The Mig-HealthCare Roadmap & Toolbox for the effective
implementation of community care models
for Migrants & Refugees
Mig-HealthCare - strengthening Community Based Care to minimize health inequalities and improve the integration of vulnerable migrants and refugees into local communities, is a three year project that was launched in May 2017, co funded by the European Union’s Health programme (2014-2020).
The project is implemented by a consortium of Universities, national authorities and NGOs from ten countries across Europe, with diverse experience on issues of public health and integration of refugees and migrants.
The Mig-HealthCare consortium comprises the following partners:
- Prolepsis Institute – Coordinator, Greece
- Medical School, University of Athens, Greece
- Region of Sterea Ellada, Greece
- National Health Operations Centre (NaHOC), Ministry of Health, Greece
- Oxfam Italia, Italy
- Ethnomedical Center, Germany
- National Center of Infectious and Parasitic Diseases, Bulgaria
- Ecole des Hautes Etudes en Sante Publique, France
- CARDET, Cyprus
- Region of Sterea Ellada, Greece
- KOPIN, Malta
- Uppsala University, Sweden
- Verein Multiculturell, Austria
- University of Valencia, Polibienestar Spain
The overall objective of Mig-HealthCare is to:
- Improve health care access for vulnerable migrants and refugees
- Support their inclusion and participation in European communities
- Reduce health inequalities
Mig-HealthCare will produce effective community-based care models, pilot tested in different contexts and countries, which will focus on health promotion and prevention. It will develop guidelines and tools to reorient health care services to a community level.
Migrants and refugees are terms that are often used interchangeably, but they are defined by the UN as follows (https://refugeesmigrants.un.org/definitions):
Refugees are “persons who are outside their country of origin for reasons of feared persecution, conflict, generalized violence, or other circumstances that have seriously disturbed public order and, as a result, require international protection. The refugee definition can be found in the 1951 Convention and regional refugee instruments, as well as UNHCR’s Statute”.
Migrants “While there is no formal legal definition of an international migrant, most experts agree that an international migrant is someone who changes his or her country of usual residence, irrespective of the reason for migration or legal status. Generally, a distinction is made between short-term or temporary migration, covering movements with a duration between three and 12 months, and long-term or permanent migration, referring to a change of country of residence for a duration of one year or more”.
Contributors: Pania Karnaki, Dina Zota, Elena Riza, William Grech, Barbara Bitschnau, Ovagem Agaidyan, Eliza Patouris, William Sherlaw, Jean-Baptiste Combes, David Brinkman, Alejandro Gil Salmerón, Jorge Garcés-Ferrer, Iva Christova, Angel Kunchev, Paolo Pezzati, Giovanna Tizzi, Hannah Bradby, Adele Lebano, Sarah Hamed, Giannakopoulou Martha, Gougianos Gavrilis, Kostas Gogosis, Gioura Naskintasvili
Suggested citation: Karnaki P., Zota D., Riza E., Grech W., Bitschnau Β., Agaidyan Ο., Patouris Ε., Sherlaw W, Combes JB., Brinkman D., Salmerón AG, Garcés-Ferrer J., Christova I., Kunchev A., Pezzati P., Tizzi G., Bradby H., Lebano A., Hamed S., & Linos A. (2019). Roadmap and Toolbox to an effective implementation of community care models for Migrants & refugees. Part of the Mig-HealthCare project -https://mighealthcare.eu/, co funded by the European Union’s Health programme (2014-2020).
Since the Middle East crisis began in 2011 Europe has seen increased flows of migrants and refugees arriving mainly at the Mediterranean shores. According to data from the UNHCR, by the end of 2014 almost 60 million people were forcibly displaced from their homes and over 1 million refugees and migrants entered the European Region in 2015. The influx of refugees and migrants into Europe is ongoing and hereby the need to address the health issues arising and facilitate health care access is increasing. The growing numbers of migrants and refugees have short and long term implications in relation to issues of security, economy and health.
With Europe being one of the major destination of displaced populations as a consequence of the armed conflicts in the Middle East and Africa, the need to harmonize actions in the healthcare sectors is of utmost importance. The freedom of mobility across countries depending on the status of refugee/migrant population groups indicates the need for reliable data on refugee/migrant health.
Fortunately, Europe does have long experience in the integration of migrants and refugees. Over the last years the European Commission has focused efforts on tackling issues related to migration and has financed a plethora of related programs. The evidence on effectiveness exists – it needs to be assessed under the prism of new developments and put to the test. Action is urgent given also Europe’s dark past in anti-migrant negative attitudes which are rising across Europe exacerbated by the adverse economic situation in many MS. European countries have a unique opportunity to put past and current experience to practice promoting the integration of refugees and migrants.
This roadmap and toolbox combines evidence from original research and other information to present concrete steps in the provision of care to migrants and refugees at a community level.
