As Lebanon strains to contain COVID-19, it is not clear which governmental public health policies apply to refugees. The government announced free testing for coronavirus in the public Rafiq Hariri University Hospital in Beirut but has not mentioned if refugees are eligible.

Lebanon’s coronavirus containment strategy is based on self-reporting and, given incidents of forced deportation and harassment of Syrian refugees from both the authorities and local communities, it is certainly less likely refugees would present themselves to the health authorities for fear of deportation.

Despite agreeing a Lebanon Crisis Response Plan with the UN for refugees, different ministries were left to implement it without coordination, just as Lebanese politicians from all sides started trying to rally popular support for ridding Lebanon from refugees - in particular from Syria, who Lebanese leaders say are causing a strain on the country’s already weak infrastructure.

This finger pointing is coupled with the leaders’ own complete disregard for the rampant corruption and lack of accountability within Lebanon’s political class, which contribute to the weakening of the country’s infrastructure.

For refugees who do find themselves back in Syria, there are different challenges according to which area they are in. In the north-east, the WHO and international NGOs (INGOs) negotiate with both Kurdish authorities as well as the government - each presenting its own hurdles.

Kurdish authorities in northeast Syria have closed the Semalka border with Iraqi Kurdistan, posing a serious dilemma for INGOs offering services in north-east Syria but concerned about their staff safety whose movement is now curtailed.

The government of Syria has stipulated all emergency response must go through its ministries. But this limits what the WHO can do in the country and gives Syrian authorities the ability to block ‘cross-line aid’ which goes from government-controlled to non-government areas.

Despite reports that doctors raised the alarm about suspected cases well before patient zero was confirmed, the government appears to be either covering up the actual extent of the spread of COVID-19 or failing to respond. Some limited testing kits have arrived but testing has barely started.

The WHO’s Syria plan is divided into three regions (north-west, north-east, and areas under government control). But concerns remain as to how workable such a decentralized plan is because of the government’s practices. In January, the UN Security Council did not renew the cross-border response resolution for the Yaroubiye border crossing between Syria and Iraq that the WHO was using to send medical supplies into north-east Syria.

Syrian authorities do not permit recently authorized ‘cross-line’ responders to engage with non-government authorities in areas outside regime control. This essentially voids the authorization to work cross-line as it is practically impossible to implement programs. The WHO has sought approval from the Syrian Ministry of Foreign Affairs to move medical supplies by land to north-east Syria.

While promising facilitation, the Ministry’s reply comes with conditions of seeking detailed approval for every shipment. When Eastern Ghouta was under siege, similar conditions led to certain supplies being removed from UN/ICRC convoys to Eastern Ghouta, and there is no guarantee this will not happen again.

Due to lack of capacity in north-east Syria, coronavirus tests conducted by the WHO there must be processed through the Central Public Health Laboratory in Damascus. Samples are transported twice a week from Qamishli to Damascus but no results were ever received from Damascus for those tests.

While the WHO is able to coordinate access to north-west Syria with the Turkish authorities, the prospective coronavirus testing capacity in the Idlib region is low – despite claims that thousands of kits are arriving, a lack of resource on the ground means potentially only 20 tests per day could be done in an area inhabited by an estimated three million people.

Following the recently announced ceasefire in the area, many internally displaced people are returning from the Turkish border to their homes in the north-west, but such mass movement increases the risk of coronavirus spreading. People also continue to move between Syria, Iraq, Turkey and Lebanon, posing a challenge to the WHO’s COVID-19 response in the Levant, as the WHO has distinct response plans for each country in the region and it is difficult to coordinate across these plans.

Challenges face refugees even if they head towards Europe due to the potential for conflation between migration control and coronavirus outbreak control. Aurelie Ponthieu, Coordinator for Forced Migration at Médecins Sans Frontières (MSF) says there is a risk some countries could use COVID-19 to impose draconian measures towards asylum seekers.

The crisis has also put a halt to search and rescue operations in the Mediterranean because European countries are not allowing boats carrying migrants to disembark under the pretext of limiting the spread of coronavirus. And for migrants who already made it - such as in Greece - they are now being put in collective quarantines in asylum centers, often with poor medical facilities.

Ponthieu also reports that migrants being quarantined on overcrowded navy ships docked in Greek ports, making social distancing impossible. And she is concerned the Greek authorities are imposing a curfew on asylum seekers but not on the local population.

