User:JoonDay/sandbox

Access to services depend on many factors, including whether a refugee has received official status, is situated within a camp, or is in the process of third country resettlement. However, refugees have a slightly higher percentage of self-rated poor health (42%) as compared to immigrants (39%), with a wider gap relative to comparable non-immigrant populations (18%). The UNHCR now recommends integrating access to primary care and emergency health services with the host country in as equitable a manner as possible. Prioritized services include areas of maternal and child health, immunizations, tuberculosis screening and treatment, and HIV/AIDS-related services. Integration can be seen in the case of Pakistan. In the 1980s, Pakistan attempted to address Afghan refugee healthcare access through the creation of Basic Health Units inside the camps. Funding cuts closed many of these programs, forcing refugees to seek healthcare from the local government. Despite inclusive stated policies for refugee access to health care on the international levels, potential barriers to that access include language, cultural preferences, high financial costs, administrative hurdles, and physical distance. Specific barriers and policies related  to health service access also emerge based on the host country context.

In Canada, barriers to healthcare access include the lack of adequately trained physicians, complex medical conditions of some refugees and the bureaucracy of medical coverage. There are also individual barriers to access such as language and transportation barriers, institutional barriers such as bureaucratic burdens and lack of entitlement knowledge, and systems level barriers such as conflicting policies, racism and physician workforce shortage. In the US, all officially designated Iraqi refugees had health insurance coverage compared to a little more than half of non- Iraqi immigrants in a Dearborn, Michigan, study. However, greater barriers existed around transportation, language and successful stress coping mechanisms for refugees versus immigrants. In addition, refugees noted greater medical conditions versus immigrants. The study also found that refugees had higher healthcare utilization rate (92.1%) as compared to the US overall population (84.8%) and immigrants (58.6%) in the study population.

Within Australia, officially designated refugees who qualify for temporary protection and offshore humanitarian refugees are eligible for health assessments, interventions and access to health insurance schemes and trauma-related counseling services. Despite being eligible to access services, barriers include economic constraints around perceived and actual costs carried by refugees. In addition, refugees must cope with a healthcare workforce unaware of the unique health needs of refugee populations. This includes access to medical and psychological care. However, these may vary depending on the host country. For instance, under the Asylum Seekers Benefits Act in Germany, asylum seekers are outside primary care and are limited to emergency health care, vaccinations, pregnancy and childbirth with limitations on specialty care. Asylum seekers have greater chance of experiencing unmet health needs as compared to the general German population. They also have greater odds of hospital admissions and at least one visit to a psychotherapists relative to the German general population. Access to treatment for specific diseases may also pose a barrier for refugees. For example, primaquine, an often recommended malaria treatment is not currently licensed for use in Germany and must be ordered from outside the country.

One potential argument for limiting refugee access to healthcare is associated with costs with states desire to decrease health expenditure burdens. However, Germany found that restricting refugee access led to an increase actual  expenditures relative to refugees which had full access to healthcare services.

The legal restrictions on access to health care and the administrative barriers in Germany have been criticized since the 1990s... for leading to delayed care, for increasing direct costs and administrative costs of health care, and for shifting the responsibility for care from the less expensive primary care sector to costly treatments for acute conditions in the secondary and tertiary sector.

Providing access to healthcare for refugees through integration into the current health systems of host countries may also be difficult when operating in a resource limited setting. In this context, barriers to healthcare access may include political aversion in the host country and already strained capacity of the existing health system. Political aversion to refugee access into the existing health system may stem from the wider issue refugee resettlement. One approach to limiting such barriers is to move from a parallel administrative system in which UNHCR refugees may receive better healthcare than  host nationals but is unsustainable financially and politically to that of an integrated care where refugee and host nationals  receive equal and more improved care all around. In response to the protracted refugee situation in Uganda, officials created an integrative healthcare model for the mostly Sudanese refugee population and for the local host nation population in their West Nile districts. Local nationals now access health care in facilities initially created for refugees.

