It is Time to Change the provision of primary health care for refugees: a policy brief

It is Time to Change the provision of primary health care for refugees: a policy brief | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article It is Time to Change the provision of primary health care for refugees: a policy brief Salman Bashzar, Mostafa Amini-Rarani This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6845568/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract The large refugee population in Iran presents the health system and the host population with various challenges, the most important of which is the incidence and spread of emerging and re-emerging diseases, which in addition to the high economic burden, can create serious challenges for the health of the host population. In this qualitative study, which aimed to identify the best options and policy recommendations for providing primary health care to refugees, it is better to first formulate minor reforms in the provision of primary health care for this group of people, because effective and efficient minor reforms can reduce a large number of challenges arising from the presence of refugees. Providing primary health care and separating refugee settlements from the host population are two policy options that primary health care providers with experience working in high-density refugee settings consider vital to implement. Implementing each of these policies will lead to a reduction in diseases, especially infectious diseases, and social harms. Introduction Today there are some 1 billion migrants globally that include 122.6 million forcibly displaced (68.3 million internally displaced, 37.9 million refugees, 8 million asylum seekers and 5.8 MILLION are other people in need of international protection). Nearly two-thirds of all refugees under UNHCR’s mandate and other people in need of international protection come from just four countries include Syrian Arab Republic, Venezuela, Ukraine, Afghanistan. Colombia, Germany, the Islamic Republic of Iran, Türkiye and Uganda hosted almost one-third of the world’s refugees and other people in need of international protection ( 1 ). about 8 million Afghans live in Iran, the majority of whom are undocumented and therefore are not counted in the national census ( 2 ). communicable diseases, food insecurity and malnutrition, Low immunization coverage, non-communicable diseases (NCDs), and Psychological disorders are the main health problems of Afghan migrants in Iran ( 3 ). There are still inequalities between migrant and non-migrant populations in terms of their ability to receive services ( 4 ), and in Iran, despite providing similar services to refugees, there are many challenges that require reforms in the service delivery system ( 3 ). These challenges, which include high rates of communicable diseases such as malaria, measles, rubella, and smallpox and the possibility of transmission to sensitive populations in the destination community, non-communicable diseases such as thalassemia, diabetes, and hypertension with a high burden on the health system of the destination country, residence in informal settlements and the increase in the phenomenon of marginalization, and subsequent environmental challenges, can, in addition to cultural and ethnic differences, low literacy and education levels, language differences, the presence of untrained refugee midwives, illegal travel between the country of origin and destination without coordination with the health system of the region of residence, lack of identity documents, employment in hard and harmful work, lack of health insurance, false beliefs about health care, especially maternal and newborn care, and lack of financial ability to receive health care, severely disrupt the health of refugees and, subsequently, the health of the destination population ( 3 , 5 ). For more than two decades, the Iranian health system has been providing refugees with primary health care similar to Iranians, but little success has been achieved, and the challenges and problems that exist target not only refugees but also the health of the destination population، For this reason, urgent reforms, before implementing fundamental reforms, to maintain, improve, and promote the health status of refugees and the people of the destination community will be among the most important measures that the health system can create and establish. Methodology In this descriptive qualitative study, purposive sampling was used to select participants to reach the best possible options in providing primary health care to refugees. Then, semi-structured interviews (Interview guide in supplementary 1) were conducted to collect data and the interviews continued until saturation point was reached. The criteria used for this purpose was having work experience as a community health worker. Participants were from local and provincial levels (community health centers and provincial health districts). Participants held the following organizational positions: primary health care providers (community health workers (midwives, nutritionists, psychologists, health experts, health workers, general practitioners)), managers (staff managers and staff experts). Most respondents had direct experience (at least 10 years) in primary health care provision. All respondents completed a written consent form and were assured of the confidentiality and anonymity of their information. In total, 27 interviews were conducted, of which 19 and 8 were at the local and provincial levels, respectively. The present study used conventional content analysis with an inductive data-driven process coding and theme development for the analysis. The duration of interviews varied between 50 to 75 minutes. MAXQDA Analytics Pro 2020 (VERBI GmbH Berlin) Release 20.2.1 was used to manage