Access to healthcare for vulnerable migrant women in England: A human security approach

Abstract

Spanish

French

The focus of this article is on post-migration entitlement and access to health security of women international migrants in England who are in vulnerable circumstances. Here ‘health security’ is defined as the protection of health within a broader public health context. The aim is to understand the factors underlying migrants’ vulnerabilities and how national and local health policies and practices respond in allowing or denying them rights to healthcare, thus impacting their ability to safeguard their health. This article is predominantly concerned with experiences of access to healthcare of categories of migrant women who may be in vulnerable situations including asylum seekers, refugees, refused asylum seekers or other undocumented migrant women, women with no recourse to public funds who are supported by local authorities, trafficked women, Roma women, women with limited fluency in English, and migrants from the European Union (EU) with no health insurance card. By examining empirical evidence of such women’s experiences of entitlement and access to healthcare we are able to gain theoretical insight into the relationship between migration, gender and human (health) security.

Keywords

England female migrants gender health security

Introduction

The concept of human security refers to a framework whereby the vital core of human life – that is, ‘fundamental human rights, basic capabilities or absolute needs’ – is protected in the face of critical pervasive threats (Alkire, 2003: 3). Its focus on all human beings irrespective of territorial boundaries distinguishes it from an approach that prioritises state security policies and practices (Tripp, 2013). Threats could include personal experience of poverty and inequality from any source, as much as national and global events such as war, terrorism, natural disasters, communicable disease and macro-level financial crises (Alkire, 2003; United Nations Development Programme, 1994).

As Purkayastha points out in the introduction to this monograph issue, a human security approach is specifically cogent to understanding migrant experience, before, during and after migration. It encompasses internal and international migration and diverse migrant categories. A multi-dimensional perspective locates both migrant movement – whether determined by choice or force, uni- or multi-directional, permanent or temporary – and migrant integration in receiving societies, in relation to access to rights and to security within interacting global and national social structures and social hierarchies such as those of gender, class, race, ethnicity, age, disability, sexuality and religion.

The focus of this article is on post-migration entitlement and access to health security of women international migrants in England who are in vulnerable circumstances. Here ‘health security’ is defined, in line with the definition of ‘human security’ given above, as the protection of health within a broader public health context rather than as protection against external threats alone (Aldis, 2008). The aim is to understand the factors underlying migrants’ vulnerabilities and how national and local health policies and practices respond in allowing or denying them rights to healthcare, thus impacting their ability to safeguard their health. The article attempts to use this case study to contribute to the growing body of feminist perspectives charting the relationship between gender, interacting with other stratification factors, and human security (Tripp, 2013). As Alkire states with regard to the conceptual framework around human security: ‘In order to be relevant in different cultures and circumstances, a sound conceptual framework must be flexible as well as concrete – to allow for specifications that change over time and contexts. But this means that many pressing questions will be resolved only in practice, after both threats and implementing institutions have been identified’ (Alkire, 2003: 6).

Vulnerability of migrant women

Women currently make up a little less than half of international migrants globally, but with large regional differences (United Nations, 2016). In Europe female migrants outnumber male migrants and in the UK a recent population survey estimates that women make up 54% of the stock of international migrants (Rienzo and Vargas-Silva, 2016). According to data on migration flows, female migrants vis-a-vis male migrants are most likely to be family/spousal migrants (around three-quarters of those entering the UK for family reasons) and least likely to be asylum seekers (around a third of those seeking asylum) (Integration up North, 2015). Women also make up a significant proportion of undocumented migrants, although obtaining precise numbers is challenging.¹

There are multiple determinants of migrants’ health status and access to healthcare in receiving societies that incorporate factors relating to origins and destinations and the entire migration process. These include biology, demography, socio-economic circumstances before, during and after migration, emigration policies in sending countries and immigration and integration policies in receiving countries, cultural backgrounds, practices and identities (including religion, ethnicity, language and health-related beliefs and behaviour), social networks including transnational networks, length of residence in receiving countries, and impact of racism and discrimination (Jayaweera, 2014a). Framed by these determinants migrants may often find themselves in vulnerable circumstances. In this article, vulnerability is defined as a fluid rather than fixed state, that is, a state that can change with time and circumstances. It is ‘a mixture of characteristics and conditions which increases susceptibility to poorer health and difficulty accessing services’ (NHS Wakefield District, 2011: 12). It can apply to any migrant at any point in time, but there are categories of migrants, described below, who may be in a vulnerable situation all or most of the time.

