Health assistance to internally displaced persons of South Waziristan Agency in camps and host community

Table of Contents

Thesis Certificate

Executive Summary

Dedication

Acknowledgements

Table of Contents

List of Tables

List of Abbreviations

Chapter 1. Introduction
1.1 Background of the Study
1.2 Aims in conducting this research
1.3 Locale of the study
1.4 Historical overview of FATA
1.5 South Waziristan Agency
1.6 Tribes & Clan
1.7 Problem Statement
1.8 General Objective of the study
1.9 Specific Objectives
1.10 Thesis Overview

Chapter 2. Literature Review

Chapter 3. Methodology
3.1 Introduction
3.2 Research Design
3.3 Methodology
3.4 Mixed study approach
3.5 Data Collection Tools
3.5.1 Survey Questionnaire
3.5.2 In-depth interview.
3.6 Review and analysis of existing data
3.7 The Research Activities
3.8 Justification for selection of locale of the study
3.9 Study Samples
3.10 Sampling Methods
3.11 Qualitative Data Analysis
3.12 Quantitative Data Analysis
3.13 Ethical Consideration
3.14 Limitations of the Research

Chapter 4. Socio-economic and Demographic Profile
I. Age and Sex structure

Chapter 5. Protection to IDPs in Camps and Host Community
I. Level of Social Capital
II. Accommodation and Food
III. Morbidity, Mortality and Mental Stress among IDPs living in Tank
IV. Health Seeking Practices
V. Mother and Child Health Care
VI. Health priority and their possible solution

Chapter 6.Conclusion & Recommendations
6.1 Discussion
6.2 Conclusions
6.3 Recommendations
6.4 Need for Further Research

References

APPENDICES

Appendix A.Guideline for in-depth Interview

Appendix B.Questionnaire

Appendix C.Map of FATA and KP

Appendix D.Pakistan and Key International Human Rights Treaties

Appendix E.In-depth Interviews transcripts

List of Tables

Table 4.1: Distribution of respondents by Age and Sex

Table 4.2: Highest Level of education background of Head of household

Table 4.3: Origin of respondents resettled in District Tank

Table 4.4: Type of IDPs household structure who settled in District Tank

Table 4.5: Ethnic background of respondents

Table 4.6: Time since displacement from Area of Origin

Table 4.7: Income sources of head of IDPs households in District Tank

Table 4.8: Total household monthly income of respondents

Table 5.1: Help provided to IDPs of SWA by their relatives during displacement

Table 5.2: Help provided to IDPs of SWA by their friends during displacement

Table 5.3: Help provided to IDPs of SWA by their fellow tribesmen during displacement

Table 5.4: Help provided to IDPs of SWA by Political/Religious Parties during displacement

Table 5.5: Help provided to IDPs of SWA by their Host Community during displacement

Table 5.6: Type of Accommodation where IDPs are residing/ have taken refuge

Table 5.7: Source of providing/paying for accommodation of IDPs living in District Tank

Table 5.8: Opinion of IDPs about living general condition of their accommodation/Place of Refuge

Table 5.9: Opinion of IDPs about standard of their Residence/Refuge

Table 5.10: Sufficiency of food intake and sources of food provision by IDPs living in Tank District

Table 5.11:Frequency of illness during last three months among IDPs by Age

Table 5.12: Incidence of illness among IDPs by sex

Table 5.13: Type of illness suffered by the respondents in the past three months

Table 5.14: Death of IDP during internal displacement in Tank

Table 5.15: Illnesses causing deaths among IDPs during period of displacement from age and sex perspective

Table 5.16: Experience of any signs of mental stress by IDPs during last three month

Table 5.17: Types of Mental stress signs among IDPs living in Tank

Table 5.18: Reasons for mental depression in IDPs by sex and age

Table 5.19: Availability of any Psychiatric/Psychological treatment to IDPs living in Tank

Table 5.20: Accessibility to health care services for IDPs living in District Tank

Table 5.21: Distance to reach the nearest health facility in District Tank

Table 5.22: Payment of cost to avail health care facility

Table 5.23: Source to provide/ pay for health care services for IDPs living in Tank

Table 5.24: Opinion of IDPs regarding quality of health care provided

Table 5.25: Mother and Neonatal care at household level among IDPs living in District Tank

Table 5.26: Health issue of great concern at household level among IDPs living in Tank

Table 5.27: Proposed solutions for health issues by IDPs living in Tank

List of Abbreviations

Abbildung in dieser Leseprobe nicht enthalten

Executive Summary

Since 2009, South Waziristan Agency (SWA) has suffered a number of violent armed conflicts between security forces and Taliban causing massive destruction, several thousand deaths and creating over a half million displaced people. Right at the start of this armed conflict, the displaced people from SWA took flight to district Tank. The recipient area was selected for this study because it is among the most backward areas in Khyber Pakhtunkhwa (KP)^[1], hosting IDPs from the most neglected agency of federally administrated tribal areas (FATA)^[2].

