Impacts of the Interim Federal Health Program reforms: A stakeholder analysis of barriers to health care access and provision for refugees.

Antonipillai, Valentina ; Baumann, Andrea ; Hunter, Andrea 等

The United Nations High Commissioner for Refugees reports that there are 65.3 million forcibly displaced migrants worldwide. (1) Of these migrants, 21.3 million are refugees seeking asylum from the endemic violence and human rights violations in their homelands. (1) In 2015, Canada opened its doors to 32 000 refugees, including government-assisted refugees (GARs), privately sponsored refugees (PSRs) and refugee claimants, all of whom are eligible to receive health care coverage under Canada's Interim Federal Health Program (IFHP) policy. (2) Prior to 2012, comprehensive health care coverage was available under the IFHP for GARs, PSRs, protected persons, refugee claimants and refused refugee claimants with negative decisions under appeal or review, or those awaiting deportation. (3) Government-funded health care insurance included basic health care, supplementary health care and drug coverage, to promote equitable treatment of vulnerable individuals, regardless of claim approval or country of origin. (3)

In 2012, changes to Canada's refugee health policy were introduced through the IFHP, significantly reducing health care coverage for certain refugee populations and resulting in the loss of insured medical care and hospital service provisions for many who had previously been covered. (4-6) Concerns for refugees and claimants, voiced by Canadian health care organizations and professionals, prompted the Federal Court of Canada to reassess the impact of the IFHP changes. (7,8) Within one month of the introduction of the 2012 IFHP reforms, eight national health associations expressed their apprehensions and opposition to the changes. (7,9,10) On February 25, 2013, a legal challenge launched by the Canadian Doctors for Refugee Care with the Canadian Association for Refugee Lawyers was successfully appealed to the Federal Court of Canada. (11) The court deemed that the IFHP reforms violated section 12 of the Canadian Charter of Rights, constituting "cruel and unusual treatment" of vulnerable refugee populations. (12) Furthermore, the court ruled that the 2012 IFHP cuts were "of no force or effect", encouraging the implementation of "health insurance coverage that is equivalent to that to which... [refugees were] entitled under the provisions of the pre-2012 IFHP". (12)

On November 4, 2014, the Federal Government of Canada announced the introduction of "Temporary Measures for the IFHP". (13) This new program reform was not a full reversal of the 2012 cuts, as ordered by the Federal Court, but it did restore some key health services to select categories of refugee populations through a more complex system of health coverage, in which six types of coverage, instead of three, were provided (13) (see Table 1). Moreover, health care coverage gaps continued to exist for refugees and refugee claimants under the new program, resulting in the formulation of provincial government-led programs and clinics for newcomers aimed at bridging the health care access gap for refugees. (14,15)

This study addresses the gap in the literature regarding the impact of the 2014 IFHP reforms on health care access and provision for refugees and refugee claimants by examining stakeholder views. Stakeholders possess critical insight that brings information to the deliberation process of policy, aiding policymakers to make decisions that are more likely to avoid unintended consequences and to fit into existing contexts. As policy-making is an information-intensive process, stakeholders who possess tacit knowledge of the current situation possess value. (16) Furthermore, policy effectiveness can be judged using several methods, one of which is to examine the acceptability of a policy by stakeholders. (17) The impact of refugee health policy is of wide significance, given the increasing volume of displaced people seeking refuge in Canada and around the world. (1) Examining the IFHP reforms is important for refugee-serving providers, organizations and policymakers, as the study contextualizes the problem of introducing reforms to refugee health policy and reveals the subsequent complexities involved in accessing and providing health care for refugees and refugee claimants.

METHODS

Semi-structured key informant interviews were conducted with 23 stakeholders. Using a stakeholder identification framework, (18) four stakeholder groups were identified: policy-makers and government officials (PG), professionals and practitioners in the field of refugee health (PP), refugee-serving civil society organizations (CSO) and refugees and refugee claimants (RRC). Policy-makers and government officials were represented at the national, provincial and local levels. Refugees and refugee claimants were included if they arrived in Canada between 2012 and 2015, having experienced the IFHP reforms. This stakeholder category included Convention refugees, (19) refugee claimants, as well as claimants who were refused or were ineligible for refugee status within the time period. The RRC participants were from designated * and non-designated countries of origin, spanning three continents: Africa, Asia and Europe (see Appendix A).

