Health care

Optimal physical and mental health is a vital resource for integration. Poor health may act as a significant barrier to integration. Ensuring that new arrivals have access to health care as soon as possible after arrival optimises the opportunities for early intervention. Health care services may provide an acceptable point of entry to services which new arrivals may otherwise be reluctant to access (e.g. counselling and support services).

Through their encounters with health care providers, newly resettled refugees can learn about other resources required for successful integration, such as social support networks and services providing assistance with housing and employment.

Resettled refugees experience a relatively high rate of both physical and mental health problems, the result of deprivation of the resources required for good health, exposure to trauma and poor access to health care prior to arrival.

United Kingdom

The Health Access for Refugees Programme (HARP) empowers refugees to access the UK health system in an appropriate way and at the appropriate time. HARP enables refugees to better understand, care for and communicate their own health needs. Asylum seekers and refugees are supported to become more confident to speak in public, share their experiences, and communicate their health needs to health professionals. Activities include: Weekly health access course to asylum seekers, Health access workshops for asylum seekers and refugees, Volunteer befrienders who accompany refugees and asylum seekers to medical appointments and advocate on their behalf where necessary, etc.

New arrivals may have health problems which either have not been diagnosed or been properly treated in the past. They may also have had limited access to preventative health care programmes in the past (e.g. immunisation, access the contraception, breast and cervical cancer screening).

While health issues may vary depending on the region from which refugees originate and the nature and duration of their displacement, common patterns identified by health care providers and researchers in countries of resettlement are documented in the Table, below. It is not uncommon for resettled refugees to have multiple and complex problems at the time of arrival.

Resettled refugees may require additional support to access and make the best use of health services particularly in the early integration period, including:

• access to free or affordable services.
• assistance in communicating with health care providers.
• information about the health care system of the resettlement country. This is important as there is considerable variation in health systems globally.
• information about the relationship between health and residency status. Resettled refugees may resist contact with health care services for all but acute health problems fearing that their permanent residence will be compromised if they are found to have a health problem.
• practical support to access health care services (e.g. transport and child care). This is particularly important for resettled refugees requiring numerous follow-up appointments and those struggling with other resettlement tasks.

Additional steps may need to be taken by resettlement countries to ensure that these needs are met, as:

• resettled refugees may not be readily identified by health care providers in the wider health care system, particularly in communities which are already very culturally diverse.
• most health care providers in resettlement countries may be unaccustomed to dealing with a patient group which has had limited or disrupted access to health care and may be unfamiliar with managing some conditions.
• financial and workload constraints required as a result of longer consultation times, multiple consultations and extra-consultation activity when providing early health care to resettled refugees. These are necessary due to the additional time taken in communicating through an interpreter, the complexity of the health issues and other patient care needs such as establishing rapport, explaining unfamiliar concepts and making referrals to specialists and allied health professionals.
• in many countries, professional interpreters are not readily available to health care providers, in particular, those in private practice. Resource constraints may hinder deployment of interpreters in publicly funded facilities.
• early health care for resettled refugees often requires the input of allied health and social support professionals, general medical practitioners and professionals with mental health and communicable disease expertise. In resettlement countries linkages between these services may not always be well established.

Table 1, based on the Common health patterns identified among resettled refugees 

While many resettlement countries make special provision for early health assessment, there is a consensus that the overall emphasis in planning should be on ensuring that resettled refugees have access to the same health care services provided to nationals. However, given the barriers many new arrivals face in accessing services, most countries recognise the need to take specific steps to ensure that resettled refugees understand and are able to make the best use of services and that the wider health system is responsive to their needs.

Payment for health services

In some resettlement countries the costs of health care and pharmaceuticals are met by the service user on a fee-for-service basis, through participation in a public or private health insurance scheme, or through a work-based health care programme (for which a qualifying period may be involved). In these cases, consideration will need to be given to arrangements for ensuring that resettled refugees have access to free or affordable health care, at least in the early integration period when they face particular financial constraints. Of particular concern in this regard are access to dental care and optometry. As indicated in the Table above, many resettled refugees have poor oral health and have lost or misplaced prescription spectacles. In some resettlement countries, these services are available to nationals on a ‘fee-for-service’ basis only or there may be long waiting periods for government funded services. Recognising the critical role oral health and visual capacity play in the integration process, a number of countries have made specific provision for resettled refugees. For example, in some countries dental care is provided during the reception phase.