Government failed in providing adequate health care support to IDPs due to the absence of legislation regarding their rights in national law. Further, due to negligence of issues related to internal displacement in UN and international law, IDPs were afforded very little health care help during displacement.

This research was designed to contribute to a policy or model to be developed to provide health care services for IDPs. The three objectives of this study were: to evaluate the role of economic and social capital level of SWA IDPs in selection of temporary shelter in IDPs camp and host community during armed conflict; to compare the prevalence of health related problems in IDPs living in camp and host community according to their sex and age; to indicate the difference between current nature and range of health services availability in IDPs camp and host community according to their sex and age.

The research employed mixed methods in achieving the above objectives. It was conducted through surveys and in-depth interviews (IDIs) with IDPs. Respondents for surveys were selected by applying systematic sampling technique with a random start. For this purpose 155 HHs were selected for survey & 5 respondents for IDIs in IDPs camps while in host community 105 respondents were selected for survey and 3 respondents for IDIs.

This study found that in the situation where government and international community was not interested to help them out during displacement, IDPs relied more on their level of social capital and economic status. Those IDPs who could afford a house or had found help from their relatives, fellow tribesmen or friends joined host community but those IDPs who were poor and unable to find any help regarding shelter, loan or food, were left with only one choice that is to join IDPs camp.

The health needs of IDPs were already heightened due to war trauma and were further worsened due to the situation of accommodation, water & sanitation, weather and overcrowding in camp; widening the gap between their health needs and health care availability. On the other hand, IDPs living in host community were free to avail the private and public health services lessening the gap between their health needs and health care availability.

It also found out that IDPs living in camps were more affected by health problems as compared to IDPs living in host community. Where, IDPs in camp were offered inadequate health facilities and were not allowed to visit Tank city for medical treatment even during emergencies causing many deaths, especially among pregnant women.

Moreover, children and old age people were most affected among many age groups while women in reproductive ages suffered more as compared to men. Even the basic mother and child health facilities related to pregnancy and neonatal health care were not incorporated in IDPs camp. Although IDPs were affected by mental stress as much as physical one but psychiatric help was totally absent in camps as well as in host communities.

Based on the results of this study, the thesis provides recommendations for the health sector reform in the areas that receive the IDPs. Like the fieldwork found that local health department in Tank was not capable to handle huge number of IDPs on its own and the study recommends international community’s health related interventions to deal with the situation. It further recommends that livelihood and shelter related issues of IDPs should be addressed legislatively and also recommends that there is a need to study IDPs situation in other agencies as well to prepare a comprehensive policy document for IDPs of FATA.

Dedication

Dedicated to my Friend, Shatir Afandi for his friendship …

Acknowledgements

Praise is to God for bestowing on me the ability, poise and velour to walk successfully through the laborious path of completing this project.

My deepest and heartiest gratitude is to my parents who gave me strength in my career and for their everlasting support and encouragement.

I would like to thank the internally displaced persons from both localities of camps and host community for their active participation in the research process.

I am profoundly thankful to my valued supervisor, Dr. Durr-e-Nayab, Head, department of Health Economics, PIDE; whose efforts, support, suggestions and guidance helped me to learn the fundamentals of carrying out this work.

Special thanks go to the Librarians of PIDE, for their time and assistance in finding relevant literature.

Finally, I would like to thank all my teachers of Development Studies department, PIDE, who have given support and guidance throughout my study.

Shahid Khan

Chapter 1. Introduction

1.1 Background of the Study

Hundreds of thousands of people are displaced due to conflict every year globally (UNHCR, 2010). Forced to flee from their homes in search of protection, some are able to find refuge with families and friends, but most are crowded into camps where they become victims of further violence, mental stress, and disease (IDMC, 2012).

As near the end of 2013, more than 28.8 million people were internally displaced by conflict and violence across the world with more than 3.5 million people being newly displaced in 2013 as a result of violence accompanying the “Arab Spring” uprisings in Syria and democratic republic of Congo with 2.4 million and one million respectively, while an estimated 0.5 million people fled their homes in both Sudan and India (IDMC, 2012).

The largest regional increase in the number of internally displaced people in 2012 was in the Middle East and North Africa where 2.5 million people were forced to flee their homes. There were almost 6 million IDPs in the region at the end of 2012, a rise of 40 per cent on the 2011 (UNHCR, 2010).

The region with the largest total number of IDPs was sub-Saharan Africa, which was hosting 10.4 million, an increase of 7.5 per cent compared to last year, thus reversing the downward trend recorded since 2004. The South American region hosted the second largest number of IDPs in 2012 with a total of 5.8 million, an increase of 3 per cent. Colombia remains the country with the highest number of IDPs in the world, with a total of between 4.9 and 5.5 million, according to the IDMC (UNHCR, 2010).

