INTRODUCTION AND CONTEXT

South Sudan gained independence from Sudan in 2011 and then fighting broke out in 2014. Since then, conflict has spread across the country and has led to immense loss of life and destruction of property. Almost 400,000 people have been killed and over four million people displaced (Braak, 2016). The South Sudan displacement crisis is now the largest in Africa and the third largest globally after Syria and Afghanistan (UNHCR, 2019a). Uganda has experienced a rapid influx of refugees displaced by the violence in South Sudan, particularly in 2016 when over a million people crossed the border in a three-month period seeking sanctuary (UNHCR, 2016). As of August 2019, over 800,000 refugees had fled from South Sudan into Uganda. Eighty-two percent of these were women and children (Adaku et al. 2016; UNHCR, 2019b). About 92% of these exiles live in refugee settlements alongside local communities whilst urban centres, such as Kampala, are home to only eight percent of the refugee population (UNHCR, 2019b). Thus, the needs for health and education services are greatest in refugee settlements, which tend to be in isolated and remote areas of the country with poor infrastructure and communication. Whilst the number of refugees per 1,000 inhabitants in Uganda has tripled to 35 since 2016, putting a huge pressure on local resources and services, external aid has been progressively dwindling, causing major gaps in the refugee response. The level of funding for the refugee response in Uganda reached an all-time low in 2019, with only 42 percent of contributions received in October 2018. Implementing partners face enormous challenges in stabilising existing programmes and meeting the minimum standards of service provision, let alone investing in long-term and more sustainable interventions. Severe underfunding has particularly compromised the quality of child protection, education services with limited investments in prevention and responses to sexual and gender-based violence (SGBV), environmental protection, support for host communities, and infrastructure. In comparison to many other countries across the globe, not least the economically richer parts of the world, Uganda’s willingness to host such large numbers of refugees stands out as positive and exemplary, which is to be applauded (International Refugee Rights Initiative, 2018). However, it is vital that there is a clear understanding of both the gap between rhetoric and reality, and the pitfalls of the settlement policy. Whilst funding is important, it cannot replace rigorous policy making and implementation that is attuned to the needs of refugees (International Refugee Rights Initiative, 2018). According to UNHCR (2019a), with 34 percent of its population living below the poverty line (US $1.9 per person per day), Uganda may be unable to fully realize a comprehensive refugee response and maintain its progressive refugee policy without adequate support from the international community The conflict in South Sudan is characterized by human rights violations, including SGBV and torture (UNHCR, 2017a; 2017b). Reports cite high levels of sexual abuse and torture; particularly rape of refugees by both government soldiers and rebel fighters (Isis-WICCE, 2015). Most refugees have experienced a multitude of human rights abuses. However in-depth information and evaluation regarding the needs of these refugees is lacking (The Guardian, 2018). Adaku et al. (2016) found diverse mental health and psychosocial support problems amongst South Sudanese refugees living in Northern Uganda, yet there are few services. This research argued for services addressing refugees’ social concerns and mental health problems. It called for further research of an in-depth nature investigating the impact of experiences on South Sudanese refugees and to address the current health and justice service provision gaps.

METHODOLOGY

The research design was qualitative, cross-sectional, descriptive and used a psychological/health and human rights approach to investigate the experiences of South Sudanese refugees living in Northern Uganda and assess the availability and use of services available to them. The research was distinctive as: (1) It collected and analysed in-depth qualitative data regarding the lived experiences of South Sudanese refugees (2) It examined state and non-state health and justice service provision (3) It investigated the quality of service responses and diversity, and (4) It provided evidence for informed policy formulation for future responses to such emergencies. Following authorisation to carry out the research by Coventry University, the Uganda National Council for Science and Technology, Gulu University and the Office of the Prime Minister in Uganda, data collection took place in May and June 2018. Two refugee settlements were selected for the study: Adjumani and Bidi Bidi. In each settlement SGBV and torture survivors, as well as service providers, were invited to volunteer to participate in the research. In total 61 refugee survivors of SGBV and torture participated in the research including 41 women (15 in Adjumani and 26 in Bidi Bidi) and 20 men (11 in Adjumani and 9 in Bidi Bidi) (see Table 1). All were adults over the age of 18 years who had fled from South Sudan and who self-reported having experienced SGBV and/or torture, either in South Sudan, on the journey to Uganda or whilst in Uganda. Table 1. Survivors participating in research by refugee settlement and by gender

