Natalia Korobkova,1 Nina Nepesova2 and Delphine Valette3
To better understand vaccination barriers and the impacts of Covid-19 on forcibly displaced persons (FDPs, i.e. refugees, and internally displaced persons (IDPs)), World Vision International carried out a multi-country survey of refugee populations in Colombia, Peru, Brazil, Uganda, the Democratic Republic of the Congo (DRC), Jordan, and Turkey, and IDPs in Venezuela. The survey found that a combination of barriers led to FDPs falling through the gaps of national Covid-19 vaccination campaigns, despite their heightened vulnerability to Covid-19 infection and transmission. Only one person out of the 1,914 FDPs surveyed reported receiving a Covid-19 vaccine. The survey also highlighted the significant indirect impacts of the pandemic on forcibly displaced families, and children specifically, with the socioeconomic aftershocks of the Covid-19 pandemic worsening displaced children’s deprivations across health and nutrition, protection support, and education.
Covid-19, forcibly displaced, internally displaced, refugees, vaccine equity, vaccine access, pandemic response, humanitarian response, children, vulnerabilities.
The Covid-19 pandemic has changed the world. It has tested our resilience and capacity to adapt; disrupted health systems; and plunged the global economy into deep contraction. Most of all, the pandemic has tested our collective sense of unity and humanity. We have witnessed countless examples of solidarity, compassion, and altruism. We have also witnessed an increase in inequality and a worsening of nationalism and discrimination, particularly in relation to Covid-19 vaccine access.
The pandemic has affected everyone, but what we do not always see is how it has not affected everyone equally. People who are forcibly displaced face myriad challenges that others do not. They must protect themselves from contracting Covid-19, access (often limited) health-care services when family members fall ill, and cope with the pandemic’s indirect impacts. They must do all of this while also living in precarious situations resulting from crises, persecution, conflict, and violence.
Despite early warnings by humanitarian agencies and public health experts (IRC 2020), the disparate impacts of the Covid-19 pandemic on forcibly displaced persons (FDPs)4 have been largely overlooked (Poe et al. 2020). Over the past months, Covid-19 cases in humanitarian settings, including amongst FDPs, have reached alarming levels (IRC 2021). In April 2021, the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) reported that over one third of countries covered by Humanitarian Response Plans recorded more cases in the first four months of 2021 than in the whole of 2020 (OCHA 2021). This is why equitable distribution of the Covid-19 vaccine to these particularly vulnerable groups is a critical and substantial challenge that must be addressed.
The vaccine deployment strategies of a large number of many low- and middle-income countries (LMICs) (based on data available) are lacking in equity and clarity about eligibility and prioritisation. This is despite the critical frameworks in place to support equitable vaccine distribution to FDPs (OHCHR 2020) and the World Health Organization’s (WHO) comprehensive guidance on vaccine allocation and prioritisation. The United Nations High Commissioner for Refugees (UNHCR) reported that in April 2021 (UNHCR 2021b), only 20 countries were known to have begun vaccinating refugees and asylum seekers on an equal footing to citizens, including Jordan and Uganda (Kasujja 2021). World Vision’s survey found that FDPs, in particular unregistered refugees and undocumented migrants in the DRC and Turkey, were being left out of national plans or were included in the plans in theory, but in practice were not receiving or were very unlikely to receive the vaccine.5
In May 2021, the International Organization for Migration (IOM) published the most comprehensive analysis on the inclusion of migrants in National Vaccination Deployment Plans available at the time. This analysis was based on a review of 152 of these plans, as well as a review of the practices of 168 countries (IOM 2021).6 It showed that 61 countries did not include refugees or asylum seekers in their plan (34) or were unclear (27) if they were included, and about 30 per cent of plans reviewed did not include IDPs (29) or were unclear (17).
During this time, high-income countries (HICs) sat on millions of surplus Covid-19 vaccine doses (UNICEF 2021), while many LMICs struggled to access doses to vaccinate their populations (Our World in Data 2021). The situation was further intensified by the second wave of Covid-19 in India in April 2021, which led the government to suspend vaccine exports. This led to shortfalls globally and disrupted vaccination campaigns (GAVI 2021), including in countries that were due to start vaccinating refugees, such as Bangladesh (WHO Bangladesh 2021).
