To analyze the impacts of the care to the population displaced by violence on the health system and the challenges that this entails.
This is a narrative review of the national and international literature in PubMed, SciELO, WHO/PAHO, and Bireme. Inclusion criteria were date of publication (from 2000), relation with the subject, and language (Spanish or English). We found 292 documents, of which 91 met the inclusion criteria.
The main challenges are the intersectoral, participatory, and integral approach (with emphasis on mental health and sexual and reproductive health), ensured accessibility to health services, the need for a reliable registration and information system of the population displaced by violence and its characteristics, and the addressing of the biopsychosocial problems of the different groups, especially women, persons with disabilities or infectious diseases, adolescents, children, ethnic minorities, older adults and the lesbian, gay, bisexual, transsexual, and intersexual population.
The lack of political will to accept and see the internal displacement by violence and its importance as a humanitarian and public health problem is an obstacle to the adequate and timely care of the population displaced by violence in Mexico.
A displaced population is defined as “individuals or groups of people who have been forced to flee their homes to escape armed conflict, generalized violence, and human rights abuses” 1 . It includes refugees – persons who crossed an international border – and internally displaced persons. This displacement becomes a public health problem 2 , 3 and a challenge for the provision of health services (HS) in both the sending and receiving areas, many of which do not have the resources to respond to a sudden and massive influx of persons4–6.
A displaced population faces a forced and abrupt transition that involves individual and family changes, both in their roles or relationships and in their material living conditions. This usually means shortages of resources, family conflicts, health risk behaviors, sexual abuse, physical and mental health problems, and human rights violations 7 . Displaced populations mainly have low and very low socioeconomic status (SES), which does not mean that persons with high SES are not displaced or do not suffer when they do so, but they can rely on greater cultural and economic capitals to face it 8 . Quality of life tends to worsen with displacement, especially in the transition phase - between choosing a temporary settlement until they can be permanently placed 9 . At this stage, there is no more emergency aid, and thus the economic situation often deteriorates 10 , 11 . The arrival of a new population affects the receiving area in relation to the labor market, security, and demand for public services. This sometimes leads to rejection and discrimination and the need to mobilize new resources at the state and city level 3 ,12 , 13 .
Official statistics on forced displacement are scarce and incomplete in Mexico. The internally population displaced by violence has increased in the country, especially in states such as Chihuahua, Michoacán, Sinaloa, Durango, and Guerrero 3 , 14 . In Mexico, 19,747,511 persons migrated internally in 2010, according to the 2015 data of the National Institute of Statistics and Geography (INEGI) 15 . The most frequent reasons were poverty, violence, and natural disasters 16 . According to the 2014 National Demographic Dynamics Survey, six out of 100 migrants moved to another state motivated by public insecurity or violence 17 . According to the latest National Survey of Victimization and Perception on Public Security (ENVIPE) in 2014, 1.6 million persons migrated internally because of violence 18 . The study of Chávez and Warnner 19 , in 2012, estimates that Mexico has half a million internal migrants, with differences according to education level (lower education level plus group and rural migration) and age (younger individuals migrate more), with little difference by sex. However, they do not differentiate the cause of migration; they only mention Chihuahua and Sonora as sending areas, with little immigration and problems of organized crime.
Mexico had high internal migration for economic reasons, mainly from the south to the north of the country. It is also a transit point for Central and South American migrants to the United States 20. However, it has not officially recognized the existence of internal migration by violence as a priority problem. Consequently, it is little visible, there is no adequate information, and the responses to this phenomenon were fragmented and insufficient, as well as the policies and programs for this population 21 . The Government must ensure the right to health, in a holistic conception, that goes beyond the medical care of the disease. This reluctance to acknowledge the existence of displaced populations hinders the care provided to them 22 .
Given the exposed problem, the objective of the study was to analyze the impacts of the care to populations displaced by violence to the health system and the challenges that this entails.
This first approach was based on the identification and analysis of the national and international literature, which contributes with information for the formulation of public policies that allow the preparation, allocation of resources, design, and implementation of national programs that respond to the needs of this vulnerable population.