Refugee Settlement	Males	Females	TOTALS
Adjumani (Pagrinya & Mungula)	11	15	26
Bidi-Bidi	9	26	35
TOTALS	20	41	61

Refugees were recruited through contact with the Refugee Welfare Councils in the settlements. They were asked to narrate their experiences using a semi-structured interview schedule. A choice of focus group discussions and/or individual interviews was given to each participant and these were conducted in Adjumani and Bidi Bidi refugee settlements, in a location which ensured confidentiality. Each interview or focus group discussion lasted between 50 to 90 minutes. They were carried out with the assistance of an interpreter and were tape recorded and transcribed into English verbatim. In addition, 37 key stakeholders were interviewed that provided health and justice services to South Sudanese refugees in Adjumani and Bidi-Bidi Refugee Settlements. These included UN (5) and Ugandan Government Officials (12), International NGOs (8) and National NGOs (5) as well as Refugee Welfare Council members (7) (see Table 2). Whilst most of these interviews took place in the refugee settlements (24), others took place in Yumbe Town (6) and Kampala (7). Each interview lasted about 60 minutes and used a semi-structured thematic interview framework. All were conducted in English and then transcribed. Following initial thematic analysis (Braun & Clarke, 2006) of the data collected in each refugee settlement, feedback meetings were held with refugees and stakeholders. In total over 130 people took part in these meetings, where initial findings were presented and then discussed. Notes of the meetings were taken in order to assist with triangulation of emerging themes. From analysis of the data the main themes were identified that related to refugee experiences as well as health and justice provision. Table 2. Key informants participating in the research

Geographical Location	United Nations Organisations	Ugandan Government	International Non-Governmental Organisations	National Non-Governmental Organisations	Refugee Welfare Councils
Adjumani Refugee Settlement	4	7	4	0	3
Bidi-Bidi Refugee Settlement	0	2	1	0	3
Kampala	0	3	0	4	0
Yumbe	1	0	3	1	1
TOTAL	5	12	8	5	7

All refugee participants, of both genders, of all ages (18 years and over) and marital status reported to have experienced or witnessed one of more of the following human rights abuses: violence (including beatings, being shot), SGBV, physical and/or psychological torture and other human rights abuses such as being unlawfully detained, being robbed or being denied healthcare. Both men and women refugees, had experienced violence, SGBV and/or torture. Men reported more cases of violence and physical and psychological torture and fewer cases of SGBV than women, whilst women were subjected high levels of violence, including SGBV, but less of torture. In some instances, women were also exposed to sexual violence after their settlement in Uganda. Seventy-five percent of the men interviewed reported being beaten and/or tortured, with 25% claiming they had been shot at or had been homosexually assaulted/raped. The majority of women participants had experienced SGBV either from South Sudanese Government Soldiers and/or rebels as well as from their husbands and other family members, particularly after arriving in Uganda. Alcohol misuse by men was cited by the majority of women as a factor underlying domestic violence in the refugee settlements. Men reported more cases of violence and torture and fewer cases of SGBV than women, whilst women were subjected high levels of violence, including SGBV, but less of torture. The main perpetrators of the atrocities in South Sudan were Government Soldiers as well as Rebels. Some refugees suffered at the hands of both. Incidents of violence, SGBV, torture and other human rights abuses declined significantly for men once they arrived in Uganda. However, for the women, rates of SGBV and other human rights abuses remained high. This was mainly as a result of domestic violence and sexual assaults by husbands and family members as well as South Sudanese and Ugandan civilians. Service provision Screening Service providers discussed the fact that refugees were frequently not screened on arrival in the refugee settlements, although a screening tool had been developed by Refugee Law Project (Dolan, 2017). Refugees should be screened and treated regarding their human rights abuse experiences. Health services The main providers of health services cited by the survivors were government health centres and services provided by Non-Government Organisations. When survivors reported having access to health services it was mainly for women who had experienced SGBV, pregnant women or those with minor aliments or injuries. Many refugees stated they were not “registered” and were therefore refused services by local agencies, such as healthcare providers. None of the male refugees had sought testing for sexually transmitted infections or treatment for SGBV including sodomy. All the interviewed men stated they had not reported their sexual or physical injuries officially and when they went to the health centres where the main treatment was Panadol medication. A number of men had bullets embedded in their limbs and claimed there were no services in the refugee settlements to remove them. Specialist treatment was available in Ugandan public government hospitals in Gulu but this was a five hour drive from Bidi Bidi settlement on the border with South Sudan. Service providers informed us that for Bidi Bidi settlement, Medical Teams International supported referrals to Arua hospital, and Interaid made referrals to Lacor hospital in Gulu and Mulago hospital in Kampala, for specialized treatments. The refugees we spoke to said that for specialist services they were referred to Kampala and some reported they had to pay their own transport costs to and from hospital and for the services, including food. Refugees stated that they had received minimal treatment for their health problems and Panadol was the main medication received. There were many challenges providing even minimal health services for refugees as the Chair of the Refugee Welfare Council in Adjumani explained:

• Socio-cultural impact

Women refugees had taken on the responsibilities of heads of household. This occurred as many men sent their women relatives to safety in Uganda whilst they stayed at home to defend their property. On arrival in Uganda every refugee was meant to be registered at the reception centres and many men were not or did not want to be because they continued to move across the border to attend to farms/cattle and livelihoods in South Sudan. The ongoing movement across the border meant that men could be accused of insurgency or paramilitary activities by Ugandan authorities. Therefore, women were registered as heads of household and given ration cards for the family. When men joined them, they became dependents on their wives or female relatives. This left men feeling that their rights as men had been denied. This was suggested to be a factor in creating domestic tensions and some suggested was a major reason for domestic violence in refugee settlements, including violence against children. Service providers informed us there were child-friendly spaces within the settlements that were regarded as safe spaces for children including early childhood development centres integrated with child friendly spaces, primary schools and secondary schools. They also stated that some partners were currently supporting the children’s education.

• Violence

Service providers informed us that most human rights abuses, including SGBV and torture, occurred in South Sudan. However, there was violence reported in the settlements including SGBV, and this was exacerbated by stress caused by a lack of food rations leading to arguments between husbands and wives. Some women and girls reported being raped, including when they had to walk long distances for instance when they were collecting firewood or water which often necessitated walking through the bush to Ugandan owned land. We were informed that personal security was lacking in settlements for women and that girls 14 years and older could be abducted, taken for instance by male relatives from the settlements to South Sudan for child/forced early marriage. It was recounted that a lot of violence and fighting was perpetuated by youth who drank alcohol and took drugs and were unemployed. All of this created a volatile situation where crowd violence could be easily ignited for instance due to the late arrival of food rations. Violence cited included fires being set and houses being burnt down.

• Justice and rights impact

Access to justice was reported to be lacking, with refugees often having to settle criminal matters through informal community structures in Uganda. Survivors did not expect justice for the human rights abuses experienced in South Sudan but did want these to be documented. All survivors living in the refugee settlements that participated in this research confirmed they knew and understood the reporting system of alleged crimes that took place within Uganda. Those who spoke of sexual offences in the settlements said that there was a clear health pathway for the cases but these were rarely followed through effectively by the criminal justice system. Most men refugees opted not to report crimes committed against them often due to high levels of stigma and shame of especially sodomised rape. Although the majority of refugees told us they generally felt secure in Uganda, they however remained concerned about violence and SGBV in the refugee settlements. Whilst they all knew of the reporting system for such incidents, they questioned the effectiveness of the process at times. For this reason, women said they would often opt for family reconciliation or interventions through informal community dispute mechanisms rather than reporting domestic violence or SGBV to the authorities.

