1. 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 MERH 2018

2. 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?

3. 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

4. Refugees and migrants in Greece
2014
2016
2017…

5. 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

6. 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?

7. 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

8. 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.

9. 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

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

11. 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

12. Thank you