Module 4 Video: Strengthening health systems in situations of protracted forced displacement

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00:00 On,

00:00 uh,

00:01 where you're journey from.

00:03 Uh,

00:03 welcome

00:04 to the 4th module of the Learning from the Evidence on Force Displacement,

00:07 uh,

00:08 Training Program.

00:09 The program,

00:10 the training is organized by the,

00:11 uh,

00:12 UK government,

00:13 UNHCR World Bank,

00:14 uh,

00:14 Building the Evidence of Force Displacement Research Program

00:17 in collaboration with the World Bank,

00:19 UNHCR Joint Data Center on Horse Displacement.

00:22 My name is Paula Ellis.

00:23 I am an impact evaluation specialist in the Building

00:25 the Evidence Program and the World Bank Group.

00:28 Today,

00:28 I'm joined by Monette Zard,

00:30 who is an associate professor and director

00:32 of the Program on Forced migration and Health

00:35 at the Columbia University Mailman School of Public Health.

00:38 Monette and her team have uh prepared this module and will be leading,

00:42 um,

00:43 its delivery today.

00:44 And,

00:45 uh,

00:45 today's session is focusing on health system

00:47 strengthening in situations of protracted displacement.

00:52 Uh,

00:53 before I head over to Monette,

00:54 uh,

00:54 I'd like to cover some,

00:56 uh,

00:56 logistical aspects.

00:58 Uh,

00:59 first,

01:00 um,

01:01 I wanted to communicate that the meeting is being recorded,

01:03 uh,

01:04 although the,

01:05 uh,

01:05 discussions that will be had in,

01:07 uh,

01:07 the breakout rooms will not be recorded.

01:09 Uh,

01:10 you're encouraged to keep your camera on throughout the session.

01:13 Um,

01:13 it's nice for speakers to,

01:14 to see who they're speaking to,

01:16 uh,

01:17 and it's a training.

01:17 So,

01:18 um,

01:19 it'd be nice if you can,

01:20 uh,

01:20 do that,

01:20 if your bandwidth,

01:21 uh,

01:21 allows.

01:22 Um,

01:23 kindly make sure to be on mute when,

01:25 uh,

01:25 we're not speaking.

01:26 We're going to have 90 minutes for the session.

01:28 And you are welcome to submit questions as they arise to the chat.

01:32 The chat will be monitored and questions will be

01:34 uh responded to.

01:36 Um,

01:37 a couple of more things,

01:38 um,

01:38 if Zoom didn't do it automatically,

01:41 kindly rename yourselves,

01:42 uh,

01:42 and put your affiliation in parenthesis,

01:46 uh,

01:46 and you can do that by right clicking,

01:48 uh,

01:48 next to your name,

01:50 uh,

01:50 in Zoom and,

01:52 um,

01:52 and typing in.

01:54 Um,

01:55 and,

01:56 uh,

01:56 I see,

01:57 um,

01:58 we have a,

01:59 a good participation,

02:00 uh,

02:01 so I'd like to invite you all to,

02:03 um,

02:04 type in the chat who you are,

02:05 where you're joining from,

02:06 and your,

02:08 your organization,

02:09 uh,

02:09 to get,

02:09 uh,

02:10 each other acquainted with,

02:11 um,

02:12 before we start.

02:13 Uh,

02:14 again,

02:14 welcome to today's module.

02:16 Um,

02:16 it is my pleasure to hand over,

02:18 uh,

02:18 the floor to Monette,

02:19 who is going to,

02:20 uh,

02:20 lead the session.

02:22 Over to you,

02:22 Monette,

02:23 with thanks.

02:25 Thank you so much,

02:26 Paula,

02:27 and uh thanks to UK Aid,

02:29 UNHCR and the World Bank,

02:32 uh,

02:32 for this opportunity to present and discuss some

02:34 of the key lessons from our three-year study

02:37 on the big questions in forced displacement and health.

02:41 And I confess that it feels somewhat surreal to be having a considered

02:45 conversation

02:46 about healthcare for refugees against the backdrop of

02:49 such overt and flagrant attacks on health facilities,

02:52 health personnel,

02:53 and civilians as we're seeing in Gaza

02:56 at present,

02:57 but that is the context and the world in which we're living.

03:01 But in any case,

03:02 I think the big Questions project really focused on humanitarian health responses

03:07 and the relationship with,

03:09 uh,

03:09 national health systems

03:11 in fragile,

03:12 low and middle-income settings in situations of protracted displacement.

03:16 And over the next 90 minutes or so,

03:18 my colleagues and I

03:20 We'll first introduce the study

03:22 and then spend some time,

03:24 secondly,

03:24 looking at health system integration and the interplay

03:28 between national and parallel health systems

03:30 in settings of protracted displacement.

03:33 Then in the third part of our remarks,

03:35 we'll look at how those systems are financed.

03:38 Um,

03:39 which was,

03:40 should take us up to about the 50,

03:41 55 minute mark.

03:43 We'll then go into small breakout room discussions to deepen

03:47 the conversation

03:48 before wrapping up in the plenary with some key takeaways from our conversation.

03:54 So just to give you a little bit of background on the project itself,

03:57 um,

03:57 the Big Question study was commissioned

04:00 by UKA,

04:01 the Bank,

04:01 the World Bank,

04:02 and UNHCR in 2019,

04:05 and it was carried out by a

04:06 consortium of universities including Columbia University,

04:10 the American University of Beirut,

04:11 Brandeis University,

04:13 Georgetown,

04:14 and uh

04:15 University de los Andes in Colombia.

04:18 The work was commissioned against a backdrop where the

04:21 majority of refugees and people in need of international protection

04:26 live in situations characterized as protracted,

04:29 defined as displacement that lasts a consecutive period of at least 5 years.

04:35 In 2018,

04:37 the Global Compact on refugees

04:39 called for expanding and enhancing the quality of national health systems

04:44 to facilitate access

04:46 by refugees alongside host communities,

04:49 including

04:50 building and equipping health facilities and strengthening health services.

04:55 The Big Questions project has really been guided throughout by that call

04:59 and the need to provide programming and policy guidance

05:03 to those national and international actors such as yourselves on this call,

05:08 who are really involved in directing and funding

05:11 health responses in situations of protracted displacement.

05:16 So

05:16 our research took up three primary questions,

05:20 including what are the common trends,

05:22 similarities,

05:22 and differences in health needs

05:25 between forcibly displaced populations and host communities

05:29 in the various geographic,

05:30 social,

05:31 and demographic contexts in which

05:33 protracted displacement occurs.

05:35 Second,

05:37 what empirical evidence,

05:38 lessons learned,

05:39 and good practices are there

05:42 on optimal ways for host countries

05:45 and development partners to be better prepared

05:49 to develop mechanisms that can systematically plan for,

05:52 identify,

05:53 prioritize,

05:53 and plan

05:55 to deliver health services

05:57 at all levels of care

05:58 for both host communities and displaced populations that live alongside them.

06:03 And then thirdly,

06:04 what are the most cost efficient mechanisms for

06:07 financing those health services for these two communities?

06:12 So our research teams really explored these questions very practically

06:17 through the lens of four country studies,

06:19 Bangladesh,

06:20 Colombia,

06:21 the DRC,

06:22 and Jordan.

06:23 And these sites were deliberately selected

06:27 to represent a diversity of geographic,

06:29 political,

06:30 and economic contexts

06:32 and covering

06:33 different types and duration of displacement.

06:36 So you'll see that,

06:37 you know,

06:37 the study includes refugees who are registered with UNHCR,

06:40 unregistered refugees,

06:42 displaced Venezuelans,

06:44 and internally displaced persons.

06:48 Uh,

06:48 in terms of the methods we used,

06:50 uh,

06:50 as all academics do these days,

06:52 we used a mixed methods approach.

06:54 Um,

06:55 and,

06:56 uh,

06:56 uh,

06:56 the fieldwork was carried out from 2019 to 2022.

07:01 So we certainly had to contend with the context of the COVID-19 pandemic in our work.

07:07 Um,

07:07 and each study comprised essentially

07:10 a desk-based literature review,

07:13 focus group discussions,

07:14 or in-depth,

07:15 in-depth interviews with host and displaced community members

07:19 as the COVID situation allowed,

07:21 health facility assessments of purposefully sampled health facilities,

07:26 including a costing component,

07:28 and then semi-structured key interviews with people working in government,

07:31 civil society,

07:32 and international organizations.

07:34 And finally,

07:35 a survey of mini national health accounts,

07:38 including data

07:39 from financing agencies and secondary data.

07:43 So moving on now to the second part of our remarks,

07:46 of our remarks,

07:47 which is really beginning to dig into

07:50 um some of our key findings and lessons,

07:53 uh,

07:53 when we look at integration

07:55 and things to consider when weighing

07:57 uh parallel versus integrated health systems.

08:01 So the influx of large numbers of refugees and IDPs can,

08:05 as we all know,

08:06 pose a significant challenge to health systems,

08:09 even in countries with advanced health systems as we've seen

08:13 in the Ukraine response.

08:15 In contexts which are fragile or conflict affected,

08:18 these strains can be acute,

08:21 and early in a humanitarian crisis,

08:23 national health systems are frequently overwhelmed by

08:26 the large influx of displaced persons.

08:29 And in this acute phase of humanitarian response,

08:32 we see

08:33 international actors addressing urgent needs

08:36 through the provision of services that are

08:37 essentially outside of the national system,

08:40 the so-called parallel system of response.

08:43 As crises extend,

08:46 transitioning from this acute phase

08:49 to the protracted phase of the humanitarian response

08:52 really requires careful coordination

08:55 to avoid inefficiencies such as duplication of services

08:59 or increased inequity and service gaps,

09:02 um,

09:02 such as services provided through the parallel system,

09:06 transitioning then to greater integration with the national health system.

09:10 And at each stage,

09:11 I think

09:12 host country health systems

09:14 are present alongside services offered by

09:17 non-state actors and private sector providers.

09:20 And so that coordination framework and thinking ahead about some of the challenges

09:24 that happen in this humanitarian to development nexus,

09:28 I think is really important.

09:30 Now,

09:31 the issue of parallel and integrated health systems

09:33 has often been framed as a binary.

09:36 In a parallel approach,

09:38 humanitarian

09:40 organizations would work in a separate

09:42 parallel system to serve the affected population,

09:45 while in an integrated response,

09:47 humanitarian organizations would work within

09:49 the existing national health system,

09:52 um,

09:52 where both host and displaced populations would access health services.

09:56 Um,

09:57 and in a minority of settings,

09:58 typically those that are high income,

10:01 host comp uh companies,

10:02 host governments may in fact be able to meet the health needs

10:06 of both displaced and non-displaced households

10:09 without the support of humanitarian organizations.

10:12 But even though we see that binary in play of And the reality

10:16 is that in most low and

10:18 middle-income countries experiencing protracted displacement,

10:22 um,

10:22 the response often sits somewhere along a continuum

10:26 from fully parallel health responses on the one side

10:30 to the fully integrated response on the other side.

10:33 And

10:34 the four country studies that were the focus of this project,

10:38 really,

10:39 each of them offers up a different blend

10:41 of humanitarian and national health service delivery,

10:45 often shaped by the national health system's capacity.

10:48 Um,

10:49 and in that context,

10:50 I think they enabled a contextualized

10:52 and nuanced analysis.

10:54 Uh,

10:55 which we used really guided by health systems strengthening frame frameworks

11:00 to look at the benefits and challenges of integration.

11:03 And I think these studies illustrate how,

11:06 um,

11:06 you know,

11:06 to what extent and for what type of service and at which time points in the response,

11:11 um,

11:12 health system integration can best encourage.

11:15 So I'll move now

11:16 to really briefly recap for each country context,

11:20 uh,

11:20 to give you a sense of how the health response was organized.

11:24 I'll do this very briefly indeed.

11:26 So in Bangladesh,

11:27 our team really focused on the 1.1 million Rohingya refugees residing in camps,

11:33 uh,

11:33 and the host populations residing in the surrounding communities.

11:37 Uh,

11:37 and in this context,

11:38 we saw parallel system.

11:39 Systems of primary care for host and displaced populations,

11:43 but integrated services at the secondary and tertiary levels.

11:46 In Colombia,

11:48 our teams focused on the two coexisting protracted migration crises,

11:52 uh,

11:52 the internal,

11:53 uh,

11:53 forced displacement caused by,

11:55 um,

11:56 the,

11:56 the violence we've seen in Colombia over decades and the armed conflict there,

12:01 and the external displacement from Venezuela.

12:04 Uh,

12:04 and I think following a presidential decree in March 2021,

12:08 we saw a shift towards more integration.

12:11 Large numbers of Venezuelans began the processes of

12:14 regularization and subsequent enrollment in national health insurance,

12:18 which then allowed them to access the full

12:20 range of services in the national health system.

12:24 In DRC

12:26 our team focused primarily on the 4.5 million IDPs residing in the country,

12:32 and here we observed full integration of health services

12:35 with both IDPs and host communities

12:37 entitled to access services in the national health system.

12:42 And yet,

12:42 uh,

12:43 I think as you'll see in some of our reflections,

12:45 extremely low access and utilization of health services,

12:49 largely driven by high out of pocket costs for services,

12:52 consumables,

12:53 and transportation.

12:55 And then finally in Jordan,

12:57 our teams focused on the 660,000 Syrian refugees residing in the country

13:02 and the vulnerable Jordanian host communities they lived alongside.

13:07 Syrian refugees in camps accessed UNHCR services for free within the camps.

13:12 Refugees outside of the camps,

13:14 which are over 80% of the Syrians during the study period,

13:18 accessed a limited set of UNHCR supported services

13:22 and had access to health services within the national health system,

13:26 paying subsidized fees.

13:28 So,

13:29 our case studies also demonstrated the implications of social,

13:33 economic,

13:34 and political context in in shaping

13:36 the structure and availability,

13:39 uh,

13:39 affordability,

13:40 accessibility,

13:41 and quality

13:42 of health services for host and displaced populations.

13:45 And as highlighted in the 2022 WHO World Report on

13:50 The health of refugees and migrants,

13:52 national policies regarding the geographic and socioeconomic integration,

13:57 um,

13:57 of these two communities can significantly impact health system responses

14:02 and adaptation to protracted crises.

14:05 So context is absolutely key,

14:07 and I think that it is important to say at the

14:09 outset that there is no one size fits all approach.

14:13 Not every situation will lend itself to an integrated approach,

14:17 and in particular,

14:18 state fragility

14:20 complicates and may limit.

14:21 The prospects for integration of health systems

14:24 as weak institutions,

14:26 lack of uh resources,

14:28 policies and practices restrict the inclusion of displaced persons.

14:32 And then on the other hand,

14:33 you have insecurity which can undermine trust

14:36 and access to health systems.

14:38 And I think it's also worth bearing in mind

14:40 that there is considerable variation

14:43 within a given national context,

14:45 and the level and type of integration can vary by time,

14:48 geography,

14:49 type of health service,

14:50 and so on.

14:51 And informal and private health sector actors also play key roles.

14:56 So,

14:56 I think with that,

14:57 I will pass it to my colleague,

14:58 Dr.

14:59 Samari,

15:00 to discuss 3 important issues to consider

15:03 when planning,

15:04 implementing,

15:05 and evaluating health systems in a protracted humanitarian setting,

15:09 including

15:10 those host government policies of encampment

15:13 and legal status determination and the implication

15:16 for health system integration.

