants "deep sadness" is exacerbated by mistrust, GBV and a fear of the future: mental health challenges are considered in terms of failure, committing sin, breaking with the norm; mental health is stigmatised.
b) Migrants generally do not seek help from formal, public health services due to: awareness they will not be seen or treated well; stigma around mental health; lack of information and resources; lack of trust/belief in formalised (Westernised) health systems.
c) Role of churches and faith is supportive and stigmatising: many migrants seek support through churches and the communities within; however, churches sometimes increase stigma, judgement and deter migrants from seeking formal help.
d) Support networks are critical to responding to mental health but vary: Congolese migrants are part of "disorganised and disjointed" communities in comparison to the tight support networks amongst Somali communities.
e) Much research on IDP health focuses on the barriers that IDPs face in accessing healthcare. While these obstacles are myriad, we used a social connections methodology to analyse what IDPs actually do and where IDPs actually turn in times of need, within and beyond the formal healthcare system. While taking into account the significant lack of resources and capacity of the formal healthcare systems of these countries, we found that the pathways to care IDPs take is also contingent upon cultural and gendered beliefs and practices. When individuals and households need to seek support, they toggle through possible social connections in an almost algorithmic fashion based on the nature of health issue; their understandings of what caused the health problems; and the social, cultural, and material capital at their disposal. Comparing Somali and Congolese IDPs in four field sites in Somalia and DRC, we see significant similarities and overlaps in pathways to care. While both countries have experienced severe erosions of state capacity, NGOs and parallel customary legal systems have filled the state's void to varying degrees of acceptance by IDP participants.
These findings link to our aims to support the right to healthcare in contexts of protracted displacement and vulnerability (SDG3) and to improve gender equality in the context of gendered access to healthcare services (SDG5).
Exploitation Route 1. Internally Displaced Persons (IDPs) in Somalia and Eastern DRC and refugees and asylum seekers in Nairobi and Johannesburg:
a) Developing displaced peoples' (and medical personnel's) awareness of neglected chronical health conditions in their communities. This increases the chances of proper diagnosis, and then treatment.
b) Improving the understanding of chronic health issues affecting displaced communities amongst the wider public and civic society (through dissemination events and social media), which is key to building a coalition for increasing displaced people's rights and access to healthcare services.

2. NGOs, civil society, local organisations of displaced people and/or working on access to healthcare:
a) The co-design and co-delivery of the project will enhance the research and advocacy capacity of the project partners and civil society organisations involved in our workshops. It will also help identify areas for further work, during and beyond the project, on chronic neglected conditions.
b) Long-lasting relationships amongst project collaborators will be fostered through the project's activities, thereby contributing to refining and circulating approaches that make healthcare services more responsive to the needs of displaced people during and beyond the project.

3. Policymakers including those responsible for governing and reforming health systems and/or IDP/refugee policies:
a) Dedicated outputs and policy engagement workshops will feed directly into national policies and national health plans, with clear proposals for accruing effective access to healthcare for displaced people.
b) Engagement between country-based practitioners and transnational actors will enable networks with a lobbying remit to uptake our research insights into best practices on health and displacement and campaign for change outside our countries of focus.
Sectors Communities and Social Services/Policy,Healthcare

URL https://displacement.sps.ed.ac.uk/
 
Description Mapping health systems' responsiveness to refugee and migrant health needs mapping review - member of strategic working group
Geographic Reach Africa 
Policy Influence Type Membership of a guideline committee
URL https://apps.who.int/iris/bitstream/handle/10665/346682/9789240030640-eng.pdf?sequence=1&isAllowed=y
 
Description Concerning 'neglect': exploring the conceptualisation and prioritisation of mental health conditions in protracted displacement contexts 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Presentation by Professor Laura Jeffery at the Edinburgh Mental Health (EMH) Conference. EMH is a University of Edinburgh wide initiative that aims to establish Edinburgh as a future global leader in interdisciplinary mental health research. EMH is an interdisciplinary network that brings together research expertise from across the university, mapping areas of research activity and fostering opportunities for new collaborations and impact/engagement activities.
Year(s) Of Engagement Activity 2022
 
Description Drones, dinghies and an army helicopter - why the state's new toys won't help South Africa's response to Covid-19 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Other audiences
Results and Impact Op-Ed by Co-Investigator Jo Vearey and Research Fellow Rebecca Walker based at the University of the Witwatersrand, along with Sally Ganda at the Scalabrini Centre of Cape Town and Francois Venter head of Ezintsha at the University of the Witwatersrand.
Year(s) Of Engagement Activity 2021
URL https://www.dailymaverick.co.za/article/2021-01-08-drones-dinghies-and-an-army-helicopter-why-the-st...
 