There is widespread evidence globally that women’s experience of migration differs from that of men (Fleury, 2016; Piper, 2006). While women can gain autonomy, financial independence and improved self-worth from migration, women’s locations within patriarchal structures and processes before, during and after migration mark out migrant women’s positions within gendered hierarchies and can lead to specific instances of precarity and vulnerability. This article is predominantly concerned with experiences of access to healthcare of categories of migrant women who may be in vulnerable situations, including asylum seekers, refugees, refused asylum seekers or other undocumented migrant women, women with no recourse to public funds who are supported by local authorities, trafficked women, Roma women, women with limited fluency in English, and migrants from the European Union (EU) with no health insurance card. By examining empirical evidence of such women’s experiences of entitlement and access to healthcare we are able to gain theoretical insight into the relationship between migration, gender and human (health) security.

The framework of rights to healthcare for migrants in the UK

In the National Health Service (NHS) that operates in the UK, healthcare is funded by general taxation and is free at the point of access for citizens and others who are ‘ordinarily resident’ in the UK. Until recently, ‘ordinary residence’ was a common law concept meaning ‘someone who is living lawfully in the United Kingdom voluntarily and for settled purposes as part of the regular order of their life for the time being, with an identifiable purpose for their residence here which has a sufficient degree of continuity to be properly described as settled’ (Powell, 2015: 4). Over the past couple of decades there have been increasing restrictions to migrants’ rights to healthcare. Most recently, the 2014 Immigration Act excluded some categories of legal migrants who do not have permanent residence, such as family migrants, labour migrants and students, from the definition of ordinary residence and therefore from access to free secondary healthcare. Also, irregular migrants – who include undocumented migrants, visa overstayers and refused asylum seekers – are not exempt from charging for secondary healthcare.

However there is a distinction between current legislation on free access to NHS primary and community healthcare on the one hand, and that on free access to NHS care in hospital and other secondary health settings on the other, with only the latter dependent on the immigration status of patients. So far, access to and treatment from General Practitioners (GPs), who are primary healthcare providers in the UK, is free for all and cannot be refused on grounds of race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition (NHS England, 2015). Nevertheless, there is evidence that some GP practices continue to refuse to register some patients including those who are homeless or asylum seekers on grounds of lack of documentation on identity or residence (Doctors of the World UK, 2015). Further, within the past year, the Department of Health has undertaken a public consultation with regard to extending charging for treatment in primary care for some categories of migrant including irregular migrants (Department of Health, 2015a).

It is important to point out that some types of healthcare such as treatment given in hospital accident and emergency departments, diagnosis and treatment of communicable diseases such as TB and HIV, and treatment of a physical or mental condition caused by torture, female genital mutilation (FGM), domestic violence or sexual violence are currently free to all irrespective of immigration status or nationality, on public health or humanitarian grounds. However, current and proposed regulations on further restrictions in access to healthcare for some migrants – including on entitlement to free emergency medical treatment in hospitals (Department of Health, 2015a) – means that there is an increasing stratification of rights to healthcare in the UK (Kelly et al., 2005). This is a cause for concern in terms of implications on health outcomes for vulnerable migrants who may be uncertain of their entitlement to free healthcare, and are fearful about seeking diagnosis and treatment because of their inability to pay (Jayaweera, 2014b; Shortall et al., 2015).

This article will now consider evidence from primary empirical research, to examine whether the human (health) security needs of vulnerable migrant women in England are being met. Do such women face inequalities in access and uptake of healthcare, and what are the facilitators and barriers relating to addressing their health needs? The evidence in this article is presented through a review of policy documents and the perspectives of commissioners and statutory and voluntary sector providers of healthcare.² The emphasis is on insight that can be gained about their knowledge and awareness of the health needs of vulnerable migrant women and about the formulation, translation and implementation of policies and practices relevant to this category, particularly at local level.³

