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Ziegler S, Bozorgmehr K. Translating restrictive law into practice: An ethnographic exploration of the systemic processing of legally restricted health care access for asylum seekers in Germany. Int J Equity Health 2024; 23:208. [PMID: 39390515 PMCID: PMC11465860 DOI: 10.1186/s12939-024-02251-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 08/09/2024] [Indexed: 10/12/2024] Open
Abstract
BACKGROUND Access to health services for asylum seekers is legally restricted in Germany. The law is subject to interpretation, therefore the chance of receiving care is not equally distributed among asylum seekers. What services are provided to whom is ultimately decided by health professionals and government employees. The respective prioritization processes and criteria are not transparent. We sought to understand how legal restrictions are translated into daily practices and how this affects the health system. We aimed to outline the complex process of cost coverage for health services for asylum seekers and provide insights into common decision-making criteria. METHODS We conducted an ethnographic exploration of routines in two outpatient clinics in two federal states over the course of three months, doing participant and non-participant observation. Additionally, we interviewed 21 professionals of health care and government organizations, and documented 110 applications for cost coverage of medical services and their outcome. In addition to qualitative data analysis and documentation, we apply a system-theoretical perspective to our findings. RESULTS To perform legal restrictions a cross-sectoral prioritization process of medical services has been implemented, involving health care and government institutions. This changes professional practices, responsibilities and (power) relations. Involved actors find themselves at the intersection of several, oftentimes conflicting priorities, since "doing it right" might be seen differently from a legal, medical, economic, or political perspective. The system-theoretical analysis reveals that while actors have to bring different rationales into workable arrangements this part of the medical system transforms, giving rise to a sub-system that incorporates migration political rationales. CONCLUSIONS Health care restrictions for asylum seekers are implemented through an organizational linking of care provision and government administration, resulting in a bureaucratization of practice. Power structures at this intersection of health and migration policy, that are uncommon in other parts of the health system are thereby normalized. Outpatient clinics provide low-threshold access to health services, but paradoxically they may unintentionally stabilize health inequities, if prioritization criteria and power dynamics are not made transparent. Health professionals should openly reflect on conflicting rationales. Training, research and professional associations need to empower them to stay true to professional ethical principles and international conventions.
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Affiliation(s)
- Sandra Ziegler
- Department of General Practice and Health Services Research, Section for Health Equity Studies & Migration, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany.
- Department of Population Medicine and Health Services Research, School of Public Health, University of Bielefeld, Universitätsstraße 25, Bielefeld, 33615, Germany.
| | - Kayvan Bozorgmehr
- Department of General Practice and Health Services Research, Section for Health Equity Studies & Migration, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany
- Department of Population Medicine and Health Services Research, School of Public Health, University of Bielefeld, Universitätsstraße 25, Bielefeld, 33615, Germany
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Ingwersen K, Thomsen SL. Workload disparities and their role in the health of migrants and natives in Germany. BMC Public Health 2024; 24:2164. [PMID: 39123183 PMCID: PMC11316351 DOI: 10.1186/s12889-024-19606-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND This study explores the health status differences between migrants and native Germans, focusing on potential disparities in their workloads. Physical and mental workloads can negatively impact individual health. Since various occupations come with distinct health-related patterns, occupational selection may contribute to systematic health disparities among socio-economic groups. Given the generally poorer health of migrants, they might experience systematic workload differences overall. METHODS We suggest a conceptual framework for the empirical analysis based on the theory of health as a durable good with health consumption and health investment as key parameters. We quantify the role of work tasks, job requirements and working conditions on individual health based on detailed information from the BIBB/BAuA labour force survey 2012 and 2018. RESULTS The empirical results reveal that migrants, i.e. foreigners and German citizens with a migration background, have a higher perception of workload and related health afflictions within the same occupation. Native Germans, on the other hand, experience a higher burden by high job requirements, both physically and mentally. The findings imply heterogeneous health impacts of work for migrants and native Germans due to differences in health consumption. CONCLUSIONS The analysis shows that migrants report worse health than natives, with stronger negative effects of work-related conditions on their health, both physically and mentally. Women, in general, report poorer health conditions than men. The findings emphasize the importance of promoting human capital to reduce economic and health disparities, though caution is advised regarding affirmative actions for migrants; further research is needed to understand the underlying mechanisms and address these issues effectively.
