Table 2.

Key challenges faced by actors in responding to refugee health issues in Malaysia.

Sector	Key Challenges as Reported by Participants	Selected Quotes
State government	Challenged by budget constraints, resulting in the need to prioritize healthcare for citizens over healthcare for foreigners including refugees and asylum-seekers. Responses to the health needs of the refugee and asylum-seeker population are partly dependent on existing immigration laws. As described, immigration laws may contradict with the professional duties of healthcare workers in treating asylum-seeker patients without documents.	“The government is also facing difficulties in trying to manage with the restricted budget they have […] I think what they did is probably something that would need to be done for them in managing and ensuring that healthcare is prioritized for Malaysian citizens.” (I09) “In theory, public health providers should provide treatment regardless of legal status; but they also have to follow the mandate from the ministry and immigration laws of the country. This places them in a difficult position when dealing with undocumented asylum-seekers.” (I03)
Civil society	Limited human and financial resources to address the comprehensive health needs of refugees and asylum-seekers. Capacities are further undermined by policy amendments involving increased foreigner fees, as more refugees and asylum-seekers turn to NGO clinics for treatment and medication. Challenges in carrying out public advocacy work due to resource constraints.	“[NGO services] are very limited and it’s not sustainable because people in the NGO clinic, they change and the manpower usually is very limited.” (I01) “I think what’s lacking is people who are a bit more vocal […] of course, we can’t expect our health NGOs to be very local, given the fact that they’d be worried about jeopardizing their own operations as well […] and the limitation of the human resources and time that they have […] that’s limiting a little bit of what they can do, outside of just delivering health services.” (I09)
UNHCR	UNHCR Malaysia’s budget does not commensurate with the actual health needs of the refugee population. Further budget cuts have occurred in the recent year due to the overall increase in refugee needs worldwide. The increase in medical fees for foreigners at public health facilities has impacted UNHCR’s capacity in delivering financial aid to refugees requiring secondary and tertiary care. The numbers requesting for such assistance has also increased. Cross-sector collaborations may be challenged due to the lack of legal framework for refugees.	“Yeah, I think the budget [of UNHCR] does not commensurate with the growth in the population and the […] amount of assistance that’s required. Yes, there is the insurance, but it’s still a challenge.” (I09) “I think one of the really big issues is the budget was cut yearly by the United Nations. The reason they say […] there are more refugees in Europe, so the money is all going to Europe, but they didn’t realize, that even though Malaysian refugees is not that critical, but they still need financial help, because they are not legally working in Malaysia, so I don’t think the cutting budget should continue.” (I05) “[…] the cost of supporting cases, of course, have more than doubled […] the number of requests for assistance has, of course, increased, because what they used to be able to afford is no longer affordable, so they’re asking UNHCR to top up or pay the whole sum for even simple things like delivery which they used to be able to afford.” (I09)
Refugee communities	CBOs lack legitimacy in their operations and in providing services given that refugees are not accorded legal status in Malaysia. Some refugee groups may not have CBOs or community leaders whom they can go to for assistance. CBOs may lack the capacity or may not be fully empowered to take care of their community members.	“Some MCH (mother-and-child health) clinics are like that, if they don’t have a document, you can’t register [the patient], so I don’t know what to do, so I say, ’Go and shop around and look for other MCHs that will accept you for the community card.’” (I06) “[For] health promotion, I mentioned that we can go through community leaders, but then community leaders also have limited reaching area. They only know the people they know, but then there are many people that are not under the community leader radar. There are some communities that don’t even have a leader.” (I07)
Private sector	Profit generating model of financing leads to high healthcare costs at private health facilities, in which refugees and asylum-seekers are not able to afford. Private companies offering healthcare insurance operate based on risk pooling and may struggle to sustain such initiatives due to low enrollment rates.	“[…] the refugee group or the so-called foreign group may have less affordability to access the private setting.” (I07) “It’s a good emergency sort of insurance policy, but the uptake is not that good […] the coverage is not that high because, some of them, first of all, they may not be aware.” (I01)
Academia	Difficulties in securing funding for refugee-related research. Existing research funding are prioritized for health issues concerning citizens. Limited access to information systems and databases containing data on health of the migrant and refugee population.	“To do research, you must get money […] [Funders] will never give you money for [refugee] work. They won’t. That’s what stops the lecturers from getting or working with UNHCR […] Oh, you’ll never get the funding for it.” (I04)