UNHCR is stressing that people’s right of asylum must not be overruled by concerns about the spread of coronavirus, while local and international NGOs across the Levant are trying to coordinate their advocacy on lifting restrictions on freedom of movement for humanitarian workers and on other policies and practices by authorities in the region which are adversely affecting refugee and other vulnerable communities.

The international community must not lose sight of the impact of the crisis on refugees and migrants. It is not enough simply to supply humanitarian and medical assistance without paying attention to the policies and practices of the different authorities who have direct control over the fate of vulnerable communities.

The author would like to thank Aurelie Ponthieu and the two INGO field workers who all agreed to be interviewed to inform this analysis piece.

About 90 per cent of refugees living in camps have no access to electricity and many lack any form of lighting at night, says a Chatham House report for the Moving Energy Initiative. Energy poverty in refugee settlements is not on the radar of international initiatives and humanitarian agencies are ill-equipped to deal with the scale of need. 

Heat Light and Power for Refugees: Saving Lives, Reducing Costs zooms in on the energy needs of refugees and displaced people worldwide, and presents the first ever estimates of the volume and costs of what they use.

'The problem goes beyond electricity. 80 per cent of those in camps rely on firewood for cooking and, as a result, we estimate that some 20,000 people die prematurely each year due to the pollution from indoor fires. Exposure to extremes of cold and heat are also killers for people living in flimsy, temporary shelter,' says Glada Lahn, senior research fellow at Chatham House. 'The current lack of provision for energy undermines the fundamental aims of humanitarian assistance,' she adds.

There are nearly 60 million forcibly displaced people in the world, and they pay staggering costs for energy. The 83,277 households living in Dadaab in Kenya, the world’s largest refugee settlement, spent an estimated $6.2 million on firewood last year, which accounts for approximately 24 per cent of their overall household income. (The average UK household spent 4 per cent of its income on energy in 2011.) In Uganda, almost half of refugee households surveyed by the UNHCR skip meals because they do not have enough fuel to cook with.

'The imperative is to find humane, creative and cost-effective ways to respond to the needs of so many individuals, most of whom are women and children.  Improving access to clean, safe and sustainable energy offers a promising way forward,' says Kofi Annan in the report’s foreword.

The report calls for an overhaul in the way that heat, light and power are delivered in humanitarian crises. It makes the case for new partnerships between humanitarian agencies and private providers to increase clean energy access in refugee settlements. Investment in energy infrastructure will also benefit host communities in some of the world’s poorest countries.

'As refugee households spend approximately $2.1 billion on energy each year, developing local markets for energy services could be part of a mix of solutions,' adds Lahn. 'Using green, culturally appropriate technologies could save lives, reduce CO2 emissions by 11 million tonnes per year and radically improve living standards. Introducing even the most basic solutions, such as improved cookstoves and basic solar lanterns, could save $323 million a year in fuel costs.' 

Other findings include:

• Rape and violence against women is common in many unlit camps. Only 4 per cent of women and girls in households in the Goudoubo camp in Burkina Faso would go out after dark due to the lack of streetlights.
• Wood equalling around 49,000 football pitches worth of forest (64,700 acres) is burned by displaced families living in camps each year, mainly in countries suffering severe deforestation, because they have no alternative sources of energy.
• Firewood consumption emits nearly twice as much CO2 as liquid petroleum gas and produces little energy in comparison to its carbon intensity.

International Development Minister Grant Shapps said:

‘Across sub-Saharan Africa, hundreds of millions of people still do not have access to electricity. Women and girls are at risk of violence after dark, families are forced to inhale toxic kerosene fumes, and energy remains unaffordable for many.

‘With the technology in place and investors coming on board, the time to act is now. The UK's Energy Africa campaign is already kick-starting a solar revolution across the continent.

‘Supporting the Moving Energy Initiative is another way Britain can help boost access to clean, reliable and affordable energy. This will transform people’s lives and help achieve the UN’s goal of universal energy access by 2030.’

European leaders need to implement common European solutions to the refugee crisis. Only joint solutions can credibly and effectively reduce the growing human suffering and social and political turmoil.