15:18 Second,

15:19 key data workforce and related socio-economic,

15:23 um,

15:23 sociopolitical factors

15:25 that really delineate the space

15:27 for successful integration of national and humanitarian health systems.

15:31 And finally,

15:31 the limitations of integration,

15:34 particularly related to state fragility,

15:36 high cost,

15:36 and low quality

15:38 of health services.

15:39 So,

15:39 Doctor Samari,

15:40 over to you.

15:44 Thank you,

15:44 Professor Zard.

15:45 So,

15:46 I'm gonna start by discussing encampment policies.

15:48 So encampment policies really play a key role

15:51 in shaping the continuation of a parallel system,

15:54 even after the acute phase of a response.

15:57 So when displaced communities are physically distinct

16:00 from host communities such as in camps,

16:02 parallel services set up

16:04 during the initial response may actually be more likely

16:07 to become long-term service delivery points for their needs.

16:11 Where basic services sort of remain separated,

16:13 systems for timely referral from camp-based services

16:17 to more specialized services outside of the camps can also

16:20 pose a formidable challenge.

16:22 For example,

16:22 in Bangladesh,

16:23 we saw

16:24 that the government restricts movement of Rohingya

16:26 refugees outside of the camp complex,

16:29 and this policy reinforces the government's official position.

16:33 That displaced Rohingya will not have a long-term presence in Bangladesh.

16:37 This position in turn sort of underpins the reality

16:40 that the political context is a key factor in shaping the extent of

16:45 health systems integration.

16:47 Restrictions on movement

16:49 outside the camps actually lead Rohingya to primarily rely on

16:52 a parallel system of NGO and INGO run health facilities

16:56 and or informal

16:58 healthcare sources located within the camp complex.

17:02 However,

17:02 to access the most advanced health services at the secondary and tertiary levels,

17:06 Rohingya referred to facilities

17:08 outside of the camps where they receive care alongside the host population.

17:13 Delivery of many secondary and tertiary services are integrated

17:17 for displaced and host

17:19 host populations.

17:20 However,

17:20 the extent of integration

17:22 is really curtailed by barriers experienced by Rohingya within the camps,

17:27 and access to healthcare services at facilities outside the camp complex

17:31 is legally and logistically limited

17:33 to those referrals,

17:35 um,

17:36 officials approved to,

17:37 to leave the camps and those who have the resources to travel.

17:42 So this shows a quote from a Rohingya refugee and,

17:45 and really just sort of

17:46 tries to demonstrate that the administrative

17:48 challenges of referrals or getting a patient

17:51 from the camp-based health system to specialized care outside the camp,

17:55 intersect with barriers to care like cost and distance to the facility.

18:00 Then we have organization

18:03 of referrals in the Jordan camp,

18:05 for example,

18:05 on the next slide.

18:08 Similarly,

18:08 in Jordan,

18:10 Syrians living in refugee camps generally receive free healthcare within the

18:14 camps and rely on referrals outside of camps for tertiary care.

18:19 Sort of in contrast to Bangladesh,

18:20 the camp-based population is a minority of the displaced population

18:24 because well over 80% of Syrians reside in urban areas

18:28 in Jordan.

18:30 Similar to Bangladesh,

18:31 though,

18:31 the camps really focus on primary

18:34 care and limit secondary health care,

18:36 and then tertiary care is really facilitated through UNHCR

18:39 referral systems that are operated by NGOs.

18:43 Nearly 70% of referrals

18:45 that go to go to private hospitals rather than the public system,

18:49 and this is primarily because of long

18:51 wait times and the fact that implementing partners

18:54 are charged with uh the more expensive foreigner rates at public facilities.

19:00 So,

19:01 while Jordan has a more clearly organized system for designating referrals,

19:05 integration

19:06 of tertiary health services for Syrian refugees is still limited by the capacity

19:11 of government-run facilities and by immigration and financing policies

19:15 that really tie the rate charged for health

19:17 services to nationality and refugee registration status.

19:22 There are 3 major gaps that we've identified in the health response.

19:27 Um,

19:27 these,

19:28 these gaps include treatment of chronic disease,

19:31 particularly for the forcibly displaced populations,

19:35 access to specialized services,

19:37 including

19:38 secondary,

19:39 hospital,

19:39 and tertiary

19:40 sort of advanced hospital care,

19:43 especially among forcibly displaced populations,

19:46 and then access to mental health care for both host and displaced populations.

19:50 An example of this.

19:52 Can come from Bangladesh and a UN led

19:55 initiative to strengthen the workforce for a comprehensive

19:58 mental and and psychosocial support program.

20:01 So mental health specialists provided consultations

20:04 and supportive supervision at community sites.

20:07 The program

20:08 really collaborated with the Department of Clinical

20:10 Psychology at a local university to adapt

20:13 educational curricula to prepare students to work

20:16 on mental

20:17 and psychological support,

20:19 uh,

20:20 services and humanitarian settings.

20:22 Um,

20:23 this is sort of a

20:24 collaborative example that could provide additional mental health care,

20:28 but really relied on NGOs and,

20:30 and academia.

20:32 It's also worth noting

20:34 that the parallel services being provided by NGOs and different entities

20:38 are being done in line with national policies

20:40 and national ministries of health and other relevant agencies

20:43 to provide supervision or oversight.

20:46 This can be a point of tension,

20:48 um,

20:48 but it can also be a point of opportunity to

20:51 create or revise guidelines on issues where national guidance is limited

20:55 or not yet developed.

20:58 In Colombia,

20:59 we saw

21:00 um some narrow disparities if you look

21:03 at differences by nationality and hospitalization.

21:06 Um,

21:08 so,

21:08 in Colombia,

21:09 where people have access

21:11 to emergency health services in the national system

21:15 for a provision in the constitution,

21:17 our research team found that in 2019 and 2020,

21:20 Venezuelans were able to access tertiary care at similar levels to Colombians as.

21:25 I by the way,

21:26 the blue dots corresponding to the Colombians in this figure

21:30 and the orange dots which correspond to the Venezuelans overlap in the graph

21:34 for all-cause hospitalization rates.

21:37 Basically,

21:38 Colombians and Venezuelans access hospital services

21:41 at similar levels.

21:43 On the next slide,

21:44 we see

21:45 wider disparities by by nationality and consultation in Colombia.

21:49 So,

21:50 if you look at the rates

21:51 of access to consultation during the same time period,

21:54 we see a disparity among these two groups,

21:56 with Colombians,

21:57 again,

21:57 shown in blue,

21:59 accessing consultations

22:01 with physicians at 7 times the rate of Venezuelans shown in orange.

22:06 This sort of reflects the two groups different

22:09 access to the national health insurance system.

22:11 While regularized Venezuelans can enroll in the health insurance system.

22:15 Um,

22:16 and thereby access a full range of inpatient

22:18 and outpatient services in the national healthcare system.

22:21 Most Venezuelans only maintain access to emergency services,

22:25 and this is primarily due to bureaucratic hurdles or processing requirements,

22:29 things like,

22:30 uh,

22:31 validating identification and documents and proof of presence in the country.

22:35 Um,

22:36 these things remain as barriers to regularization and

22:38 enrollment in the national health insurance system.

22:42 In terms of data availability,

22:44 um,

22:46 in Colombia,

22:46 our research team use the RIPS data,

22:49 uh,

22:50 which consolidates information on costs,

22:52 hospitalizations,

22:53 consultations,

22:54 and basic patient characteristics,

22:57 including immigration status

22:59 within the CISPRO,

23:01 Colombia's National Health Information System.

23:04 It is really worth noting that this sort

23:06 of comparative analysis of health service utilization,

23:10 rates and costs was only possible in Colombia because of this data infrastructure.

23:15 Um,

23:16 in other countries that we look at,

23:18 we found a paucity of demographic and epidemiologic and health service

23:22 utilization data that was sufficiently comprehensive in scope,

23:26 that is captured,

23:27 um,

23:27 and represented host and displaced

23:30 populations and

23:31 um disaggregated

23:33 by migration status or a reasonable proxy,

23:36 so things like

23:37 nationality or administrative areas or geographic areas.

23:41 This really complicated our efforts

23:44 to identify and plan to address health needs in context of the response.

23:49 Um,

23:50 in particular,

23:50 we're lacking data over time,

23:52 things like

23:53 repeated cross sections or even longitudinal data,

23:57 and this really constrains

23:58 the ability of policymakers and practitioners

24:01 to assess and anticipate shifting health needs,

24:04 um,

24:05 health differences between host and displaced communities,

24:08 health service utilization.

24:09 And demographic and epidemiologic profiles

24:12 of the forcibly displaced population

24:15 relative to an appropriate comparison group within the host population.

24:20 This is a long-term need

24:22 for sustained investments and data collection processes.

24:26 Um,

24:27 we need data collection that really meaningfully and accurately

24:29 captures the demographic and health profiles of host and refugee

24:34 populations,

24:35 um,

24:36 over time.

24:38 Um,

24:39 on the next slide,

24:40 we have

24:42 Um,

24:44 some information about leveraging the displaced health workforce.

24:46 So something that really rose in our,

24:48 um,

24:50 data was that as health systems are strained during the response

24:53 to forced displacement,

24:54 human resource policies and workforce initiatives

24:57 are really another important aspect for practitioners to consider

25:01 when

25:01 working to fill service gaps for both host and displaced populations.

25:06 And we have some sort of

25:08 suggestions about how to achieve this on this slide,

25:11 including

25:11 You know,

25:12 official permissions for work,

25:13 task shifting strategies,

25:15 support from professional bodies and training institutions,

25:18 and community engaged and multi-sectoral partnerships.

25:23 So,

25:24 some key factors in

25:27 Transition to greater integration.

25:30 An integrated approach to healthcare can really provide

25:34 widespread benefits in terms of planning and sustainability,

25:37 cost effectiveness,

25:39 and continuity of care for both the displaced and host populations.

25:43 Um,

25:43 humanitarian health practitioners,

25:46 national governments,

25:46 and international donors should really plan from the earliest

25:50 phase of a displacement crisis,

25:52 um,

25:52 for the possibility that a crisis might become protracted

25:56 and require sustainable long-term solutions.

26:00 As outlined

26:01 in the UNHCR Global Public Health strategy,

26:04 the process of transitioning to a more integrated health system

26:07 should really be guided by a medium and long-term approach

26:10 that has clear milestones and support from donors.

26:14 And when you're translating to a more integrated

26:16 service delivery system,

26:18 governments need to scale up the entire system.

26:21 This is a slow process that,

26:23 as you can see in Colombia,

26:24 um,

26:25 requires ongoing support from the parallel system to implement.

26:30 It's also important to note that not every situation

26:34 will lend itself to an integrated approach in some political contexts,

26:38 particularly where

26:39 the government concerned is a party to uh to conflict.

26:44 Um,

26:44 the role of humanitarian NGOs and NGOs remains really critical.

26:49 State fragility also complicates and may limit the prospect for integration,

26:54 given weak state institutions,

26:57 things like corruption,

26:58 a lack of resources,

26:59 and a lack of security.

27:01 These all serve to undermine the trust and access to health care overall.

27:05 Uh,

27:06 key factors for donors and government and humanitarian actors to

27:10 consider include

27:12 the political context,

27:13 the available funding,

27:15 and the potential for improved health outcomes,

27:18 and equitable health outcomes

27:20 among both the host and displaced populations.

27:24 The DRC case

27:26 offers some examples of pitfalls,

27:29 uh,

27:30 over

27:31 the sort of over reliance on an integrated

27:33 approach in contexts where government institutions are not

27:36 yet able to quite meet the needs of the population,

27:39 whether host or displaced.

27:41 Um,

27:42 in this context,

27:43 scaling down the parallel systems to strengthen.

27:45 Um,

27:46 health service delivery would risk cutting off access to health services.

27:51 Efforts to strengthen the availability,

27:52 quality,

27:53 and affordability of health services in government facilities have to be pursued

27:57 alongside parallel systems of health service delivery,

28:00 at least for now.

28:02 Um,

28:03 in the DRC also,

28:04 where IDPs and host populations have fully

28:06 integrated access to the National Health system,

28:09 there's low health service utilization.

28:11 This is driven primarily by

28:13 things like high cost,

28:14 which

28:15 actually dissuade both,

28:17 both the host and the displaced populations from accessing health services

28:20 at all levels.

28:22 Um.

28:24 For the purposes of this presentation,

28:25 healthcare costs are defined as those expenses that

28:27 are really incurred by households to pay providers

28:30 for health services rendered.

28:33 Uh,

28:33 in the DRC,

28:34 the,

28:34 the public healthcare system really suffers

28:37 from limited and often delayed funding.

28:40 Uh,

28:41 they have frequent

28:42 stock out shortages in human resources and unaffordable out of pocket costs

28:47 that ultimately lead to underutilization of services.

28:52 In this context,

28:53 the parallel system is actually a lifeline,

28:55 um,

28:56 and transitioning away from it can,

28:58 uh,

28:59 significantly decrease access to care.

29:01 RHA,

29:02 who was our research partner,

29:04 recorded an illustrative example of this over a decade

29:07 ago when they,

29:08 when funding for free drugs ended at a

29:10 free clinic,

29:11 uh,

29:12 attendance decreased substantially,

29:14 although staffing and patterns of health needs remained the same.

29:20 So,

29:20 on the next slide,

29:21 we see trends in the health needs and spending among urban refugees in Jordan,

29:26 because the situation in Jordan provides

29:28 another pertinent example of how out of pocket costs to access health services

29:33 really drive

29:34 health service utilization.

29:36 The orange line on the graph really shows the

29:38 percentage of urban refugees who stated that they accessed.

29:42 Needed health care in the past month,

29:44 and it dipped to 22% in 2018.

29:48 This,

29:49 this was concurrent with a change in the Ministry of Health policy

29:53 that increased out of pocket co-payments to 80%.

29:57 However,

29:57 utilization increased again in 2021,

30:00 and this corresponded to another change in Ministry of Health policies

30:04 that reduced the co-payment to 20%.

30:06 This change

30:07 also corresponded to the establishment of a multi-dor

30:10 account for health,

30:11 a promising practice for health systems financing

30:14 that will be discussed in the lecture on financing.

30:18 Governments and donors really must work to establish

30:21 enforcing norms and rules around proper

30:24 and predictable charging for health services

30:27 through government regulations and policies.

30:30 With that,

30:30 I will turn the discussion over to Mike Woodman

30:33 of UN UNHCR who will address some of the reflections

30:37 on UNHCR's experiences with integrated and parallel health systems,

30:41 as well as suggestions for practitioners in this space.

30:49 Thank you,

30:50 uh,

30:50 Samari.

30:51 You,

30:51 you can hear me OK?

30:56 Yes,

30:57 we can.

30:58 Great.

30:59 Uh,

30:59 thanks very much for the opportunity to share some of

31:02 our reflections and also for the excellent presentation so far,

31:06 highlighting all the

31:08 diversity of context,

31:09 but also the,

31:10 the challenges and the need for tailored approaches.

31:14 Um,

31:14 within our

31:15 public health strategy,

31:16 inclusion

31:17 is one of our strategic objectives,

31:19 but I must say that it's not at all costs.

31:23 And this goes alongside other objectives,

31:26 uh,

31:27 including building partnerships

31:29 and enhancing health system capacity.

