Strategic Health Policy Directions in Refugee Resettlement

1. Strategic Health Policy Directions in Refugee Resettlement Joy Baldwin Medical Services Branch Citizenship and Immigration Canada Vancouver B.C. February 20, 2007

2. Immigration Health Policy • Medical Services Branch is committed to developing strategic health policy through domestic and international partnerships that is in keeping with CIC’s focus of playing a lead role within the Government of Canada on International migration and protection policy.

3. Role of Medical Services BranchCIC • Protection of public health and public safety • Prevent excessive demand on the Canadian Health Care System • Mitigate health risk due to migration • Works to improve health outcomes for immigrants • Contribute to the successful integration of refugees into Canada and the Canadian health care system • Contribute to maintaining sustainable Canadian health and social services

4. Business lines within MSB • Immigration Medical Examination Program • Refugee Health Management (pre-post arrival) • Management and quality assurance of Designated Medical Practitioners (DMPs) • Public Health Surveillance • Interim Federal Health Program (IFH) • Overseas programs

5. Areas of Focus • Building capacity to develop strategic health policy that is responsive to current and emerging challenges • Developing effective health risk mitigation strategies • Facilitating a seamless health integration framework/continuum • Providing a client-centered approach to meeting health needs for high risk clients

6. Evidence Based Policy Change • Strengthen capacity for policy analysis and development through • Enhanced environmental analysis • Stakeholder consultations • Strengthening relationships with existing partners, such as Metropolis • Contributing to research collaboration with key national and international partners

7. Understanding Global Health Risks and Trends • International epidemiological and field intelligence gathered through consultation with: • WHO • UNHCR • IOM • Other country partners(US-CDC,Australia,UK) • PHAC • Regionally CIC-Regional Medical Office)

8. Building Canadian Partnerships and Synergies • Strengthened partnerships with provincial/ territorial public health authorities (CCMOH) • Enhanced communication with Canadian health care networks • Identify gaps through environmental scan of Canadian health care networks for newcomers to Canada • Linking with local CIC and service provider organizations

9. Trends and Challenges • International trend: • Other major immigration receiving countries such as U.S. and Australia are enhancing their immigration medical screening for high-risk population; • Better integration of high risk population for mutual benefits of receiving countries and immigrants. • Epidemiological evidence: • Certain population at higher risk to develop conditions of public health concerns; • CIC resettlement process: refugee group processing • Large movement of population over a short period of time • All coming from high health risk environment • Significant number of individuals to resettle in a location putting pressure on the local halth infrastructure

10. Current/Emerging International Health Risks • Increasing MDRTB and XDRTB (extremely resistant TB – resistant to two second line medications plus others) • HIV/TB co-infection • Epidemics (measles, polio, SARS, Avian flu)

11. RISK MITIGATION • Pre-departure interventions to optimize health outcomes (vaccination, malaria treatment, etc.) • Urgent referral of complex Pulmonary Tuberculosis Inactive required to report to PH within 7 days of arrival. • HIV notification to provinces/territories (nominal/non) • Implementation of an improved process for Refugee Claimants (RC) and in Canada applicants in November 2003. • Working with partner countries to standardize tuberculosis investigation • Enhanced post-arrival assessment

12. Criteria for enhanced immigration health management • Difficult environmental conditions • Limited health prevention and care in the past • Epidemiological evidence of high disease rate • Large Group resettlement process for refugees • International trend towards enhanced interventions

13. New initiative: enhanced immigration health management for high risk population The Karen refugee experience

14. Epidemiological evidence of high disease rate • Frequent outbreaks of malaria, dengue hemorrhagic fever, cholera, influenza-like illness over the past few years in the camp. • High Tuberculosis (TB) and MDR-TB incidence/prevalence amongst refugees in Thailand.

15. Tuberculosis statistics amongst refugees in Thailand • TB prevalence in Thailand refugee camps over the past two years: 2,674/100,000 (1) • MDR-TB (1): • 76/100,000 for the Burmese refugees - 10% of all positive cultures; • 126/100,000 for the Hmong refugees - 30% of all positive cultures. (1) Reference: personal exchange with the IOM Regional Medical Official in Bangkok. • Active TB diagnosed amongst the 805 Karen refugees coming in Canada: 9 cases/805 refugees: 745/100,000 • WHO estimated sputum smear positive pulmonary TB rate per 100,000 (3 year average for 2004/2005/2006)(2): • Thailand: 61/100,000 • Myanmar:73/100,000 (2) From the PHAC web site.

16. Enhanced immigration health management of Karen Refugees Includes pre-departure and post-arrival interventions: • Enhanced TB management: • Shorter validity date of the immigration medical examination (IME) • All children ≤ 10 years old referred to Public Health (PH) authority • All cases of Pulmonary TB-inactive (PTI) referred to PH authority for an urgent assessment • Fitness to fly assessment within 72 hours pre-departure • Facilitation of a comprehensive medical examination post-arrival in Canada which will be covered by the Interim Federal Health (IFH) program • Enhanced coordination and facilitation by CIC • Strengthened collaboration between PHAC (Public Health Agency of Canada), provincial health authorities and CIC as well as timely sharing of information

17. Success of the client centered approach to enhanced health management for the Karens • Enhanced collaboration and information sharing was positive • Integrated approach to health management is an effective model however refining of the delivery is needed

18. Karen Experience Lessons learned • Need for more formalized communication with the regions on health issues • better coordination between public health , primary care and service provider organizations in some regions

19. Principles of the Client Centered Approach • Evidence based policy change to meet changing and diverse needs of our clients • Flexible and adaptable client centered service provision • Comprehensive needs focused care • Integrated and seamless continuum of care • Consultative and coordinated approach • Effective

20. Challenges • Information sharing and privacy considerations • Logistical challenge of moving large groups of protracted refugees from high risk environments • Limitations of Canadian health care infrastructure

21. Next steps • Research and policy development • Strengthen partnerships with PHAC, P/T and municipal PH authorities • Update of the medical surveillance process • Ongoing collaboration with partners to facilitate linkage and integration of HIV positive applicants in the Canadian health care system. • Ongoing collaboration with partners to develop enhanced health immigration management for populations with higher health risks • Enhance partnerships at all levels to facilitate clients successful integration into Canadian healthcare system and optimize health outcomes

22. Integrated policy framework to ensure optimal health outcomes