The Danish Research Centre for Migration, Ethnicity and Health
Migration, Ethnicity and Health A Scandinavian perspective
Allan Krasnik, MD, PhD, MPH Professor and Centre Director Berlin, April 21, 2015
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Sweden A model welfare society with open borders
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Norway
The new rich – in need of migrant workers
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Denmark “– the protective democracy”
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The Danish Research Centre for Migration, Ethnicity and Health The Danish Research Centre for Migration, Ethnicity and Health The Danish Research Centre for Migration, Ethnicity and Health
The Nordic welfare perspective
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Societal discourse and refugees
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Health status and access to health services for migrants in Scandinavia: an overview 1.
How many migrants are there in Denmark, Norway and Sweden?
2.
Where do they come from?
3. How do migrants in Scandinavia fare in terms of socioeconomic position? 4. Health status of migrants
5. Use of health services 6. National strategies and initiatives addressing migrant and ethnic minority health
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1. How many migrants are there in Denmark, Norway and Sweden? Table 1 Foreign-born population in 2013 Foreign-born* Country
Total population
European Union (27)
Total
%
502.899.726 50.872.674 10,1
Born in (other) EU states
%
Born in a non-EU country
%
17.334.807
3,4
33.537.867
6,7
Denmark
5.602.628
548.411
9,8
180.073
3,2
368.338
6,6
Norway
5.049.223
662.526
13,1
292.640
5,8
369.886
7,3
Sweden
9.555.893
1.472.353
15,4
495.803
5,2
976.550
10,2
Source: Eurostat [migr_pop3ctb]
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1. How many migrants are there in Denmark, Norway and Sweden? (continued) Figure 2
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2. Where do the migrants come from? Immigration to Denmark 1945 -2015 1945 –1965 • Immigrants from Norway, Sweden, UK, Germany and USA • Few refugees (Hungary) 1966 • • •
- 1980 Guestworkers from Turkey, Yugoslavia, Pakistan Family reunited Few refugees (Polen, Chile, Vietnam)
1980-1990: • Family reunited • Refugees (Irania, Iraque, Lebanon, Sri Lanka) 1990-: • Family reunited • Refugees (Lebanon, former Yugoslavia, Iraque, Irania, Somalia, Afghanistan, Syria) • Workers from Eastern Europe since 2004 Berlin, April 21, 2015 Dias 11
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3. How do migrants in Scandinavia fare in terms of socio-economic position? Figure 4
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4.
Health status of migrants
•
A great proportion, but not all, of the health disadvantages experienced by migrants is related to their generally unfavourable socio-economic position
•
Many migrants came as labour migrants, most with low levels of education. The disadvantages of this group may persist into the second or third generation.
•
More recent waves of migrants, include highly skilled, high income migrants.
•
The diversity in migrants is also reflected in health outcomes, which can be better as well as worse than those of the majority population.
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4.Differences in the state of health of migrants among the Scandinavian countries?* •
More migrants in DK rated their health as poor, compared to migrants in N and SE
•
The gap in health outcomes between migrants and nonmigrant populations was greatest in DK
•
Migrants seem to experience worse health in countries with poor integration policies
•
SE was classified as fitting in to the ‘multi-cultural’ model of integration policy, while N was seen to follow a more ‘assimilationist’ model.
*Malmusi, D. (2014). Immigrants' health and health inequality by type of integration policies in European countries. European Journal of Public Health, Vol. 25; No.2, 293-299. Berlin, April 21, 2015 Dias 14
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4.
Health status of migrants (continued) General measures of health for migrants in Scandinavia: Mortality • All-cause mortality in first generation migrants lower than that of the majority population.
• Descendants (second generation) show higher all-cause mortality rates, than the first generation, and even higher compared to the majority population at the same age. • However, Pakistani female migrants in Norway have higher all-cause mortality rates than all other migrant groups and ethnic Norwegians.
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Health Status/Risk factors among Pakistani Immigrants in Norway
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Kumar B. N et al Oslo Immigrant Health Profile , FHI 2008
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4.
Health status of migrants (continued)
Mental health
•
In Norway the prevalence rate of mental health problems high among immigrants from non-Western countries (24%) and highest among the refugee population (31%).
•
Female migrants, even non-refugee migrants, also more at risk for developing mental health issues due to acculturation problems, isolation, and language barriers among other factors.