31:32 So,

31:32 in essence,

31:33 we aim for responsible and an effective inclusion in national health systems,

31:38 and

31:39 by responsible,

31:40 I mean that the health systems

31:43 should have the capacity to meet the needs of refugees and host communities.

31:48 And some of the benefits and drawbacks,

31:51 as mentioned.

31:52 Inclusion in health systems is,

31:55 is especially important because

31:57 displacement is typically protracted.

32:00 There is extremely rarely a situation

32:03 where there may be a displacement that's very short-lived and a return.

32:06 It,

32:07 it unfortunately is not the case.

32:09 Um,

32:10 we do know that inclusion enhances

32:13 social cohesion and equity.

32:15 It is more cost-effective in the,

32:17 in the long term,

32:19 and it promotes an approach to strengthen the health

32:22 system as a whole and leaving no one behind.

32:26 Uh,

32:27 what we do know also is that inclusion is often

32:30 as a gradual process and it can be stepwise and slow.

32:35 Um,

32:35 in,

32:35 in our experience,

32:36 often,

32:38 it's easiest to include in,

32:39 in vertical programs such as EPI,

32:42 HIV,

32:43 TB,

32:44 and malaria.

32:45 Um,

32:45 but this is often the fact that these programs are externally funded by,

32:50 by big donors and,

32:51 and are well-running,

32:52 and they have instruments to provide

32:54 additional incentives for inclusion of refugees.

32:58 Uh,

32:59 on the positive side,

33:00 we do a biannual survey of 50 countries and we see

33:05 very good levels of inclusion,

33:07 particularly in primary care,

33:08 but as the report has highlighted,

33:11 there are big issues when it comes to secondary

33:14 and tertiary referral care services.

33:17 So,

33:18 successful inclusion usually comes through a combination of,

33:22 of political will

33:24 plus a resilient health system.

33:26 And these two

33:28 factors

33:29 are often not,

33:30 not in place at the same time.

33:32 There may be countries with strong political will but very fragile health systems,

33:37 and,

33:38 and they can be the converse.

33:40 Um,

33:41 and unfortunately,

33:41 as stated in the report,

33:43 the majority of refugees are hosted in the countries with,

33:46 with the more fragile health systems.

33:50 Just like to touch on a few country examples,

33:52 and Ukraine was mentioned,

33:54 the crisis there.

33:56 And we saw the European Union Temporary Protection Directive,

34:00 which gave immediate access.

34:04 To refugees to national health systems in the European Union.

34:08 So,

34:08 a very good example of a rapid,

34:10 uh,

34:11 response to immediate inclusion in health systems without

34:14 a parallel

34:16 humanitarian response.

34:18 Uh,

34:18 and I'm not speaking about Moldova,

34:20 uh,

34:21 which is outside the European Union.

34:24 Um,

34:24 but I just want to state that

34:27 inclusion on paper doesn't always mean inclusion fully in practice,

34:32 and there can still be barriers faced,

34:34 and these could be

34:36 language,

34:36 financial,

34:38 or access to specialized services such as GBV

34:42 and

34:43 for this reason,

34:43 monitoring and advocacy is,

34:45 is essential.

34:49 Just another example of

34:51 an

34:52 lesson that we have learned is advancing on inclusion

34:56 uh too rapidly or into systems that are not quite ready.

35:00 And I'll give the example of Djijibouti where there

35:02 was a very strong political commitment to include refugees

35:06 and a health system that was being supported externally

35:10 and capacity being built.

35:12 But

35:13 unfortunately,

35:15 our NGO partners withdrew and we realized that the system was not

35:19 able to fully meet the needs of the refugees and they faced significant

35:24 access issues.

35:25 This required us to re-engage with the government,

35:28 uh,

35:28 with the Ministry of Health

35:29 and provide direct financing to the ministry to manage

35:33 services in camps.

35:35 Uh,

35:35 now,

35:35 we are working on,

35:37 uh,

35:38 Further inclusion,

35:39 but this will be a long-term and and stepwise process,

35:43 including with support through the World Bank.

35:46 Uh,

35:46 I have another more positive example from Mauritania

35:50 where Embera camp on the Mali border.

35:54 With World Bank support to the country

35:56 to strengthen the health system.

35:59 Through the,

36:00 the host community and refugee window,

36:02 there was financing made available for,

36:04 for that district,

36:06 and there's been a very successful

36:08 transition to Ministry of Health Services,

36:11 but this has been based on a

36:14 Transition plan together with the government

36:17 and also on engaging our NGO partners

36:20 to accompany the transition

36:23 and gradually withdraw.

36:25 Um,

36:25 however,

36:25 we do still subsidize care for the refugees,

36:29 uh,

36:29 so we're,

36:30 we're midway in the process.

36:32 Uh,

36:33 just to highlight some of the key lessons learned for us,

36:35 I think there's several things that,

36:37 that stand out that I may have mentioned already.

36:40 And this is the risk of transitioning too

36:43 quickly or when the system isn't quite ready,

36:45 and therefore,

36:46 the need to analyze the readiness of the system.

36:50 Uh,

36:50 the need to identify what support is needed for that system and,

36:54 and what support is available through,

36:57 through donors,

36:58 uh,

36:58 humanitarian actors,

37:00 development actors.

37:02 Uh,

37:02 also assessing the capacity of refugees to pay user fees.

37:06 Many countries,

37:06 there will be some user fees as mentioned,

37:09 and,

37:09 and what is the livelihoods access,

37:11 what is the capacity to pay?

37:14 And in that sense,

37:14 also establishing safety nets for the most

37:17 vulnerable if they cannot be included in any

37:20 national social safety net program.

37:23 Uh,

37:23 the need to develop multi-stakeholder,

37:26 multi-year plans,

37:27 uh,

37:27 which are adequately financed.

37:30 Also engaging with development partners very early on in a crisis.

37:34 I think very important to set a platform

37:37 uh for transitioning.

37:39 We also internally as UNHCR need to recognize that

37:43 inclusion requires investment.

37:45 It,

37:46 it requires us to invest resources and to accompany

37:49 a,

37:50 a transition plan.

37:52 And

37:53 also the need to document practices,

37:54 and I think the big questions report is,

37:57 is a very good example of that.

37:59 Uh,

37:59 but we also need to

38:01 continue documenting good practices

38:03 and lessons learned through other initiatives and,

38:06 and evaluations.

38:08 Um,

38:09 I think I will stop there.

38:12 Um,

38:12 maybe some reflections

38:14 finally just on navigating transition.

38:18 Um,

38:19 just very briefly,

38:19 if you don't mind very briefly,

38:21 yes,

38:21 I think

38:22 it,

38:22 it's always desirable to,

38:24 to transition.

38:26 Um,

38:28 how it's often the stepwise process.

38:31 So as I've mentioned,

38:32 trying to

38:34 Integrate

38:35 initially from the onset of a crisis,

38:38 but if parallel services are needed,

38:39 making sure these are aligned with the national standards and protocols

38:43 to facilitate transition

38:45 and the important need for,

38:47 for partnerships.

38:48 Uh,

38:49 so with that,

38:49 um,

38:50 thanks very much and um

38:52 over back to you.

38:54 Great.

38:54 Thank you so much,

38:55 Mike,

38:55 and um we're running a little short on time,

38:57 so I'm gonna go straight to Doctor Wu Zheng from Georgetown University

39:01 to lead us through the financing discussion.

39:03 Over to you,

39:04 Wu.

39:05 Uh,

39:05 thanks for that.

39:06 So I'll pick up the discussion on health financing.

39:10 Before I jump into the presentation,

39:12 I just want to emphasize the importance of the context.

39:16 Improving financial commitment to support the

39:19 health service delivery in a displaced population

39:23 goes beyond the health sector

39:25 and require multi-sectoral collaboration and strong

39:29 commitment from both donors and host governments

39:33 as well as the humanitarian and development partners.

39:37 The host government classification of the displaced person,

39:41 particularly,

39:42 uh,

39:42 the official recognition

39:44 and registration of refugees or internally displaced person status,

39:49 play an important role

39:51 in the ability to track spending on health

39:54 as well as attainability of financing from,

39:57 uh,

39:58 from our national health system.

40:00 Circling back to our early discussion on the,

40:04 uh,

40:05 encampment.

40:06 The extent of the engagement between displaced and

40:09 the host community has implications for the willingness to

40:14 invest in the health system.

40:16 Just give you uh one example.

40:18 In Jordan,

40:19 we see examples of health system investment benefiting the host community

40:25 in part because of many refugees

40:28 live outside the camp and access the services

40:32 in the same facilities as the host population.

40:36 In contrast,

40:37 in Bangladesh,

40:38 the separation of the refugees

40:41 into camps

40:43 means health system investment are less likely to benefit the both host and the

40:48 displaced population.

40:50 With that,

40:51 I will move to the discussion of the health financing framework

40:55 and it's possible uh

40:58 adaptation in settings affected by the forced displacement.

41:03 So these slides,

41:04 you can see.

41:05 The

41:06 very typical framework on health financing.

41:09 It includes the three elements.

41:11 The left side is uh the first element

41:14 on collecting revenue.

41:16 The resources that can be collected through different mechanisms,

41:20 uh,

41:21 for example,

41:22 the general taxation,

41:23 payroll tax,

41:24 private insurance,

41:25 user fees,

41:26 and,

41:27 uh,

41:27 um,

41:28 donor resources.

41:30 Some of the financial resources are collecting

41:33 mechanisms will have the pooling functions,

41:36 which means

41:37 the money can be used for others,

41:40 but some mechanisms that do not.

41:42 User fee is an example

41:44 that doesn't have the pooling function.

41:47 Once uh resources are pool,

41:50 they can be used to purchase the services,

41:53 using different payment mechanism.

41:56 So here you can see we also listed some of the payment mechanisms,

42:00 fee for service,

42:01 capitation line and budget and,

42:04 and so on.

42:05 So this is mostly for the

42:07 national health systems um financing framework.

42:11 This framework can be adapted to the humanitarian settings uh to account for

42:15 parallel services as well as the humanitarian

42:19 support through the national um system.

42:22 And this slides

42:24 just uh summarize up some possible adaptions

42:27 for financing the health system accessed by displaced of,

42:30 um,

42:32 population.

42:33 Uh,

42:34 international donors are critical resources of

42:36 the revenue in the humanitarian settings.

42:39 It is typically dispersed through the international organizations

42:44 such as UNHCR,

42:45 UNICEF,

42:46 and WHO.

42:47 The host of,

42:48 uh,

42:49 government can sometimes can also be important sources of the revenue

42:53 through government budget

42:55 or in some cases through the bilateral

42:58 or multilateral fund channeled through the government.

43:02 Our pocket spending is quite common.

43:04 It is uh one of the key barriers to accessing care

43:08 for refugees and the,

43:10 uh,

43:10 vulnerable host populations

43:12 and some other mechanisms as well.

43:16 Because many organizations are involved in the,

43:19 the,

43:20 in funding health services for displaced population,

43:23 increasing the pooling and reduce,

43:26 reducing fragmentation of financing will be very,

43:29 very important.

43:31 Finally,

43:32 on purchase of the services,

43:34 which is on the right side,

43:35 here we're more focused on the type of our providers delivering the services,

43:40 how they contract with the funders.

43:43 And how the coordination and competitions um uh amongst um

43:49 themselves.

43:49 The providers can include the international

43:52 and local NGO facilities,

43:54 as well as the government and private facilities.

43:59 O

44:00 So despite the heterogeneity of the displaced population

44:06 in this study in these four countries,

44:08 the external funding are the major sources of the revenue

44:14 to provide the services in 3 countries,

44:17 which means,

44:18 uh,

44:19 Bangladesh,

44:20 Jordan,

44:21 and DRC.

44:22 Uh,

44:23 Columbia,

44:24 uh,

44:24 the,

44:25 the national funding seems to

44:27 provide a

44:29 more important role.

44:31 So donor fund is account 87% of the health,

44:36 health spending for Rohingya refugees in Bangladesh,

44:39 about 53% for Syrian refugees in Jordan.

44:43 In DRC we see some humanitarian

44:47 uh providers also provide the free care to displaced uh communities,

44:52 but,

44:52 but we don't have the data to disaggregate the spending by

44:56 displacement status.

44:58 In Colombia,

45:00 Uh,

45:01 international support,

45:02 uh,

45:03 for displaced Venezuelans account for $31

45:08 per person per year.

45:10 One of the key challenges of,

45:13 of relying on international donor fund is that

45:17 they are primarily voluntary contributions

45:20 and fluctuated from one year to the other.

45:24 International donors' commitment are limited in time and scope.

45:28 This will cause us the unpredictability and instability in funds

45:33 and also hinders the implementing agencies' ability

45:38 to plan for the long-term project.

45:41 One of the promising practice uh for improving the coordination

45:46 and pulling of the resources which was mentioned by uh my colleague previously

45:51 is the mud donor accounts uh in Jordan.

45:54 And this account in,

45:56 uh,

45:56 in which a portion of the donor fund for

45:59 that was put

46:00 into this uh single account

46:03 and um money from this account can be used strategically

46:07 by the ministry.

46:08 Of course,

46:08 coordination,

46:09 um,

46:10 have a coordination with the international donors

46:13 to um

46:15 invest in a prioritized the area.

46:17 And in that way,

46:18 uh,

46:19 the resources can benefit both refugees and the host of populations.

46:25 Next time.

46:29 Putting our financial resources is generally

46:31 very fragmented in humanitarian settings,

46:34 but varied depends on the overall levels of the

46:37 integration between our national and humanitarian health system.

46:42 Pulling mechanisms are most advanced in Colombia,

46:45 where the government used the budget,

46:47 uh government budget

46:48 or payroll tax to finance health services for Venezuelans.

46:53 In this context,

46:55 Uh,

46:55 the key questions are how to expand the,

46:58 uh,

46:58 fiscal space to finance the,

47:00 um,

47:01 health services

47:02 to include more of Venezuela in the health insurance.

47:06 In Jordan,

47:08 Refugee health is an integral part of the country's uh joint response plan

47:13 for refugee crisis

47:15 and donors' contribution are poured to support the refugee and host communities,

47:21 multilateral and sometimes

47:24 the bilateral donors adopt the

47:26 uh global compact on refugee framework and focus the supports,

47:31 uh,

47:31 on the services provided within the national healthcare system.

47:36 In DRC some donors' funding is channeled through the government while some

47:41 fundings actually go directly to the international or local health providers.

47:47 And,

47:48 uh,

47:49 similar to Jordan,

47:50 Bangladesh also has a joint response plan

47:53 that provide very,

47:55 plays a very important role

47:57 in coordinating uh financial resources to respond to the Rohingya health needs

48:03 and the implementation of this joint plan is carried out by a

48:08 lot of uh uh UN agencies and nat national or international NGOs.

48:14 Then

48:15 it's very important to strengthen our coordination

48:18 among various health providers,

48:21 yeah,

48:21 to avoid duplication of the sepsis

48:24 and fill in the sepsis gap.

48:27 Next item.

48:29 Contract with the uh different health providers

48:33 is an important task to ensure donors' fund is used appropriately

48:38 to meet the health needs of the displaced and host uh populations.

48:42 Over now,

48:43 uh,

48:43 many healthcare providers contract to the

48:47 contracted to deliver services.

48:50 Depends on the size of the displaced population.