and organize the transcripts systematically. Trustworthiness was ensured using the criteria proposed by Lincoln and Guba ( 6 ). Results Policy Options 1- Establish separate structures to provide PHC to refugees explanation This option suggests that independent structures for providing primary health care services for refugees be formed in the form of comprehensive health service centers, in which human resources are used from among specialized and trained refugees to provide services, or the required human resources are trained from among them in short-term courses. Advantages - Greater accountability and responsibility from service providers - Reduced transmission of infectious diseases in the host population - Prevention of conflicts and elimination of cultural, ethnic and linguistic challenges between service providers and recipients - Greater access of refugees to services - Better effectiveness of health education-based programs and interventions Disadvantages - Refugees' lack of confidence in the established structure and processes - Difficulty in networking and interactions - Difficulty in recruiting refugees - Lack of trained and skilled refugees in the health sector - Difficulty in inter-sectoral coordination - High costs of creating physical spaces and hiring human resources Considerations To create a new structure for providing primary health care for refugees, cross-sectoral interactions and collaborations between the complexes managed by the Ministry of Health and other organizations in cities with large refugee populations, as well as a careful study and location of the required spaces, are essential. 2- Establishing shelters and settling refugees and building a PHC service complex explanation This option suggests that in cities with high refugee densities, special settlements be established outside the city but close to the city. This would reduce the level of contact between the host population and refugees, reducing many of the challenges and conflicts between the two groups. Primary health care would also be easily provided, and even trained refugees themselves could be used to provide services. Advantages - Reducing ethnic conflicts and violence - Reducing the prevalence and incidence of communicable diseases - Increasing the quantity and quality of PHC services in both refugee and host communities - Effective refugee health management - Increasing refugees' access to primary health care - Increasing the effectiveness of education-based interventions - Reducing the costs of health services for refugees Disadvantages -Increasing health challenges and harms, especially social and environmental harms, in shelters -High probability of occurrence and prevalence of infectious diseases, especially respiratory and digestive diseases Considerations To implement this option, extensive inter-sectoral coordination must be carried out at the national and regional levels, and a Health Impact Assessment related to the construction of settlements must be prepared and developed. Policy Recommendation Since the implementation of each of the above options requires its own specific requirements, the government can consider the following recommendations as its main strategies to facilitate refugees' access to health care and prevent disruptions in the health of the destination population. - Identifying refugees and their place of residence - Issuing identity documents to them - Assessing health status upon arrival and periodically - Training specialized human resources from among refugees - Training existing human resources to recognize the cultural and social context of refugees - Developing regulations with clear boundaries for the provision of primary health care services Discussion It is widely accepted that refugees are at risk of poorer health outcomes, including mental health and general well-being ( 7 ). A common denominator for refugee populations is access to health care through primary health care networks in the resettlement country. Studies have focused on a variety of interventions, such as developing individual skills of refugees, primary care workers, systems integration models and structures, and systems or services integration structures, and interventions that result in increased communication ( 8 ). However, noting that providing efficient and effective health care is one of the complex challenges of health systems, this review argues that segregating and providing services in refugee-specific primary health care settings can improve the health of refugees. From the perspective of the participants in the present study, proper management of refugee health should start with more detailed reforms, and therefore, the establishment and establishment of refugee-specific primary health care service centers is an option that will solve many of the related challenges. Conclusion Refugees have created numerous health-related challenges for the host populations in recent years, so choosing efficient and effective policies to manage the health of refugees and, consequently, the health of the host population is a necessity for the health system administrators. Achieving universal health coverage is a goal that must be achieved by considering the health of refugees and making reforms in the form of service delivery and facilitating access to primary health care for them. Therefore, as initial measures, the policy options proposed can solve many health-related challenges in the refugee and host populations. Declarations Ethics approval and consent to participate: Ethical approval was received by Isfahan university of medical sciences ethics committee (Research Ethics Sub Committee research ethics committees of nursing, rehabilitation and management schools- approval number: IR.MUI.NUREMA.REC.1400.164). this study was conducted in accordance with the