“Community Health refers to the health status of a defined group of people and the actions and conditions, both private and public (governmental), to promote, protect, and preserve their health” (McKenzie et al., 2005).
Community is defined as “a group of people, often living in a defined geographical area, which may share a common culture, values and norms, and are arranged in a social structure according to relationships which the community has developed over a period of time. Members of a community gain their personal and social identity by sharing common beliefs, values and norms which have been developed by the community in the past and may be modified in the future. They exhibit some awareness of their identity as a group and share common needs and a commitment to meeting them” (Green and Ottoson, 1999).
Community-based care / community-based services / programmes defined as “the blend of health and social services provided to an individual or family in his/her place of residence for the purpose of promoting, maintaining or restoring health or minimizing the effects of illness and disability”. These services are especially valuable for the most vulnerable members of the community like migrants/refugees, older adults etc. (A glossary of terms for community health care and services for older persons http://www.who.int/kobe_centre/ageing/ahp_vol5_glossary.pdf)
The Mig-HealthCare roadmap & toolbox emphasize an approach that can be implemented at a local community level by local health professionals.
This roadmap is valuable and useful resource for a wide variety of stakeholders both at the individual as well as the organizational level. Targeted stakeholders include:
- Health professionals of all specialties including medical doctors & nurses working at different level, local, regional and national
- Health care administrators
- Managers & staff of health care services including hospitals and health care centers at local, regional and national levels
- Migrants/refugees and their representative bodies
- Patients, their families and caregivers
- The necessary actions a health professional needs to engage in during delivery of care to migrants & refugees namely
- Continuity of information
- Language, Culture & Communication Issues
- Language and communication
- Cultural issues
- Health literacy
- Health issues of particular importance for migrants & refugees that will pose challenges to health care services especially at the community level:
- Mental Health
- Maternal/ child health
- Health promotion
- Cervical and Breast cancer screening
- Colorectal cancer screening
- Physical activity
- Oral Health/ Dental Care
- Non Communicable diseases (NCDs) & chronic conditions
- The Mig-HealthCare algorithm which is a tool to guide health professionals when delivering care to migrants/refugees.
This roadmap is a valuable and useful resource for a wide variety of stakeholders both at the individual as well as the organizational level. Targeted stakeholders include:
Mig-HealthCare’s vision for this roadmap & toolbox is to:
- Help the health professionals working primarily at the community health care level to familiarize themselves with the key areas of importance in refugee/migrant health.
- Provide health professionals with a valuable set of best practices and handy tools to facilitate their work and to increase their efficiency in delivering appropriate care to migrants/refugees.
- Create a network of professionals experienced in refugee/migrant health who through using this roadmap & toolbox will improve their related knowledge and experience.
The Mig-HealthCare roadmap & toolbox can be used in different ways. Indicatively:
- Health professionals can refer to the roadmap content at any time to become informed about the issues of importance when delivering health care to migrants/refugees. One can refer to specific health issues when it is necessary to address a particular problem or consult the content in its entirety.
- Health professionals but also community level stakeholders can adapt best practices as described in the roadmap & toolbox for the particular situation in their community.
- Health professionals can use the tools that are presented under each health issue for their patients or to facilitate their own work.
- Physicians can use the algorithm when they are consulting a migrant/refugee patient to ensure they address the issues of importance the Mig-HealthCare project has identified for the health of migrants/refugees.
This roadmap and toolbox was created as part of the Mig-HealthCare project following extensive research on the:
The Algorithm is a tool, comprising a set of questions, which has been developed with the aim to:
(a) guide the user on how to access all the categories and tools that are available through the Roadmap & Toolbox
(b) help the user identify the health issues of importance when providing care to a specific migrant/refugee.
If using the algorithm, please ask the migrant/refugee the algorithm questions and provide the answers. At the end a brief report will be generated.
Filling in the algorithm for one migrant/refugee, should take approximately 20 minutes.
Please note that if you do not complete until the end the algorithm for the specific person you have started it for, and you need to start completing it for someone new, you should press the refresh button in the browser you are using (or ctr + F5) in order to start again from the beginning.
The adoption of this roadmap & toolbox requires certain prerequisites outside the control of the Mig-HealthCare project.
People escaping poverty and war continue to arrive to the EU with plans of settling permanently. Improving access to effective health care for these vulnerable groups (as for the rest of the native population) requires a transition from institutional to community-based care and integrated services.
The current financial and political instability in many EU countries poses a threat to the development of integrated Public Health Care (PHC) services. Integrated PHC requires coordinated action, capacity building, trained health care professionals and supportive personnel such as cultural mediators, translators, and health promotion specialists. This roadmap & toolbox recognises that integrated PHC is not equally well developed across the EU and hence anticipates the difficulties health care professionals face when delivering social and health care to migrants and refugees. In addition legislation ensuring universal social and health care access of refugees and migrants (regardless of status) is also not uniformly offered across the EU.