Access to healthcare services
Access to services depend on many factors, including whether a refugee has received official status, is situated within a camp or is in the process of third country resettlement. However, refugees have a slight higher percentage of self-rated poorer health ( 42%) as compared to immigrants (39%), with a wider gap relative to comparable non-immigrant populations ( 18%). Prioritized services include areas of maternal and child health, immunizations, tuberculosis screening and treatment, and HIV/AIDS-related services. Despite such inclusive policies for refugee access to health care, potential barriers to health service access include language, cultural preferences, high financial costs, administrative hurdles, and physical distance. Specific barriers and policies towards access to health also emerge based on the host country context.

In the 1980s, Pakistan attempted to address Afghan refugee healthcare access through the creation of Basic Health Units inside the camps. However, funding cuts closed many of these programs, forcing refugees to seek healthcare from the local government. In Dearborn, Michigan, comparing health care access of officially designated Iraqi refugees to that of non- Iraqi immigrants found that all refugees had health insurance coverage compared to a little more than half of immigrants in the study. However, greater barriers existed around transportation, language and successful stress coping mechanisms for the study refugees versus immigrants. In addition, refugees noted greater medical conditions versus immigrants. The study also found that refugees in the study sample had a higher health care utilization rate ( 92.1%) as compared to the US overall population ( 84.8%) and  immigrants in the study population ( 58.6%).

In Canada, the lack of adequately trained physicians as well as complex medical conditions of some refugees and bureaucracy of medical coverage may inhibit access, primarily in physician wait times. There are individual barriers to access such as language and transportation barriers, institutional barriers such as bureaucratic burdens and lack of entitlement knowledge, and systems level barriers such as conflicting policies, racism and physician workforce shortage.

Within Australia, officially designated refugees who qualify for temporary protection and offshore humanitarian refugees are eligible for health assessments, interventions and access to health insurance schemes and trauma - related counseling services.< ref name = "Murray">  Despite being eligible to access services, barriers include economic constraints around perceived and actual costs and a healthcare workforce unaware of the unique health needs of refugee populations. Perceived legal barriers such as fear that disclosing medical conditions may prohibit reunification of family members and current policies which reduce assistance programs also limit access to health care services.

Those who have yet to be granted official status as refugees and are still within the asylum process have some legal, yet restricted rights to access healthcare in the European Union. Access to health care include access to medical and psychological care. However, these may vary depending on the country an asylum seeker is in. For instance, under the Asylum Seekers Benefits Act in Germany, asylum seekers are outside primary care and are limited to emergency health care, vaccinations, pregnancy and childbirth with limitations on specialty care. In Germany, asylum seekers had greater chance of experiencing unmet health needs as compared to the general German population. They also have greater odds of hospital admissions and at least one visit to a psychotherapists relative to the German general population. Once within the resettlement country, access to treatment for specific diseases may also pose a barrier for refugees. For example, primaquine, an often recommended malaria treatment is not currently licensed for use in Germany and must be ordered from outside the country.

One reason for limiting access to health care for refugees is associated with costs. States desire to decrease health expenditure burdens, particularly during the global economic slowdown which occurred in 2008 and 2009. In addition, there is states desired to reduce apparent abuse of generous asylum rights. However, restricting access led to actual excess in expenditures relative to refugees which had full access to health care in the German case.

″ "The legal restrictions on access to health care and the administrative barriers in Germany have been criticised since the 1990s... for leading to delayed care, for increasing direct costs and administrative costs of health care, and for shifting the responsibility for care from the less expensive primary care sector to costly treatments for acute conditions in the secondary and tertiary sector." < ref name="Pross">

Access to healthcare for refugees through integration into the current health system of host countries may also be difficult when operating in a resource limited setting. In this context, barriers to health care access may include political aversion by the host country and already strained capacity of the existing health system. Political aversion for access of refugees into the existing health system may stem from the wider issue refugee resettlement.  < ref name="Tuepker">

Refugees who are in the process of resettlement within a third country which have more robust health infrastructure may also face barriers in the form of more stringent entrance health screening protocols. Due to the 2014-2016 Ebola Outbreak in West Africa, the US Centers for Disease Control and Prevention updated its ability to quarantine persons entering the United States with the following diseases: "cholera, diphtheria, infectious tuberculosis (TB), plague, smallpox, yellow fever, viral hemorrhagic fevers, severe acute respiratory syndromes, and influenza caused by novel or re-emergent influenza viruses."