Recently, Pakistan has experienced large-scale involuntary internal displacement caused by a range of factors. The main cause for this internal displacement in the spring of 2009 was the military operation against militants in Malakand region of the KP province and FATA, leading to an exodus of about 2.7 million people in a little over a fortnight, creating one of the largest displacement crises in recent times (HRCP, 2010). Besides human rights abuses by militant groups, conflicts between tribal leaders and sectarian clashes even further swelled the volume of internal displacement in Pakistan (HelpAge, 2010).

In FATA including many parts of KP, the hub of this armed conflict is South Waziristan. In October 2009, as the result of Pakistan military’s operation RAH-E-NIJAT against militants in South Waziristan, approximately twenty seven thousand households fled from South Waziristan to nearby district Tank (FDMA, 2013).

Local government in district Tank, which is adjacent to South Waziristan Agency (SWA), badly failed in providing satisfactory relief to IDPs. When compared to other recipient areas of IDPs in KP, IDPs in Tank are provided with very limited humanitarian relief by United Nations (UN) and International nongovernmental organizations (INGOs). Except World Food Programme (WFP) and UNHCR most of INGO’s were also not present here on the pretext that Tank is not suitable from a security point of view^[3].

Currently the IDPs are a persisting element in Tank society, bringing new challenges to the public sectors. This is particularly so in the health sector where the impact of conflict resulted in the huge number of IDPs settlement in the recipient areas of Tank which ultimately overburdened the public health delivery. Unfortunately, the public health institutions in Tank that provided services to the IDPs had no experience of developing health programmes and providing health services for a large number of people arriving simultaneously.

In this instance, very few studies are undertaken in the context of conflict to analyze the situation of IDPs health. Especially no one has taken account of the health problems faced by IDPs in complex setting of camp and host community. Most of the researchers are concerned with IDPs health problems in camp and ignore IDPs problems living in host community. Even more, studies are required to look at the health from age and gender perspective to formulate a health policy to better address health problems.

1.2 Aims in conducting this research

This research aims to provide recommendations to the public health sector of Pakistan and international humanitarian organizations in order to develop a policy fulfilling the health needs of all internally displaced persons specific to needs of women, children and old according to their sex and age.

Several factors point to the value of such research. Firstly, some parts of KP & FATA and Balochistan are still unstable in terms of security and are prone to armed conflict which can create more IDPs. Secondly, there is almost no research done on armed conflict in tribal context of South Waziristan from a health perspective. Thirdly, it is important to know the effects of economic status and social capital on IDPs health in a tribal cultural setting.

Fourthly, there is a need to compare IDPs health needs in camps and host communities from a gender and age perspective. In this regard an emphasis on psychological health is deemed very important. Fifthly, it is most important to analyse strengths and weaknesses of government and international humanitarian organizations current health programme’s adequacy and appropriateness targeting these displaced populations.

1.3 Locale of the study

Tank is currently holding huge number of SWA’s IDPs both in camps at kot Azam a rural area that is 25 km away and in host community in city as well. Tank has a spread of more than 1679 Sq.Km and estimated population is about 0.55 million for the current year. Tank is bounded by the districts of Lakki Marwat to the northeast, Dera Ismail Khan to the east and southeast, and South Waziristan to the southwest, west, and northwest. The climate in Tank reaches 110-120 °F in summer. However in the cold, harsh winters in the mountains to the west, people from SWA come to Tank for milder weather and then move back during the summer.

1.4 Historical overview of FATA

Over the years difficult terrain, lack of education, and poor infrastructure has created a wedge between the tribal belt and the rest of the country. It has approximately 27,220 square kilometers of land, which shares nearly three hundred miles of the total 1,640 miles of border with Afghanistan (Cheema, 2008). “It is the poorest, least developed part of Pakistan. Literacy is only 17 percent, compared to the national average of 40 percent; among women it is 3 percent, compared to the national average of 32 percent. Per capita income is roughly $250, half the national average of $500 (Fishman, 2010).

The FATA is not subject to rulings by national or provincial courts, instead it is governed through Frontier Crimes Regulation (FCR), a legal system adopted by Pakistan at independence and rooted in British colonial practice and traditional tribal Jirga (Latif & Musarrat, 2012). Under the FCR disputes between tribes and the Pakistani state are managed through the interaction of political agents and tribal representatives, or Maliks (Cheema, 2008).

The political agent is empowered to coerce tribesmen through threats and bribes. His coercive power includes collective punishment of a tribe for the actions of individual members and his rulings are not subject to judicial review or appeal. The political agent's executive authority is backed by a local constabulary force (levies and khassadars) and under more extreme circumstances by the Frontier Corps (FC) and Pakistan Army (Abbas & Qazi, 2009).

FATA comprises of seven tribal agencies namely Bajur, Mohmand, Orakzai, Khyber, Kurram, North and South Waziristan and six Frontier Regions (FRs) namely Peshawar, Tank, Bannu, Kohat, Lakki and Dera Ismail Khan. The president of Pakistan directly administers FATA through the governor of NWFP and his appointed political agents (PAs). The FATA has newly been given the right of representation in National Assembly and political parties are allowed to contest seats from here.

