Mass migrations of people are occurring at unprecedented rates. Half of the 27.1 million refugees worldwide are aged <18.1 Less than 1% of refugees are resettled in a third country offering permanent residence and a pathway to citizenship.2
In 2020, the United Nations High Commissioner for Refugees (UNHCR) and the International Organization for Migration launched an initiative to support third-country resettlement programs and complementary pathways that maintain international protections yet increase capacity.3,4 Complementary pathways include humanitarian admissions and visas, community sponsorship, family reunification, and third-country employment and educational opportunities.
Currently, most third-country resettlement by UNHCR occurs in the United States, Canada, Sweden, France, and Germany.2 Each country has a different health care system and resettlement process. The US Refugee Admissions Program, an interagency partnership of government and nongovernmental agencies overseas and in the United states, coordinates US resettlement of refugees.5 During the past 2 years, the United States accepted Afghans and Ukrainians without refugee status emergently through complementary pathways, namely Operations Allies Welcome, a humanitarian admission program, and United for Ukraine, a pilot private sponsorship program.6–8 Because Afghan and Ukrainian paroles lack formal refugee visa status, an act of Congress was required to allow access to health insurance.9
With the exception of some differences for the province of Quebec, Canada, has 3 pathways of resettlement: Government Assisted Refugees Program (GAR), Private Sponsorship of Refugees Program (PSR), and Blended Visa Office Referred Program (BVOR).10 The pathways differ primarily in assignment of responsibility for providing settlement assistance and financial support in the first year of resettlement. The majority of refugees in Canada are resettled through the GAR pathway. Canada’s PSR program has existed for 40 years and is a complementary model for increasing resettlement capacity. In addition to providing in-kind and direct cash assistance support for 1 year, PSR and BVOR sponsors are expected to set up housing and health care, and assist with employment searches, education and language, and community integration.11 Health insurance access is similar for all paths. Pathway assignment, however, is not random in that refugees with known medical and social complexity are assigned to the GAR pathway, which provides formal case management. In recent years, Canada has also developed additional specialized entry pathways to facilitate mass migration related to large-scale humanitarian crises: the Special Immigration Measures Program for Afghan Nationals12 and the Canada–Ukraine Authorization for Emergency Travel.13 Although intended to provide an urgent response, these pathways have been critiqued for additional delays in the processing of preexisting refugee claims, as well as for the potential to create racialized differences in settlement supports.
In this issue of Pediatrics, Saunders et al set out to understand the degree of medical complexity and the extent to which pediatric refugees in the different Canadian resettlement models use health care in the first year after arrival in Ontario.14 Using 10 years of data sets, they compared a large sample size of 0- to 17-year-old refugees with a larger-matched, Ontario-born cohort. Further comparison was done on the basis of the resettlement pathway. When compared with Ontario-born children, newly arrived refugee children had similar use of the emergency department for respiratory illnesses and injuries but differed in the type, not amount, of subspecialty care, namely infectious disease and neurodevelopmental care rather than behavioral and mental health care. Outpatient visits were the highest contributor of costs across all pathway groups; however, primary care utilization, emergency department visits, and hospitalization were highest in GARs.
Given that children with medical complexity were assigned as GARs, it is not surprising that the mean 1-year health system cost was highest in this cohort. The authors concluded that children in the PSR pathway are healthier and spend less health care dollars than those in the GAR or BVOR pathways. However, they also determined that, regardless of resettlement pathway, excess demand by pediatric refugees on the health care system is minimal. In the future, additional data regarding health care utilization by undocumented migrants and those receiving interim federal health funding would provide further insights about the consequences of barriers to accessing services.
These findings enhance the evidence-based knowledge for understanding the cost and benefits of traditional and complementary resettlement pathways. Medical guidance supports targeted, evidence-based clinical care upon arrival.15–17 Although there are predictable costs of medical resettlement for refugees, an increased understanding of the utilization of health care by resettled refugees can support efforts to build capacity through cost comparison. As the authors highlighted, future studies examining the impact of care integration models, community-based supports, and timely access to services on neurodevelopmental outcomes would be particularly relevant to critical developmental windows in pediatrics.
Research has demonstrated higher employment and earnings 15 years postarrival for those in the PSR pathway; less is known about long-term health effects.18 Refugees experience trauma preflight, during flight and during resettlement.19 Well-supported refugees can adjust and acculturate rather than become isolated and marginalized. What is the psychological effect of community versus government support? Are there other lived differences between the groups, such as experiences of racism? Private sponsorship may provide a warmer welcome and benefit a newcomer by creating a social network to protect against marginalization and isolation. However, without proper oversight, PSRs may lack cultural safety and result in harmful paternalism rather than mutualism.20,21 Understanding the longer-term health care costs and utilization effects of initial resettlement pathways may further support best practices in resettlement.
For 2023, the US Presidential Determination set a refugee-admissions target of 125 000.7 In the same year, the Canadian government hopes to resettle 380 000 to 465 000 new permanent residents.22 Yet, 27.1 million refugees are in need of a permanent home. As the global community strives to increase third-country refugee resettlement, best practice resettlement models will help guide capacity-building. Saunders et al14 provide evidence that pediatric refugee resettlement does not pose excessive demands on the health care system. Further studies are needed to understand the long-term benefits of traditional and complementary resettlement models and their effects on reception and integration.
Dr Green drafted the initial manuscript, and critically reviewed and revised the final manuscript; Dr Audcent critically reviewed and revised the manuscript for important intellectual content; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2022-057441.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLAIMER: The authors have indicated they have no conflicts of interest relevant to this article to disclose.
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