LMICs, which host the majority of the world’s FDPs, also often deal with overwhelmed health systems and a host of other issues that contribute to their vaccine shortages. These issues include poor financial resources, lack of capacity (e.g. cold chain equipment and reliable electricity), and weak infrastructure to implement vaccination programmes and reach people living in rural and remote areas. A lack of strong and efficient distribution systems, shortage of sufficient health workers, and inadequate facilities, combined with high rates of vaccine hesitancy,7 are leading some of the poorest countries, such as the DRC and South Sudan, to send doses to other countries (Jerving 2021) or throw away expired doses (Aizenman 2021). These countries are facing a double burden to cope with the effects of the Covid-19 pandemic on their own populations and those they host, all with less resources than HICs.
A solution is available to ensure vaccine delivery to FDPs: COVAX. As of July 2021, COVAX (Covid-19 Vaccines Global Access) aimed to deliver 2 billion doses to vaccinate countries’ high-risk populations by the end of 2021, with agreements or commitments in place from over 190 countries. A further 1.8 billion doses were planned to be made available by early 2022 for 92 LMICs (CEPI et al. 2021). This included Uganda, host to one of the world’s largest refugee populations. While COVAX has established a ‘humanitarian buffer’ to save 5 per cent of vaccine doses for emergency purposes, such as vaccinating refugees who may not otherwise have access to vaccines, the buffer is considered a mechanism of last resort. In addition to this, the actual cost of delivering vaccines in emergency hotspots and responsibility for paying for delivery and distribution is not always clear, with global humanitarian appeals not appearing to cover vaccine roll-outs (IASC 2021).
As we know, global mechanisms do not always reach the most vulnerable individuals. Thus, ahead of World Refugee Day 2021, World Vision spoke directly with FDPs in several settings to hear their perspectives and the issues most affecting their families. This was done through a survey, which focused on two key areas: Covid-19 vaccine access, including information, eligibility, and availability; and Covid-19’s indirect impact on livelihoods and subsequent effect on children’s living conditions, education, health, nutrition, and wellbeing.
The survey, which was conducted in eight countries between 25 April and 9 May 2021, used a mix of sampling methodologies (random, purposive, and convenience sampling). A total of 339 households in Brazil (39), Peru (50), Colombia (43), Venezuela (39), Turkey (49), Jordan (39), Uganda (34), and the DRC (46), with an average number of six people represented per household, were interviewed over the phone or face-to-face.8 Consideration was given to the sex, age, legal status, and living situations of the respondents. Respondents lived in many contexts, including urban, rural, semi-urban, slums, refugee/IDP camps, and low‑income housing settings, and over 62 per cent were women, reflecting the high number of female-led households amongst displaced families, particularly in Colombia, Peru, and Venezuela. The survey was supplemented with desk-based research.
Survey data and desk-based research show that several of the host governments made efforts to include FDPs in national Covid-19 vaccination, prevention, and treatment plans. A number of refugees in Brazil (51 per cent), Jordan (38 per cent), and Peru (32 per cent) reported that their host countries provided them with temporary legal status so that they could access any services available to FDPs. In Jordan, the government adapted the vaccinations and health-care measures it already provided to asylum seekers and refugees (OECD 2020), to respond to Covid-19-related needs. Colombia vaccinates registered Venezuelan refugees and provides them with access to Covid-19 health care (Treisman 2021). Peru approved temporary health coverage for migrants suspected of or testing positive for Covid-19 (IISD SDG Knowledge Hub 2020). Turkey provided registered refugees with free protective equipment, Covid-19 tests, and treatment, irrespective of whether they were entitled to these social security benefits. In addition to Covid-19 tests and comprehensive health care (d’Orsi 2020), Uganda has identified refugees as a priority group and is targeting them in their vaccine roll-out (UNHCR 2021a).
