Rapport of the WONCA LISBOA 2014 workshop

Primary care for migrants in times of crisis

Workshop by the WONCA SIG on migrant care, international health and travel medicine


Goal of the workshop was the exchange of information and ideas about the consequences of the ongoing economic and political crisis on the healthcare of vulnerable groups, especially migrants.

The workshop was organized and presented by Dutch, Greek, Irish, Canadian, English and Turkish colleagues.

About 70 people from many different countries were present. Their names and e-mail were collected for future contact.


The ongoing economic crisis mainly affects disadvantaged groups, such as migrants. Austerity measures are leading to reduction in healthcare services (e.g. interpreter services) and new healthcare charges have large impact on migrants. In addition to impaired access to healthcare, xenophobia and harsh living circumstances negatively influence their health.

Political crises create large groups of refugees with specific health problems, such as the current epidemic of poliomyelitis in Syria, threatening to expand to Syrian refugees in Turkey and Europe.

Global crises thus lead to local problems in health and healthcare access for migrants and socially marginalized groups. Family Physicians are usually the first to face these problems and should be aware of the impact of crisis on health. At the same time primary care offers unique possibilities to guarantee accessible quality care to all in the population, including vulnerable migrant groups.


After the introduction by Dr Maria van de Muijsenbergh (The Netherlands)  the workshop started with three short presentations on the “Influence of crises on health and access to healthcare for migrants.”:

Professor Adem Ozkara (Turkey) gave a clear picture of the health problems in the population of Syrian refugees in Turkey.

Dr Marwa Achmed from the UK explained the procedures for prevention of a polio outbreak in the UK as a result from the Syrian crisis.

Professor Christos Lionis (Crete) explored the effects of the economic crisis on access to healthcare for migrants in Greece.

Their presentations are attached as PDF.


After this the participants shared their own knowledge and experiences regarding the effects of crisis on health and access to healthcare for migrants.

Dr. Maria van den Muijsenbergh lead the plenary discussion in which examples of influence of the crisis were inventoried. We exchanged the challenges faced in providing good care for vulnerable groups.


Following this discussion we focused on possible solutions in patient health care, needs of GP’s and impact on medical schools.

Patrick O’Connell from Limerick, Ireland showed us the start of a project of integrated care for vulnerable groups.

Suzanne Gagnon form Quebec, Canada informed us about the refugee’s health clinic in Quebec .

Their presentations are attached as PDF as well.

After these two presentations, the participants discussed in small groups about other examples of good quality primary care for migrants and other vulnerable groups.

– What do you need to provide this care?

– How do we teach this to our students?

– How could the SIG on migrant care help?


In the lively discussion many problems were shared in the care for migrants, particularly financial barriers in access to care, the lack of time of general practitioners and lack of knowledge concerning specific disorders. In the plenary exchange participants also shared their ideas  and possible solutions for providing good quality of care for migrants

Summary of the possible solutions for providing good quality of care to vulnerable groups

from the group discussions:

  1. Employ migrants as social assistants
  2. Use movie/film/media material as means of information and education
  3. Found an (inter)national advocacy organization for GP’s; share ideas and experiences. Like our SIG?
  4. Use simple and clear language to communicate better with patients
  5. Educate migrants on the healthcare system (including insurance)
  6. Use interpreters in the practice
  7. Use medical staff/students with migrant background
  8. Use Google translate
  9. Improve education on medical schools on this subject
  10. Construct a website for GP’s (and students) with background information and protocols of providing care to migrants: Example from the Netherlands: www.huisarts-migrant.nl
  11. Stimulate enthusiasm amongst colleagues
  12. Be more self-confident: We have the knowledge!
  13. Set priority to improvement of mental health care.
  14. Remove cultural barriers
  15. Be aware of different intercultural expectations
  16. Be in charge or get involved with the coordination of care

For further information on the WONCA special interest group please contact: maria.vandenmuijsenbergh@radboudumc.nl

For further information on RESTORE: www.RESTORE.eu

You can join our Facebook group for further contact and exchange: www.facebook.com/SIGmigrantcare


Attach: summaries of presentations


Adam Ozkara (Turkey): Health Issues among the Syrian Refugees in Turkey

More than 1 million Syrian refugees were hosted in Turkey (June 2014), 250 000 of those live registered in 22 refugee camps. The rest (800,000) live inside the various Turkish cities

The number is constantly increasing.

