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Lloy Wylie, PhD Saime Ozcurumez , PhD May 29, 2014

Engaging for Health Policy Transformation Health Care Access and Diverse Communities in Canada and Turkey. Lloy Wylie, PhD Saime Ozcurumez , PhD May 29, 2014. Health Status and Service Utilization.

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Lloy Wylie, PhD Saime Ozcurumez , PhD May 29, 2014

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  1. Engaging for Health Policy TransformationHealth Care Access and Diverse Communities in Canada and Turkey Lloy Wylie, PhD SaimeOzcurumez, PhD May 29, 2014

  2. Health Status and Service Utilization • 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

  3. Problem Statement • 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

  4. Research question(s) • 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?

  5. Conceptualizing Access: Structure • 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

  6. Integrated Analysis • 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

  7. Conceptualizing Access: Agency • 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 Safety Each examines different elements of the health care system All draw attention to contextualizing the analysis of barriers.

  8. Conceptualizing Engagement • 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

  9. Methods • 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

  10. Quebec and BC Policy • 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).

  11. Canadian Policy Context • 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).

  12. Access Barriers • 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

  13. Assessment of Strategies • 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

  14. Engagement • 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

  15. Conceptual Analysis • 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

  16. Refugee Health in Turkey • 1 million Syrians have fled to Turkey, according to UN estimates • Those without documentation go to camps

  17. Turkish Policy Response • 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

  18. Policy Implementation • 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

  19. Challenge • 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

  20. Strategies for Change • 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

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