Policies on return and reintegration of displaced healthcare workers towards rebuilding conflict-affected health systems: a review for The Lancet-AUB Commission on Syria

Abstract

Background War and armed conflicts severely disrupt all health system components, including the healthcare workforce. Although data is limited on the scale of health care worker (HCW) displacement in conflict zones, it is widely acknowledged that conflict conditions result in the displacement of a significant portion of qualified HCWs from their country of origin. While voluntary HCW return is integral to health system rebuilding in conflict-affected and post-conflict settings, there has been little exploration of the nature of national or international policies which encourage HCW return and reintegration to their home countries in the post-conflict period. Methods We conducted a systematic review to identify policies and policy recommendations intended to facilitate the return of displaced HCWs to their home countries and acknowledge their contribution to rebuilding the post-conflict health system. We searched three bibliographic databases and a range of organisational and national health agency websites to identify peer-reviewed articles and grey literature published in English or Arabic between 1 January 1990 to 24 January 2021, and extracted relevant information. We classified policies and policy recommendations using an adapted version of the UNHCR 4Rs Framework. Results We identified nine peer-review articles and four grey literature reports that fit our inclusion criteria, all of which were published in English. These covered issues of repatriation (n = 3), reintegration (n = 2), health system rehabilitation and reconstruction (n = 2); six documents covered several of these themes. Information was available for nine conflict contexts: Afghanistan, Iraq, Kosovo, Lebanon, Namibia, Northern Uganda, South Sudan, Timor Leste, and Zimbabwe. Findings demonstrate that health system rebuilding and rehabilitation serve as precursors and reinforcers of the successful return, repatriation, and reintegration of displaced HCWs. Conclusions Despite the significant numbers of HCWs displaced by conflict, this study identified few specific policies and limited information explicitly focused on the repatriation and reintegration of such workers to their home country in the post-conflict period. Additional research is needed to understand the particular barriers faced by conflict-displaced HCWs in returning to their home country. Conflict-affected and post-conflict states should develop policies and initiatives that address factors within and beyond the health sector to encourage displaced HCW return and provide sustainable reintegration solutions for those who return to post-conflict health systems.

Oral health system strengthening in fragile and conflict-affected states: A systematic review

“…Conflicts typically deplete a significant portion of a country's resources, placing the health system in competition with other government priorities, notably pronounced in oral health care services, even within the broader health system [41,53]. Furthermore, national health systems often become intentional or unintentional targets during conflicts, compelling health care workers to migrate in disaster situations [65][66][67][68][69]. This phenomenon has been observed in countries like Cambodia, Mozambique, Rwanda, and Haiti, where the already sparse health care workforce has faced casualties and migrations [41][42][43][44].…”

Health system strengthening in fragile and conflict-affected states: A review of systematic reviews

“…Hence, involving traditional community leaders and empowering the community as service users to propose their own solutions was emphasised as a means to enhance healthcare delivery, ensure cultural appropriateness, and overcome resistance [42]. Faith-based organisations, including churches, also played an influential role in reaching out to migrant healthcare workers and mobilising them to return to their home countries to strengthen the post-conflict health systems in their respective countries [45]. Furthermore, communities have played a role in mobilising political will for quality healthcare services [34].…”

“…Conflict-affected settings faced unique challenges in terms of health workforce. During conflicts, national health systems and healthcare workers often become targets, leading to displacement, injuries, or even death because of targeted attacks or collateral damages [39,45,46,55,56]. In such settings, healthcare workers tend to leave their jobs or country, seeking safety and recognition for their skills elsewhere.…”

“…Despite the challenges, available evidence suggests that some healthcare workers chose to remain in conflict-affected settings or return from migration due to personal connections, community support, intrinsic motivations, and favourable working conditions [45,55]. At times, policymakers have introduced programmes to reintegrate returned healthcare workers; however, it appears that, logistical, and financial barriers, legal status, and certification posed significant challenges to their reintegration [45].…”

“…Despite the challenges, available evidence suggests that some healthcare workers chose to remain in conflict-affected settings or return from migration due to personal connections, community support, intrinsic motivations, and favourable working conditions [45,55]. At times, policymakers have introduced programmes to reintegrate returned healthcare workers; however, it appears that, logistical, and financial barriers, legal status, and certification posed significant challenges to their reintegration [45]. In some areas, the returning healthcare workers had a better chance of employment due to the better education they may have gained; however, there is evidence that feelings of emotional resentment from, or even being threatened by those who did not leave; and working through this situation had been challenging [45].…”