Health assessment or health check

Many countries offering refugee resettlement recognise the importance of making formal arrangements for resettled refugees to participate in a thorough health assessment or a ‘health check’ either prior to or soon after their arrival. There are a number of reasons for this:

• Resettled refugees may have urgent and serious health care needs in the early period of resettlement that may not be readily met through general health care services.
• Formalised health assessment offers a means of detecting and treating communicable disease. This is important to protect the health of the individual as well as the community. It also helps to maintain broader political and community support for refugee resettlement programmes in the receiving community.
• If offered routinely through a formal system, health assessment can help to avoid unnecessary repeat investigations that might otherwise occur if it is provided on an ad hoc basis through the general health system.
• Provision for formal health assessment enhances the prospects for early identification and treatment, particularly of diseases and conditions that are currently asymptomatic such as non-communicable diseases.
• Formal health assessment can provide important information to assist with the integration of resettled refugees with needs, such as resettled refugees with disabilities.
• Formalised health assessments, if offered in the resettlement country, provide an opportunity to introduce new arrivals to specific treatment and illness prevention services (such as dental and child health surveillance programs), to link them with other resources required for successful integration, and to familiarise them with the health care system.

In this context it is important to distinguish health assessment from health screening. Screening is typically a standardised process that is both limited and selective. While it may have benefits for the individual, in an integration context, screening is performed primarily to meet public health goals (in particular, prevention of the spread of communicable diseases in receiving communities). In contrast, an assessment is a thorough, holistic process that is tailored to the needs of the individual patient and performed with their ongoing management in mind.

Health assessment is offered with differing degrees of formality in existing countries of resettlement. In some integration programmes, it is offered through a dedicated programme (either prior to departure or during reception), with resettled refugees being routinely required or invited to participate. Others use outreach and capacity building strategies to ensure that new arrivals are able to access this care through the wider health system. In some instances, limited health assessment may be offered in the country of departure with other aspects being provided on reception.

The International Organization for Migration (IOM) provides a program of pre-departure health assessment on behalf of resettlement governments, along with treatment of certain diseases. Pre-departure screening can provide information to assist resettlement countries to plan for resettled refugees in advance of their arrival. However, pre-departure health assessment is not a substitute for post arrival health assessment as it tends to be limited and selective. Further conditions of a more chronic and complex nature will require long term follow-up in the resettlement country. It is not uncommon for there to be a prolonged period between the pre-departure health check and the refugee arriving in the resettlement country. Post arrival health assessment is important to identify and treat any problems that have developed in this period.

In some countries, participation in health screening is mandatory (often being part of the refugee selection process), while in others it is voluntary. Although there may be potential public health benefits from screening, it should be rational and conducted respecting refugee’s rights.

While health assessment should be offered as soon as possible after arrival, in practice, resettled refugees may find it difficult to prioritise health care over other integration tasks. For this reason, it is prudent to offer a generous period for participation in health assessment. In countries with no or limited provision for pre-departure or reception health screening, measures to ensure that assessment is offered early in the integration period will be of greater importance. Procedures for obtaining informed consent, conducting pre and post-test counselling and for adequate follow-up of problems identified are important considerations in health assessment programmes.

Preventing and treating communicable disease in refugee communities

Considerable social stigma is attached to communicable diseases in many countries. Confidentiality will be particularly important when treating resettled refugees with these diseases, as many will be reluctant to disclose their disease status even to close family members.

In planning for the prevention and treatment of communicable disease in refugee communities it will be important to consider:

• access to communicable disease diagnosis and care.
• engaging bilingual caseworkers to provide advice to planners and health professionals and direct support to affected resettled refugees.
• resources to ensure that relevant health professionals are aware of potential communicable diseases affecting refugee communities and are able to offer high quality and sensitive care. These may include access to technical assistance, written resources and professional development programmes.
• prevention of blood-borne viruses in refugee communities. Prevention, education and treatment programmes may be poorly developed in countries of origin and resettled refugees may have limited knowledge of the transmission, prevention and treatment of blood-borne viruses. Where practical, refugee communities should have access to culturally sensitive multilingual information.
• intensive integration support for resettled refugees with communicable diseases requiring complex and long-term treatment regimens (e.g. HIV, TB). Resettled refugees may need some support to understand the need for ongoing treatment; practical assistance to ensure their compliance with treatment regimens and psychological support to deal with the consequences of a positive diagnosis.

