1. HPH Task Force Migration, Equity & Diversity
Ensuring Equity in Health Care Organisations: The Contribution of the HPH – TF MED
Dr Antonio Chiarenza
Leader of HPH-TF MED
Coordinator of the HPH network of Emilia-Romagna
Simposium
Embedding Health Equity in Policy, Practice and Participation
October, , Montreal 1

2. Outline of the presentation
What is the TF MED: where does it come from and where is it going
The changing context for responsiveness to diversity
The impact of the refugee crisis on EU health care systems
What defines a health care organisation as being responsive to diversity
Ensuring effective implementation of policy measures through the Equity standards
Future steps for the TF MED

3. Migrant-Friendly Hospitals (www
Migrant-Friendly Hospitals ( a European initiative to promote health and health literacy of migrants and ethnic minorities AT DE DK EL ES FI FR IT NL SV UK IR
Kaiser-Franz-Josef-Spital, Vienna, Austria
Immanuel-Krankenhaus GmbH,
Rheumaklinik Berlin-Wannsee,
Berlin, Germany
Kolding Hospital, Velje-Kolding, Denmark
Hospital ”Spiliopoulio Agia Eleni”,
Athens, Greece
Hospital Punta de Europa,
Algeciras-Cádiz, Spain
Turku University Hospital, Turku, Finland
Hôptial Avicenne, Paris, France
James Connolly Memorial Hospital,
Dublin, Ireland
Azienda Unità sanitaria Locale di
Reggio Emilia, Reggio Emilia, Italy
Academic Medical Centre,
Amsterdam, The Netherlands
Uppsala University Hospital,
Psychiatric Centre,
Uppsala, Sweden
Bradford Hospitals NHS Trust,
Bradford, U.K.
HPH TASK FORCE ON MIGRATION, EQUITY& DIVERSITY (MED)
HEALTH PROMOTING HOSPITALS NETWORK OF EMILIA – ROMAGNA
AZIENDA USL DI REGGIO EMILIA – DIREZIONE GENERALE

4. The HPH Task Force on Migrant Friendly & Culturally Competent Health Care is established within the WHO-HPH Network in 2005
Aims of the Task Force
To create a framework for continuity after the conclusion of the MFH project
To share and disseminate best policies and practice (e.g. MFH concepts, models and tools)
To foster co-operation and alliances between healthcare organisations
To support health care organisations in becoming MF & CC organisations as indicated in the Amsterdam Declaration
HPH TASK FORCE ON MIGRATION, EQUITY& DIVERSITY (MED)
HEALTH PROMOTING HOSPITALS NETWORK OF EMILIA – ROMAGNA
AZIENDA USL DI REGGIO EMILIA – DIREZIONE GENERALE 4 4

5. A journey towards equity a conceptual shift
Initial stage
Second stage
Third stage
Latest stage
TF MFH
established within WHO-HPH
Framework
Cultural
Competence
TF MFCCH
and COST ACTION HOME
Framework
Intercultural
Competence
TF MFCCH
and PILOTING of the EQUITY STANDARDS
Framework
Diversity sensitivity
2016- onwards
TF MED
and IMPLEMENTATIONof the
EQUITY STANDARDS
Framework
Equity
HPH TASK FORCE ON MIGRATION, EQUITY& DIVERSITY (MED)
HEALTH PROMOTING HOSPITALS NETWORK OF EMILIA – ROMAGNA
AZIENDA USL DI REGGIO EMILIA – DIREZIONE GENERALE

6. The changing context of diversity responsiveness
Two fundamental shifts
Recognition of the limits of “cultural competence” when implemented in practice.
Changes in the dimensions of “diversity” regarded as relevant in health care.

7. Limitations in the use of cultural competence in practice
Assumption that culture can be reduced to a technical skill. (Kleinman & Benson, 2006)
Existing models of CC interpret culture as if it only had to do with ethnicity and race (Kumas-Tan et al. 2007)
Simplistic representations of culture are by definition stereotypical (Johnson & Munch, 2009).
Focusing on cultural differences has detracted attention from the role of socio-economic factors (Simon and Mosavel, 2008)

8. Changes in the dimensions of “diversity” regarded as relevant in health care.
New migration has brought with it an increased level of diversity that calls for an equity approach to address the multiple factors that contribute to variation in health care experience.
Different origins: increased diversification in countries of origin
Diverse socioeconomic backgrounds: migrant groups are less organised, more legally differentiated, and more socially stratified
Different immigrant status: economic workers, undocumented migrants, asylum seekers, refugees,...
Intra-group diversity: diversity within the same national or ethnic group

9. THE IMPACT OF THE REFUGEE CRISIS ON EUROPEAN HEALTH CARE SYSTEMS (2015-2016)
The refugee crisis in Europe has made it evident that we need to address the issue of multiple diversity and vulnerability in order to respond effectively to migrants’ needs

10. A complex and dynamic phenomenon

11. A resource package is available at: http://www.sh-capac.org/
Identifying challenges for health providers related to the refugee crisis
Methods: 10 Focus groups and 20 interviews in 10 EU countries (February – March 2016).
Targeted professionals: health professionals; social workers, volunteers, NGO representatives, local authority representatives, cultural mediators, psychologists, (…)
A resource package is available at:
Objectives:
to identify the new challenges for care professionals
to investigate how the situation of asylum seekers impacted on the accessibility to health care.
to collect effective solutions to address access barriers to health care.

