Blog post written by Matt Oliver Kinsella, an RLI Research Affiliate currently undertaking a PhD with the Human Rights Consortium at the University of London, in collaboration with the International Refugee Rights Initiative (IRRI), Uganda. This piece was originally published on the International Refugee Rights Initiative blog.

In February 2019, Ethiopia issued a National Refugee Proclamation, joining several of its neighbours in the Greater Horn of Africa region[1] in expanding the rights granted to refugees living in the country. Amongst other provisions, the new law allows refugees access to national health services on the same basis as Ethiopian nationals and contains provisions that improve access to education, justice, employment, and other services.  With nearly 900,000 refugeesliving in the country, primarily from South Sudan, Somalia, Eritrea, Sudan and Yemen, this is no small commitment, and the move has been lauded by the United Nations High Commissioner for Refugees (UNHCR) as a welcome expansion of Ethiopia’s long-standing open policies towards receiving and hosting refugees. Indeed, the head of UNHCR went so far as to describe the law as “one of the best refugee laws, not only in Africa, but in the world” during a visit to the country earlier in the year. But given Ethiopia’s general challenges in terms of access to healthcare, more investments are needed – in particular, when it comes to mental health, which continues to receive only limited attention in the region.

A regional trend, an international norm

Ethiopia joins DjiboutiKenya and Uganda in their commitment to strengthen the legal rights of refugees to access healthcare systems and other social services.  Part of the impetus for Ethiopia’s new law is the Comprehensive Refugee Response Framework (CRRF). In the Greater Horn of Africa region, five countries have taken steps to implement the CRRF – Djibouti, Ethiopia, Kenya, Somalia and Uganda – and the region has developed a regional approach via the Intergovernmental Authority on Development (IGAD). The CRRF promotes the integration of refugees into the health and public services of host countries, supported by international actors, to benefit both displaced people and their hosts.

Such policies are important in meeting the right to health for refugees.  This vital human right is well established in international human rights law, being recognised in the Universal Declaration of Human Rights and a number of other important treaties.[2]  The right to health is interpreted broadly as the right of all people “to the enjoyment of the highest attainable standard of physical and mental health” (ICESCR, 1966), and is understood to contain a number of components, such as access to the “underlying determinants of health[3] and “the right to a system of health protection providing equality of opportunity for everyone.”  The right to health must also be applied so that all people – including refugees – can access health services without discrimination.  As UNHCR asserts, under the 1951 Refugee Convention, “refugees should enjoy access to health services equivalent to that of the host population.”[4]

Challenges in practice

While Ethiopia has been progressive in lifting legal restrictions on refugees’ right to access healthcare, major challenges lie ahead.  Partly, this is because healthcare systems in Ethiopia and across the wider region operate with extremely limited funding – itself a reflection of general resource constraints.  For instance, the average annual Current Health Expenditure (CHE) per capita for countries in the region is around 64 USD,[5] with Sudan spending the most at 152 USD and Ethiopia the least at 28 USD per capita.[6]

Moreover, Ethiopia, like many countries in the region, continues to be affected by conflict, unrest and political tensions, both within its own borders and in neighbouring states.  This can make it more difficult to develop and invest in healthcare systems in particular areas, and public services such as healthcare provision can themselves be a factor in creating or sustaining divisions.  For instance, a perception that particular areas or groups are benefitting more than others from services can contribute to friction between displaced people and the host community.  In the Gambella region, which hosts more than half of all refugees in Ethiopia, host communities have felt marginalised and the strain on local services has contributed to tensions with the refugees, leading some humanitarian agencies to deliberately link healthcare programming with peacebuilding activities.

Little attention for mental health

While the right to health expressly includes both physical and mental health, the latter is often neglected. Mental, neurological and substance-use disorders represent around 14% of all health needs worldwide, and despite increasing attention to this area over the past twenty years, mental health is still given low priority by many governments, donors and policy-makers.  Many countries lack appropriate and effective mental health policies, systems and institutions, and it is often the poorest countries which allocate the smallest proportion of their stretched health budgets to mental health.[7]  As the Commission on Global Mental Health and Sustainable Development concluded in their report last year, “the quality of mental health services is routinely worse than the quality of those for physical health. Government investment and development assistance for mental health remain pitifully small.

Addressing mental health for refugees is particularly complex, for a number of reasons.  First, the mental health requirements of refugees and displaced people can be high, characterised by an elevated incidence of specific disorders such as depression, trauma and anxiety.  Conflict, poverty and displacement have enormous impacts on the psychological wellbeing of affected people, with many of the same factors that lead to migration also being key determinants of mental health.[8]  Most displaced people show normal distress reactions and display remarkable resilience in the face of adversity.  Yet, there is evidence of an increased prevalence of mental disorders and people with pre-existing mental health conditions are likely to be particularly adversely affected by conflict and displacement.  Studies suggest that rates of both Post-Traumatic Stress Disorder (PTSD) and depression are high amongst conflict-affected people, with estimates ranging between 15 and 30%.  For children in conflict, the figures become truly alarming, with rates of PTSD at 47%, depression at 43% and anxiety at 27%.[9]  Considering the large number of displaced people in the Horn of Africa, these statistics suggest a very high level of mental health problems in the region.  Responding to these needs is no small task.