Policies and practices on access to healthcare for vulnerable migrant women

Healthcare policies and provision in the UK are devolved in the different countries (England, Wales, Scotland and Northern Ireland) and there are differences between the systems operational in each country. This article relates to healthcare policies and practices in England. In accordance with the 2012 NHS and Social Care Act, commissioning, planning and operation of health services are meant to take place predominantly at local level, involving Clinical Commissioning Groups (CCGs) made up of local GP practices and Public Health Departments in Local Authorities.⁴ Thus, the development of health needs assessments and strategies to address health needs of local populations are meant to reflect the particular demographic make-up of each local area including local diversity. The national Department of Health guidance clearly stipulates that health coverage should include mental health as well as physical health and health protection and prevention of ill-health. It should also encompass the needs of the entire population including those vulnerable groups who experience inequalities and find it difficult to access services and those with complex and multiple needs (Department of Health, 2013).

While current policies and guidance on locally produced and owned strategic assessment and planning to improve population health outcomes and reduce health inequalities do exist, and include migrants on the one hand, and ‘vulnerable groups’ on the other, as not necessarily overlapping categories, such assessments and planning have a broad remit in terms of population coverage. An examination of existing guidance and resource documents relating to vulnerable population groups reveals that there do not exist any policies or guidance on addressing health needs explicitly of vulnerable migrant women (Inclusion Health, 2014; Jayaweera, 2016; Rose et al., 2011). This is despite the fact that prior to NHS reorganisation arising from the 2012 Act mentioned above, and immigration rules changes signalling increasing restrictions in access to healthcare for migrants as discussed earlier, specific recommendations on addressing health needs of vulnerable migrant women had been made by voluntary sector organisations advocating on behalf of women’s rights. These recommendations include: collecting data disaggregated by gender as well as ethnicity/nationality on migrants in local areas, and data on women by migration situation; more gender-sensitive delivery of primary care, mental health services, screening and preventive health including language support, and full representation of women in multi-agency forums on reviewing needs and developing services for migrant communities. There is also a recommendation for a policy and pathway on maternity care for vulnerable migrants, for performance indicators and training for recognition of and response to gender-based violence at initial health checks and the importance of ensuring that interventions do not take place without women’s informed choice (Feldman, 2012). As we shall see from the primary research reported in this article, many of these recommendations have yet to be implemented in policy and service delivery relating to migrant women.

Challenges to the health security of vulnerable migrant women

Types and extent of knowledge and services

Document review supported by evidence from interviews with commissioners and service providers reveal that at present NHS commissioned services for migrant women are often delivered as part of support to: (a) both men and women migrants; or (b) women generally, among which are migrant women; or (c) vulnerable groups, among which are vulnerable migrants, mainly asylum seekers and Roma. But where there is a specific national policy, guidance or service pathway – for example around FGM, survivors of domestic violence or trafficking, pregnant asylum seekers, or Syrian refugees – there is more likelihood of needs assessment, research and intervention that impact positively on the health of vulnerable migrant women (Department of Health, 2015b).

The survey of commissioners of health services in local areas and in-depth interviews with commissioners and providers of healthcare disclose a disjuncture between policy intention to tackle health inequalities and improve the health of vulnerable population groups, and a lack of knowledge and awareness of the circumstances of vulnerability of specific categories of migrant women and their health needs arising from these. While the survey responses⁵ cover a wide range of English regions and local areas, there is limited knowledge among most healthcare commissioners about the health of migrants compared to available data on the size and composition of the migrant population in general in the local areas they represent. An organisational role with specific responsibility for migrant health exists only among a few commissioning bodies (Clinical Commissioning Groups and Public Health teams in Local Authorities). As far as migrant women are specifically concerned, targeted health policies, programmes and practices appear most likely to be applied to asylum seekers and refugees; this is probably because as stated earlier, there is a dedicated service pathway and funding stream for this category, for example pregnant asylum seekers and mental health services for vulnerable adult migrants. However, the interviews with service providers also reveal that specialist health services for asylum-seeking women are currently under threat. As one interviewee put it:

When I started in 2000 there was an asylum seeker co-ordination team at the Department of Health … and it was much better then, there were specialist services in various parts of the country, everywhere people were dispersed to … it was mostly about prevention and community development and helping people to understand the NHS and the local staff to understand them, and it’s practically gone now.