12. A complex situation of diverse groups and migratory trajectories
DESTINATION
STRANDED
Settling migrants
Longer stay of migrants
Continuous care should be integrated in the regular health system
TRANSIT
ARRIVAL
People on the move
Only desired to continue their journey to destination
Acute and emergency care required
Newly arrived
Many short stay migrants
Acute and emergency care required
Humanitarian crisis situation

13. Different levels of entitlement to access to health services
The legal status linked to the migration trajectory stage as well as outcomes of the asylum seeking procedure play an important role in migrants’ access to health care
Newly arrived migrants are in principle “irregular migrants”
Migrants in transit do not claim asylum
Asylum seekers at destination (may be lodging an application, awaiting a decision, awaiting an appeal)
Migrants granted refugee or protected status
Failed asylum seekers (awaiting deportation)
Irregular (undocumented) migrants

14. Legislative and administrative barriers
Different procedures depending on the status of the asylum seeker (e.g.: sexual and reproductive care; family planning; child care)
Prolonged waiting time before receiving refugee status has an impact on health and mental health
Poor knowledge and different interpretations of legislation
Linguistic and cultural barriers
Lack of interpreters has a negative impact on the quality of care
Linguistic barriers make it difficult to handle cultural barriers (e.g.: woman’s health, mental health, child care...)
Concern about confidentiality and ethnic concordance (mental health; care for victims of violence)

15. Organisational barriers and lack of coordination
Limited availability of services; unequal distribution of facilities;
Specialist care is hard to reach (e.g.: mental health; dental care); complex appointment systems;
Lack of coordination between different care providers (e.g.: care of victims of violence) .
Lack of information for both providers and migrants
Lack of health records (e.g.: vaccination status of children );
Absence of exchange of information within and between countries;
Lack of information and knowledge on how to navigate the system.

16. Lessons learned
Health systems have been affected differently, depending on whether migrants were at the arrival, transit or destination.
Health-care systems have still not adapted to respond adequately to their diverse needs.
Diverse needs should be identified according to the intersection of individual/family characteristics and social position (e.g.: gender-migrant status-economic situation-health situation).
Cultural competence needs to be integrated with alternative concepts such as equity, intersectionality, person-centered care.

17. WHAT DEFINES A HEALTH CARE ORGANISATION AS BEING RESPONSIVE TO DIVERSITY ?

18. How should health professionals work effectively with diversity?
They should avoid a “recipe” approach.
They should be able to work across differences
They should learn from the patient,
They should favour a case-by-case assessment of needs and priorities
They should engage in self-reflection and self- critique 18

19. How should health organisations work effectively with diversity?
Develop specific policies and programmes that address equity and diversity priorities
Link health data to socio-demographic information
Build staff capacity at all levels to address equity and diversity
Address all barriers which prevent or limit people accessing health care
Provide person and family-centred care
Promote equitable participation of users/community. 19

20. HOW DO HEALTH CARE ORGANISATIONS ENSURE EFFECTIVE IMPLEMENTATION AND ASSESSMENT OF THESE POLICIES AND MEASURES ?

21. Equitable access and utilisation Equitable quality of care
Ensuring responsiveness to diversity by using the TASK FORCE MED Equity Standards
Equity in policy
Equitable access and utilisation
Equitable quality of care
Equity in participation
Promoting equity
Identify appropriate structure and process to conduct the assessment
Gain management support/ Align with existing policies
Measure compliance with the five standards
Identify areas of improvements and obstacles to implementation
Select outcomes indicators
Develop an action plan
Develop policies, governance and performance monitoring systems, which promote equity;
Address barriers which prevent or limit people accessing and benefiting from health care services;
Provide health care services that are responsive to the diverse needs of patients and families;
Develop equitable participatory processes that respond to the needs and preferences of all users;
Promote equity in the community through cooperation, advocacy and capacity building.
Identify sample best practices
Select sample indicators
The Self-Assessment Tool and frameworks are available at:

22. Task Force MED programme (2017-2019)
From pilot to effective implementation of equity in health care
WORK PLAN & Working Groups
WG 1: Develop a Rapid Assessment Tool
WG 2: Promote the tool to as wide a range of audiences as possible and expand the network
WG 3: Develop an online self-assessment tool including an evidence gathering system for country reporting
WG 4: Develop a manual for implementation, including standards, outcome indicators and examples of best practice

23. Scientific committee of the TF MED
Bernadette Nirmal Kumar and Ragnhild Spilker, The Norwegian Centre for Migration and Minority Health, NAKMI, Norway
David Ingleby, University of Amsterdam, The Netherlands
Eeva Hakkinen, Mikkeli Central Hospital, Finland
Laura McHugh, Galway University Hospital, Ireland
James Glover, Community Health, Dublin, Ireland
Marie Serdynska, Montreal Children’s Hospital, McGill University Health Centre, Canada
Karima Karmali, The Hospital for Sick Children, Toronto, Canada
Elizabeth Abraham, Critical Link International, Canada
Lidia Horvat, Department of Health and Human Services, Melbourne, Australia
Manuel Fernandez Gonzalez, Uppsala University Hospital, Sweden
Hans Verrept, FPS Health, Food Chain Safety and Environment, Belgium
Manuel Garcia-Ramirez, CESPYD, University of Seville, Spain
Antonio Chiarenza, Task Force Chair, AUSL of Reggio Emilia, Italy

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