During the last four decades, millions of people have fled their homes and sought asylum in other countries. According to the United Nations High Commissioner for Refugees (UNHCR) , by the end of 2010, there were about 15.4 million refugees and approximately 0.85 million asylum-seekers worldwide. Nearly 80 per cent of the refugees and asylum-seekers are located in developing countries (mostly in sub-Saharan Africa and Asia). The international community and host countries have been successful in helping refugees and asylum-seekers (hereafter collectively referred to as refugees) who have settled in camps or camp-like settings. Today, refugees move into cities and urban locations in anticipation for good living conditions and services, such as health care and education . Recent data show that half of the world’s refugees live in non-camp settings , whereas in urban areas, the number of refugees almost doubled by the end of 2009, surpassing the number of refugees in camps . Refugees are not always welcomed into urban areas of the host country, and usually live in shantytowns and slums in and around cities where they compete for services with other immigrants and the autochthonous urban poor. The change in refugee demographics has consequences for refugee policies, protection and the provision of services, including health care. UNHCR has responded to the change in refugee settlement by revising its 1997 policy on refugees in urban areas. The new policy from 2009 recognises urban locations as legitimate places for refugees to reside and emphasises the responsibility of UNHCR to provide protection and services to refugees .
The world is increasingly urbanising as people are moving from rural areas to cities, especially in developing countries. More than 60 per cent of the world’s population is projected to live in urban areas and more than 50 per cent of them are likely to be poor . The same trend is expected for refugees in developing countries , where cities and towns are expanding and growing fast towards refugee camps. Moreover, refugees who flee from cities tend to seek refuge in urban areas. The opportunities to find work, education, health care and better livelihoods are greater in cities, and act as pull factors for refugees towards urban areas. As a result, refugees become part of and are affected by urbanisation. According to The United Nations Human Settlements Programme (UN-HABITAT) estimates, 5.3 million displaced people, including refugees, asylum-seekers, internally displaced persons and other forms of migrants are now living in cities in the developing world, particularly in sub-Saharan Africa and Western and Southern Asia . In addition to urbanisation, ageing of refugees in some protracted and relatively stable situations, creates an epidemiological shift from infectious to chronic diseases [2, 9]. A similar epidemiological transition is occurring in the general populations of developing countries . Information on age distribution among urban refugees in developing countries is limited, possibly owing to a lack of enumeration and refugee mobility. However, data from UNHCR show that elderly populations (60 years and above) constitute two to four per cent of urban refugees in Africa, Asia and Latin America and are older than those living in camps .
Globally, NCDs are the leading cause of death. Approximately 80 per cent of deaths linked to NCDs occur in developing countries . And although communicable diseases remain the main cause of death in most developing countries, the probability of death from NCDs, particularly in urban areas, is greater than that in the developed world [12, 13]. The incidence of NCDs is predicted to increase more rapidly in developing countries than elsewhere in the world . The common health problems of refugees are psychological disorders, injuries, infectious diseases, under-immunisation in children and under-managed chronic conditions such as hypertension, diabetes and chronic pain [15–18]. Chronic NCDs are now becoming a concern, particularly in middle-income populations that are affected by conflicts . For example, in the case of Iraqi refugees, NCDs were the predominant health problems . Similar health problems were reported during the Balkan crises [20, 21]. In both situations, the international community faced numerous challenges to attend to refugees’ health care needs. The management of chronic health conditions is expensive and depletes the already limited resources available for refugee health care . The health care strategy and policy for the UNHCR and other aid agencies are based on experiences from camp settings, where refugees are easily accessible .
Moreover, health care delivery to refugees in cities is not an easy task, even in developed countries [23, 24]. Therefore, in the urban areas of developing countries, refugees’ access to health care and other services cannot be guaranteed owing to limited resources, the hidden and scattered nature of the population, a lack of security and cultural and language barriers. Sometimes legal and recognition aspects are also obstacles for refugees to receive health care even in countries with good health care systems (e.g., Malaysia). Typically, refugees and asylum-seekers do not have similar rights for accessing health care as the local population and some host governments do not assure the safety of refugees. Only ten per cent (compared to 85 per cent of the camp-based refugee population) of urban refugees had access to public health assistance in 2007 . Refugees come from different countries and have different experiences with, understandings of and expectations for health and health care . Accordingly, their health needs may require more than basic primary health care . The primary health care available is usually not sufficient to address most chronic diseases, such as cardiovascular disease (CVD), diabetes and cancer, which require prolonged care and expensive treatment [27, 28]. The shortcomings of international policies to address the needs of refugees in urban locations were highlighted during the experience with Iraqi refugees in Middle Eastern cities . Furthermore, many chronic health problems perceived by refugees as not emergencies are ignored  due to preoccupation with other needs (food, shelter, employment, legal status) or are overlooked by health care providers owing to a lack of plans or capacities.
Despite the challenges to urban refugee health care delivery, some communicable diseases (e.g., HIV/AIDS and tuberculosis) receive attention from host countries in the interest of national public health. However, the provision of care for refugees suffering from chronic illnesses and requiring specialised consultations, expensive medications, health education and preventive health services is not adequate [5, 29–31]. With respect to refugee health research, communicable diseases and mental health conditions have been studied in the context of refugees. However, NCDs among refugees (except mental health conditions) in developing countries are not adequately addressed. Routine medical screening of refugees arriving (30-90 days post-arrival) in resettlement countries have found different rates of NCDs [18, 32, 33]. The aim of this study is to review the literature to determine the prevalence and distribution of chronic NCDs among urban refugees living in developing countries and to describe refugee access to health care for NCDs. We will also compare the prevalence of NCDs among urban refugees with the prevalence in their home countries, when data are available, to evaluate the impact of refugee and asylum-seeker status on prevalence.