Ethics approval was obtained from the Hamilton Integrated Research Ethics Board. Purposive sampling methodology was used to recruit key stakeholders in consultation with experts in the field of refugee health and policy. Stakeholders were sampled if they were affected by or able to influence the IFHP policy process. (20) Interviews were conducted between May 2015 and August 2015. As nearly 50% of refugees are received by and resettled in Ontario, (21) the majority of stakeholders were interviewed across various cities within the province. Interview guides were constructed in consultation with experts in refugee health and qualitative research at McMaster University. The interview style and probes were developed to promote a conversation with stakeholders during the interview, maintaining a "conversation with a purpose" style using an openended approach to gather data. (22) Interviews lasted 20-90 minutes and were recorded. All 23 digital recordings were securely stored and transcribed by the primary investigator (VA).

A stakeholder analysis was conducted by systematically gathering and analyzing qualitative data to obtain insight into stakeholder positions, interests and influences regarding the 2014 IFHP reforms. To understand stakeholder experiences as a result of the policy reforms, a phenomenological approach was employed to analyze stakeholder perceptions. (23,24) Themes were abstracted using a constant comparative approach with QSR International NVivo 10. Positions of stakeholders and barriers to providing and accessing health care for refugee populations emerged. The coding process incorporated both a priori codes based on the literature and inductive codes derived from the data. Specifically, data analysis was guided by a modified version of the Health Care Access Barrier model, including cognitive, structural and financial barriers, (25) with the addition of socio-political barriers (see Figure 1). (26) Moreover, a stakeholder map was generated to analyze the relationship between stakeholders' positions on the IFHP 2014 reforms and their ability to influence policy. (27) The quality of the results was confirmed by verifying rigour through triangulation, thick description and NVivo 10 audit trial. (28)

RESULTS

Several common themes emerged from the perceptions of refugee health stakeholders regarding barriers to accessing and providing health care for refugee populations during the 2014 IFHP reforms. Only four barriers to health care access were common across all four stakeholder groups: lack of awareness and miscommunication, lack of continuous and comprehensive care, negative political discourse and increased costs of care.

Cognitive barrier: Lack of awareness and miscommunication

A lack of awareness and miscommunication about the IFHP was a barrier to the provision of health care for refugees and refugee claimants. The implementation of the new Temporary Measures for the IFH Program on November 4, 2014, involved no efforts by the federal government to facilitate awareness except by listing coverage details on the official website. Lack of efforts to implement complex plans resulted in persisting confusion initiated by the 2012 IFHP retrenchments as to refugee patient eligibility for services. According to a stakeholder,

"The government is doing the base minimum as opposed to doing the right thing. The implementation has been terrible because there has not been any significant communication that is actually going to the providers, or to the refugee lawyers, or to the refugee-serving organizations, or to the refugees themselves, because confusion means that less people will know that they are eligible and confusion will mean that less providers will know what is eligible and therefore, the end result will be that refugee claimants will not have access." (PG2)

The confusion and complexity of coverage plans deterred providers from offering services covered under the program. One physician summarized the impact, stating,

"Physicians who accept IFH a year ago still are not accepting it now and part of that is although there is increased scope of insurance coverage many people just don't understand it ... [the coverage plans] are so complicated, so people often get turned away in private offices, or be asked to sign forms assuming responsibility for financial costs ... I think for those who understand it, it's lovely to know that children now have the same coverage that they had in the past, but if you survey a lot of health care workers I'd be surprised if they actually understood that." (PP2)

Moreover, a lack of IFHP awareness exists among refugees and claimants. According to a refugee-serving provider,

"People are not aware of what's going on especially with so many changes ... I cannot name you one client out of these 300 or 400 files that came here and knew that [the IFHP] is their health coverage." (PP6)

The lack of awareness limited refugees' ability to understand or question the circumstances of their care. As one refugee stakeholder indicated, "We don't know why we pay for services now, because first everything is covered and then in 2012, after then, everything was paying, it was the system." (RRC2)

Structural barrier: Lack of continuous and comprehensive care

Most participants expressed opposition to the reforms because there was a lack of continuous and comprehensive care accessible to refugees and refugee claimants. Refused refugee claimants and people applying for pre-removal risk assessment did not have access to health care coverage. (13) A key stakeholder relates an additional example of the impact of discontinued coverage:

"Some people have trouble accessing [the IFHP] because they fall into sort of the gray area between the application that they are going to make as a refugee claimant and their actual arrival on Canadian soil and so we have seen ... one gentleman who was in the hospital for a week with no coverage and he didn't have coverage because he never made it to his initial citizenship and immigration interview and so he was falling into that gray area. We've had other people like that but not so severe as that one gentleman who came up with a bill for $20,000." (PP5)