The first key finding indicates that FDPs face multiple barriers to accessing Covid-19 vaccines, even when they are available to them. This is largely due to a lack of reliable information, xenophobia and mistrust, and/or migration status. Out of 339 household interviews (representing 1,914 FDPs), only one refugee in Uganda reported receiving a Covid-19 vaccine.
Lack of reliable information is a critical barrier that prevented or deterred FDPs from accessing the Covid-19 vaccine. Almost half (45 per cent) of respondents reported not receiving any Covid-19 information, affecting their knowledge and awareness about vaccine eligibility, safety, and costs. Even if FDPs wished to get vaccinated, the majority (68 per cent) had not heard of any vaccine roll-out plans in their communities, and many (47 per cent) did not know if they were even eligible to receive a vaccine or thought they were ineligible.
In the absence of adequate governmental communication strategies providing fact-based information about Covid-19 vaccines to FDPs, FDPs have no choice but to resort to less reliable sources such as social media. Further complicating matters, the pandemic has led to what the WHO has called an ‘infodemic’ (Fleming 2020). An ‘infodemic’ can be explained as an over-abundance of information from many sources (some accurate and some not) that quickly spreads. The majority of respondents said that they used ‘informal’ or unverified information to find out about the Covid-19 pandemic. The top three sources reported were social media (40 per cent), television (25 per cent), and friends and relatives (24 per cent). This suggested that even FDPs that said they had access to Covid-19 information did not necessarily have accurate information, which may compound inaccurate beliefs about Covid-19 and vaccines.
Even when national communication campaigns are in place, unless they are tailored to specifically include messages to reach FDPs, information may still not reach the most marginalised and vulnerable. This is because information may be communicated via inaccessible channels (IFRC 2020) or in a way that does not make sense to these communities. For example, language and cultural differences can lead to misinterpretation of messages and present barriers to accessing health information (Kluge et al. 2020).
Information channels also vary greatly depending on context, as some may not have access to electronic or online resources. For example, in Uganda, 76 per cent of respondents said that they rely primarily on the radio to access Covid-19 information. In the DRC, however, the majority of refugees surveyed reported that they do not own electronics, so presumably they have more limited access to information that is not provided using offline tools such as posters and pamphlets, or in-person communication. This is especially relevant as when FDPs were asked about which sources they trusted to inform them about the effectiveness and safety of vaccines, respondents said that health providers (52 per cent) had their highest level of trust, followed by religious leaders. Depending on local Covid-19 prevention measures, access to in-person meetings with these individuals may be limited, which could cause further challenges to IDPs seeking trusted advice.
For those who could access information, additional barriers such as xenophobia may prevent FDPs from accessing vaccines and contribute to hesitancy. The survey found that all FDPs had experienced increased xenophobia, including hate speech and physical attacks, over the past 12 months. FDPs in Peru (46 per cent), Colombia (28 per cent), Brazil (15 per cent), and Turkey (10 per cent) reported the highest numbers. Respondents also said that they were being blamed for the virus, with Central African refugees in the DRC (32 per cent) most likely to report this, followed by South Sudanese refugees in Uganda (17 per cent).
Increased economic and financial pressures on host populations due to the indirect impact of the Covid-19 pandemic have also aggravated existing xenophobic attitudes and contributed to lessening support for FDPs by host governments.
These findings support existing evidence that xenophobia (UN 2020) has been fuelled by the pandemic. This is largely due to the ‘othering’ of displaced people within political discourse and media as well as discriminatory restrictions towards these populations who are often seen by host communities and governments as a threat to public health (Rohwerder 2021; ESCWA 2020).
FDPs face greater risk of contracting Covid-19 and have fewer resources to fight it. When populations live in overcrowded, unsanitary living conditions with inadequate access to water, sanitation, and hygiene services (Vince 2020) – such as large camps or informal settlements – their risk of disease significantly increases, including their vulnerability to Covid-19. Respondents in Turkey (61 per cent) and the DRC (60 per cent) told us that lockdown rules and movement restrictions were more stringent for them than for host communities, which affected their access to health care. Beyond this, even when restrictions are equal, they can still disproportionately affect FDPs. For example, in Uganda, the government banned public and private transportation, which prevents FDPs in refugee settlements from accessing essential health services as homes can be located several kilometres from service points (Persons with Specific Needs Sub-Working Group, Uganda 2020).