48:53 And the extent of the integration uh with,

48:56 with the National Health System,

48:58 the number of services providers varied significantly.

49:03 Healthcare providers can be mixed and include,

49:05 uh,

49:06 uh,

49:06 as I mentioned before,

49:07 include the government facilities,

49:09 NGO facilities,

49:11 and private fac facilities.

49:14 Despite the strong commitment of the funders and

49:18 extensive experience in contracting with uh healthcare providers,

49:23 one of the challenges we identified from this study is that

49:27 funders are frequently limited the organizational

49:31 and funding structure that only allows the

49:34 short-term contract with the healthcare providers.

49:37 Most of them,

49:38 the health providers receive one-year contract.

49:41 Sometimes it can be even shorter.

49:44 Which makes it very,

49:45 very difficult for the health providers to make a long-term plan,

49:50 particularly for in the first year of the project

49:54 when

49:55 the health providers need a,

49:58 a

49:59 significant amount of money to um

50:02 have a capital investment.

50:05 Yeah

50:06 The disruption,

50:07 next slide,

50:09 yeah.

50:09 The disruption and availability of our health services are

50:14 among the major reasons why displaced population may prefer

50:18 to seek care in private facilities.

50:21 Uh,

50:22 focus group,

50:23 uh,

50:23 um,

50:24 participants

50:25 in Jordan described how

50:28 long,

50:29 uh,

50:29 waiting times for life-saving cares lead to participants to seek care,

50:34 uh,

50:35 outside the contracted facilities.

50:38 Here is the quote.

50:39 We're not insured in,

50:42 um,

50:43 Any private hospitals.

50:45 It used to be through the UNHCR but not anymore.

50:49 They referred the,

50:51 uh,

50:51 my father and give him an appointment after a year and a half.

50:55 If we wait for a year and a half,

50:58 and he will die for sure.

51:00 So,

51:01 this kind of inefficient referral or the contracting arrangements

51:06 can contribute to the increase of the healthcare cost

51:10 when disruptions are availability of services drive people

51:14 to seek care in a private facilities.

51:19 Um,

51:19 in those facilities are unpredictable.

51:22 And unregulated user fees may exacerbate the challenge to access care.

51:29 Next.

51:33 Contract contract health uh health providers provide a

51:38 wide range of services to displaced population.

51:42 All 4 countries included in this study has a clear benefit package

51:48 that extended to the displaced population,

51:51 but with a wide,

51:52 wide variation

51:54 between them

51:55 in terms of coverage.

51:57 Uh,

51:57 in Colombia,

51:58 this is the country with the most comprehensive health coverage

52:02 if Venezuela are enrolled in the health insurance,

52:06 but unfortunately,

52:08 a significant amount of the

52:10 Venezuelans

52:12 are not,

52:13 uh,

52:14 enrolled in the health insurance,

52:16 which means,

52:16 uh,

52:17 many of them cannot access the,

52:19 to the,

52:20 to the care,

52:21 uh,

52:21 comprehensive care.

52:23 Services offered to the displaced population in other three countries,

52:28 um,

52:29 more focused on the primary health care with limited referral services

52:34 along with other health system challenges,

52:36 for example,

52:37 the shortage of medicine.

52:39 The limited benefit,

52:41 uh,

52:41 benefit package also drives the patients away from seeking care,

52:46 uh,

52:47 in other places.

52:50 In our our country studies,

52:52 the main gap we identified,

52:55 uh,

52:55 actually my colleague also previously mentioned

52:59 is the management of the mental health

53:02 as well as the management of the non-communicable diseases.

53:07 And this uh kind of uh,

53:10 uh,

53:10 um,

53:11 uh,

53:11 services,

53:12 uh,

53:13 either not available

53:14 or offered in a low quality that may

53:18 uh drive,

53:19 drive the people from seeking care outside.

53:23 Next slide.

53:26 Given

53:27 uh the challenges,

53:29 uh,

53:30 uh,

53:30 uh,

53:30 we have in terms of the getting fundings and because,

53:34 um,

53:34 also because the short-term funding is unpredictable

53:38 fundings as well as the huge barriers to accessing

53:42 health services due to the cost,

53:44 new financing mechanisms,

53:46 uh,

53:47 should be explored.

53:49 Uh,

53:49 the current,

53:51 uh,

53:51 practice in terms of the,

53:53 uh,

53:53 providing services

53:55 is more donor-supported from the supply side.

53:59 The support could also be considered

54:02 from the demand side,

54:04 uh,

54:05 such as supporting the,

54:06 uh,

54:07 premiums for health insurance

54:09 or voucher schemes.

54:11 Uh,

54:11 such a subsidy provided to the displaced population

54:15 may also help facilitate the integration

54:19 into the national healthcare system,

54:21 although

54:23 the implementation of such program must be managed with the care

54:27 in order

54:29 to avoid overwhelming uh uh health system capacity or creating,

54:34 creating the disincentives to treat the displaced,

54:37 uh,

54:37 community.

54:39 There are also some programs are using incentives to promote good behavior

54:45 and link the payment to the performance of the healthcare providers,

54:49 which,

54:50 um,

54:50 this is uh more like pay for performance program.

54:54 You may heard this uh pro

54:56 name a lot.

54:58 This program has been used widely

55:00 and can be effective,

55:02 uh,

55:03 even in some of the conflict-affected uh coun countries.

55:08 While very few applications exist in humanitarian settings,

55:12 the International Committee of the Red

55:14 Cross launched a humanitarian impact bond in

55:18 2017.

55:19 The bond provided the fund to build the physical rehabilitation centers

55:24 in three humanitarian.

55:26 settings.

55:27 Under this arrangement,

55:29 the funders

55:30 only pay back the investors in full

55:33 with the interest if project

55:36 is deemed a success according to an outside uh evaluation.

55:41 It's very interesting,

55:42 um,

55:43 uh.

55:44 Uh,

55:44 case.

55:45 If possible,

55:46 humanitarian and,

55:47 and development partners,

55:49 particularly those with the multi-year funding cycles,

55:52 should also strategically,

55:54 uh,

55:55 prioritize some existing project

55:58 and provide a long-term contract to,

56:01 uh,

56:01 some of services providers

56:03 that uh need a large,

56:05 uh,

56:05 capital investment

56:07 that will help them to

56:09 make a long-term plan,

56:10 uh,

56:10 if needed.

56:12 Moreover,

56:13 although a minimum package of the health

56:15 services are often established in humanitarian settings,

56:19 the package should be monitored

56:21 and adjust based on the changing health need of the displaced population.

56:26 As we mentioned earlier,

56:27 mental health,

56:28 uh,

56:29 chronic diseases,

56:31 become increasingly prominent needs among the displaced population

56:35 in uh incorporating

56:38 uh cost-effective interventions to address this need

56:42 should be seriously considered and integrated to,

56:45 into the

56:47 essential benefit package.

56:49 Lastly,

56:50 I think our study also underscored the very importance

56:54 of the financial arrangement that are embedded in a

56:57 policy that supports the long-term resilience

57:00 and in that way,

57:02 improving the likelihood of a displaced population

57:05 to reduce the cost barrier

57:08 of very importance

57:10 and Improving health financing should be

57:12 also accompanied by the necessary policies

57:15 to support the legal status to allow the refugees to

57:20 uh work

57:21 and get the salary paid and uh to prove

57:25 uh uh to have a more active likelihood or income generation program for them.

57:32 So with that,

57:33 I will hand over to um

57:36 Fernando who will give a remarks on the financing piece.

57:43 Just 5 minutes please,

57:44 Fernando,

57:45 if you don't mind.

57:46 Sure,

57:47 thank you.

57:47 Let me focus

57:48 on a couple of issues,

57:49 uh,

57:50 on the health financing,

57:52 particularly,

57:53 specifically

57:54 from the view of the World Bank.

57:56 The World Bank came from the experience of working on emergency situations,

58:00 catastrophic events,

58:02 and working with other partners to resolve those,

58:05 and it's that experience that shaped

58:08 how we start.

58:09 to work and engage with forcibly displaced populations.

58:13 That's in the acute phase of these emergency situations.

58:17 So,

58:18 over time,

58:19 we have improved on how we can finance,

58:21 we have been more agile to re-allocate resources from existing projects,

58:27 etc.

58:27 and working better with other humanitarian organizations.

58:32 It might not be ideal,

58:33 but we have worked much better,

58:36 uh,

58:36 and learned a lot over the last 20 years,

58:38 certainly over the last 10 years.

58:41 Having said that,

58:42 uh,

58:42 the,

58:43 the bank has a very important mandate which is we have to work with the governments.

58:48 We don't,

58:49 we don't,

58:50 uh,

58:50 our mandate is to work with the governments and the financing goes

58:54 to the governments.

58:55 We can work in different ways with other partners,

58:59 but obviously we have to engage with the governments,

59:01 that's our.

59:02 Mandate

59:03 and,

59:03 and it's through that channel

59:05 that we can finance the bulk of our

59:08 support

59:09 for forcibly displaced populations.

59:12 Having said that,

59:13 it's the,

59:14 the,

59:14 the positive of that

59:15 is that it will require that we take an integrated approach,

59:20 not always necessarily,

59:22 but because it's through the government,

59:24 we'll have to find solutions that will

59:28 take the access to healthcare through an integrated approach.

59:32 Um,

59:32 I think that over the last 10 years,

59:36 there have been several changes in terms of the financing,

59:39 particularly,

59:39 we have now the global,

59:41 um,

59:42 concessional financial facility that was triggered,

59:46 uh,

59:46 particularly after the Syrian crisis,

59:49 although after that,

59:50 this fund,

59:51 which is a multi-donor fund

59:53 specifically for forcibly displaced populations,

59:56 was also,

59:57 uh,

59:57 providing support for the Venezuelan crisis.

1:00:00 So,

1:00:01 those are new sources of funding specifically for this type of situations

1:00:06 which complement our support to the countries,

1:00:09 to the health systems.

1:00:11 In several countries,

1:00:12 we have had

1:00:13 already existing projects that work with internally displaced populations

1:00:17 and sometimes with externally displaced populations.

1:00:20 or people coming from other parts and

1:00:23 working with individual projects that were already existing

1:00:26 and restructured to support those new needs,

1:00:29 or

1:00:30 they already consider for internally displaced populations,

1:00:34 some of those supports.

1:00:36 I want to focus on also in my comments on

1:00:40 Three key aspects which I think are um

1:00:43 key areas where we should focus on health financing

1:00:47 that,

1:00:48 that have an important impact on overall access but also overall results

1:00:55 for the displaced populations and also for the hospital facilities.

1:00:58 The first one is the financing of primary healthcare facilities.

1:01:03 Um,

1:01:03 it,

1:01:04 it is a very important approach to make sure that

1:01:07 not only

1:01:09 children and,

1:01:10 and,

1:01:12 and,

1:01:12 and young people have access to um a series of services

1:01:15 that will have an impact in terms of early childhood development,

1:01:19 a package of services that's well systematized,

1:01:22 that we have worked as the World Bank

1:01:24 and development partners in other countries have worked,

1:01:26 so it's a very clear Uh,

1:01:29 key set of services that's really important to make sure that we minimize

1:01:34 the impact on the children

1:01:36 and,

1:01:36 and the future adults,

1:01:38 uh,

1:01:38 uh,

1:01:39 both not only in,

1:01:40 in,

1:01:40 in physical health but also in mental health.

1:01:43 We have experiences of that.

1:01:45 Unfortunately,

1:01:45 the last one is,

1:01:46 uh,

1:01:47 on Palestine,

1:01:48 I say unfortunately because some of the

1:01:50 advances that we,

1:01:51 we have seen there,

1:01:52 my

1:01:54 My,

1:01:54 my,

1:01:55 right now in Palestine,

1:01:56 go back,

1:01:56 but in,

1:01:57 in any case,

1:01:58 the experience is,

1:01:59 is there.

1:02:00 In fact,

1:02:00 the United Nations Refugee and Works Agency has a highly developed uh approach to

1:02:06 primary healthcare with electronic data and the

1:02:09 other element that I want to mention,

1:02:11 which is uh quality of care.

1:02:13 It,

1:02:14 it,

1:02:14 it might not be the,

1:02:15 there are a lot.

1:02:16 Of financing,

1:02:17 but if we have a monitoring,

1:02:19 in terms of quality of care with the specific indicators

1:02:23 that uh allow us to uh make sure that the financing produces those results,

1:02:28 this will,

1:02:29 can make a very important change in terms of how people are treated

1:02:33 and how people may demand those services.

1:02:36 In many countries,

1:02:38 the services that are Available to refugees are low-quality services,

1:02:42 they might be public,

1:02:43 they might be integrated,

1:02:44 but they are low quality.

1:02:46 It might be that they are as low quality as for the host communities,

1:02:49 right?

1:02:50 So uh emphasis on investing in quality of care,

1:02:54 monitoring

1:02:55 and link those to financing is critical.

1:02:58 The,

1:02:58 the other aspect that primary healthcare can provide uh

1:03:02 Support is for the elderly or people with chronic conditions.

1:03:05 It's really critical that we er er not only

1:03:09 have a clear er er information on who's there and what ages and,

1:03:14 and,

1:03:14 and make sure that they have access to

1:03:16 uh preventive services,

1:03:18 to detection of early detection of chronic conditions

1:03:21 and that may help uh an impact on reducing.

1:03:25 Jordan is a case in point.

1:03:27 Women are accessing services for breast cancer,

1:03:30 but unfortunately at later stages

1:03:33 than the host communities.

1:03:35 There are pilots where these experiences are being improved,

1:03:39 but they need,

1:03:41 they need to be scaled.

1:03:42 All these issues can be,

1:03:43 be dealt at the primary healthcare level.

1:03:46 Finally,

1:03:46 the issue of uh joining forces with other development.

1:03:50 Partners and creating pooling is critical.

1:03:53 Unfortunately,

1:03:53 the limitation of that is the capacity of each country

1:03:57 to provide support in the long term.

1:03:59 Uh,

1:04:00 as we can see now,

1:04:01 the forcibly displaced populations are not uh staying for 567,

1:04:07 they're,

1:04:07 they're staying

1:04:08 for 10 years longer

1:04:10 and the support of um

1:04:12 uh of partners will no longer be able to.

1:04:15 To be done

1:04:16 through a specific pools always,

1:04:18 but it might ended up being linked to support

1:04:22 to mechanism,

1:04:23 global mechanism financing like the World Bank,

1:04:26 uh,

1:04:26 IDA support,

1:04:28 etc.

1:04:29 So

1:04:31 let me stop there because I think those would be

1:04:34 aspects that we can discuss in,

1:04:35 in-depth in the,

1:04:36 uh,

1:04:37 in the breaker rooms.

1:04:38 Let me stop there.

1:04:39 Thank you.

1:04:40 Fantastic.

1:04:41 Thank you,

1:04:41 Fernando.

1:04:42 Very,

1:04:42 very efficient conveying of,

1:04:44 uh,

1:04:44 of a lot of information there,

1:04:46 so I really appreciate it.

1:04:47 We are running a little,

1:04:49 uh,

1:04:49 over time,

1:04:50 so I'm gonna take us straight into the breakout rooms,

1:04:52 which will be your

1:04:54 opportunity to discuss some of these themes in a bit more detail with our speakers.

