Immigrants' access to health insurance: no equality without awareness

Health System Response to Refugees' and Migrants' Health in Iran: A Strengths, Weaknesses, Opportunities, and Threats Analysis and Policy Recommendations

Objective: Iran is one of the main hosts of Afghan refugees. This study aims to provide comprehensive evidence to increase Afghan migrants' access to healthcare services in Iran. Methods: To assess the health system's response to Afghan migrants in Iran, we conducted three phases for SWOT analysis, including: 1-developing a review and comprehensive analysis of documents, laws, and, programs, 2-conducting semi-structured interviews with policymakers and experts, and 3-mapping the results through the Levesque's conceptual framework for healthcare access. Results: We evaluated the response of the health system to Afghan migrants' health needs in three domains: 1-Approachability and ability to perceive migrants; 2-Ability to reach, engage, and availability and accommodation and appropriateness; 3-The ability to pay and affordability. For each of the three domains, we identified strengths, weaknesses, opportunities, and threats, complemented with evidence-based suggestions to improve migrants' access to needed healthcare services. Conclusion: Given the rising trend of immigration and deteriorating financial crises, we recommend appropriate strategies for the adoption of specialized focus services, gateway services, and restricted services. Also simplifying financial procedures, and implementing innovative insurance mechanisms are essential.

Access to Healthcare Services among Thai Immigrants in Japan: A Study of the Areas Surrounding Tokyo

Numerous undocumented and uninsured foreigners living in Japan have faced barriers when trying to obtain appropriate healthcare services, which have occasionally led to issues with unpaid medical bills to medical institutions. Although information on health and socioeconomic status is essential to tackle such issues, relevant data has been unavailable due to difficulties in contacting this population. This study involved a cross-sectional survey using questionnaires concerning the general demographic characteristics, socioeconomic status, health profiles, information access, and knowledge/attitude/practice of health insurance of Thai nationals living in Japan. The study participants included Thai nationals who lived in Tokyo and the surrounding prefectures. The survey was conducted mainly at public religious events from September 2022 to December 2022. Overall, the questionnaires were obtained from 84 participants, though 67 participants were included in the final analysis after excluding missing variables. There were participants with unspecified visa status (32.8%) and uninsured status (40.3%). Among them, 86.4% expressed positive attitudes towards health insurance. However, multivariate multivariable regression analyses revealed the low insurance practice status among the unspecified visa group (aOR, 0.02; 95% CI, 0.00-0.13). Overall, the results reveal limited access to healthcare services in subgroups of Thai immigrants in Japan.

Assessing the contribution of migration related policies to equity in access to healthcare in European countries. A multilevel analysis

Access to good healthcare and the conditions for good health is one of the central dimensions of immigrant integration. National health policies play a major role in equipping residents with the necessary entitlements to accessible and acceptable healthcare services. Rarely analysed so far is the contribution of migration-related health policies to equity in access to healthcare between immigrants and the general population. To address this gap, this study analysed whether the extent to which migration is considered within national health policies moderates the association between immigration status and subjectively perceived unmet medical need in Europe. Using data from the 2019 European Union Statistics on Income and Living Conditions (EU-SILC) survey in combination with the Migration Integration Policy Index (MIPEX) a multilevel analysis was carried out assessing the cross-level interaction between immigration status and MIPEX scores controlling for individual-level factors such as age, gender, education and employment status. While our results showed that immigrants are more likely to report unmet medical need than the general population (adjusted Odds Ratio (aOR) = 1.32; 95% confidence interval (CI) 1.22-1.43), the cross-level interaction indicated increased relative inequality in unmet medical need between immigrants and the general population in countries with high MIPEX scores compared to countries with low MIPEX scores (aOR = 1.39, 95% CI: 1.18-1.63). The main reason for this increase of inequality on the relative scale was the overall lower prevalence of unmet medical need in countries with high MIPEX scores. In conclusion, our findings indicate that even in countries with relatively migration-friendly health policies inequalities in access to healthcare between immigrants and the general population persist.

[Psychosocial care of refugees in Germany : Insights from the emergency relief and development aid]

Approximately 1.2 million refugees have arrived in Germany since autumn 2014. They are often appraised as being a challenge for the German healthcare system because the acute need for healthcare support was large and appeared suddenly while at the same time resources were limited. This situation was previously unknown for a western European healthcare system, whereas it constitutes a typical challenge for nongovernmental organizations that are active in the field of emergency relief and development aid and that have developed a large number of successful intervention concepts. Of central importance in this context are the basic principles of equal rights, participation of those affected, the principle of nonmaleficence, the resource orientation instead of a deficit orientation as well as the need for integrated and stepped care models. These can serve as general principles not only in the setting of development aid in crisis areas worldwide but also in the health services provided to refugees in the current situation in Germany.

