Health assessments of asylum seekers within the Swedish healthcare system
Type of text: Doctoral thesis
Published by: Umeå University
Author: Robert Jonzon
Short description of text
Thesis based on three original papers. The objective ‘to explore to what extent the Swedish healthcare system provides optimal conditions for asylum seekers to access the HA [health assessment] and how the HA could meet their own perceived health needs, as well as society’s demand on detecting contagious diseases, from a public health perspective’ (Abstract).
Most important results
– ‘The main results of this thesis indicate the lack of a coherent national system and approach to facilitate healthcare services, in this case with focus on HAs, for asylum seekers. Though national policies do exists, there are no common pattern as to how these are implemented and applied at regional and local level, to guide how to organize services and procedures in relation to the HA. Moreover, there seemed to be no national supervision or professional training options available to the health professionals working within this field. Even though the HAs most commonly are carried out in ordinary primary healthcare centers, the data reveal a picture of a parallel system where citizens are provided healthcare on different premises than asylum seekers and other categories of migrants.
Though the main purposes of the HA is to identify health problems that require immediate attention, detect infectious diseases and to give information on the Swedish healthcare system, our data indicate that this is not fully accomplished, nor in a satisfactory way. The focus is to a large extent on control of communicable diseases and less on care for illnesses perceived by the asylum seekers. Poor communication and information to the asylum seekers before, under and after the HA contribute to building barriers that reduces the prospect of accessing healthcare for the asylum seekers. Despite that the asylum seekers considered the quality of the HA to be unsatisfactory, and that it did not contributed to the fulfillment of their right to health, they embraced the offer as such, of having an HA’ (p. 46).
– ‘The only systematic attempt by which the Swedish state has tried to identify health threats among migrants is to invite asylum seekers to a HA. However, the mental health sufferings among the asylum seekers does not get necessary attention and are, according to our data, overlooked. The HA were considered vital and were introduced in Sweden in the 1980s when migrants to a large extent arrived from areas where HIV and AIDS was common. The fear of HIV and AIDS at that time was massive and the HA has ever since, not least among the migrants, to a large extent been perceived merely as a check for HIV, which data from this research also confirm’ (p. 49).
– ‘Far from all asylum seekers attend the HA, in fact only every other, as an average at national level. Data from this research show that asylum seekers view the HA with suspicions and may thus refrain from it since they are not sufficiently informed about the purpose of the HA. They also have questions and fear about a possible linkage between detection of diseases, for most part HIV, and how this may interfere with their asylum process. This fear is so strong that even among those having obtained a residence permit, fear of deportation remain, since that is what they think will happen if detected with HIV’ (p. 49).
– ‘In this research project we have identified two major issues that negatively influences accessibility and build barriers to the HA, offered to asylum seekers. First, it is a matter of communication, where poor communication on health related issues at different stages of the asylum seeking process have a negative impact on the accessibility to the HA. Data from this research show that poor communication is apparent already when the migration authority give initial information to 53 the asylum seekers on various matters, among them their right to a HA. Further, the informants reported poor or failed communication in relation to the actual invitation to the HA from the healthcare sector. One informant commented on this failure that she lost her chance to know about her health status. However, poor communication also reduces the likelihood of securing the public health purposes of the HA, namely detect contagious diseases that might be a threat to other people. Second, it is a matter of how the individual county council structures and organizes its healthcare in relation to the HA. Our data show a patchwork of different structures linked with varying coverage’ (p. 52).
– In the conclusion it is being argued that ‘it is clear that the HIV-pandemic fueled the call for screening migrants in the 1980s, since at that time, many arrived from high endemic areas. Thus, the healthcare targeting asylum seekers is built on an assumption that asylum seekers are a risk to the host population and thus they need to be controlled for communicable diseases. Yet, the fact is that many migrants most at risk, for themselves and at times also to others, never get an invitation to a HA, since they do not belong to the “right” category of migrants’ (p. 57).
“Accessibility” and “quality” as two operational indicators proposed by the UN Committee on Economic, Social and Cultural Rights, in order to monitor the implementation of “the right to health”, as well as a further development of this framework to adapt it to the analysis of populations in risk situations, using five dimensions as proposed by Obrist et al: availability, accessibility, affordability, adequacy and acceptability, applied in their “Health Access Livelihood Framework” – model.
Mixed methods. A quantitative cross-sectional design using different questionnaires, directed at administrators, healthcare professionals and former asylum seekers, and a qualitative, interpretative and descriptive research approach, guided by grounded theory, based on individual interviews among former asylum seekers.
– ‘I would suggest a new “National Health Reception System”, financed and secured by the state and targeting all immigrants coming to Sweden, no matter on what grounds. They should all be reached by a welcoming health-voucher, valid for a free visit at any general primary healthcare unit. This first visit, that to some would be the only one, should aim for a basic presentation of the Swedish healthcare system besides a health interview. It would then guide and decide any further action, based on needs and universal access. This health reception system should be totally separated from the migration authority, since the present rule where the migration authority give information on the HA has to some asylum seekers created worries on if the outcome of the HA may interfere with the asylum application’ (p. 58).
– ‘Healthcare services targeting asylum seekers and other migrants ought to move away from being a parallel system to mainstream primary healthcare practice … A robust sustainable primary healthcare must have the capacity it takes to serve all people living in the community, no matter who they are. Any nurse or GP working in primary healthcare should be equipped and able to see any individual in need for their services. In a primary healthcare setting, discriminatory actions should not be based on who you are as a person or what kind of migrant you are, but rather what health needs you might have … Data from this research is clear on the excessive need for training of healthcare personnel in communication skills, which include cross cultural communication … some insight and knowledge in medical sociology and anthropology would benefit any nurse or GP working in a cross cultural setting’ (p. 59).
Suggestions for further research
‘Study number one in this research project was about identifying variations in policies and implementation of HAs for asylum seekers in Sweden through analyses of structures and processes of HAs in different Swedish counties and discusses how this in turn might influence the coverage. This study could be referred to as a baseline study, and a new similar study would add useful information on the progress and development of this part of the healthcare system.
Future research may, based on findings from this research, explore and analyze if, and if so, how, mobile healthcare may represent a positive alternative or complement to traditional stationary healthcare centers, in carrying out HAs on asylum seekers and increase the coverage.
If a shift from present policy and practice will take place in the near future it would be suitable and important to do an intervention research and follow the change and outcome of it’ (p. 59-60).