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Affiliation(s)
- Kai Ingwersen
- Institute of Economic Policy, Leibniz University Hannover, Königsworther Platz 1, D-30167, Hannover, Germany
| | - Stephan L Thomsen
- Institute of Economic Policy, Leibniz University Hannover, Königsworther Platz 1, D-30167, Hannover, Germany.
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Führer A. [Determinants of asylum seekers' health and medical care in Germany]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2023; 66:1083-1091. [PMID: 37707509 PMCID: PMC10539189 DOI: 10.1007/s00103-023-03762-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/18/2023] [Indexed: 09/15/2023]
Abstract
Asylum seekers in Germany are exposed to a variety of health-related stressors, while their access to medical care is impaired. This review explains some of the determinants that structure this situation, for example by elaborating on how the Asylum Seekers' Benefits Act (ASBA), billing via treatment vouchers, and accommodation in refugee shelters affect asylum seekers' health and healthcare utilization. Hereby, it becomes clear that the exclusion of asylum seekers from the welfare system is detrimental to their health, is expensive, and raises ethical and legal questions. In particular, the huge discretionary scope of the social welfare offices in the assumption of costs as well as the different models for billing medical services for asylum seekers are potentially unjust and lead to a plurality of care, which lacks legal and ethical justification.The second part of the article shows that asylum seekers generally suffer from the same health problems as people with statutory health insurance-with the exception of mental illnesses, which are substantially more common among asylum seekers, but are often undiagnosed and frequently inadequately treated.This leads to three practical conclusions: (1) asylum seekers should be integrated into statutory health insurance, (2) from a public health point of view, accommodation in refugee shelters should be avoided in favor of decentralized accommodation, and (3) to ensure diversity-sensitive care for all patients, the healthcare system must make adjustments to its structures and practices.
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Affiliation(s)
- Amand Führer
- Institut für Medizinische Epidemiologie, Biometrie und Informatik, Profilzentrum Gesundheitswissenschaften, Martin-Luther-Universität Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Deutschland.
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Führer A, Taché S, Riemenschneider H, Bozorgmehr K, Diaz-Monsalve S, Knipper M, Mews C, Schwienhorst-Stich EM, Siebert U, Strelow KU, Ziegler S. [The Migration and Health Teaching Network: consolidating and developing education and training]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2023; 66:1130-1134. [PMID: 37737318 PMCID: PMC10539183 DOI: 10.1007/s00103-023-03765-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/22/2023] [Indexed: 09/23/2023]
Abstract
Patients with migration history often encounter barriers to accessing healthcare in Germany, which lowers the quality of care available to them and can affect their overall health. These barriers in access to healthcare are due to both adverse health policies and a lack of migration-related - and diversity-sensitive - content in medical and other health profession teaching. Although most healthcare professionals regularly care for patients with individual or generational migration experience in Germany, teaching content relevant to the healthcare of these patients has not yet been anchored in the curriculum. At best, it is taught in the form of electives or other optional courses.To address this gap, the Teaching Network Migration and Health was created with the goal of promoting the development of human rights-based, diversity-sensitive, and equity-oriented curricula at medical and healthcare professions schools. It aims to (1) connect individuals active in teaching and promote the exchange and collaborative development of teaching materials, (2) use this collective knowledge and experience to develop a model course on migration and health, and (3) develop strategies for the longitudinal implementation of this course into the regular medical and other health professional school curricula. These efforts are flanked by evaluative accompanying research. Anyone interested in joining the network is invited to join and strengthen the network by contacting the authors.
