Promoting access to preventive chemotherapy for neglected tropical diseases among refugees in Niger

Preliminary epidemiological evidence indicates that refugees are exposed to schistosomiasis, soil-transmitted helminths, trachoma, and taeniasis; all treatable neglected tropical diseases(NTDs). To control these diseases, ministries of health (MoHs) often carry out the distribution of medicines to people affected. However, refugees are excluded in these programmes.

Niger hosts around 250,000 refugees including children, elderly, and disabled people, mostly from Nigeria and Mali, due to ongoing conflicts within the Sahel and Lake Chad Basin regions. This population is particularly vulnerable to NTDs, and usually come from poor rural areas, with limited public health or water and sanitation services. Forcefully removed from their homes, they often travel through difficult terrain, arriving at overcrowded settlements that lack adequate sanitation and face reduced access to public health services and economic opportunities.

Addressing the unmet need 

Ensuring that refugees and displaced persons have access to adequate health services is a principle within the United Nations Leave No One Behind Agenda. Although the provision of health services to refugees is the responsibility of the United Nations’ High Commissioner for Refugees (UNHCR), the Ministry of Health (MoH) and local NTD officials in Niger highlighted the need to strengthen coordination across the public health and humanitarian sectors. This came in response to growing concerns that refugee settlements may act as hotspots for NTDs and that growing and untreated displaced populations may re-introduce NTDs in areas with low disease prevalence.  

The World Health Organization’s NTD roadmap for 2030 therefore recommends that refugees have access to treatment. 

About the project 

This project trialled the use of a systems-based approach to identify and examine the factors shaping refugees’ access to preventive chemotherapy (PC) treatment in Niger. A systems-based framework helps to comprehensively outline the interactions between actors, processes, and contextual factors shaping the outcome of an intervention. This in turn helps decision-makers to identify optimal intervention areas for positive change. 

Objectives 

• Identify the mechanisms that limit refugees’ access to PC treatment for NTDs (soil-transmitted helminths, schistosomiasis, trachoma, and onchocerciasis) in Niger 

• Identify the pathways through which refugees participate in control activities managed by the MoH and the MoH’s capacity to monitor this process 
• Outline strategies that have the potential to enhance access to PC among refugees, drawing on the findings from the systems modelling exercise 

The project was implemented in three phases:  

1. Outline key ‘problem areas’ – unstructured interviews with national-level stakeholders from NTD and humanitarian agencies to understand any issues affecting the operations of humanitarian and NTD agencies concerning refugees’ access to PC treatment. 
2. Problem formulation – semi-structured interviews with participants from stage one and frontline officers operating in a refugee camp in Ouallam district. It served to uncover factors (in)directly shaping problems identified during stage one and to outline interactions between them. 
3. Modelling – a systematic desk-based consolidation of stakeholders’ representations of system operations was developed to graphically represent identified linkages, impacts, and feedback mechanisms.   

Achievements of the project  

The project has helped to expose the following issues: 

• Growing population displacement stretches the monitoring capacity of and material resources available to NTD and humanitarian agencies to respond to refugees’ treatment needs 
• The number of treatments required by refugees in Niger is affected by their living situation. Settlements are commonly based in endemic areas, living conditions are inadequate, and back-and-forth travel facilitates disease transmission among local communities and across borders 
• Awareness-raising activities help to counteract risk practices facilitating NTDs transmission as well as treatment acceptance within refugee settlements 
• The type of refugee settlement (informal or formal), geographical proximity to hosting native villages, length of residence, involvement in community governance structures, and enrolment in public schools determine the likelihood of refugees being reached by the MoH’s treatment activities  
• NTD programmes’ frontline operations are affected by limited access to information on the PC treatment options available to refugees and associated community-based interventions. 

Next steps 

Drawing on the evidence gathered through this study, local NTD and humanitarian agencies are able to outline critical actions that could improve refugees’ access to PC treatment for NTDs in Niger. Unlimit Health is striving to facilitate further discussion across both types of agencies to foster the development of a common programmatic agenda on the subject, as part of its broader commitment to the Sustainable Development Goal’s principle of ‘Leaving No One Behind’.