A third barrier to accessing vaccines that arose from the survey findings was migration status. Fear of the consequences related to potentially needing to disclose immigration status (Zard et al. 2021) to access vaccines (and a broader range of Covid-19 health services) acted as a deterrent for unregistered refugees and IDPs (Kluge et al. 2020). Some respondents said that they would be ‘very unlikely’ or ‘somewhat unlikely’ to get the vaccine because of documentation concerns. Other respondents reported that shutdowns due to the pandemic led to their asylum and/or refugee claim or resettlement process being delayed or halted, particularly in Uganda, potentially excluding them from vaccination campaigns.
While these three intersectional barriers (lack of reliable information, xenophobia, and migration status) were the primary drivers of vaccine hesitancy, more than one third of respondents (36 per cent) reported being hesitant to get the Covid-19 vaccine even if it was available and accessible. Hesitancy rates were especially high amongst respondents in Turkey (71 per cent), Peru (46 per cent), the DRC (43 per cent), and Brazil (41 per cent). Reasons were varied and dependent on context. Out of the 36 per cent who said they were unlikely to get the vaccine, some felt the vaccine was not safe (22 per cent) or ineffective (22 per cent), or they did not want to share their personal information to register (13 per cent).
The second key finding was that the indirect impact of Covid-19 on livelihoods has significantly affected FDPs’ living conditions, education, health, nutrition, and overall wellbeing.
The pandemic had a significant impact on FDPs’ income, with the majority of respondents reporting an income drop (73 per cent) or job loss (40 per cent) in the last 12 months. This is primarily due to the types of jobs they do, which are often casual and thus lacking in regulation when a lockdown takes place or they themselves fall sick. Due to de facto barriers to economic inclusion, including restrictions on employment rights and options (legally or in practice) and/or lack of access to bank accounts, refugees are 60 per cent more likely than host communities to work in industries highly affected by the Covid-19 pandemic (Dempster et al. 2020).
The survey also found that women, who represent a large proportion of survey respondents and heads of households in Venezuela, Peru, and Colombia, have been more affected by livelihood disruptions (Cone 2020) and income losses (64 per cent) than men (36 per cent) (Dempster et al. 2020). Determining the full impact of economic shocks on FDPs’ livelihoods is difficult, but evidence does show a difference between FDPs and host communities. In Jordan, 35 per cent of Syrian refugees lost their employment as a result of the pandemic versus 17 per cent of Jordanian citizens (Kebede, Stave and Kattaa 2020). In Lebanon, 60 per cent of Syrians lost their jobs permanently compared to 39 per cent of Lebanese (ILO 2020).
The secondary effects of these income losses have led to significant psychological impacts and strains at home for FDPs, with 77 per cent of families reporting increased levels of stress and tension. Additionally, respondents reported being unable to meet their food (77 per cent), accommodation (71 per cent), education (69 per cent), and health-care (68 per cent) needs. A staggering 77 per cent of respondents also reported the dramatic impact of the Covid-19 pandemic on their psychological wellbeing as a result of social and daily stressors (Spiritus-Beerden et al. 2021), such as xenophobia, living conditions, migration status, and financial hardship.
Although less susceptible to the physical effects of Covid-19, respondents reported a number of indirect impacts they were worried about when asked what their top Covid-19 concerns were for their children. Community safety (40 per cent), lack of shelters for children (40 per cent), limited food or poor diet (37 per cent), lack of psychosocial support (28 per cent), dropping out of school (22 per cent), and exposure to violence, neglect, abuse, and exploitation (14 per cent) were the top concerns mentioned.
Communities are perceived to be less safe for children than before the Covid-19 pandemic. Eighty per cent of respondents in Colombia reported worrying more about children’s safety. Safe shelter was critically missing before the pandemic, but is even more reduced now, with respondents in Peru (71 per cent), Venezuela (69 per cent), the DRC (68 per cent), Colombia (67 per cent), and Uganda (29 per cent) reporting no access to safe shelter for large proportions of forcibly displaced children.
