CONTRACT N°: ECHO/ADM/BUD/2010/01208
(October 2010 - January 2011)
Final Evaluation Report
8th February 2011
A. Executive Summary
i. The scope of the evaluation covered the actions funded by DG ECHO in the health sector to support Burmese refugees in Thailand, between 2004 and 2009. The objective was double: to provide (i) a retrospective (ex-post) assessment of the appropriateness, efficiency and effectiveness of the actions over the period, and (ii) a prospective strategic assessment with a view to identifying practical options for both the continued funding of health to the refugees and enhanced transfers towards sustainable solutions. [§1-2]
ii. The ToR included fourteen evaluation questions, which have been used for most headings in chapters B.3 and B.4.of the report. The field visits and meetings were carried out by two consultants between13 October and 5 November 2010, and covered five of the six refugee camps as well as most of the relevant actors and stakeholders. [§3-4]
Key findings – Retrospective assessment
iii. The camps for Burmese refugees in Thailand are the result of the ongoing conflict between the central Burmese regime and some ethnic minorities. This conflict comes with bouts of overt armed violence, in particular in relation to the Karen, and virtually continuous repression, exclusion and well documented human rights abuses. [§5-26]
iv. To the approx. 140.000 refugees in the camps –for some of them since 1984- should be added at least 470.000 IDPs in Eastern Burma/Myanmar, including 110.000 who may be hiding in remote areas frequently affected by military operations. There are also more than 3 million Burmese economic migrants –mostly illegally- in Thailand. [§6-7]
v. The future of the refugees and their legal status remains bleak and uncertain. Return is not currently an option. Thailand is not party to the 1951 Refugee Convention, and the work of UNHCR has been significantly limited (no registration since 2005, no camp management or coordination role). The position of the RTG (Royal Thai Government) aims at maintaining the country's traditional independence, security at the borders, and a safe regional trading environment. Since 1997, severe restrictions have been imposed on access and livelihood for the refugees. [§10, 17-18, 57]
vi. A resettlement process to third countries (mostly USA) has started in 2004, implemented by IOM and UNHCR; it has so far accepted more than 69,000 Burmese refugees. Their places in the camps have however immediately been filled by new arrivals. [§11]
vii. DG ECHO has been supporting food assistance to the refugees in Thailand since 1995, and since 2004 it has funded the provision of basic health assistance in six of the nine camps along the border, by three implementing partners. [§12, 27]
viii. Due to the RTG policy of containment, the camps are essentially dependent from external assistance; healthcare is therefore highly relevant both at the general level, and by subsectors. Outbreak control is a key issue. The main diseases are usual in refugee camps: respiratory tract infections or water and hygiene related problems. [§14-6, 19-24, 36-7]
ix. Available statistics generally indicate a satisfactory health condition in all camps over the concerned period, compared with standard reference indicators and even more so with Burma/Myanmar. Visited medical facilities appeared efficient in their daily work and did not report acute shortages other than imposed temporary buildings, some lack of space during large outbreaks, limited capacity of laboratories, electricity shortages etc. All major health risks have been addressed, resulting in low mortality rates and appropriate outbreak and disease control. The indicators used to measure mortality rates appear however flawed and would probably need to be re-defined. [§28-31]
x. Gender aspects are adequately considered by the two partners who directly manage the Mother and Child Health, although birth delivery facilities can be quite basic. All young children were checked for weight, height and vaccinations. Traditional culture and faith are not conducive to the use of condoms or family planning. Due to the same factors and the camp containment, HIV figures are low. [§62-65]
xi. This situation reflects the effectiveness of health structures which have been organized to the best of the partners' abilities over a long period, despite the mentioned shortages and some other constraints, e.g. uncontrolled population movements, fragmented health responsibilities in some camps, a lack of policy on referrals, a 'brain drain' in trained medical staff due to resettlement, or weak coordination between partners, donors, and with the Thai health authorities. [§28, 32, 33-35, 48-50]
xii. While the overall political situation seems less stalemated compared to the past years, it is still higher level politics that determine the fate of the camps and preclude any crucial improvement. By and large, this situation has become one the most protracted and silent "creeping" humanitarian crises. [§10, 25-6]
xiii. Surface figures for the camps indicate that, whereas the area ratio/beneficiary is generally adequate in most camps, the smallest of them (Tham Hin) appears dangerously crowded, which may impact on health, sanitation and fire hazards. [§31]
xiv. In this context, the CHWs (Community Health Workers) are the "ears and eyes" of the partners in the camps, for preventive care and population headcount purposes. Efficient networks are operated in all the camps except in the largest one, Mae La. [§32]
xv. Budget cuts carried out in the framework of the new strategy (below) have led to drastic rationalisation efforts. One of the partners has e.g. decreased its operational costs by nearly 30% over 2 years, and its expatriate staff costs by nearly 60% (partly compensated by an increase of 10% of the costs of the national staff).
xvi. More worryingly however, the medical, training and rehabilitation costs have also been decreased by a margin of 30 to 90% (including most CHWs in Mae la) whilst the number of beneficiaries has reportedly decreased by 8% only over the same period. Such a downward spiral needs to be carefully controlled by indicators of quality, to prevent detrimental effects on the health condition of the population.
xvii. Efficiency and cost-efficiency of the partners are further undermined by the high and often unpredictable costs of referrals to Thai hospitals. Since refugees are not covered by the Universal Coverage or by a Thai insurance scheme, secondary healthcare are invoiced at cost. A partner stated that they have reduced referrals to "live-saving cases only, to the bare essential", to cope with ECHO budget restrictions.
xviii. A partner has repeatedly presented low overall cost-efficiency ratios. Reasons could be found in the small size of the camp which impacts on possible economies of scale, but also e.g. in the higher salaries paid to the Burmese camp staff, combined with the proportionately larger number of such staff per beneficiary. The partner's rationale is based on the desire to ensure high quality standards of healthcare in a situation that is not judged comparable to the conditions incurred by the other relevant actors. The findings of the evaluation did not fully support the relevance of these claims.