Overcoming the barriers in establishing access to healthcare services for migrants and mobile

populations: best practices

Henrique Barros

Vienna, July 2010

Ministério da Saúde

- Language;

- Cultural specificities;

- Religious beliefs;

- Lack of appropriate services;

- Fear, stigma, discrimination;

Barriers to health care

- HIV epidemiologic profiles in migrants and mobile populations;

- why migrants, particularly undocumented migrants, consistently appear to be at increased risk of treatment failure.

Knowledge gaps

If you, or someone in your family, had problems related with HIV where would you go to obtain Health Care N %

Don’t know 151 10.0

Health Centre 545 36.1

Hospital 611 40.4

Health Centre & Hospital 43 2.8

National Coordination for AIDS 46 3.0

Private medicine 75 5.0

Health Centre & Private medicine 4 0.3

Hospital & Private medicine 8 0.5

Other 28 1.9

If you wanted information about HIV, what source of information would you prefer?

Can’t get information 11 0.7

Don’t need information 16 1.1

Friends and family 99 6.6

Doctors 947 62.8

Nurses 20 1.3

TV, Radio, Newspapers 42 2.8

Internet 311 20.6

Community organizations; NGOs 22 1.5

Pharmacy 15 1.0

Other 24 1.6

Portugal

Portugal

Female Male 

n % n % P

 

None 209 36,0 269 44,3 0.004  

Cost 25 4,3 15 2,5 0.107  

Language 6 1,0 10 1,6 0.453  

Distance 14 2,4 12 2,0 0.693  

Waiting time 312 53,7 284 46,8 0.017  

Health care providers 127 21,9 86 14,2 0.001  

Fear of losing job 7 1,2 4 0,7 0.376  

Other 65 11,2 49 8,1 0.076  

Barriers in access to the National Health Service

Economic concerns

Work-related obstacles 

Transportation and safety issues

Social context

• Cost of transports• Cost of medical treatment• Avoiding loss of income

• Power dynamics• Sick leave• Working hours, overtime and days off• Access to the official documents

• Fear of harassment and arrest by the police• Forced to pay bribes

• Gender issues (violence)

Factors that restrict migrants’ access to health care

A community-based survey of sexual attitudes and lifestyles among 746 Africans in London found that 34% had ever tested for HIV.

HIV testing resides almost exclusively within the domain of the professional sector. More innovative approaches to testing that encourage overlap with the popular and folk sectors may improve acceptability and help reduce stigma. Example - community-based voluntary counselling and testing, like that successfully implemented in Kenya (The Voluntary HIV Counselling and Testing Efficacy Study Group, 2000), with lay people trained as counsellors and rapid HIV tests performed in community settings.

Promoting HIV testing

Access to health care insurance and work permit

Arrest by the police

• If needed, introduce a separate identification system for migrants on ART, so they do not need access to their health care insurance cards (or work permits) for ART

• Advise the patients to keep extra pills on them at all times, in case they are arrested and kept from their medicines

Migrants – ARV therapy

Cost of treatment

Discrimination

• Provide all parts of ART for free• Support transportation costs

• Provide tools and guidelines for the delivery of ART to migrants• Train health care staff on issues of cultural

sensitivity and the relationship between migration and health

Migrants – ARV therapy

Language and communication

Social support

• Use high-quality professional translators• Use peer educators who speak the patients’ own

language, and can relate to the patient’s background and situation in the host country• Use visual information• Provide written information in the patients’ own

language

• Provide peer support groups• Eliminate social support as an inclusion criterion for

ART (if present)• Provide extra support and attention to adherence

during follow-ups

Migrants – ARV therapy

Limited sick leave/ability to attend follow-up appointments

• Give follow-up appointments after migrants’ working hours, so migrants do not have to miss work to attend them• Show more flexibility and tolerance for

migrants who miss regular appointments• Provide ART at different type of clinics or

community centres, and thereby reduce the distance to health care centres, thus making regular appointments less time consuming• Provide ART where the migrants work and

live (combine with directly observed therapy for tuberculosis if possible)

Migrants – ARV therapy

Taking medicine at work • Careful integration of ART into the patient’s daily life• Provide education and information on

adherence in the patient’s own language• Create a good relationship and good

cooperation between the patient and health care provider• Keep medicines in discrete packages

so they cannot be recognized by colleagues as HIV medication

Migrants – ARV therapy