The refugee crisis poses a serious challenge, both to the welfare of refugees and to European societies. In 2015, more than 1.5 million migrants crossed into the European Union. From Italy to Poland, and from Greece to Germany, countries face immense challenges in responding to requests for humanitarian aid, asylum, and integration. The associated integration challenges in housing, language, work and welfare are already formidable. Failing to manage them properly poses serious threats to social cohesion and political stability.

European countries have had sufficient time to analyse and assess the long-standing challenges which created the current crisis. Now it is time to act – not individually and at the expense of others, but jointly and in a spirit of European solidarity. This is why Vision Europe – a partnership between seven leading think tanks and foundations in Europe – will in 2016 focus its efforts on providing practical solutions to the current refugee crisis, and its root causes. We, the seven signatories, writing in an individual capacity, see an urgent need for a common European approach, to compliment local and national efforts.

At present, there is no consensus among member states on how to respond to the crisis, neither on the objectives to be achieved or the methods to be used.  But disagreements on substance must be overcome now. Building on current discussions, we propose a comprehensive agenda at the EU level, with five major dimensions.

First, it is important to control the EU’s external borders so that only refugees fleeing war and persecution, who have a legitimate right to seek asylum, can enter and potentially remain in the EU. The porous nature of the EU’s external borders has meant an unacceptable loss of control in the eyes of many EU citizens and has raised false hopes for irregular migrants trying to enter the Union. The control of the borders of the Schengen Area should be a collective effort of the EU and all Member States, coordinated by European Institutions with professional staff and with financial support provided to Member States at the EU’s periphery. Regaining control of the EU’s external borders is essential to preserve open internal borders.

Second, beyond implementing the already agreed upon relocation of 160,000 refugees from Greece and Italy, the EU should develop a system which distributes a much larger number of refugees across the Union, directly from the hotspots in the EU and the neighbouring counties such as Turkey, Jordan or Lebanon. Member States not willing to host refugees themselves could choose to make a primarily financial contribution to the system. A Migration Solidarity Fund should be created to manage this compensatory system. Turkey’s efforts to reduce the crossings in the Aegean Sea should be matched by a willingness among EU Member States to take in refugees in an orderly manner. The Conclusions from the European Council seem to move in the right direction in this regard.

The third measure should be to improve, standardize and speed up the processes to determine asylum applications. The sooner refugees know whether they can stay, the more energy can be invested in their integration into host countries’ societies and in family reunions. The sooner a decision is taken, the fairer and more feasible it is to send back those whose requests are refused in full respect of international law and human rights. And EU members cannot afford to have vastly different standards in granting asylum status.  Under international law, there can be no limit set on the number of those eligible to request asylum.

As a fourth measure, we recommend expanding efforts at the EU level to improve the living conditions of refugees staying in countries close to their countries of origin. Many refugees want to return to their homes as soon as the situation becomes safe again. They should not be driven to start the hazardous journey to the European Union only because of unbearable conditions in the countries where they are currently sheltering.

Last but not least, the EU and its Member States should work vigorously towards ending the violent conflicts that are the principal causes of the crisis. Europe must invest heavily in the Syria peace process, in particular. The EU must also raise the ambition and resources of its Neighbourhood Policy, with a focus on helping to stabilise the region and on improving the living conditions and economic opportunities in the Southern neighbourhood.

But action is also required at the national level, especially in the EU countries where significant numbers of refugees have received or are expected to receive asylum. The distribution of refugees across municipalities and regions should be fair and should come with adequate support and resources from the national level, emphasising education and language training. The recognition of professional competences and support to enter the labour market should be available at a very early stage. Within our societies, we need a dialogue between refugees and the host society. It should be made clear that respect for human rights, democratic values and cultural norms is indispensable for a prolonged stay in the respective European host country.

Coming from seven European countries, with different national policies and approaches to the refugee crisis, the foundations and think tanks of Vision Europe are working together to advance new ideas, to frame an informed debate and to emphasize the benefits of common European solutions to Europe-wide problems. Europe is strong enough to manage the migration challenges, but only if political leaders act now, act responsibly and use the resources at their disposal, including support for civil society working in this area. We must not leave the public space to populists and nationalists offering false promises. Only a European solution will be workable and sustainable.