Declaration of Helsinki, including the requirement of informed consent from participants (Informed consent was obtained from all individual participants included in the study). Consent for publication: The authors confirm that they have read the journal’s policies and that this manuscript is submitted in accordance with those policies Availability of data and materials: YES Competing interests: The authors declare no competing interests, financial or non-financial. Funding: This manuscript has been derived from a Research project, supported financially by Isfahan University of Medical Sciences (Grant No. 2400163-2021 November 28). Authors' contributions: The two authors participated equally in drafting and preparing the article Acknowledgment: We express our gratitude to all the experts and researchers who took part in this study. References UNHCR. UNHCR’s Refugee Population Statistics Database (2025). Available from: https://www.unhcr.org/refugee-statistics / Accessed may 01, 2025 Organization WH. Mapping health systems’ responsiveness to refugee and migrant health needs. Mapping health systems’ responsiveness to refugee and migrant health needs2021. Pysklywec M, McLaughlin J, Tew M, Haines T. Doctors within borders: meeting the health care needs of migrant farm workers in Canada. Cmaj. 2011;183(9):1039-42. Lebano A, Hamed S, Bradby H, Gil-Salmerón A, Durá-Ferrandis E, Garcés-Ferrer J, et al. Migrants’ and refugees’ health status and healthcare in Europe: a scoping literature review. BMC public health. 2020;20:1-22. Spallek J, Zeeb H, Razum O. What do we have to know from migrants' past exposures to understand their health status? a life course approach. Emerging themes in epidemiology. 2011;8(1):1-8. Lincoln YS, Guba EG. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Directions for Program Evaluation. 1986;1986(30):73-84. Robertshaw L, Dhesi S, Jones LLJBo. Challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries: a systematic review and thematic synthesis of qualitative research. 2017;7(8):e015981. M PI, Walpola R, Harris-Roxas B, Li J, Mears S, Hall J, et al. Improving primary health care quality for refugees and asylum seekers: A systematic review of interventional approaches. Health expectations : an international journal of public participation in health care and health policy. 2022;25(5):2065-94. Additional Declarations No competing interests reported. Supplementary Files supplementary1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 02 Sep, 2025 Reviewers agreed at journal 18 Aug, 2025 Reviews received at journal 30 Jul, 2025 Reviewers agreed at journal 30 Jul, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviewers invited by journal 27 Jul, 2025 Editor invited by journal 25 Jul, 2025 Editor assigned by journal 01 Jul, 2025 Submission checks completed at journal 30 Jun, 2025 First submitted to journal 30 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6845568","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":491862748,"identity":"c3df9c12-b83b-4adf-99ff-9f8a3a494bff","order_by":0,"name":"Salman Bashzar","email":"","orcid":"","institution":"Social Determinants of Health Research Center, Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Salman","middleName":"","lastName":"Bashzar","suffix":""},{"id":491862749,"identity":"b5c39e89-b450-4f05-8b88-2df9224aa5e8","order_by":1,"name":"Mostafa Amini-Rarani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYLCCBAYJOShTAkweIEaLMYlagCCxgWg36TYwP93wcIdF+trZ7ReYbrZZMPC3H2A8XIFHi9kBNrMbiWckcrfdOVPAnNsmwSBxJoHh4Bm8WhiAWtqAWm7kJIC1MNxgYDiIz5lmB9i/gbSkm8G0yBPWwgO2JcHsRvoBsBYDgloO85SBtBgCHcZwOOecBI/hmcQG/FqOt2+7+bOtTh5oy8PHOWV1cnLHDx/+iE8LAzOcxWNwAEQyMDDi1YAM2B8Qq3IUjIJRMApGGAAASfpPsgJ0RtwAAAAASUVORK5CYII=","orcid":"","institution":"Health Management and Economics Research Center, Isfahan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Mostafa","middleName":"","lastName":"Amini-Rarani","suffix":""}],"badges":[],"createdAt":"2025-06-08 05:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6845568/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6845568/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87808744,"identity":"3a0739ff-1596-4bfe-a328-1e0b831ec154","added_by":"auto","created_at":"2025-07-29 08:57:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":469625,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6845568/v1/ed5dd75c-0682-4ebe-b0e8-4487d23d09a7.pdf"},{"id":87807136,"identity":"d7b3799f-4516-4d05-bf20-084a58bf13d2","added_by":"auto","created_at":"2025-07-29 08:41:52","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16053,"visible":true,"origin":"","legend":"","description":"","filename":"supplementary1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6845568/v1/002f17f1b26068a89e2b6a0a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"It is Time to Change the provision of primary health care for refugees: a policy brief","fulltext":[{"header":"Introduction","content":"\u003cp\u003eToday there are some 1\u0026nbsp;billion migrants globally that include 122.6\u0026nbsp;million forcibly displaced (68.3\u0026nbsp;million internally displaced, 37.9\u0026nbsp;million refugees, 8\u0026nbsp;million asylum seekers and 5.8 MILLION are other people in need of international protection). Nearly two-thirds of all refugees under UNHCR’s mandate and other people in need of international protection come from just four countries include Syrian Arab Republic, Venezuela, Ukraine, Afghanistan. Colombia, Germany, the Islamic Republic of Iran, Türkiye and Uganda hosted almost one-third of the world’s refugees and other people in need of international protection (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). about 8\u0026nbsp;million Afghans live in Iran, the majority of whom are undocumented and therefore are not counted in the national census (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). communicable diseases, food insecurity and malnutrition, Low immunization coverage, non-communicable diseases (NCDs), and Psychological disorders are the main health problems of Afghan migrants in Iran (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). There are still inequalities between migrant and non-migrant populations in terms of their ability to receive services (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), and in Iran, despite providing similar services to refugees, there are many challenges that require reforms in the service delivery system (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese challenges, which include high rates of communicable diseases such as malaria, measles, rubella, and smallpox and the possibility of transmission to sensitive populations in the destination community, non-communicable diseases such as thalassemia, diabetes, and hypertension with a high burden on the health system of the destination country, residence in informal settlements and the increase in the phenomenon of marginalization, and subsequent environmental challenges, can, in addition to cultural and ethnic differences, low literacy and education levels, language differences, the presence of untrained refugee midwives, illegal travel between the country of origin and destination without coordination with the health system of the region of residence, lack of identity documents, employment in hard and harmful work, lack of health insurance, false beliefs about health care, especially maternal and newborn care, and lack of financial ability to receive health care, severely disrupt the health of refugees and, subsequently, the health of the destination population (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFor more than two decades, the Iranian health system has been providing refugees with primary health care similar to Iranians, but little success has been achieved, and the challenges and problems that exist target not only refugees but also the health of the destination population، For this reason, urgent reforms, before implementing fundamental reforms, to maintain, improve, and promote the health status of refugees and the people of the destination community will be among the most important measures that the health system can create and establish.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eIn this descriptive qualitative study, purposive sampling was used to select participants to reach the best possible options in providing primary health care to refugees. Then, semi-structured interviews (Interview guide in supplementary 1) were conducted to collect data and the interviews continued until saturation point was reached.\u003c/p\u003e\u003cp\u003eThe criteria used for this purpose was having work experience as a community health worker. Participants were from local and provincial levels (community health centers and provincial health districts). Participants held the following organizational positions: primary health care providers (community health workers (midwives, nutritionists, psychologists, health experts, health workers, general practitioners)), managers (staff managers and staff experts). Most respondents had direct experience (at least 10 years) in primary health care provision. All respondents completed a written consent form and were assured of the confidentiality and anonymity of their information. In total, 27 interviews were conducted, of which 19 and 8 were at the local and provincial levels, respectively. The present study used conventional content analysis with an inductive data-driven process coding and theme development for the analysis. The duration of interviews varied between 50 to 75 minutes. MAXQDA Analytics Pro 2020 (VERBI GmbH Berlin) Release 20.2.1 was used to manage and organize the transcripts systematically. Trustworthiness was ensured using the criteria proposed by Lincoln and Guba (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePolicy Options\u003c/strong\u003e\u003c/p\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e1- Establish separate structures to provide PHC to refugees\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eexplanation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis option suggests that independent structures for providing primary health care services for refugees be formed in the form of comprehensive health service centers, in which human resources are used from among specialized and trained refugees to provide services, or the required human resources are trained from among them in short-term courses.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdvantages\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Greater accountability and responsibility from service providers\u003c/p\u003e\n \u003cp\u003e- Reduced transmission of infectious diseases in the host population\u003c/p\u003e\n \u003cp\u003e- Prevention of conflicts and elimination of cultural, ethnic and linguistic challenges between service providers and recipients\u003c/p\u003e\n \u003cp\u003e- Greater access of refugees to services\u003c/p\u003e\n \u003cp\u003e- Better effectiveness of health education-based programs and interventions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisadvantages\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Refugees\u0026apos; lack of confidence in the established structure and processes\u003c/p\u003e\n \u003cp\u003e- Difficulty in networking and interactions\u003c/p\u003e\n \u003cp\u003e- Difficulty in recruiting refugees\u003c/p\u003e\n \u003cp\u003e- Lack of trained and skilled refugees in the health sector\u003c/p\u003e\n \u003cp\u003e- Difficulty in inter-sectoral coordination\u003c/p\u003e\n \u003cp\u003e- High costs of creating physical spaces and hiring human resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eConsiderations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTo create a new structure for providing primary health care for refugees, cross-sectoral interactions and collaborations between the complexes managed by the Ministry of Health and other organizations in cities with large refugee populations, as well as a careful study and location of the required spaces, are essential.