1,721,030 research outputs found
Tuberculosis among migrant populations in the European Union and the European Economic Area
No full textBackground: Although tuberculosis (TB) incidence has been decreasing in the European Union/European Economic Area (EU/EEA) in the last decades, specific subgroups of the population, such as migrants, remain at high risk of TB. This study is based on the report 'Key Infectious Diseases in Migrant Populations in the EU/EEA' commissioned by The European Centre for Disease Prevention and Control. Methods: We collected, critically appraised and summarized the available evidence on the TB burden in migrants in the EU/EEA. Data were collected through: (i) a comprehensive literature review; (ii) analysis of data from The European Surveillance System (TESSy) and (iii) evidence provided by TB experts during an infectious disease workshop in 2012. Results: In 2010, of the 73 996 TB cases notified in the EU/EEA, 25% were of foreign origin. The overall decrease of TB cases observed in recent years has not been reflected in migrant populations. Foreign-born people with TB exhibit different socioeconomic and clinical characteristics than native sufferers. Conclusion: This is one of the first studies to use multiple data sources, including the largest available European database on infectious disease notifications, to assess the burden and provide a comprehensive description and analysis of specific TB features in migrants in the EU/EEA. Strengthened information about health determinants and factors for migrants' vulnerability is needed to plan, implement and evaluate targeted TB care and control interventions for migrants in the EU/EEA
Reproducing differential racialisation: social triage in migrant mental health services in England
No full textIn England, coverage for treatment of post-traumatic stress disorder (PTSD), a health condition that disproportionately affects forced migrants, is universal, in principle provided free of charge to all. Yet, multiple informal access barriers typically arise and informal systems of social triage may emerge. Using intersectional analysis, this study asks what political and moral rationalities inform social triage in the NHS. It is particularly attentive to how and why a supposedly universal service reproduces differential racialisation, in which multiple and co-existing populations are stratified and ranked as more or less belonging to a nation. Fieldwork was conducted in two waves, in 2015-2016 and in 2019-2021. It included six months of participant observation in an NGO; 21 semi-structured interviews with health professionals across 16 different NHS and NGO service providers, purposively sampled until saturation was reached; six interviews with mental health commissioners and national policymakers; and analysis of grey literature. Transcripts and fieldnotes were analysed inductively to identify themes using NvivoR1. Results were validated by interviewees. Despite being covered, undocumented migrants and asylum seekers were systematically excluded from NHS PTSD services, through social triage. People with refugee status were prioritised. Mental health care providers consciously and subconsciously reproduced differential racialisation, which generated health inequality. This was facilitated by: austerity; omitting immigration status in measurement of health inequality; securitisation of mental health services and minoritised Muslim populations; and bifurcated activism in which the forced migrant sector was disconnected from established struggles to combat racism in mental health care. Policies extending coverage to undocumented migrants and asylum seekers must be accompanied by extra monitoring, as well as financial, political and social support to service providers. Key messages • Health professionals informally, but systematically, reproduce differential racialisation in the rationing of health care through practices such as obfuscation and silencing critique. • Informal systems of social triage erode universal health coverage. This is exacerbated in contexts of austerity, where health professionals use their discretion to ration limited resources
Social capital and enrolment in community-based health insurance in Senegal
No full textUniversal coverage is a core health system goal which can be met through a variety of health financing mechanisms. The focus of this PhD is on one of these mechanisms, community-based health insurance (CBHI). CBHI aims to
provide financial protection from the cost of seeking health care through voluntary prepayment by community members; typically it is not-for-profit and aims to be community owned and controlled. Despite its popularity with international policymakers and donors, CBHI has performed poorly in most low and middle income countries. The overarching objective of this PhD is therefore to understand the determinants of low enrolment and high drop-out in CBHI. The PhD builds on the existing literature, which employs mainly economic and health system frameworks, by critically applying social capital
theory to the analysis of CBHI. A mixed-methods multiple case study research design is used to investigate the relationship between CBHI, bonding and bridging social capital at micro and macro levels and active community
participation. The study focuses on Senegal, where CBHI is a component of national health financing policy. The results suggest that CBHI enrolment is determined by having broader social networks which provide solidarity, risk pooling, financial protection and financial credit. Active participation in CBHI may prevent drop-out and increase levels of social capital. Overall, it seems
CBHI is likely to favour individuals who already possess social, economic, cultural and other forms of capital and social power. At the macro level, values (such as voluntarism, trust and solidarity) and power relations inhering in social networks of CBHI stakeholders are also found to help explain low levels of CBHI enrolment at the micro level. The results imply the need for a fundamental overhaul of the current CBHI model. It is possible that the needed reforms would require local institutions to develop new capacities and resources that are so demanding that alternative public sector policies such as national social health insurance might emerge as a preferable alternative
