Integrating Refugees into National Health Systems: Enhancing Equity and Strengthening Sustainable Health Services for All.

According to United Nations High Commissioner for Refugees (UNHCR), until June 2017, 65.6 million people were forcibly displaced worldwide of whom 22.5 million were refugees. Historically, health services for refugee populations have been provided primarily through dedicated health clinics located within refugee camps run by UNHCR or international non-governmental organizations. However, as patterns of mobility and emergency duration have changed, there is recognition that these parallel health services in camps are unsustainable and insufficiently benefit the surrounding host populations, many of whom are also vulnerable. Instead, UNHCR has called for the integration of refugee populations into national health systems, and the World Bank recently established a US$2 billion fund for refugee-hosting governments to support the integration of refugees and host communities, covering multiple sectors, including health. This move towards a "humanitarian-development nexus" has the potential to support refugees and nationals, while increasing the capacity of national systems. There has been limited research exploring the issue of integrating refugees into health systems and its effects on such systems. Thus, there is limited evidence available to international, regional or national actors in terms of which types of arrangements may work best in a particular context. We will conduct case studies in three different countries currently hosting large numbers of refugees: Lebanon (1.1m), Jordan (655,624), and Uganda (940,800). We plan to focus on Syrian refugees in Lebanon and Jordan, and South Sudanese refugees in Uganda. While policies in Lebanon, Jordan and Uganda have all integrated refugees into health systems to some degree, they differ widely in their approach, and in the structure of the underlying health system. We will analyse each country case separately and then seek to identify patterns across the three cases, so as to be able to draw conclusions that are relevant to other contexts. Specifically, our research will seek to understand the perceptions and experiences of stakeholders as well as host and refugee populations towards refugees' integration into national health systems including how these stakeholders understand the meaning of integration and perceive its desirability. It will identify the structural, institutional and individual/community factors that have shaped policies on integration of refugees, including refugee health workers, into national health systems. The study will also assess how the pattern and extent of refugee integration across these three contexts has affected health services received by refugee and host populations and how financial mechanisms and flows affected financial sustainability of services. We will then convene national, regional and international policy and decision-makers to reflect upon the findings from these analyses, and identify their implications for future policy and practice. Within each of the three country cases we will employ a mixed-method approach that will be tailored to match local circumstances. We plan to identify timelines for the development of refugee policies and will conduct a policy analysis to understand how policies and practices evolved and why. We will then use existing datasets and primary data collection within district level cases, to explore how different aspects of refugee integration into national health systems over time has affected availability, access to health services and quality of health care. A comparative study, across these three different contexts, will enable decision-makers within the three countries to learn from and consider alternative approaches to refugee integration, but will also provide evidence and policy recommendations that will be transferable to other existing and future refugee settings. We also seek to inform global policy and guidance on this issue, working with actors such as the UNHCR, the World Bank and WHO among others.

This study will employ a comparative case study approach focusing on three countries currently hosting large numbers of refugees: Lebanon (1.1m), Jordan (655,624), and Uganda (940,800). We plan to focus on Syrian refugees in Lebanon and Jordan, and South Sudanese refugees in Uganda. Our research will seek to: (i) understand the perceptions and experiences of stakeholders (international, regional, and national) as well as host populations and refugee populations towards refugees' integration into national health systems including how these stakeholders understand the meaning of integration and how desirable various actors believe it to be (ii) identify the factors that have shaped the adoption and implementation of policies supporting the integration of refugees into national health systems in these three countries (iii) assess how the pattern and extent of refugee integration has affected health services received by both refugee and host populations and (iv) assess financial flows and the financial sustainability of services. We will then convene national, regional and international policy and decision-makers to reflect upon the findings from these analyses, and identify their implications for future policy and practice.
Within each of the three country cases, we will employ a mixed-method, qualitative and quantitative, approach that will be tailored to match local circumstances. We plan to identify timelines for the development of refugee policies (generally and in regard to access to national health services) and will conduct a policy analysis to understand how policies and practices evolved and why. We will then use existing datasets and primary data collection within district level cases, to explore how different aspects of refugee integration into national health systems over time has affected availability, access to health services, quality of health care, and felt experiences of seeking care, as well as financial sustainability.

As refugee crises have become chronic, and the volume of population flows has increased, there are growing calls to better integrate refugees into their host countries. International agencies such as the World Bank and the UNHCR have both called for enhanced integration of refugees as a means to find more sustainable solutions to refugee crises, but also as a potential entry point for strengthening host country economies, social services and health systems. While countries such as Jordan, Lebanon and Uganda have all, to varying degrees, sought to integrate large refugee populations, there is an extremely limited empirical base to guide their policies and strategies, and lessons from high-income countries may not always be relevant to low and middle income country contexts.
Impact through informing policy and practice: This research will provide critical evidence to inform national, regional and international policies and strategies concerning the integration of refugees in national health systems. We will work with policy-makers, program managers and, affected citizens and refugees in Lebanon, Jordan, and Uganda, as well as donors and other international actors to help them reflect up on the learnings from this research and refine their policies, plans, and strategies regarding the integration of refugees into national health systems. We will also work with international actors - particularly UNHCR, the World Bank and WHO - to inform their global policies and (in the case of the World Bank) lending practices, to reflect learnings from this grant that can be broadly applied across other countries. In doing so we hope to ensure enhanced access to responsive and high quality health services for refugees, as well as for host populations, and strengthen national health systems, in order to achieve universal health coverage and the sustainable development goals (SDGs). Such systems strengthening will ultimately result in better health outcomes for both host population and refugees.
We will seek to ensure these impacts through implementing strategic knowledge translation (KT) activities in all three counties, alongside close collaboration with ministries of health and other stakeholders to ensure the uptake of the generated evidence. Representatives from UNHCR in the Middle East participated in a recent workshop we held on this topic in Beirut (January 2018), and we have obtained a letter of support from UNHCR Headquarters. We have also solicited support and guidance from Ministries of Health in all the three countries.
Impact through theoretical and methodological development: This study will contribute to the advancement of theories and models of integration of refugees into national health systems - which are still scarcely developed. This interdisciplinary health policy and systems research convening researchers from multiple expertise and disciplines including health systems, refugees and humanitarian crises, political science, sociology, economics and public health, will guide this type of research that can be replicated in the future. This work will also contribute to the advancement of the science of KT in the field of health in conflict.
Impact through identifying data quality and needs: Through mapping available data from governments, UNHCR and other organizations, this project will identify data quality, gaps and needs and inform strategies to strengthen coordination mechanisms among these agencies. This work will further support and strengthen our conceptual framework to assess the integration of refugees into national health systems.
Impact through enhancing capacity: We will build capacity in conducting interdisciplinary health systems research, particularly of junior researchers (PhD, post-doctoral, MPH students, and research fellows) from affected communities (i.e. Lebanon, Jordan, Syria, Uganda, and South Sudan). K2P Center will also build capacity of country teams in KT through training and close mentorship