In many parts of the world, the provision of health care services is difficult, particularly if the goal is to reach and care for the most marginalized and vulnerable people. Consider, however, the challenges posed by trying to maintain the same level of care while operating in places where the population is forced to move to regions where natural resources are poor, where fear may govern cross-group interactions, where water and sanitation systems are non-existent or severely curtailed, and where logistics are subject to the policies and rules of several equally-legitimate players.

In refugee/IDP and disaster settings, the movements of large numbers of people or entire communities has tremendous implications for the systems of health care that are designed to serve them. Care systems need to be responsive to the population’s rapidly changing needs.  For example, providers and their tools may need to be mobile. Diseases may change. For example, most Rwandans at home were not at risk for malaria because of the altitudes; however when they fled to eastern Zaire/Congo, they needed prophylaxis – and suffered severely when they got sick. Providers must also decide the level of differentiation of services for the migrant population and the host population [most “refugee”funds cannot be used to serve local, host peoples].
   
Two areas of high attention in recent  humanitarian situations are psycho-social care and sexual and gender-based violence (SGBV).  While post-traumatic stress disorder (PTSD) is a commonly cited outcome for thousands of individuals who suffer extreme loss or danger, the greater concern is how to care for entire communities that suffer from non-normal situations that place significant stress on the social and psychological support structures and processes of groups. In a  like manner, SGBV is sometimes at epidemic levels when opportunities for violence and abuse are the environment for many people– crowded conditions, lack of work or even purpose, limited resources, loss of empowerment or control.

The constraints are many and the challenges continue to grow.