The Institute for Global Health and Development
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Item Integrating healthcare financing for refugees into national health systems: findings from a rapid review of the literature(Elsevier, 2025-10-16) Bertone, Maria Paola; Palmer, Natasha; Witter, SophieAs the number of refugees increases and displacement becomes protracted, providing equitable healthcare in sustainable ways is increasingly challenging. The Global Compact for Refugees calls for greater inclusion of refugees in national health systems. However, evidence is limited on the most suitable approaches to achieve integration, including from a health financing perspective. This study reviewed normative and empirical literatures on health financing for refugees, reflecting on existing arrangements, and their level of integration with national health systems. A total of 52 documents were reviewed following a purposeful search of grey and published literature. Data were analysed according to core health financing sub-functions as defined by the WHO, specifically reflecting on pathways and approaches to integration for each. The analysis found that challenges remains in relation to funding for refugee healthcare, and areas of focus concern fair burden-sharing and engagement of development funders. Fund pooling proves to be a potential entry point for integration to reduce fragmentation in health financing through use of existing mechanisms (budgets or social health insurance schemes), despite challenges highlighted in the empirical literature. Fewer documents look at purchasing and benefit packages, and they highlight the importance of tailoring those to the specific needs of refugees. In relation to equity and efficiency, integration is often assumed to lead to improvements, but evidence is limited and issues related to the underlying weaknesses of the national health system might hamper the benefits of integration. Overall, the review findings support the development of hypotheses as to how best support health financing integration processes, and highlight areas for further research.Item Care as Resistance, Care as Agency, Care as a Burden: A Relational Exploration of the Impact of Giving and Receiving Care on Refugees’ Lives(Oxford University Press, 2025-09-23) Baillot, Helen; Vera Espinoza, Marcia; Yurdakul, G.; Beaman, J.; Mügge, L.; Scuzzarello, S.; Sunanta, S.This chapter discusses the multidimensionality and multidirectionality of care and its impact upon refugees’ pathways toward inclusion. Drawing on qualitative data collected during workshops and interviews with 55 recently recognized refugees in Scotland, the chapter explores how care in multiple forms is experienced, given, and negotiated. The chapter draws from ideas around care that conceptualize it as a means to resist restrictive government policies, as an expression of agency within familial and social contexts, and as a burden that affects people differentially as they seek to rebuild lives in new country contexts. In exploring the multiple dimensions and directions of care and the ways it intersects with gender and immigration status, among other social locations, we highlight conceptual and empirical parallels between care and integration. One, the text suggests, should not be understood without full consideration of the other. The chapter concludes by calling for care to be accorded a greater importance in explorations of refugees’ integration experiences, in ways that fully encompass care’s potentialities and limitations for the people who provide and receive it.Item Exploring refugees' experience of accessing dental health services in host countries: a scoping review(Frontiers Media S.A., 2024-03-12) Asfari, Elaf; Rodriguez, Andrea; Dakessian, Arek; Yuan, SiyangIntroduction: Refugees often face worse oral health outcomes, such as periodontal diseases and dental caries in host countries due to barriers including language and cultural differences, institutional discrimination, and restricted use of dental health services. This scoping review aims to map and summarise the available studies on refugees’ experience of accessing dental health services in the host countries, to identify the main characteristics of the dental health services that refugees access and to explore the barriers and enablers to navigate the dental health service system in their host countries. Methods: The Joanna Briggs Institute (JBI) framework was adopted. PubMed, Scopus, Assia, CINAHL and Social Services Abstract were searched. A search strategy was developed using Medical Subject Headings (MeSH) terms and a combination of search operators and syntax used in MEDLINE were adopted for the remaining databases. Data were synthesised using thematic analysis. Results: Fourteen articles were included. Most studies used qualitative methods and Australia seemed to be the country with the highest number of publications surrounding this topic. The included studies showed that refugees frequently encountered substantial obstacles when attempting to access dental services in host countries. Numerous barriers such as language barriers, cultural differences, and lack of health insurance or financial support hindered refugees' ability to access these services. Additionally, many refugees possessed limited knowledge of the dental care system in their new country. As a result of untreated dental problems, refugees suffered from pain and other health complications. Discussion: This scoping review explored the challenges refugees have experienced in accessing dental health services in host countries, which included the key barriers such as affordability, accessibility, accommodation, availability, awareness, and acceptability. The scarcity of relevant research highlighted the need for a more comprehensive understanding of refugees’ experiences accessing dental health services in host countries. Limited data were identified regarding evidence focusing on the characteristics of dental services accessed by refugees in host countries.Item Weakening Practices Amidst Progressive Laws: Refugee Governance in Latin America during COVID-19(Taylor and Francis Group, 2023-10-05) Zapata, Gisela P.; Gandini, Luciana; Vera Espinoza, Marcia; Prieto Rosas, VictoriaThis paper develops a comparative assessment of the