Associate Professor Ignacio Correa-Velez School of Public Health and Social Work, Queensland University of Technology, Australia ‘Addressing health vulnerabilities of migrants in large migration flows: An inter- regional roundtable discussion’ 25 th April 2016, Geneva, Switzerland AUSTRALIA’S RESPONSE TO THE HEALTH NEEDS OF IRREGULAR MIGRANTS AND REFUGEES: D IVERSE MODELS OF HEALTH CARE AND BEST CASE PRACTICES

Australia’s Refugee and Humanitarian Programme Australia’s Healthcare System Health status of irregular migrants and refugees Irregular migrant and refugee health care models Best case practices Final reflections OUTLINE 2

AUSTRALIA’S REFUGEE AND HUMANITARIAN PROGRAMME Offshore component Nearly 14,000 refugee and humanitarian entrants per annum Onshore component 2009 – 2013: 51,637 irregular migrants arrived by boat South Asia, Southeast Asia and the Middle East Immigration detention until granted a visa or removed from Australia Since August 2012: Third country processing (Papua New Guinea and Nauru) Feb 2016: About 1,800 people in immigration detention, and 29,000 asylum seekers living in the community on bridging visas 3

SUPPORT AVAILABLE TO HUMANITARIAN ENTRANTS Settlement services (Australian Government) Cultural orientation programme (offshore component) Humanitarian Settlement Services (HSS) – 6 months (many irregular migrants are ineligible) Complex Case Support (CSS) Programme (complex needs) – 5 years Adult Migrant English Programme Translating and Interpreting Services (TIS National) Mainstream services (all levels of government) (e.g. Medicare, Centrelink, Job Services) Community support (family, friends, ethnic and religious organisations) 4

AUSTRALIA’S HEALTH CARE SYSTEM 5 AIHW, 2014

HEALTH STATUS OF IRREGULAR MIGRANTS AND REFUGEES ( KAY ET AL, REFUGEE HEALTH CLINIC, QLD, 2009 ) Infectious diseases*Africa (n=362) Eastern Mediterranean (n=100) Southeast Asia (n=111) Total (n=573) Hep B Surface antigen + Surface antibody + (immune) 27 (8%) 140 (39%) 1 (1%) 48 (48%) 11 (10%) 47 (43%) 39 (7%) 235 (41%) Hep C IgG +10 (3%)2 (2%)1 (1%)13 (2%) HIV (Anti-HIV positive)1 (0.3%)001 (0.2%) Malaria + (ICT test or thick/thin blood films) 6 (2%)01 (1%)7 (1%) Schistosomiasis (+ serology)51 (14%)032 (30%)83 (16%) Strongyloides (+ serology)16 (5%)1 (1%)6 (6%)23 (4%) Syphilis (Treponema EIA test +)13 (4%)02 (2%)15 (3%) 6 * Valid cases

HEALTH STATUS OF IRREGULAR MIGRANTS AND REFUGEES ( KAY ET AL, REFUGEE HEALTH CLINIC, QLD, 2009 ) Nutritional deficiencies and nutritional status AfricaEastern Mediterranean Southeast AsiaTotal Iron deficiency116/288 (40%)20/80 (25%)17/85 (20%)153/453 (34%) Vitamin D deficiency91/347 (26%)48/93 (52%)41/107 (38%)180/547 (33%) Vitamin A deficiency † 31/169 (18%)3/28 (11%)15/58 (26%)49/255 (19%) Stunted (height for age) ‡ 23/145 (16%)2/34 (6%)21/55 (38%)46/234 (20%) Underweight (BMI for age) ‡ 12/138 (9%)0/32 (0%)15/52 (29%)27/222 (12%) Underweight (weight for age)* 13/96 (14%)1/21 (5%)13/39 (33%)27/156 (17%) Overweight (BMI for age) ‡ 5/138 (4%)0/320/525/222 (2%) Overweight (weight for age)*10/96 (10%)2/21 (10%)1/39 (3%)13/156 (8%) 7 † Only tested in children ≤10 years of age ‡ Children <15 years of age *Children <10 years of age

MODELS OF HEALTH CARE – IMMIGRATION DETENTION Private health care provider contracted by Government Primary health care model: General practitioners, nurses, counsellors, psychologists Health induction assessment on arrival Personal and medical history Physical examination Mental health screening and assessment (quarterly) Screening pathology tests as required Referral to specialist services as required Strong evidence of negative impact of prolonged detention on mental and physical health 8

