Mental health coverage for forced migrants: Managing failure as everyday governance in the public and NGO sectors in England.

High-income countries (HICs) which are said to have "reached" universal health coverage (UHC) typically still have coverage gaps, due to both formal policies and informal barriers which result in "hypothetical access". In England, a user fee exemption has in principle made access to treatment for post-traumatic stress disorder (PTSD) and other mental health conditions thought to be caused by certain forms of violence universal, regardless of immigration status. This study explores the everyday governance of this mental health coverage for forced migrants in the English National Health Service (NHS) and NGO sector. Fieldwork was conducted in two waves, in 2015-2016 and 2019-2021, including six months of participant observation in an NGO and 21 semi-structured interviews with psy professionals across 16 NHS and NGO service providers. Further interviews were conducted with mental health commissioners and policymakers, as well as analysis of grey literature. Despite being formally covered for certain types of mental health care, in practice asylum seekers and undocumented migrants were often excluded by NHS providers. Undocumented migrants were also often excluded by NGO providers. Several rationalities linked discursive fields to practices developed by psy professionals and other street-level bureaucrats to govern coverage, in a process of "managing failure". These rationalities are presented under three paired themes which draw attention to tensions and resistance in the governance of coverage: medicalisation and biolegitimacy; austerity and ethico-politics; and differential racialisation and decolonisation. Rationalities were associated with strategies and tactics such as social triage, clinical advocacy, obfuscation, evidence-based advocacy and silencing critique. The concept of "health coverage assemblage" is introduced to explain the complex, unstable, contingent and fragmented nature of UHC policies and programmes. Misrecognition and underestimation of the everyday work of health professionals in promoting, resisting and reproducing diverse rationalities within the assemblage may lead to missed opportunities for reform.

Fragmentation by design: Universal health coverage policies as governmentality in Senegal.

There is increasing international consensus that countries need to reduce health system fragmentation in order to achieve universal health coverage (UHC). Yet there is little agreement on what drives fragmentation, in particular the extent to which fragmentation has a political purpose. This study analyses a highly fragmented health financing system through a UHC policy that aims to remove user fees for people aged 60 and over in Senegal. 53 semi-structured interviews (SSIs) and focus group discussions with the target population were conducted in four regions in Senegal over a period of six months during 2012. A further 46 SSIs were conducted with key informants at the national level and in each of the four regions. By analysing explanations of the successes and failures of policies, an understanding of power relations in state institutions, communities and individuals is gained. The concept of governmentality is used to interpret the results. The interviewees' main concern was to implement or resist various techniques of control over the conduct of bureaucrats, health workers, patients and the wider population. These techniques included numeracy and calculation, referral letters, ID cards, data collection, new prudentialism, active citizenship and ethical self-formation through affinities of the community. The techniques sought to make two types of subjects; citizens subjects of rights and obligations; and autonomous subjects of choice and self-identity. A key implication is that in Senegal, and perhaps elsewhere, fragmentation of the health system plays a key role in the formation and control of subjects, in the name of "freedom". As such, fragmentation may be an inherent feature of UHC. Interventions that aim to reduce fragmentation based on evidence of its inefficiency, inequity and ineffectiveness in reducing poverty and ill health may be missing this point.

Inequalities Between Migrants and Non-Migrants in Accessing and Using Health Services in Greece During an Era of Economic Hardship.

A cross-sectional study was conducted from April 2013 until March 2014 to explore the existence of inequalities in access to and utilization of health services by migrants compared to non-migrants in Greece and to test the influence of various factors on these disparities. Also, we investigated the influence of several socioeconomic and demographic characteristics. Study population included 1,152 migrants and 702 non-migrants. Migrants, participants suffering from a chronic disease, those without health insurance, and patients who assessed their health status as not at all good/a little good/moderate were statistically more likely to report unmet needs in getting their medication. Uninsured participants, females, those unemployed or without a permanent occupational status, and those who assessed their health status as not at all good/a little good/moderate were statistically more likely to report unmet needs in access to health services during the last year. Regarding the use of health services, those with health coverage, non-migrants, and females were statistically more likely to go for a blood test as a hospital outpatient. Greece, despite administrative delays and barriers, provided full coverage to the uninsured, asylum seekers, and migrants, even many groups of undocumented migrants.

Removing user fees for health services: A multi-epistemological perspective on access inequities in Senegal.

