Health for a 50 year old refugee camp

To start with this week, and as if to prove the point regarding sustainability of funding for vertical programmes, see this article on cash crisis for Global Fund. Financing ongoing interventions, let alone new ones, is going to be a huge challenge over the coming few years.

I had the opportunity to visit a refugee camp in the south-west of Uganda this week. It was a strange and fascinating experience, which i largely viewed from a medical standpoint. The camp has a long, long history, originally opened in 1957 and since then playing host to various waves of refugees from Burundi, Rwanda, DRC and, most recently, Somalia. It was a new and strange concept to me, that a refugee camp should be over 50 years old. But as repatriate rates fall age becoming a commoner feature - leaving a population in limbo, unable to fully integrate into their host country and unable/not wanted back in their original country.

Health within these camps is provided, at the moment and until January 1st (when one NGO takes full control), by several NGO's who take most of their funding from the United Nations High Commission for Refugees.  The fascinating irony of this was that these refugee's received far better primary healthcare than their surrounding nationals. It was all free at the point of delivery, which although was in keeping with national guidance, rarely happened at national centres as drug and testing stores were normally empty within a week of their arrival, leaving patients to buy their own. Clinical officers, who competed for higher than average salaries (contributing to the internal brain drain), could choose from a variety to rapid, point of care tests to help with their diagnosis and select from a variety of drugs. One striking example from that day was that IV Ceftriaxone - the choice antibiotic for meningitis and severe pneumonia - was available in these health centres but not in the nearby University Teaching Hospital. I guess at this point it's important to note that this service did not exclude Ugandan nationals. In fact approximately 40% of their patients were local people, travelling into the "camp" for healthcare

What is the consequence of this? On face value it means that it is possible to provide high quality care to potentially vulnerable populations; an equitable and commendable aim. But, there is also the risk in creating a dual health system with questionable sustainability. What happens when this NGO decides that another refugee camp needs it services more? Do they pull out, leaving their drugs and equipment, and leaving the health workers to move back to their original homes to find a national salary? Most likely, following the short burst of healthcare provided by the NGO, the population is plunged back into the situation it started, and back to the drawing board of building its health system. Its a situation i have seen happen before and i am sure happens across the world.

I have to say though, in this situation and watching these health centres so successfully provide for the basic health needs of the "camp" with an all Ugandan team, employed by a foreign NGO, is a satisfying experience and perhaps there is a lot to be learned from them that can be applied generically. Maybe the answer therefore is in the handover, making sure that the good work that these NGO's do is not lost, and its not a case of back to the drawing board.