Rising numbers of refugees, prolonged displacement and reduced funding have led to challenges in terms of how to address their healthcare needs, with different approaches taken, ranging from parallel mechanisms to arrangements that are integrated (to different extents) within the national health system. Increasingly, global frameworks call for focus on the inclusion of refugees in national health systems. Based on six case studies, this paper analyses the trajectory towards health system integration in the healthcare responses for refugees to understand how contextual features play a role, and explore enablers and barriers of greater health system integration. Methods included documentary reviews, key informant interviews and focus group discussions (FGDs). Analysis was carried out separately for each setting and findings were later mapped, compared and contrasted for synthesis. All settings follow a normative pathway from an initial parallel response to hybrid, transitional arrangements to health system integration – though the latter is at different stages across settings. Some elements influence the timeframe of the shift, its completeness and effectiveness. These include: the scale and pace of refugee flow; the salience of political discourses on refugees and public perceptions, in some instances mediated by ethnic and cultural affinity; the country’s level of income and social protection systems; existing legal and policy frameworks, refugee rights and societal integration processes; availability of funds; capacity of the national health system, and its universalist approach. While it is difficult to alter some of these elements, each has to be carefully considered for health system integration processes. Priorities will generally include promptly strengthening local health systems to address the difference in healthcare provision for refugees and hosts, and effectively leveraging available funding (including from development and private sector sources) as well as existing, inclusive health system arrangements, such as free healthcare or social health insurance.

The global refugee population has nearly doubled in the last decade, and many of these populations face chronic displacement, often in neighbouring countries with limited resources. Emergency, short-term responses are being transitioned to longer term approaches, including a focus on inclusion through coverage in national health systems. However, analysis of empirical and comparative evidence on how to enact these approaches has been limited. In this article, we analyse the inclusion of refugees in six low and middle-income country (LMIC) health systems (Kenya, Kurdistan Region of Iraq (KRI), Mauritania, Pakistan, Peru and Zambia). Using a shared framework and tools, we collected data over 2023 to 2025, using document reviews, key informant interviews, focus group discussions and participatory workshops. Analysis was carried out separately for each setting, validated locally, and later compared and contrasted for synthesis. We focus on key health system domains – governance, health financing, service delivery (including health workforce) and health information systems - outlining the attributes of refugee inclusion and system integration in each, identifying patterns across the case studies and barriers and enablers. We identify leverage points for improving integration but highlight that inclusion of refugees into national health systems is complex and does not guarantee improved outcomes, especially when refugees previously benefited from a higher level of resources and are being included in strained host health systems. However, committed government leadership, coordinated international support, and multi-year investments in strengthening key components of the local health system, including enabling refugee health staff to engage effectively in it, can make the transition one which benefits both refugee and host communities.

Objective: To identify and address factors impacting maternal and perinatal deaths using a facility-based death audit review system integrated with community engagement for implementing doable solutions. Design: Mixed methods approach Setting: District Matiari, Sindh, Pakistan. Population : Cases of maternal deaths, neonatal deaths and stillbirth Methods: Facility-based death audit review system integrated with community engagement based on WHO guidelines, established in three secondary level care health facilities. The ”Four Delays Model” was applied to identify and address factors contributing to maternal and perinatal deaths. Main outcome measures: Factors contributing to delays in maternal and newborn care; implemented doable solutions addressing these delays. Results: Using the “Four Delays Model” key factors identified were i) Lack of education and awareness (Delay 1-2), ii) Inadequate transport mechanism (Delay 3), iii) Multiple referrals (overlapping Delay 3-4), and iv) Limited facility operational hours and delayed medical care (Delay 4). Local audit committee recommended and implemented doable solutions including community awareness sessions engaging both men and women, ambulance services, improved referral systems, and facility-level administrative measures such as providing antenatal cards, maintaining DHIS records, and enhancing inter-facilities communications. Conclusion: Local community engagement influenced the willingness of policymakers to implement actionable solutions. Health systems need to improve women’s access and availability of healthcare facilities during and after pregnancy. Scaling up audit review systems with feedback loops is recommended for future reduction in mortality rates in resource constrained settings particularly where comprehensive national-level mortality data is lacking.