Mental health coverage for forced migrants: managing failure as everyday governance in the public and NGO sectors in England
No full textHigh-income countries (HICs) which are said to have “reached” universal health coverage (UHC) typically still have coverage gaps, due to both formal policies and informal barriers which result in “hypothetical access”. In England, a user fee exemption has in principle made access to treatment for post-traumatic stress disorder (PTSD) and other mental health conditions thought to be caused by certain forms of violence universal, regardless of immigration status. This study explores the everyday governance of this mental health coverage for forced migrants in the English National Health Service (NHS) and NGO sector. Fieldwork was conducted in two waves, in 2015–2016 and 2019–2021, including six months of participant observation in an NGO and 21 semi-structured interviews with psy professionals across 16 NHS and NGO service providers. Further interviews were conducted with mental health commissioners and policymakers, as well as analysis of grey literature. Despite being formally covered for certain types of mental health care, in practice asylum seekers and undocumented migrants were often excluded by NHS providers. Undocumented migrants were also often excluded by NGO providers. Several rationalities linked discursive fields to practices developed by psy professionals and other street-level bureaucrats to govern coverage, in a process of “managing failure”. These rationalities are presented under three paired themes which draw attention to tensions and resistance in the governance of coverage: medicalisation and biolegitimacy; austerity and ethico-politics; and differential racialisation and decolonisation. Rationalities were associated with strategies and tactics such as social triage, clinical advocacy, obfuscation, evidence-based advocacy and silencing critique. The concept of “health coverage assemblage” is introduced to explain the complex, unstable, contingent and fragmented nature of UHC policies and programmes. Misrecognition and underestimation of the everyday work of health professionals in promoting, resisting and reproducing diverse rationalities within the assemblage may lead to missed opportunities for reform
Why do people drop out of community-based health insurance?: findings from an exploratory household survey in Senegal
Full text linkAlthough a high level of drop-out from community-based health insurance (CBHI) is frequently reported, it has rarely been analysed in depth. This study explores whether never having actively participated in CBHI is a determinant of drop-out. A conceptual framework of passive and active community participation in CBHI is developed to inform quantitative data analysis. Fieldwork comprising a household survey was conducted in Senegal in 2009. Levels of active participation among 382 members and ex-members of CBHI across three case study schemes are compared using logistic regression. Results suggest that, controlling for a range of socioeconomic variables, the more active the mode of participation in the CBHI scheme, the stronger the statistically significant positive correlation with remaining enrolled. Training is the most highly correlated, followed by voting, participating in a general assembly, awareness raising / information dissemination and informal discussions / spontaneously helping. Possible intermediary outcomes of active participation such as perceived trustworthiness of the scheme management / president; accountability and being informed of mechanisms of controlling abuse/fraud are also significantly positively correlated with remaining in the scheme. Perception of poor quality of health services is identified as the most important determinant of drop-out. Financial factors do not seem to determine drop-out. The results suggest that schemes may be able to reduce drop-out and increase quality of care by creating more opportunities for more active participation. Caution is needed though, since if CBHI schemes uncritically fund and promote participation activities, individuals who are already more empowered or who already have higher levels of social capital may be more likely to access these resources, thereby indirectly further increasing social inequalities in health coverage
Fragmentation by design: universal health coverage policies as governmentality in Senegal
No full textThere is increasing international consensus that countries need to reduce health system fragmentation in order to achieve universal health coverage (UHC). Yet there is little agreement on what drives fragmentation, in particular the extent to which fragmentation has a political purpose. This study analyses a highly fragmented health financing system through a UHC policy that aims to remove user fees for people aged 60 and over in Senegal. 53 semi-structured interviews (SSIs) and focus group discussions with the target population were conducted in four regions in Senegal over a period of six months during 2012. A further 46 SSIs were conducted with key informants at the national level and in each of the four regions. By analysing explanations of the successes and failures of policies, an understanding of power relations in state institutions, communities and individuals is gained. The concept of governmentality is used to interpret the results. The interviewees’ main concern was to implement or resist various techniques of control over the conduct of bureaucrats, health workers, patients and the wider population. These techniques included numeracy and calculation, referral letters, ID cards, data collection, new prudentialism, active citizenship and ethical self-formation through affinities of the community. The techniques sought to make two types of subjects; citizens subjects of rights and obligations; and autonomous subjects of choice and self-identity. A key implication is that in Senegal, and perhaps elsewhere, fragmentation of the health system plays a key role in the formation and control of subjects, in the name of “freedom”. As such, fragmentation may be an inherent feature of UHC. Interventions that aim to reduce fragmentation based on evidence of its inefficiency, inequity and ineffectiveness in reducing poverty and ill health may be missing this point
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