Provision of integrated care requires a legislative framework in which universal access to health and social care is protected and services respond to the specific needs of migrants and refuges. Within this framework issues related to prevention, self-management of disease, NCDs, mental health issues and promotion of maternal and child health need to be addressed and services at the community level developed. In many instances these integrated services are not available for the general population let alone vulnerable migrants and refugees.
Legislation is an important prerequisite for delivering optimal health and health care professionals need to know the circumstances in each country in order to facilitate delivery of services. Legislation concerning the provision of health care to migrants/refugees differs among Member States. For more information concerning health care access legislation for migrants/refugees in each MS please access the MIPEX tool - http://www.mipex.eu/ - as well as the Mig-HealthCare database https://mighealthcare.eu/
Access to healthcare is a fundamental human right (Charter of Fundamental Rights of Europe- Article 35). Such access is undeniably affected by poverty, social exclusion, discrimination, communication ability due to language and cultural differences as well as legal and administrative differentiations within and between countries. In order to achieve equal access to healthcare for all (WMA 69th World Assembly-May 2016) the health needs of refugees and migrants must be included. According to the WHO (2018), access of refugees and migrants into the healthcare systems will help reduce health inequalities and will improve global health security.
- Guaranteeing the same legal entitlement as other residents of the country is a fundamental step towards improving migrants’ access to health services. This aspect is particularly urgent for undocumented migrants, such as visa or permit ‘over stayers’, rejected asylum seekers and individuals who have entered a country without documentation. Limitations to health care entitlement are sometimes justified as a measure to discourage ‘health tourism’. This concern and the discriminating rhetoric behind it are not supported by evidence from studies on undocumented migrants. Limiting access to emergency services has been proved both ineffective and costly (Mladovsky, Rechel, Ingleby, & McKee, 2012b).
- To foster better living conditions for migrants in host countries, and at least access to fundamental needs (access to potable water, shower and toilets). Studies show the consequences of being homeless: higher risk of physical diseases (scabies, respiratory or vaccine preventable diseases), higher risk of mental health diseases (stress to not know where to sleep, higher risk of violence).
- To design health policies that respond to migrants’ needs. Available studies have emphasised that migrant health policy is often influences by changing political representation, economic and financial circumstances. In order to justify sustainable migrant health policy, good quality data on the health status, needs, and expectations of migrants with regards to health is required. The Mig-HealthCare research confirms the persistent lack of data on perceptions and needs expressed by migrants themselves, with these perceptions and needs all too often described by service providers.
- A call for the systematic inclusion of the determinant "migration background" in official health monitoring is underlined by different sources as one path to make available data more precise, reliable and comparable.
- The crucial role played by primary care in delivering high quality, culturally sensitive and appropriate care for migrants, especially those in vulnerable situations has been underlined by recent studies (de Brún et al., 2015; Kohls, 2011; O’Donnell et al., 2016). Despite this interest, most of the scientific production on European countries focuses on the health status of migrants, women, children, middle aged men and older people rather than on when and how the migrants’ health needs are met.
- Green LW, Ottoson JM. Community and Population Health, Eighth edition. Vol. 4. Boston: WCB/McGraw-Hill; 1999. pp. 41–42. [Google Scholar]
- WHO Centre for Health Development (Kobe, Japan). (2004). A glossary of terms for community health care and services for older persons. Kobe, Japan: WHO Centre for Health Development. https://apps.who.int/iris/handle/10665/68896
- World Health Organisation (2018) Health needs of refugees and migrants in the European region https://www.who.int/migrants/publications/EURO-Practices.pdf?ua=1
- McKenzie JF, Pinger RR, Kotecki JE. An Introduction to Community Health. Jones and Bartlett Publishers; Boston: 2005. p. 5. [Google Scholar]
- Mladovsky, P., Ingleby, D., & Rechel, B. (2012). Good practices in migrant health: the European experience. Clinical Medicine, 12(3), 248–252. https://doi.org/10.7861/clinmedicine.12-3-248
- de Brún, T., de-Brún, M. O., van Weel-Baumgarten, E., van Weel, C., Dowrick, C., Lionis, C., … MacFarlane, A. (2015). Guidelines and training initiatives that support communication in cross-cultural primary-care settings: appraising their implementability using Normalization Process Theory. Family Practice, cmv022. https://doi.org/10.1093/fampra/cmv022
- Kohls, M. (2011). Morbidität und Mortalität von Migranten in Deutschland (1. Aufl). Nürnberg: Bundesamt für Migration und Flüchtlinge.
- O’Donnell, C. A., Burns, N., Mair, F. S., Dowrick, C., Clissmann, C., van den Muijsenbergh, M., … MacFarlane, A. (2016). Reducing the health care burden for marginalised migrants: The potential role for primary care in Europe. Health Policy, 120(5), 495–508. https://doi.org/10.1016/j.healthpol.2016.03.012