1:04:59 Um,

1:04:59 so,

1:05:00 uh,

1:05:00 the first breakout room,

1:05:01 you get to select which breakout room you go to.

1:05:04 So the first breakout room is focused on health system integration.

1:05:08 So,

1:05:09 probing those issues we presented in the first part of our remarks.

1:05:13 The second breakout room will be focused on health system financing,

1:05:16 picking up on some of the themes,

1:05:18 uh,

1:05:19 that Fernando and Wu shared in the second part of our,

1:05:22 um,

1:05:23 presentation.

1:05:24 And then the third,

1:05:25 uh,

1:05:26 is a focus on data.

1:05:27 So the 3rd breakout room is a focus on data,

1:05:30 which sort of criss-crosses both themes.

1:05:33 Um,

1:05:33 so,

1:05:34 please select your groups now.

1:05:36 We are going to spend 20 minutes in the breakout room.

1:05:40 And have a very,

1:05:41 very short report back.

1:05:42 So volunteer to be rapporteurs

1:05:44 because I'll only be asking for the one headline idea

1:05:48 from each of your groups,

1:05:49 uh,

1:05:49 in the report back.

1:05:50 So thank you very much.

1:05:52 Pick your breakout room.

1:05:54 Uh,

1:05:54 you'll be in good hands for the next 20 minutes,

1:05:56 and we look forward to hearing your voices in those rooms.

1:06:22 Well,

1:06:23 I have to say it was wrenching to be brought back.

1:06:27 Because we were in the midst of a very,

1:06:29 very interesting,

1:06:30 um,

1:06:31 set of reflections.

1:06:33 Uh,

1:06:33 so my apologies to all of you because I'm sure you're experiencing the same thing,

1:06:37 which is you wanted those breakout rooms to continue.

1:06:40 Um,

1:06:41 unfortunately,

1:06:42 uh,

1:06:42 we are,

1:06:43 uh,

1:06:43 operating against the,

1:06:44 the clock a little bit.

1:06:45 So,

1:06:46 uh,

1:06:46 I hope that this is just the beginning of a conversation between all of us,

1:06:50 but

1:06:50 I'd like to call on the rapporteur for Breakout Group One

1:06:54 to just give us,

1:06:55 you know,

1:06:55 the two or three headline ideas

1:06:58 that emerged,

1:06:59 uh,

1:06:59 in the course of uh Breakout Group One,

1:07:03 which focused on health system integration.

1:07:06 So,

1:07:06 I think that was Anna Sophia.

1:07:09 That is correct,

1:07:10 thank you very much.

1:07:10 Honestly,

1:07:11 I think it's hard to try to summarize in a couple of sentences,

1:07:13 but I'll pick out the things I thought were interesting.

1:07:15 Apologies to the group if they see something else.

1:07:18 Um,

1:07:19 we both talked about,

1:07:20 uh,

1:07:20 the geographic setting,

1:07:21 of course,

1:07:22 uh,

1:07:23 having an impact on whether or not parallel or integrated systems are possible,

1:07:27 uh,

1:07:27 with camp settings often not actually

1:07:29 uh allowing for an integrated system to be possible.

1:07:33 And also looking at how we need to from the beginning,

1:07:36 uh,

1:07:37 consider whether integration is possible as opposed to default opting for

1:07:41 parallel systems at the beginning of a crisis.

1:07:44 Also talked about the ethical dilemma about

1:07:47 how parallel systems sometimes have higher quality,

1:07:49 and how do we figure that out,

1:07:50 like,

1:07:50 what is being offered to host communities versus displaced populations.

1:07:54 And

1:07:55 integration sometimes only serves the registered population.

1:07:58 What does that mean for everybody else?

1:08:00 We just need to consider whether or not um it's actually

1:08:04 possible for the national system to absorb the funding coming in

1:08:07 and perhaps there needs to be a,

1:08:09 I mean,

1:08:09 a coordinated response to where do we channel funds into

1:08:12 the national system because we can see there's space for it

1:08:14 and having um a parallel system with INGOs,

1:08:17 for example,

1:08:18 where we can see at least in the short term,

1:08:20 uh,

1:08:20 the system can't handle it.

1:08:22 Thank you very much.

1:08:22 And

1:08:23 sorry to the group if anything key was missed.

1:08:25 Not at all.

1:08:26 That was masterfully done.

1:08:27 Well done.

1:08:28 Um,

1:08:28 so I'm gonna call on Breakout Group Two

1:08:31 on financing for a similarly succinct report back.

1:08:34 We are gonna run to 10:35 or 135 past the hour,

1:08:38 so

1:08:39 bear with me,

1:08:40 anyone,

1:08:40 but we will,

1:08:41 we will finish,

1:08:42 uh,

1:08:42 at 5 minutes,

1:08:43 uh,

1:08:43 past our,

1:08:44 our end time.

1:08:45 So breakout room two,

1:08:47 who's the report back?

1:08:51 We haven't identified one,

1:08:52 but,

1:08:52 uh,

1:08:53 we only,

1:08:54 uh,

1:08:54 went through

1:08:55 the first question,

1:08:57 I'm just wondering whether,

1:08:58 Lucia,

1:08:59 if you want to report what we discussed.

1:09:08 Uh,

1:09:09 Lucier,

1:09:10 also,

1:09:10 I think that Deanie was taking,

1:09:12 I think that Deanie was taking the,

1:09:14 the notes,

1:09:14 and she

1:09:15 mentioned that she would take the notes for rapporteur.

1:09:18 I don't know,

1:09:19 Deni.

1:09:20 Is that correct?

1:09:24 Hi,

1:09:24 yes,

1:09:24 um,

1:09:25 I'm happy to report back.

1:09:27 Uh,

1:09:28 so there was,

1:09:28 uh,

1:09:28 a lot of discussion on the,

1:09:30 uh,

1:09:31 financing

1:09:32 difficulties,

1:09:34 um,

1:09:34 in terms of referral services,

1:09:36 um,

1:09:36 and how,

1:09:37 uh,

1:09:38 providers are

1:09:39 seeing a downward trend in financing for referral services,

1:09:43 um,

1:09:43 that they're always looking for more funding.

1:09:46 Um,

1:09:46 there's also,

1:09:47 there was also a lot of discussion on,

1:09:49 um,

1:09:50 mobility of the displaced and how,

1:09:54 uh,

1:09:54 the,

1:09:55 you know,

1:09:56 the back and forth between the,

1:09:58 the impermanence um

1:10:01 leads to

1:10:02 um complications in registration and that the displaced need

1:10:06 to be registered in order to access services,

1:10:09 um,

1:10:10 and,

1:10:10 but they also saw opportunities for in,

1:10:14 for example,

1:10:15 in data sharing into the national healthcare system,

1:10:17 there were

1:10:18 Um,

1:10:18 discussion about,

1:10:19 um,

1:10:19 challenges in,

1:10:21 uh,

1:10:23 In dealing with public systems as opposed to the private sector,

1:10:27 and our colleague from the,

1:10:29 from the IFC also discussed,

1:10:31 um,

1:10:32 you know,

1:10:33 uh,

1:10:33 looking into,

1:10:34 uh,

1:10:36 Into opportunities.

1:10:37 I think,

1:10:38 Fernando,

1:10:38 if you could step in for,

1:10:40 for this part,

1:10:41 or also Matthew.

1:10:42 Thank you.

1:10:44 Just very quickly,

1:10:45 the key point is that there are different contexts.

1:10:47 In the case of Colombia,

1:10:49 Venezuelans move all around,

1:10:51 so,

1:10:51 uh,

1:10:52 and clearly for tertiary services,

1:10:54 that's not a problem because they can enter emergency services,

1:10:58 but it is a problem for the critical first level of care primary.

1:11:02 Healthcare.

1:11:02 Now,

1:11:03 a key issue that the two

1:11:06 colleagues from NGOs mentioned,

1:11:08 they do have a lot of services

1:11:11 that can provide the value-added knowledge services

1:11:14 in terms of quality providers,

1:11:16 where people are looking for services.

1:11:19 And that's a key value added that

1:11:22 we have not figured out how to finance

1:11:25 because usually multi-donors,

1:11:27 trust funds or poolings are working with the government

1:11:30 and,

1:11:30 and,

1:11:31 and forgetting that NGOs and civil society organizations

1:11:34 have a knowledge that not the government,

1:11:37 that the government may not

1:11:39 necessarily have,

1:11:40 so we have to figure it out how to engage

1:11:42 in those long-term transitions

1:11:44 to not get lost all these.

1:11:46 Knowledge and all this value added that civil society and NGOs have

1:11:51 as their own sources are drying up because of the,

1:11:54 you know,

1:11:54 acute phase being over,

1:11:56 how we can support that knowledge,

1:11:59 knowledge,

1:12:00 that uh quality services that,

1:12:03 that they,

1:12:03 they are supporting,

1:12:05 so that's one way of looking at this.

1:12:07 I hope I am representing correctly,

1:12:09 but anyways,

1:12:10 uh,

1:12:10 Lucia and Matthew,

1:12:11 if you have any other comments over.

1:12:14 I think that's,

1:12:15 I think that's perfect.

1:12:16 Thank you so much.

1:12:17 And again,

1:12:17 apologies for cutting off what was clearly a rich discussion.

1:12:20 Um,

1:12:21 so very quickly,

1:12:23 break out room

1:12:24 23 on data,

1:12:26 uh,

1:12:26 report back,

1:12:27 Jen,

1:12:27 or anyone from your team?

1:12:29 So I'm gonna do the report back.

1:12:31 Um,

1:12:32 so we had a very rich discussion about how

1:12:35 data again is really context-specific and there's some really

1:12:39 sort of good local data collection efforts that are attempting to capture this,

1:12:44 but then again,

1:12:45 it sort of isn't

1:12:46 integrated or

1:12:48 um accessible at a large scale,

1:12:50 so data transparency and

1:12:53 accessibility while maintaining data protections is really important.

1:12:57 And so,

1:12:58 We talked a little bit about

1:13:00 the

1:13:01 limit or the reasons why longitudinal data

1:13:04 collection is often challenging across these contexts,

1:13:07 namely,

1:13:07 it's resource intensive and

1:13:10 populations are often on the move,

1:13:11 and so that's,

1:13:12 you know,

1:13:12 makes ongoing data collection on the same populations over time very difficult.

1:13:17 Um,

1:13:17 we discussed

1:13:19 the need for,

1:13:20 um,

1:13:21 our

1:13:22 colleagues brought up the need for sort of

1:13:24 Legal and governance,

1:13:26 uh,

1:13:27 advice or examples around,

1:13:30 uh,

1:13:30 guidelines that really help sort of

1:13:33 protect migrants and offer data protection,

1:13:37 um,

1:13:38 while

1:13:39 sort of achieving the goal of data

1:13:40 availability and making data collection possible.

1:13:43 And so people are really interested in sort of,

1:13:45 is there a good example.

1:13:48 Of legal protection and guidelines or a context

1:13:51 in which this is being really done well

1:13:53 to balance the needs of data collection against the the data protection needs.

1:13:59 Great.

1:14:00 Thank you so much.

1:14:02 So,

1:14:03 with that,

1:14:04 um,

1:14:04 we,

1:14:05 unfortunately have to draw our time together to a close,

1:14:08 but

1:14:09 if I were to attempt to summarize,

1:14:10 which is a foolhardy thing,

1:14:12 um,

1:14:13 I won't attempt to summarize,

1:14:14 but let me just say that I think there are certain

1:14:16 themes that have emerged just very clearly from those breaks.

1:14:19 rooms,

1:14:20 as well as,

1:14:21 um,

1:14:21 you know,

1:14:22 from the presentations today.

1:14:23 And I think the first one for me is context,

1:14:25 context,

1:14:26 context,

1:14:27 both the political context and political will,

1:14:30 which seems to underpin any movement towards

1:14:33 successful movement towards health system integration.

1:14:36 But then also that context around the

1:14:38 national health system's capacity and really identifying,

1:14:42 um,

1:14:42 both the

1:14:43 confluence of those two things as being critical for moving forward on this issue.

1:14:48 I think,

1:14:49 um,

1:14:49 that in turn highlights the importance of planning

1:14:53 from the earliest phases of a process,

1:14:55 uh,

1:14:56 of a displacement crisis so that we don't

1:14:58 default to the parallel system,

1:15:00 but our thinking

1:15:01 in that medium and long-term way that I

1:15:03 think UNHCR has highlighted as being critical,

1:15:06 but also leadership,

1:15:08 uh,

1:15:08 for putting those conversations on the table and the respective roles of donors,

1:15:13 INGOs,

1:15:14 and others within the national system to really

1:15:17 high.

1:15:19 Like complementary expertise and roles to move that discussion forward,

1:15:23 um,

1:15:23 and coordination,

1:15:24 I think is absolutely key and goes along with leadership,

1:15:27 really identifying

1:15:28 where and how

1:15:30 the health,

1:15:30 the health system response from the humanitarian side

1:15:34 can feed into and support the national system,

1:15:36 where the gaps are,

1:15:38 and really think about how,

1:15:40 uh,

1:15:40 you know,

1:15:40 we can bring the value added,

1:15:42 uh,

1:15:42 into that system and have donors play a complementary role in incentivizing.

1:15:47 Uh,

1:15:47 a more integrated approach.

1:15:49 And then finally,

1:15:50 the inclusion.

1:15:52 On paper

1:15:54 doesn't necessarily always match up to inclusion in reality,

1:15:57 and I think

1:15:58 Mike really highlighted that in his presentation,

1:16:02 always being mindful

1:16:03 of the lived reality of the refugees and displaced populations that we are

1:16:10 trying to serve in these processes.

1:16:12 So,

1:16:12 I think those for me were certain key takeaways,

1:16:15 and I,

1:16:15 I really want to thank you all,

1:16:17 our audience,

1:16:18 uh,

1:16:18 for sticking with us in this presentation and

1:16:20 for sharing your ideas in the breakout rooms.

1:16:23 I would like to thank,

1:16:24 uh,

1:16:25 the World Bank team,

1:16:26 um,

1:16:27 uh,

1:16:27 that organized this conversation.

1:16:29 And of course our panelists and speakers,

1:16:32 uh,

1:16:32 for,

1:16:32 um,

1:16:33 sharing their reflections with us.

1:16:35 Um,

1:16:35 and I would like to thank,

1:16:37 of course,

1:16:37 my own,

1:16:38 uh,

1:16:38 team as well,

1:16:39 uh,

1:16:40 Jennifer Ostrosky,

1:16:41 Catherine McCann,

1:16:42 uh,

1:16:42 as well as the many people behind the scenes at the World Bank who really made the,

1:16:46 the,

1:16:46 the workshop come together.

1:16:48 So thank you all very much,

1:16:49 and this will be recorded

1:16:51 and do reach out to us at any point if there are any issues you'd like to follow up on.

1:16:56 Thank you all.

1:16:59 Bye-bye.

