The place of social work in improving access to health services among refugees: A case study of Nakivale settlement,Uganda

Abstract

About 70.8 million individuals are displaced worldwide, and of these, 25.9 million are refugees. Accessibility to health care is a central aspect of the well-being of refugees. This article examines the communication, institutional and socio-cultural challenges to access and use of health services among refugee women and children and conceptualises the social work position in tackling such issues. The study used mixed quantitative and qualitative methods. The findings indicate complex experiences of refuge and ongoing gendered oppression and vulnerability. This research proposes a rights-based social work approach to addressing impediments at micro, meso and macro levels.

Keywords

Access barriers health services refugees rights-based approach social work Uganda women and children

Introduction

Around 71 million people are estimated to currently be displaced worldwide, 26 million of whom are classified as refugees (United Nations High Commissioner for Refugees [UNHCR], 2019a). Refugees are defined by the United Nations (UNHCR, 1951) Geneva Convention Article 1(2) as ‘individuals who are outside their country of nationality with a well-founded fear of being persecuted or, owing to such fear, are unwilling to avail themselves of the protection of that country’. Unlike other migrants who choose to move to improve their lives, refugees need protection from host states for safety and to access basic human rights (UNHCR and International Detention Coaltion [IDC], 2016). This poses a significant challenge to low-income nations that host the majority of the world’s refugees (85%) (UNHCR, 2018). Uganda is one such low-income country, where the refugee population has grown from half a million in 2016 to 1.36 million in 2019 (UNHCR, 2018). Half of these refugees are adult women, and the majority (60%) are children of all genders under the age of 18 (UNHCR, 2019b: 6). Most of Uganda’s refugees come from neighbouring states such as South Sudan, Democratic Republic of Congo (DRC), Burundi, Ethiopia, Eritrea and Rwanda (UNHCR, 2019b). These countries are deeply affected by poverty, conflict, poor health systems and high burdens of disease. The World Health Organization (WHO) indicates that the socio-economic conditions surrounding relocation and the structural conditions in the settlement sites pose challenges and intensify the vulnerability of refugees to poorer health outcomes (WHO, 2018). Refugee women and children on the move are exceptionally vulnerable to inequities that operate through exploitation and abuse (Alsaba and Kapilashrami, 2016; Berends, 2017; Freedman, 2019; International Organization for Migration [IOM], 2014; Papadopoulos, 2008). In line with the Sustainable Development Goal (SDG) three, the host states must ensure and promote the well-being of refugees. This necessitates broad and integrated access to health services – encompassing health promotion, disease prevention, treatment, rehabilitation and palliative care (Berends, 2017; Fernandes and Miguel, 2009). While accessing health services is fundamental to the well-being of refugees, this is often not a possibility for them in the host countries (Fernandes and Miguel, 2009). This is due to their disempowered refugee status, limited host-language skills, lack of access to formal jobs and unclear legal statuses (Stamatel and Zhang, 2018).

Moving from ‘vulnerability to vulnerability’, as described by Palattiyil and Sidhva (2011: 89), can help us to conceptualise risks that refugees continue to face within the host country. Although it is widely acknowledged that refugees experience extreme difficulties in accessing required services (Stamatel and Zhang, 2018), there is scant information concerning the problems of accessing health services for refugees in low-income countries with minimal social services. This article examines the communication, institutional and socio-cultural barriers to access and use of health services among refugee women and children and conceptualises the position of social work in tackling these. First, the article will explore the relationship between social work and migration and a contextualise settlement practice with refugees. Second is an overview of Uganda’s refugee policy. Third, I document methods of data collection and the key findings. The final section provides a discussion of the key themes from the data, reflections for social work practice and conclusions.

Social work and migration

Social work aims to engage people to address life challenges and enhance their well-being (International Federation of Social Workers [IFSW] et al., 2014), therefore refugee women and children need social work’s support to settle into their new destinations. Social workers, alongside other front-line professionals, offer immediate and continuing support to mitigate the distress of relocation. Universal social work with immigrants has been construed as ‘settlement practice’, ‘settlement work’ or ‘settlement social work’ (Valtonen, 2008). Settlement practice involves case management, empowerment and connecting of refugees to vital resources in society so that they function autonomously (Valtonen, 2008). Settlement practice is informed by several approaches such as human rights, preventive, critical social work, ecological, strengths and empowerment. However, this research draws on the RBA.

