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Impacts of the Interim Federal Health Program reforms: A stakeholder analysis of barriers to health care access and provision for refugees
Abstract
p> BACKGROUND: Changes to the Interim Federal Health Program (IFHP) in 2012 reduced health care access for refugees and refugee claimants, generating concerns among key stakeholders. In 2014, a new IFHP temporarily reinstated access to some health services; however, little is known about these changes, and more information is needed to map the IFHP’s impact.
OBJECTIVE: This study explores barriers occurring during the time period of the IFHP reforms to health care access and provision for refugees.
METHODS: A stakeholder analysis, using 23 semi-structured interviews, was conducted to obtain insight into stakeholder perceptions of the 2014 reforms, as well as stakeholders’ position and their influence to assess the acceptability of the IFHP changes.
RESULTS: The majority of stakeholders expressed concerns about the 2014 IFHP changes as a result of the continuing barriers posed by the 2012 retrenchments and the emergence of new barriers to health care access and provision for refugees. Key barriers identified included lack of communication and awareness, lack of continuity and comprehensive care, negative political discourse and increased costs. A few stakeholders supported the reforms as they represented some, but limited, access to health care.
CONCLUSION: Overall, the reforms to the IFHP in 2014 generated barriers to health care access and provision that contributed to confusion among stakeholders, the transfer of refugee health responsibility to provincial authorities and the likelihood of increased health outcome disparities, as refugees and refugee claimants chose to delay seeking health care. The study recommends that policy-makers engage with refugee health stakeholders to formulate a policy that improves health care provision and access for refugee populations.</p
... 6 The foundation of the IFHP was to provide medical care to refugees that was comparable to the care a Canadian would receive, recognizing that the maintenance of health was crucial for their successful integration into Canada. 7 The IFHP development coincided with the introduction of the federal Hospital Insurance and Diagnostic Services Act, which provided coverage for provincial health plans affecting all Canadians and formed the foundation for the Canada Health Act. 8 Public opinion towards refugees was generally positive through the remainder of the 20th century, with many Canadians embracing the idea of Canada as a safe haven for those in need. ...
... Furthermore, these changes to the IFHP disproportionately impacted women and children in particular, due to their historically greater health care needs upon arrival. 7 The policy changes evoked confusion amongst the health care community, related to the breadth of insurance coverage and increased strain on provincial health care systems required to compensate for the lack of federal coverage. 7 In light of the 2012 IFHP changes, Canadian physicians began to advocate heavily for refugee care. ...
... 7 The policy changes evoked confusion amongst the health care community, related to the breadth of insurance coverage and increased strain on provincial health care systems required to compensate for the lack of federal coverage. 7 In light of the 2012 IFHP changes, Canadian physicians began to advocate heavily for refugee care. 11 The formation of organizations such as the Canadian Doctors for Refugee Care, the Canadian Association of Refugee Lawyers, and Justice for Children and Youth resulted in a Supreme Court challenge of the new IFHP. ...
Canada represents a global leader in refugee resettlement, having embraced an identity of multiculturalism that promotes the acceptance of newcomers. A crucial factor in facilitating post-arrival integration of newcomers into Canadian society is the maintenance of good health through the provision of adequate health care services. Throughout the past century, there has been an increase in the number of refugees in Canada, beginning largely in the post-World War period and extending into the second half of the twentieth century. This influx has required the development of health care systems and coverage specific to unique post-arrival medical needs of refugees. The history of refugee health care has been shaped by both policy and advocacy on behalf of refugees, resulting in a larger breadth of coverage today than ever before. This article summarizes the evolution of health care services provided to refugees, challenges that particular populations of refugees have faced in accessing care, and suggestions for continued improvements in refugee access to health care services.
... Another example comes from the Canadian Interim Federal Health Program (IFHP), which provides healthcare coverage on a temporary basis to protected persons, such as refugee claimants and resettled refugees. In 2012, significant reductions were made to the kinds of healthcare services IFHP recipients received as they waited to be established in Canada (Evans et al. 2014;Antonipillai et al. 2017). This had a significant impact on refugees needing ongoing health services and care, including pregnant people and those with diabetes and mental health diagnoses (Evans et al. 2014). ...
... This was a clear example of the ability of health policy to cause or reduce harm: in this case, maternal and fetal morbidity. Due to concerted efforts of healthcare providers and the general public, the reforms were revised and reversed in 2014, but confusion and distrust resulting from the policy has left lingering effects on refugee access to healthcare (Antonipillai et al. 2017). ...