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Affiliation(s)
- Amand Führer
- Institut für Medizinische Epidemiologie, Biometrie und Informatik, Profilzentrum Gesundheitswissenschaften, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Stephanie Taché
- Bereich Allgemeinmedizin, Medizinische Fakultät Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - Henna Riemenschneider
- Bereich Allgemeinmedizin, Medizinische Fakultät Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Kayvan Bozorgmehr
- Sektion Health Equity Studies & Migration, Abteilung Allgemeinmedizin und Versorgungsforschung, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- AG Bevölkerungsmedizin und Versorgungsforschung, Fakultät für Gesundheitswissenschaften, Universität Bielefeld, Bielefeld, Deutschland
| | - Sonia Diaz-Monsalve
- Zentrum für Medizin und Gesellschaft, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Michael Knipper
- Professur für Global Health, Migration und Kulturwissenschaften in der Medizin, Institut für Geschichte, Theorie und Ethik der Medizin, Justus-Liebig-Universität Gießen, Gießen, Deutschland
| | - Claudia Mews
- Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Eva-Maria Schwienhorst-Stich
- Institut für Allgemeinmedizin und Lehrklinik der Medizinischen Fakultät, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Ute Siebert
- Projekt "Empowerment für Diversität - Allianz für Chancengleichheit in der Gesundheitsversorgung", Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Kai-Uwe Strelow
- Rudolf Frey Lernklinik, Universitätsmedizin Mainz, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Sandra Ziegler
- Sektion Health Equity Studies & Migration, Abteilung Allgemeinmedizin und Versorgungsforschung, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Janella M, Alber R, Amler M, Bollmann J, Böhme N, Martin M, Hoebel J. ["Shaping change together": conference report from the 2023 Poverty and Health Congress]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2023; 66:1051-1057. [PMID: 37615681 DOI: 10.1007/s00103-023-03754-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/25/2023]
Affiliation(s)
- Maren Janella
- Geschäftsstelle Berlin, Gesundheit Berlin-Brandenburg e. V., Berlin, Deutschland
| | - Regine Alber
- Geschäftsstelle Berlin, Gesundheit Berlin-Brandenburg e. V., Berlin, Deutschland
| | - Marion Amler
- Geschäftsstelle Berlin, Gesundheit Berlin-Brandenburg e. V., Berlin, Deutschland
| | - Julian Bollmann
- Geschäftsstelle Berlin, Gesundheit Berlin-Brandenburg e. V., Berlin, Deutschland
| | - Nicole Böhme
- Geschäftsstelle Berlin, Gesundheit Berlin-Brandenburg e. V., Berlin, Deutschland
| | - Marina Martin
- Geschäftsstelle Berlin, Gesundheit Berlin-Brandenburg e. V., Berlin, Deutschland
| | - Jens Hoebel
- Fachgebiet Soziale Determinanten der Gesundheit, Robert Koch-Institut, Nordufer 20, 13353, Berlin, Deutschland.