An RBA is ‘a conceptual framework that integrates the norms, standards and principles of the international human rights system into the policies, programmes and processes of development and humanitarian actors’ (UNHCR, 2008: 26). This approach is founded on the principles of participation and empowerment. The RBA is vital and is based on the notion of common humanity and global citizenship (Ife, 2001). Settlement practice is one phase of the process of international protection (Valtonen, 2008). The rights of refugees in Uganda are protected under the Refugee Act (2006), which is an adaptation of the 1951 UNHCR Convention relating to the status of refugees. In order to protect the human rights of refugees, practitioners must identify problems that are related to transition and settlement.

Settlement practice with refugees

Social work intervenes in the lives of refugees at the micro, meso and macro levels. Adams et al. (2009) assert that social work involves working alongside the social order to realise social transformation or therapeutic support for people. Micro-level measures focus on the individual psychosocial aspects of integration and personal processes of adaptation. Examples of such measures include dissemination of information on accessible services, rights and obligations of refugees. Social work practitioners also arrange for the safe and fast settlement of newly arrived refugees and prompt delivery of material support (Payne, 1996). It is also important for practitioners to identify each refugee’s strengths and resilience. These measures improve the social connectivity of individual refugees (Adams et al., 2009).

Meso-level measures accentuate the community as the focal point for meeting the needs of vulnerable people (Dominelli, 2007). Interventions at this level are based on community relations and support such as financial, emotional and translation services. This is because most refugees are likely to be unfamiliar with formal services. For example, empowering groups of refugees to interact and discuss their challenges improves their welfare (Adams et al., 2009). Valtonen (2008) advises that community outreach and alliance with community support networks are needed in order to identify and prevent settlement and integration problems. It also aids the development of tolerance (Dominelli, 2007) and culturally competent interventions among professionals.

Macro interventions are those that involve wider engagement with the political actors and decision-makers (Valtonen, 2008). This involves policy development and advocacy for the rights and needs of the most vulnerable. Securing funding for efficient delivery of support services to refugees would be an example of this. These measures aim to transform discriminatory social structures rather than changing individuals (Mwenyango and Palattiyil, 2019).

Uganda’s refugee policy

Uganda started hosting refugees after the Second World War when Polish refugees settled in Nyabyeya, Masindi District (Office of the Prime Minister [OPM], 2017). Subsequently, refugees have increasingly relocated to Uganda due to the presence of sparsely populated chunks of land in some regions, proximity to refugee sending countries and existing ethnic relations (Orach and De Brouwere, 2005). A migrant to Uganda qualifies for refugee status if she or he proves that they are under fear of being persecuted for reasons as set out in the Refugee Act of 2006, such as race, sex, religion and nationality (Government of Uganda [GoU], 2006). Uganda is also a signatory to other international legal instruments, including the 1951 Refugee Convention, the 1976 Protocol and the 1969 Organisation of African Unity (OAU) Convention which spells out the rights and entitlements of refugees. The OPM coordinates refugee response and management activities under Schedule 3 of the Constitution of the Republic of Uganda. The government is supported by implementing partners (IPs) under a tripartite agreement. Under this, the OPM, the UNHCR and IPs provide services (including health) to refugees. Most of the funding to IPs come from the UNHCR. There are also operating partners (OPs) who are not directly funded by the UNHCR, such as the Finnish Refugee Council (FRC). Refugees are placed by the OPM in settlement sites, including Nakivale, Kyaka II, Oruchinga, Kyangwali, Kiryandongo, Paralonya, Rhino Camp, Imvepi, Madi Okolllo, Maaji and the integrated camps of Adjumani (Mwenyango and Palattiyil, 2019; OPM, 2015).

Methods

The article is based on research carried out in the Nakivale refugee settlement (NRS) from August to December 2017. The study examined ‘the health needs of refugee women and children and the role of social work in responding to such needs’, using mixed quantitative and qualitative methods. This research focuses on two key questions: (a) Which barriers impeded access to the use of health services among refugee women and children in the NRS? (b) How can social work improve access to health services?

The NRS in Isingiro district was chosen as a Ugandan settlement case study. The NRS covers 185 square kilometres of land with three main zones including Juru, Base and Rubondo camps. It is one of the oldest refugee settlements, and compared with others it has a good demographic representation of the refugees in the country (OPM, 2017), which ensured participation from a diversity of respondents. Research approval was obtained from the OPM Department for Refugees, the University of Edinburgh, Makerere University and the Uganda National Council for Science and Technology (UNCST). Further ethical procedures comprised training research assistants about the importance of maintaining confidentiality to protect individual participants, securing informed consent, voluntary participation and seeking permission to tape-record their responses to avoid loss of data. After transcription, the audio files were erased, and all sensitive quotes have been anonymised.