The article I edited for Wikipedia is already live on Wikipedia Refugee> Access to Healthcare. The original text which I modified follows as such:

Often refugees are not given access to their host country's health programs, which might lead to higher rates of diseases, including malaria and other parasitic infections (no source). In the 1980s, Pakistan attempted to address this issue by setting up Basic Health Units in refugee camps; however funding cuts closed many of these programs, forcing refugees to seek healthcare from the local government. Refugee access to healthcare varies a lot by host country, and is often very limited. The services that are available can be confusing and difficult for refugees to navigate.6 Another issue is availability of malarial treatments in countries where it is not endemic. For example, Primaquine, a often recommended malaria treatment is not currently licensed for use in Germany, and must be ordered from outside the country.Due to concerns about refugee health and the possible impact on the local populations, some countries, including the United States and Australia, have implemented pre-departure and post-arrival screening and treatment protocols for malaria. However, screening for malaria in asymptomatic refugees does not appear to be the norm.

Below is the outline for my research paper.

=Overview=

Non-Camp Healthcare Access
=Conclusions=

=See Also (links)= Migrant Health

Health in Syria

Syrian Civil War

=References=

1.	Al-Ammouri, Iyad, and Ayoub, Fares (2016). "Heart Disease in Syrian Refugee Children: Experience at Jordan University Hospital." Annals of Global Health 82.2 300-306.

2.	Alsaba, K. and A. Kapilashrami (2016). "Understanding women's experience of violence and the political economy of gender in conflict: the case of Syria." Reproductive Health Matters 24(47): 5-17.

3.	Amnesty International (2014). Agonizing Choices: Syrian Refugees in Need of Health Care in Lebanon. London: Amnesty International.

4.	Archangelidi, Olga, Panos Theodoromanolakis, and Mantas John (2015). "The Provision of Health Services in Jordan to Syrian Refugees." ARCHIVOS DE MEDICINA 9.2. 2.

5.	Ay, M., P. A. Gonzalez and R. C. Delgado (2016). "The Perceived Barriers of Access to Health Care Among a Group of Non-camp Syrian Refugees in Jordan." International Journal of Health Services 46(3): 566-589.

6.	Doganay, M. and H. Demiraslan (2016). "Refugees of the Syrian Civil War; Impact on reemerging infections, health services and Biosecurity in Turkey.” Health Security 14(4): 220-225.

7.	Doocy, S., E. Lyles, L. Akhu-Zaheya, A. Burton and G. Burnham (2016). "Health service access and utilization among Syrian refugees in Jordan." International Journal for Equity in Health 15: 15.

8.	Doocy, S., E. Lyles, L. Akhu-Zaheya, A. Oweis, N. Al Ward and A. Burton (2016). "Health Service Utilization among Syrian Refugees with Chronic Health Conditions in Jordan." PLOS One 11(4): 12.

9.	Doocy, S., E. Lyles, T. Roberton, L. Akhu-Zaheya, A. Oweis and G. Burnham (2015). "Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan." Bmc Public Health 15: 10.

10.	El-Khatib Z, Scales D, Vearey J, Forsberg BC. (2013). “Syrian refugees, between rocky crisis in Syria and hard inaccessibility to healthcare services in Lebanon and Jordan.” Conflict and Health 7(18).

11.	El-Khatib, Z., D. Scales, J. Vearey and B. C. Forsberg (2013). "Syrian refugees, between rocky crisis in Syria and hard inaccessibility to healthcare services in Lebanon and Jordan." Conflict and Health 7(1): 18.

12.	Ensuring Access to Health Care: Operational Guidance on Refugee Protection and Solutions in Urban Areas. http://www.unhcr.org/en-us/protection/health/4e26c9c69/ensuring-access-health-care-operational-guidance-refugee-protection-solutions.html?query=health%20care

13.	International Federation of Red Cross and Red Crescent Societies and the Jordan Red Crescent (2012). Syrian Refugees living in the Community in Jordan - Assessment Report. International Federation of Red Cross and Red Crescent Societies and the Jordan Red Crescent. Amman, Jordan, Jordan Red Crescent.

14.	Khan MS, Osei-Kofi A, Omar A, et al. (2016) “Pathogens, prejudice, and politics: the role of the global health community in the European refugee crisis.” Lancet Infect Dis. 2016 16: e173–77.