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Gottlieb N, Siegel M. Associations between physical and mental health and the utilization of ambulatory and emergency healthcare among asylum-seekers: results from a cross-sectional survey in Berlin, Germany. Int J Equity Health 2023; 22:99. [PMID: 37221582 DOI: 10.1186/s12939-023-01914-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/10/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Despite a high burden of chronic and mental illness, asylum-seekers show low utilization of ambulatory specialist healthcare. Forgoing timely healthcare when facing access barriers may direct them toward emergency care. This paper examines interrelations of physical and mental health and utilization of ambulatory and emergency care, and explicitly addresses associations between the different types of care. METHODS A structural equation model was applied to a sample of n = 136 asylum-seekers living in accommodation centers in Berlin, Germany. Utilization patterns of emergency care (outcome) and physical and mental ambulatory care (endogenous predictors) were estimated, while controlling for age, gender, chronic conditions, bodily pain, depression, anxiety, length of stay in Germany (exogenous predictors) and self-rated health (endogenous predictor). RESULTS Associations were observed between ambulatory care utilization and poor self-rated health (0.207, CI: 0.05; 0.364), chronic illness (0.096, CI: 0.017; 0.175) and bodily pain (0.019, CI: 0.002; 0.036); between mental healthcare utilization and anxiety (0.202, CI: 0.051; 0.352); and between emergency care utilization and poor self-rated health (0.621, CI: 0.059; 1.183), chronic illness (0.287, CI: 0.012; 0.563), mental healthcare utilization (0.842, CI: 0.148; 1.535) and anxiety (0.790, CI: 0.141; 1.438) (values in parentheses show estimated regression coefficients and 95% confidence intervals). We found no associations between the utilization of ambulatory and emergency care. CONCLUSIONS Our study generates mixed results concerning associations between healthcare needs and ambulatory and emergency care utilization among asylum-seekers. We found no evidence that low utilization of ambulatory care contributes to emergency care utilization; neither did we find evidence that ambulatory treatment obviates the need to seek emergency care. Our results indicate that higher physical healthcare needs and anxiety are associated with more utilization of both ambulatory and emergency care; whereas healthcare needs related to depression tend to remain unmet. Both the undirected and under-utilization of health services may reflect navigation and accessibility issues. To facilitate more needs-based and effective healthcare utilization and thus contribute to health equity, support services such as interpretation and care navigation as well as outreach are warranted.
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Affiliation(s)
- Nora Gottlieb
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, PO Box 10 01 31, 33501, Bielefeld, Germany.
- Department of Health Care Management, Technische Universität Berlin, Strasse des 17. Juni 135, 10623, Berlin, Germany.
| | - Martin Siegel
- Department of Empirical Health Economics, Technische Universität Berlin, Strasse des 17. Juni 135, 10623, Berlin, Germany
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Rast E, Perplies C, Biddle L, Bozorgmehr K. Between Care and Coercion: Asylum Seekers’ Experiences With COVID-19 Containment and Mitigation Measures in German Reception Centres. Int J Public Health 2023; 68:1605230. [PMID: 36994090 PMCID: PMC10041458 DOI: 10.3389/ijph.2023.1605230] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 02/27/2023] [Indexed: 03/14/2023] Open
Abstract
Objectives: COVID-19 containment and mitigation measures have been criticised for amplifying pre-existing individual and structural vulnerabilities among asylum seekers. We qualitatively explored their experiences with and attitudes towards pandemic measures to inform people-centred responses in future health emergencies.Methods: We interviewed eleven asylum seekers in a German reception centre (July-December 2020). The semi-structured interviews were recorded, transcribed, and analysed thematically with an inductive-deductive approach.Results: Quarantine was experienced as burdensome by participants. Shortcomings in social support, everyday necessities, information, hygiene, and daily activities exacerbated the strains of quarantine. Interviewees held different opinions about the usefulness and appropriateness of the various containment and mitigation measures. These opinions differed by individual risk perception and the measures’ comprehensibility and compatibility with personal needs. Power asymmetries related to the asylum system furthermore impacted on preventive behaviour.Conclusion: Quarantine can amplify mental health burdens and power asymmetries and can therefore constitute a considerable stressor for asylum seekers. Provision of diversity-sensitive information, daily necessities, and accessible psychosocial support is required to counteract adverse psychosocial impacts of pandemic measures and safeguard wellbeing in this population.