Aart de Geus
Chairman and Chief Executive Officer, Bertelsmann Stiftung, Germany

Artur Santos Silva
President, Fundação Calouste Gulbenkian, Portugal

Guntram Wolff
Director, Bruegel, Belgium

Mikko Kosonen
President, Finnish Innovation Fund Sitra, Finland

Piero Gastaldo
Secretary General, Compagnia di San Paolo, Italy

Robin Niblett
Director, Chatham House, United Kingdom

Yves Bertoncini
Director, Jacques Delors Institute, France

Refugees in Burkina Faso, Kenya and Jordan will benefit from greater access to affordable, clean energy for domestic use and to power ‘microbusinesses’, following a grant scheme from the Moving Energy Initiative which launches today.

The Moving Energy Initiative is supporting projects ranging from a solar-powered ICT hub in Kenya’s Kakuma camp and vegetable growing zones watered by solar-powered pumps in Burkina Faso’s Goudoubo camp, to reliable energy generation for north Jordan’s Al Mafraq hospital where Syrian refuges and local residents access health care.

In total, four projects will be implemented over the next 12 months, with all involving training for refugees and local staff to use and maintain the clean energy technologies. They aim to deliver tangible reductions in CO2 emissions whilst increasing access to vital services, saving costs and providing livelihood opportunities for local communities and refugees. The projects are also expected to fuel entrepreneurship, opening up the potential for setting up businesses, small shops and restaurants which can expand beyond this initial grant.    

Project partners were chosen through an open and competitive process kicked off in February 2017 in Burkina Faso, Kenya and Jordan. Bidders were asked to demonstrate their ability to provide solutions that reduce fossil fuel consumption and increase access to energy in camps. The successful projects were chosen on the basis of the applicants’ ability to innovate in a humanitarian setting, as well as their track record and their approach to sustainability.

Find out more about why these projects are needed and the impact they aim to have by watching the video:

Check out the Moving Energy Initiative website for more information.

Keep updated on the progress of these projects as they develop by following us on Twitter @CH_EERD. 

Related content

Moving Energy Initiative: Sustainable Energy for Refugees and Displaced People

The Moving Energy Initiative Expert Workshop

Toolkits for the Moving Energy Initiative

Early last month NATO launched a new maritime security mission, ostensibly to prevent people smuggling across the Aegean Sea. This mission, however, was not originally a reaction to the humanitarian catastrophe at sea. Instead, it was a response to growing Russian assertiveness.

A maritime patrol unit was first discussed in the North Atlantic Council in December 2015, when the Alliance agreed to provide a ‘tailored package of assurances’ to Ankara in a period of heightened tensions after Turkey shot down a Russian jet. The package included measures such as early reconnaissance planes (AWACS), air policing, naval presence in the Eastern Mediterranean, provisions for Maritime Patrol Aircrafts (MPA) and Intelligence, Surveillance & Reconnaissance (ISR), and port visits. None of the discussion at the time linked it with protecting refugees. Now framing this decision in that light creates a new mission for NATO’s Maritime Command (MARCOM), a mission that it has never conducted before.

Neither NATO’s founding documents or the most recent 2010 Strategic Concept provide for this type of mission, and NATO units are not trained to carry out an actual rescue mission. Protecting strategic assets and goods, such as oil tankers, escorting naval vessels providing food into conflict zones, deterring piracy and monitoring the Mediterranean for terrorist activity have been the main priorities for MARCOM in the post-Cold War period. These activities and maritime exercises were aimed at defence against non-state actors.

The positioning of NATO’s maritime fleet in the Aegean Sea to save refugees, however, has the potential to be used as a deterrent against Russia’s Anti Access/Anti-Denial capacity in the eastern Mediterranean. Russia, meanwhile, has increased its naval presence at the Tartus naval base in Syria, which it has used to support its air campaigns in Syria. This level of reciprocated military build-up is hard to sustain in the long-run.   

NATO−Russia tensions

Over the past few years, Russia’s assertive policies – its multiple military operations, the continuing modernization of its army and ‘simulated attacks’ such as the one in 2013 that tested Sweden’s air defence response mechanisms − have increasingly worried the Alliance and its partners. Clashing interests over Syria’s future and Russia’s attacks against the Western-supported rebel groups have also served to increase tensions between NATO member states and Russia. Recent analysis logged 60 dangerous incidents in the Euro-Atlantic area between Russia and NATO counties in the period between March 2014 and March 2015. NATO’s preparedness has been severely tested by these incidents, and has led the alliance to strengthen its presence on Europe’s southern flank.

