UNHCR aims to ensure that all refugees are able to fulfil their rights to access essential public health services. Its public health programmes are guided by the Global Strategy for Public Health (GSPH) 2014- 2018 whose vision is to ensure that all refugees are able to enjoy their rights to access four broad sub-sectors of public health services: a) primary and secondary health care, b) HIV prevention, protection, care and treatment, and reproductive health services, c) food security and nutrition, and d) water, sanitation and hygiene (WASH) services.

UNHCR and its partners provide significant public health services in 51 countries reaching about 10.5 million refugees. Where health service provision is integrated into national health systems, data and information is obtained through the national health information systems and surveys (health access and utilization surveys done by UNHCR for refugees in non camp/urban settings, or national demographic and health surveys). UNHCR has an Integrated Refugee Health Information System (IRHIS), which is used to monitor refugee health status where services are provided specifically for refugees.

UNHCR used IRHIS to collect and analyze health information in 18 countries, with a population of 4,575,052 under surveillance. In 149 out of 170 (87.6%) refugee settlements under-five mortality was within acceptable standards (< 1.5 under-five deaths per 1,000 under-five population). Globally, the weighted average under-five mortality rate was maintained at 0.3 per 1000 under-five per month, an improvement from 2017 (0.4 per 1000 under-five population per month). 40% of all deaths reported were children under the age of five years. The leading causes of under-five deaths were neonatal conditions (24.7%), malaria (15.9%), lower respiratory tract infections (14.8%), acute malnutrition (7.2%) and watery diarrhea (2.1%). Globally, the weighted average crude mortality rate for the same period was 0.13 deaths per 1,000 population per month, which is within the acceptable standards (< 0.75 deaths per 1,000 population per month).

Despite continued influxes of refugees from Myanmar, South Sudan and the Democratic Republic of Congo into neighbouring countries, mortality rates were maintained below the emergency threshold in most settlements. In coordination with partners, UNHCR’s public health teams responded to various outbreaks in refugee settings including diphtheria and suspected measles in Bangladesh, cholera and viral hemorrhagic fever in Kenya and Uganda, and scurvy in Kenya.

UNHCR and its partners reported 7,575,193 consultations at the health facilities, 92.3 % of them being diagnosed with communicable diseases, 3.9% were non-communicable diseases, 1.9% were mental health conditions and 1.9% injuries cases. The top five causes of morbidity were upper respiratory tract infections (24.7%), malaria (22.1%), lower respiratory tract infections (11.4%), skin diseases (6.7%) and watery diarrhea (5.7%). Childhood diseases had a similar profile, except that acute malnutrition (4%) continued to be an additional major cause of morbidity among this age group.

In line with UNHCR’s Global Public Health Strategy efforts continued throughout 2018 to promote and facilitate access to comprehensive reproductive health services including maternal and newborn health and family planning.

In 2018, 81.3% of country operations under surveillance achieved the standard of at least 90% of deliveries occurring in health facilities (an increase from 75% of operations in 2015). With regards to complete antenatal care (ANC), 25% of operations reached more than 90% coverage of four or more antenatal visits (a slight improvement from 2017 which was 22.2%) and only 31.3% reached >90% coverage of three postnatal visits within six weeks of delivery (cf. 26% in 2015). Much sensitization has to be done to empower pregnant women and their partners to attend ANC and PNC. Strengthening links between the community and the health facility can increase utilisation of services, including ANC, and impact maternal and neonatal mortality as well as stillbirths.

Although progress has been made on skilled attendance at delivery, there are still significant problems in quality of care including respectful maternity care. Maternal deaths are reported and audited in refugee operations. In 2018, 100 percent of maternal deaths were audited within 48 hours. Of audited maternal deaths which occurred in six countries in East Africa 94% of deaths occurred in health facilities with 59% occurring in the post partum period. Haemorrhage (often associated with uterine rupture) was the leading cause of maternal death (44%), followed by embolism (19%), and sepsis or infections (18%). Third delay factors were significant contributors to maternal mortality highlighting the need to strengthen comprehensive emergency obstetric care services including referral.

