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Refugees and Sustainable Health Development in Iran

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Refugees and Sustainable Health Development in Iran ARCHIVES OF Arch Iran Med. January 2021;24(1):27-34 IRANIAN doi 10.34172/aim.2021.05 http://www.aimjournal.ir MEDICINE Open Original Article Access Refugees and Sustainable Health Development in Iran Mohammad Mehdi Kiani, PhD Candidate1,2; Khatere Khanjankhani, PhD Candidate1; Afsaneh Takbiri, PhD1; Amirhossein Takian, MD, PhD1,2,3* 1Department of Health Management and Economics, School of Public Health,Tehran University of Medical Sciences (TUMS), Tehran, Iran 2Health Equity Research Center (HERC), Tehran University of Medical Sciences (TUMS), Tehran, Iran 3Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Abstract Background: Refugees’ access to quality healthcare services might be compromised, which can in turn hinder universal health coverage (UHC), and achieving Sustainable Development Goal (SDG), ultimately. Objective: This article aims to illustrate the status of refugees’ access to healthcare and main initiatives to improve their health status in Iran. Methods: This is a mixed-method study with two consecutive phases: qualitative and quantitative. In the qualitative phase, through a review of documents and semi-structured interviews with 40 purposively-selected healthcare providers, the right of refugees to access healthcare services in the Iranian health system was examined. In the quantitative phase, data on refugees’ insurance coverage and their utilization from community-based rehabilitation (CBR) projects were collected and analyzed. Results: There are international and upstream policies, laws and practical projects that support refugees’ health in Iran. Refugees and immigrants have free access to most healthcare services provided in the PHC network in Iran. They can also access curative and rehabilitation services, the costs of which depend on their health insurance status. In 2015, the government allowed the inclusion of all registered refugees in the Universal Public Health Insurance (UPHI) scheme. Moreover, the mean number of disabled refugees using CBR services was 786 (±389.7). The mean number of refugees covered by the UPHI scheme was 112,000 (±30404.9). Conclusion: The United Nations’ SDGs ask to strive for peace and reducing inequity. Along its pathway towards UHC, despite limited resources received from the international society, the government of Iran has taken some fundamental steps to serve refugees similar to citizens of Iran. Although the initiative looks promising, more is still required to bring NGOs on board and fulfill the vision of leaving no one behind. Keywords: Iran, Refugees, Sustainable health development, Universal health coverage Cite this article as: Kiani MM, Khanjankhani K, Takbiri A, Takian A. Refugees and sustainable health development in Iran. Arch Iran Med. 2021;24(1):27–34. doi: 10.34172/aim.2021.05. Received: February 13, 2020, Accepted: October 4, 2020, ePublished: January 1, 2021 Introduction refugees and migrants arrived in the European Union in Globally, about 214 million people move internationally, 2015.6 The recent wars in Syria, Iraq and other countries while approximately three-quarters of a billion people have caused large-scale displacement and refugees who are migrate within their own country, both of which pose seeking to migrate to safe countries to live.7 considerable challenges to health policy making.1-3 As a Cross-border migrants have heterogeneous life consequence of war, torture, violations, and disparities in experiences and they may have experienced discrimination race, religion, nationality, ethnicity, and political freedom, and marginality before, during, or after travel.8 As a the global number of refugees, migrants, asylum seekers and result, migrants face higher risk of infectious diseases, displaced people has historically reached the highest ever.4 non-communicable diseases (NCDs) and mental health According to the United Nations High Commissioner for problems.6 The greater diversity of refugee population Refugees (UNHCR), 70.8 million individuals were forced has brought new challenges to the national health care to displace by the end of 2019 worldwide.5 This is an systems,9 especially for countries that host a large numbers increase of 2.9 million people over the previous year, and of them.10 Refugees and asylum seekers are vulnerable the world’s forcibly displaced population remained at a groups with significant and complex health needs.11 record high, including: 25.4 million refugees—the highest Migration is considered a social, political and ever seen; 40 million internally displaced people; and health challenge, in terms of providing access to high 3.1 million asylum-seekers. Fifty-three percent of refugees quality