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Affiliation(s)
- Eilin Rast
- Section Health Equity Studies & Migration, Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Clara Perplies
- Section Health Equity Studies & Migration, Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Louise Biddle
- Section Health Equity Studies & Migration, Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Kayvan Bozorgmehr
- Section Health Equity Studies & Migration, Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Bielefeld, Germany
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8
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Gottlieb N, Ohm V, Knörnschild M. The Electronic Health Insurance Card for Asylum-Seekers in Berlin: Effects on the Local Health System. Int J Health Policy Manag 2022; 11:1325-1333. [PMID: 33949813 PMCID: PMC9808340 DOI: 10.34172/ijhpm.2021.34] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 03/28/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND In debates on asylum-seekers' access to healthcare it is frequently claimed that restrictions are necessary to prevent unduly high health service utilization and costs. Within Germany, healthcare provision for asylum-seekers varies across the different states. Berlin's authorities removed some barriers to healthcare for asylum-seekers by introducing an electronic health insurance card (HIC) in 2016. We used the HIC introduction in Berlin as an opportunity to investigate the effects of improved healthcare access for asylum-seekers on the local health system. METHODS The study applied a mixed-methods design. A cost analysis compared expenses for outpatient and inpatient health services for asylum-seekers before and after the HIC introduction, based on aggregate claims data and information on expenses for humanitarian healthcare provision that were retrieved from the Berlin authorities. Semi-structured interviews with 12 key informants explored organizational effects like administrative workloads and ethical dilemmas for staff. We performed a content analysis and used respondent validation to enhance the accuracy and trustworthiness of our results. RESULTS The HIC has reduced bureaucratic complexity and administrative workloads; it has enabled unprecedented financial transparency and control; and it has mitigated ethical tensions. All the while, average per person expenses for outpatient health services have declined since the HIC introduction. However, our cost analysis also indicates a rise in the utilization and costs of inpatient care. CONCLUSION The HIC introduction in Berlin suggests that the removal of barriers to healthcare for asylum-seekers can create win-win-situations by reducing administrative workloads, advancing financial transparency, and mitigating ethical tensions, whilst cutting the costs of outpatient healthcare provision. Removing barriers to healthcare thus appears to be a more prudent policy choice than maintaining mechanisms of restriction and control. However, high inpatient care utilization and costs warrant further research.
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Affiliation(s)
- Nora Gottlieb
- Department of Health Care Management, Technical University Berlin, Berlin, Germany
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Vanessa Ohm
- Berlin School of Public Health, Berlin, Germany
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Healthcare Providers’ Knowledge of Value-Based Care in Germany: An Adapted, Mixed-Methods Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148466. [PMID: 35886327 PMCID: PMC9322307 DOI: 10.3390/ijerph19148466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/02/2022] [Accepted: 07/05/2022] [Indexed: 12/04/2022]
Abstract
Background: Value-Based Care (VBC) is being discussed to provide better outcomes to patients, with an aim to reimburse healthcare providers (HCPs) based on the quality of care they deliver. Little is known about German HCPs’ knowledge of VBC. This study aims to investigate the knowledge of HCPs of VBC and to identify potential needs for further education toward implementation of VBC in Germany. Methods: For evidence generation, we performed a literature search and conducted an online survey among HCPs at 89 hospitals across Germany. The questionnaire was based on published evidence and co-developed with an expert panel using a mixed methods approach. Results: We found HCPs to believe that VBC is more applicable in surgery than internal medicine and that well-defined cycles of care are essential for its application. HCPs believe that VBC can reduce health care costs significantly. However, they also assume that implementing VBC will be challenging. Conclusions: The concept in general is well perceived, however, HCPs do not want to participate in any financial risk sharing. Installing an authority/independent agency that measures achieved value, digital transformation, and that improves the transition between the inpatient and the outpatient sectors are top interests of HCPs.
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Hintermeier M, Gold AW, Erdmann S, Perplies C, Bozorgmehr K, Biddle L. From Research into Practice: Converting Epidemiological Data into Relevant Information for Planning of Regional Health Services for Refugees in Germany. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:8049. [PMID: 35805705 PMCID: PMC9265908 DOI: 10.3390/ijerph19138049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/24/2022] [Accepted: 06/26/2022] [Indexed: 12/02/2022]
Abstract
Health data of refugees and asylum seekers (ASR) is not routinely collected in Germany. Based on health data of ASR collected in 2018 in regional accommodation centres, we developed a dashboard to estimate regional burden of disease in Baden-Wuerttemberg, Germany. We aimed to find out how scientific data can support actors involved in healthcare planning for ASR in Germany and, within this scope, to explore how healthcare planning is conducted in this context. We conducted 12 qualitative semi-structured interviews including a usability test for a health data dashboard with regional decision-makers. Results showed that healthcare planning processes for ASR in Germany involve a complex set of actors in both long- and short-term decision-making. Data gained from representative surveys can support long-term decision-making and thus support the resilience of the health system, but it must balance the need for simple data presentation with transparent communication of potentially complex methods.