... 36,37 Many provinces have a 3-month waiting period before new, landed immigrants are eligible for provincial health coverage 38 causing delays in seeking or accessing health services. 22,[39][40][41] Findings are likely shaped by what services are publicly covered, as family doctor and psychiatrist services are available free of charge for individuals with provincial insurance in all provinces, but services from clinical counsellors, psychologists, or social workers may be more accessible through team-based primary care. This may also explain our observation that among people who received consultations, the percentage of people who saw a psychiatrist was highest among recent immigrants. ...
... However, changes and cuts to this program have created confusion among health providers and consumers alike regarding eligibility and coverage. [38][39][40] The lack of data on severity of symptoms prevented us from accounting for this potential confounder. Additionally, the survey asks respondents whether they describe themselves as male or female. ...
Objective:
To examine the association between usual place of primary care and mental health consultation among those with self-reported mood or anxiety disorders. We also describe access to mental health services among people who are recent immigrants, longer-term immigrants, and nonimmigrants and determine whether the association with place of primary care differs by immigration group.
Methods:
We used data from the Canadian Community Health Survey (2015 to 2016) to identify a representative sample of individuals with self-reported mood or anxiety disorders. We used logistic regression, with models stratified by immigration group (recent, longer-term, nonimmigrant), to examine the association between usual place of primary care and receiving a mental health consultation in the previous 12 months.
Results:
Higher percentages of recent and longer-term immigrants see a doctor in solo practice, and a higher percentage of recent immigrants use walk-in clinics as a usual place of care. Compared with people whose usual place of care was a community health center or interdisciplinary team, adjusted odds of a mental health consultation were significantly lower for people whose usual place of care was a solo practice doctor's office (AOR = 0.71; 95% CI, 0.62 to 0.82), a walk-in clinic (AOR = 0.75; 95% CI, 0.66 to 0.85), outpatient clinic/other place (AOR = 0.72 95% CI, 0.59 to 0.88), and lowest among people reporting no usual place other than the emergency room (AOR = 0.59; 95% CI, 0.51 to 0.67). Differences in access to mental health consultations by usual place of primary care were greatest among immigrants, especially recent immigrants.
Conclusions:
People with mood or anxiety disorders who have access to team-based primary care are more likely to report mental health consultations, and this is especially true for immigrants. Expanded access to team-based primary health care may help reduce barriers to mental health services, especially among immigrants.
... Three articles mentioned legal status as a potential barrier preventing migrants or refugees from accessing health care 25,28,29 . Depending on the legal environment of the host country, the legal status may marginalize asylum seekers or undocumented migrants by preventing them from accessing the same care as migrants with legal refugee status 28 . ...
... This might be attributed to various factors: In the international literature, underdeveloped healthcare systems in countries of origin, challenges of understanding the new healthcare system, and language barriers are found to be the most important barriers to access [26,[29][30][31]. They restrict the utilization at the patient, provider, and system-level [32], and complicate access by means of social isolation [33]. ...
Background: The growing immigration to Germany led to more patients whose medical needs are divergent from those of the domestic population. In the field of dental health care there is a debate about how well the German health system is able to meet the resulting challenges. Data on asylum-seekers' dental health is scarce. This work is intended to reduce this data gap.
Methods: We conducted this retrospective observational study in Halle (Saale), Germany. We included all persons who were registered with the social welfare office (SWO) in 2015 and received dental treatments. From the medical records, we derived information such as complaints, diagnoses, and treatments.
Results: Out of 4107 asylum-seekers, the SWO received a bill for 568 people. On average, there were 1.44 treatment cases (95%-CI: 1.34-1.55) and 2.53 contacts with the dentist per patient (95%-CI: 2.33-2.74). Among those, the majority went to the dentist because of localized (43.2%, 95%-CI: 38.7-47.7) and non-localized pain (32.0%, 95%-CI: 27.8-36.2). The most widespread diagnosis was caries (n = 469, 98.7%, 95%-CI: 97.7-99.7). Conclusion: The utilization of dental care is lower among asylum-seekers than among regularly insured patients. We assume that the low prevalence rates in our data indicate existing access barriers to the German health care system.
... 6 In fact, the admission rates for refugee children at Sick Kids Hospital in Toronto nearly doubled. 7,8 As a result of their ethical responsibilities to treat patients in emergencies, many public hospitals across the country absorbed the costs of providing care for uninsured refugee themselves. 10 The University Health Network in Toronto, for instance, reported an unpaid service debt totalling greater than Can$800 000 for uninsured emergency services alone due to the IFHP reforms. ...