Globally, 24.7 percent of under-five deaths were neonatal deaths. UNHCR continued efforts to improve quality and coverage of essential neonatal care especially in countries with the highest mortality rates. In 2018, UNHCR started to implement the “Saving Maternal and Newborn Lives” project with funding from the Bill and Melinda Gates Foundation in Cameroon, Niger, and Chad. By expanding coverage of key low-cost, high-impact maternal and newborn interventions, the project is improving the quality of care provided to refugees through a multi-pronged approach that includes: additional medications and supplies; infrastructure improvements for health facilities (such as the installation of solar panels for maternity departments and rickshaw ambulances for women in labour); improving thermal care including through kangaroo mother care, and capacity building of health workers including community health workers in home visit for the newborn.

UNHCR is also working with partners to improve contraceptive services in refugee sites. Although the uptake of contraception is improving, there are still significant gaps in provider attitudes, method-mix, stock outs and disempowerment of women affecting health seeking behaviour.

Adolescent pregnancy and its consequences represent a major public health issue with enormous social implications, in many countries of the world. UNHCR and partners continued to try to increase access and utilisation of services in this age group including through specific outreach in eastern Chad, Burundi and Algeria. From 2014 to 2017, there has been a reduction in the proportion of deliveries among under 18s from 6.4% in 2014 to 4.3% in 2018.

A survey on the UNAIDS 90 90 90 targets was conducted in 22 UNHCR refugee sites in 14 country operations from May to December 2018, assessing HIV testing and treatment cascades. Findings showed that 37% of the sites achieved 90% of estimated People living with HIV (PLHIV) knowing their status; while 77% of operations achieved 90% PLHIV who know their status being linked to care and on HIV treatment; and only 24% of site operations achieved 90% of PLHIV on ART being virally suppressed. In 2019, UNHCR will reinforce HIV counselling and testing, scaling up testing approaches that help increase uptake among people who do not typically use healthcare services and amongst those at highest risk of infection and more investment in support to those on treatment.

During 2018, UNHCR provided support to ensure the continuation of HIV services for refugees and other displaced populations affected by humanitarian emergencies in approximately 50 UNHCR operations. Across its operations, in 2018 UNHCR provided HIV counselling and testing, including testing pregnant women, to nearly 500,000 people of concern to UNHCR. In camp-based settings under surveillance there were 13,422 refugees on ART – over a four-fold increase since 2014.

UNHCR supports services for the clinical management of rape and other forms of sexual violence in humanitarian emergencies. This includes the provision of post-exposure prophylaxis, emergency contraception and prophylaxis for sexually transmitted infections for survivors, psychosocial support and mental health services, and referral for legal and protection services. Across UNHCR’s operations, in 2018 Sexual and Gender- Based Violence (SGBV) services (including referral for clinical services, mental health and psychosocial support, community-based protection) were provided to over 27,000 refugees and other displaced populations. In Burundi, Bangladesh, Thailand and Nepal less than 50% of survivors of sexual violence received PEP within 72 hours. Late presentation of sexual violence survivors is one of the major factors affecting provision of health services.

Improving the prevention of under-nutrition and micronutrient deficiencies in addition to managing the existing cases of malnutrition as best as possible, is a priority for UNHCR. The new nutrition and food security road map, developed in late 2017 and currently undergoing external review and harmonisation with new guidance and tools (Sphere, SDGs, new WHO/UNICEF thresholds etc.) aims at providing guidance on how to effect positive change for improvement in nutrition status in refugee populations. Promoting and supporting adequate infant and young child feeding (IYCF), remains a major effort in improving nutrition as does working in synergy with other sectors. In line with this, the Infant and Young Child Friendly Framework, which aims to bring multiple sectors together around the theme of improving young child and infant survival and improving growth and development, was rolled out further in East Africa and during the emergency in Bangladesh in 2017 and through 2018. Increasing collaboration with UN agencies and other partners in including refugees into treatment and prevention programmes has been a major drive for country operations through 2018, although there is still a great deal of ground to be covered in harmonising different valets of the continuum of care, there has been progress in this area.