Children’s lack of access to food or poor diet was reported as the top concern for most FDPs in Colombia (67 per cent), Venezuela (56 per cent), and Peru (50 per cent). This response parallels the main coping strategy that respondents reported adopting – reducing the quantity and quality of food (61 per cent) – and echoes existing reports on increases in hunger and malnutrition (UNHCR 2021b). A World Vision survey conducted in Latin America in 2020 found that families were unable to provide decent food for their children, and as many as one third of children were going to bed hungry (Korobkova 2020). An assessment between June and September 2020 found that 74 per cent of respondents in Syria and 65 per cent of respondents in Lebanon worried that they would not have enough to eat in the coming months (Breidy 2020).
Although reported as largely available in Turkey and Jordan, the survey found that mental health and psychosocial support services were significantly affected by the Covid-19 pandemic. In particular, respondents in Colombia (52 per cent), Peru (48 per cent), Venezuela (56 per cent), and Brazil (31 per cent) reported concerns about impeded access to psychosocial support services.
Children’s education across the world has been deeply affected by the pandemic. In April 2021, the United Nations Educational, Scientific and Cultural Organization warned of a ‘generational catastrophe’ (UNESCO 2021). Forcibly displaced children are particularly disadvantaged due to existing barriers to education. Before the pandemic, a refugee child was twice as likely to be out of school as a non-refugee child (Grandi 2020). Children dropping out of school was a top concern for respondents, particularly in Turkey, Jordan, and Uganda. This may be explained by a number of reasons, such as the inability to afford school fees and supplies due to income losses, ongoing school closures, and/or limited or complete lack of accessibility of remote learning.9
Across all countries, gaps in accessibility to remote education were reported (i.e. no countries said they had complete remote access with all necessary tools available), although children in Turkey and Jordan had greater access. FDPs surveyed in Turkey said that 100 per cent of schools had remote learning arrangements in place; however, 31 per cent said they had no resources to access the arrangements. In Jordan, 100 per cent of schools had some arrangements in place for students to continue learning (89 per cent remote learning); with only 8 per cent of students stating they had no tools available to access. In the DRC, despite one third of schools still being temporarily closed (and no remote learning services or tools available or school arrangements in place), half of respondents said their children were not in school because they did not have the resources to send them.
Education disruptions also affected children’s nutrition and protection. These were two of the other top concerns for children, and are due to school meals not being available and children not having a protective environment to go to either when stress and tensions are high at home.
The survey found that a combination of factors, including stay-at-home orders, movement restrictions, school closures, and increased stress linked to livelihood losses, have led to heightened exposure to violence, neglect, abuse, and exploitation for children. Respondents in the DRC (41 per cent) were particularly concerned about this: families reported resorting to negative coping strategies at the cost of the social wellbeing of family members, especially children. Early marriage was reported – in Uganda (17 per cent), the DRC (8 per cent), and Jordan (5 per cent) – as one way that some respondents dealt with the effects of income or job loss. Respondents from three quarters of the countries surveyed said that they had sent their children to work to compensate, with especially high levels reported in the DRC (43 per cent) and Uganda (18 per cent). As children face increased protection risks, the survey found that a range of protection services have been severely disrupted, particularly in Colombia, Peru, Venezuela, the DRC, and Uganda.
Millions of the most vulnerable are being left behind in the race to access vaccines. Barriers in policy and practice are affecting FDPs’ ability to protect themselves from the direct and indirect impacts of the Covid-19 pandemic or to access vaccines. Yet the world will only emerge from the pandemic if vaccine distribution is inclusive and equitable.
While the survey results are only indicative of the situations faced by the respondents in eight countries, the overarching experiences are likely to apply to many FDPs. Thus, decision makers must consider how to adjust their recovery plans to better address their specific needs.