health services in order to achieve Sustainable come from three countries (Somalia 1, Afghanistan 2.7, Development Goals (SDGs), and particularly the concept Syria 4.2 million). Turkey is the top host country by of universal health coverage (UHC).12 SDG 3 aims to accommodating 2.5 million refugees.2 More than a million ‘ensure healthy lives and promote well-being for all at all *Corresponding Author: Amirhossein Takian, MD, PhD; School of Public Health, Tehran University of Medical Sciences, Enqelab Square, Tehran, Iran. Tel: +989121041412; Email: [email protected] Kiani et al ages’, including that of migrants, while a number of other these criteria, seven documents were selected and content SDGs incorporate elements related to health outcomes analyzed. and migration. Key development issues such as health, The aim of this phase was to investigate the international education, labor, gender, and urbanization are among the as well as upstream national policies and laws that support elements that may affect refugees’ populations. Improving refugee’s health and identified healthcare services provided migrants and all vulnerable people’s health depends for refugees in Iran. on equity, as countries work towards achieving SDGs, The results of literature review helped us to prepare particularly those related to poverty, inequality, hunger an interview guide which we used to conduct 40 semi- and food insecurity, employment and peace.6 structured interviews with purposefully identified key For nearly four decades, the Islamic Republic of informants, i.e. healthcare providers from both PHC and Iran has provided asylum for refugees and is currently rehabilitation service, aiming to investigate the facilitators the host to millions of refugee.13 Iran hosts 979,410 of and barriers to refugees’ access to healthcare services in documented (registered and issued refugee identity Iran. cards [Amayesh]) Afghan refugees (1 May 2019).5 There The interviews were performed between May and are also an estimated 1.5 to 2 million undocumented August 2017 and took place at participants’ workplaces. Afghans in Iran.14 In addition, at least 620 000 Afghans The interviewees were initially informed of the study who hold Afghan passports and Iranian visas also live in objectives, data collection, interview recordings and Iran.15 Most refugees reside in urban settings, with only their role in the study, while we ensured them about less than 3% living in 20 settlements by the UNHCR , data confidentiality. Depending on their willingness, enjoying comprehensive regularization plan.16,17 Further, the interviewees gave their written or verbal consent. about 32 000 Iraqi nationals live as refugee in Iran.18 Iran’s The interviews were digitally recorded and transcribed government has been implementing many initiatives to verbatim. Except for two cases, where the interviewees did improve refugees’ access to health care in the country, not allow recording, all interviews were transcribed by the mostly using domestic resources. Recently, in response researchers. The mean time of the interviews was around to refugees’ health needs and with the implementation 30 minutes. of health transformation plan (HTP), the Iran’s pathway We used the thematic analysis approach to data analysis. toward universal health coverage, new policies have been First, we became familiar with the scope and variety of launched to expand social insurance and improve access the transcripts, and then, one researcher (AT2) began and quality of healthcare services for refugees in Iran.19 to identify the key concepts and issues to set the initial This article aims to illustrate the status of refugees and thematic framework. The identified constructs and themes immigrants’ access to healthcare and main initiatives to were then compared with some relevant theories and improve their health in Iran. experiences to identify the concepts and contradictions, aiming to draw similar patterns and relationships from the Materials and Methods findings. This is a mixed-method study with two consecutive phases. Quantitative Study Phase Qualitative Study Phase Second, we obtained the existing descriptive statistics First, using targeted sampling, we conducted content about refugees who were insured by the Universal Public analysis of selected key documents (See Table 1). The Health Insurance (UPHI) scheme, as well as the number inclusion criteria were the communication of the of refugees with disability who were covered under document by the Supreme Leader, Constitution Law, the community-based rehabilitation (CBR) projects approval by the Islamic Consultative Assembly of Iran, (2013−2017). The source of data was the Ministry of approval by the Ministry of Health and Medical Education Health and Medical Education (MoHME), Iran’s Health and international
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