Quantitative procedures

A structured questionnaire was administered face-to-face by two graduate research assistants who were fluent in the local dialects. The questionnaire collected statistical data on aspects such as age, sex, country of origin, education, religion, marital status, household information, and data on health status and health services. Based on the research methodology of Krejcie and Morgan (1970), a table for determining sample size from a given population was devised and then 377 women were determined as the optimal number to survey from a population of 19,126 adult refugee women (mean age = 33.9, standard deviation = 11.6 years). The sample consisted of nearly the same number of residents selected from each zone using the formula: [k = N / n] where N = 377 and n = 126, hence k = 3. With a random starting point of 1, every woman living in the third household was selected for the survey.

More than half of the participants were refugee women from Congo (55.2%), whereas 41.4 percent were Rwandese and Burundians. Refugee women of other nationalities (Somalis, Tanzanians and Eritreans) only formed a small portion (3.5%). More than half (69%) had lived in the settlement for over 5 years. The respondents spoke diverse (15) languages; however, the most predominant were Kinyabwisha, Kirundi and Kinyarwanda. Given that the age of consent in Uganda is 18, only women who were of this age and above could participate. Most (61.2%) of the women were married (n = 229), around 20 percent were single, and 19 percent were separated or widowed; 6.1 percent of the participants indicated having never given birth. A larger proportion (30.0%) of the women with children (n = 349) had 6 or more children. Most women (58%) worked as peasants on the nationals’ (local Ugandans’) farms. Most of the respondents had attained primary education (41.4%) of 7 or fewer years, while a comparable proportion (40.1%) had no formal education whatsoever. The respondents had strong beliefs in God as a great source of help, peace and provision. Pentecostal Christianity had the most adherents (33.4%), followed by Catholics (23.1%) and Protestants (20.7%), and only 9.8 percent identified as Muslims.

Qualitative interviews

Additional in-depth interviews were conducted with refugee women (n = 31) and key informants (n = 32). The samples for each category were reached by a process of theoretical saturation, that is, when no new qualitative data were emerging (Corbin and Strauss, 2008). Refugee women were purposively selected based on their descriptive characteristics (from the survey). The key informants were chosen based on their involvement in supporting refugees. They included staff from OPM, IPs and OPs. The interviews involved open-ended questions and were conducted in English.

Analysis

Quantitative data were sorted, edited and coded. A coding frame was developed using numerical codes and the data were entered for analysis using the Statistical Package for the Social Sciences (SPSS Version 17.0). The analysis involved generating descriptive statistics, including generating frequency distribution tables, cross-tabulations, and univariate and bivariate analyses (chi-square statistics). Qualitative data were analysed using a phenomenological approach and done in stages as outlined by Hycner (1985). It was transcribed verbatim followed by bracketing and phenomenological reduction. Then crystallisation and condensation of data were performed to generate units of general meaning. Central themes emerged from these clusters, which I have contextualised for a deeper understanding of the phenomenon under investigation.

Key findings: Barriers to access and utilisation of health services

Results from both the surveys and interviews revealed diverse factors that impede access to and use of health services among women and children in the NRS. These involved three central themes: communication, institutional and societal challenges.

Communication problems

Language barriers

Language is an important factor which can fundamentally shape provision, access and utilisation of health care services (Valtonen, 2008). As previously mentioned, the refugee participants spoke 15 languages, including many languages that were not used by most service providers. Participants recounted the challenges involved during interactions. One key informant clarified that

[y]ou can go to the doctor and when you don’t have someone who can explain your problem in your language, that is very hard. (Ethiopian refugee leader, Base Camp)

Language barriers led to inaccurate diagnosis and treatment, including prescriptions, and generally resulted in poor use of time and resources. In an investigation of refugee claimant women in Montreal and Toronto, Merry et al. (2011) identified language barriers and the absence of translators as significant problems for both women and service providers. A key informant disclosed a similar problem while examining the use of volunteers in health education:

The instructors we use, especially for English, the English skills they have are basic, at times they don’t deliver as expected. (Community development officer [CDO], FRC)

This illustrates that they pass on folk remedies since they cannot fully comprehend the messages that they are supposed to deliver. This can seriously affect the quality of health care received by refugees.