1:17:01 Bye.

showAllTimestamps

no

transcript

On, uh, where you're journey from. Uh, welcome to the 4th module of the Learning from the Evidence on Force Displacement, uh, Training Program. The program, the training is organized by the, uh, UK government, UNHCR World Bank, uh, Building the Evidence of Force Displacement Research Program in collaboration with the World Bank, UNHCR Joint Data Center on Horse Displacement. My name is Paula Ellis. I am an impact evaluation specialist in the Building the Evidence Program and the World Bank Group. Today, I'm joined by Monette Zard, who is an associate professor and director of the Program on Forced migration and Health at the Columbia University Mailman School of Public Health. Monette and her team have uh prepared this module and will be leading, um, its delivery today. And, uh, today's session is focusing on health system strengthening in situations of protracted displacement. Uh, before I head over to Monette, uh, I'd like to cover some, uh, logistical aspects. Uh, first, um, I wanted to communicate that the meeting is being recorded, uh, although the, uh, discussions that will be had in, uh, the breakout rooms will not be recorded. Uh, you're encouraged to keep your camera on throughout the session. Um, it's nice for speakers to, to see who they're speaking to, uh, and it's a training. So, um, it'd be nice if you can, uh, do that, if your bandwidth, uh, allows. Um, kindly make sure to be on mute when, uh, we're not speaking. We're going to have 90 minutes for the session. And you are welcome to submit questions as they arise to the chat. The chat will be monitored and questions will be uh responded to. Um, a couple of more things, um, if Zoom didn't do it automatically, kindly rename yourselves, uh, and put your affiliation in parenthesis, uh, and you can do that by right clicking, uh, next to your name, uh, in Zoom and, um, and typing in. Um, and, uh, I see, um, we have a, a good participation, uh, so I'd like to invite you all to, um, type in the chat who you are, where you're joining from, and your, your organization, uh, to get, uh, each other acquainted with, um, before we start. Uh, again, welcome to today's module. Um, it is my pleasure to hand over, uh, the floor to Monette, who is going to, uh, lead the session. Over to you, Monette, with thanks. Thank you so much, Paula, and uh thanks to UK Aid, UNHCR and the World Bank, uh, for this opportunity to present and discuss some of the key lessons from our three-year study on the big questions in forced displacement and health. And I confess that it feels somewhat surreal to be having a considered conversation about healthcare for refugees against the backdrop of such overt and flagrant attacks on health facilities, health personnel, and civilians as we're seeing in Gaza at present, but that is the context and the world in which we're living. But in any case, I think the big Questions project really focused on humanitarian health responses and the relationship with, uh, national health systems in fragile, low and middle-income settings in situations of protracted displacement. And over the next 90 minutes or so, my colleagues and I We'll first introduce the study and then spend some time, secondly, looking at health system integration and the interplay between national and parallel health systems in settings of protracted displacement. Then in the third part of our remarks, we'll look at how those systems are financed. Um, which was, should take us up to about the 50, 55 minute mark. We'll then go into small breakout room discussions to deepen the conversation before wrapping up in the plenary with some key takeaways from our conversation. So just to give you a little bit of background on the project itself, um, the Big Question study was commissioned by UKA, the Bank, the World Bank, and UNHCR in 2019, and it was carried out by a consortium of universities including Columbia University, the American University of Beirut, Brandeis University, Georgetown, and uh University de los Andes in Colombia. The work was commissioned against a backdrop where the majority of refugees and people in need of international protection live in situations characterized as protracted, defined as displacement that lasts a consecutive period of at least 5 years. In 2018, the Global Compact on refugees called for expanding and enhancing the quality of national health systems to facilitate access by refugees alongside host communities, including building and equipping health facilities and strengthening health services. The Big Questions project has really been guided throughout by that call and the need to provide programming and policy guidance to those national and international actors such as yourselves on this call, who are really involved in directing and funding health responses in situations of protracted displacement. So our research took up three primary questions, including what are the common trends, similarities, and differences in health needs between forcibly displaced populations and host communities in the various geographic, social, and demographic contexts in which protracted displacement occurs. Second, what empirical evidence, lessons learned, and good practices are there on optimal ways for host countries and development partners to be better prepared to develop mechanisms that can systematically plan for, identify, prioritize, and plan to deliver health services at all levels of care for both host communities and displaced populations that live alongside them. And then thirdly, what are the most cost efficient mechanisms for financing those health services for these two communities? So our research teams really explored these questions very practically through the lens of four country studies, Bangladesh, Colombia, the DRC, and Jordan. And these sites were deliberately selected to represent a diversity of geographic, political, and economic contexts and covering different types and duration of displacement. So you'll see that, you know, the study includes refugees who are registered with UNHCR, unregistered refugees, displaced Venezuelans, and internally displaced persons. Uh, in terms of the methods we used, uh, as all academics do these days, we used a mixed methods approach. Um, and, uh, uh, the fieldwork was carried out from 2019 to 2022. So we certainly had to contend with the context of the COVID-19 pandemic in our work. Um, and each study comprised essentially a desk-based literature review, focus group discussions, or in-depth, in-depth interviews with host and displaced community members as the COVID situation allowed, health facility assessments of purposefully sampled health facilities, including a costing component, and then semi-structured key interviews with people working in government, civil society, and international organizations. And finally, a survey of mini national health accounts, including data from financing agencies and secondary data. So moving on now to the second part of our remarks, of our remarks, which is really beginning to dig into um some of our key findings and lessons, uh, when we look at integration and things to consider when weighing uh parallel versus integrated health systems. So the influx of large numbers of refugees and IDPs can, as we all know, pose a significant challenge to health systems, even in countries with advanced health systems as we've seen in the Ukraine response. In contexts which are fragile or conflict affected, these strains can be acute, and early in a humanitarian crisis, national health systems are frequently overwhelmed by the large influx of displaced persons. And in this acute phase of humanitarian response, we see international actors addressing urgent needs through the provision of services that are essentially outside of the national system, the so-called parallel system of response. As crises extend, transitioning from this acute phase to the protracted phase of the humanitarian response really requires careful coordination to avoid inefficiencies such as duplication of services or increased inequity and service gaps, um, such as services provided through the parallel system, transitioning then to greater integration with the national health system. And at each stage, I think host country health systems are present alongside services offered by non-state actors and private sector providers. And so that coordination framework and thinking ahead about some of the challenges that happen in this humanitarian to development nexus, I think is really important. Now, the issue of parallel and integrated health systems has often been framed as a binary. In a parallel approach, humanitarian organizations would work in a separate parallel system to serve the affected population, while in an integrated response, humanitarian organizations would work within the existing national health system, um, where both host and displaced populations would access health services. Um, and in a minority of settings, typically those that are high income, host comp uh companies, host governments may in fact be able to meet the health needs of both displaced and non-displaced households without the support of humanitarian organizations. But even though we see that binary in play of And the reality is that in most low and middle-income countries experiencing protracted displacement, um, the response often sits somewhere along a continuum from fully parallel health responses on the one side to the fully integrated response on the other side. And the four country studies that were the focus of this project, really, each of them offers up a different blend of humanitarian and national health service delivery, often shaped by the national health system's capacity. Um, and in that context, I think they enabled a contextualized and nuanced analysis. Uh, which we used really guided by health systems strengthening frame frameworks to look at the benefits and challenges of integration. And I think these studies illustrate how, um, you know, to what extent and for what type of service and at which time points in the response, um, health system integration can best encourage. So I'll move now to really briefly recap for each country context, uh, to give you a sense of how the health response was organized. I'll do this very briefly indeed. So in Bangladesh, our team really focused on the 1.1 million Rohingya refugees residing in camps, uh, and the host populations residing in the surrounding communities. Uh, and in this context, we saw parallel system. Systems of primary care for host and displaced populations, but integrated services at the secondary and tertiary levels. In Colombia, our teams focused on the two coexisting protracted migration crises, uh, the internal, uh, forced displacement caused by, um, the, the violence we've seen in Colombia over decades and the armed conflict there, and the external displacement from Venezuela. Uh, and I think following a presidential decree in March 2021, we saw a shift towards more integration. Large numbers of Venezuelans began the processes of regularization and subsequent enrollment in national health insurance, which then allowed them to access the full range of services in the national health system. In DRC our team focused primarily on the 4.5 million IDPs residing in the country, and here we observed full integration of health services with both IDPs and host communities entitled to access services in the national health system. And yet, uh, I think as you'll see in some of our reflections, extremely low access and utilization of health services, largely driven by high out of pocket costs for services, consumables, and transportation. And then finally in Jordan, our teams focused on the 660,000 Syrian refugees residing in the country and the vulnerable Jordanian host communities they lived alongside. Syrian refugees in camps accessed UNHCR services for free within the camps. Refugees outside of the camps, which are over 80% of the Syrians during the study period, accessed a limited set of UNHCR supported services and had access to health services within the national health system, paying subsidized fees. So, our case studies also demonstrated the implications of social, economic, and political context in in shaping the structure and availability, uh, affordability, accessibility, and quality of health services for host and displaced populations. And as highlighted in the 2022 WHO World Report on The health of refugees and migrants, national policies regarding the geographic and socioeconomic integration, um, of these two communities can significantly impact health system responses and adaptation to protracted crises. So context is absolutely key, and I think that it is important to say at the outset that there is no one size fits all approach. Not every situation will lend itself to an integrated approach, and in particular, state fragility complicates and may limit. The prospects for integration of health systems as weak institutions, lack of uh resources, policies and practices restrict the inclusion of displaced persons. And then on the other hand, you have insecurity which can undermine trust and access to health systems. And I think it's also worth bearing in mind that there is considerable variation within a given national context, and the level and type of integration can vary by time, geography, type of health service, and so on. And informal and private health sector actors also play key roles. So, I think with that, I will pass it to my colleague, Dr. Samari, to discuss 3 important issues to consider when planning, implementing, and evaluating health systems in a protracted humanitarian setting, including those host government policies of encampment and legal status determination and the implication for health system integration. Second, key data workforce and related socio-economic, um, sociopolitical factors that really delineate the space for successful integration of national and humanitarian health systems. And finally, the limitations of integration, particularly related to state fragility, high cost, and low quality of health services. So, Doctor Samari, over to you. Thank you, Professor Zard. So, I'm gonna start by discussing encampment policies. So encampment policies really play a key role in shaping the continuation of a parallel system, even after the acute phase of a response. So when displaced communities are physically distinct from host communities such as in camps, parallel services set up during the initial response may actually be more likely to become long-term service delivery points for their needs. Where basic services sort of remain separated, systems for timely referral from camp-based services to more specialized services outside of the camps can also pose a formidable challenge. For example, in Bangladesh, we saw that the government restricts movement of Rohingya refugees outside of the camp complex, and this policy reinforces the government's official position. That displaced Rohingya will not have a long-term presence in Bangladesh. This position in turn sort of underpins the reality that the political context is a key factor in shaping the extent of health systems integration. Restrictions on movement outside the camps actually lead Rohingya to primarily rely on a parallel system of NGO and INGO run health facilities and or informal healthcare sources located within the camp complex. However, to access the most advanced health services at the secondary and tertiary levels, Rohingya referred to facilities outside of the camps where they receive care alongside the host population. Delivery of many secondary and tertiary services are integrated for displaced and host host populations. However, the extent of integration is really curtailed by barriers experienced by Rohingya within the camps, and access to healthcare services at facilities outside the camp complex is legally and logistically limited to those referrals, um, officials approved to, to leave the camps and those who have the resources to travel. So this shows a quote from a Rohingya refugee and, and really just sort of tries to demonstrate that the administrative challenges of referrals or getting a patient from the camp-based health system to specialized care outside the camp, intersect with barriers to care like cost and distance to the facility. Then we have organization of referrals in the Jordan camp, for example, on the next slide. Similarly, in Jordan, Syrians living in refugee camps generally receive free healthcare within the camps and rely on referrals outside of camps for tertiary care. Sort of in contrast to Bangladesh, the camp-based population is a minority of the displaced population because well over 80% of Syrians reside in urban areas in Jordan. Similar to Bangladesh, though, the camps really focus on primary care and limit secondary health care, and then tertiary care is really facilitated through UNHCR referral systems that are operated by NGOs. Nearly 70% of referrals that go to go to private hospitals rather than the public system, and this is primarily because of long wait times and the fact that implementing partners are charged with uh the more expensive foreigner rates at public facilities. So, while Jordan has a more clearly organized system for designating referrals, integration of tertiary health services for Syrian refugees is still limited by the capacity of government-run facilities and by immigration and financing policies that really tie the rate charged for health services to nationality and refugee registration status. There are 3 major gaps that we've identified in the health response. Um, these, these gaps include treatment of chronic disease, particularly for the forcibly displaced populations, access to specialized services, including secondary, hospital, and tertiary sort of advanced hospital care, especially among forcibly displaced populations, and then access to mental health care for both host and displaced populations. An example of this. Can come from Bangladesh and a UN led initiative to strengthen the workforce for a comprehensive mental and and psychosocial support program. So mental health specialists provided consultations and supportive supervision at community sites. The program really collaborated with the Department of Clinical Psychology at a local university to adapt educational curricula to prepare students to work on mental and psychological support, uh, services and humanitarian settings. Um, this is sort of a collaborative example that could provide additional mental health care, but really relied on NGOs and, and academia. It's also worth noting that the parallel services being provided by NGOs and different entities are being done in line with national policies and national ministries of health and other relevant agencies to provide supervision or oversight. This can be a point of tension, um, but it can also be a point of opportunity to create or revise guidelines on issues where national guidance is limited or not yet developed. In Colombia, we saw um some narrow disparities if you look at differences by nationality and hospitalization. Um, so, in Colombia, where people have access to emergency health services in the national system for a provision in the constitution, our research team found that in 2019 and 2020, Venezuelans were able to access tertiary care at similar levels to Colombians as. I by the way, the blue dots corresponding to the Colombians in this figure and the orange dots which correspond to the Venezuelans overlap in the graph for all-cause hospitalization rates. Basically, Colombians and Venezuelans access hospital services at similar levels. On the next slide, we see wider disparities by by nationality and consultation in Colombia. So, if you look at the rates of access to consultation during the same time period, we see a disparity among these two groups, with Colombians, again, shown in blue, accessing consultations with physicians at 7 times the rate of Venezuelans shown in orange. This sort of reflects the two groups different access to the national health insurance system. While regularized Venezuelans can enroll in the health insurance system. Um, and thereby access a full range of inpatient and outpatient services in the national healthcare system. Most Venezuelans only maintain access to emergency services, and this is primarily due to bureaucratic hurdles or processing requirements, things like, uh, validating identification and documents and proof of presence in the country. Um, these things remain as barriers to regularization and enrollment in the national health insurance system. In terms of data availability, um, in Colombia, our research team use the RIPS data, uh, which consolidates information on costs, hospitalizations, consultations, and basic patient characteristics, including immigration status within the CISPRO, Colombia's National Health Information System. It is really worth noting that this sort of comparative analysis of health service utilization, rates and costs was only possible in Colombia because of this data infrastructure. Um, in other countries that we look at, we found a paucity of demographic and epidemiologic and health service utilization data that was sufficiently comprehensive in scope, that is captured, um, and represented host and displaced populations and um disaggregated by migration status or a reasonable proxy, so things like nationality or administrative areas or geographic areas. This really complicated our efforts to identify and plan to address health needs in context of the response. Um, in particular, we're lacking data over time, things like repeated cross sections or even longitudinal data, and this really constrains the