London School of Hygiene & Tropical Medicine

Globally, there are over 35 million refugees. Refugees – especially those who face protracted displacement for longer periods of time – frequently face challenges integrating into labour markets due to legal and social restrictions on their employment. This includes health workers who are refugees, who may not be able to work in countries hosting them despite the crucial skills they offer. While there are ongoing efforts to improve refugees’ right to work, such as the Global Compact on Refugees, progress towards ensuring refugees have access to employment remains a huge challenge.

Uganda is an example of a refugee-hosting country which has made significant commitments to promote “self-reliance” among refugees, including allowing refugees to work, own businesses, and have freedom of movement. A recent report published by the Centre for Global Development looked at the reality of labour market conditions for refugees across 51 countries and found that Uganda scored as high as any high-income country in terms of laws protecting refugees’ right to work. Nevertheless, lack of knowledge about the laws on work permits for refugees commonly acts as a barrier to recruitment of refugees in Uganda.

In the health arena, many refugees report that in practice they are often excluded from meaningful work in public health facilities and in humanitarian response efforts. For World Refugee Day, we spoke to Dr Jennifer Palmer, Associate Professor of Anthropology in Global Health, about her research among South Sudanese health workers who are refugees in Uganda. Her recent study explores the social dynamics and governance issues affecting their employment opportunities in Uganda.

Can you tell us more about the background to South Sudanese refugees fleeing to Uganda?

The renewed conflict in 2013 led to massive displacement, both within South Sudan and across international borders. One million South Sudanese people fled to Uganda, including many health workers who needed to escape economic hardship and political violence, including being targeted by armed groups if seen to be providing care for the opposing side.

I had spent many years in South Sudan doing research and working on health system building projects. Whenever I spoke to my friends and collaborators who had been displaced to Uganda, I was shocked to hear about their struggles to find employment. These were incredibly skilled healthcare professionals who I knew were such a precious resource in South Sudan. This motivated me to investigate the barriers to their integration into the workforce in Uganda. In 2017 I took an exploratory visit to Uganda to meet up with one of my long-term clinical collaborators and together we spoke to humanitarian agencies to scope out this project.

Can you tell us more about the study?

We collaborated with two brilliant refugee-led organisations in Uganda, Youth Social Advocacy Team (YSAT) based in the Rhino camp settlement and South Sudan Women Building Association (SSWBA) in the Kiryandongo settlement, who identified refugee health workers to interview. These organisations are familiar with both South Sudanese and Ugandan contexts and their insights into the politics of humanitarian aid and community issues have been invaluable.

Finding health workers was challenging as many were isolated from each other without a common workplace and being new to a refugee camp, not everyone knew what people had done before they were displaced.

What did you find?

Our interviews revealed that very few health workers secured jobs commensurate with their experience and qualifications. South Sudanese healthcare professionals face barriers in having their credentials recognised by professional bodies in Uganda. They sometimes need to re-train and all must pay fees to equate their credentials, register and maintain their practicing license at higher rates than Ugandans because refugees are classed as ‘foreign workers’.

Complex bureaucratic processes are compounded by the fact that government health facilities often restrict jobs to Ugandan citizens, despite these jobs being partly funded by humanitarian aid for the refugee response. Health workers with credentials from Ugandan institutions gave examples of NGOs only offering them volunteer positions to avoid having to spend money and engage with bureaucracies to secure work permits.

These barriers resulted in refugee health workers being pushed into less challenging roles in private clinics, poorly paid positions on village health teams, or out of the health sector altogether.

How do these challenges relate to the healthcare system in Uganda?

Uganda faces a significant health worker shortage, but there is also a paradoxical surplus of unemployed domestic health workers because there’s not enough investment to fund more jobs in the health system. Domestic underemployment is partly why refugees may be excluded from applying to these scarce positions, beyond those already mentioned.

Addressing these issues requires increasing investment in health worker positions to meet the UN’s Sustainable Development Goals, streamlining hiring practices to avoid vacant positions and addressing discriminatory practices that limit recruitment of refugee health workers.

How can humanitarian organisations and governments better support the employment of refugee health workers in Uganda?

The Global Code of Practice on International Recruitment of Health Personnel monitors the movement of health workers to address brain drain from low-income countries to high-income countries like the UK. There needs to be a similar emphasis on monitoring health workers who are crossing from crisis settings into low-income countries. Introducing accountability for this kind of reporting is crucial to ensure support and resources for their employment.

There is also a need for creative, quick and low-cost ways to support refugees in Uganda to get their credentials transferred over, licensed and, when necessary, into training programmes that can upskill them to fit the requirements of the new health system contexts people are living in. As a wider issue, there needs to be advocacy to remove the requirement for refugees to have additional work permits to secure formal employment.

What are the implications of your work for supporting refugees’ access to employment?

To our knowledge, this is the first study to investigating refugee health worker livelihood experiences in Africa. We are now trying to connect with others working in diverse crisis settings to advocate for more research on the topic, including on policy interventions to improve refugee health worker inclusion into local health systems. Our collaborators have used the research findings in their advocacy work. YSAT co-chairs the Uganda working group on NGO staff recruitment for the global Charter4Change initiative focused on localisation of humanitarian aid, and will use this data to advocate for changes in NGO practices. SSWBA have plans to discuss refugee health worker unemployment in Parliament. Both organisations have helped establish networks for health workers within refugee settlements and have elected representatives to increase communications with humanitarian and other actors in Uganda.

This World Refugee Day, we want to highlight the longstanding issue of employment opportunities for refugees. The example of South Sudanese health workers in Uganda emphasises that refugees can play an important role in contributing to humanitarian health. More work is needed globally to ensure employment of refugees. Ensuring meaningful employment for refugees not only benefits the individuals but also enhances overall health and stability of host communities.

You can read more about this work in the article below:

Palmer, J., Sokiri, S., Nhial, J., Vivian, A., Ferris, D., Venner, G. and John Jal Dak (2024). From humanitarian crisis to employment crisis: The lives and livelihoods of South Sudanese refugee health workers in Uganda. The International Journal of Health Planning and Management. https://doi.org/10.1002/hpm.3777