Health Services in Bhutanese Refugee Camps

Health services in Bhutanese refugee camps were a coordinated system of primary healthcare, disease prevention, maternal and child health, and mental health support delivered to over 100,000 Lhotshampa refugees in the seven camps of southeastern Nepal. The health system, developed over more than two decades with the support of the United Nations High Commissioner for Refugees (UNHCR) and multiple implementing partners, achieved significant improvements in health indicators including infant mortality, immunization coverage, and disease control — though mental health and chronic disease management remained persistent challenges throughout the camps' existence.^[1]

The Association of Medical Doctors of Asia (AMDA), a Japanese-founded international medical NGO, served as the lead health implementing partner for most of the camps' operational period, managing health posts, training refugee health workers, and coordinating referrals to Nepali government hospitals. Other organizations, including the Nepal Red Cross Society and various international NGOs, provided complementary services in nutrition, water and sanitation, and psychosocial support.^[2]

Health Infrastructure

Each of the seven camps had at least one health post — a basic outpatient clinic staffed by trained refugee health workers under the supervision of qualified medical officers. The larger camps, including Beldangi I and Sanischare, had more extensive facilities with separate outpatient departments, maternal health units, pharmacy dispensaries, and observation beds. Health posts were constructed using the same bamboo-and-thatch or bamboo-and-tin materials as other camp structures, later upgraded in some cases with more permanent construction.

Medical equipment and supplies were procured through UNHCR and AMDA supply chains. A standard camp health post was equipped with basic diagnostic tools (stethoscopes, blood pressure monitors, thermometers), a dispensary stocked with essential medications from the WHO Essential Medicines List, and basic laboratory capacity for malaria smears, urinalysis, and sputum examination for tuberculosis. More complex diagnostic procedures and specialized treatments required referral to district hospitals in nearby Birtamod, Bhadrapur, or Damak, or in serious cases to regional hospitals in Biratnagar.^[3]

Primary Healthcare

The health posts provided outpatient consultations for common illnesses including acute respiratory infections, diarrheal diseases, skin infections, intestinal parasites, malaria, and musculoskeletal complaints. Treatment followed standardized protocols aligned with WHO guidelines for refugee settings. Refugee health workers — community members who had received training from AMDA ranging from several weeks to several months — conducted initial assessments, dispensed medications for routine conditions, and referred complex cases to supervising medical officers.

Community health volunteers (CHVs), a network of trained refugees embedded within each sector and sub-sector, formed the frontline of the health system. CHVs conducted home visits, identified and referred sick individuals, monitored nutritional status of children, promoted hygiene practices, and assisted with health education campaigns. The CHV program was widely regarded as one of the most effective components of the camp health system, enabling early detection and treatment of common conditions.^[2]

Maternal and Child Health

Maternal and child health (MCH) services were a priority throughout the camps' existence. Antenatal care was provided through dedicated MCH clinics in each camp, with trained refugee midwives conducting regular prenatal check-ups, monitoring high-risk pregnancies, and providing iron and folic acid supplementation. Deliveries were encouraged to take place at the camp health posts under the attendance of trained birth attendants, though home deliveries remained common, particularly in the early years.

The Expanded Programme on Immunization (EPI) was implemented across all camps, providing vaccinations against tuberculosis (BCG), diphtheria, pertussis, tetanus (DPT), polio, measles, and hepatitis B. Immunization coverage rates in the camps consistently exceeded 90 percent — higher than the national average in Nepal at the time — and contributed to the virtual elimination of vaccine-preventable disease outbreaks within the refugee population. Growth monitoring and supplementary feeding programs targeted malnourished children under five, and the prevalence of acute malnutrition declined significantly over the camps' operational period.^[1]

Infant mortality rates, while initially elevated in the earliest years of the camps when conditions were most chaotic, declined steadily as health services matured. By the 2000s, infant mortality in the camps was estimated to be lower than the national average for Nepal, reflecting the concentrated investment in maternal and child health services.

Disease Control

The subtropical Terai environment of southeastern Nepal presented significant disease challenges. Malaria, transmitted by Anopheles mosquitoes in the low-lying, flood-prone camp areas, was a major concern, particularly during and after the monsoon season. Control measures included insecticide-treated bed net distribution, indoor residual spraying, and prompt diagnosis and treatment of cases. A malaria surveillance system, coordinated with Nepal's National Malaria Control Programme, tracked incidence and triggered response measures when thresholds were exceeded.

