Displaced populations and health systems: Reflections on policy and practice of health system integration, from the TWG FCAS session at HSR2024

December 18th is International Migrants Day, and this year's celebration and mobilisation focuses specifically on ensuring health access for migrants throughout their journey. A 2024 IOM study found that in just half of 100 countries assessed did all migrants have the same access to government-funded health services as nationals, and we know that health systems play an essential role in ensuring equitable access to health services for all people. International Migrants Day is an occasion for the Thematic Working Group on Health Systems in Fragile and Conflict-Affected Settings (TWG FCAS) and the Health Systems Global community more broadly to reflect on the growing reality of displacement and how health systems can be designed to support progress towards Universal Health Coverage that includes displaced populations.

The topic of health systems and displacement has been one of the core themes of the TWG FCAS throughout the last two years. It all started at HSR2022 in Bogota where the TWG FCAS organised a session on ‘Reducing conflict, confronting pressure: Health system and policy response to the humanitarian and health crises as a result of international migration in Latin America’. The discussion was very successful and generated interesting debates between members well beyond the Latin American region. Reflections culminated in this year’s organised session on ‘Displaced Populations & Health Systems: Round Table on the Policy & Practice of Health System Integration’, bringing together a panel with representatives from regions across the globe. It is difficult to do justice to the rich and engaged conversation between panel and audience. We attempt a summary below, hoping that it will contribute to continuing this conversation within the TWG FCAS and beyond, with the aim of expanding the evidence on what works for health system integration and improve policies and practices for equitable, sustainable just and inclusive health systems.

The long road to health system integration

A first presentation by Shatha Elnakib (Johns Hopkins University), based on a recent, illuminating paper, aimed at setting the scene. She reflected on what “health system integration” means and how this idea has emerged over the last decade but more prominently since 2016, coinciding with the Syrian refugee influx to Europe and heightened securitization debates. Importantly, the analysis noted a gap between global prioritization and national implementation, underscoring how political context and framing (eg terms like "self-reliance" and "inclusion" (see Ibrahim’s contribution below)) influence the discourse around refugee integration.

To complement the presentation and kickstart the roundtable debate, the TWG FCAS had put together a specifically-commissioned video , that brought together voices from Sub-Saharan Africa, Latin America, and the Middle East, featuring refugees, health workers, and implementers who are often not represented at international conferences and who shared personal experiences and challenges in relation to the gap between policies on health system integration, and the reality that they observe on the ground. These testimonies highlighted three main messages:

• The integration of the refugee or migrant health workforce as a challenge but also a potential opportunity.
• The weakness of the existing public health systems compared to the standards of humanitarian response, in terms of quality of care, accessibility, costs, etc.
• Funding challenges, in relation to the gap between needs and funding levels, but also funding cycles (often too short) and the division of funding responsibilities.

Regional perspectives and experiences

The roundtable discussion, moderated by Barbara Profeta (TWG FCAS / SDC, Switzerland) brought voices from across the globe, reflecting on the themes emerging from the video and beyond.

Ali Ardalan (WHO EMRO) reflected on the point made about weak and overstretched health systems in host countries making integration particularly challenging. Drawing from regional examples, he recounted the experience of Iran, which has hosted millions of Afghan refugees, and Jordan, which initially adopted inclusive health policies for refugees but later struggled to sustain them due to resource constraints. With the financing of health system integration in mind, Irene Torres (Fundacion Octaedro, Ecuador) reflected on the gaps at country level, where governments often fail to transfer sufficient funds for social services, including health, to refugee hosting areas leading to delays and inefficiencies in service delivery. She shared the experience of Ecuador where the arrival of half a million Venezuelan migrants increased demand for health services, yet did not provoke the social unrest that might have been expected. Irene emphasized that the inefficiencies in public budgeting, rather than the presence of migrants, were often the root cause of gaps in health service delivery. A clear argument on starting integration with the individuals - the people in the health system -was made by Cynthia Maung (Mae Tao Clinic, Thailand), whodetailed Thailand’s long history of adapting its health system to migrant needs, including undocumented migrant workers and refugees from Myanmar, and stressed the importance of integrating mobile and marginalized populations through the implementation of community-based health interventions. Yuta Momose (ILO, Regional Office for Asia and the Pacific) introduced the economic dimension of integration, highlighting how displaced populations contribute as workers within host countries (including as health workers), often without recognition.

Going beyond the specific issues highlighted in the video and broadening the discussion, the intervention by Fouad M. Fouad (ReBUILD for Resilience & AUB/LSTM) stressed the importance of challenges beyond the health systems, looking at governance and legal frameworks which hamper effective health system integration. Countries, such as Lebanon, restrict refugees’ ability to work because of political considerations. Such political constraints, he argued, undermine the potential for successful integration and meaningful change. The complexities and political salience of the terminology we use was explored by Ibrahim Bou-Orm (LSTM). Drawing from his recent work in Mauritania, he highlighted the tension between the terms ‘inclusion’ and ‘integration’ in local policy debates. He noted that the preference of governments for ‘inclusion’ often entails limited access to higher-quality humanitarian healthcare, without fostering true self-reliance or broader integration of refugees into social, economic, and political systems.

Looking Ahead: Towards Durable Solutions

In concluding, Egbert Sondorp (KIT & TWG FCAS) reminded the audience of the changing landscape of displacement. He reflected on how, just 20 years ago, there were discussions about abolishing UNHCR due to the relatively small number of refugees, a stark contrast to today's global reality. Egbert emphasized the critical imperative of effective health system integration. He noted that, despite the deeply political nature of refugee issues, the need is urgent collective action and pragmatic approaches to addressing these challenges. As displacement continues to reshape the global health landscape, the debate should move beyond concepts and rhetoric. Analysing current practices and lessons learned, and proposing technical, efficient, yet politically feasible and contextually adapted options for health system integration is the challenge ahead for the global health policy and systems research community. The TWG FCAS will continue to foster networks and exchanges across stakeholders to promote such action, and advocate for equity, sustainability, and justice through inclusive health systems.

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