Plan Sésame (PS) is a user fee exemption policy launched in 2006 to provide free access to health services to Senegalese citizens aged 60 and over. Analysis of a large household survey evaluating PS echoes findings of other studies showing that user fee removal can be highly inequitable. 34 semi-structured interviews and 19 focus group discussions with people aged 60 and over were conducted in four regions in Senegal (Dakar, Diourbel, Matam and Tambacounda) over a period of six months during 2012. They were analysed to identify underlying causes of exclusion from/inclusion in PS and triangulated with the household survey. The results point to three steps at which exclusion occurs: (i) not being informed about PS; (ii) not perceiving a need to use health services under PS; and (iii) inability to access health services under PS, despite having the information and perceived need. We identify lay explanations for exclusion at these different steps. Some lay explanations point to social exclusion, defined as unequal power relations. For example, poor access to PS was seen to be caused by corruption, patronage, poverty, lack of social support, internalised discrimination and adverse incorporation. Other lay explanations do not point to social exclusion, for example: poor implementation; inadequate funding; high population demand; incompetent bureaucracy; and PS as a favour or moral obligation to friends or family. Within a critical realist paradigm, we interpret these lay explanations as empirical evidence for the presence of the following hidden underlying causal mechanisms: lacking capabilities; mobilisation of institutional bias; and social closure. However, social constructionist perspectives lead us to critique this paradigm by drawing attention to contested health, wellbeing and corruption discourses. These differences in interpretation lead to subsequent differential policy recommendations. This demonstrates the need for the adoption of a "multi-epistemological" perspective in studies of health inequity and social exclusion.

Equitable access to health insurance for socially excluded children? The case of the National Health Insurance Scheme (NHIS) in Ghana.

To help reduce child mortality and reach universal health coverage, Ghana extended free membership of the National Health Insurance Scheme (NHIS) to children (under-18s) in 2008. However, despite the introduction of premium waivers, a substantial proportion of children remain uninsured. Thus far, few studies have explored why enrolment of children in NHIS may remain low, despite the absence of significant financial barriers to membership. In this paper we therefore look beyond economic explanations of access to health insurance to explore additional wider determinants of enrolment in the NHIS. In particular, we investigate whether social exclusion, as measured through a sociocultural, political and economic lens, can explain poor enrolment rates of children. Data were collected from a cross-sectional survey of 4050 representative households conducted in Ghana in 2012. Household indices were created to measure sociocultural, political and economic exclusion, and logistic regressions were conducted to study determinants of enrolment at the individual and household levels. Our results indicate that socioculturally, economically and politically excluded children are less likely to enrol in the NHIS. Furthermore, households excluded in all dimensions were more likely to be non-enrolled or partially-enrolled (i.e. not all children enrolled within the household) than fully-enrolled. These results suggest that equity in access for socially excluded children has not yet been achieved. Efforts should be taken to improve coverage by removing the remaining small, annually renewable registration fee, implementing and publicising the new clause that de-links premium waivers from parental membership, establishing additional scheme administrative offices in remote areas, holding regular registration sessions in schools and conducting outreach sessions and providing registration support to female guardians of children. Ensuring equitable access to NHIS will contribute substantially to improving child health and reducing child mortality in Ghana.

Measles among migrants in the European Union and the European Economic Area.

AIMS: Progress towards meeting the goal of measles elimination in the EU and the European Economic Area (EEA) by 2015 is being obstructed, as some children are either not immunized on time or never immunized. One group thought to be at increased risk of measles is migrants; however, the extent to which this is the case is poorly understood, due to a lack of data. This paper addresses this evidence gap by providing an overview of the burden of measles in migrant populations in the EU/EEA. METHODS: Data were collected through a comprehensive literature review, a country survey of EU/EEA member states and information from measles experts gathered at an infectious disease workshop. RESULTS: Our results showed incomplete data on measles in migrant populations, as national surveillance systems do not systematically record migration-specific information; however, evidence from the literature review and country survey suggested that some measles outbreaks in the EU/EEA were due to sub-optimal vaccination coverage in migrant populations. CONCLUSIONS: We conclude that it is essential that routine surveillance of measles cases and measles, mumps and rubella (MMR) vaccination coverage become strengthened, to capture migrant-specific data. These data can help to inform the provision of preventive services, which may need to reach out to vulnerable migrant populations that currently face barriers in accessing routine immunization and health services.

How do economic crises affect migrants' risk of infectious disease? A systematic-narrative review.