Such increased tensions could create a situation whereby accidents and miscalculations lead to escalation. NATO forces and Russia are already engaged in further force posturing − the decision to accelerate Montenegro’s accession to NATO and the increased conduct of wartime exercises, such as NATO’s search for submarines in open waters (Dynamic Manta 2016), reconnaissance operations (Cold Operation 16) or Russia’s simulated exercises, for instance – which could undermine global stability. Three weeks after the Russian jet was shot down, a Russian patrol ship fired warning shots at a Turkish vessel to attract attention and avoid a collision. This event did not escalate but given the heightened tensions, similar events may spiral out of control.  

The tentative cease-fire in Syria is a confidence building measure that could normalize and rebuild relations. But further steps should be taken to establish political dialogue, open up the channels for potential meetings at the NATO−Russia Council, and increase transparency and risk mitigation in exercises and activities. The longer both sides wait, the more likely a confrontation will be.

To comment on this article, please contact Chatham House Feedback

England and Australia are considered standard-bearers of universal access to health services, with the former’s National Health Service (NHS) recognized as a global brand and the latter’s Medicare seen as a leader in the Asia-Pacific region. However, through the exclusion of migrant and refugee groups, each is failing to deliver true universality in their health services. These exclusions breach both their own national policies and of international commitments they have made.

While the marginalization of mobile populations is not a new phenomenon, in recent years there has been a global increase in anti-migrant rhetoric, and such health care exclusions reflect a global trend in which undocumented migrants, refugees and asylum seekers are denied rights.

They are also increasingly excluded in the interpretation of phrases such as ‘leave no one behind’ and ‘universal health coverage’, commonly used by UN bodies and member states, despite explicit language in UN declarations that commits countries to include mobile groups.

Giving all people – including undocumented migrants and asylum seekers – access to health care is essential not just for the health of the migrant groups but also the public health of the populations that host them. In a world with almost one billion people on the move, failing to take account of such mobility leaves services ill-equipped and will result in missed early and preventative treatment, an increased burden on services and a susceptibility to the spread of infectious disease.

England

While in the three other nations of the UK, the health services are accountable to the devolved government, the central UK government is responsible for the NHS in England, where there are considerably greater restrictions in access.

Undocumented migrants and refused asylum seekers are entitled to access all health care services if doctors deem it clinically urgent or immediately necessary to provide it. However, the Home Office’s ‘hostile environment’ policies towards undocumented migrants, implemented aggressively and without training for clinical staff, are leading to the inappropriate denial of urgent and clearly necessary care.

One example is the case of Elfreda Spencer, whose treatment for myeloma was delayed for one year, allowing the disease to progress, resulting in her death.

In England, these policies, which closely link health care and immigration enforcement, are also deterring people from seeking health care they are entitled to. For example, medical bills received by migrants contain threats to inform immigration enforcement of their details if balances are not cleared in a certain timeframe. Of particular concern, the NGO Maternity Action has demonstrated that such a link to immigration officials results in the deterrence of pregnant women from seeking care during their pregnancy.

Almost all leading medical organizations in the United Kingdom have raised concerns about these policies, highlighting the negative impact on public health and the lack of financial justification for their implementation. Many have highlighted that undocument migrants use just and estimated 0.3% of the NHS budget and have pointed to international evidence that suggests that restrictive health care policies may cost the system more.

Australia

In Australia, all people who seek refuge by boat are held, and have their cases processed offshore in Papua New Guinea (PNG) and Nauru, at a cost of almost A$5 billion between 2013 and 2017. Through this international agreement, in place since 2013, Australia has committed to arrange and pay for the care for the refugees, including health services ‘to a standard of care broadly comparable to that available to the general Australian community under the public health system’.

However, the standard of care made available to the refugees is far from comparable to that available to the general population in Australia. Findings against the current care provision contractor on PNG, Pacific International Hospital, which took over in the last year, are particularly damning.

For instance, an Australian coroner investigating the 2014 death from a treatable leg infection of an asylum seeker held in PNG concluded that the contractor lacked ‘necessary clinical skills’, and provided ‘inadequate’ care. The coroner’s report, issued in 2018, found the company had also, in other cases, denied care, withheld pain relief, distributed expired medication and had generally poor standards of care, with broken or missing equipment and medication, and services often closed when they were supposed to be open.