Health Insurance: Awareness, Utilization, and its Determinants among the Urban Poor in Delhi, India

This study reports the awareness, access, and utilization of health insurance by the urban poor in Delhi, India. The study included 2998 households from 85 urban clusters spread across Delhi. The data were collected through a pretested, interviewer-administered questionnaire. Logistic regression was performed for determinants of health insurance possession. Only 19% knew about health insurance; 18% had health insurance (8% Employees State Insurance Scheme - ESIS - 8% Central Government Health Scheme - CGHS - 1.4%; Rashtriya Swasthya Bima Yojana (RSBY) - 9.4% of the eligible households). In case of health needs, 95% of CGHS, 71% ESIS beneficiaries, and 9.5% of RSBY beneficiaries utilized the schemes for episodic and chronic illnesses. For hospitalization needs, 54% of RSBY, 86% of ESIS, 100% CGHS utilized respective services. Residential area, migration period, possession of ration card, household size, and occupation of the head of the household were significantly associated with possession of RSBY. RSBY played a limited role in meeting the healthcare needs of the people, thus may not be capable of contributing significantly in the efforts of achieving equity in healthcare for the poor. Relatively, ESIS and CGHS served the healthcare needs of the beneficiaries better. Expansion of ESIS to the informal workers may be considered.

Health insurance and care-seeking behaviours of female migrants in Accra, Ghana

People working in Ghana’s informal sector have low rates of enrolment in the publicly funded National Health Insurance Scheme. Informal sector workers, including migrant girls and women from northern Ghana working as head porters (kayayei), report challenges obtaining insurance and seeking formal health care. This article analyses how health insurance status affects kayayei migrants’ care-seeking behaviours. This mixed-methods study involved surveying 625 migrants using respondent-driven sampling and conducting in-depth interviews with a sub-sample of 48 migrants. Analyses explore health status and health seeking behaviours for recent illness/injury. Binary logistic regression modelled the effects of selected independent variables on whether or not a recently ill/injured participant (n = 239) sought health care. Although recently ill/injured participants (38.4%) desired health care, less than half (43.5%) sought care. Financial barriers overwhelmingly limit kayayei migrants from seeking health care, preventing them from registering with the National Health Insurance Scheme, renewing their expired health insurance policies, or taking time away from work. Both insured and uninsured migrants did not seek formal health services due to the unpredictable nature of out-of-pocket expenses. Catastrophic and impoverishing medical expenses also drove participants’ migration in search of work to repay loans and hospital bills. Health insurance can help minimize these expenditures, but only 17.4% of currently insured participants (58.2%) reported holding a valid health insurance card in Accra. The others lost their cards or forgot them when migrating. Access to formal health care in Accra remains largely inaccessible to kayayei migrants who suffer from greater illness/injury than the general female population in Accra and who are hindered in their ability to receive insurance exemptions. With internal migration on the rise in many settings, health systems must recognize the varied needs of populations in multi-ethnic and multilingual countries to ensure that internal migrants can access affordable, quality health services across domestic borders.

Comparison of access to health services among urban-to-urban and rural-to-urban older migrants, and urban and rural older permanent residents in Zhejiang Province, China: a cross-sectional survey

BACKGROUND

While much literature reported the access of Chinese older migrants to health services, little was known about the differences among sub-groups of older adults, including urban-to-urban and rural-to-urban migrants, and urban and rural permanent residents. This study aimed to examine the access of these four groups to health services in Zhejiang Province, China and provide an evidence for the development of health services policies.

METHODS

A cross-sectional survey was conducted in community-dwelling older adults (aged 60 years or above) in 2013. Participants were recruited by random sampling. Demographic information and access to health services for the elderly populations were obtained via interviews using a self-designed structured questionnaire. Pearson's chi-square tests and Cochran-Mantel-Haenszel (CMH) tests were performed to examine the differences in access to health services among the four groups. Binary logistic regression was conducted to explore the associations of participants' visits to doctors with their group status after controlling confounding factors.

