Refugee health: Lessons learned from Jordan in response to the refugee crisis

Za’atari Refugee Camp, Mafraq, Jordan

Registered Syrian Refugees in Jordan August 2014 Jordan 613,252 Za’atari Camp 79,562 Azraq Camp 11,443 King Abdullah Park & Cyber City Camps 1,180 Host Communities 521,067 North Mafraq 155,962 Irbid143,544 Ajloun10,017 Jerash11,176 South Karak9,599 Tafilah2,488 Ma’an7,199 Aqaba 2,960 Central Amman 169,778 Zarqa 67,210 Madaba 10,614 Balqa 19,443 Age Demographics

Iraqi and Other Refugees in Jordan Approx. 28,000 Iraqi refugees living mainly in Amman, Zarqa, Irbid, and Mafraq Approximately 4,350 Sudanese, Somali, and other refugees in Jordan, living mainly in small communities in Amman. Non-Syrian refugee groups in Jordan are generally older populations (registered) Percentage of registered refugees between (UNHCR, June 2014) 22%Syrian 55.5%Iraqi 67.9%Other

Major Health Problems for Syrian Refugees Non- communicable, chronic diseases (NCDs) Hypertension, diabetes, cardiovascular disease, asthma Communicable diseases, acute illness Polio, measles, other severe contagious diseases Infections, parasites, skin conditions, gastro- intestinal issues, seasonal illness Conflict-related or other injuries, wounds, disabilities Women’s health issues Reproductive health issues, HIV/STDs

Health Intervention CHALLENGES Discrimination against refugees, refusal of service Documentation requirements prevent access to services Distance and cost of transport to health centers Lacking awareness of rights and available healthcare services Care-seeking practices are reactive, not preventive Lack of education on health risks and healthy lifestyle practices Refugee mistrust of healthcare system in Jordan Lack of follow-up after initial treatment Lack of women’s access to healthcare system and health education Lacking supply of medications, medical equipment, number of facilities, qualified staff

Health Intervention CHALLENGES Discrimination against refugees, refusal of service Documentation requirements prevent access to services Distance and cost of transport to health centers Lacking awareness of rights and available healthcare services Care-seeking practices are reactive, not preventative Lack of education on health risks and healthy lifestyle practices Refugee mistrust of healthcare system in Jordan Lack of follow-up after initial treatment Lack of women’s access to healthcare system and health education Lacking supply of medications, medical equipment, number of facilities, qualified staff IRD health interventions address all of these issues.

The IRD Strategy Community-level health referral system Awareness of health services Education and preventative self- healthcare Empowerment and self- management of refugees Medical supplies and equipment MoH staff training Vaccination and health education campaigns Building capacity of existing host country institutions NGO/Aid Partners (UNHCR, UNICEF) Community Health Workers (CHWs) MoH

IRD Health Intervention Achievements Over the last 4 years, IRD has implemented two health interventions for Syrian and Iraqi Refugees and achieved significant outcomes. 47,538 home visits 91,659 referrals to MoH centers (1,500 monthly) 32,549 patients served 53 health education and 2 vaccination campaigns supported 70,000 (approx.) campaign beneficiaries 1,449 MoH healthcare staff trained 26 MoH centers served

IRD Health Intervention Achievements 20% refugee beneficiaries surveyed using MoH clinics Baseline study (2010) 93% refugee beneficiaries surveyed using MoH clinics Endline study (2014) More Endline Data 71% patients said service was better than expected 97% of patients said they would visit MoH clinics again 95% of patients were satisfied with MoH clinics services

Challenges/Lessons Learned Delays in obtaining required approval of program action plan from government ministries caused delays in implementation Periodic turn-over in the health director position over the life of the program caused some confusion Intensive and time-consuming administrative, financial, and follow-up procedures for equipment donation Security-related delays in program activity in certain areas (Ma’an, Karak) Barriers to provision of subsidized services to Iraqi refugees due to changes in internal MoH regulations Limited capacity of some local partners to complete technical/financial reports Limited funding to address additional needs

Future Steps Continue and enhance effective collaboration with MoH, including capacity- building for staff and provision of equipment and supplies Increase number of partnerships MoH health centers throughout Jordan in order to serve increasing number of refugees in Jordan’s governorates Provide more feedback to MoH on quality of services based on refugee patient exit interviews collected by CHWs Train and involve refugees as peer-to-peer educators in promoting national health education campaigns Work with more local organizations targeting at-risk groups to ensure that none are left out of healthcare access Work toward building coalition of national and international agencies that serves refugees in Jordan in order to strengthen collaboration.