1.5 South Waziristan Agency

It is a mountainous region of northwest Pakistan, bordering Afghanistan and covering some 11,585 km² (4,473 mi²). It comprises the area west and southwest of Peshawar between the Tochi River to the north and the Gomal River to the south, forming part of Pakistan's Federally Administered Tribal Areas (FATA). Troops of the British Raj coined a name for this region "Hell's Door Knocker" in recognition of the fearsome reputation of the local fighters and inhospitable terrain. The region became part of Pakistan in 1947 (Cheema, 2008).

The Agency is divided into three administrative subdivisions of Sarwakai, Ladha and Wana. These three sub-divisions are further divided into eight Tehsils: Ladha, Makin (Charlai), Sararogha, Sarwekai, Tiarza, Wana and Toi Khullah. Birmal Sarwakai is administered by Assistant Political Officer whereas Ladha and Wana Sub Divisions are administered by Assistant Political Agents. Each tehsil is headed by a Political Naib Tehsildar. The Malik system introduced by the British government is functioning in the Agency. Maliks used to work like media between administrations and the (Qaum) or Tribe.

The Maliki is hereditary and devolves on the son and his son so on and so forth for which regular benefits and subsidies are sanctioned from time to time (Abbas & Qazi, 2009). During this armed conflicts in SWA, Maliks were very much targeted by Taliban because Taliban considered them corrupt and declared them brokers working for establishment. Moreover, common youth opinion in SWA regarding Malik in also not positive and most of them consider them responsible for under development of their agency.

1.6 Tribes & Clan

The Mahsuds and Waziris are the two main tribes of this Agency. There are also the Burki (whose enclave is in the heart of Mahsud territory), some Dotanis, Sulaiman Khail and other Powindah settlers in the southwest corner of the Agency between Thati to Zarmelan. The Bhittanis inhabit a strip of country along the southeast border of the Agency. Its total population is 0.8 million.

1.7 Problem Statement

FATA is a conflict endemic area with periodic outbreaks of violence since 2002 (Fishman, 2010). The mass displacements of people from FATA in 2009 have not repatriated yet and majority of them are living in IDPs camp and host communities in many cities of Pakistan. The SWA IDPs situation is going to be even worse due to recent killing of Hakimullah Mehsud and in response Taliban are once again organizing against government in South Waziristan, FATA and many parts of KP namely Swat that will eventually result in more internal displacement of people.

It is evident that UN & international community’s lack of interest in solving problems related to internal displacement at global level and weak response by government to facilitate IDPs in South Waziristan has resulted in high levels of mistrust and dissatisfaction. On one side SWA IDPs are blamed for supporting Taliban and provided with very less humanitarian help by government while on the other side UN, INGOs, government and media has been obsessed with war on terror in Swat and most of the development funds are spent there.

During armed conflict, when SWA IDPs were struck equally hard by deaths, diseases and unemployment many among them on their basis of higher economic status & social capital managed to join host community to share public and private available facilities as compared to those who were poor and left with no choice but to join IDPs camp.

IDPs that were already in miserable condition got even worse due to absence of many public facilities especially health related facilities in camp. These facilities were inadequate to their needs and some avenues of health like mental health care was absolutely absent. The health facilities were not tailored according to the sex and age of IDPs. Especially the health needs of people with special needs in age group 65 and above were not addressed at all.

A comparative study was therefore needed, to explore the many important issues related to IDPs in both localities, that is camp and host community, Firstly, those local tribal dynamics of support system needs to be explored that had played a key role in facilitation of IDPs in the times when government and other international players have almost neglected them. Secondly, it is important to know the perception of IDPs living in both settings regarding the effects of type of accommodation on their health.

Thirdly, to explore psychological and as well physical health needs of IDPs in both localities in a comparative manner to evaluate the effect of available health facilities was also very important. Lastly, health needs of IDPs of both sexes & of all ages and inadequacy in provision of health facilities at both localities, was much needed to be found out for designing of an effective health policy for them.

1.8 General objective of the study

To assess the health needs of SWA IDPs who temporarily settled in IDPs camp and in host community in District Tank.

1.9 Specific objectives

- To evaluate the role of economic status and social capital of SWA IDPs in selection between temporary shelter in IDPs camp and host community during armed conflict.
- To compare the prevalence of health related problems in IDPs living in camp and host community according to their sex and age.
- To indicate the difference between current nature and range of health services availability in IDPs camp and host community according to their sex and age.

1.10 Thesis Overview

The thesis begins with background information on IDPs legal status, their health needs and is then followed by literature reviews of armed conflict and their consequences, health needs and health services availability. Furthermore, the thesis explains the details of the research methodology, analysis of results and discusses the important findings of the study.