ability of policymakers and practitioners to assess and anticipate shifting health needs, um, health differences between host and displaced communities, health service utilization. And demographic and epidemiologic profiles of the forcibly displaced population relative to an appropriate comparison group within the host population. This is a long-term need for sustained investments and data collection processes. Um, we need data collection that really meaningfully and accurately captures the demographic and health profiles of host and refugee populations, um, over time. Um, on the next slide, we have Um, some information about leveraging the displaced health workforce. So something that really rose in our, um, data was that as health systems are strained during the response to forced displacement, human resource policies and workforce initiatives are really another important aspect for practitioners to consider when working to fill service gaps for both host and displaced populations. And we have some sort of suggestions about how to achieve this on this slide, including You know, official permissions for work, task shifting strategies, support from professional bodies and training institutions, and community engaged and multi-sectoral partnerships. So, some key factors in Transition to greater integration. An integrated approach to healthcare can really provide widespread benefits in terms of planning and sustainability, cost effectiveness, and continuity of care for both the displaced and host populations. Um, humanitarian health practitioners, national governments, and international donors should really plan from the earliest phase of a displacement crisis, um, for the possibility that a crisis might become protracted and require sustainable long-term solutions. As outlined in the UNHCR Global Public Health strategy, the process of transitioning to a more integrated health system should really be guided by a medium and long-term approach that has clear milestones and support from donors. And when you're translating to a more integrated service delivery system, governments need to scale up the entire system. This is a slow process that, as you can see in Colombia, um, requires ongoing support from the parallel system to implement. It's also important to note that not every situation will lend itself to an integrated approach in some political contexts, particularly where the government concerned is a party to uh to conflict. Um, the role of humanitarian NGOs and NGOs remains really critical. State fragility also complicates and may limit the prospect for integration, given weak state institutions, things like corruption, a lack of resources, and a lack of security. These all serve to undermine the trust and access to health care overall. Uh, key factors for donors and government and humanitarian actors to consider include the political context, the available funding, and the potential for improved health outcomes, and equitable health outcomes among both the host and displaced populations. The DRC case offers some examples of pitfalls, uh, over the sort of over reliance on an integrated approach in contexts where government institutions are not yet able to quite meet the needs of the population, whether host or displaced. Um, in this context, scaling down the parallel systems to strengthen. Um, health service delivery would risk cutting off access to health services. Efforts to strengthen the availability, quality, and affordability of health services in government facilities have to be pursued alongside parallel systems of health service delivery, at least for now. Um, in the DRC also, where IDPs and host populations have fully integrated access to the National Health system, there's low health service utilization. This is driven primarily by things like high cost, which actually dissuade both, both the host and the displaced populations from accessing health services at all levels. Um. For the purposes of this presentation, healthcare costs are defined as those expenses that are really incurred by households to pay providers for health services rendered. Uh, in the DRC, the, the public healthcare system really suffers from limited and often delayed funding. Uh, they have frequent stock out shortages in human resources and unaffordable out of pocket costs that ultimately lead to underutilization of services. In this context, the parallel system is actually a lifeline, um, and transitioning away from it can, uh, significantly decrease access to care. RHA, who was our research partner, recorded an illustrative example of this over a decade ago when they, when funding for free drugs ended at a free clinic, uh, attendance decreased substantially, although staffing and patterns of health needs remained the same. So, on the next slide, we see trends in the health needs and spending among urban refugees in Jordan, because the situation in Jordan provides another pertinent example of how out of pocket costs to access health services really drive health service utilization. The orange line on the graph really shows the percentage of urban refugees who stated that they accessed. Needed health care in the past month, and it dipped to 22% in 2018. This, this was concurrent with a change in the Ministry of Health policy that increased out of pocket co-payments to 80%. However, utilization increased again in 2021, and this corresponded to another change in Ministry of Health policies that reduced the co-payment to 20%. This change also corresponded to the establishment of a multi-dor account for health, a promising practice for health systems financing that will be discussed in the lecture on financing. Governments and donors really must work to establish enforcing norms and rules around proper and predictable charging for health services through government regulations and policies. With that, I will turn the discussion over to Mike Woodman of UN UNHCR who will address some of the reflections on UNHCR's experiences with integrated and parallel health systems, as well as suggestions for practitioners in this space. Thank you, uh, Samari. You, you can hear me OK? Yes, we can. Great. Uh, thanks very much for the opportunity to share some of our reflections and also for the excellent presentation so far, highlighting all the diversity of context, but also the, the challenges and the need for tailored approaches. Um, within our public health strategy, inclusion is one of our strategic objectives, but I must say that it's not at all costs. And this goes alongside other objectives, uh, including building partnerships and enhancing health system capacity. So, in essence, we aim for responsible and an effective inclusion in national health systems, and by responsible, I mean that the health systems should have the capacity to meet the needs of refugees and host communities. And some of the benefits and drawbacks, as mentioned. Inclusion in health systems is, is especially important because displacement is typically protracted. There is extremely rarely a situation where there may be a displacement that's very short-lived and a return. It, it unfortunately is not the case. Um, we do know that inclusion enhances social cohesion and equity. It is more cost-effective in the, in the long term, and it promotes an approach to strengthen the health system as a whole and leaving no one behind. Uh, what we do know also is that inclusion is often as a gradual process and it can be stepwise and slow. Um, in, in our experience, often, it's easiest to include in, in vertical programs such as EPI, HIV, TB, and malaria. Um, but this is often the fact that these programs are externally funded by, by big donors and, and are well-running, and they have instruments to provide additional incentives for inclusion of refugees. Uh, on the positive side, we do a biannual survey of 50 countries and we see very good levels of inclusion, particularly in primary care, but as the report has highlighted, there are big issues when it comes to secondary and tertiary referral care services. So, successful inclusion usually comes through a combination of, of political will plus a resilient health system. And these two factors are often not, not in place at the same time. There may be countries with strong political will but very fragile health systems, and, and they can be the converse. Um, and unfortunately, as stated in the report, the majority of refugees are hosted in the countries with, with the more fragile health systems. Just like to touch on a few country examples, and Ukraine was mentioned, the crisis there. And we saw the European Union Temporary Protection Directive, which gave immediate access. To refugees to national health systems in the European Union. So, a very good example of a rapid, uh, response to immediate inclusion in health systems without a parallel humanitarian response. Uh, and I'm not speaking about Moldova, uh, which is outside the European Union. Um, but I just want to state that inclusion on paper doesn't always mean inclusion fully in practice, and there can still be barriers faced, and these could be language, financial, or access to specialized services such as GBV and for this reason, monitoring and advocacy is, is essential. Just another example of an lesson that we have learned is advancing on inclusion uh too rapidly or into systems that are not quite ready. And I'll give the example of Djijibouti where there was a very strong political commitment to include refugees and a health system that was being supported externally and capacity being built. But unfortunately, our NGO partners withdrew and we realized that the system was not able to fully meet the needs of the refugees and they faced significant access issues. This required us to re-engage with the government, uh, with the Ministry of Health and provide direct financing to the ministry to manage services in camps. Uh, now, we are working on, uh, Further inclusion, but this will be a long-term and and stepwise process, including with support through the World Bank. Uh, I have another more positive example from Mauritania where Embera camp on the Mali border. With World Bank support to the country to strengthen the health system. Through the, the host community and refugee window, there was financing made available for, for that district, and there's been a very successful transition to Ministry of Health Services, but this has been based on a Transition plan together with the government and also on engaging our NGO partners to accompany the transition and gradually withdraw. Um, however, we do still subsidize care for the refugees, uh, so we're, we're midway in the process. Uh, just to highlight some of the key lessons learned for us, I think there's several things that, that stand out that I may have mentioned already. And this is the risk of transitioning too quickly or when the system isn't quite ready, and therefore, the need to analyze the readiness of the system. Uh, the need to identify what support is needed for that system and, and what support is available through, through donors, uh, humanitarian actors, development actors. Uh, also assessing the capacity of refugees to pay user fees. Many countries, there will be some user fees as mentioned, and, and what is the livelihoods access, what is the capacity to pay? And in that sense, also establishing safety nets for the most vulnerable if they cannot be included in any national social safety net program. Uh, the need to develop multi-stakeholder, multi-year plans, uh, which are adequately financed. Also engaging with development partners very early on in a crisis. I think very important to set a platform uh for transitioning. We also internally as UNHCR need to recognize that inclusion requires investment. It, it requires us to invest resources and to accompany a, a transition plan. And also the need to document practices, and I think the big questions report is, is a very good example of that. Uh, but we also need to continue documenting good practices and lessons learned through other initiatives and, and evaluations. Um, I think I will stop there. Um, maybe some reflections finally just on navigating transition. Um, just very briefly, if you don't mind very briefly, yes, I think it, it's always desirable to, to transition. Um, how it's often the stepwise process. So as I've mentioned, trying to Integrate initially from the onset of a crisis, but if parallel services are needed, making sure these are aligned with the national standards and protocols to facilitate transition and the important need for, for partnerships. Uh, so with that, um, thanks very much and um over back to you. Great. Thank you so much, Mike, and um we're running a little short on time, so I'm gonna go straight to Doctor Wu Zheng from Georgetown University to lead us through the financing discussion. Over to you, Wu. Uh, thanks for that. So I'll pick up the discussion on health financing. Before I jump into the presentation, I just want to emphasize the importance of the context. Improving financial commitment to support the health service delivery in a displaced population goes beyond the health sector and require multi-sectoral collaboration and strong commitment from both donors and host governments as well as the humanitarian and development partners. The host government classification of the displaced person, particularly, uh, the official recognition and registration of refugees or internally displaced person status, play an important role in the ability to track spending on health as well as attainability of financing from, uh, from our national health system. Circling back to our early discussion on the, uh, encampment. The extent of the engagement between displaced and the host community has implications for the willingness to invest in the health system. Just give you uh one example. In Jordan, we see examples of health system investment benefiting the host community in part because of many refugees live outside the camp and access the services in the same facilities as the host population. In contrast, in Bangladesh, the separation of the refugees into camps means health system investment are less likely to benefit the both host and the displaced population. With that, I will move to the discussion of the health financing framework and it's possible uh adaptation in settings affected by the forced displacement. So these slides, you can see. The very typical framework on health financing. It includes the three elements. The left side is uh the first element on collecting revenue. The resources that can be collected through different mechanisms, uh, for example, the general taxation, payroll tax, private insurance, user fees, and, uh, um, donor resources. Some of the financial resources are collecting mechanisms will have the pooling functions, which means the money can be used for others, but some mechanisms that do not. User fee is an example that doesn't have the pooling function. Once uh resources are pool, they can be used to purchase the services, using different payment mechanism. So here you can see we also listed some of the payment mechanisms, fee for service, capitation line and budget and, and so on. So this is mostly for the national health systems um financing framework. This framework can be adapted to the humanitarian settings uh to account for parallel services as well as the humanitarian support through the national um system. And this slides just uh summarize up some possible adaptions for financing the health system accessed by displaced of, um, population. Uh, international donors are critical resources of the revenue in the humanitarian settings. It is typically dispersed through the international organizations such as UNHCR, UNICEF, and WHO. The host of, uh, government can sometimes can also be important sources of the revenue through government budget or in some cases through the bilateral or multilateral fund channeled through the government. Our pocket spending is quite common. It is uh one of the key barriers to accessing care for refugees and the, uh, vulnerable host populations and some other mechanisms as well. Because many organizations are involved in the, the, in funding health services for displaced population, increasing the pooling and reduce, reducing fragmentation of financing will be very, very important. Finally, on purchase of the services, which is on the right side, here we're more focused on the type of our providers delivering the services, how they contract with the funders. And how the coordination and competitions um uh amongst um themselves. The providers can include the international and local NGO facilities, as well as the government and private facilities. O So despite the heterogeneity of the displaced population in this study in these four countries, the external funding are the major sources of the revenue to provide the services in 3 countries, which means, uh, Bangladesh, Jordan, and DRC. Uh, Columbia, uh, the, the national funding seems to provide a more important role. So donor fund is account 87% of the health, health spending for Rohingya refugees in Bangladesh, about 53% for Syrian refugees in Jordan. In DRC we see some humanitarian uh providers also provide the free care to displaced uh communities, but, but we don't have the data to disaggregate the spending by displacement status. In Colombia, Uh, international support, uh, for displaced Venezuelans account for $31 per person per year. One of the key challenges of, of relying on international donor fund is that they are primarily voluntary contributions and fluctuated from one year to the other. International donors' commitment are limited in time and scope. This will cause us the unpredictability and instability in funds and also hinders the implementing agencies' ability to plan for the long-term project. One of the promising practice uh for improving the coordination and pulling of the resources which was mentioned by uh my colleague previously is the mud donor accounts uh in Jordan. And this account in, uh, in which a portion of the donor fund for that was put into this uh single account and um money from this account can be used strategically by the ministry. Of course, coordination, um, have a coordination with the international donors to um invest in a prioritized the area. And in that way, uh, the resources can benefit both refugees and the host of populations. Next time. Putting our financial resources is generally very fragmented in humanitarian settings, but varied depends on the overall levels of the integration between our national and humanitarian health system. Pulling mechanisms are most advanced in Colombia, where the government used the budget, uh government budget or payroll tax to finance health services for Venezuelans. In this context, Uh, the key questions are how to expand the, uh, fiscal space to finance the, um, health services to include more of Venezuela in the health insurance. In Jordan, Refugee health is an integral part of the country's uh joint response plan for refugee crisis and donors' contribution are poured to support the refugee and host communities, multilateral and sometimes the bilateral donors adopt the uh global compact on refugee framework and focus the supports, uh, on the services provided within the national healthcare system. In DRC some donors' funding is channeled through the government while some fundings actually go directly to the international or local health providers. And, uh, similar to Jordan, Bangladesh also has a joint response plan that provide very, plays a very important role in coordinating uh financial resources to respond to the Rohingya health needs and the implementation of this joint plan is carried out by a lot of uh uh UN agencies and nat national or international NGOs. Then it's very important to strengthen our coordination among various health providers, yeah, to avoid duplication of the sepsis and fill in the sepsis gap. Next item. Contract with the uh different health providers is an important task to ensure donors' fund is used appropriately to meet the health needs of the displaced and host uh populations. Over now, uh, many healthcare providers contract to the contracted to deliver services. Depends on the size of the displaced population. And the extent of the integration uh with, with the National Health System, the number of services providers varied significantly. Healthcare providers can be mixed and include, uh, uh, as I mentioned before, include the government facilities, NGO facilities, and private fac facilities. Despite the strong commitment of the funders and extensive experience in contracting with uh healthcare providers, one of the challenges we identified from this study is that funders are frequently limited the organizational and funding structure that only allows the short-term contract with the healthcare providers. Most of them, the health providers receive one-year contract. Sometimes it can be even shorter. Which makes it very, very difficult for the health providers to make a long-term plan, particularly for in the first year of the project when the health providers need a, a significant amount of money to um have a capital investment. Yeah The disruption, next slide, yeah. The disruption and availability of our health services are among the major reasons why displaced population may prefer to seek care in private facilities. Uh, focus group, uh, um, participants in Jordan described how long, uh, waiting times for life-saving cares lead to participants to seek care, uh, outside the contracted facilities. Here is the quote. We're not insured in, um, Any private hospitals. It used to be through the UNHCR but not anymore. They referred the, uh, my father