We carried out a narrative review of the literature on forced migration associated with violence and the response of health systems in documents published from 1995 to 2016. We included studies with different methodologies, from any country. The searches in PubMed, SciELO, WHO/PAHO, and Bireme were performed under the following terms in English and Spanish:
Health services and/or Health system and internal displacement by violence;
Displaced population and health services;
Forced displacement and health in Mexico.
Inclusion criteria were date of publication, relation with the subject, and language (Spanish or English). Each document was classified by document type, geographical context, and category in relation to the subject (Table).
We found 292 documents, of which 91 met the inclusion criteria. Most (n = 75) were from the Latin America, almost all from Colombia. Of the 11 documents from Mexico, two were directly related to health services 23 , 24 (Figure).
We found scarce specific literature on the effect of forced displacement on HS. The articles related to the subject have identified its potential negative impact on human resources, as well as the increase in the needs of drugs, inputs, and infrastructure in health services 2 .
A study on health and forced displacement in Sri Lanka, although focusing on post-conflict, has found three documents on HS. Most focused on the mental health problems of the displaced population 25 .
The article of the International Center for Migration and Health 26 has highlighted the areas that should be the focus of health policies for this population: communication, infection control, maternal and child health, occupational health, violence, creation of health indicators, and staff preparation for the intercultural capabilities needed for the care of ethnic minority groups. Principle 19 of the “Guiding Principles on Internal Displacement” of the United Nations prioritizes the care of the displaced population with disabilities, infectious diseases, and women, especially in the field of sexual and reproductive health (SRH) 1 . The World Health Organization (WHO) 2 mentions that the public health should avoid inequities between the displaced population and the host population regarding the health condition and access to HS. To this end, it proposes that health rights should be ensured without discrimination and obstacles should be removed for preventive and curative interventions that reduce excess morbidity and mortality and minimize the consequences both on community health and cohesion.
Some studies have focused on barriers to access to services. The most mentioned ones were the geographic, economic, cultural, and bureaucratic barriers5,12,27–30. Some strategies used in Colombia to ensure access were the priority affiliation to social security or the portability of this affiliation, the flexibility to adapt to obstacles such as the frequent absence of identification document, and the care with mobile health brigades and managers29,31–33.
Others have mentioned the lack of staff training to handle social and health emergencies, aggravated by the high turnover from the work under stress conditions, lack of resources, and insecurity 34 . They also have highlighted local shortcomings in developing policies to support the displaced populations, whether for lack of interest, ability, incentives, or funding 12 , 3 5 . Most of the experiences came from Colombia, where a care model was designed for displaced populations, based on mobile teams focused on Primary Health Care (PHC) and specific manuals 4 , 36 .
There is a consensus about the characteristics that the HS should have for displaced populations, such as cultural acceptability2,5,26,37–39, integrality 24 , 40 , appropriate information system4,41–43, being it intersectoral4,12,29,44–47, participatory 5 , 29 , 33 , and accessible24,27–31,37,43,48–5 1 , and with security measures that ensure the lives of both the population and health personnel1 , 12 , 34 , 44 , 52 (Box 1).
Other factors have also been identified on the challenges for the HS:
The existing resources in the receiving area and previous planning. According to the WHO, the political and security conditions of a country allow predicting possible displacements, planning activities and resources, and creating protocols for when the situation occurs 5 , 54 .
Population type: minority ethnic groups or population similar to the receiving area 37 . Most displaced populations in the Latin America are ethnic minorities (indigenous and Afro-descendants)14,56–58.
The age groups of the displaced population and their health status1,5,27,28,47,59–67, with emphasis on childhood, adolescence, adult women, minority ethnic groups, the lesbian, gay, bisexual, transsexual, and intersexual population (LGBTI) population, and persons with disabilities or chronic or infectious disease requiring long-term treatment, such as TB and AIDS (Box 2).
Since most displaced populations have a low educational level 19 , 62 , they require information on health, rights, and services, to improve their use, especially on SRH (prevention and detection of cervical and breast cancer, sexually transmitted infections/HIV, and family planning) 55 .