A field survey in 2013 gave the following results

  • 90% in and the 60% out of the camps of the Syrian refugees use health services
  • Individuals with chronic diseases 7.3% in and 7.6% out of the camps
  • Adults with sleep disorders 23.8% and 14.3% out of the camps
  • Children with sleep disorders 24.6% and 17.2% out of the camps
  • 6051 births were recorded in last two years in the camps.
  • 13% of women in the camps and 14% of women out of camps are pregnant
  • 51.1% in and 46.3% out of the camps think there is a need for psychological support
  • 30.6% in and 54% out of the camps have difficulty in finding medicines
  • 73.8% of children under five years old in and 54.6% out of the camps are vaccinated against polio.
  • 71.8% of children under 10 years in and 58.7% out of the camps are vaccinated against measles

World Health Organisation has confirmed 10 polio cases and 22 suspected cases in Syria.

The risk of polio spreading across the Middle East increased. Over 23 million of children in surrounding countries of Syria aged five and under were vaccinated (Jordan, Turkey, Lebanon, Egypt, Iraq, West Bank and Gaza). In Turkey 8,500 volunteers aim to go door-to-door to vaccinate 1.5 million children.

Beyond numbers, there is also an emotional burden. Being away from home and facing uncertainty about the future affects Syrian refugees psychologically, socially, and physically. Health-care workers providing services to this vulnerable population are also affected. Doctors are now providing services to a large population with no medical records, who are socially and psychologically affected, and with a language barrier. Doctors face situations that are very difficult to manage. They work long hours, and manage several urgent cases. As a nurse explained to us, it is not just wounds caused by bombs or bullets that need treatment, but also spiritual wounds, fears, and pains, which need to be healed.

Total expenditure for Syrian Refugees 2.5 billion $ in 2014, from which 100 million $ to healthcare.


Marwa Ahmed GP at Royal Arsenal Medical Centre, London, POLIO CRISIS AND UK RESPONSE

In1988 two billion children around the world have been immunised against polio

Cases were reduced by > 99% from an estimated 350,00 cases to 406 reported cases in 2013.

Only 3 countries in the world have never stopped the transmission of polio (Nigeria, Pakistan and Afghanistan). In the UK, the last case of domestically acquired polio infection was in 1982. The last polio case recorded in Syria was back in 1999.

In Syria the first reported case of Polio infection was on 14 July 2013. Ten cases were confirmed in the laboratory and 12 others are suspected. The cases are probably a result of a steep fall in child immunisation rates in Syria owing to the on-going war

As Polio return to Syria, Europe becomes vulnerable because of the weaknesses in European polio defences, the extensive levels of travel between Europe and Israel, the millions of refugees fleeing Syria.

Recommendations by NHS England to all of the GP practices were sent as follows.

  • To be alert to symptoms and signs of polio in anyone who has arrived from Syria
  • Screen any child under 5 years of age who has arrived from Syria since 01/08/2013 (who has not had oral polio virus vaccine in the last 4 weeks) for polio virus infection by sending faecal sample to the local laboratory
  • Ensure all new arrivals from Syria are brought up to date with UK immunisation schedule as appropriate to their past immunisation history
Professor Christos Lionis, University of Crete, Greece: The effect of the financial crisis on access to healthcare for migrants in Greece

Migrants are mainly employed in construction, domestic care and manufacturing

Access to healthcare for legal migrants if they have insurance is the same as for citizens

Undocumented migrants have restricted rights: access only to ER services for life-threatening conditions (HIV, childbirth included).

They pay the full fee if they visit PHC. Access is based on the goodwill of the doctors. They pay full cost for all lab tests. They usually try to find NGOs for care.

Limitations in the system are the lack of interpreting services, difficulties to access information of services. Especially persons with chronic diseases or persons in need of surgery are affected.

Because of the financial crisis there is an increase use of public health services, emergency department visits, outpatient visits and in uninsured patients

There is a decrease in public health spending, in medical supplies, personnel at hospitals and PHC centers and a general decrease in quality of services offered.

Nurses’ salaries decreased with 14%.

Main barriers accessing health care according to the health care professionals are language difficulties, no health care coverage, traumatic experiences and social deprivation.

Barriers according to the migrants are lack of understanding or knowledge, administrative problems and denied health coverage.