This study id organized in six chapters, the outline of which is as follows:

Chapter 1: Background of study

In this chapter information on status of internally displaced persons is discussed from a global perspective. Further background of area of study and origin of IDPs, their health needs and availability of health care facilities is discussed. Lastly, problem is stated and objectives are framed to address this problem.

Chapter 2: Literature review

In this chapter, IDPs legal status and their health needs are analyzed with the purpose of gaining a more detailed understanding of their causes and consequences, particularly with regard to the affected population and health services availability. It also highlights the deficiency in academic literature regarding health related data and material.

Chapter 3: Research Methodology

Details of the research methodology employed in the study are presented in this chapter. It discusses the conceptual framework of the research; methods used and the reasons for choosing the methods and their application; and the research process such as the sampling procedure and the analysis of the data.

Chapter 4 & 5: Results of the study

These two chapters present qualitative and quantitative data through parallel approaches and demonstrate the characteristics of the IDPs’ health status during their exile from their homelands. Themes, sub-themes and categories were developed from both qualitative and quantitative data regarding IDPs’ health status and access to essential health services offered by the public sector. It also examines barrier to health services for IDPs and discusses their level of satisfaction with the available health services in the areas where they lived.

Chapter 6: Conclusions & recommendations

This chapter brings together the findings of the research with the evidence of the health needs of the IDPs and the local authorities’ response to them. This is followed by discussion and arguments regarding the findings of the research and their support in the literature. Further limitations of the study and insights for relevant research are explored. Lastly, it concludes the argument by formulating recommendations for the Pakistani public health sector in order to improve health systems, particularly as applied to the displaced populations.

Chapter 2. Literature Review

The International Committee of the Red Cross (ICRC), the UNHCR and some major non-governmental organizations (NGOs) have developed their own definitions of internal displacement, which usually reflects their operational “peoples of concern”. A more inclusive (and still evolving) working definition for IDPs used in this thesis is based on the working description of the UN Guiding Principles on Internal Displacement:

“Internally displaced persons are persons or groups of persons who have been forced or obliged to flee or leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized state border ( R. G. Cohen & Deng, 1998) .”

Given the broad scope of the description, this thesis chooses to focus only on those internally displaced who have been forced to flee from “armed conflict, situations of generalized violence, and violations of human rights”. Those who have been internally displaced as a result of natural or man-made disasters are not included in this thesis.

Despite the fact that there are more than 28 million internally displaced persons (IDPs) around the world, their plight is still little known (IDMC, 2012). As compared to IDPs who are given less international protection, refugees are treated quite opposite. Both IDPs and refugees have been forced to leave their homes because of armed conflict. While IDPs do not cross boundary, refugees cross it. This crossing of boundary has major consequences in terms of the protection available to them by international law (Rae, 2011).

Although refugees and IDPs often flee for similar reasons, IDPs do not cross international borders largely because they expect their governments to protect them, or they are denied asylum by other nations. While the number of refugees has been declining in recent years, IDP numbers are drastically increasing to more than double the amount of refugees. When first calculated in 1982, IDPs totaled about 1.2 million in eleven countries. At the end of 2008, that number had grown to 26 million in 49 countries (UNHCR, 2010).

The most significant differences in international law regarding the rights of IDPs and refugees is that the latter are protected by Convention relating to the Status of Refugees (CSR) (OHCHR 1951), whereas IDPs derive their human rights protection from UN guiding principles (GPs). Refugee’s human rights are expertly policed and promoted by the office of the United Nations High Commissioner for Refugees (UNHCR), earning them priority in the law and in institutional protection. On the other hand guiding principles are not protected by any UN institution and hence receive less compliance internationally (Goodwin-Gill & McAdam, 1996).

These GPs are basically drawn from international human rights and humanitarian law. Whereas human rights provisions are too general in nature and are meant to be universally applied, those linked to humanitarian law are meant to cover more specific needs arising in armed conflicts and are more directly applicable to internal displacement. In cases where humanitarian law is ineffective human rights law becomes the only source of legal protection for IDPs since core human rights, such as the right to life and the prohibition of cruel treatment are not tolerable under any circumstances (Phuong, 2004).

Despite the fact that main provisions of humanitarian law addresses the needs and human rights of war victims irrespective of their boundary crossing; still it is used in a way to favours those who (refugee’s) crosses national boundary. It provides a more comprehensive protection for refugees during international armed conflicts, whereas the law regulating internal armed conflicts is less elaborate and provides fewer benefits to IDPs (Goldman, 1998). Since, it is during internal conflicts where displaced persons number is often increased and requires more specific protection against the warring parties.

Although the number of IDPs in 1980´s arose to10 million as a result of armed conflict in Sub-Saharan Africa, it was in 1991 when the need of a separate law concerning IDPs was realized. This delay was caused by many UN institutions and international organizations. In this regard, international committee of the Red Cross, who is the regulatory body of Humanitarian law, was of the concern that existing humanitarian law is capable enough to look after IDPs during armed conflict and there is no need to devise a separate law for IDPs as it may undermine the existing refugee protection system (Phuong, 2004).