Due to a steady rise in the number of refugees accepted by Canada in recent years, the need for government funding to cover the health care needs of this population has similarly increased. Despite this increased need, government funding via the Interim Federal Health Program (IFHP) was cut dramatically in 2012 by the Conservative government. In 2016, the Liberal government restored full refugee health care coverage. This article provides an overview of refugee health care funding decisions in Canada over the past decade, and explores the impact that such decisions have on the health outcomes of this population. Furthermore, this article compares and contrasts refugee health care funding in Canada with that in other world regions with high refugee influx. Key potential areas for funding improvement are identified.
The global refugee crisis and the increased number of refugees seeking asylum in Canada has led the federal government to enact a series of policy reforms related to refugee healthcare coverage and spending. This paper provides a critical review of the Interim Federal Health Program (IFHP), drawing on concepts from social justice, migration, and market-oriented theories while examining policy rhetoric, legal ramifications, and media portrayals. The recommendations in this article aim to reduce health inequities and healthcare access barriers for the refugee population in Canada. Findings suggest Canadian federal policies have contributed to refugee health disparities.
Background
Migrant populations are less likely to use health services or obtain prescription drug coverage in Canada, compared to their non-migrant counterparts. This research examines factors that influence migrants' access to prescription drugs. It explores factors that impede migrants’ access to essential medications and the mechanisms in place to assist uninsured and under-insured immigrants and refugees. This study aims to inform key policies and practices pertaining to healthcare and prescription drug programs for immigrants and refugees.
Methods
A constructivist grounded theory methodology was employed to facilitate the development of an integrated set of theoretical concepts that synthesize, interpret and display processual relationships related to prescription drug coverage access for immigrants and refugees. Following ethics approval, 25 migrant patients and migrant-serving providers were interviewed using semi-structured interviews between July and December 2019 in Ontario, Canada. Qualitative data collected from key informant interviews were analyzed using grounded theory techniques and a constant comparative approach.
Results
Participant perspectives on migrants’ experiences accessing prescription drugs revealed four challenges: informational gaps, financial constraints, coverage inconsistencies and social differences. These impediments to medication access led to refusals of care, medication anxiety, coverage unawareness, coping behaviours to manage the loss of access to prescription drugs and long-term health consequences. Supports identified include navigational aid, providers who are coverage knowledgeable and culturally sensitive, and short-term solutions such as funds, samples and compassionate programs. Gaps in short-term supports were perceived by participants who proposed key policy and practice recommendations, primarily in support of universal pharmacare.
Conclusion
Addressing barriers to medication access for migrant populations involves intersectoral policy approaches, such as universal pharmacare complimented by drug monitoring system safeguards and informational supports. These strategies aim to alleviate difficulties migrant patients experience upon accessing medications they need.
Purpose
Access to health-care services for refugees are always impacted by many factors and strongly associated with population profile, nature of crisis and capacities of hosing countries. Throughout refugee’s crisis, the Jordanian Government has adopted several healthcare access policies to meet the health needs of Syrian refugees while maintaining the stability of the health-care system. The adopted health-care provision policies ranged from enabling to restricting and from affordable to unaffordable. The purpose of this paper is to identify the influence of restricted level of access to essential health services among Syrian refugees in Jordan.
Design/methodology/approach
This paper used findings of a cross-sectional surveys conducted over urban Syrian refugees in Jordan in 2017 and 2018 over two different health-care access policies. The first were inclusive and affordable, whereas the other considered very restricting policy owing to high inflation in health-care cost. Access indicators from four main thematic areas were selected including maternal health, family planning, child health and monthly access of household. A comparison between both years’ access indicators was conducted to understand access barriers and its impact.
Findings
The comparison between findings of both surveys shows a sudden shift in health-care access and utilization behaviors with increased barriers level thus increased health vulnerabilities. Additionally, the finding during implementation of restricted access policy proves the tendency among some refugees groups to adopt negative adaptation strategies to reduce health-care cost. The participants shifted to use a fragmented health-care, reduced or delayed care seeking and use drugs irrationally weather by self-medication or reduce drug intake.
Originality/value
Understanding access barriers to health services and its negative short-term and long-term impact on refugees’ health status as well as the extended risks to the host communities will help states that hosting refugees building rational access policy to protect whole community and save public health gains during and post crisis. Additionally, it will support donors to better mobilize resources according to the needs while the humanitarian actors and service providers will better contribute to the public health stability during refugee’s crisis.