• Security

When South Sudanese refugees crossed the Ugandan border, UNHCR made a policy decision to mix South Sudanese ethnic groups in the refugee settlements. This had made many refugees suspicious as they felt that perpetrators of atrocities were living amongst them. This sense of insecurity was particularly evident amongst men in Adjumani Refugee Settlement, in particular Pagrinya Zone which was near the border with South Sudan. A number of men recounted incidents of threats and violence, including the burning of their huts, which meant they have left their family compound to hide and in order to protect their families. Whilst some had reported the incidents to the Settlement Commanders, they claimed a lack of protection. The male refugees whom we interviewed, especially in Pagrinya, described feeling insecure due to people from the South Sudanese Government visiting their families who had become refugees living in Northern Uganda. Women survivors were concerned about their personal security, in particular SGBV and domestic violence, although service providers informed us that in Bidi Bidi Settlement there were no reported SGBV cases . However refugee girls and women when collecting firewood or water claimed that all kinds of crimes took place within the settlement perimeter. Indeed, one refugee woman said that her husband followed her from South Sudan to Uganda and started to hit her again. She told us that she reported the situation to the International Red Cross who assisted to provide her protection. Threats came not just from husbands, but also male refugees and the Ugandan community. There was a real concern by mothers that their daughters were being kidnapped and forced into marriage back in South Sudan by their husbands and other male heads of households. The Ugandan authorities were well aware of this and had implemented an awareness raising campaign on this issue in the settlements which stated that forced marriage was illegal and that marriage of girls under eighteen years old was also illegal. They also tried to protect girls when they become aware of a crime through moving them to safe locations sometimes in different settlements. Service providers informed us that security in the settlements was provided through neighbourhood watch and police posts in all zones together with armed forces. However, some of the refugees we spoke to told us that they had witnessed or experienced violence in the settlements and that police intervention was limited due to a lack of resources.

Social Justice and rights issues

Social justice services included assistance in taking cases to court, protection and child safeguarding, access to justice, education regarding rights, and limited support with access to health care. Ugandan police received training on providing justice for refugees and followed procedures for crime reporting, completed the necessary paperwork and also assessed the perpetrator’s mental state. However, there were many logistical challenges to getting justice for refugees, including insufficient numbers of police officers, lack of transport, paper and pens to make reports and a lack of fuel for police vehicles and motor bikes. For example, in Pagrinya, Adjumani settlement, the police station only had access to one motorcycle to provide policing for approximately 250,000 people. Social justice support was said to be particularly lacking for women survivors of SGBV. The courts were long distances away and it was reported that 10% of cases waited over one year to be heard. Service providers informed us that the recent use of mobile courts was attempting to assist with this. The conflicting laws between South Sudan and Uganda on child marriage were causing difficulties and the police in Uganda were trying their best to educate South Sudanese that in Uganda it was unlawful for a girl under the age of eighteen to marry. Cultural traditions were considered important by refugees to resolve justice issues. However, in the case of South Sudan refugees, these often contradicted Ugandan law.. For example, we were informed by service providers that refugee registration details, including the name of household heads, could be changed on request by household members. Sometimes, household separation was done on request by specific cases by the Office of the Prime Minister based on unacceptable circumstances e.g. child marriage. Mobile courts had been introduced in all zones in Bidi Bidi Settlement to reduce on the challenges of logistics. Some women police officers have also been deployed in the settlement to settle family disputes along gender lines. It was reported by the service providers we spoke to that supervision structures were being put in place by stakeholders with the aim of tackling bribery.

Gender issues

It was generally felt that gender sensitivity, inequalities and more sensitive approaches towards gender differences were needed. Male survivors were often excluded from programmes and men found it difficult to discuss mistreatment by women. It was felt that men found it harder to disclose abuses and providing medical treatment assisted them to overcome stigma and shame e.g. of sodomy rape. Service providers, including prisons, lacked knowledge to deal with men who had been raped . Also, child trafficking needed to be tackled. There also needed to be more focus on tackling gynaecological health problems of women who found these issues stigmatising and therefore did not come forward for treatment. Chris Dolan, Director of the Refugee Law Project stated thus:

CONCLUSION AND RECOMMENDATIONS

Thematic analysis of interviews with South Sudanese men and women refugee survivors of SGBV and/or torture and stakeholders resulted in four themes: experiences of refugee survivors, service provision for survivors, impact of experiences, and gender issues. All the refugees whom we spoke to shared their experiences of SGBV and/or torture. Few had previously been asked about their human rights abuses. Despite the significant physical health, emotional, social-cultural and rights impact of their experiences, the health and justice service responses were minimal. Few refugees, particularly men, had access to counselling. To conclude, our research argues that SGBV and/or torture are violations of refugees’ rights; their bodies and health, and therefore their right to health care and social justice should go ‘hand in hand’ (Liebling & Baker, 2010). It is important that service providers remain sensitive to gender differences, cultural context, and approaches are informed by a considered understanding and normalisation of the impact of refugees’ traumatic experiences (Liebling, 2018). Whilst many refugees recognise, they would struggle to get ‘formal’ justice for the human rights abuses committed against them in South Sudan, they did appreciate having the opportunity to narrate their experiences. Provision of the holistic model we recommend would ensure refugees and their families feel validated which in turn will assist them to utilise their resilience and agency to continue the process of recovery (Liebling et al. 2014; Liebling & Baker, 2010). The following recommendations are made for Ugandan and international partners to further develop and implement where practical:

• Comprehensive screening and treatment of human rights abuses: All refugees should be screened and treated regarding their human rights abuse experiences. Clinics need to be better resourced and require logistics to carry out their work effectively including regular supplies of medication and treatment, surgery facilities and vehicles. Post-exposure prophylaxis and emergency contraception is urgently needed in the local health clinics to prevent HIV infection and conception of a child following rape.
• Adequate staffing for physical and psychological health care: We recommend where possible that the Ministry of Health together with NGOs including Doctors of the World (Medecins Sans Frontiers) employ physical and psychological health care staff to bring the settlements up to at least the Ministry of Health minimum health care requirements.
• Psychological support and counselling: We recommend provision of group and individual trauma counselling and psycho-social support for refugees and their children involving health care teams and community organisations. There needs to be clear referral pathways into these services. Training to increase the capacity of health professionals in settlement health centres to be able to assess the health needs of refugees with trauma-related difficulties and provide person-centred counselling would be helpful. It is important that issues of shame and stigma are addressed sensitively by service providers as this assists disclosure. Specialist medical treatment for men and women survivors is essential. Services need to tackle drug and alcohol abuse particularly amongst the youth as well as domestic violence. The services should be informed by involvement of the Refugee Welfare Councils and include traditional approaches to promote recovery and integration. Training of community and peer refugee counsellors would also help improve access to services. We also recommend developing effective support systems for service providers to maintain positive emotional health and tackle burnout. Reflective groups for staff to support each other and recruitment of adequate staff numbers would assist reduce the burden on staff.
• Improved education and livelihoods: We recommend the need for increasing the resourcing of Government primary schools including the number of classrooms, teachers and books. Credit and loans could be available to support the establishment of social enterprises, which would assist refugees with an income and to be able to provide emotional support within their groups, their family and to other survivors in the settlements. The provision of more secondary schools in the settlements and vocational training for the youth would be helpful.
• Police improvements: The recruitment of police including more women police officers to Bidi Bidi and Adjumani refugee settlements would be a short term solution. The police also require logistical support including more private rooms for interviewing survivors, vehicles, and practical resources to carry out their role. This would enable them to provide more effective security and outreach services in the settlements.
• Social justice: The “culture” of sexual and gender-based violence including domestic violence needs to be broken by continued awareness campaigns in the refugee settlements (Isis-WICCE, 2015). We envisage local dialogue and debate that covers the dignity of women, men and children and respect due to them, and their value, equality and the tragic consequences on them and their communities when they are subjected to sexual violence. This debate should include men and boys so that they too are part of the solution. Provision of specialist treatment for SGBV and torture survivors should be extended to enable survivors, including men who find it particularly difficult, to come forward. The use of locally trained mentors through the Refugee Welfare Councils would assist with this.
• Legal justice and policy: Extending the use of mobile courts as well as regular visits by organisations assisting refugees resolve social justice issues would help improve access to justice. Refugee policy should include provision and resources for treatment for survivors of human rights abuses and anti-discrimination provisions with penalties for those who abuse refugees including adverse consequences in the law for those who violate this.

Limitations

This qualitative research included participants’ in-depth narratives. It is acknowledged that a relatively small sample size was used and therefore there are limitations regarding generalisability of the findings. The project recruited refugee survivors of SGBV and torture through the Refugee Welfare Councils in the settlements, therefore the participants had a certain degree of expertise regarding the subject of inquiry. Service providers were recruited from a range of UN, Government, International and National Non-Government Organisations, who therefore had a range of expertise regarding the research.

Acknowledgments

We are most grateful to all those we interviewed including refugees, the Government of Uganda and all stakeholders, for their participation and the knowledge and experiences they shared. We hope that this summary in some small way repays that investment of time. For further discussion please contact: Dr Helen Liebling E-mail: Helen.Liebling@coventry.ac.uk, Professor Hazel Barrett E-mail: H.Barrett@coventry.ac.uk, Professor Lilly Artz E-mail: lillian.artz@uct.ac.za. and Ms Faddy Gladys Canogura E-mail: kiwepi383@gmail.com.

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