Support and advocacy to access health services

Integration caseworkers and agencies supporting resettled refugees in the reception period play an important role in assisting them to undertake early health assessment and in linking them with services in their community for ongoing management. This may involve providing information about services, promoting the importance of early health care, briefing health care providers about the person’s special needs, arranging appointments and interpreters and negotiating transport and other practical matters (e.g. childcare).

While support to access health services can be provided either in place of, or in addition to, a dedicated clinical service, it is particularly important in those countries where resettled refugees are reliant on the wider health care system for early health care. A particular advantage of this approach is that support is delivered locally in the receiving community.

What information will new arrivals need to access health assessment and early health care?

Consider incorporating the following into both pre-departure and post arrival information for new arrivals and those providing support:

• the benefits of making contact with a doctor as soon as possible after arrival.
• information about the relationship between health and legal status.
• the importance of making appointments; how they can be made; and whether it is important to be ‘on time’ (health care is accessed on an ad hoc basis in many countries of origin and/or asylum. Failure to attend, or being late for, appointments can be a source of conflict between resettled refugees and health care providers).
• how to find a doctor and the importance of continuity of care.
• how services are paid for or accessed (e.g. fee-for-service, insurance or registration arrangements).
• programmes to assist people on low incomes, to meet the costs of health care and pharmaceuticals.
• information about specialist refugee health services where relevant.
• arrangements for interpreters for health care consultations.
• information on services for people with special health care needs (e.g. those with disabilities).
• the culture of the health care system of the resettlement country (e.g. confidentiality, the concept of informed consent, doctor–patient relationships).
• any features of the structure or culture of the health system that contrasts with those in the country of origin or asylum (e.g. pharmaceuticals tend to be more stringently regulated).
• arrangements for dental health care, immunisation, child health surveillance (with these differing markedly between countries), hearing, optometry and women’s health care;
• how specialists are accessed (e.g. in some countries this might be through referral from a general practitioner, while in others specialists can be accessed directly).
• the role of allied health professionals such as social workers and psychologists.
• the importance and role of illness prevention programs and the concept of illness prevention (which may not be a feature of health care in some countries of origin or asylum).

Building capacity in the wider health system

A number of initiatives have been developed in existing resettlement countries to enhance the capacity of the wider health system to respond to the needs of resettled refugees, including:

• formal partnerships between health services to provide coordinated, multi-disciplinary care either within a community or from a specific service setting;
• multi-disciplinary service provider networks to enhance communication, mutual understanding, coordination and referral between providers (e.g. infectious disease and mental health professionals, integration caseworkers, general practitioners);
• referral protocols between health care providers;
• protocols to ensure that resettled refugees are identified and that they are offered sensitive support (e.g. interpreters);
• funding programs and financial incentives to enable general health care services to meet additional costs associated with providing care to resettled refugees (e.g. to employ bilingual workers, to offer longer consultations);
• partnerships between health services and other settings such as schools to enhance identification and referral of resettled refugees with particular health needs;
• the development of ‘help-desk’ services for health professionals requiring assistance in the management of more complex health issues.

Labour development and support

There are a number of ways in which existing integration programmes have successfully built work force capacity in refugee health. These include:

• identifying professionals with skills and interest in refugee health care (e.g. health professionals from refugee or diaspora communities, nationals with humanitarian experience) and recruiting them to work in specialist services or in areas where a large number of refugees settle. These professionals may also be deployed on a sessional basis or in an advisory capacity.
• designing and delivering professional development programmes, particularly for those health professionals involved in formalised early assessment or in areas where a large number of new arrivals settle.
• developing resource materials for health professionals.
• providing health professionals with access to cultural consultants/cultural mediators.
• providing health professionals, particularly those in the wider health care system, with access to consultation with a more experienced practitioner to support them in dealing with complex and difficult issues.
• providing debriefing and peer support to health professionals who see many resettled refugees or who have limited peer support, such as medical practitioners in solo practices.

Capacity building in refugee and wider communities

The diaspora and wider communities have an important role in both providing practical support to resettled refugees accessing health services and in assisting them to understand and negotiate the health care system and to act as their advocates within it.

This potential has been tapped in a number of countries of resettlement through capacity building activities such as befriending and volunteer programmes. In some countries these programs have a specific focus on health. In others, health issues have been built into broader social support programmes.