RESULTS

The two-week hospital visiting rates were significantly lower in migrants (55.56% in rural-to-urban and 62.50% in urban-to-urban) than that in urban and rural permanent residents (67.40 and 82.25%, respectively; p < 0.01). The majority of older adults who received a diagnosis indicating need for hospital treatment accepted the treatment, with no significant difference among the four groups after controlling for health service need (χ2 = 7.08, p = 0.07). On the other hand, 30.05% of the older adults did not visit a doctor when they got ailments in the past 2 weeks prior to the survey, and 16.42% (33/201) did not receive hospital treatment after receiving a diagnosis indicating need for hospital treatment. Factors including age, marital status, educational attainment, major financial source, and living with family members did not influence health services use.

CONCLUSIONS

Targeted social and health policies integrating the strengths of government, society and families should be implemented to further improve health services use for different groups of older adults.

Know where to go: evidence from a controlled trial of a healthcare system information intervention among immigrants

BACKGROUND

Immigrants may face problems with accessing the Danish healthcare system due to, for example, lack of knowledge of how to navigate it, which may cause inappropriate healthcare-seeking. Danish municipalities provide a mandatory introduction and language programme for newly arrived immigrants, but no information on the healthcare system is offered. This study investigated what effects information about the Danish healthcare system may have on the hypothetical healthcare-seeking behaviour of newly arrived immigrants and their actual healthcare use.

METHODS

A prospective intervention study of 1572 adult immigrants attending two language schools in Copenhagen was carried out. Two intervention groups received either a course or written information on the Danish healthcare system, respectively, while the control group received neither. Survey data included three case vignettes on healthcare-seeking behaviour (flu-like symptoms, chest pain and depression) and were linked to registry data on sociodemographic characteristics and healthcare use in the year to follow. Logistic regression and binomial regression analyses were performed.

RESULTS

Appropriate hypothetical healthcare-seeking behaviour was reported by 61.8-78.8% depending on the vignette. Written information showed no effect on immigrants' hypothetical healthcare-seeking behaviour, while the course showed a positive effect on hypothetical healthcare-seeking behaviour for flu-like symptoms (adjusted odds ratio [AOR] = 1.71, 95% confidence interval [CI] = 1.01-2.91, p-value = 0.0467), but not on chest pain or depression. The interventions did not affect immigrants' actual healthcare use; all groups made lower use of health care services in the following year compared with the year where the study took place, except for the use of dental care which remained stable.

CONCLUSIONS

Information on the healthcare system embedded in the language school programme has the potential to facilitate immigrants' access to healthcare. Yet, the results underscore the need for further refinement and development of educational interventions, as well as ensuring adequate utilisation of healthcare services by other means. Multi-dimensional and multi-sectional efforts are important for integration issues within healthcare in Europe.

TRIAL REGISTRATION

Health-seeking behaviour among newly arrived immigrants in Denmark ISRCTN24905314 , May 1, 2015 (Retrospectively registered).

Social and Economic Policies Matter for Health Equity: Conclusions of the SOPHIE Project

Since 2011, the SOPHIE project has accumulated evidence regarding the influence of social and economic policies on population health levels, as well as on health inequalities according to socioeconomic position, gender, and immigrant status. Through comparative analyses and evaluation case studies across Europe, SOPHIE has shown how these health inequalities vary according to contexts in macroeconomics, social protection, labor market, built environment, housing, gender equity, and immigrant integration and may be reduced by equity-oriented policies in these fields. These studies can help public health and social justice advocates to build a strong case for fairer social and economic policies that will lead to the reduction of health inequalities that most governments have included among their policy goals. In this article, we summarize the main findings and policy implications of the SOPHIE project and the lessons learned on civil society participation in research and results communication.

Social Hazards as Manifested Workplace Discrimination and Health (Vietnamese and Ukrainian Female and Male Migrants in Czechia)

Social hazards as one of the dimensions of workplace discrimination are a potential social determinant of health inequalities. The aim of this study was to investigate relations between self-reported health and social hazard characteristics (defined as—discrimination as such, violence or threat of violence, time pressure or work overload and risk of accident) among Vietnamese and Ukrainian migrants (males and females) in Czechia by age, education level and marital status. This study is based on data from a survey of 669 immigrants in Czechia in 2013. Logistic regression analysis indicates that the given independent variables (given social hazards and socio-demographic characteristics), as predictors of a quality of self-reported health are more important for immigrant females than for males, irrespective of citizenship, albeit only for some of them and to differing extents. We found out that being exposed to the selected social hazards in the workplace leads to worsening self-rated health, especially for females. On the other hand, there was no statistically significant relationship found between poor self-rated health and discrimination as such. Reality calls for more research and, consequently, better policies and practices in the field of health inequalities.