Global acute malnutrition (GAM) is one of the main nutrition indicators tracked for the purposes of determining needs and for monitoring health status. In 2018, 33/74 sites (44.6%) met the GAM standards of < 10%, whilst 8/74 (10.8%) were above the emergency threshold of ≥ 15%. These results represent an improved situation regarding the proportion of sites above the emergency threshold compared to 2017 where this was 21.4%, but a large decrease in proportion of sites meeting GAM targets in 2018 compared to 2017. The 2018 data falls short of the target of 77% of the surveyed sites recording GAM <10%. The proportion of sites in 2018 in an emergency situation was far higher in 2018 compared to in 2017 at 35% compared to 16% in 2017. 2018 also saw many new sites included such as those from Sudan. Sites where GAM is ≥ 15% were recorded in 6 locations in Gambella, Ethiopia and in Sudan.

Comparing the 2018 results to previous years, improvements in GAM were noted in 22/70 (31.4%) sites in Bangladesh, Chad, Ethiopia, Kenya, South Sudan and Sudan. Deterioration in GAM was noted in only 1/70 (1.4%) sites in a camp receiving new refugees in Tanzania.

In order to have a more comprehensive understanding of the longer term nutrition status of refugee children, and a three-dimensional vision of nutritional status, UNHCR also considers stunting and anaemia to be of critical importance. Stunting amongst children 6 – 59 months of age met the standard of <20% in 23/74 sites (31.1%) whereas just as many sites 22/74 (29.7%) registered stunting prevalence above the critical level of ≥40%. The proportion of sites meeting stunting standards has improved slightly from 2017 to the end of 2018. The majority of sites, for which we have previous data for comparative purposes, show that the prevalence of stunting is stable or persistently high with no significant change (39/70 sites 55.7%). Improvement in stunting was noted in 18/70 sites (25.7%) in Bangladesh, Chad, Ethiopia, Kenya, South Sudan, Sudan and Tanzania. Deterioration of stunting was observed in a much greater proportion of sites than in previous years 13/70 sites (18.6%) compared to 5.7% in 2017 in Ethiopia, Kenya, Nepal, Niger and South Sudan.

Anaemia in children 6 – 59 months old is used as a measure of iron deficiency and general micronutrient status. Only 3/68[1] (4.4%) met the standard of <20%, whilst 32/68 (47.1%) were under the critical level of < 40%. This means that over half of the sites exhibited anaemia levels of the critical ≥ 40% threshold 36/68 sites (52.9%). The majority of sites, for which we have previous data for comparative purposes, show that the prevalence of anaemia is stable but persistently high (29/64 sites 45.3%). However it is concerning that in 8/64 sites (12.5%) anaemia is significantly higher than previous surveys, although this is a lower proportion than in 2017 the trend in sites in some countries (Bangladesh, Ethiopia, Kenya, Nepal and Tanzania) is still concerning.

Although these nutrition survey results show that the indicators of long term nutrition status of anaemia and stunting are of particular concern amongst refugee children, with an alarming sense of deterioration in stunting, it is worth noting that there have been statistically significant improvements in stunting in 18/70 (25.7%) of the sites and in anaemia in 26/64 sites (40.6%).

Of the 65 sites where exclusive breastfeeding was reported, 63.1% (41/65) met the UNHCR target of ≥70% of children 0-5 months who received only breastmilk during the previous day. This is quite an improvement compared to the levels observed in 2015 and 2016 (53.1% and 54.6% respectively) and a stable situation compared to 2017 where the proportion was 63.9%. This is an encouraging improvement since 2015 and previously and links in to the work that field teams and partners have been doing on infant and young child feeding.

The indicator of GAM is very sensitive to changes in the environment, living conditions, health care access and food security situation, displacement and as such can fluctuate year on year depending on the context. This makes direct comparisons challenging if there have been major changes in context. It is, however, an extremely useful indicator for measuring the severity of a situation and planning for programmes in consequence.