state of asylum in Brazil, Chile, Mexico, and Uruguay. It argues that an accelerated weakening of refugee protection, exacerbated during the pandemic, has taken place across the region. Faced with growing mixed flows, the region’s refugee framework has either been used as an ad hoc regularization mechanism or not been broadly used. Also, pandemic mitigation measures have further weakened access to asylum, through militarization and border closures, and a platitude of deterrence practices. These regressive practices may result in the undermining, abandonment and/or replacement of the region’s widely praised refugee governance.Item Participation by conflict-affected and forcibly displaced communities in humanitarian healthcare responses: A systematic review(Elsevier, 2020-12-09) Rass, Ella; Lokot, Michelle; Brown, Felicity L; Fuhr, Daniela C; Asmar, Michèle Kosremelli; Smith, James; McKee, Martin; Bou-Orm, Ibrahim; Yeretzian, Joumana Stephan; Roberts, BayardBackground Community participation in health responses in humanitarian crises is increasingly promoted by humanitarian actors to support adoption of measures that are relevant and effective to local needs. Our aim was to understand the role of community participation in humanitarian health responses for conflict-affected populations (including forcibly displaced populations) in low- and middle-income countries and the barriers and facilitators to community participation in healthcare responses. Methods Using a systematic review methodology, following the PRISMA protocol, we searched four bibliographic databases for publications reporting peer-reviewed primary research. Studies were selected if they reported how conflict-affected populations were involved in healthcare responses in low- and middle-income settings, and associated changes in healthcare responses or health outcomes. We applied descriptive thematic synthesis and assessed study quality using study design-specific appraisal tools. Results Of 18,247 records identified through the database searching, 18 studies met our inclusion criteria. Various types of community participation were observed, with participation mostly involved in implementing interventions rather than framing problems or designing solutions. Most studies on community participation focused on changes in health services (access, utilisation, quality), community acceptability and awareness, and ownership and sustainability. Key barriers and facilitators to community participation included political will at national and local level, ongoing armed conflict, financial and economic factors, socio-cultural dynamics of communities, design of humanitarian responses, health system factors, and health knowledge and beliefs. Included studies were of mixed quality and the overall strength of evidence was weak. More generally there was limited critical engagement with concepts of participation. Conclusion This review highlights the need for more research on more meaningful community participation in healthcare responses in conflict-affected communities, particularly in framing problems and creating solutions. More robust research is also required linking community participation with longer-term individual and health system outcomes, and that critically engages in constructs of community participation.Item Health system governance in settings with conflict-affected populations: a systematic review(Oxford University Press, 2022-03-22) Lokot, Michelle; Bou-Orm, Ibrahim; Zreik, Thurayya; Kik, Nour; Fuhr, Daniela C; El Masri, Rozane; Meagher, Kristen; Smith, James; Asmar, Michele Kosremelli; McKee, Martin; Roberts, BayardHealth system governance has been recognized as critical to strengthening healthcare responses in settings with conflict-affected populations. The aim of this review was to examine existing evidence on health system governance in settings with conflict-affected populations globally. The specific objectives were (1) to describe the characteristics of the eligible studies; (2) to describe the principles of health system governance; (3) to examine evidence on barriers and facilitators for stronger health system governance; and (4) to analyse the quality of available evidence. A systematic review methodology was used following Preferred Reporting Items for Systematic Review and Meta-Analysis criteria. We searched six academic databases and used grey literature sources. We included papers reporting empirical findings on health system governance among populations affected by armed conflict, including refugees, asylum seekers, internally displaced populations, conflict-affected non-displaced populations and post-conflict populations. Data were analysed according to the study objectives and informed primarily by a governance framework from the literature. Quality appraisal was conducted using an adapted version of the Mixed Methods Appraisal Tool. Of the 6511 papers identified through database searches, 34 studies met eligibility criteria. Few studies provided a theoretical framework or definition for governance. The most frequently identifiable governance principles related to participation and coordination, followed by equity and inclusiveness and intelligence and information. The least frequently identifiable governance principles related to rule of law, ethics and responsiveness. Across studies, the most common facilitators of governance were collaboration between stakeholders, bottom-up and community-based governance structures, inclusive policies and longer-term vision. The most common barriers related to poor coordination, mistrust, lack of a harmonized health response, lack of clarity on stakeholder responsibilities, financial support and donor influence. This review highlights the need for more theoretically informed empirical research on health system governance in settings with conflict-affected populations that draws on existing frameworks for governance.Item Social determinants and mental health needs of Palestine refugees and UNRWA responses in Gaza during the COVID-19 pandemic: a qualitative assessment(BioMed Central, 2022-12-08) Jamal, Zeina; ElKhatib, Zoheir; AlBaik, Shatha; Horino, Masako; Waleed, Mohammed; Fawaz, Farah; Loffreda, Giulia; Seita, Akihiro; Witter, Sophie; Diaconu, KarinBackground: Due to pre-existing difficulties, refugees are