15.	Kousoulis, A. A., M. Ioakeim-Ioannidou and K. P. Economopoulos (2016). "Access to health for refugees in Greece: lessons in inequalities." International Journal for Equity in Health 15: 3.

16.	McGinn, T. (2009). Barriers to Reproductive Health and Access to Other Medical Services in Situations of Conflict and Migration.

17.	Murshidi MM, Hijjawi MQB, Jeriesat S, Eltom A. (2013). “Syrian refugees and Jordan's health sector.” The Lancet 382(9888):206-207.

18.	Murshidi, M. M., M. Q. B. Hijjawi, S. Jeriesat and A. Eltom (2013). "Syrian refugees and Jordan’s health sector." Lancet 382.

19.	Oktay F., Sahlool Z, Sankri-Tarbichi AG, Kherallah M. (2012). “Evaluation report of health care services at the Syrian refugee camps in Turkey.” Avicenna J Med. 2(2):25-8.

20.	Ozaras, R., Balkan, II and M. Yemisen (2016). "Prejudice and reality about infection risk among Syrian refugees." Lancet Infectious Diseases 16(11): 1222-1223.

21.	Ozaras, R., H. Leblebicioglu, M. Sunbul, F. Tabak, Balkan, II, M. Yemisen, I. Sencan and R. Ozturk (2016). "The Syrian conflict and infectious diseases." Expert Review of Anti-Infective Therapy 14(6): 547-555.

22.	Parkinson, S. E. and O. Behrouzan (2015). "Negotiating health and life: Syrian refugees and the politics of access in Lebanon." Social Science & Medicine 146: 324-331.

23.	Perez-Molina, J. A., M. J. Alvarez-Martinez and I. Molina (2016). "Medical care for refugees: A question of ethics and public health." Enfermedades Infecciosas Y Microbiologia Clinica 34(2): 79-82.

24.	Petchesky RP, Batniji R, Khatib L, Cammett M, Sweet J, Basu S, Jamal A, et al.(2014) “Governance and health in the Arab world.” The Lancet 383(9914):343-355.

25.	Refaat, M. and K. Mohanna (2013). Syrian refugees in Lebanon: facts and solutions. Lancet.

26.	Samari, Goleen (2015). "The Response to Syrian Refugee Women’s Health Needs in Lebanon, Turkey and Jordan and Recommendations for Improved Practice." Article, "Knowledge & Action," Humanity in Action, Inc. 27. Savas, N., E. Arslan, T. Inandi, A. Yeniceri, M. Erdem, M. Kabacaoglu, E. Peker and O. Aliskin (2016). "Syrian refugees in Hatay/Turkey and their influence on health care at the university hospital." International Journal of Clinical and Experimental Medicine 9(9): 18281-18290.

28.	Sfeir, R. (2007). Strategy for National Health Care Reform in Lebanon. Beirut, Universite St Joseph.

29.	Spiegel, P. B., Checchi, F., Colombo, S., & Paik, E. 2010. Health-care needs of people affected by conflict: Future trends and changing frameworks. The Lancet, 375(9711), 341-5.

30.	Tahirbegolli B, Çavdar S, Sümer EÇ, Akdeniz SI, Vehid S. (2016). “Outpatient admissions and hospital costs of Syrian refugees in a Turkish university hospital.” Saudi Medical Journal 37(7):809-812. doi:10.15537/smj.2016.7.13839.

31.	von Schreeb, J., C. Unge, R. Brittain-Long and H. Rosling (2008). "Are donor allocations for humanitarian health assistance based on needs assessment data?" Global Health 3.

32.	World Health Organization (2013). Regional response to the crisis in the Syrian Arab Republic 2013: World Health Organization. Geneve, Switzerland, World Health Organization.

33.	Zetter, R. 2007. “More Labels, Fewer Refugees: Remaking the Refugee Label in an Era of Globalization.” Journal of Refugee Studies. 20 (2): 172-192. doi: 10.1093/jrs/fem011

Data sources
http://data2.unhcr.org/en/situations/mediterranean

World Health Organization (WHO). Global Health Expenditure database http://apps.who.int/nha/database