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

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