BACKGROUND: It is not well understood how economic crises affect infectious disease incidence and prevalence, particularly among vulnerable groups. Using a susceptible-infected-recovered framework, we systematically reviewed literature on the impact of the economic crises on infectious disease risks in migrants in Europe, focusing principally on HIV, TB, hepatitis and other STIs. METHODS: We conducted two searches in PubMed/Medline, Web of Science, Cochrane Library, Google Scholar, websites of key organizations and grey literature to identify how economic changes affect migrant populations and infectious disease. We perform a narrative synthesis in order to map critical pathways and identify hypotheses for subsequent research. RESULTS: The systematic review on links between economic crises and migrant health identified 653 studies through database searching; only seven met the inclusion criteria. Fourteen items were identified through further searches. The systematic review on links between economic crises and infectious disease identified 480 studies through database searching; 19 met the inclusion criteria. Eight items were identified through further searches. The reviews show that migrant populations in Europe appear disproportionately at risk of specific infectious diseases, and that economic crises and subsequent responses have tended to exacerbate such risks. Recessions lead to unemployment, impoverishment and other risk factors that can be linked to the transmissibility of disease among migrants. Austerity measures that lead to cuts in prevention and treatment programmes further exacerbate infectious disease risks among migrants. Non-governmental health service providers occasionally stepped in to cater to specific populations that include migrants. CONCLUSIONS: There is evidence that migrants are especially vulnerable to infectious disease during economic crises. Ring-fenced funding of prevention programs, including screening and treatment, is important for addressing this vulnerability.

Tuberculosis among migrant populations in the European Union and the European Economic Area.

BACKGROUND: Although tuberculosis (TB) incidence has been decreasing in the European Union/European Economic Area (EU/EEA) in the last decades, specific subgroups of the population, such as migrants, remain at high risk of TB. This study is based on the report 'Key Infectious Diseases in Migrant Populations in the EU/EEA' commissioned by The European Centre for Disease Prevention and Control. METHODS: We collected, critically appraised and summarized the available evidence on the TB burden in migrants in the EU/EEA. Data were collected through: (i) a comprehensive literature review; (ii) analysis of data from The European Surveillance System (TESSy) and (iii) evidence provided by TB experts during an infectious disease workshop in 2012. RESULTS: In 2010, of the 73,996 TB cases notified in the EU/EEA, 25% were of foreign origin. The overall decrease of TB cases observed in recent years has not been reflected in migrant populations. Foreign-born people with TB exhibit different socioeconomic and clinical characteristics than native sufferers. CONCLUSION: This is one of the first studies to use multiple data sources, including the largest available European database on infectious disease notifications, to assess the burden and provide a comprehensive description and analysis of specific TB features in migrants in the EU/EEA. Strengthened information about health determinants and factors for migrants' vulnerability is needed to plan, implement and evaluate targeted TB care and control interventions for migrants in the EU/EEA.

The impact of stakeholder values and power relations on community-based health insurance coverage: qualitative evidence from three Senegalese case studies.

Continued low rates of enrolment in community-based health insurance (CBHI) suggest that strategies proposed for scaling up are unsuccessfully implemented or inadequately address underlying limitations of CBHI. One reason may be a lack of incorporation of social and political context into CBHI policy. In this study, the hypothesis is proposed that values and power relations inherent in social networks of CBHI stakeholders can explain levels of CBHI coverage. To test this, three case studies constituting Senegalese CBHI schemes were studied. Transcripts of interviews with 64 CBHI stakeholders were analysed using inductive coding. The five most important themes pertaining to social values and power relations were: voluntarism, trust, solidarity, political engagement and social movements. Analysis of these themes raises a number of policy and implementation challenges for expanding CBHI coverage. First is the need to subsidize salaries for CBHI scheme staff. Second is the need to develop more sustainable internal and external governance structures through CBHI federations. Third is ensuring that CBHI resonates with local values concerning four dimensions of solidarity (health risk, vertical equity, scale and source). Government subsidies is one of the several potential strategies to achieve this. Fourth is the need for increased transparency in national policy. Fifth is the need for CBHI scheme leaders to increase their negotiating power vis-à-vis health service providers who control the resources needed for expanding CBHI coverage, through federations and a social movement dynamic. Systematically addressing all these challenges would represent a fundamental reform of the current CBHI model promoted in Senegal and in Africa more widely; this raises issues of feasibility in practice. From a theoretical perspective, the results suggest that studying values and power relations among stakeholders in multiple case studies is a useful complement to traditional health systems analysis.

Enrolment of older people in social health protection programs in West Africa--does social exclusion play a part?

