Improving access to health care for asylum seekers, migrants and refugees in Greece Lenio Capsaskis, Academy Associate, Centre for Global Health Security, Chatham House 19 May 2018- MERH 2018

Research Aim To gain a better understanding of the barriers migrants face in accessing appropriate health care in Greece and discuss potential strategies to overcome these barriers. Research Questions Following recent policy changes in Greece, what is the current political, social and legal landscape of migrant access to health care? What are the main barriers migrants still face in accessing appropriate services and why? What strategies to improve the availability of appropriate services can the Greek Ministry of Health, international and local organisations develop from the lessons learned so far?

Methodology Literature review Semi-structured interviews with 12 key stakeholders: Ministry of Health (Centre for Disease Control and Prevention, National Health Operations Centre) International and national NGOs (MSF, Faros, PRAKSIS) International organisations (UNHCR, UNFPA, WHO) Regional international organisations (WHO) Greek academia/solidarity movement Framework analysis Focus on the intersection between system and user Key informant multi-sectoral roundtable

Refugees and migrants in Greece 2014 2015-2016 2016 2017…

Greek health system One of the highest proportions of private health expenditure (31%) of OECD countries Horizontal cuts rather than tailored reallocation Shortage of staff, long waiting times and short appointments New law- social security for uninsured in 2016

Supply Approachability Acceptability Availability Affordability Appropriateness Language barriers- most frequently cited barrier Bureaucratic system- very difficult to navigate Some reports of rude and racist staff Staff in health centres and citizens support centres not aware of laws Law for free health care for asylum seekers & refugees- BUT with unattainable caveats sometimes Undocumented migrants excluded Long waiting time for appointments Cost of medicines the biggest challenge particularly for undocumented migrants Lack of medicines at health centres and hospitals Lack of continuity of care- people mobile within the country and no provision for appropriate follow up services No support with post-hospitalisation and ‘discontinuation’ Language barriers- how appropriate is it really?

Demand Ability to perceive Ability to seek Ability to reach Ability to pay Ability to engage Overly high expectations Have become less so as months have gone on Lack of autonomy or social integration; significant of NGO and social worker support for health system navigation Not such a challenge for those living in urban areas, though it remains a challenge for those in camps NGOs running accompaniment programmes to hospitals People not working or in very low paid work means their ability to pay for medicines is very limited Social pharmacies not always able to provide correct medication, particularly long term Most frequently cited barrier: people do not know their rights Tend to seek care from NGOs as feels familiar and less daunting after bad experience with wider system Undocumented migrants may fear system

Addressing barriers through reform What: 239 local health clinics in 80 different regions Health promotion, treatment, social support, referral, outreach in schools, communities, for vaccinations Where: socio-economic criteria and needs assessment- particularly urban areas (six opened so far) For who: Local health unit, open to the entire community By who: Family doctors, nursing staff, midwives and social workers How: European Union funds, WHO in-country technical support, eventually funded by government Overwhelmingly from interviews, primary health care reforms were cited as critical for achieving universal health coverage and providing person-centred care for communities including asylum seekers, migrants and refugees.

How reforms can work for migrant communities Translation in health centres- discussion on the role of cultural mediation Multilingual help desks in health centres Training staff on intercultural medicine/wider healthcare Focusing on continuity of care, particularly for mental health and chronic illnesses, through community health structures and tailored support Organising working hours around vulnerable populations Using migrant community structures to conduct outreach Establishing community health groups

Barriers to implementation Austerity Private sector blocking reforms Lack of data social determinants of health and thinking more widely about their impact.

Conclusions from research Who does ‘political commitment’ refer to? Is UHC just rhetoric- funding mechanisms and service provision not aligned with this aim Legal provisions- improved access or role of NGOs as advocates? Disconnect between Ministries Many pilot projects, but few taken to scale Universal challenges requiring long term investment in the Greek health system spill over effects for the entire population

Thank you