Written by Dr Manal Etemadi, Research Fellow in NCDs in Humanitarian Settings at LSHTM

When we think about refugees, we often think about the immediate challenges of displacement: finding safety, shelter and food. Yet for many displaced people, some of the greatest challenges emerge long after they have crossed a border. Accessing healthcare can become a constant struggle, with financial, legal and social barriers preventing people from getting the care they need.

On World Refugee Day (20 June), it is worth reflecting on an often-overlooked reality: for millions of refugees and undocumented migrants around the world, access to healthcare remains challenging outside of the humanitarian settings.

My research has focused on understanding these barriers, particularly among Afghan refugees and undocumented immigrants living in Iran. Their experiences offer important lessons for low and middle-income countries seeking to achieve universal health coverage while hosting large, displaced populations.

A long history of hosting refugees

For more than 40 years, Iran has hosted Afghan refugees and migrants, making it one of the largest refugee-hosting countries in the world. Unlike many humanitarian settings, most Afghan refugees in Iran live in urban and semi-urban areas alongside local communities.

Despite significant economic pressures, a large national population of around 90 million people, and the impact of international sanctions, Iran has taken important steps to expand healthcare access for registered refugees. Refugees recognised by UNHCR can enrol in the national health insurance scheme.

For some of the most vulnerable refugee households, access to Universal Public Health Insurance is funded entirely or partially by UNHCR, while others must pay the full premium themselves. In our research, we described this as a "double burden of vulnerability" – because all refugees are vulnerable, while some are more vulnerable due other factors, like chronic disease or unemployment, which means double vulnerability is a requirement to receive premium-waived health insurance.

For many so-called ‘non-vulnerable’ refugees, the cost of insurance coverage is unaffordable – especially considering that many refugees have large households which results in higher insurance premiums.

The gap between protection and access

While many registered refugees continue to face financial barriers, the situation is even more complex for undocumented migrants.

An estimated two million undocumented Afghan immigrants live in Iran. Because they are not formally recognised by the UNHCR as refugees, they are generally not eligible for the health insurance arrangements available to registered refugees.

This creates a difficult policy dilemma. When people cross borders through irregular routes and remain undocumented, international funding mechanisms are often unavailable. As a result, much of the responsibility for healthcare financing falls on host countries that may already be facing substantial economic constraints.

In Iran, undocumented migrants often rely on out-of-pocket payments to access healthcare. For families with limited resources, healthcare decisions can become financial decisions. Our research found that people may postpone treatment, avoid preventive care or seek help only when illnesses become severe. The consequences can affect not only individual health outcomes but also wider public health goals.

Why refugee health matters for everyone

The Iranian context highlights an important reality that is often overlooked: some of the countries hosting the largest refugee populations in the world are themselves low- and middle-income countries facing significant political, economic and financial pressures. Many countries host large displaced populations for decades rather than during short-term emergencies. These protracted situations receive less international attention, yet they present some of the most complex challenges for achieving equitable healthcare access.

Supporting refugee health cannot be seen solely as the responsibility of host countries. Achieving meaningful progress requires sustained international cooperation, investment and recognition of the challenges faced by countries that continue to host displaced populations over decades.

Looking ahead: World Refugee Day

World Refugee Day is an opportunity not only to recognise the resilience of refugees, but also to reflect on the systems that shape their health and wellbeing.

Greater international attention must be paid to refugee-hosting regions that receive relatively little visibility despite carrying a significant share of the responsibility. Understanding and supporting these contexts will be essential if we are to ensure that displaced populations are not left behind.