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

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.