Donor governments must ensure equitable access to vaccines between countries by:
Host governments must ensure equitable access to vaccines within countries by:
There are tangible risks associated with excluding FDPs from vaccination campaigns as leaving large groups unvaccinated opens the door for further mutations and puts everyone at risk. While the implications of this for the world as a whole should not be underestimated, we must acknowledge that it is FDPs specifically who will suffer the most due to lack of access to vaccines and the arrival of further mutations. FDPs do not have access to adequate health care in illness, nor the socioeconomic safety nets required to protect them from the aftershocks of Covid-19.
Governments have a role to play in ensuring greater support for FDPs as they face Covid-19 and the challenges that come in its wake.
Donor governments should:
Host governments should:
* This IDS Bulletin was funded by the UK government’s Foreign, Commonwealth & Development Office (FCDO) through the Covid Collective. The Covid Collective cannot be held responsible for errors, omissions, or any consequences arising from the use of information contained. Any views and opinions expressed do not necessarily reflect those of FCDO, the Covid Collective, or any other contributing organisation. For further information, please contact: covid-collective.net.
† The authors would like to extend their appreciation to the dedicated efforts of our colleagues across World Vision, especially those in Brazil, Peru, Colombia, Venezuela, Turkey, Jordan, Uganda, and the Democratic Republic of the Congo (DRC).
‡ World Vision is a Christian relief, development, and advocacy organisation dedicated to working with children, families, and communities to overcome poverty and injustice. Inspired by our Christian values, we are dedicated to working with the world’s most vulnerable people. We serve all people regardless of religion, race, ethnicity, or gender.
◊ This article is based on the High Risk – Low Priority: Why Unlocking COVID-19 Vaccine Access for Refugees and Internally Displaced Communities is Critical for Children report released by World Vision in June 2021 to bring urgent attention to the pandemic’s impact on forcibly displaced persons (FDPs) and their challenges accessing Covid-19 vaccines. It uses primary data collected from a multi-country survey and was supplemented by desk-based research to further elaborate on those findings and provide contextual background. Other data presented is as of July 2021.
1 Natalia Korobkova, Advocacy and External Engagement Technical Director, World Vision, Canada.
2 Nina Nepesova, expert consultant, formerly Global Director for Humanitarian Policy and Advocacy, World Vision International.
3 Delphine Valette, Senior Policy, Advocacy and Campaigns Consultant (humanitarian and international development sectors).
4 Forcibly displaced persons (FDPs) have been defined by this study as refugees (registered or unregistered) and IDPs.
5 The results of World Vision’s survey are not representative of the whole refugee and/or IDP populations in respective countries and are indicative of the situations faced by surveyed respondents at the time of assessment.
6 The list of the 168 countries included in the review by IOM referenced by this article was not made public.
7 Although it did not come up strongly in the survey, vaccine hesitancy has been reported to have affected the vaccination process amongst refugees and asylum seekers (Athumani 2021).
8 All of World Vision’s in-person interviews were conducted in compliance with Covid-19 safety regulations and local mandates.
9 World Vision’s survey findings reflect a broader learning gap for displaced children, which has been accentuated by the Covid-19 pandemic, including the ‘digital divide’ and lack of learning resources. In five of the 10 countries hosting the largest numbers of refugees, less than 20 per cent of households have a computer at home, with only two countries passing the 20 per cent mark.
10 See Access to Covid-19 Tools (ACT) Accelerator.
11 See 10 Steps to Community Readiness.
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© 2022 The Authors. IDS Bulletin © Institute of Development Studies. © Crown Copyright 2022. | DOI: 10.19088/1968-2022.117
This is an Open Access article distributed for non-commercial purposes under the terms of the Open Government Licence 3.0, which permits use, copying, publication, distribution and adaptation, provided the original authors and source are credited and the work is not used for commercial purposes.
The IDS Bulletin is published by Institute of Development Studies, Library Road, Brighton BN1 9RE, UK. This article is part of IDS Bulletin Vol. 53 No. 2 April 2022 ‘Humanitarianism and Covid-19: Structural Dilemmas, Fault Lines, and New Perspectives’; the Introduction is also recommended reading.