Lack of information

Communication about available support is crucial for target service users to understand the importance of seeking services (Valtonen, 2008). A lack of information was cited as an issue affecting access and use of health services among refugees. One key informant was speaking about an escalation of fistula cases among refugee women and revealed that

[t]here is not much effort which has [been] done to make these people aware of this issue or to just to be encouraged to go to the health center. (Community activist, American Refugee Council)

The absence of appropriate information limits the determination to seek services. Language barriers, especially when combined with low literacy levels, can result in service users not being aware of what support they could be receiving. The absence of appropriately communicated information limits the ability of refugees to seek support from service providers.

Institutional barriers

Institutional barriers denote upstream processes influencing access to health care (Weiss and Lonnquist, 2003). Results revealed institutional barriers, including a lack of health care and medicine and scarcity of diagnostic equipment, long queues, negative attitude of health care providers, mistrust, lack of coordination and low funding.

Absence of health care resources

Health-enhancing products should be accessible to improve health outcomes (Cohen et al., 2000). Consistent with previous studies (e.g. Deacon and Sullivan, 2009), this research found insufficient to no availability of required health resources. A major problem facing primary health care centres is that of shortages of medicine and diagnostic equipment. Most survey participants (55.5%) pointed out that Panadol (a paracetamol-based painkiller) is regularly distributed to manage all illnesses. This symptomatic treatment for pain relief frustrated both refugees and service providers and discouraged the use of professional services. This was described by a key informant:

You find a mother has walked from X or the end of whatever village, comes, lines up, say from 8:00 up to 4:00, yet is then informed by the doctor that the prescribed drug is not there. (CDO, FRC)

This mirrors frustration from medicine stock-out at health facilities. The facilities and resources in the settlement are intended to serve both the refugees and the host community. It is a way of rewarding local hosts for providing the settlement land (UNHCR, 2019b). However, this arrangement is inaccurately designed and makes it impossible to sustain the huge demand.

Specialised care, such as that for people with special needs (PSNs) and services for children, are not available at NRS. One refugee respondent revealed that some acute conditions among children are merely managed in the community:

Something comes out like a tooth then [. . .] it will develop a maggot then a child dies, yet at the hospital, they don’t treat those, but then when you go to local people in the community, they remove them. (Congolese woman, Base Camp)

The absence of specialised care forces refugees to invent unapproved options for managing ill-health, which places the lives of children in jeopardy. This is also exacerbated by long queues and over-waiting at the facilities; 10.3 percent of the women talked about long queues in the facilities as routine and that waiting stretched for 5 hours and more. Staff become overwhelmed with high volumes of work, which can result in a lack of empathy for their patients.

The inconsiderate attitude of health care providers

The negative attitude of some health care providers discourages refugee women from seeking health services. About 6.6 percent of women mentioned that health care providers are rude and disrespected them. A key informant reported distress and afflictions which women experience under the watch of the health workers:

You find out that in the hospital room, there is only one doctor maybe who is to attend to 8–10 mothers who are pregnant and they are all going to give birth . . . some are not attended to, and some give birth on the floor; sometimes we face a problem of doctors or perhaps proud nurses who cannot be bothered. (Refugee women’s leader, Base Camp)

Besides individuals’ attitudes, the above quote suggests that the poor doctor–patient ratio is the primary cause of these social/emotional dynamics. Lack of empathy by service providers leads to mistrust between refugees and the service providers (Svenberg et al., 2009). This was revealed by a key informant who said,

[t]hey do not trust our doctors; they perceive that it is their doctors back in Congo who can do it [treat]. There were people here who had started clinics and they were forced to shut them down; some were even doing operations. (CDO, FRC)

Entrenched doubts about the health system affect whether refugees seek formal health care and relationships. However, cultural beliefs about disease and cure can be a further cause of mistrust, as revealed by another key informant:

They associate most [of] these diseases [with] witchcraft, so instead of coming to health centres they always run to witch doctors [traditional healers]. (Assistant Commandant, OPM)

This is due to perceptions that divine causes do not require medical mediations. It replicates Svenberg et al. (2009), whose respondents inferred djinns (evil spirits) to explain reasons for illness, particularly about mental health. Sometimes, as we have seen, mistrust may be well-founded, as when service providers offer inappropriate treatments to avoid additional recording or coordination work.