Same was the opinion of UN human rights commission that only wanted to devise an ´appropriate framework´ out of existing human right law for IDPs protection and avoided word legal (R. G. Cohen & Deng, 1998). Some UN officials argued for a comprehensive approach to protect refugees and IDPs inside the refugee law and emphasized the negative impact of formulating new standards for the protection of IDPs on the status of refugees and asylum seekers (Phuong, 2004).

Hence, influenced by many UN and international humanitarian actors, Guiding Principles on IDPs were formulated instead of formulating a binding law. These GPs take a very broad approach to internal displacement based on a general understanding of the meaning of protection for the internally displaced. It covers a broad range of human rights and all phases of displacement. The emphasis is put on the protection of special groups, notably women and children, who represent the great majority of internally displaced persons (Kalin, 2008).

The GPs have certainly raised awareness of IDPs, sensitized international community and articulated their specific needs. That’s why, keeping in view the importance of these guide lines on IDPs protection; African Union has introduced 1st binding law for IDPs protection termed as Kampala protection formulated in 2009 that was enforced on 6th December, 2012, and is ratified by fifteen African countries.

Although the Guiding Principles address most aspects of the problem of internal displacement, some issues are mentioned too briefly or not at all. Minorities are often the first targets of persecution and, as a result, the first populations to be internally displaced. Cases of forcible relocation of minority groups are too numerous to be cited here. However, minorities are only mentioned once in the whole document, in Principle 9, where they are referred to together with peasants and pastoralists. Another provision contained in Principle 6(2)(a) prohibiting ‘ethnic cleansing’ indirectly addresses the issue, but more specific and stronger provisions could have been included (Kalin, 2008).

The issue of safe areas is not mentioned at all in the Guiding Principles and consequently, it hinders freedom of movement within country and right to asylum in case of IDPs. The most significant weakness of the GPs however, is that it is a non-binding instrument. Hence, usefulness of GPs is greatly limited where states and international humanitarian actors are not legally bound to respect them (Phuong, 2004).

In the absence of an overarching binding law, states that had ratified adherence to the human rights protection are responsible to look after IDPs (Clapham, 2006). However, even when states have ratified key human rights treaties, the rights of the individual cannot be assured. For example, IDPs in Colombia have endured decades of human rights violations despite the fact that state has ratified key human rights treaties and laws (Mooney, 2005).

In the case of Pakistan situation is even worse where due to the military operation against extremists an exodus of IDPs took place from the affected areas in 2009. It is surprising that despite hosting one of the world’s largest displaced populations in modern times-4 million refugees from Afghanistan- the country remains surprisingly ill-equipped to deal with large scale internal displacement both at policy and implementation level (HRCP, 2010). Pakistan has not even implemented through domestic legislation the UN guiding principles on internal displacement.

Due to lack of international support, both in law and capacity and ill-preparedness of state to protect the overload of IDPs resulted in huge suffering for internally displaced Persons. In these sorts of situations IDPs mostly rely on their economic status and social capital to decide whether to go to IDPs camps or take refuge somewhere else (Goodhand, Hulme, & Lewer, 2000).

As many people from FATA are already settled in big cities of Pakistan for business purpose (Shinwari, 2012) the wealthiest IDPs easily found refuge in major cities, including cities outside the conflict area; the vulnerable were displaced within their districts of origin or to neighbouring rural areas; and the most vulnerable went to camps during displacement.

In a house-hold level study in Columbia the majority of the study population recovered from unemployment on the basis of their relatives and kinship support after violence (Engel & Ibáñez, 2007). In the same manner, Many IDPs settled in these cities on the basis of their own wealth while many got help from their relatives and friends for the sake of their settlement.

The provision of help and support during displacement by relatives, friends and tribesmen termed as social capital is a function of trust, social norms, participation and it play an important role in recovery (Murphy, 2007). People in traditional societies in times of disasters highly depend on their social capital that consists of resources embedded in their social networks and social structure (Woolcock, 1998). It can be a sort of safety net for IDPs to rely on their ethnic background for support during displacement both in finding some suitable shelter and fulfil their food intake.

It is estimated that among 14.7 million IDPs who were protected and assisted by UNHCR in 2010 globally; an estimated 52% of the total live outside formal camps in both rural and urban areas (IDMC, 2012). The phenomenon of internally displaced persons (IDPs) residing within host communities is still relatively unexplored in comparison to what is known about IDPs living in camps (UNHCR, 2010).

The underlying assumption of UNHCR operations—that IDPs can be best cared for when they are settled in camps also does not support the real situation of IDPs in camps. These camps portrays a picture of seclusion where a huge number of IDPs are kept in unhygienic and crowded places in urban slums and poor rural localities (Vincet & Sorenson, 2001).

IDPs camps embody a number of other striking contradictions. While they are supposedly governed by international law and human rights, the operation of such law and rights in camp sites is often non-existent. On the other hand, in host community settings, IDPs through their strength of social capital cope better with the problems arising during displacement (Rae, 2011).