Description GCRF Protracted Displacement website 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Study participants or study members
Results and Impact A dedicated project website was set up in 2020 to increase the visibility of project outputs and promote wider public engagement. The website is multilingual in English, French, and Somali. The website will host reports of the 2020 work packages 1) led by ACMS at the University of Witwatersrand in Johannesburg (South Africa) and 2) led by ARQ in the Netherlands. The website will continue to showcase project activities, findings, dissemination events, publications, and other outputs.
Year(s) Of Engagement Activity 2020,2021
URL https://displacement.sps.ed.ac.uk/
 
Description New UK Gov funding for SPS researchers to take on global sustainable development challenges 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact New UK Gov funding for SPS researchers to take on global sustainable development challenges
Edinburgh researchers are tackling some of the biggest global development challenges - from the demands on urban infrastructure caused by climate change and poverty, to improving healthcare and rights among displaced populations - with new funding from the UK Government.
Experts at the University of Edinburgh's School of Social and Political Science (SPS) have received a slice of a new £147million investment package from UK Research and Innovation (UKRI) for various projects.
The awards - from UKRI's Global Challenges Research Fund (GCRF) Collective Programme - bring together a wide range of researchers from across the UK and developing countries. The aim is to generate innovative solutions to intractable development issues and contribute to enabling healthier and safer lives, sustainable development and prosperity.
The funded projects run across UKRI's six strategic GCRF Challenge portfolios: global health; education; sustainable cities; food systems; conflict; and resilience. They are aligned to the UK Government's aid strategy and the United Nations' Sustainable Development Goals.
The SPS awards include:

GCRF Challenge portfolio: Cities and Sustainable Infrastructure
Project theme: (Re)thinking the off-grid city: Human infrastructure interactions in the context of urban crisis and urban change
SPS projects:
Cool Infrastructures: Life With Heat in the Off-Grid City - £1,777,882; PI - Professor Jamie Cross
This project aims to benefit people with partial or limited access to electricity in low-income urban settlements across Yaoundé (Cameroon), Karachi (Pakistan), Hyderabad (India), Jakarta (Indonesia) and beyond. Its objectives are to improve access to affordable, sustainable cooling, and reduce the impact of heat waves for these groups.
Navigating the grid in the 'world-class city': poverty, gender, and access to services in India, Pakistan and Sri Lanka - £818,748; PI - Professor Jonathan Spencer
This project sets out to reduce urban poverty in South Asia by providing workable, context-sensitive solutions to the problems poor communities encounter in accessing key infrastructural services. The team will work with partners in three cities - Lahore, Colombo and Mumbai.

GCRF Challenge portfolio: Security, Protracted Conflict, Refugees and Forced Displacement
Project theme: Development-based approaches to Protracted Displacement
SPS projects:
Improving healthcare at the intersection of gender and protracted displacement amongst Somali and Congolese refugees and IDPs - £2,809,679; PI - Professor Laura Jeffery
This project aims to help people affected by displacement in Eastern DRC, Somalia, Kenya and South Africa to access appropriate healthcare for long-term physical and mental health conditions associated with protracted displacement, conflict and gendered violence.
Maghreb Action on Displacement and Rights (MADAR) Network Plus - £1,871,675; PI is based at Keele University. SPS lead - Professor Laura Jeffery
The MADAR project aims to directly impact the lives of those affected by displacement and to enhance the research and advocacy capacity of civil society organisations in the Maghreb and other South-South displacement contexts.

Professor Tobias Kelly, Co-Director of Research at the School of Social and Political Science, said:
"Researchers at the School of Social and Political Science in Edinburgh have long addressed some of the world's most enduring challenges, providing critical and important insights, as well as supporting practical responses.
"These latest projects funded under the GCRF Collective Programme focus on urban development and forced displacement, and will help improve access to healthcare, energy and government services in multiple places across the globe."
Full details about UKRI's GCRF Collective Programme are available in this brochure.
Year(s) Of Engagement Activity 2020
URL http://www.sps.ed.ac.uk/about/news/2020/new_uk_gov_funding_for_sps_researchers_to_take_on_global_sus...
 
Description No country for poor people: South African government must act on its motto of 'saving lives and protecting livelihoods' 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Op-Ed by one of our Research Fellows Rebecca Walker based at the University of the Witwatersrand, and her colleague Elsa Oliveira on the impact of covid lockdown and xenophobia on refugee women in Johannesburg.
Year(s) Of Engagement Activity 2022
URL https://www.dailymaverick.co.za/article/2021-03-24-no-country-for-poor-people-south-african-governme...
 
Description Social Connections online methods training module 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Study participants or study members
Results and Impact QMU and UoE co-designed and recorded (and translated from English into French where necessary) materials with which to facilitate weeklong online training in QMU's Social Connections method for the project's field research teams in the project's field countries (Somalia, DRC, Kenya, South Africa). The online Social Connections methods training module was piloted with the project's field research team at SIDRA in Mogadishu (Somalia) over the course of a week in November 2020. Following the pilot, in 2021 the online Social Connections methods training module was rolled out with the project's field research teams at SIDRA in Garowe (Somalia), UEA Bukavu (Eastern DRC), Amref in Nairobi (Kenya), and ACMS at the University of Witwatersrand in Johannesburg (South Africa), including focus group discussions with displaced populations in project field sites.
Year(s) Of Engagement Activity 2020,2021
 
Description Your home is the place you can't return to, and the place where you are doesn't appear to want you - Blog post 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Blog post by by one of our Research Fellows Rebecca Walker based at the University of the Witwatersrand. The post highlights mental health issues amongst mostly displaced populations in Johannesburg, South Africa.
Year(s) Of Engagement Activity 2021
URL https://displacement.sps.ed.ac.uk/2021/04/05/your-home-is-the-place-you-cant-return-to-and-the-place...