and give him an appointment after a year and a half. If we wait for a year and a half, and he will die for sure. So, this kind of inefficient referral or the contracting arrangements can contribute to the increase of the healthcare cost when disruptions are availability of services drive people to seek care in a private facilities. Um, in those facilities are unpredictable. And unregulated user fees may exacerbate the challenge to access care. Next. Contract contract health uh health providers provide a wide range of services to displaced population. All 4 countries included in this study has a clear benefit package that extended to the displaced population, but with a wide, wide variation between them in terms of coverage. Uh, in Colombia, this is the country with the most comprehensive health coverage if Venezuela are enrolled in the health insurance, but unfortunately, a significant amount of the Venezuelans are not, uh, enrolled in the health insurance, which means, uh, many of them cannot access the, to the, to the care, uh, comprehensive care. Services offered to the displaced population in other three countries, um, more focused on the primary health care with limited referral services along with other health system challenges, for example, the shortage of medicine. The limited benefit, uh, benefit package also drives the patients away from seeking care, uh, in other places. In our our country studies, the main gap we identified, uh, actually my colleague also previously mentioned is the management of the mental health as well as the management of the non-communicable diseases. And this uh kind of uh, uh, um, uh, services, uh, either not available or offered in a low quality that may uh drive, drive the people from seeking care outside. Next slide. Given uh the challenges, uh, uh, uh, we have in terms of the getting fundings and because, um, also because the short-term funding is unpredictable fundings as well as the huge barriers to accessing health services due to the cost, new financing mechanisms, uh, should be explored. Uh, the current, uh, practice in terms of the, uh, providing services is more donor-supported from the supply side. The support could also be considered from the demand side, uh, such as supporting the, uh, premiums for health insurance or voucher schemes. Uh, such a subsidy provided to the displaced population may also help facilitate the integration into the national healthcare system, although the implementation of such program must be managed with the care in order to avoid overwhelming uh uh health system capacity or creating, creating the disincentives to treat the displaced, uh, community. There are also some programs are using incentives to promote good behavior and link the payment to the performance of the healthcare providers, which, um, this is uh more like pay for performance program. You may heard this uh pro name a lot. This program has been used widely and can be effective, uh, even in some of the conflict-affected uh coun countries. While very few applications exist in humanitarian settings, the International Committee of the Red Cross launched a humanitarian impact bond in 2017. The bond provided the fund to build the physical rehabilitation centers in three humanitarian. settings. Under this arrangement, the funders only pay back the investors in full with the interest if project is deemed a success according to an outside uh evaluation. It's very interesting, um, uh. Uh, case. If possible, humanitarian and, and development partners, particularly those with the multi-year funding cycles, should also strategically, uh, prioritize some existing project and provide a long-term contract to, uh, some of services providers that uh need a large, uh, capital investment that will help them to make a long-term plan, uh, if needed. Moreover, although a minimum package of the health services are often established in humanitarian settings, the package should be monitored and adjust based on the changing health need of the displaced population. As we mentioned earlier, mental health, uh, chronic diseases, become increasingly prominent needs among the displaced population in uh incorporating uh cost-effective interventions to address this need should be seriously considered and integrated to, into the essential benefit package. Lastly, I think our study also underscored the very importance of the financial arrangement that are embedded in a policy that supports the long-term resilience and in that way, improving the likelihood of a displaced population to reduce the cost barrier of very importance and Improving health financing should be also accompanied by the necessary policies to support the legal status to allow the refugees to uh work and get the salary paid and uh to prove uh uh to have a more active likelihood or income generation program for them. So with that, I will hand over to um Fernando who will give a remarks on the financing piece. Just 5 minutes please, Fernando, if you don't mind. Sure, thank you. Let me focus on a couple of issues, uh, on the health financing, particularly, specifically from the view of the World Bank. The World Bank came from the experience of working on emergency situations, catastrophic events, and working with other partners to resolve those, and it's that experience that shaped how we start. to work and engage with forcibly displaced populations. That's in the acute phase of these emergency situations. So, over time, we have improved on how we can finance, we have been more agile to re-allocate resources from existing projects, etc. and working better with other humanitarian organizations. It might not be ideal, but we have worked much better, uh, and learned a lot over the last 20 years, certainly over the last 10 years. Having said that, uh, the, the bank has a very important mandate which is we have to work with the governments. We don't, we don't, uh, our mandate is to work with the governments and the financing goes to the governments. We can work in different ways with other partners, but obviously we have to engage with the governments, that's our. Mandate and, and it's through that channel that we can finance the bulk of our support for forcibly displaced populations. Having said that, it's the, the, the positive of that is that it will require that we take an integrated approach, not always necessarily, but because it's through the government, we'll have to find solutions that will take the access to healthcare through an integrated approach. Um, I think that over the last 10 years, there have been several changes in terms of the financing, particularly, we have now the global, um, concessional financial facility that was triggered, uh, particularly after the Syrian crisis, although after that, this fund, which is a multi-donor fund specifically for forcibly displaced populations, was also, uh, providing support for the Venezuelan crisis. So, those are new sources of funding specifically for this type of situations which complement our support to the countries, to the health systems. In several countries, we have had already existing projects that work with internally displaced populations and sometimes with externally displaced populations. or people coming from other parts and working with individual projects that were already existing and restructured to support those new needs, or they already consider for internally displaced populations, some of those supports. I want to focus on also in my comments on Three key aspects which I think are um key areas where we should focus on health financing that, that have an important impact on overall access but also overall results for the displaced populations and also for the hospital facilities. The first one is the financing of primary healthcare facilities. Um, it, it is a very important approach to make sure that not only children and, and, and, and young people have access to um a series of services that will have an impact in terms of early childhood development, a package of services that's well systematized, that we have worked as the World Bank and development partners in other countries have worked, so it's a very clear Uh, key set of services that's really important to make sure that we minimize the impact on the children and, and the future adults, uh, uh, both not only in, in, in physical health but also in mental health. We have experiences of that. Unfortunately, the last one is, uh, on Palestine, I say unfortunately because some of the advances that we, we have seen there, my My, my, right now in Palestine, go back, but in, in any case, the experience is, is there. In fact, the United Nations Refugee and Works Agency has a highly developed uh approach to primary healthcare with electronic data and the other element that I want to mention, which is uh quality of care. It, it, it might not be the, there are a lot. Of financing, but if we have a monitoring, in terms of quality of care with the specific indicators that uh allow us to uh make sure that the financing produces those results, this will, can make a very important change in terms of how people are treated and how people may demand those services. In many countries, the services that are Available to refugees are low-quality services, they might be public, they might be integrated, but they are low quality. It might be that they are as low quality as for the host communities, right? So uh emphasis on investing in quality of care, monitoring and link those to financing is critical. The, the other aspect that primary healthcare can provide uh Support is for the elderly or people with chronic conditions. It's really critical that we er er not only have a clear er er information on who's there and what ages and, and, and make sure that they have access to uh preventive services, to detection of early detection of chronic conditions and that may help uh an impact on reducing. Jordan is a case in point. Women are accessing services for breast cancer, but unfortunately at later stages than the host communities. There are pilots where these experiences are being improved, but they need, they need to be scaled. All these issues can be, be dealt at the primary healthcare level. Finally, the issue of uh joining forces with other development. Partners and creating pooling is critical. Unfortunately, the limitation of that is the capacity of each country to provide support in the long term. Uh, as we can see now, the forcibly displaced populations are not uh staying for 567, they're, they're staying for 10 years longer and the support of um uh of partners will no longer be able to. To be done through a specific pools always, but it might ended up being linked to support to mechanism, global mechanism financing like the World Bank, uh, IDA support, etc. So let me stop there because I think those would be aspects that we can discuss in, in-depth in the, uh, in the breaker rooms. Let me stop there. Thank you. Fantastic. Thank you, Fernando. Very, very efficient conveying of, uh, of a lot of information there, so I really appreciate it. We are running a little, uh, over time, so I'm gonna take us straight into the breakout rooms, which will be your opportunity to discuss some of these themes in a bit more detail with our speakers. Um, so, uh, the first breakout room, you get to select which breakout room you go to. So the first breakout room is focused on health system integration. So, probing those issues we presented in the first part of our remarks. The second breakout room will be focused on health system financing, picking up on some of the themes, uh, that Fernando and Wu shared in the second part of our, um, presentation. And then the third, uh, is a focus on data. So the 3rd breakout room is a focus on data, which sort of criss-crosses both themes. Um, so, please select your groups now. We are going to spend 20 minutes in the breakout room. And have a very, very short report back. So volunteer to be rapporteurs because I'll only be asking for the one headline idea from each of your groups, uh, in the report back. So thank you very much. Pick your breakout room. Uh, you'll be in good hands for the next 20 minutes, and we look forward to hearing your voices in those rooms. Well, I have to say it was wrenching to be brought back. Because we were in the midst of a very, very interesting, um, set of reflections. Uh, so my apologies to all of you because I'm sure you're experiencing the same thing, which is you wanted those breakout rooms to continue. Um, unfortunately, uh, we are, uh, operating against the, the clock a little bit. So, uh, I hope that this is just the beginning of a conversation between all of us, but I'd like to call on the rapporteur for Breakout Group One to just give us, you know, the two or three headline ideas that emerged, uh, in the course of uh Breakout Group One, which focused on health system integration. So, I think that was Anna Sophia. That is correct, thank you very much. Honestly, I think it's hard to try to summarize in a couple of sentences, but I'll pick out the things I thought were interesting. Apologies to the group if they see something else. Um, we both talked about, uh, the geographic setting, of course, uh, having an impact on whether or not parallel or integrated systems are possible, uh, with camp settings often not actually uh allowing for an integrated system to be possible. And also looking at how we need to from the beginning, uh, consider whether integration is possible as opposed to default opting for parallel systems at the beginning of a crisis. Also talked about the ethical dilemma about how parallel systems sometimes have higher quality, and how do we figure that out, like, what is being offered to host communities versus displaced populations. And integration sometimes only serves the registered population. What does that mean for everybody else? We just need to consider whether or not um it's actually possible for the national system to absorb the funding coming in and perhaps there needs to be a, I mean, a coordinated response to where do we channel funds into the national system because we can see there's space for it and having um a parallel system with INGOs, for example, where we can see at least in the short term, uh, the system can't handle it. Thank you very much. And sorry to the group if anything key was missed. Not at all. That was masterfully done. Well done. Um, so I'm gonna call on Breakout Group Two on financing for a similarly succinct report back. We are gonna run to 10:35 or 135 past the hour, so bear with me, anyone, but we will, we will finish, uh, at 5 minutes, uh, past our, our end time. So breakout room two, who's the report back? We haven't identified one, but, uh, we only, uh, went through the first question, I'm just wondering whether, Lucia, if you want to report what we discussed. Uh, Lucier, also, I think that Deanie was taking, I think that Deanie was taking the, the notes, and she mentioned that she would take the notes for rapporteur. I don't know, Deni. Is that correct? Hi, yes, um, I'm happy to report back. Uh, so there was, uh, a lot of discussion on the, uh, financing difficulties, um, in terms of referral services, um, and how, uh, providers are seeing a downward trend in financing for referral services, um, that they're always looking for more funding. Um, there's also, there was also a lot of discussion on, um, mobility of the displaced and how, uh, the, you know, the back and forth between the, the impermanence um leads to um complications in registration and that the displaced need to be registered in order to access services, um, and, but they also saw opportunities for in, for example, in data sharing into the national healthcare system, there were Um, discussion about, um, challenges in, uh, In dealing with public systems as opposed to the private sector, and our colleague from the, from the IFC also discussed, um, you know, uh, looking into, uh, Into opportunities. I think, Fernando, if you could step in for, for this part, or also Matthew. Thank you. Just very quickly, the key point is that there are different contexts. In the case of Colombia, Venezuelans move all around, so, uh, and clearly for tertiary services, that's not a problem because they can enter emergency services, but it is a problem for the critical first level of care primary. Healthcare. Now, a key issue that the two colleagues from NGOs mentioned, they do have a lot of services that can provide the value-added knowledge services in terms of quality providers, where people are looking for services. And that's a key value added that we have not figured out how to finance because usually multi-donors, trust funds or poolings are working with the government and, and, and forgetting that NGOs and civil society organizations have a knowledge that not the government, that the government may not necessarily have, so we have to figure it out how to engage in those long-term transitions to not get lost all these. Knowledge and all this value added that civil society and NGOs have as their own sources are drying up because of the, you know, acute phase being over, how we can support that knowledge, knowledge, that uh quality services that, that they, they are supporting, so that's one way of looking at this. I hope I am representing correctly, but anyways, uh, Lucia and Matthew, if you have any other comments over. I think that's, I think that's perfect. Thank you so much. And again, apologies for cutting off what was clearly a rich discussion. Um, so very quickly, break out room 23 on data, uh, report back, Jen, or anyone from your team? So I'm gonna do the report back. Um, so we had a very rich discussion about how data again is really context-specific and there's some really sort of good local data collection efforts that are attempting to capture this, but then again, it sort of isn't integrated or um accessible at a large scale, so data transparency and accessibility while maintaining data protections is really important. And so, We talked a little bit about the limit or the reasons why longitudinal data collection is often challenging across these contexts, namely, it's resource intensive and populations are often on the move, and so that's, you know, makes ongoing data collection on the same populations over time very difficult. Um, we discussed the need for, um, our colleagues brought up the need for sort of Legal and governance, uh, advice or examples around, uh, guidelines that really help sort of protect migrants and offer data protection, um, while sort of achieving the goal of data availability and making data collection possible. And so people are really interested in sort of, is there a good example. Of legal protection and guidelines or a context in which this is being really done well to balance the needs of data collection against the the data protection needs. Great. Thank you so much. So, with that, um, we, unfortunately have to draw our time together to a close, but if I were to attempt to summarize, which is a foolhardy thing, um, I won't attempt to summarize, but let me just say that I think there are certain themes that have emerged just very clearly from those breaks. rooms, as well as, um, you know, from the presentations today. And I think the first one for me is context, context, context, both the political context and political will, which seems to underpin any movement towards successful movement towards health system integration. But then also that context around the national health system's capacity and really identifying, um, both the confluence of those two things as being critical for moving forward on this issue. I think, um, that in turn highlights the importance of planning from the earliest phases of a process, uh, of a displacement crisis so that we don't default to the parallel system, but our thinking in that medium and long-term way that I think UNHCR has highlighted as being critical, but also leadership, uh, for putting those conversations on the table and the respective roles of donors, INGOs, and others within the national system to really high. Like complementary expertise and roles to move that discussion forward, um, and coordination, I think is absolutely key and goes along with leadership, really identifying where and how the health, the health system response from the humanitarian side can feed into and support the national system, where the gaps are, and really think about how, uh, you know, we can bring the value added, uh, into that system and have donors play a complementary role in incentivizing. Uh, a more integrated approach. And then finally, the inclusion. On paper doesn't necessarily always match up to inclusion in reality, and I think Mike really highlighted that in his presentation, always being mindful of the lived reality of the refugees and displaced populations that we are trying to serve in these processes. So, I think those for me were certain key takeaways, and I, I really want to thank you all, our audience, uh, for sticking with us in this presentation and for sharing your ideas in the breakout rooms. I would like to thank, uh, the World Bank team, um, uh, that organized this conversation. And of course our panelists and speakers, uh, for, um, sharing their reflections with us. Um, and I would like to thank, of course, my own, uh, team as well, uh, Jennifer Ostrosky, Catherine McCann, uh, as well as the many people behind the scenes at the World Bank who really made the, the, the workshop come together. So thank you all very much, and this will be recorded and do reach out to us at any point if there are any issues you'd like to follow up on. Thank you all. Bye-bye. Bye.

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