Information for professional education and development

Consider incorporating information on the following in professional education and development programmes:

• country background information. Further resources on country of origin information can be found here.
• how refugee patients can be identified.
• protocols for the identification and management of communicable diseases.
• what, if any, investigations have been performed in the context of formal predeparture or reception health assessment or screening.
• the importance of offering overall health assessment in the resettlement country (particularly in countries where this is not offered through a formalised program).
• the impact of trauma and torture and how this can be addressed in care (e.g. dealing with a disclosure, making referrals).
• allied health services available to resettled refugees, in particular, specialist services for survivors of trauma and torture, victims of gender-based violence (GBV).
• booking and working with interpreters.
• cultural and religious factors affecting relationships with health care providers. See for example the following document that outlines Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians. This report aims to provide information on the sociocultural background of the Syrian population as well as cultural aspects of mental health and psychosocial wellbeing relevant to care and support. It is based on an extensive review of the available literature on mental health and psychosocial support (MHPSS), within the context of the armed conflict in Syria.
• cultural views of health and illness. For example, some resettled refugees are from cultures where explanatory models of illness differ from the biomedical approach advocated in many resettlement countries.
• cultural and religious factors that may affect health care provision. For example, the bruises left by ‘cupping’, a traditional healing method in some Asian cultures, may be mistaken for abuse in children. Some resettled refugees use traditional remedies which may result in adverse reactions if taken in conjunction with bio-medicines.
• key features of the structure and culture of the health care system in countries-of-origin (e.g. the relative importance of appointment systems, doctor–patient relationships, the role of traditional healing methods).
• the importance of self-care (including peer support and debriefing) to avoid stress and burn-out.

The overall goal in planning post arrival health services should be to ensure that resettled refugees have access to the same range and quality of services provided to nationals.

The advantages of specialist refugee health services

In some resettlement countries, initial health assessment may be provided through a specialist service or programme, with arrangements for ongoing support being arranged through a community-based provider. The advantage of this system is that management can be structured and resourced to accommodate the intensive patient care needs typically experienced by new arrivals at the time of reception (e.g. longer consultations, interpreters).

If provided by a multi-disciplinary team from the same premises, this system also minimises the organisational effort that would otherwise be involved in accessing multiple health care providers in different venues.

Through their contact with a large number of resettled refugees, specialist services are in a position to identify and document trends and issues; to explore and model appropriate responses to these and to develop specialist expertise. This information, together with their particular focus on refugee health care, provides a basis for:

• developing and delivering professional development programs and resources for health care providers in the wider health care system.
• providing specialist advice to other health care providers.
• planning appropriate responses to care in the wider health care system.
• raising awareness of and advocating the needs of resettled refugees to other health care providers, government and refugee and wider communities.

Specialist services may also play an important role in providing support to resettled refugees with particularly complex needs. However, there are a number of problems associated with establishing special refugee health services as a sole response to their needs:

• Specialist services seldom attract sufficient resources to meet the needs of all new arrivals.
• Specialist services alone may work against providers in the wider health care system developing skills and confidence in caring for resettled refugees and in assuming responsibility for their support.
• In many countries of resettlement, resettled refugees are placed across a broad geographic area, making it difficult to ensure access to a specialist service.
• Unless specialist services can be provided in local communities, their capacity to develop relationships with, and subsequently link new arrivals to, resources and services at the local level is limited.
• Specialist services may pathologise the refugee experience and cast resettled refugees as different.

Nevertheless, specialist services and programmes may have a role in an overall strategy of ensuring that the wider health care system is responsive to resettled refugees.

Provision of information to the wider community

Antipathy toward refugee communities in resettlement countries can be fuelled by a perception that resettled refugees carry diseases which pose a threat to the receiving community or that they are a burden on the health care system.

Integration service providers can ensure that receiving communities are accurately and appropriately informed about health matters affecting resettled refugees by:

• emphasising the resilience of resettled refugees.
• indicating that many of the health problems experienced by resettled refugees are the result of past deprivation and poor prior health care, most of which can be addressed by appropriate health care in the early integration period.
• providing accurate information on the risk of communicable disease which is often poorly understood and unfounded.
• When providing information, there is a need to strike a balance between identifying the health care needs of resettled refugees while at the same time being careful not to reinforce negative stereotypes of resettled refugees and perceived threats.