PUB - Publikationen an der Universität Bielefeld

**Background:** In mid-2023, around 110 million forcibly displaced people lived worldwide, of whom more than 36 million were refugees including over 6 million refugees from Afghanistan. Iran and Germany are the primary host countries for Afghan refugees in the Middle Eastern and European regions, respectively. Globally, host countries encounter major impediments in equitably addressing the general and healthcare needs of refugee populations, which may differ from the needs of citizens. Addressing these needs promptly and accurately necessitates precise observation and systematic data collection on the health and overall living conditions of these populations.

**Aim:** This international collaborative doctoral research between Iran and Germany was the first study that, through a comprehensive pool of primary and secondary data, estimated the health and living conditions of documented (legal) Afghan refugee populations residing in Iran and compared these conditions with those of the same population residing in Germany, using findings from studies available in this country, while paying attention to the similarities and differences of healthcare systems and existing health policies and plans for these refugee populations settled in the two host countries.

**Methods:** This research employed a triangulation approach, integrating independent yet interconnected quantitative, qualitative, and comparative studies. It encompassed five distinct studies including conducting (i) a systematic review of empirical health studies, which facilitated gaining insights into the existing body of literature and identifying key areas and challenges for further investigation, (ii) a cross-sectional survey analyzing health- and living conditions-related data of a sample of 402 documented Afghan refugees residing in Tehran province, Iran, (iii) semi-structured interviews with 13 documented refugees and 7 key informants, which added breadth and depth to the findings, (iv) a scoping review to compare the health systems and refugee health policies and plans in Iran and Germany, which served to better understand the strengths and weaknesses of the respective systems, allowing for knowledge exchange and formulating informed policy recommendations, and (v) a comparative analysis of the health and living conditions of the documented Afghan refugee populations residing in Iran and Germany, which provided an opportunity to explore similarities and differences, contributing to a broader understanding of these populations’ well-being conditions on an international scale.

**Results:** Both systematic and scoping reviews uncovered significant deficiencies in research and knowledge, as well as inefficiencies in refugee health and integration policies such as inadequate implementation of Universal Health Coverage (UHC), the absence of updated and consistent health data and surveillance systems for refugees, insufficient utilization of evidence in formulating refugee health policies, and incomplete assessments of refugees’ health needs, particularly in Iran. Findings from the survey and interviews conducted in Iran showed that legal access and the number/availability of healthcare providers/facilities were not obstacles to accessing healthcare for refugees. However, inadequate health insurance coverage (limited financial access) and general poverty emerged as the main issues. Additionally, challenges related to processes and fees of extending residence permits, limited (health) education, employment inequities, social isolation among women, household violence, and certain culture and tradition-related health behaviors were identified as further issues negatively impacting Afghan refugee populations in the two host countries.

**Conclusions and recommendations:** Several measures have been taken in response to the health needs of refugees and their integration into the two host countries. Yet, there is still a long way to go to achieve UHC and equitable health for Afghan refugee populations, particularly in Iran. This study recommends that Iranian and German policymakers undertake crucial measures to establish resilient and responsive healthcare systems for refugee populations. This can be achieved by demonstrating robust political commitment and support, enhancing capacity for effective UHC implementation, adopting coherent health policies that comprehensively integrate refugee health considerations, facilitating national multi-sectoral collaborations, and broadening international partnerships to share insights and experiences. Additional recommendations include encouraging language learning (in Germany), creating employment opportunities, improving education, raising awareness about health behaviors associated with tradition and culture, shaping a positive public image of refugees (social cohesion and community engagement) through available infrastructures such as the media, supporting female refugees against household violence, and increasing their participation in society by empowering them through education and teaching skills.