This has also been reiterated by the Royal Australasian College of Physicians, which has appealed to the Australian government to end its policies of offshore processing immediately, due to health implications for asylum seekers. This echoes concerns of the medical community around the government’s ongoing attempts to repeal the ‘Medivac’ legislation, which enables emergency medical evacuation from PNG and Nauru.

Bad policy

Both governments have signed up to UN Sustainable Development Goals commitment to ‘safe and orderly migration’, an essential component of which is access to health care. The vision for this was laid out in a global action plan on promoting the health of refugees and migrants, agreed by member states at the 2019 World Health Assembly.

However, rather than allow national policies to be informed by such international plans and the evidence put forward by leading health professionals and medical organizations, the unsubstantiated framing of migrants as a security risk and economic burden has curtailed migrant and refugee access to health care.

The inclusion of migrants and refugees within universal access to health services is not merely a matter of human rights. Despite being framed as a financial burden, ensuring access for all people may reduce costs on health services through prevention of costly later-stage medical complications, increased transmission of infections and inefficient administrative costs of determining eligibility.

Thailand provides an example of a middle-income country that recognized this, successfully including all migrants and refugees in its health reforms in 2002. Alongside entitling all residents to join the universal coverage scheme, the country also ensured that services were ‘migrant friendly’, including through the provision of translators. A key justification for the approach was the economic benefit of ensuring a healthy migrant population, including the undocumented population.

The denial of quality health services to refugees and undocumented migrants is a poor policy choice. Governments may find it tempting to gain political capital through excluding these groups, but providing adequate access to health services is part of both governments’ commitments made at the national and international levels. Not only are inclusive health services feasible to implement and good for the health of migrants and refugees, in the long term, they are safer for public health and may save money.

England and Australia are considered standard-bearers of universal access to health services, with the former’s National Health Service (NHS) recognized as a global brand and the latter’s Medicare seen as a leader in the Asia-Pacific region. However, through the exclusion of migrant and refugee groups, each is failing to deliver true universality in their health services. These exclusions breach both their own national policies and of international commitments they have made.

While the marginalization of mobile populations is not a new phenomenon, in recent years there has been a global increase in anti-migrant rhetoric, and such health care exclusions reflect a global trend in which undocumented migrants, refugees and asylum seekers are denied rights.

They are also increasingly excluded in the interpretation of phrases such as ‘leave no one behind’ and ‘universal health coverage’, commonly used by UN bodies and member states, despite explicit language in UN declarations that commits countries to include mobile groups.

Giving all people – including undocumented migrants and asylum seekers – access to health care is essential not just for the health of the migrant groups but also the public health of the populations that host them. In a world with almost one billion people on the move, failing to take account of such mobility leaves services ill-equipped and will result in missed early and preventative treatment, an increased burden on services and a susceptibility to the spread of infectious disease.

England

While in the three other nations of the UK, the health services are accountable to the devolved government, the central UK government is responsible for the NHS in England, where there are considerably greater restrictions in access.

Undocumented migrants and refused asylum seekers are entitled to access all health care services if doctors deem it clinically urgent or immediately necessary to provide it. However, the Home Office’s ‘hostile environment’ policies towards undocumented migrants, implemented aggressively and without training for clinical staff, are leading to the inappropriate denial of urgent and clearly necessary care.

One example is the case of Elfreda Spencer, whose treatment for myeloma was delayed for one year, allowing the disease to progress, resulting in her death.

In England, these policies, which closely link health care and immigration enforcement, are also deterring people from seeking health care they are entitled to. For example, medical bills received by migrants contain threats to inform immigration enforcement of their details if balances are not cleared in a certain timeframe. Of particular concern, the NGO Maternity Action has demonstrated that such a link to immigration officials results in the deterrence of pregnant women from seeking care during their pregnancy.

Almost all leading medical organizations in the United Kingdom have raised concerns about these policies, highlighting the negative impact on public health and the lack of financial justification for their implementation. Many have highlighted that undocument migrants use just and estimated 0.3% of the NHS budget and have pointed to international evidence that suggests that restrictive health care policies may cost the system more.

