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

根据联合国难民事务高级专员办事处(难民署)的数据，截至2017年6月，全球有6560万人被迫流离失所，其中2250万人是难民。从历史上看，难民保健服务主要是通过设在难民署或国际非政府组织经营的难民营内的专门保健诊所提供的。然而，随着流动模式和紧急情况持续时间的改变，人们认识到，难民营中的这些并行保健服务是不可持续的，对周围的收容人口没有足够的惠益，他们中的许多人也很脆弱。相反，难民署呼吁将难民人口纳入国家卫生系统，世界银行最近为难民收容政府设立了20亿美元的基金，以支持难民和收容社区的融合，涵盖包括卫生在内的多个部门。这一走向“人道主义-发展联系”的举措有可能支持难民和国民，同时提高国家系统的能力。探讨将难民纳入保健系统的问题及其对这些系统的影响的研究有限。因此，国际、区域或国家行为者可获得的证据有限，表明哪类安排在特定情况下可能最有效。我们将在目前接收大量难民的三个不同国家进行案例研究：黎巴嫩(110万人)、约旦(65.5624人)和乌干达(94.08万人)。我们计划重点关注黎巴嫩和约旦的叙利亚难民，以及乌干达的南苏丹难民。虽然黎巴嫩、约旦和乌干达的政策都在某种程度上将难民纳入了卫生系统，但它们在方法和基本卫生系统的结构方面存在很大差异。我们将分别分析每个国家的情况，然后设法确定这三个情况的模式，以便能够得出与其他情况相关的结论。具体地说，我们的研究将设法了解利益攸关方以及收容和难民人口对难民融入国家卫生系统的看法和经验，包括这些利益攸关方如何理解融入的意义和它的可取性。它将确定影响难民，包括难民保健工作者融入国家卫生系统的政策的结构、体制和个人/社区因素。该研究还将评估这三种情况下难民融入的模式和程度如何影响难民和收容人口接受的保健服务，以及资金机制和流动如何影响服务的财务可持续性。然后，我们将召集国家、区域和国际政策制定者和决策者，思考这些分析的结果，并确定其对未来政策和实践的影响。在这三个国家的每一个案例中，我们都将采用适合当地情况的混合方法。我们计划确定制定难民政策的时间表，并将进行一项政策分析，以了解政策和做法是如何演变的以及为什么演变。然后，我们将使用现有的数据集和在地区一级病例中收集的主要数据，探讨难民融入国家卫生系统的不同方面如何随着时间的推移影响可获得性、获得卫生服务和卫生保健的质量。在这三个不同背景下进行比较研究，将使这三个国家的决策者能够学习和考虑难民融入社会的替代办法，但也将提供证据和政策建议，可用于其他现有和未来的难民环境。我们还寻求与难民署、世界银行和世卫组织等行为者合作，为这一问题提供全球政策和指导。

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.