On the other hand, commissioners say they are concerned about issues such as pregnancy and postnatal care, FGM, sexual and reproductive health and health relating to domestic violence, affecting vulnerable migrant women in particular. However, with respect to direct commissioning and provision, the issues most cited by commissioners include interpreting and translation services and outreach approaches for harder-to-reach categories of women. The finding that in response to the survey question ‘Do you feel that the CCG/LA is commissioning adequate and appropriate healthcare services for vulnerable migrant women at present?’ the most common answer among local commissioners is ‘don’t know’, suggests a significant lack of knowledge and/or apathy about the circumstances and health needs of vulnerable migrant women. There is evidence of multi-agency working to provide or improve health services for local populations, for instance with local authority housing and social services, voluntary sector organisations including faith-based organisations, and migrant community organisations, but hardly any representation of migrant women in assessment and commissioning bodies. In general, commissioners feel that there are multiple barriers to providing health services for vulnerable migrant women, such as lack of knowledge about local diversity of circumstances and needs, and the lack of capacity of staff and available funding to deal with specific issues affecting this category, as the following quote from a commissioner shows:

It is hard to make reliable and generalizable judgements that support effective planning in relation to meeting the healthcare needs of a small, diverse and transitory group that changes constantly and significantly in its characteristics, and about which little reliable (independently verifiable) information exists.

Voluntary sector perspectives

An in-depth perspective of the circumstances of vulnerable migrant women in local areas, their health needs, and problems and barriers in providing health security for them is gained from interviews with staff in voluntary organisations that provide community health services. The types of services offered include training health professionals to understand communities and their health needs better and to provide a culturally sensitive delivery of services, offering information on health systems and healthcare entitlements to new arrivals or groups less likely to access healthcare, and most importantly, providing support around wider determinants of health – for example poverty, housing – that impinge on health and wellbeing. Some of these interventions are commissioned and funded by the state sector, but more often than not a substantial extent of funding is provided by charitable trusts or the national lottery. As one interviewee stated: ‘every pound the voluntary sector gets from the local authority and CCG, they probably pull in another 3 pounds from other funding into the city to do the work … because there is not enough money coming in through public services’.

One of the main barriers to good health and access to healthcare for migrant women is inequalities in wider determinants of health and in some cases severe deprivation – for instance, the impact of not having recourse to state welfare benefits or exploitative working conditions that lead to poor health outcomes. Interviewees in voluntary organisations particularly highlighted the importance of meeting the broader social and economic needs of women who came to them for health support. The manager of a vulnerable adults outreach service in the East of England explained how ‘the more social and holistic interventions than just general health interventions’ provided by the multi-disciplinary team in his organisation, including doctors and nurses, differ from statutory healthcare in getting to the heart of the problems faced by many migrant women who are, or end up, in vulnerable circumstances.

We provide services across the board to wherever they are needed and we tailor our services to the barriers and needs of the group we are working with so if that is Roma women we have developed links with Roma interpreters and Roma people locally and have developed a network and training programme around their needs. We also do a similar programme for refugees and asylum seekers and tailor that around language and cultural knowledge base of those particular groups, so a lot of work around FGM and honour based violence. If it’s more to do with sex work and people trafficked, a fair amount from Eastern Europe, specific work … with people in the sex industry and looking at exit strategy. … We would intensively work with people for as short a time as possible and then get them back into normal midwifery, social care etc. A multi-factorial approach.

He also recognised the way wider socio-economic circumstances of migrants including women create barriers to accessing healthcare and impact negatively on health outcomes, and how dealing with these broader social determinants of health put pressure on voluntary sector service provision:

So if they are fleeing domestic violence or if they have lost their job or fallen out of the system, most of the people we are seeing have no recourse to public funds, they can’t get benefits easily… and so they fall hard and fast into absolute street homelessness and poverty and destitution very quickly. Even if they are injured at work or [experience a] relationship breakdown there is absolutely no safety net there for them. That can be a struggle for us to find the appropriate services … you got to remember we are working with the most vulnerable and most marginalised in that they tend to be working in modern slavery … or they are being controlled by a gang or a man or group who has got their passport or ID. For all those reasons they are more vulnerable to mental and physical health issues, sexual health issues, unwanted pregnancies. Secondly they are less likely to access prevention services or cure services from the NHS.