There are many issues associated with the way these camps are conceived and built. These shelter camps are not designed keeping in mind the cultural values and gender divide of the IDPs. Peoples feel humiliated to live in tents most of the cases. As evident in case of KP IDPs camps, internally displaced Women observe ‘Purdah’, and they do not come out and are kept in tent all the day to avoid interaction with unrelated men (IDMC, 2012). Girls and women are also rarely permitted to deal with men alone, that’s why they are usually missing in the distribution queues and hence are deprived of support in camps especially in case of female headed households (UNICEF, 2011).

In these camps in KP, women suffer due to non-consideration of cultural norms in designing of many facilities. For example toilet facilities for male and female are constructed adjacent to each other, making it extremely difficult for women to visit toilets in day time. They have to wait for male family members to return and accompany the girls to toilets. Water and sanitation conditions are also bad. (HRCP, 2010).

Due to insufficient recreational space in the camps, children and young adults are victimized by drug addiction. Many young girls end up in prostitution due to absence of parental guidance and poverty in these camps. When these camps are dissolved by state; many children become homeless and as a result join criminal gangs (Ronstrom, 1989).

Humanitarian actors often overlook environmental factors while designing IDPs camps facilities (Salama, Spiegel, & Brennan, 2001). The location of camp is often not suited to IDPs in most of the case where people from cold areas are located in camps in hot plains in extreme heat, as in the case of KP. IDPs camps are overly crowded as well where tents are too close and under one tent some 10-12 peoples are living together.

As compared to IDPs living in host communities who share basic facilities with host communities, IDPs living in camps are more vulnerable to environmental factors, mostly in terms of overcrowding and unsuitable weather resulting in higher morbidity levels (Roberts, Odong, et al., 2009). Where as in host communities it is easier to forget the trauma of armed conflict due to busy life, relatives and availability of health practitioners, in camps, the scenario is totally opposite.

In camps, IDPs are kept in social exclusion and are not provided with psychological counselling and psychiatric treatment (Porter & Haslam, 2005). In IDPs camps many social rituals like marriages and birthdays that are great source of entertainment & happiness are not celebrated. This unhealthy mental and social status of IDPs is compounded by lack or complete absence of physical and mental health facilities which leads to over thinking about the loved ones that are killed or lost hence, resulting in mental disorders (Roberts, Odong, et al., 2009).

In the first few days when IDPs issue is hot on media healthcare facilities are provided to affected peoples but this health care support diminishes very soon. Moreover, whilst ‘Band Aid’ solutions to existing health problems are useful in the short term, the need for long-term public health interventions to enable displaced communities full access to and participation in their new ‘host’ communities is not ensured (Vincet & Sorenson, 2001).

Moreover, these health facilities are not in line with the needs and priorities of the internally displaced individuals. It is universally accepted that war victim’s health needs are more in line with mental problems like depression, anxiety, sleeplessness (Roberts, Damundu, Lomoro, & Sondorp, 2009). In IDPs camps, however it is the general health related facilities that are provided to all (Hamid & Musa, 2010).

Most of the programmes for medical care consider IDPs homogeneous group of people and do not consider the diversity of age and gender, whereas in crises, the health of women, girls, boys, men and the elderly are affected differently (IASC, 2004). In this regard, the deaths of pregnant women during forced displacement mostly accounts for the highest mortality rate among all age groups (Vincet & Sorenson, 2001). In recently displaced persons from South Waziristan, 15 percent of the total households included at least one pregnant woman of which only 44 percent had received any antenatal care (UNICEF, 2011).

Children, on account of their young age, are more exposed to the difficulties and risks associated with displacement (Joop & De Jong, 2002). Their health is mostly addressed in perspectives of malnutrition and immunization programmes and their psychological needs remain mostly a neglected area (Betancourt & Khan, 2008).

During armed conflict the emotional immaturity results in post-traumatic stress for children on account of their little tolerance of violence (Kim, Torbay, & Lawry, 2007). Where majority of the children displaced in the wake of the military operations in KP were aged between 3 months to 11 years and complained of problems including depression, phobias, acute stress disorder, post-traumatic stress syndrome and sleep disorders (HRCP, 2010).

During internal displacement, population bearing the brunt of health related inadequacies are peoples in old age (HelpAge, 2010). The highest morbidity levels in elderly is caused by bad environmental conditions which further exacerbated due to non-availability of appropriate health care facilities (Thomas & Thomas, 2004). Where UNHCR categorizes old aged people as the most vulnerable and consider them as people with special needs, very little care is provided to them during displacement.

The loss of status and prestige, exclusion and poor quality of life in camps result in severe depression for the elderly. In older ages they are more prone to cardiovascular disease, disabilities and dementia compounded by general physical weakness (Haywood, Garratt, & Fitzpatrick, 2005). They are also challenged by mobility problems to get medical help. Their reliance on assisting devices like walking sticks, hearing aids, glasses that are lost due to displacement make them more vulnerable during displacement (IASC, 2004).