especially susceptible to the negative effects of the pandemic; nonetheless, the pandemic’s effect on this group is still unclear. The purpose of this study was to determine the effects of the COVID-19 pandemic on the mental health of Palestine refugees in Gaza by identifying the role of social determinants. During the pandemic, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) enacted a number of policies and measures. The purpose of this research was to assess their efficacy and acceptability. Methods: This qualitative study took place between August and November 2020. Twenty-nine key-informant interviews were conducted remotely with UNRWA Headquarters, field and clinical staff in Gaza and with community members, aged ≥18 years and residing in Rafah and Jabalia camps. We sought informed consent verbally or via email. Data was coded based on the framework for social determinants of mental health. Results: Interview results indicated that the relationship might be unidirectional, with COVID-19 causing the degradation of living conditions and vice versa, with living conditions exacerbating the COVID-19 situation by facilitating virus transmission. In other instances, the association between mental health determinants and COVID-19 might be bidirectional. In terms of experiencing violence and anxieties, women, children, and daily-paid employees were significantly more disadvantaged than other groups in the community. UNRWA modified its service delivery techniques in order to continue providing essential services. In general, UNRWA’s strategies throughout the pandemic were deemed beneficial, but insufficient to meet the needs of Gazans. Conclusion: The pandemic highlights the need to go beyond disease treatment and prevention to address social determinants to improve refugees’ health and reduce their susceptibility to future shocks. UNRWA has rapidly implemented telemedicine and mental telehealth services, making it imperative to assess the efficacy of these novel approaches to provide care at a distance. A long-term option may be to employ a hybrid strategy, which combines online and in-person therapy.Item The determinants of the quality of clinical management among diabetic and hypertensive patients in a context of fragility: A cross-sectional survey from Lebanon(Frontiers Media S.A., 2022-07-25) Saleh, Shadi; Muhieddine, Dina; Hamadeh, Randa; Dimassi, Hani; Diaconu, Karin; Arakelyan, Stella; Ager, Alastair; Alameddine, MohamadIntroduction: The management of NCDs is a growing challenge in low- and middle-income settings with the increasing prevalence and the associated demands that such conditions make on health systems. Fragile settings both exacerbate the risk of NCDs and undermine systems capacity. Lebanon is a setting where strategies to address rising NCDs burden have faced particularly acute contextual challenges. Methods: We conducted a cross-sectional survey with patients accessing non-communicable disease across 11 primary care centers within the Greater Beirut and Beqaa areas. Response were received from 1,700 patients. We generated a Clinical Management Index Score as a measure of quality of care, and scores related to a range of socio-demographic characteristics and other context specific variables. Results: Significantly higher clinical management index scores (better quality of care) were associated with patients living in the semi-urban/rural context of Beqaa (compared to Greater Beirut), having health insurance coverage, aged above 60, having high levels of educational attainment, and making partial or full payment for their treatment. Relatively lower index scores (poorer quality of care) were associated with Syrian nationality (compared to Lebanese) and with patients suffering from diabetes or hypertension (compared to comorbid patients). Conclusion: The study identified a wide margin for improving quality of NCDs care in fragile contexts with particular gaps identified in referral to ophthalmology, accessing all prescribed medication and receiving counseling for smoking cessation. Additionally, findings indicate a number of predictors of comparatively poor quality of care that warrant attention, notably with regard to Syrian nationality/legal status, lack of health coverage, seeking free health provision and lower educational attachment. Although these are all relevant risk factors, the findings call on donor agencies, NGOs and provider institutions to design targeted programs and activities that especially ensure equitable delivery of services to diabetic and hypertensive patients with compounded vulnerability as a result of a number of these factors.Item Lessons from refugees: Research ethics in the context of resettlement in South America(Berghahn, 2020-06-01) Vera Espinoza, MarciaRefugees are the main experts on their own experiences of displacement. They constantly challenge academic research practice and ethical guidelines, as their own lives are under study. This article shares some reflections from research with Colombian and Palestinian resettled refugees in Chile and Brazil, shedding light on refugees’ agency in determining what constitutes safe and ethical research practices.Item Refugees, political bounding and the pandemic: Material effects and experiences of categorisations amongst refugees in Scotland(Routledge, 2022-04-25) Burns, Nicola; Mulvey, Gareth; Piacentini, Teresa; Vidal, Nicole L.Scholars are increasingly interested in and concerned with both the way various migrant populations are categorised, and the lived impacts of that categorisation. In this article, we examine how categorisation was experienced by people at various stages of the refugee journey during the biggest public health crisis for generations. We argue, using original interview data, that the way refugees are categorised, or politically bound, has material impacts on the way they experience their lives, and that this was evident in extremis during the Covid-19 lockdown in Scotland. As populations attempted to traverse public health messaging, this is shown to interact with longstanding state proclivities to control, marginalise and stratify. Consequently, how people experienced and managed the request to ‘stay home and save lives’ varied markedly by where they were in their refugee journey and how they arrived in the UK.