Australia

In Australia, all people who seek refuge by boat are held, and have their cases processed offshore in Papua New Guinea (PNG) and Nauru, at a cost of almost A$5 billion between 2013 and 2017. Through this international agreement, in place since 2013, Australia has committed to arrange and pay for the care for the refugees, including health services ‘to a standard of care broadly comparable to that available to the general Australian community under the public health system’.

However, the standard of care made available to the refugees is far from comparable to that available to the general population in Australia. Findings against the current care provision contractor on PNG, Pacific International Hospital, which took over in the last year, are particularly damning.

For instance, an Australian coroner investigating the 2014 death from a treatable leg infection of an asylum seeker held in PNG concluded that the contractor lacked ‘necessary clinical skills’, and provided ‘inadequate’ care. The coroner’s report, issued in 2018, found the company had also, in other cases, denied care, withheld pain relief, distributed expired medication and had generally poor standards of care, with broken or missing equipment and medication, and services often closed when they were supposed to be open.

This has also been reiterated by the Royal Australasian College of Physicians, which has appealed to the Australian government to end its policies of offshore processing immediately, due to health implications for asylum seekers. This echoes concerns of the medical community around the government’s ongoing attempts to repeal the ‘Medivac’ legislation, which enables emergency medical evacuation from PNG and Nauru.

Bad policy

Both governments have signed up to UN Sustainable Development Goals commitment to ‘safe and orderly migration’, an essential component of which is access to health care. The vision for this was laid out in a global action plan on promoting the health of refugees and migrants, agreed by member states at the 2019 World Health Assembly.

However, rather than allow national policies to be informed by such international plans and the evidence put forward by leading health professionals and medical organizations, the unsubstantiated framing of migrants as a security risk and economic burden has curtailed migrant and refugee access to health care.

The inclusion of migrants and refugees within universal access to health services is not merely a matter of human rights. Despite being framed as a financial burden, ensuring access for all people may reduce costs on health services through prevention of costly later-stage medical complications, increased transmission of infections and inefficient administrative costs of determining eligibility.

Thailand provides an example of a middle-income country that recognized this, successfully including all migrants and refugees in its health reforms in 2002. Alongside entitling all residents to join the universal coverage scheme, the country also ensured that services were ‘migrant friendly’, including through the provision of translators. A key justification for the approach was the economic benefit of ensuring a healthy migrant population, including the undocumented population.

The denial of quality health services to refugees and undocumented migrants is a poor policy choice. Governments may find it tempting to gain political capital through excluding these groups, but providing adequate access to health services is part of both governments’ commitments made at the national and international levels. Not only are inclusive health services feasible to implement and good for the health of migrants and refugees, in the long term, they are safer for public health and may save money.

Last month the European Commission proposed that the EU should mobilize the next tranche of funding for Turkey (€3 billion) under the EU–Turkey deal agreed in 2016. The deal is part of a rapidly developing strategy on the part of the EU to improve cooperation on migration issues with countries of origin as well as those through which migrants and refugees transit en route to Europe. Since 2015, the EU has ramped up negotiations, with the New Partnership Framework underpinning arrangements with countries such as Niger, Mali and Ethiopia, and endorsing a memorandum of understanding between Italy and Libya in February 2017.

A common thread that runs across all of these deals is their focus on containment in exchange for funding, rather than a principled approach to refugee protection. For example, the EU has committed around €6 billion to Turkey as a contribution towards the cost of humanitarian assistance for the over 3 million Syrian refugees residing there. This funding also operates as an incentive for Turkey to take back all refugees and migrants who have irregularly arrived in Greece via Turkey since the deal entered effect.

Similarly, the EU is providing financial support to Libya in exchange for its cooperation in reducing the flow of migrants and refugees towards Europe, while the New Partnership Framework aims to reduce the number of migrants and refugees departing for Europe in exchange for EU aid. While financial incentives geared towards containment do not amount to new policy, with the increasing number of deals being negotiated, the use of such a strategy appears to be both accelerating and becoming more explicit.

An effective investment?

Implementation of these deals has been hindered by obligations under international law, raising questions not only as to their legality but also their value for money.

Under the EU–Turkey deal, refugees arriving in Greece irregularly were to be returned to Turkey, with an equal number of Syrian refugees resettled to Europe in exchange. However, implementation of this aspect of the deal has been limited.

