Engaging for Health Policy Transformation

Health Care Access and Diverse Communities in Canada and Turkey

Lloy Wylie, PhDSaime Ozcurumez, PhD

May 29, 2014

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Canadian research shows inequalities in health, and ‘racialized’ groups experiencing poorer health determinants: housing, income, work

Literature also shows wide variation of service access across locations and services, with barriers for a range of ethnic groups

Emergency Rooms as point of access to health care system

Health Status and Service Utilization

Canada has a strong legislative context to:◦ Support equality◦ Facilitate access to health care◦ Create expectations that public services adapt to the

multicultural reality of Canada Aboriginal peoples, immigrants, and ethnically

diverse communities:◦ Face discrimination in society◦ Experience barriers in accessing health services

There is a disjuncture between policies, political commitments and patient experiences

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Problem Statement

What are the barriers to health care access faced by immigrants in Canada, and what types of processes are people engaged in to address those barriers?

◦ 1. How do health service providers, immigrant associations and policy documents frame health care access barriers for immigrants?

◦ 2. What is being done to address access barriers, and how are these strategies assessed?

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Research question(s)

Critical Theory: examines the structural barriers◦ 1) economic 2) social and 3) political exclusion

Health Services Research ◦ 1) financial; 2) non-financial; and 3) equitable

quality of care

◦ 1) socio-economic, 2) cultural, and 3) institutional barriers

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Conceptualizing Access: Structure

Spheres of Influence = Structural Barriers:◦ Economic and Financial Barriers◦ Social and Cultural Barriers◦ Political and Institutional Barriers

Zone of Interaction = Interpersonal Barriers◦ Relationships within institutions (patients and

providers)◦ Engagement between community and institutions

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Integrated Analysis

Constructivism Agency of people working to make change, despite

structural barriers Social reality is a construction based on the actor’s frame of

reference within the setting

Cultural Safety Nursing Relationships Social, political and economic contexts

Interdisciplinary Approach Health Services Research, Political Economy and Cultural

SafetyEach examines different elements of the health care systemAll draw attention to contextualizing the analysis of barriers.

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Conceptualizing Access: Agency

Health Services Research Patients involvement in decision making = more

responsive services

Political Science Engagement as a method to both improve

accountability and enhance democracy

Nursing / Cultural Safety Engagement between care providers and

patients/families supports the therapeutic process

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Conceptualizing Engagement

Two urban centres (Montreal and Vancouver)◦ Common federal legislation◦ Different health governance, society, engagement

Data gathering:◦ Review of Legislation and guidelines (Federal, provincial and

health authority)◦ Interviews with purposefully sampled respondents (service

providers, program managers, and immigrant associations) who are involved in efforts to improve health care access

Data analysis◦ Transcripts coded for barriers, strategies and engagement

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Methods

Quebec Charter of Rights and Freedoms◦ “Every person has a right to full and equal recognition and

exercise of his human rights and freedoms, without distinction, exclusion or preference based on race, colour…language, ethnic or national origin” (Quebec, 1975: Section 10).

BC Multiculturalism Act◦ “(g) recognize the inherent right of each British Columbian,

regardless of race, cultural heritage, religion, ethnicity, ancestry or place of origin, to be treated with dignity, and

◦ (h) generally, carry on government services and programs in a manner that is sensitive and responsive to the multicultural reality of British Columbia” (British Columbia, 1996a: Section 3).

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Quebec and BC Policy

Canadian Charter of Rights and Freedoms◦ “Every individual is equal before and under the law…without

discrimination based on race, national or ethnic origin, colour, religion” (1982: Part 1, Section 15, subsection 1)

Canadian Multiculturalism Act◦ “encourage and assist the social, cultural, economic and

political institutions of Canada to be both respectful and inclusive of Canada’s multicultural character” (1988: Section 3, subsection 1f)

CHA – guarantees access to health care◦ “the health care insurance plan of a province…must provide

for insured health services on uniform terms and conditions and on a basis that does not impede or preclude … reasonable access” (Government of Canada, 1985: Section 12).

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Canadian Policy Context

Social / Cultural Barriers ◦ Lack of knowledge of the health care system ◦ Language barriers ◦ Ethno-cultural differences in access to care, different

perspectives on meaning and health, and service use

Economic Barriers◦ Institutional level financial barriers (lack of $ for programs)◦ Immigrants’ economic circumstances (downward social

mobility)

Political / Institutional Barriers◦ Governance and system design barriers (organization,

location, approach, planning)◦ Immigrants’ and refugees’ legal status

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Access Barriers

Policies and guidelines◦ “does legislation help? It can, if you have people on the ground who are

willing to push for that” (Vancouver prog. manager)◦ “It’s always ‘given the resources’. So…when we say zero deficit, it’s not

always easy” (Montreal prog. manager)

Intercultural training◦ little time for intercultural training◦ research suggests intercultural training is ineffective (Bowen et al

2011) – needs to be mandated Interpretation services

◦ Often not available, or not used; reliance on family/staff

Bridging programs◦ Liaison staff; shared information sessions; program linkages

Community Health Partnerships◦ Communities aware of their needs, more appropriate, shifting costs

onto communities, limiting ability for advocacy as associations become care providers 13

Assessment of Strategies

Formal Engagement◦ Montreal – the Committee focuses on system level changes

(employment equity)◦ Vancouver – engagement emphasis on program adaptation

Informal processes of engagement ◦ Ad-hoc engagement processes are important in shaping experiences. ◦ Health care providers call immigrant associations for advice◦ immigrant associations bring in health service providers to share

information to members

Perspectives on engagement◦ Knowledge brokerage – info sharing between community and system◦ Advocacy and awareness raising – to make health care system aware of

immigrants’ concerns◦ Service partnerships –community groups deliver services together with the

health care system (health promotion)◦ reliant on key individuals to support dialogue - unsustainable

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Engagement

Barriers are multi-faceted and do not act in isolation from each other, but are dynamic and interact◦ Spheres of Influence: social, economic, political

Relationships are framed by SOI◦ Zone of Interaction: the negotiated space where

interaction shapes experiences

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Conceptual Analysis

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1 million Syrians have fled to Turkey, according to UN estimates

Those without documentation go to camps

Refugee Health in Turkey

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Turkey has established a “temporary protection regime” for Syrians, which includes:◦ An open border policy◦ no forcible returns◦ Registration with the Turkish authorities and

support inside the borders of the camps. ◦ “Guest” rather than refugee status◦ Full rights to access to health care services

Turkish Policy Response

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Not uniformly applied

Unregistered Syrian refugees experience difficulty in accessing services

Emergency care is covered, but not follow-up

Hospital administrators refuse to recognize the decree, demand payments for health care

Policy Implementation

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Gap between policy and implementation

Discrepancies between documented and undocumented Syrians in Turkey – undocumented having access barriers.

“Guest” status creates uncertainty – unclear about the obligations and legal meaning

Challenge

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Policy can create the legislative supports to ensure access to services

In order to realize the goals of policy, strategies for change should take on:

◦ social realm (addressing racism / cultural biases),

◦ economic (ensure adequate funding), economic opportunities

◦ Logistical supports (knowledge of policy and processes)

◦ and political / institutional contexts (organizational supports to facilitate engagement in decision making)

◦ Interpersonal relationships matter - Care providers need to be held to account for upholding policy commitments

Strategies for Change