Tuberculosis (TB) was another significant health challenge. The crowded living conditions in the camps facilitated transmission, and TB case detection and treatment programs operated in all camps under the DOTS (Directly Observed Therapy, Short-course) strategy recommended by WHO. Treatment completion rates were high, aided by the close-knit community structure that facilitated treatment observation and follow-up. Diarrheal diseases, particularly during the monsoon season, were addressed through oral rehydration therapy, water treatment and distribution improvements, and sanitation campaigns.^[2]

Mental Health and Psychosocial Support

Mental health was among the most pressing and least adequately addressed health challenges in the camps. The refugee population carried the trauma of forced expulsion from Bhutan — loss of homes, land, citizenship, and in many cases separation from family members. Prolonged displacement, uncertainty about the future, restricted freedom of movement, and the frustration of statelessness compounded these traumas over the years.

Studies conducted in the camps documented high rates of depression, anxiety, post-traumatic stress disorder (PTSD), and somatic complaints. Suicide rates were alarmingly elevated compared to both surrounding Nepali communities and global averages. Between 2004 and 2006, a cluster of suicides in the camps drew international attention and prompted UNHCR and its partners to strengthen mental health and psychosocial support (MHPSS) services.^[4]

Psychosocial support programs were established in all camps, employing trained refugee counselors who provided individual and group counseling, support groups for specific populations (women, elderly, youth), and community-based psychosocial activities. The Centre for Victims of Torture (CVICT), a Nepali NGO, and the International Organization for Migration (IOM) provided specialized services including trauma counseling and psychoeducation. However, the scale of mental health needs far exceeded the available resources, and many individuals with significant mental health conditions went untreated.

Cultural factors also influenced mental health service delivery. Stigma around mental illness was prevalent, and many refugees were reluctant to seek counseling or psychiatric care. Traditional healers (dhami-jhankri) continued to be consulted for conditions that might be understood in biomedical terms as depression or anxiety. The MHPSS programs attempted to integrate traditional and biomedical approaches, with varying success.^[1]

Nutrition

Nutritional status was monitored through regular surveys and growth monitoring of children under five. The World Food Programme (WFP) provided general food rations, while supplementary and therapeutic feeding programs targeted malnourished individuals. Despite these interventions, micronutrient deficiencies — particularly anemia (iron deficiency), iodine deficiency, and vitamin A deficiency — remained prevalent, especially among women of reproductive age and young children. The limited dietary diversity available through rations (primarily rice and lentils) contributed to these deficiencies.^[5]

Community-managed vegetable gardens, supported by implementing partners, provided supplementary fresh produce and contributed to dietary diversity. Nutrition education programs promoted optimal infant and young child feeding practices, including exclusive breastfeeding for the first six months of life.

Health Worker Training and Capacity

The training of refugee health workers was a significant investment that yielded long-term benefits. AMDA and its partners trained hundreds of refugees as health assistants, auxiliary nurse midwives, laboratory technicians, pharmacy assistants, and community health volunteers. While these trained individuals could not practice formally outside the camp system due to their lack of recognized qualifications and legal status in Nepal, the skills they acquired proved valuable in resettlement countries, where many former camp health workers pursued further training and entered healthcare professions.^[2]

Legacy

The health system developed in the Bhutanese refugee camps demonstrated that even in resource-constrained settings, coordinated primary healthcare built on community health worker networks can achieve strong outcomes. The immunization coverage rates, infant mortality reductions, and disease control achievements of the camp health system were recognized as exemplary within the global refugee health community. The principal shortcoming — inadequate mental health services relative to the enormous psychosocial burden of protracted displacement — reflected a gap that continues to challenge refugee health programs worldwide.

References

1. UNHCR. "Bhutanese Refugees." https://www.unhcr.org/asia/bhutanese-refugees
2. Association of Medical Doctors of Asia (AMDA). https://www.amda.or.jp/eng/
3. UNHCR. "Bhutanese Refugees Mark 20 Years in Exile." https://www.unhcr.org/us/news/stories/bhutanese-refugees-nepal-frustrated-lack-progress
4. Human Rights Watch. "Trapped by Inequality: Bhutanese Refugee Women in Nepal." 2003. https://www.hrw.org/reports/2003/nepal0903/
5. World Food Programme. "Nepal." https://www.wfp.org/countries/nepal