EC Funded Primary Healthcare and Psychosocial Support Programme for IDPs in the Tuzla canton of BiH, 2000-2003

We have been working with internally displaced persons (IDPs) in the Tuzla canton since 1996. This project, completed in September 2003, was primarily funded by the EC, with valuable contributions made by: The Diana, Princess of Wales Memorial Fund, the Stanley Thomas Johnson Foundation, the American Embassy Office of Defense Cooperation, the William Cadbury Trust, the Ajahma Charitable Trust and the Toy Trust.

Project Activities

The RI programme provided primary healthcare, psychosocial support, physiotherapy, special educational teaching and advocacy services for a total beneficiary group of approximately 8,500 refugees. In addition, contingency funds were utilised to support a tuberculosis control project for refugees in the region. The key activities are described below:

Primary Health Care RI offered a comprehensive range of primary health care services to beneficiaries, through the efforts of a team of three family doctors (two whole time equivalents) and three community nurses. As well as operating a clinic base in Tuzla, a mobile clinic visited each of the collective centres on a regular basis, and those patients who were very ill or disabled were seen and cared for at home. All treatments were dispensed free of charge. Both acute and chronic diseases were managed, with close liaison with secondary care services where appropriate.

A strong emphasis was placed on child health promotion, with health education and preventive health initiatives coordinated by our team of community nurses. Specific training was provided to improve their skills and knowledge base in this area.

Psychosocial Support

Trained social workers operated alongside the medical team, providing counselling services and both individual and group therapy for this neglected and deeply traumatised population. Many refugees suffer with chronic anxiety disorder and stress as a result of their past experiences and the current pressures of daily life in the collective centres and settlements. Staff helped to alleviate much of the distress and suffering that reached beyond the normal limits of human existence.

A structured training programme enabled the range of activities to be expanded to offer support to families enduring the painful process of identifying "missing" relatives: RI staff worked with families throughout this process, providing information, support, and a link between families and the other agencies involved.

Staff also worked with a large number of beneficiaries with overt mental illness, ranging from depression to schizophrenia. A key part of their work was to identify those requiring input from specialist mental health services, and RI had a contract with a local psychiatrist to provide such services when required.

Physiotherapy and Special Education Teaching

One of the most disadvantaged groups to which RI offered its services were people with physical and learning difficulties. A high percentage of this group were children with learning difficulties. In Bosnia-Herzegovina these children are doubly disadvantaged, firstly by their refugee status, and secondly by the stigma commonly attached to children with learning difficulties. For their mothers there is a feeling of failure at the birth of a less than perfect child. The state provides no services for these children or their mothers and many of their fathers have been killed. Many parents lack the knowledge and skills needed to cope with such disability.

A physiotherapist and special education teacher provided one-to-one sessions to help children and their families learn to manage the disability or learning difficulty. After an initial needs assessment, an individual programme of care was developed for each patient. The physiotherapist and special education teacher then visited regularly to monitor progress and adjust the programme as necessary. They worked with local schools, attempting to integrate these children into mainstream education. Where this was not possible, support was provided for family members and other carers to provide a safe and stimulating environment at home.

As well as educating parents and family members to better understand and manage the illness or disability, special efforts were made to promote better understanding and greater tolerance in the community.

Tuberculosis Control

Tuberculosis (TB) is a growing problem for the refugee population throughout the Balkans. Allied to the primary health care element of the programme, we implemented a TB control project in conjunction with the National TB Programme.

This involved: the training of primary health care workers; increasing the capacity of local laboratory services; and the delivery of community workshops to raise awareness and reduce the stigma associated with TB within the refugee population.

A full description of the project is available in the reports/publications section.

Advocacy

In addition to the medical services outlined above, RI raised awareness about the continuing needs of displaced people by advocating on a daily basis on behalf of the beneficiary group. This involved representing the interests of the group to national and international, governmental and non-governmental organisations. Nationally, the staff regularly met with representatives of the Bosnian government and the Ministry of Health. On an international level project staff liaised with the European Commission, United Nations, the British government's Department for International Development and other potential donors and decision-makers.

Part of the advocacy provided by RI was the advice and information that the teams offered to the beneficiary group. By assisting the beneficiary group to develop an awareness of their rights and by helping them to access the services available to them, RI helped them to regain control of their lives.

In addition to the delivery of the above services, the programme incorporated a major training element, both clinical and administrative, for all local staff.

Impact

In the contracted period RI :

• expanded capacity to support an estimated 8,500 beneficiaries.
• monitored the health needs of displaced persons in collective centres and settlements in the Tuzla canton of Bosnia.
• promoted preventive health concepts among beneficiaries.
• contributed to mother and child health education.
• supported the social interaction of isolated individuals within beneficiary groups.
• improved the physical, psychological and social well-being of beneficiaries.
• supported families through the traumatic process of identification of missing relatives, cooperating fully with the International Commission on Missing Persons (ICMP) and the International Committee of the Red Cross (ICRC).
• supported those Kosovar refugees arriving in the project area, although numbers were less than expected due to the resolution of conflict within Kosovo.
• supported families with members suffering from physical or learning disabilities.
• contributed to measures to control the increasing incidence of TB within the displaced population of the Tuzla canton.
• benefited from a series of training workshops designed to improve their clinical (medical, nursing and psychosocial) skills and capacity to develop into a fully independent local NGO.

The most positive aspects of delivering this project were: the undoubted need for support within the beneficiary population; the opportunity to see our local staff benefit from the training provided, developing their skills and able to provide an increasing range of high quality services; the opportunity to see the impact those services had on the lives of refugees in the target area; and the close working relationship that developed with UNHCR and the relevant cantonal and federal ministries in particular.

The single most negative experience was to see the rapid withdrawal of a host of other local and international organisations from the target area, as the financial support from the international community has dwindled. This had many implications for the delivery of our services, as we (in conjunction with UNHCR and cantonal ministries) had to continually reassess which camps and collective centres were in most need of our support: the level of need for health, social, educational and economic interventions is just as great as it was three years ago, but the resources available to support local authorities have been decimated.

This project has had a significant impact on our approach to the long-term sustainability of services. As well as improving the delivery of the project, the training programme was structured to increase the capacity of our local staff to design, implement and manage future projects independently. With the establishment of a local organisation employing the core staff from this project, the success of this approach will hopefully be confirmed in the years to come.