Accounts such as these bring to vivid focus the way lack of rights and entitlements associated with migrant status intersect with gendered experiences of work and personal relationships associated with women’s migrant condition, to create circumstances that are detrimental to their human security.

The following case histories recounted by a health provider in a voluntary organisation commissioned by the statutory health sector to support pregnant asylum seekers and recent mothers in a large city, discloses the challenges faced by the mainstream health system in providing health services that are sensitive to the specific needs of vulnerable migrant women. It shows that even where there is a designated national and local service structure and pathway for a category of vulnerable migrants – in this case, pregnant asylum seekers – the lack of awareness and resources to take a holistic approach to the lives of such women leads to continuing insecurities in their lives and those of their children.

The problem starts from the hospital really. The women will give birth, and I don’t think the hospital staff, the midwives, there is this aim to get them out of hospital as soon as they have the baby. I don’t think they stop to ask the question what sort of accommodation are you going back to? Do you have the means to support yourself? We had one lady who was transferred back to [the accommodation centre for asylum seekers] and she had given birth the day before and her nipples were absolutely sore and bleeding. Ideally she should have stayed in hospital and got her breast feeding established. Obviously the baby had had two supplementary feeds, she comes out, she is in the initial accommodation, and she does get the supplementary feed that the baby was on in the hospital, but how do you make up a feed in the accommodation which has got 300 odd people and the kitchen is a distance from your room and you don’t have hot water in the room, the facilities to boil water, and you haven’t got a flask etc. so what do you do? In the end she made one of the feeds up with bottled water. It was the sessional volunteer who went in and tried to iron out the problems and speak to security and say this can’t happen, otherwise the baby will have gastroenteritis.

Again:

Another lady was sent home, and I had a call from the midwife to say she had no food, she was staying in a hotel, still Home Office accommodation, she was right up in the attic and the midwife said she had no food so she went out and bought her fish and chips that afternoon, and then she’s got something to eat in the evening and next morning. … Midwives in the hospital assist with what they visually see post-delivery. The emphasis in the hospital is getting them out as soon as possible but identifying the individual who may have extra needs, I don’t think it happens with all the midwives but it seems to be an issue. They are not asking the questions. I’ve worked in hospitals myself, I have seen how sometimes midwives do things, it’s not necessarily the best. But the way pressure is put on them and the number of staff in the ward area, sometimes it can be difficult for them.

Voluntary sector healthcare providers also highlighted the difficulties in moving vulnerable women on to mainstream health services such as mental health services or preventive services for chronic illnesses, after they have provided initial support. One service provider talked about the challenges of local availability of mainstream mental health services and translation, and their lack of adaptability to address mental health needs arising from the particular experiences of some migrant women: ‘a lot of the wellbeing cognitive behavioural therapy type approaches … seem to be group type approaches … are not translated, and are not necessarily appropriate for the needs of someone who has experienced trauma or exploitation’.

Other challenges to creating health security for vulnerable migrant women brought up in the interviews with healthcare providers in voluntary organisations include commissioning gaps and inconsistent service provision across different geographical areas: ‘it’s very hit and miss’. At times actual needs on the ground affecting different categories of migrant women in local areas are not adequately identified. For instance in one local area it was focus groups with Eastern European women rather than standard formal needs assessment that revealed alcohol consumption and smoking prevalence hidden within households, ‘behind closed doors’, because of its infringement of cultural gender norms.

Many voluntary sector interviewees were critical of the effectiveness and impact of some of the existing programmes. For instance, there was concern that strategies such as cultural sensitivity training for health professionals or needs assessment of particular groups have been in existence for many years, but with little noticeable improvement in targeted service change to meet specific needs of vulnerable migrant women. One interviewee spoke of a pilot project commissioned by the CCG starting up in her area: ‘it will not be an actual service, it will yet again look at need and a directory of support services, signposting and training people, helping mainstream GPs and their staff to signpost more effectively’. Another area of concern around effectiveness related to the provision of translation and interpreting services in healthcare delivery. There is reported inconsistency in local areas with funding cutbacks and reorganisation of services resulting in patients relying on doctors’ communication skills or on family or friends despite long-standing evidence that this is bad practice in terms of maintaining patient confidentiality, particularly where there is a possibility of family control over vulnerable women or a reluctance on their part to divulge health conditions in the presence of people they know well. As one woman said to the healthcare provider: ‘they are giving me a leaflet about a well woman clinic but how can I talk about these things with my son?’ Advice and training provided to frontline healthcare staff on supporting migrant patients in one area of interaction – for instance registering with a GP – do not always take into account other areas of unmet need experienced by the patients. For example, one voluntary sector provider presented local evidence that registration with GPs is less of an issue for Roma and other Eastern European migrant women than ongoing problems around obtaining appointments, with at least some of the reasons to do with Practice reception staff not making an effort to understand different accents:

To get an appointment is a big problem … the telephone system makes it particularly difficult actually, she was saying, she is Slovak and people say to her please make an appointment, so she phones up and with her accent there is still no appointment whereas her colleagues who are English phone up [and] there is an appointment. So there is discrimination.

The key point raised by interviewees, particularly in the voluntary sector, is that despite the existence of (relatively small-scale) local initiatives for health professionals such as needs assessment, training and information on signposting, real evidence of service change that meets the variety and interacting health needs of vulnerable migrant women is relatively limited.

Commissioners of health services and statutory healthcare providers were more positive about joined up services provision between the statutory and voluntary sectors than were their voluntary sector colleagues. Commissioners stressed the contribution of voluntary sector specialist provision on tackling staff burden in mainstream health services. As one commissioner put it:

The hospital trust and the voluntary sector work really well together and the hospital trust really like the voluntary sector providing this additional support because it relieves pressure of the community midwives who would otherwise have to sort out a lot of these issues for the women.

Voluntary sector providers were positive about the work they do around holistic outreach approaches and wrap-around support for hard-to-reach migrant categories, but felt somewhat unsupported by the lack of recognition given to the roles they play in enabling better access and better outcomes for migrants: ‘the voluntary sector is by and large motivated by a desire to help and they are not bureaucratic and they speak for people who are voiceless and [CCGs] should be engaging with them and supporting them’.

Human (health) security for vulnerable migrant women?

This article has attempted to examine the relationship between migration, gender and human security through a case study of policies and practices relevant to access to healthcare among vulnerable migrant women in local areas in England.

The empirical evidence discussed in this article shows that providing health security for vulnerable migrant women in a way that takes into account their circumstances and needs, is not yet a paramount concern that is enshrined in policy and healthcare commissioning in England. Among the many reasons for this is the lack of information on social determinants of health and health needs of specific population categories of migrants in local areas. For women there is a gap in understanding the effects of multiple interacting factors of gender, class, national origin, ethnicity, legal immigration status, that place some migrant women in disadvantaged positions in receiving society social structures. Largely in the absence of disaggregated gender sensitivity data, policy and service commissioning continue to cover well-trodden general service pathways for migrants. The evidence reveals that it is service providers in voluntary organisations in local areas that are most successful in identifying and addressing the health insecurities of different categories of vulnerable migrant women, associated with diverse migration histories and post-migration circumstances. However, the evidence also reveals that they operate in an environment where barriers include difficulties in translating specific needs of migrant women to mainstream health provision, and ever-increasing hostile policies towards migrant entitlements to healthcare. For the human rights, capabilities and needs of migrant women in receiving societies to be fully realised, existing service pathways and interventions must be re-examined and new health and social strategies that challenge multiple, intersecting insecurities must be developed.

Footnotes

Acknowledgements

I am especially grateful to Rosalind Bragg and Rayah Feldman at Maternity Action for their advice and support throughout the project.

Funding

I am grateful to the Women’s Health and Equality Consortium and Maternity Action in England for funding the project on which this article is based.

Notes

Author biography

Hiranthi Jayaweera is a Research Associate in the School of Anthropology in the University of Oxford and was a Senior Researcher at the Centre on Migration, Policy and Society (COMPAS) in the University of Oxford from 2005 to 2015. She has a particular research interest in issues around global migration and health, and the integration of migrants particularly in the UK, and has undertaken quantitative and qualitative research in both areas. Hiranthi has a DPhil in Sociology and has researched, taught and written about issues related to social divisions, particularly gender and ethnic divisions in the UK. Before working at COMPAS she was a researcher at the National Perinatal Epidemiology Unit (NPEU) in the University of Oxford.

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