Chapter 3. Methodology

3.1

This chapter focuses on the methods applied in this research. It begins with the overall objective of the study and proposes a conceptual framework for the study design. It further explains the methodology used, following the process of research design, the development of the questionnaires, the sampling procedure, the collection and the process of analyzing the data.

3.2 Research Design

Research design is the plan, structure, and strategy of investigation conceived so as to obtain answers to research questions and to control variance (Sarantakos, 1993). The concept of this research is based on the failure of the UN and other international bodies to address health related issues of IDPs in specific and their human rights issues in general of IDPs. It is shown in the conceptual framework that how in the absence of relevant legislation the low level of economic status and social capital compounds the miseries of IDPs during displacement.

For this purpose a comparison is drawn between IDPs living in camps and host community from a sex and age perspective to measure the gap between their health care requirements and health needs fulfilment. The purpose of this conceptual framework is to describe in an organized way the researcher’s conceptual thinking in order to achieve the objectives of the research.

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3.3 Methodology

This study was a descriptive-exploratory study based on mixed study approach by using both qualitative and quantitative research methods for data collection.

3.4 Mixed study approach

According to Miles and Huberman (1994), using both qualitative & quantitative methods by applying mixed study approach for collection of data enables a researcher to corroborate data from different sources, enhance the richness of the investigation, and meet the challenge of considering views that might not have been considered or encountered. Mixed methods for data collection were used in this study to explore the weaknesses and gaps in the provision of better health programmes and services for the IDPs by the government and other concerned organizations.

3.5 Data Collection Tools

3.5.1 Survey questionnaire

A structured questionnaire for a quantitative survey among the IDPs of SWA was constructed for data collection. There were seven sections in the questionnaire:

1) Socio-demographic profile
2) Level of social capital
(3) Situation of IDPs camp verses host community setting
4) Prevalence of physical health problems (morbidity & mortality)
5) Health services availability, its diversity and satisfaction of respondents
6) Emotional stress
7) Mother and child care

The questionnaire was first field tested among 20 Mehsud IDPs who came from SWA to live in Barakahu, Islamabad. After consultation with the research supervisor and the comments received in the proposal defense it was revised as necessary before the final survey.

3.5.2 In-depth interview

In-depth interviewing is a qualitative research technique that involves conducting intensive individual interviews with a small number of respondents to explore their perspectives on a particular idea, program, or situation (Miles & Huberman, 1994). An interview guide (annex.3) was developed for the In-depth interviews (IDIs) to not only complement quantitative findings of this study but also to dig deeper and find answers to those results which could not be explained without a deeper understanding of issues.

For this purpose, researcher has done eight in depth interviews to find empirical saturation regarding quantitative findings. Five IDIs were held with IDPs living in camps and three with those living in host community to delve more deeply into the quantitative findings of the study. The respondents were selected through purposive sampling to find out the issues related to forced displacement, morbidity and mortality.

3.6 Review and analysis of existing data

The literature for IDPs status in UN and international law was sorted out along with research articles, newspapers etc. WFP and NRC officials provided the number of all registered households, and total population for this study. The data were segregated for all tribes of SWA registered with them. Data were further subdivided into IDPs living in camp and in host community with complete addresses. The same data was used to draw the primary sampling frame for this study.

3.7 The Research Activities

This research activity was conducted from September 2012 – August 2013 when the armed conflict in SWA was over. This research was conducted in key stages. First, conducting a literature and document review to give background and context to the study. Second, preparation of data collection tools such as constructing a survey instrument (a structured questionnaire), a guiding document consisted of questions for the in-depth interviews. The formulation of the research questions was based not only on knowledge gained from the available literature but also from being employed in the public health sector there for over four years.

Third, to determine the locale for conducting this study this ended up with District Tank as the chosen area. Fourth, data was collected by using survey questionnaire and in depth interviews to obtain a grounded understanding of issues. Work experience at Agha Khan university Hospital outreach department provided a background of research which was of use in this study.

3.8 Justification for selecting locale of the study

District Tank situated in the extreme south of KP was chosen as the locale of study as it hosts majority of the IDPs from SWA. Although easily accessible, negligence of state, UN and INGOs is visible in terms of providing humanitarian relief to IDPs residing in Tank. Most of the INGOs were not delivering any relief on the pretext that security situation is dangerous in the district.

In addition, the choice of the field area was based on the presence of IDPs both in camps and host community which enabled comparing the health assistance offered to IDPs both at rural and urban settings. Also these two places were accessible to the researcher in terms of security and access to conduct interviews.

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^[1] Pak, J. "Budgetary Imbalances in the Health Care System of Khyber Pakhtunkhwa: 1990-2007."

^[2] Abbas, H. and S. H. Qazi (2009). Pakistan’s Troubled Frontier, Washington.

^[3] Local Mehsud tribes men perception