Although the population of older people in Africa is increasing, and older people are becoming increasingly vulnerable due to urbanisation, breakdown of family structures and rising healthcare costs, most African countries have no social health protection for older people. Two exceptions include Senegal's Plan Sesame, a user fees exemption for older people and Ghana's National Health Insurance Scheme (NHIS) where older people are exempt from paying premiums. Evidence on whether older people are aware of and enrolling in these schemes is however lacking. We aim to fill this gap. Besides exploring economic indicators, we also investigate whether social exclusion determines enrolment of older people. This is the first study that tries to explore the social, political, economic and cultural (SPEC) dimensions of social exclusion in the context of social health protection programs for older people. Data were collected by two cross-sectional household surveys conducted in Ghana and Senegal in 2012. We develop SPEC indices and conduct logistic regressions to study the determinants of enrolment. Our results indicate that older people vulnerable to social exclusion in all SPEC dimensions are less likely to enrol in Plan Sesame and those that are vulnerable in the political dimension are less likely to enrol in NHIS. Efforts should be taken to specifically enrol older people in rural areas, ethnic minorities, women and those isolated due to a lack of social support. Consideration should also be paid to modify scheme features such as eliminating the registration fee for older people in NHIS and creating administration offices for ID cards in remote communities in Senegal.

Why do people drop out of community-based health insurance? Findings from an exploratory household survey in Senegal.

Although a high level of drop-out from community-based health insurance (CBHI) is frequently reported, it has rarely been analysed in depth. This study explores whether never having actively participated in CBHI is a determinant of drop-out. A conceptual framework of passive and active community participation in CBHI is developed to inform quantitative data analysis. Fieldwork comprising a household survey was conducted in Senegal in 2009. Levels of active participation among 382 members and ex-members of CBHI across three case study schemes are compared using logistic regression. Results suggest that, controlling for a range of socioeconomic variables, the more active the mode of participation in the CBHI scheme, the stronger the statistically significant positive correlation with remaining enrolled. Training is the most highly correlated, followed by voting, participating in a general assembly, awareness raising/information dissemination and informal discussions/spontaneously helping. Possible intermediary outcomes of active participation such as perceived trustworthiness of the scheme management/president; accountability and being informed of mechanisms of controlling abuse/fraud are also significantly positively correlated with remaining in the scheme. Perception of poor quality of health services is identified as the most important determinant of drop-out. Financial factors do not seem to determine drop-out. The results suggest that schemes may be able to reduce drop-out and increase quality of care by creating more opportunities for more active participation. Caution is needed though, since if CBHI schemes uncritically fund and promote participation activities, individuals who are already more empowered or who already have higher levels of social capital may be more likely to access these resources, thereby indirectly further increasing social inequalities in health coverage.

Can social capital help explain enrolment (or lack thereof) in community-based health insurance? Results of an exploratory mixed methods study from Senegal.

CBHI has achieved low population coverage in West Africa and elsewhere. Studies which seek to explain this point to inequitable enrolment, adverse selection, lack of trust in scheme management and information and low quality of health care. Interventions to address these problems have been proposed yet enrolment rates remain low. This exploratory study proposes that an under-researched determinant of CBHI enrolment is social capital. Fieldwork comprising a household survey and qualitative interviews was conducted in Senegal in 2009. Levels of bonding and bridging social capital among 720 members and non-members of CBHI across three case study schemes are compared. The results of the logistic regression suggest that, controlling for age and gender, in all three case studies members were significantly more likely than non-members to be enrolled in another community association, to have borrowed money from sources other than friends and relatives and to report having control over all community decisions affecting daily life. In two case studies, having privileged social relationships was also positively correlated with enrolment. After controlling for additional socioeconomic and health variables, the results for borrowing money remained significant. Additionally, in two case studies, reporting having control over community decisions and believing that the community would cooperate in an emergency were significantly positively correlated with enrolment. The results suggest that CBHI members had greater bridging social capital which provided them with solidarity, risk pooling, financial protection and financial credit. Qualitative interviews with 109 individuals selected from the household survey confirm this interpretation. The results ostensibly suggest that CBHI schemes should build on bridging social capital to increase coverage, for example by enrolling households through community associations. However, this may be unadvisable from an equity perspective. It is concluded that since enrolment in CBHI was less common not only among the poor, but also among those with less social capital and less power, strategies should focus on removing social as well as financial barriers to  financial protection from the cost of ill health.

Migration and health in an increasingly diverse Europe.

The share of migrants in European populations is substantial and growing, despite a slowdown in immigration after the global economic crisis. This paper describes key aspects of migration and health in Europe, including the scale of international migration, available data for migrant health, barriers to accessing health services, ways of improving health service provision to migrants, and migrant health policies that have been adopted across Europe. Improvement of migrant health and provision of access for migrants to appropriate health services is not without challenges, but knowledge about what steps need to be taken to achieve these aims is increasing.