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5. Migrants’ access to healthcare Formal factors (legal rights; financial barriers) Informal factors (patient- and system related)
Delay in diagnosis and treatment
Increased morbidity and 18 mortality Berlin, April 21, 2015
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5. Migrants’ use of health services in Scandinavia Entitlements:
•
Entitlements to health care are equivalent to that of nationals in the case of migrants with legal residence permit
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Variations in degree of coverage and affordability between the three countries with regard to asylum seekers and undocumented migrants.
•
The MIPEX Health Strand will soon include a comprehensive overview of entitlements and access to health services in all European countries.
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Formal rights in DK
Asylum seekers: Entitled to necessary, urgent and/or pain relieving care including antenatal care (children full right to preventive services) Undocumented migrants: Entitled to obtain emergency care only Migrants and refugees: Rights like other residents
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5. Migrants’ use of health services in Scandinavia (Continued) Emergency services use: Health services use among migrants tends to follow similar patterns across Europe: •
Overall higher rates of ER visits among migrants in Scandinavia.
•
The main barriers to access to non-ER services for migrants is • language and communication based, • and among asylum seekers and undocumented migrants, lack of entitlements to health services.
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5. Migrants’ use of health services in Scandinavia (Continued) Despite high rates of use of health services, studies have shown low levels of satisfaction among migrants with services received. Some of the issues identified:
language barriers, differences in conceptualizations of health and illness, low cultural competence among health professionals, mismatched expectations on both sides.
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Special initiatives in Denmark Refugees: Integration focused health examination – new legislation Responsibility of municipalities Non-documented migrants: Special clinic staffed by volounteer health workers Established by Danish Red Cross and the Danish Medical Association
Specialized services: Centers for Traumatized refugees and migrants Migrant health clinics
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Municipal interventions targeted ethnic minorities 2012
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Municipal interventions targeted ethnic minorities – types (N = 160)
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7. National strategies addressing migrant and ethnic minority health in Scandinavia
Denmark • No national strategy until recently. • Initiatives at municipal and regional level, and some NGO-led. • New law mandates health checks be offered at municipal level to all resettled refugees.
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Norway
Sweden • No national strategy • National PH strategies address ‘vulnerable’ and ‘segregated’ population groups • The Right to Health Care Initiative guidelines for better access to health services for irregular migrants in all municipalities
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Nasjonal strategi om innvandreres helse 2013-2017 The strategy is based on White Papers to the Norwegian Parliament (Meld. St.16, 2010-201; Melt. St. 6, 2011-2012), which clearly emphasizes on addressing the social determinants of health, in order to reduce the existing health differences.
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PURPOSE OF THE STRATEGY
GOAL Provide equitable healthcare services to everyone regardless of diagnosis, place of residence, economic status, gender, place of birth, ethnicity or the individual’s circumstance. Care must be adjusted to cater and suit circumstances and unique needs.
AIM Promote equity in Health- and Care Services through identifying the health challenges of migrants and to develop measures that would address such challenges. Berlin, April 21, 2015 Dias 28
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National Strategy - Immigrant Health 2013 The State shall ensure that: Health care providers at all levels have basic knowledge about various migrant groups’ disease incidence and the cultural challenges related to ensuring equitable healthcare services. Health care providers at all levels shall facilitate good communication with non Norwegian speaking patients. This includes securing a qualified interpreter when the need arises. Healthcare services must be equipped with updated knowledge about migrants’ health and their use of the healthcare service, as well as use the knowledge in the development of services. Berlin, April 21, 2015 Dias 29
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Some of the measures - Strengthen health centers and school health services
-Strengthen capacity for the training of healthcare professionals
- Granting authority to access and link existing registry data about migrants health use of healthcare service - Establish a research network in the area of migrant health.
- Dialogue seminars to disseminate information about the strategy to relevant stakeholders and to facilitate effective followup.
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Changing perspectives From focus on patient information to focus on general health literacy From focus on professional cultural competences to focus on broader diversity competences among health professionals From focus on health professionals to focus also on policy, management and organization Berlin, April 21, 2015 Dias 33
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Equity in health ”Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that none should be disadvantaged from achieving this potiential, if it can be avoided” Source: Whitehead, M. The concepts and principles of equity. WHO, 1991
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Hip Hip Hurrah !
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BREAK
A Threat – or an Opportunity?
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