Lack of coordination

Refugee services must be harmonised in order to be comprehensive (UNHCR, 2019b). However, the lack of coordination between the service providers is a pressing and ongoing challenge for the efficient provision of health services in NRS. This was reflected in the words of a key informant:

Sometimes you find like ten organisations, providing the same things . . . and there is limited coordination of these services and this also can be seen in terms of the actual outputs. (Social work academic)

Uncoordinated approaches in service provision create needless duplication and resource wastage, resulting in diminished outcomes in terms of the number of people assisted by services. Lack of coordination is also due to competition among agencies supporting refugees. Agencies in the settlement are faced with the fact that they need to compete for funding from the main partner – the UNHCR. The local agencies’ desire for funding can be at odds with the UNHCR’s desire to streamline services (Dunn, 2016).

Inadequate funding and poverty

A lot of refugee work depends on international donations and funding. Sadly, this is not enough to meet the overwhelming need for services (Dunn, 2016). One key informant expressed concern over insufficient funding for programmes:

Our calendar year ends by 31st December [2017] which we are coming to, so we start worrying about 2018 because under [the] emergency everyone is touched – everyone is willing to donate but as refugees stabilise the donors also start giving less. (Senior Official, Real Medicine Foundation )

Funding cuts affect planning and response to need, and mean life or death for refugees. Although the reduction in aid has frequently been attributed to the economic crises in the Eurozone, the perceptions of high corruption¹ rates in Uganda, especially after the suspected mismanagement of refugee resources at the OPM, also explains reduced aid (National Population Council [NPC], 2018). The gap created by decreased budgets must be covered by refugees who are also poor, as stated by a refugee respondent:

At home, you don’t have food, you don’t have anything, so money for buying medicine is also a challenge. (Burundian woman, Rubondo)

Like the rest of Ugandans, the high levels of poverty in the settlement are due to a lack of employment and dependence on unpredictable rain-fed agriculture (NPC, 2018).

Socio-cultural barriers

Socio-cultural barriers were perceived as influences on health and care which arise from social norms and cultural values. These incorporate gender dynamics and cultural and religious obligations. The WHO (2010) identifies gender inequality as an important social inequality that can affect access to health care. One key informant pointed out the effect of gender relations on health:

Some women have disagreements with their husbands so when they are eager to come to health centres, they are not allowed by their husbands. (Village health team coordinator)

This denotes that gender determines and influences health choices. Women and children live in a cultural context that is dominated by men as the main decision-makers (Nalukwago et al., 2019), which affects their well-being because of reduced autonomy. For instance, the clinicians cited that women suffer from recurrent episodes of sexually transmitted infections because their male partners decline to seek medical services. Cultural perceptions also shape the lifestyle of refugees in terms of choices and practices, as stated by a key informant:

Some deny drugs [and instead say] they are going to pray, [that] God will cure them everything, for example, HIV. (Counsellor, Medical Teams International)

Culture and religion determine who decides what and when, discriminatory norms, violence against women, biased divisions of work, leisure and prospects of improving one’s life (Commission on Social Determinants of Health [CSDH], 2008). For instance, some stigmatising conditions such as fistulae are escalated by cultural norms and values (Nalukwago et al., 2019).

Discussion

I have in the foregoing section presented the communication, institutional and socio-cultural factors that intersect and impact women and children’s access to health services. The resulting discussion frames these findings into two key themes – refuge and well-being; and gender, health and refuge.