Second, in light of how little is spent on healthcare in general, it is perhaps not surprising that the availability of dedicated mental healthcare is very low in the Horn of Africa.  For example, none of the countries in the region has more than three mental health workers per 100,000 people.[10] On average, every one mental health worker serves more than 70,000 people, and they may do so with limited access to training and resources. Mental health workers may also be concentrated in urban centres, further reducing provision of mental health support in rural and peripheral regions – often the places where displaced people live.  National healthcare systems in the region are therefore unlikely to be able to meet the mental health needs of their own populations, much less any additional demand for mental health support for refugees, without significant investment and institutional strengthening.  This means that the mental healthcare needs of refugees in the region will likely continue to be served by humanitarian agencies, such as the International Organisation for Migration (IOM) and Médecins Sans Frontières (MSF).  Yet despite these efforts, it is quite common to hear humanitarian agencies state that their psychosocial services are stretched in the face of mounting needs – as MSF did earlier this year.

Third, even where mental health services are available, there can be barriers which prevent refugees from accessing them.  For instance, healthcare facilities may be located far from the areas where refugees live, so that distance, cost, and sometimes insecurity, make it difficult to travel there. In some cases, there may be a lack of awareness that services are available at all.  Likewise, refugees and displaced people are not a homogenous group and there are likely to be people with specific vulnerabilities and needs that affect their ability to access mental healthcare, including women, children, the elderly, ethnic and linguistic minorities, and those with pre-existing mental or physical disabilities. Ensuring services, whether delivered by governments or humanitarian actors, are accessible to these groups is vital to ensuring they are delivered equitably and without discrimination. There is also a strong stigma towards mental health issues in the Horn of Africa, with cultural expectations discouraging or preventing people from seeking and accessing support.  For refugees, this can be exacerbated by cultural and linguistic differences with the host communities, such as not speaking the same language as the healthcare provider.  As such, ensuring that services are culturally appropriate, and working to reduce the barriers and stigma that reduce uptake of services, are significant challenges.

No health without mental health?

In light of these issues, and given that the Horn of Africa is hosting around four million refugees and asylum seekers, those countries which are promoting and improving access to healthcare for displaced people as Ethiopia did recently, are making an important gesture of solidarity.  Hopefully, with time, other states in the region will follow suit.  However, it is important that mental health is recognised as a vital part of the right to health, both for citizens and for refugees in the region, and that governments and international actors invest in the development of healthcare systems able to meet these needs.  This will mean mobilising political will and funding to help alleviate the enormous, yet invisible burden of psychological suffering among displaced people in the region.  There remains a long way to go before the slogan “no health without mental health” becomes a reality.

[1] The wider Horn of Africa region is defined in this article as including the eight member states of the Intergovernmental Authority on Development (IGAD): Djibouti, Eritrea, Ethiopia, Kenya, Somalia, South Sudan, Sudan and Uganda.

[2] Including the International Covenant on Economic, Social and Cultural Rights (ICESCR), the Constitution of the World Health Organisation and the African Charter on Human and Peoples’ Rights (the Banjul Charter).

[3] This might include for instance, clean water and sanitation, safe food, nutrition, housing, and gender equality.

[4] UNHCR’s view is expressly rejected by some states, who impose limits on equal access to healthcare for refugees.

[5] Average based on 2016 data from WHO for the countries of Djibouti, Kenya, Ethiopia, Eritrea, Sudan and Uganda.  Data for Somalia and South Sudan not available.

[6] A comparison with healthcare expenditures among the rich countries of the OECD highlights extraordinary global inequalities: none of the OECD members spends less than 1,000 USD per capita on healthcare, while the average is above 3,700 USD.  Not only is this latter figure more than fifty times the average for the countries of the Horn of Africa, it even exceeds the per capita Gross Domestic Product (GDP) of every country in the region.

[7] Minas, H, “Human Security, Complexity, and Mental Health System Development,” in Patel, V., Minas, H., Cohen, A., Prince, M., (eds)., Global Mental Health – Principles and Practice. Oxford University Press: Oxford, 2014, p.157.

[8] Ibid, p.148.

[9] Tol, W. A.; Bastin, P.; Jordans, M. J. D.; Minas, H.; Souza, R.; Weissbacker, I.; Van Ommeren, M.; “Mental Health and Psychosocial Support in Humanitarian Settings, “In Patel, V., Minas, H., Cohen, A., Prince, M., (eds). Global Mental Health – Principles and Practice. Oxford University Press: Oxford, 2014, p. 384

[10] Total mental health workers per 100,000 population as reported in WHO Mental Health ATLAS Member State Profiles, 2017: Eritrea 2.48; Ethiopia 1.74; Kenya 0.19; South Sudan 0.52; Sudan 0.64; Uganda 2.96.  Data for Djibouti and Somalia not available.  Figures include all psychiatrists, psychologists, mental health nurses, social workers, etc.

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