Objectives
The aims of our study were to describe the disease spectrum of refugees, to analyse to what extent their healthcare needs could be met in an outpatient primary care walk-in clinic and which cases required additional services from secondary care (ie, outpatient specialists or hospitals).
Design
Retrospective longitudinal observational study.
Setting
The study was based on routine data from a walk-in clinic in the largest central first reception centre in Hamburg, Germany between 4 November 2015 and 21 July 2016.
Participants
1467 asylum seekers with 4006 episodes of care (ie, distinctive health problems) resulting in 5545 consultations. The patients were 60% men and had a mean age of 23.2 years. About 90% of the patients were from Central Asia or from the Middle East and North Africa.
Primary and secondary outcome measures
The endpoint of our analyses was referral to secondary care. Time to event was defined as days under treatment until the first referral. Predictor variables were the patients’ diagnoses grouped in 46 categories. The data set was analysed by Cox regression allowing for multiple failure times per patient. This analysis was adjusted for age, sex and country of origin.
Results
Referrals to secondary care occurred in 15.5% of the episodes. The diagnosis groups with the highest referral rates were ‘eye’ (HR 4.9; 95% CI 3.12 to 7.8; p≤0.001), ‘teeth/gum symptom/complaint or disease’ (3.51; 2.52 to 4.9; p≤0.001) and ‘urological system/female or male genital’ (2.50; 1.66 to 3.77; p≤0.001). Age, sex and country of origin had no significant effect on time until referral.
Conclusions
In most cases, the walk-in clinic physicians could provide first-line medical care for the health problems of patients not integrated in the German healthcare system. Additional resources were needed particularly not only for visual impairment and dental problems but also for psychological disorders, antenatal care and certain infections and injuries.
After years of cuts, Canada's refugee health-care program, the Interim Federal Health Program (IFHP), was fully restored in 2016. In this exploratory study, eleven semi-structured qualitative interviews were conducted with refugee service providers in the City of Ottawa to learn about their experience with the restored IFHP to date. Five themes emerged from the interviews: service provision challenges during the years of IFHP cuts; support for IFHP restoration; entitlement gaps in the current IFHP; ongoing confusion about the IFHP; and administrative barriers deterring health professionals from IFHP participation. More research is needed to determine whether the identified challenges with the reinstated IFHP arise on a national scale.
Après des années de réductions budgétaires, le programme canadien de soins de santé aux réfugiés, ou Programme fédéral de santé intérimaire (PFSI), a été pleinement réha-bilité en 2016. Dans cette étude exploratoire ont été menés onze entretiens qualitatifs semi-structurés avec des fournis-seurs de services aux réfugiés de la Ville d'Ottawa pour en savoir plus sur l' expérience qu'ils ont à ce jour du PFSI réha-bilité. De ces entretiens se sont dégagés cinq thèmes : les défis en matière de fourniture de services au cours des années de réductions budgétaires du PFSI, l' appui à la réhabilitation du PFSI, les lacunes de statut dans le PFSI actuel, la confusion actuelle concernant le PFSI, et les obstacles administra-tifs décourageant les professionnels de la santé de participer au PFSI. Des travaux de recherche sont encore nécessaires pour établir si les défis qui accompagnent la réhabilitation du PFSI se situent à l' échelle nationale.
Background
Stakeholders, as originally defined in theory, are groups or individual who can affect or are affected by an issue. Stakeholders are an important source of information in health research, providing critical perspectives and new insights on the complex determinants of health. The intersection of built and social environments with older adult mobility is an area of research that is fundamentally interdisciplinary and would benefit from a better understanding of stakeholder perspectives. Although a rich body of literature surrounds stakeholder theory, a systematic process for identifying health stakeholders in practice does not exist. This paper presents a framework of stakeholders related to older adult mobility and the built environment, and further outlines a process for systematically identifying stakeholders that can be applied in other health contexts, with a particular emphasis on concept mapping research.
Methods
Informed by gaps in the relevant literature we developed a framework for identifying and categorizing health stakeholders. The framework was created through a novel iterative process of stakeholder identification and categorization. The development entailed a literature search to identify stakeholder categories, representation of identified stakeholders in a visual chart, and correspondence with expert informants to obtain practice-based insight.
Results
The three-step, iterative creation process progressed from identifying stakeholder categories, to identifying specific stakeholder groups and soliciting feedback from expert informants. The result was a stakeholder framework comprised of seven categories with detailed sub-groups. The main categories of stakeholders were, (1) the Public, (2) Policy makers and governments, (3) Research community, (4) Practitioners and professionals, (5) Health and social service providers, (6) Civil society organizations, and (7) Private business.