MODELS OF HEALTH CARE - REFUGEES AND IRREGULAR MIGRANTS LIVING IN THE COMMUNITY Service modelCharacteristicsBenefits & limitations GP primary care Linking to private GP; initial health screen/ comprehensive assessment; referrals as required GP-led primary care model; Dependent on Medicare eligibility; Lack of training/skills/cultural competence Community health centre (CHC) Linking to multidisciplinary publicly funded community health centre ; initial health screen/ comprehensive assessment; referrals as required Some CHC run refugee programs; Referral pathways well stablished; access to multiple services in one location (e.g. counselling, allied health); some CHC may see Medicare ineligible patients Specialist community clinic or centre Linking to refugee specialist centre on arrival ; initial health screen and services; over time link patient to GP and primary care/ mainstream services; may continue specialist services (e.g. torture & trauma) Services skilled around refugee health needs; Medicare ineligible may be able to receive ongoing care; supported by local public tertiary hospital (pathology, imaging, etc); requires to prioritise clients due to high demand 9 Owen et al, 2009; St Vincent’s Health Australia, 2012; Russell et al, 2013

MODELS OF HEALTH CARE - REFUGEES AND IRREGULAR MIGRANTS LIVING IN THE COMMUNITY Service modelCharacteristicsBenefits & limitations Refugee health nurse (RHN) Linking to RHN; initial health screen; links to GP and other services; ongoing care coordinator until refugee ready for referral to mainstream services Holistic care coordination; may be employed by specialist clinic, CHC or tertiary service; limited to basic assessment and referral to GP/some allied health; cannot undertake medical screening, prescribe, refer to specialist Hospital specialist clinic Referral service for designated target groups; specialist intervention (e.g. infectious diseases, vitamin D therapy, paediatric care) Usually staffed by doctors and nurses with extensive experience working with refugees; short-term intervention Mixed A combination of the aboveAdapted to local needs and resources 10 Owen et al, 2009; St Vincent’s Health Australia, 2012; Russell et al, 2013

BEST CASE PRACTICE: ‘ASYLUM SEEKERS INTEGRATED HEALTHCARE PATHWAY’ – SOUTH EASTERN MELBOURNE, South Eastern Melbourne Medicare Local, 2012 Asylum seekers released from detention pre-registered by RED CROSS (n=371) Health care registration desk Data Collection (n=327; 88%) (Red Cross staff) Would you like to see a doctor? NO YES NON Dr/Nurse Triage tool S1 Onsite Interpreter Dr/Nurse Triage tool S2 Clinical Consultation Onsite GP, medication, vaccination Category 0 Not to be seen at all or declines Provide info about CHS Category 1 Requires immediate care (Monash Health to coordinate) Category 2a Refugee focused CHS (Monash Health to coordinate) Category 2b Private GP – appointment to be provided (Medicare local coord.) Category 3 Private GPs – future appointment organised by Red Cross Appointment and outcome desk

BEST CASE PRACTICE: PROPOSED MODEL FOR PRIMARY HEALTH CARE DELIVERY FOR REFUGEES IN AUSTRALIA (RUSSELL ET AL, 2013) 12 Primary Health Networks Reception / Settlement services Generalist refugee focused health care service (GPs, Refugee health nurses) Specialist refugee focused health care service Mainstream primary care (i.e. general practices, community health centres) Non-health services (i.e. housing, welfare) Dental and allied health care Other health services (i.e. hospitals, mental health services) Case management Interpreter services

FINAL REFLECTIONS Prolonged detention of irregular migrants is harmful Models of care: one size does not fit all Refugee/migrant health – broader local/national contexts Government support for generalist primary health care - refugee/irregular migrant-focused health services Strategic policy framework Partnership, collaboration and advocacy (all relevant sectors) “Refugee/migrant champions” Health screening guidelines adapted to local contexts 13

FINAL REFLECTIONS Access to fee-free interpreter services in primary health care settings Case coordination/management approach (i.e. Refugee Health Nurses) Clear protocols for the successful transition of refugee/migrant clients and their health information from refugee/migrant focused to mainstream services Training of primary health care workforce around refugee health and cultural competence Refugee/migrant community participation/empowerment (e.g. bicultural workers) 14