Under EU asylum law, Greece is obliged to provide access to asylum procedures for those arriving on its shores. Given that most arrivals from Turkey came from refugee-producing countries (including Syria, Afghanistan and Iraq), an individualized assessment of ‘safe third country’ is required before any possible return to Turkey can take place. This requires a finding that Turkey can guarantee effective access to protection for the individual in question, including protection against refoulement (i.e. forced return to a country where he or she is at risk of serious harm or persecution). By the end March 2018, only 2,164 people had been returned to Turkey.

As for Italy, with EU support, under the MOU with Libya it has been training as well as providing funding and logistical support to the Libyan coastguard – including an Italian naval presence in Libyan waters – to intercept boats in the Mediterranean. Given the mounting evidence of abuse of migrants and refugees, whether by Libyan coastguards or inside Libyan detention centres, this raises questions as to whether the support being provided by Italy and the EU amounts to a breach of international law.

Despite concerns about the protection risks for refugees, advocates of such deals claim they have the potential to prevent dangerous journeys, saving lives and interrupting the business model of smugglers. Numbers crossing the Mediterranean have indeed dropped since the deals were agreed. However, in Libya it has created an ‘anti-smuggling’ market which, despite leading to a reduction of migration in the short term, may not be sustainable in the long term if it drives conflict between various non-state actors.

In the case of the EU–Turkey deal, while it has led to a fall in arrivals to the Greek islands in the first six months of 2017, there is also evidence that smugglers were already adapting their routes, forcing refugees and migrants to travel on the more dangerous central Mediterranean route.

For now, at least, these deals appear to have gained significant popular support within the EU. Italy’s approaches in Libya, for example, have been broadly backed by the Italian public – unsurprising given that some polls indicate 50 percent of the Italian population believe migrants to be a threat to public security. However, the drivers of public attitudes towards refugees and migration are complex and, as noted in a policy brief published under the Chatham House–ODI Forum on Refugee and Migration Policy, influenced in part by narratives driven by politicians and the media.

What some of these deals have achieved is the significant flow of aid money towards job creation and economic opportunities for refugees, incentivizing policy change in some contexts and producing real benefits for the refugees concerned (while reducing pressures on them to move onwards via dangerous journeys).

A prominent example is the Jordan Compact, a 2016 agreement between Jordan, the EU and international financial institutions including the World Bank to improve the livelihoods and education of Syrian refugees inside Jordan. While challenges in its implementation remain, including concerns about labour rights, the Jordan Compact has resulted in real improvements in education and access to the labour market for Syrian refugees. The Jordanian government has made policy concessions on access to work permits for Syrian refugees, removing some of the barriers that prevented refugees accessing jobs, while the EU has committed to ease trade barriers for goods produced in Jordanian factories on condition they hire a percentage of Syrian refugees.

Likewise, the EU–Turkey deal’s most successful component has been its financial contribution of €3 billion of aid under the EU Facility for Refugees towards support for the 3.7 million Syrian refugees currently being hosted by Turkey. This includes €1 billion allocated to the Emergency Social Safety Net, described by the European Commission as the ‘largest single humanitarian project in the history of the EU’, directly impacting the livelihoods of some 1.1 million vulnerable refugees.

Moving ahead

While some aspects of these deals reflect a genuine effort to cooperate in addressing the needs of refugees, other elements risk undermining the very essence of the global refugee protection regime.

The diplomatic squabble over a proposed refugee ‘swap’ of 1,250 refugees between the US and Australia in February 2017 highlights the danger of refugees becoming bargaining chips. Similarly, the Kenyan government’s announcement that it would close Dadaab refugee camp in late November 2016 cited the EU-Turkey deal as justification. Migration partnerships which emphasise the securing of EU borders against refugee arrivals may diminish the willingness of states in the Global South to continue to host large numbers of refugees.

While the positive aspects of such deals deserve acknowledgement, understanding their impact on refugee protection must be given greater attention. This is vital not only to ensure their workability but also to ensure that those countries who spearheaded the creation of the global refugee protection regime do not end up undermining its existence.

This roundtable focuses on the economic dimensions of displacement and migration and brings together an international group of experts from government, international organizations, civil society, research institutes and the private sector.   

The event was co-hosted with the Overseas Development Institute.