Furthermore, privately sponsored refugees also experienced limited health care coverage upon arrival in Canada. They are refugees recognized by the United Nations High Commission for Refugees, (29) yet they only received basic health care coverage in Canada. This included physician and hospital visits as well as diagnostic and laboratory tests. (13) If they were in need of prescription medication or supplementary care, they were only covered for these services if their condition posed a threat to public health or public safety. The lack of comprehensive care was expressed by the majority of stakeholders as a barrier to appropriate access:

"[Those affected by the cuts] include people from such places as Syria where there is no doubt that people are in need of protection, and even those people are not getting medications covered. So if somebody is coming from Syria, coming as a privately sponsored refugee and they have cancer, it's too bad for you, your cancer medication is not covered." (PP3)

Socio-political barrier: Political discourse

Many stakeholders recognized that "Canada is a nation of immigrants and refugees", yet throughout the political discourse, actors inappropriately referred to refugee claimants as queue jumpers. Interviewed stakeholders explained the impacts of the negative political discourse on accessing health care:

"There are two different lines--it's [the discourse] conflating immigration policy with refugee policy and rules on purpose and ... [it] feeds that kind of mean spiritedness that wants to protect Canada from some, you know, infusions of people breaking the rules and so they're trying to make it sound like refugees are rule breakers as opposed to legitimate immigrants that wait their turn and come when asked." (PP3)

"The negative discourse results in social stigma around all refugees and claimants labeling them as "bogus" without consideration of those that are genuine in need of humanitarian aid. Stigma discourages refugees and claimants from seeking help within the Canadian health care system." (PG4)

"It's a program that we should be proud of and instead of that, the political discourse ... is trying to tarnish it, as though people are misusing the program, and that they're not entitled to it, and that they're "bogus" and "failed". All of these negative words make people feel embarrassed to seek help so, that does affect access." (PG2)

Financial barrier: Increased costs

Stakeholders perceived the IFHP reforms over the past four years as having increased provincial spending. According to policy-makers: "As a provincial government, we looked at [all of the IFHP reforms] as a setback in health care" (PG5); "Ontario is picking up the costs so this is yet another insidious form of downloading." (PG4);

"The reforms have led to some refugees being denied care even when they are eligible ... so the provinces have to pick up the health care costs of people turning up uninsured in ERs in poorer health than they could be if they actually received their services earlier." (PG3)

Moreover, stakeholders reported that barriers to access included the financial cost of care placed on refugees and claimants:

"We just saw a [refugee] woman who came 7 months' pregnant. She came with malaria and was in the hospital for more than a week and because she went to the emergency they put her in the ICU and with all the specialists; they were sending her bills. Her bill is more or less $30,000 and she doesn't have a way to pay." (CSO2)

Additionally, as a result of the lack of awareness among care providers and refugees regarding the IFHP reforms, health care organizations were spending more:

"What community health centres have been reporting is that they are having to use their small amount of funding for refugees and refugee claimants who may actually be able to access IFH." (PG3)

Stakeholder views

The majority of policy-makers expressed views opposing the 2014 changes to the IFHP (n = 4), indicating that the refugee health policy changes did not ameliorate the devastating impact of the 2012 retrenchments experienced by refugee populations and, instead, exacerbated the problem of access and provision of health care. Many of the CSO and PP members held mixed views (n = 8). Participants who held mixed views supported the restoration of some services in 2014 but opposed the remaining limitations to health care under the IFHP. The majority of refugees and refugee claimants (n = 4) supported the 2014 IFHP reforms because the insurance plan offered in 2014 provided more coverage than their former plans, either in their country of origin or the 2012 plan previously provided under the IFHP in Canada:

"If it covers some health care then, of course, I support it. Nobody wants to pay so much money when they're sick. They have to pay the bills, the rent and then their medical bills." (RRC2)

Altogether, eight stakeholders expressed opposing views to the 2014 reforms, on the basis that the changes did not alleviate problems posed by the 2012 retrenchments; ten held mixed views, supporting the reinstatement of some services in 2014 but opposing the remaining cutbacks; four supported the 2014 reforms; and one did not comment. The stakeholder map (Figure 2) displays participant positions and their ability to influence the policy. The map categorizes participants as low-priority, advocate, antagonistic or problematic stakeholders. Low-priority individuals support the policy but cannot influence policy change; advocates support the policy and have a high influence over the policy process; problematic stakeholders oppose the policy but do not have enough influence over it; and antagonistic stakeholders oppose the policy and retain high influence to change it. (27) The majority of stakeholders were categorized as antagonistic or problematic, which reflects their opposing and mixed views regarding the 2014 changes to the IFHP and reveals a need for stakeholder engagement before future changes to the IFHP are implemented. Most stakeholders expressed opposition or mixed views towards the reforms in 2014 as a result of the aforementioned barriers to accessing and providing health care.