Conclusions
Stakeholders related to older adult mobility and the built environment span many disciplines and realms of practice. Researchers studying this issue may use the detailed stakeholder framework process we present to identify participants for future projects. Health researchers pursuing stakeholder-based projects in other contexts are encouraged to incorporate this process of stakeholder identification and categorization to ensure systematic consideration of relevant perspectives in their work.
The impact of social and economic determinants of health status and the existence of racial and ethnic health care access disparities have been well-documented. This paper describes a model, the Health Care Access Barriers Model (HCAB), which provides a taxonomy and practical framework for the classification, analysis and reporting of those modifiable health care access barriers that are associated with health care disparities. The model describes three categories of modifiable health care access barriers: financial, structural, and cognitive. The three types of barriers are reciprocally reinforcing and affect health care access individually or in concert. These barriers are associated with screening, late presentation to care, and lack of treatment, which in turn result in poor health outcomes and health disparities. By targeting those barriers that are measurable and modifiable the model facilitates root-cause analysis and intervention design.
This paper provides guidance on how to do a stakeholder analysis, whether the aim is to conduct a policy analysis, predict policy development, implement a specific policy or project, or obtain an organizational advantage in one's dealings with other stakeholders. Using lessons learned from an analysis of alcohol policy development in Hungary, it outlines issues to be considered before undertaking the stakeholder analysis concerning the purpose and time dimensions of interest, the time-frame and the context in which the analysis will be conducted. It outlines advantages and disadvantages of an individual or team approach, and of the use of insiders and outsiders for the analysis. It describes how to identify and approach stakeholders and considers the use of qualitative or quantitative data collection methods for estimating stakeholder positions, levels of interest and influence around an issue. A key message is that the process of data collection and analysis needs to be iterative; the analyst needs to revise and deepen earlier levels of the analysis, as new data are obtained. Different examples of ways of analyzing, presenting and illustrating the information are provided. Stakeholder analysis is a useful tool for managing stakeholders and identifying opportunities to mobilize their support for a particular goal. However, various biases and uncertainties necessitate a cautious approach in using it and applying its results.
The growing popularity of stakeholder analysis reflects an increasing recognition of how the characteristics of stakeholders--individuals, groups and organizations--influence decision-making processes. This paper reviews the origins and uses of stakeholder analysis, as described in the policy, health care management and development literature. Its roots are in the political and policy sciences, and in management theory where it has evolved into a systematic tool with clearly defined steps and applications for scanning the current and future organizational environment. Stakeholder analysis can be used to generate knowledge about the relevant actors so as to understand their behaviour, intentions, interrelations, agendas, interests, and the influence or resources they have brought--or could bring--to bear on decision-making processes. This information can then be used to develop strategies for managing these stakeholders, to facilitate the implementation of specific decisions or organizational objectives, or to understand the policy context and assess the feasibility of future policy directions. Policy development is a complex process which frequently takes place in an unstable and rapidly changing context, subject to unpredictable internal and external factors. As a cross-sectional view of an evolving picture, the utility of stakeholder analysis for predicting and managing the future is time-limited and it should be complemented by other policy analysis approaches.
This article has several related purposes. First, the authors lay out a process for strategic management tailored to the needs of organizations in public or third-sector settings. The process recognizes some of the paradoxes and problems involved in doing strategic management in those settings and shows how to avoid such difficulties. Second, we describe techniques or tools that are useful in carrying out the search, synthesis, and selection activities required by each stage of the process. Finally, we suggest ways to improve the results of strategic management and call for planners to take on multiple roles to support the process.
Obesity as a major public health and economic problem has risen to the top of policy and programme agendas in many countries, with prevention of childhood obesity providing a particularly compelling mandate for action. There is widespread agreement that action is needed urgently, that it should be comprehensive and sustained, and that it should be evidence-based. While policy and programme funding decisions are inevitably subject to a variety of historical, social, and political influences, a framework for defining their evidence base is needed. This paper describes the development of an evidence-based, decision-making framework that is particularly relevant to obesity prevention. Building upon existing work within the fields of public health and health promotion, the Prevention Group of the International Obesity Task Force (IOTF) developed a set of key issues and evidence requirements for obesity prevention. These were presented and discussed at an IOTF workshop in April 2004 and were then further developed into a practical framework. The framework is defined by five key policy and
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