Refuge and well-being

The impact of conflict in the countries neighbouring Uganda has been felt by women and children who have been forced into refuge. Considering that most women and children lose their property because of the conflict, their life after the relocation deteriorates further due to economic deprivation, poor physical health and inadequate access to basic needs and services. The poor health status of refugee women and children in the NRS was due to a combination of factors such as poor living conditions and limited access to disease prevention, treatment and rehabilitation services. This easily fits into experiences of the refugees documented in a large body of literature concerning the poor living conditions of refugees (e.g. Allan, 2014; Palattiyil and Sidhva, 2011; Wachter et al., 2016). Refugees flee to a new country with the expectations of protection and achieving a decent quality of life, but they end up suffering challenges. While the government maintains an open-border policy, allowing all asylum seekers to enter the country without prior planning, new arrivals ultimately live on the edge of society and subsist on humanitarian assistance. Papadopoulos (2002) states that humanitarian assistance in various refugee situations is often provided based on the multiplicity of socio-political circumstances rather than on the objective appreciation of their needs. This minimalist protection ensures bare survival, but not a dignified life (Grayson, 2017). About 6.6 percent of the refugee women in the NRS had experienced negative treatment from service providers who allegedly were rude and disrespectful of them. For instance, when asked about how to improve health care for women and children in the settlement, one refugee woman explicitly said that ‘It is better those who work at the health centres, those nurses, midwives or doctors to be counselled and trained so that when we go there they could treat us well’. Although humanitarian assistance is essential during crises, it may well cause inadvertent harm and increase pain if it is not administered in a sensitive way (Papadopoulos, 2010). Disrespect for refugee women in the NRS is consistent with previous research on other refugee contexts showing a high degree of stigma as well as discriminatory and authoritarian policies against forced migrants (Freedman, 2019; Palattiyil and Sidhva, 2011). Freedman describes the symbolic violence experienced by refugee women arriving in Europe, and particularly those who are easily identified as Muslim. In an interview with a Syrian woman in Paris, a participant said,

[t]hey gave me 1 kg of chocolate biscuits, and I told them I don’t like chocolate. But then they said ‘I thought you said you were hungry. If you are hungry, you will eat them’. I felt so humiliated. They just treated me as if I was stupid. (Freedman, 2019: 10)

Discrimination excludes refugees from citizenship which is mandatory by international law (UNHCR and IDC, 2016). Discrimination also deprives them of the agency to communicate their needs and affects physical and mental health (Fernandes and Miguel, 2009). Discrimination highlights how refugee status interacts with gender as a social determinant of health.

Gender, health and refuge

Gender dynamics affect access and utilisation of health services for refugee women and children. It is an essential determinant of health because it influences exposure to common drivers of ill-health, health care-seeking patterns and the response of the health systems to illness (Hawkes et al., 2017). As one assistant counsellor said, ‘we have communities where women will tell you, for example, their husbands don’t allow them to go for fistula and HIV treatments’. Although services such as family planning were available, over 19.8 percent of women stated that using contraception was not their decision. Stamatel and Zhang (2018) state that refugee women and children suffer from cultural influences and attempts to ‘protect’ them from unknown dangers. For instance, violence against women and children, and cultural and faith-based belief(s), reduce social connections and access to community resources. Erez and Bhat (2010) highlight the role of patriarchy (or male hegemony) as the cultural basis underlying gender roles and power differentials between the different genders. The gender norms that exalt male sexual dominance limit women’s ability to control their reproductive and sexual health (Nalukwago et al., 2019). Consistent with Crawford et al. (2017), I argue that gender analysis should not be confined to relations between men and women but should be broadened to include wider social contexts such as the household, the community and the state. In refugee situations, the concept of gender needs to be considered through the intersecting forms of marginalisation that structure women’s lives differently from those of men, such as economic position (Alsaba and Kapilashrami, 2016; Olivius, 2014). A gendered analysis needs to focus on social-cultural norms that create unequal gender relations and women’s oppression. It should adopt a gender mainstreaming perspective, promote gender equality, and empower women and girls (UN, 2016).

Implications for social work with refugees

Mwansa (2011) maintains that social problems not only open doors for the profession but also prompt social workers to establish innovations for transformation, empowerment and development. The data reveal a need for social work to create improved health at the micro, meso and macro levels. At the micro-level, social workers must perform case management, connect clients to vital resources and empower them to secure needed resources (Adams et al., 2009). Social work practitioners must therefore possess problem-solving abilities, and know accessible resources and networking skills to link clients with resources. As reflected in one of the accounts of a counsellor at Tutapona organisation, who said ‘they [refugees] have lost hope, they feel like life is not worth living, so they don’t care’, refugees need support in understanding their emotions and assistance to develop coping skills.

Analysis of qualitative and quantitative data indicates that the factors hindering women and children’s access to health services arise from social injustices and discrimination. As suggested by a social work academic interviewed, ‘in these refugee settlements we need to think more about the community’; consequently it is vital that group and community work in refugee settings should be brought to the fore alongside casework. As a growing profession in Uganda, social work practice with refugees must focus on the refugee community, first as the location of unmet needs and second as a primary resource for meeting needs (Mwansa, 2011). Through community involvement and engagement, social work would learn about the most pressing health needs, identify strengths and reduce vulnerability. Mwenyango and Palattiyil (2019) state that the use of group work and community approaches significantly unlocks the resilient capacities of refugees and leads to the development of more supportive informal care systems. For instance, a strong outreach programme and the involvement of staff of immigrant background would foster timely recognition of problem areas and bridge the distance between communities and the formal services (Valtonen, 2008), helping develop a more pro-active agency response and building community self-reliance. Through empowerment, they gain control over their circumstances. However, community practice requires the adoption of culturally sensitive approaches based on comprehensive individual-based needs assessment.