The UoC Experience (university of Crete) is a cooperation between several organizations on Crete and the Municipality of Iraklion, all working with uninsured patients and migrants .

One of these is the Practice Based Research Network on Crete consisting of 18 GPs working in Primary Health Care settings in rural areas. Of these practitioners, 15 work within the public healthcare system, two operate from private practices in Chania, and one is based at the primary care unit of Heraklion.

Efforts are being made all over Greece with mobile units supported by Medecins du Monde to assist migrants with: vaccination, mental health, dental health, housing conditions, chronic diseases, antenatal care, violence related problems.

Dr Patrick O’Donnell, Clinical Fellow in Social Inclusion Limerick City, Ireland: Partnership for Health Equity

Limerick has a population of 91,454, served by an estimated 34 general practice surgeries, four primary care teams, network of 9 health centres and one University Hospital.

Patients have an insurance by a medical card system: weekly income must be below €184 (single, living alone). This card covers free GP care, prescribed drugs, appliances, inpatient & outpatient public hospital services and some dental/optical/hearing issues.

The new Partnership for Health Equity sought to establish basic primary care service for marginalised patients in Limerick. Targeted, low-threshold medical services have been successfully introduced in Dublin and Cork.

No such service available in Limerick and only anecdotal evidence of the need for it.

Within 3 months a proposal for GP services for marginalises groups in Limerick City was realised. Aim was to inform the development of GP service in consultation with relevant stakeholders.


  • Provide firm evidence on specific healthcare service needs for the marginalised groups mentioned.
  • Compare what had been already planned for the project with what various stakeholders felt should be offered by a GP service.
  • Specify the configuration of the service in terms of clinical objectives.

A stakeholder analysis was done and followed by a process of stakeholder engagement  Stakeholder’s views on their relationship with the project were elicited through 34 consultations over a ten week period with a purposeful sample of service providers, homeless and drug using clients and their families. All stakeholders where in favour of the project.

There was a high level of medical card registration, but those with a card often faced barriers to actually receiving GP care. Perceived obstacles to care included the breakdown of the patient-GP relationship and frequent change of patient address.

Conclusions and findings:

There is a need for primary care service for marginalised groups in Limerick city. Expected suggestion were: BBV testing and vaccination, menyal health care, skin wounds and infections, basis GP care, addiction issues, STI screening.

Unexpected suggestions were: need of dental care, contraception, cervical smears, antenatal care, overdose prevention

‘Unexpected’ clinic services will need training, logistical changes or the development of close relationships with other community and secondary care services.

Project as planned prior to this exercise can be enhanced to meet the needs as expressed by the stakeholders, and this may also allow a widening of the provision of GP care to other marginalised groups in the city.


Suzanne Gagnon: the Refugee Health Clinic, Quebec city, Canada

Quebec city in 2006 had 22160 immigrants (4%), half of them between 25 and 44 years, 50% are immigrants for economic purpose.

They are well educated (65% with a post-secondary diploma vs 52% pop), but have a low income (median income 20500$ vs 26200$ pop) and are often unemployed (9.7% vs 5% pop).
A study done by the Regional Health Agency showed that this population didn’t have access to medical services and as a result the Refugee Health clinic was opened in 2007.

The mandate of this clinic is:

  • To do a bio-psychosocial evaluation of the refugees in the first weeks after their arrival
  • To follow-up this population during the first year after their arrival
  • To educate for health this population when needed
  • To help the health professionals of the Quebec city area for this population
  • To teach the Health professionals, students and residents in medicine to the health problems in this population and the way to help them
  • To work with the community organisms with mandates with this population
  • To link our services with the professionals of schools and French classes

The team consists of 2 full time, university degree nurses, 5 physicians (part time), 2 FT social workers, a nutritionist (part time), community worker (part time), interpreters (part time)

Based on the model developed in Quebec City the Quebec Provincial program for Refugees Health was developed, as an expert network in Refugees Health (Quebec city, Montreal, Sherbrooke) with satellites in smaller towns. This is a collaborative platform in development, based in Community Health Centers.

During the first year after their arrival Federal program for Health problems

(operated by Immigration Canada and managed by  «Blue Cross») covers some treatments and consultations with health professionals uncovered by the Provincial Health Insurance plan: dentist, optician, physiotherapist, but only for basic demands or emergency problems.