From Parallel Provision to Health System Integration: Exploring the Trajectory and Contextual Drivers of the Healthcare Response for Refugees in Six Low- and Middle-Income Countries

Rising numbers of refugees, prolonged displacement and reduced funding have led to challenges in terms of how to address their healthcare needs, with different approaches taken, ranging from parallel mechanisms to arrangements that are integrated (to different extents) within the national health system. Increasingly, global frameworks call for focus on the inclusion of refugees in national health systems. Based on six case studies (Kenya, Kurdistan Region of Iraq, Mauritania, Pakistan, Peru and Zambia), this paper analyses the trajectory towards health system integration in the healthcare responses for refugees to understand how contextual features play a role, and explores enablers and barriers of greater health system integration. Methods included documentary reviews, key informant interviews and focus group discussions (FGDs). Analysis was carried out separately for each setting and findings were later mapped, compared and contrasted for synthesis. All settings follow a normative pathway from an initial parallel response to hybrid, transitional arrangements to health system integration—though the latter is at different stages across settings. Some elements influence the timeframe of the shift, its completeness and effectiveness. These include: the scale and pace of refugee flow; the salience of political discourses on refugees and public perceptions, in some instances mediated by ethnic and cultural affinity; the country's level of income and social protection systems; existing legal and policy frameworks, refugee rights and societal integration processes; availability of funds; capacity of the national health system, and its universalist approach. While it is difficult to alter some of these elements, each has to be carefully considered for health system integration processes. Priorities will generally include promptly strengthening local health systems to address the difference in healthcare provision for refugees and hosts, and effectively leveraging available funding (including from development and private sector sources) as well as existing, inclusive health system arrangements, such as free healthcare or social health insurance.