There are insufficient health services for all of the people in the camps and a lack of access to medical facilities external to the camps. Particular problems include inaccessible health services that are often far from their homes, lack of finance to reach them, lack of access to medicines and lack of doctors including specialised doctors or services for higher needs patients. Critical to the women was the lack of female doctors. The shortage of Sexual and Reproductive health services, often donor and ideologically driven, is a major problem for women and girls in the camps and the host community.
There are many negative impacts relating to shelters in the camps. They are crowded, both in terms of how many people are accommodated in each shelter and in their high density. This crowded living is unfamiliar and stressful for many families. The shelters are hot and poorly ventilated, without any relief from heat especially for the majority of families who do not have solar power for fans. There are few shaded or cool areas in the camps that people can go to. As they are impermanent structures, the shelters are easily damaged, insecure, and not watertight in the rainy season. These factors combine to create discomfort, family conflict and health risks for all members of the community.
Women and girls’ freedom of movement in the camps is strongly curtailed both by the very high risks of rape, sexual abuse, and harassment as well by social expectations that women and girls have no right or place outside the home. This has a major impact on their experiences when accessing water, food, and fuel. In several consultations’ women referred to risks of ‘bad mouthing’ and the verbal harassment of women who either by choice or necessity move around the camps alone to collect rations, water, attend learning centres or visit women-friendly spaces.
Simply going to the toilet is surrounded by both enormous risk and extreme fear of social sanctions if they are seen entering a latrine. As many toilets and water points are located close to mosques or teashops, women frequently do not use them during the day when they might be seen. As a result, many refrain from eating or drinking during the day but then face increased risks of sexual abuse when they are forced to use poorly lit latrines at night, especially if these are some distance from their shelter or if closer facilities are not in use due to lack of maintenance. In some camps, women face particular risks collecting water due to the very limited number of clean water points. This forces many women and girls to walk long distances into neighbouring camps or into the forest to collect water. This exponentially increases the risk of rape and sexual abuse, either from men hostile to others accessing ‘their’ neighbourhood facilities, or when they are alone in the forest.
WASH was another problem area identified which affects all members of the community. In addition to its intersections with SGBV risks, there were also concerns for all groups of men and women and children, about water access and quality, uncovered and dirty drains, inadequate rubbish collection, and unsegregated and dirty toilet and bathing facilities.
While people are greatly appreciative of the support they receive, it is very difficult to live well without work and income. The distribution of food and non-food items also has many challenges. Many concerns were shared about the overall insufficiency of aid, the location or distance of distribution centres, from the refugees’ homes, and the harsh and sometimes abusive and discriminatory collection conditions.
Girls 0 – 12 years:
Unsafe shelter was discussed as the major problem for all age groups including young girls. Refugees cannot afford to rent homes by themselves so are forced to share housing often with strangers. Children left alone while their parents work, and who cannot attend school are at high risk. There are no safe spaces where the children can go to play. It was noted that unclean or distant water points and inadequate or poorly managed drains and sanitation in the camps significantly increase disease and safety risks in the camps, particularly for children.
Women discussed how the reduction in health services and the decrease in the number of hospitals had a major impact on babies and young children. Camps are so widely spread that they reported that children with fever sometimes went into shock during the long journey to a hospital and that some people had died because they could not access medical care. Vaccination programs receive supplies to match the number of registered refugee children, but because unregistered refugees and people from the host population also access the hospital, some children are not vaccinated. The low level of food rations is affecting the health of all children, with cases of malnutrition starting to appear.
Girls 13 – 17 years:
As above, and it was reported that many children of this age could not attend school because they had to work to assist provide their families with basic goods. Again this was seen as a contributing factor to early marriage.
If these girls are raped and become pregnant .. because they are too small and get damaged…often they need to spend a long time in hospital and their families cannot afford this.Refugee woman, 2019
The reductions in humanitarian aid are leading to a much higher rate of child and early marriage and its consequences, including girls too young to give birth, bearing children. The loss of hospitals and distances which need to be traversed to reach them means that very young pregnant girls are not getting the prenatal support (or nutrition) they need. Girls are also beginning to show signs of malnutrition. Young girls often are allocated the task of collecting water, and this puts them in danger of harassment as they move through the camp and wait in queues. Teenage girls are reacting to the pressures and showing signs of anxiety and depression or going out of the camp to work illegally in places that expose them to a high risk of sexual exploitation.
Women 18 – 24 and 25 – 50 years:
Participants discussed problems in being able to get enough rations and cash to survive. They were often requested to provide sex to landlords.
The owner’s brother asked her ‘You are a refugee, how you are rented the house?’, so she said ‘Your sister already know about this’. So the police offer said ‘OK, you can stay our house rental period if I ask to sex with me you can continue stay in the house’.Refugee woman, 2019
It was discussed that only having a UNHCR card as identity made women very vulnerable to this sort of abuse, as the landlords thought they could abuse them with impunity, and there is a high level of difficulty in securing rental accommodation.
The women reported that at times they could not get enough food for their families, or medicine or transport. While they did have access to local hospitals, they discussed being sexually abused by guards and medical personnel.
… sometimes the Doctors do the harassment – This is really happen!Refugee woman, 2019
Often women could not afford medication and this forced them to take and to remain in employment where they were being sexually abused but saw no alternative.
These women are of childbearing age, and there is no affordable health care for them, so things go wrongRefugee woman, 2019
Women reported that there was only short term shelter available for women fleeing violence. This was also not safe, with many cases of rape and harassment in the shelter.
They are advised to go and find a job, but if they do, there is no one to look after the children. They just have to leave them in an unsafe space while they work. After one month the women have to leave and often return to their abusive husbands because they have nowhere else to go
Reductions in energy provision and Infrastructure have been exacerbated by the reductions of services. In the dry season, women and children often queue all day to find that there is no water when they get to the front of the queue. Some are having to scavenge for food. The standard of housing is deteriorating because of a lack of building materials. Inadequate charcoal supply means that if a family cannot reach the few filtered water pumps, they are not able to boil the water they drink unless they leave the camps to forage for firewood. These conditions are forcing many women to work illegally outside the camps. Others are resorting to survival sex as a means to feed their families. The inadequate supply of all basic provisions is causing stress, family conflict and mental health problems, and women reported a large increase in suicide and suicidal thoughts. The large increase in drug and alcohol use and its impacts was a major theme. Women reported that while it is mainly a male problem, some women were also using drugs and alcohol, and so the impacts cut across all age groups. It is having an extremely negative effect on family life, causing an increase in DV, and using scarce family resources. Younger children are taking the example of their older siblings, and starting to take drugs at an early age. This all increases the burden of responsibility already carried by the women. The lack of building materials is leading to constantly decreasing standards of shelter, made worse in the wet season, and increased insecurity in the refugees’ homes.
As already marginalised and stigmatised groups, the participants saw the situation of these women as very similar. They experienced additional difficulties because of the reduction in humanitarian aid to those living in families and suffered more SGBV when trying to fulfil their most basic needs. It was reported that even if they could acquire building materials often there was no one to assist them to repair their houses. The elderly and those with disabilities were often isolated because of the poor state of roads and pathways.
There are no specialised physical or mental health care services available to this group, many of whom have been in exile for years. They have a lot of health issues but cannot afford to get help.
As already marginalised and stigmatised groups, the participants saw the situation of these women as very similar.