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Affiliation(s)
- Maren Hintermeier
- Section for Health Equity Studies & Migration, Department of General Practice and Health Services Research, Heidelberg University Hospital, 69120 Heidelberg, Germany; (A.W.G.); (C.P.); (K.B.)
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, 33501 Bielefeld, Germany;
| | - Andreas W. Gold
- Section for Health Equity Studies & Migration, Department of General Practice and Health Services Research, Heidelberg University Hospital, 69120 Heidelberg, Germany; (A.W.G.); (C.P.); (K.B.)
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, 33501 Bielefeld, Germany;
| | - Stella Erdmann
- Institute of Medical Biometry, Heidelberg University Hospital, 69120 Heidelberg, Germany;
| | - Clara Perplies
- Section for Health Equity Studies & Migration, Department of General Practice and Health Services Research, Heidelberg University Hospital, 69120 Heidelberg, Germany; (A.W.G.); (C.P.); (K.B.)
| | - Kayvan Bozorgmehr
- Section for Health Equity Studies & Migration, Department of General Practice and Health Services Research, Heidelberg University Hospital, 69120 Heidelberg, Germany; (A.W.G.); (C.P.); (K.B.)
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, 33501 Bielefeld, Germany;
| | - Louise Biddle
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, 33501 Bielefeld, Germany;
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11
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Wenner J, Biddle L, Gottlieb N, Bozorgmehr K. Inequalities in access to healthcare by local policy model among newly arrived refugees: evidence from population-based studies in two German states. Int J Equity Health 2022; 21:11. [PMID: 35073919 PMCID: PMC8785512 DOI: 10.1186/s12939-021-01607-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 12/10/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Access to healthcare is restricted for newly arriving asylum seekers and refugees (ASR) in many receiving countries, which may lead to inequalities in health. In Germany, regular access and full entitlement to healthcare (equivalent to statutory health insurance, SHI) is only granted after a waiting time of 18 months. During this time of restricted entitlements, local authorities implement different access models to regulate asylum seekers’ access to healthcare: the electronic health card (EHC) or the healthcare voucher (HV). This paper examines inequalities in access to healthcare by comparing healthcare utilization by ASR under the terms of different local models (i.e., regular access equivalent to SHI, EHC, and HV).
Methods
We used data from three population-based, cross-sectional surveys among newly arrived ASR (N=863) and analyzed six outcome measures: specialist and general practitioner (GP) utilization, unmet needs for specialist and GP services, emergency department use and avoidable hospitalization. Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals for all outcome measures, while considering need by adjusting for socio-demographic characteristics and health-related covariates.
Results
Compared to ASR with regular access, ASR under the HV model showed lower needs-adjusted odds of specialist utilization (OR=0.41 [0.24-0.66]) while ASR under the EHC model did not differ from ASR with regular access in any of the outcomes. The comparison between EHC and HV model showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). GP and emergency department utilization, unmet needs and avoidable hospitalization did not show significant differences in any of the fully adjusted models.
Conclusion
ASR using the HV are disadvantaged in their access to healthcare compared to ASR having either an EHC or regular access. Given equal need, they use specialist services less. The identified inequalities constitute inequities in access to healthcare that could be reduced by policy change from HV to the EHC model during the initial 18 months waiting time, or by granting ASR regular healthcare access upon arrival. Potential patterns of differences in GP utilization, unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies.
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