The ﬁndings suggest that refugee women and children need access to key services such as medicines, testing equipment, medical personnel and health facilities. Despite limited funding, social workers can advocate for resources to meet the need to promote resilience and social justice (Adams et al., 2009). It is essential to challenge injustice by advocating for the development of health services by promoting, protecting and sustaining policies to meet both practical and non-practical aspects of settlement (IFSW, 2012).

Furthermore, it is important to understand that several other professionals (such as health workers) who work alongside social workers also possess the necessary expertise to work with refugee women and children. As specified by an assistant counsellor at the OPM, ‘we must work with each other because, in one way or another, one issue has a way of involving all of us’. This shows the importance of social work referrals and coordination services. The need to strengthen the integrated multi-disciplinary approach connecting social workers and other professionals such as psychiatrists, counsellors and health workers is urgent for a seamless practice. Social workers in particular are well-placed to support a more integrated service (Adams et al., 2009) as they are likely to have specialised knowledge and skills to support women and children in crises. They can also become involved in improving relationships between refugees and health service providers and in addressing the reports of inconsiderate attitudes and mistrust from other service providers. In addition, they can provide counselling skills (one-off sessions, crisis work or long-term sessions) for victims of torture and trauma who perceive other professionals as distant and insensitive. To increase their significance to refugee women and children, social workers must research the various issues inhibiting their effective settlement. They must participate in the design and delivery of health services as well as act as liaison officers between the refugee community and other administrative and professional teams. This research and work on improving the health and other services for refugees should also feed back and be incorporated into the actual training of social work students and be included in the social work curriculum. For example, formal social work education should include refugee studies and cross-cultural counselling (IFSW, 2012) in order to develop a strong professional identity that is relevant to inter-professional teamwork.

Given the country’s low and unstable funding for refugee assistance, social workers cannot fulfil their obligations without the support of the government, the UNHCR and partners. Policymakers must develop an RBA, putting in place durable solutions, providing social protection, ensuring comprehensive and coordinated assistance, gender mainstreaming in health care and humanitarian assistance, and clarifying processes and procedures of assistance. This will help to streamline social work responses as a rights-based profession and reinforce social workers’ confidence in supporting refugee women and children.

Conclusion

This research reveals the complex experiences of refuge for women and children in Uganda. Many women and children are relocated into new forms of vulnerability and gendered oppression. The communication, institutional and socio-cultural impediments that may arise can result in the violation or neglect of refugee women and children’s rights. However, the RBA offers a moral basis to social work practice, both at the level of day-to-day work with clients and in policy advocacy and activism (Ife, 2001). I have shown the importance of social work in the promotion and protection of the right to health. Social workers are able to raise issues that may not be apparent to other support workers (including health workers), such as cultural or religious factors that impact on refugees’ well-being. The right to health includes the right to resources that maintain health and access to universal, affordable health care (Bywaters and Davis, 2012). The RBA parallels Valtonen’s (2008) principles for working with refugees: respect, self-determination, social justice and professional integrity. Respect based on human dignity is important for interpersonal relations. Social workers must be attentive to each client’s unique history, characteristics and situation, such as the traumatic events that led to flight, and their experiences during transit and in the destination countries (Valtonen, 2008). Self-determination recognises the rights of refugees to make their own choices and decisions. Although refugees might have limited information about accessible services as reported here, the role of the practitioner is to provide information about the choices and their likely consequences. Reflection on social justice is important to provide equal chances for refugees to access health services and thrive. Social workers must challenge injustice and discrimination at all levels, while the development of specific knowledge in settlement practice is vital for professional integrity.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Hadijah Mwenyango

Notes

Author biography

Hadijah Mwenyango is an assistant lecturer in Social Work and Social Administration (SWSA) at Makerere University, Uganda. With teaching and research experience from Scotland and Uganda, her research interests include social work, forced migration and refugees, health and human rights. She is also a member of the Global Refugee Health Research Network (GRHRN) established at the University of Edinburgh UK, to promote collaborative research and knowledge exchange activities.

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