Financial crisis, austerity, and health in Europe.

The financial crisis in Europe has posed major threats and opportunities to health. We trace the origins of the economic crisis in Europe and the responses of governments, examine the effect on health systems, and review the effects of previous economic downturns on health to predict the likely consequences for the present. We then compare our predictions with available evidence for the effects of the crisis on health. Whereas immediate rises in suicides and falls in road traffic deaths were anticipated, other consequences, such as HIV outbreaks, were not, and are better understood as products of state retrenchment. Greece, Spain, and Portugal adopted strict fiscal austerity; their economies continue to recede and strain on their health-care systems is growing. Suicides and outbreaks of infectious diseases are becoming more common in these countries, and budget cuts have restricted access to health care. By contrast, Iceland rejected austerity through a popular vote, and the financial crisis seems to have had few or no discernible effects on health. Although there are many potentially confounding differences between countries, our analysis suggests that, although recessions pose risks to health, the interaction of fiscal austerity with economic shocks and weak social protection is what ultimately seems to escalate health and social crises in Europe. Policy decisions about how to respond to economic crises have pronounced and unintended effects on public health, yet public health voices have remained largely silent during the economic crisis.

Informal payments for maternity health services in public hospitals in Greece.

BACKGROUND: Private health expenditure for consuming maternity health services has been identified as an issue within public hospitals. AIM: To estimate level of private health expenditure, in the form of informal payments, for maternal services in public hospitals in Greece. METHODS: The study population consisted of 160 women who had recently given birth in three provincial general hospitals and one general hospital in Athens. A three-part questionnaire was developed in order to collect financial information regarding the use of public obstetrics services in Greece. RESULTS: The mean age of respondents was 29.5 (±5.6) years. There was a high rate of informal payments with 74.4% of women involved in informal transactions. Mean total private payments were €1549 (±992), representing 7.9% of the mean annual per capita income in Greece. Mean informal payment was €848 (±714). For 56.3% of the respondents, it was at the obstetrician's request, on top of formal payment of €701 (±1351). Total informal payments were higher for women who gave birth in Athens (p<0.001), for Greek women compared to non Greek (p<0.001) and for deliveries that were conducted by women's personal obstetrician (p=0.001). CONCLUSION: There is a large black economy in the field of obstetric services, as 74.4% of women who used public maternity services had to pay under-the-table payments corresponding approximately to the net salary of an intern physician. There is a need for the state to adopt innovative strategies and mechanisms in order to reduce informal payments for obstetric services in the public sector.

Good practices in migrant health: the European experience.

Migrants comprise a growing proportion of European populations. Although many are healthy, those who do need healthcare often face barriers and the care they receive may be inappropriate to their needs. This paper summarises good practices identified in a review of health services for migrants in Europe. Governments should ensure that migrants are entitled to health services, that the services are appropriate to their needs and that data systems are in place to monitor utilisation and detect inequities. Health services should adopt a 'whole organisation approach', in which cultural competence is viewed as much as a task for organisations as for individuals. Health workers should take steps to overcome language, social and cultural barriers to care. In each case, existing examples of good practice are provided. At a time when support is growing in some countries for political parties pursuing anti-immigrant agendas and governments in all countries are pursuing austerity policies, there is a greater need than ever for the public health community to ensure that migrants have access to services that are effective and responsive to their needs.

Is there a statistical relationship between economic crises and changes in government health expenditure growth? an analysis of twenty-four European countries.

OBJECTIVE: To identify whether, by what means, and the extent to which historically, government health care expenditure growth in Europe has changed following economic crises. DATA SOURCES: Organization for Economic Cooperation and Development Health Data 2011. STUDY DESIGN: Cross-country fixed effects multiple regression analysis is used to determine whether statutory health care expenditure growth in the year after economic crises differs from that which would otherwise be predicted by general economic trends. Better understanding of the mechanisms involved is achieved by distinguishing between policy responses which lead to cost-shifting and all others. FINDINGS: In the year after an economic downturn, public health care expenditure grows more slowly than would have been expected given the longer term economic climate. Cost-shifting and other policy responses are both associated with these slowdowns. However, while changes in tax-derived expenditure are associated with both cost-shifting and other policy responses following a crisis, changes in expenditure derived from social insurance have been associated only with changes in cost-shifting. CONCLUSIONS: Disproportionate cuts to the health sector, as well as reliance on cost-shifting to slow growth in health care expenditure, serve as a warning in terms of potentially negative effects on equity, efficiency, and quality of health services and, potentially, health outcomes following economic crises.