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e2- \u003cstrong\u003eEstablishing shelters and settling refugees and building a PHC service complex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eexplanation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis option suggests that in cities with high refugee densities, special settlements be established outside the city but close to the city. This would reduce the level of contact between the host population and refugees, reducing many of the challenges and conflicts between the two groups. Primary health care would also be easily provided, and even trained refugees themselves could be used to provide services.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdvantages\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Reducing ethnic conflicts and violence\u003c/p\u003e\n \u003cp\u003e- Reducing the prevalence and incidence of communicable diseases\u003c/p\u003e\n \u003cp\u003e- Increasing the quantity and quality of PHC services in both refugee and host communities\u003c/p\u003e\n \u003cp\u003e- Effective refugee health management\u003c/p\u003e\n \u003cp\u003e- Increasing refugees\u0026apos; access to primary health care\u003c/p\u003e\n \u003cp\u003e- Increasing the effectiveness of education-based interventions\u003c/p\u003e\n \u003cp\u003e- Reducing the costs of health services for refugees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisadvantages\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-Increasing health challenges and harms, especially social and environmental harms, in shelters\u003c/p\u003e\n \u003cp\u003e-High probability of occurrence and prevalence of infectious diseases, especially respiratory and digestive diseases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eConsiderations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTo implement this option, extensive inter-sectoral coordination must be carried out at the national and regional levels, and a Health Impact Assessment related to the construction of settlements must be prepared and developed.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePolicy Recommendation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSince the implementation of each of the above options requires its own specific requirements, the government can consider the following recommendations as its main strategies to facilitate refugees\u0026apos; access to health care and prevent disruptions in the health of the destination population.\u003c/p\u003e\n\u003cp\u003e- Identifying refugees and their place of residence\u003c/p\u003e\n\u003cp\u003e- Issuing identity documents to them\u003c/p\u003e\n\u003cp\u003e- Assessing health status upon arrival and periodically\u003c/p\u003e\n\u003cp\u003e- Training specialized human resources from among refugees\u003c/p\u003e\n\u003cp\u003e- Training existing human resources to recognize the cultural and social context of refugees\u003c/p\u003e\n\u003cp\u003e- Developing regulations with clear boundaries for the provision of primary health care services\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIt is widely accepted that refugees are at risk of poorer health outcomes, including mental health and general well-being (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). A common denominator for refugee populations is access to health care through primary health care networks in the resettlement country.\u003c/p\u003e\u003cp\u003eStudies have focused on a variety of interventions, such as developing individual skills of refugees, primary care workers, systems integration models and structures, and systems or services integration structures, and interventions that result in increased communication (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, noting that providing efficient and effective health care is one of the complex challenges of health systems, this review argues that segregating and providing services in refugee-specific primary health care settings can improve the health of refugees. From the perspective of the participants in the present study, proper management of refugee health should start with more detailed reforms, and therefore, the establishment and establishment of refugee-specific primary health care service centers is an option that will solve many of the related challenges.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRefugees have created numerous health-related challenges for the host populations in recent years, so choosing efficient and effective policies to manage the health of refugees and, consequently, the health of the host population is a necessity for the health system administrators. Achieving universal health coverage is a goal that must be achieved by considering the health of refugees and making reforms in the form of service delivery and facilitating access to primary health care for them. Therefore, as initial measures, the policy options proposed can solve many health-related challenges in the refugee and host populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was received by Isfahan university of medical sciences ethics committee (Research Ethics Sub Committee research ethics committees of nursing, rehabilitation and management schools- approval number: IR.MUI.NUREMA.REC.1400.164).\u0026nbsp;this study was conducted in accordance with the Declaration of Helsinki, including the requirement of informed consent from participants (Informed consent was obtained from all individual participants included in the study).