Deteriorating circumstances in terms of food and non-food assistance in many operations are clearly having negative consequences on populations’ ability to cope, a late term indicator of this being deterioration in GAM prevalence. Once this happens, populations have often exhausted their normal coping strategies and are forced to resort to potentially harmful or risky practices to meet their basic and essential needs. This obviously sets populations back and it takes a lot of time to recover lost assets and regain an acceptable nutrition level. Although there were no surveys conducted in Eastern Chad in 2018, the camps further north are an example of where GAM prevalence has dramatically deteriotated since 2015.

While the causes of malnutrition vary, food insecurity is a significant factor. Many UNHCR operations have suffered increasing cuts to food assistance over the past few years and there is an increasing trend in the number of countries afected. Cuts to food assistance are particularly worrying as refugees often have limited other legal options to increase their income or access to food. Many resort to potentially harmful coping strategies to meet their basic needs which can increase protection risks such as pulling children out of school to work and selling sex. UNHCR continues to monitor food security of refugees through nutrition surveys. UNHCR and the World Food Programme continue to jointly fundraise for operations of concern including Cameroon, Chad, Ethiopia and Mauritania. Meanwhile the Agencies are collaborating to target (and prioritize) those most in need recognizing that in some operations, needs are not being met.

In conclusion, UNHCR remains extremely concerned about the continued high levels of anaemia and persistently high levels of stunting and GAM in many refugee operations. UNHCR is working on several fronts to address this including 1) the distribution of specialized nutritious products in key operations coupled with relevant multisectoral programming (e.g. WASH, MHPSS, malaria prevention and treatment, deworming, improved IYCF and maternal and child heath), 2) promotion of the IYCF framework, 3) advocacy for well-balanced food rations where provided in-kind (including the provision of fortified blended foods), 4) improving the methods of data collection and reporting to inform improved decision making and advocacy.

In line with the 2014–2018 Global Public Health Strategy and working towards SDGs, UNHCR is ensuring that refugees have access to safe water of sufficient quality and quantity and access to adequate and equitable sanitation and hygiene services, both at home and in public spaces including market places, schools, and health care facilities.

Access to adequate and safe WASH services contributes to UNHCR’s health objectives: reducing morbidity and mortality. In addition, WASH services are a prerequisite to ensuring UNHCR’s core protection mandate, as these services are necessary for a safe and dignified life. In alignment with the “participation revolution” of the Grand Bargain and UNHCR’s Accountability to affected population, WASH interventions are designed using participatory approaches. With the roll out of the Global Compact for Refugees, UNHCR is emphasizing WASH solutions which ease pressure on host communities and utilise robust technologies that reduce long term operations and maintenance costs and environmental impact.

UNHCR faces many challenges including aging WASH infrastructure in camps and settlements, limited capacity of local government in protracted situations, and scarce water resources in many areas. This is combined with budgetary constraints in many operations. In response to these challenges, UNHCR works with implementing and operating partners to maximize efficiency through data driven decision making. In 2018, UNHCR continued to roll out the WASH monitoring information system (WASH MIS) which has household service level data as well as community level asset registers. UNHCR performs trainings and capacity building workshops with staff and partners in how to collect, analyse, and utilise data from the WASH MIS.

The average litres per person per day globally was at 20.2 litres. In 2018 a total of 31 water supply systems were rehabilitated and upgraded to solar or solar hybrid. The average number of persons per latrine was 22. No change could be observed compared to 2017. This exceeds the post-emergency standard of 20 ppl and the recommendation to provide latrine access at household level to improve hygiene and mitigate protection risks. In 2018, UNHCR continued to promote “waste to value” sanitation technologies, building additional urine diversion dry toilets in Ethiopia. In total there are 3,500 toilets serving 17,000 refugees, reducing the contamination of soil and groundwater and producing a soil conditioning fertiliser.

Country Reports

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UNHCR gratefully acknowledges the support of our partners in the publication of these reports.


iRHIS aims to strengthen evidence based decision-making in humanitarian programmes. It integrates a range of information management tools that can be used to assess, monitor and evaluate humanitarian interventions across a range of sectors and operational settings. The tools have been developed by the UNHCR but are freely available for partners to use in the field.

For more information please visit the iRHIS website https://his.unhcr.org or write to HQHIS@unhcr.org