[Currently working on the Refugee Program in a Delhi based organization, The Other Media]
What should the standard of health care for refugees be in an urban area? How should the policy be framed and how should this policy be implemented? These are some of the question that this article seeks to answer, based on the experience of working with Burmese refugees in New Delhi. It is not an exhaustive study of the access to health care in a metropolitan city like Delhi but is based on some hands on experience of our attempt to facilitate health care services in case of serious illness.
In countries like India, which has neither ratified the UN Convention on the Status of Refugees, 1951 nor has adopted a refugee protection and rights legislation, refugees come within the mandate of UNHCR. Although the Government of India informally recognizes refugee status and allows them to live within its territory, it formally does not take the responsibility to care for refugees in areas of employment, education, health care, social security and other areas. Be that as it may, experiences of negoitation with state institutions that are mandated to provide basic services speak of the various ways in which the State may or may not aid refugees while they stay in the host country. It is for this reason that the role of UNHCR and its Implementing/Operational Partners become important, not only as a pressure group but also as an agency that would support and facilitate refugee protection and assistance in the city.
Health care for Burmese refugees 1 in New Delhi comes under the mandate of UNHCR with the responsibility of implmenting the policy and programs delegated to Implementing Partner, the YMCA. Refugees are encouraged to access Government hospitals for treatment as they are free. Additionally, YMCA in discharging its support functions provides translators, community health workers, a shuttle service from select points to the hospital, and psychosocial support for unaccompanied minors and women. Lastly, doctors in YMCA provide primary health care facilities and reimbursement of costs of medicines on submitting the medical prescription and bills. Thus, although refugees have an avenue in accessing government hospitals and health centres, serious health issues often go untreated due to monetary constraints.
The question then is, what should be the nature of support and assistance in ensuring that health issues do not go untreated?
A Way Out, But What Lessons Does this Example Teach Us?
A recent experience would help raise some of these concerns. In September 2008, the Desk was approached by a 78 year old Chin refugee seeking assistance for immediate heart surgery for a pacemaker. A recognized refugee, he lives with his two children, does not earn and is supported by an allowance of Rs. 1400 by UNHCR New Delhi.
This request led us to get in touch with the Government hospital which had earlier diagnosed him 2 where it was recommended that the patient be admitted at once. This is relevant and indicates the extent of confusion and lack of clarity on the ways in which health becomes an accessible service on part of both the patient and the hospital. This is an example of the little knowledge about refugees and their situation amongst people generally and institutions such as these in particular. On the other hand, the Desk on its part assumed that admission was not possible because the patient not only does not have the monetary resources for such a surgery 3 but is also a non citizen, meaning that he would not be entitled to free medical services for surgeries such as these that cost a lot of money. The refugees themselves, more often than not, intimidated by the way in which government hospitals such as these work – lack of information that is readily available, the little time that doctors usually have for patients in a typical situation, and lack of sufficient knowledge about the bureaucratic nature of these institutions.
The hospital was infromed about these constraints such as the paucity of financial resources and lack of proof proof indicating his economic status such as a BPL Card or a Ration card. We were told that admission and free treatment would be possible if we could submit an Income Certificate 4 from the Sub-Divisional Magistrate 5. With the assistance of Socio-Legal Information Centre, one of the Implmenting Partners, the patient was received the Income Certificate and within 2 months was admitted to the hospital. A “Purchase Committee” assessed his file and agreed to assisting the patient. At the time of writing this article, the patient is back home with a successful surgery.
Some points are worth highlighting from this experience. It brings to the fore, questions of the extent and nature of health care and assitance available to refugees generally in India. This is perhaps the first time that a refugee with negligible income is able to get treated free of cost for major illness/health condition.
Long Term Implications
What does this experience imply for refugee communities, the UNHCR and the Government in the long run. Perhaps the hospital on its part addressed this issue in the manner it did purely from a medical point of view, oblivious to other legal and policy considerations 6. If an income certificate is the only hurdle between poor refugees and access to these services, this should become part of the health policy and be disseminated across all refugee communities.
The Role of the Implementing Partners in their “Support” Functions
The YMCA and SLIC have an important role to play to ensure that specialized health care becomes a reality. Thus, while not only ensuring that information about the procedures involved in applying for an income certificate and helping refugees acquire them would have to be undertaken by them on a regular basis, their role in equipping community social workers and community health workers to “work” the health care system would also be crucial. Similar would be the role of other NGOs in this regard.
Community Health Workers would need to be trained in not only language skills but also on the nature of the health care system and the way it operates. Often refugees are frustrated by the way they are treated in the hospitals, not knowing that Indians run the risk of an indifferent hospital staff equally. This leads to a feeling of discrimination and hostility towards the Indians which could be avoided.
However, a team of Burmese community health care workers unaccompanied by Indians would not help in building capacities of the Burmese in the long run.
The Role of the Burmese Community
This also highlights the importance of language skills amongst all refugees despite knowing well that not all are able to learn either Hindi or English well. From our experience, most of the Community Health Workers are ill-equipped to deal with these situations on their own.
The question as to the nature of assistance and the standard of health care for refugees is one that the UNHCR itself is trying to answer. While the perspective that refugees should access the existing system without the need for establishing parallel system specifially for refugees is appreciated, what is clearly lacking in New Delhi is a well thought out system of equipping refugees and local authorities to deal with the fact that refugees would always have the need to access basic services, notwithstanding the lack of governement policy in this regard. For the Burmese community in particular, pressure on the Government on the question of health care is another way of bringing their concerns to the fore, in a situation where relations between India and Burma are warm to the exclusion of any concern for human rights and and democracy in Burma.
1.This example would also apply to any other refugee seeking similar assistance.
2.G B Pant Hospital in North Delhi.
3.A pacemaker costs Rs 45,000 or Rs. 60,000 depending on what the patient opts. In a private hospital, there would be additional expenses of rent for the bed and medicines etc.
4.An income certificate is issued in about three weeks. An application is made to the Sub-Divisional Magistrate by submitting a copy of the ration card, an affidavit regarding residence, occupation, property owned and income. A local enquiry is conducted by the office and the certificate issued on submission of the Report.Refer http://www.delhigovt.nic.in/dept/pubserv/Income.asp#q1 (accessed 8 March 2009)
5.Each district in Delhi is under the charge of the (). It is further divided into sub-division with each such sub-division under the charge of a Sub-Divisional Magistrate.
6.I would like to thank my colleague, Mr Leo Fernandez for bringing out this point while discussing this matter with him.