\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e \u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that they have read the journal\u0026rsquo;s policies and that this manuscript is submitted in accordance with those policies\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e \u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYES\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e \u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests, financial or non-financial.\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e \u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript has been derived from a Research project, supported financially by Isfahan University of Medical Sciences (Grant No. 2400163-2021 November 28).\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe two authors participated equally in drafting and preparing the article\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e \u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe express our gratitude to all the experts and researchers who took part in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUNHCR. UNHCR\u0026rsquo;s Refugee Population Statistics Database (2025). Available from: https://www.unhcr.org/refugee-statistics / Accessed may 01, 2025\u003c/li\u003e\n\u003cli\u003eOrganization WH. Mapping health systems\u0026rsquo; responsiveness to refugee and migrant health needs. Mapping health systems\u0026rsquo; responsiveness to refugee and migrant health needs2021.\u003c/li\u003e\n\u003cli\u003ePysklywec M, McLaughlin J, Tew M, Haines T. Doctors within borders: meeting the health care needs of migrant farm workers in Canada. Cmaj. 2011;183(9):1039-42.\u003c/li\u003e\n\u003cli\u003eLebano A, Hamed S, Bradby H, Gil-Salmer\u0026oacute;n A, Dur\u0026aacute;-Ferrandis E, Garc\u0026eacute;s-Ferrer J, et al. Migrants\u0026rsquo; and refugees\u0026rsquo; health status and healthcare in Europe: a scoping literature review. BMC public health. 2020;20:1-22.\u003c/li\u003e\n\u003cli\u003eSpallek J, Zeeb H, Razum O. What do we have to know from migrants\u0026apos; past exposures to understand their health status? a life course approach. Emerging themes in epidemiology. 2011;8(1):1-8.\u003c/li\u003e\n\u003cli\u003eLincoln YS, Guba EG. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Directions for Program Evaluation. 1986;1986(30):73-84.\u003c/li\u003e\n\u003cli\u003eRobertshaw L, Dhesi S, Jones LLJBo. Challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries: a systematic review and thematic synthesis of qualitative research. 2017;7(8):e015981.\u003c/li\u003e\n\u003cli\u003eM PI, Walpola R, Harris-Roxas B, Li J, Mears S, Hall J, et al. Improving primary health care quality for refugees and asylum seekers: A systematic review of interventional approaches. Health expectations : an international journal of public participation in health care and health policy. 2022;25(5):2065-94.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6845568/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6845568/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe large refugee population in Iran presents the health system and the host population with various challenges, the most important of which is the incidence and spread of emerging and re-emerging diseases, which in addition to the high economic burden, can create serious challenges for the health of the host population. In this qualitative study, which aimed to identify the best options and policy recommendations for providing primary health care to refugees, it is better to first formulate minor reforms in the provision of primary health care for this group of people, because effective and efficient minor reforms can reduce a large number of challenges arising from the presence of refugees. Providing primary health care and separating refugee settlements from the host population are two policy options that primary health care providers with experience working in high-density refugee settings consider vital to implement. Implementing each of these policies will lead to a reduction in diseases, especially infectious diseases, and social harms.\u003c/p\u003e","manuscriptTitle":"It is Time to Change the provision of primary health care for refugees: a policy brief","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-29 08:41:47","doi":"10.21203/rs.3.rs-6845568/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-02T18:29:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9803037726471571019372956146604196045","date":"2025-08-18T08:35:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-30T11:04:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175062654933959567927445789700693144757","date":"2025-07-30T10:36:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59984431639910602908829173243562388154","date":"2025-07-28T06:16:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"110433843035852314143431904567204980181","date":"2025-07-28T04:25:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-27T21:23:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-25T14:18:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-01T07:06:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-01T03:05:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-06-30T22:09:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"234ef19e-1f2d-4c6e-beff-251da3d0991b","owner":[],"postedDate":"July 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-29T08:41:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-29 08:41:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6845568","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6845568","identity":"rs-6845568","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}