Given the lack of specific information about the challenges to HS, they can be deduced from the health information of the displaced population, which is abundant. Although the conditions of forced migration by violence in other continents are different because of their magnitude and socio-political context, there are common characteristics in displaced populations: most are poor, women, with low education level, with traumatic experiences and stress, placed in areas with poor health conditions, with few belongings, and often without identity documents 5 .
Most references have identified mental health problems42,44,50,60,68– 72 from stress and the accompanying trauma of displacement, often preceded by murders, threats, violations, and losses. To this, we can add the stress in the receiving area, from unemployment, discrimination, and loss of networks. The most common problems were depression and post-traumatic stress syndrome (PTSD), whose magnitude depends on personal factors and the environment5,57,71–73.
The second most mentioned subject was the SRH needs of women, especially teenagers, because of the risk of sexual abuse and exploitation both at the receiving place and within the displaced group itself 74 , 75 . This involves efforts to identify and prevent unwanted pregnancy, STI/HIV, and unsafe abortion and to ensure the availability of contraceptives, including emergency contraceptives, and antiretrovirals 1 , 5 ,73 , 75 , 76 .
Other groups mentioned were older adults53 and persons with disabilities 1 , 53 . The LGBTI population was considered important because of the discrimination they may be subject to, even in the HS, and those with STI/HIV treatments to ensure continuity 1 , 77 . Hence the importance of having an epidemiological surveillance system 63 that ensures timely diagnosis and continuity of treatment, as well as the diagnosis of available resources. We found some articles on specific subjects: increased canine rabies in displaced areas 78 , oral health 79 , 80 , and occupational health 26 , 81 .
The PAHO comments that a massive internal displacement produces an increased magnitude and distribution of the burden of the disease and, therefore, increases the volume and composition of the demand for services 36 . Most documents mentioned one or more of the HS components:
Infrastructure and equipment: in addition to the resources for emergency humanitarian care, health care actions are contemplated as part of the integral care of the victims. They can be individual (prosthesis, physical and mental rehabilitation) or collective (provision of equipment and inputs, construction of health centers) 82 , 83 . Massive displacement can cause shortages of care resources in the absence of appropriate preparation for these situations 30 .
Human resources (HR). The health staff needs to be trained on the care of displaced populations 5 , 54 , as well as state and city authorities. Adequate remuneration and emotional restraint are important in the initial stages of emergency, followed by security measures 26 , 36 ,82 . International agencies have designed manuals for emergency care and for mental health problems in this population 36 , 44 , 72 , 84 - 86 .
Reinforcement of services: in particular SRH 5 , 75 , 76 and mental health 42 , 55 . In Colombia, the Integral Care System for Population Displaced by Violence details the HS required. The services range from prevention and emergency care up to psychosocial relocation and rehabilitation 48 .
The financing of health care for displaced populations was a scarce subject in the documents. There was a consensus that financial resources are scarce or late 30 and national budget actions are needed so that the local population is not negatively affected12 . Other texts mentioned funding sources 29 , 87 , payment mechanisms29 , 86 , 88 , or the budget allocated for the reparation of victims 35 . However, no article has done a detailed study of health costs derived from displacement 89 . Given that displaced families are poor and should also abandon their sources of income, their ability to pay is minimal, even for transportation to the health unit 5 3 . The WHO highlights the persistent scarcity of resources for mental health care, a priority service for displaced populations 85 .
Other components: different subjects have been addressed, such as intersectoriality, participation, and empowerment of the displaced population 4 , 29 , 55 , 82 , the role of non-governmental organizations 14 ,2 1 , 55 , and the role of the academy28 , 35 , 41 , 62 , 80 both in care and in research.
Despite underreporting, 281,418 persons are known to be victims of internal displacement forced by violence, mainly in the Northern states and Guerrero, caused by organized crime 21 or religious problems. In general, the subject of displaced populations has been little studied and recognized, with no specific policies or legal framework in the field of health services 23 , 53 . An exception is Chiapas, where a law was passed to protect the rights of this population 90 . There are state legislations in Guerrero and Sinaloa 14 . The Federal Project for the Care of Displaced Indigenous People does not include health aspects, but it recognizes both the existence of an indigenous population displaced by some type of violence and the lack of specific legislation that recognizes and characterizes it
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