Date Published: August 16, 2017
Publisher: Public Library of Science
Author(s): Valeria Cetorelli, Gilbert Burnham, Nazar Shabila, Ignacio Correa-Velez.
During the summer of 2014, ISIS overran Nineveh governorate in Northern Iraq. Yazidis and other religious minorities were subjected to brutal attacks and forced to seek refuge into the neighbouring Kurdistan Region, where they remain living in local communities or in camps. This survey provides a population-based assessment of the health needs and care seeking behaviours of Yazidis and other groups currently residing in camps.
The survey covered 13 camps managed by the Kurdish Board of Relief and Humanitarian Affairs. A systematic random sample of 1,300 households with a total of 8,360 members were interviewed between November and December 2015. Participants were asked if any household members had needed care for a health condition in the two weeks preceding the survey, and whether care was obtained from the camp primary health care centre, an outside public hospital or a private clinic. If care was received, the out-of-pocket payment was recorded; otherwise, the reason for not seeking care was queried.
In 33.9% (CI: 31.0–37.0) of households one or more members had needed care for a health condition in the two weeks preceding the survey. The most likely to have needed care were older persons (18.5%; CI: 13.6–24.6) and infants (18.0%; CI: 11.6–26.8). The reported health conditions revealed a complex picture of communicable and non-communicable diseases as well as mental health problems and physical injuries. Care was primarily sought from private clinics (41.8%; CI: 36.4–47.4) or public hospitals (27.3%; CI: 22.6–32.7) rather than from the camp primary health care clinics (23.6%; CI: 19.5–28.2). The mean out-of-pocket payment for care received was nearly 3 times higher in public hospitals than in the camp primary health care clinics and nearly 11 times higher in private clinics. Cost was the main perceived barrier to obtaining health services.
Demand for health services was high among Yazidis and other minorities living in camps. Private services were preferred in spite of the tenuous economic circumstances of displaced households. Declines in public sector funding may further restrict access from camp clinics stressing the need for alternative access strategies.
There are currently more people displaced by conflict and persecution than at any other time since World War II . Ensuring that their health needs are adequately addressed is an increasing challenge for humanitarian agencies and host country governments. Until recently, camp-based health care strategies have focused on communicable diseases and maternal and child care . While traditional health priorities remain relevant, demographic and lifestyle changes are shifting the disease burden towards non-communicable diseases that are more complicated and costly to manage. Violence and displacement also result in physical injuries and mental health problems that may require long-term specialised care .
This study covered the 13 BRHA camps hosting Yazidis and other groups displaced by ISIS from Nineveh governorate: Bajed Kandala, Bardarash, Bersive, Chamisku, Dawdiya, Essian, Garmawa, Karbato, Khanke, Mamilian, Rwanga, Shariya, and Sheikhan. To ensure that all camps were sufficiently represented, we selected a stratified systematic random sample of 100 households in each camp, yielding a total of 1,300 households. For each camp, we determined a sampling interval k as the ratio of camp size to sample size. We chose a random number from 1 to k to identify a starting household and selected every kth household thereafter.
Of the 1,300 selected households, 93 (7.2%) were replaced with households living in the nearest shelter because responsible adults were absent (6.5%) or they refused to participate in the survey (0.7%). The interviewed households included a total of 8,360 members (Table 1). The average household size was 6.9 (CI: 6.7–7.1). The proportion of males and females was 50.5% (CI: 49.5–51.5) and 49.5% (CI: 48.5–50.6) respectively; 42.9% (CI: 41.4–44.4) of household members were children under 15 years of age. All households were displaced from their homes in Nineveh governorate during the ISIS attacks of June-August 2014, and approximately 80.0% (CI: 77.9–81.9) were Yazidi. In the majority of households (54.5%; CI: 51.5–57.5) no one was formally employed at the time of the survey; casual labour, savings and humanitarian assistance constituted the main sources of support.
The increasingly complex burden of diseases among displaced populations, including communicable and non-communicable conditions as well as mental health problems and physical injuries, requires new health system strategies . The household survey reported here provided a population-based assessment of the health needs and care seeking behaviours for a representative sample of Yazidis and other minority groups displaced by ISIS and currently living in camps in the Kurdistan Region of Iraq. The aim of the survey was to collect data that can help redesign health services for this population in an environment of growing demands and dwindling resources. Many of the issues identified, including burden of diseases and barriers to care, are common to the millions of displaced persons in the region.
Communicable and non-communicable diseases as well as mental health problems and physical injuries were commonly reported reasons for needing care among displaced Yazidis and other minorities residing in BRHA camps. Although access to health services was good at the time of the survey, most households sought care from private clinics or public hospitals rather than from the camp PHCCs. Health status and access to care risk to deteriorate in the longer term, as funding to the public health system declines and the economic situation of in-camp households becomes even more tenuous. New strategies are required to address the health needs of displaced populations while limiting service costs.