DISCUSSION

Principal findings

The majority of participants expressed opposing and mixed views regarding the 2014 IFHP reforms and were subsequently categorized as problematic and antagonistic stakeholders, because they believed that the 2014 changes did not provide comprehensive coverage for refugees. Instead, stakeholders conveyed the impression that with respect to the 2012 retrenchments these changes both created and contributed to persisting barriers to health care access and provision for refugees. This is a significant finding given that a wide spectrum of views were included and only a small number of respondents represented refugee advocates. Instead of promoting equitable health outcomes for a vulnerable group of refugees, the 2014 IFHP reforms continued to retrench coverage, which prevented refugees and claimants from having access to continuous and comprehensive health care. Moreover, there was a lack of awareness and miscommunication regarding the 2014 IFHP reform content, eligibility criteria and coverage levels, which contributed to the immense confusion among stakeholders. The resulting confusion led some providers to refuse care to refugees or ask refugees to assume financial costs for their health care, despite their inability to afford them. As a result, refugee populations would delay seeking health care until an emergency, at which point the province and health care organizations would pay the costs. The negative political discourse also contributed to stigma and tensions within communities that prevented refugees from accessing health care.

Strengths and limitations

The diverse array of perceptions retrieved from a variety of refugee health stakeholders is a notable strength of the study. The key insights obtained from stakeholder perceptions have contributed to understanding the IFHP reform landscape in 2014 for incoming refugee populations and may explain long-term consequences faced by these individuals after resettlement in Canada. The stakeholder analysis provides point-in-time snapshots related to the IFHP 2014 reforms in which stakeholder positions and influence are subject to change. Therefore, a limitation of the study is that the data obtained are valid only for the time during which they were collected. (30)

Implications

In contrast with non-public actors, such as professionals and organizations that administered the changes to refugee health policy, "institutional contours of the Canada Polity have led to a situation in which publicly accountable actors tend to have less of a national reach". (31) The government's minimal effort to coordinate and consult with key stakeholders, including consumers (refugees) and administrators, led to one of Canada's main challenges regarding the implementation of effective refugee health care reform. The paucity of stakeholder engagement in formulating and implementing the IFHP reforms in 2012 and 2014 has resulted in unintended consequences. Moreover, limited collaboration between federal and provincial governments over the past four years has contributed to the development of a fragmented system whereby provincial-led coverage programs and clinics for newcomers attempted to bridge the gap. (15)

In response to the confusion created by the reforms and the concerned voices of many stakeholders, the newly elected Liberal Government of Canada restored comprehensive health care coverage for all refugees and claimants through the IFHP on April 1, 2016. (32) In a press release, the government acknowledged the barriers associated with the IFHP retrenchments in 2012 and asserted that the IFHP restoration in 2016 "will improve the health outcomes of refugees and asylum claimants, while also protecting public health for all Canadians. Restoring the Interim Federal Health Program will also provide financial relief to Canadians who privately sponsor refugees, reduce the administrative burden faced by health-care professionals serving refugees, and ease health-care funding pressure on provincial and territorial governments". (33) To advance these objectives and to avoid the unintended consequences resulting from reforming the IFHP in the future, a commitment to data collection, information sharing and evidence-informed policy-making with the inclusion of stakeholder dialogues is necessary. Without this systematic and comprehensive approach, reforming the IFHP will result in social and human costs, such as those revealed by stakeholders in this study. Future research is needed to assess the effectiveness of the IFHP in achieving equitable health outcomes for refugee populations. Efforts that are aimed at integrating insights from relevant research could both facilitate policy change and, ultimately, improve health outcomes for vulnerable refugee populations.

CONCLUSION

This study reveals key stakeholders' perception that the 2014 changes to refugee health policy exacerbated existing barriers and generated additional barriers to access and provision of health care, barriers that deter refugees and claimants from seeking health care and consequently lead to health outcome disparities for a vulnerable population. In Canada, policy-makers and government officials, civil society organizations, and professionals and practitioners expressed opposition to the 2014 IFHP reforms, reporting that the lack of communication and awareness about the reforms created confusion, which contributed to the protraction of the decreased provision of care for refugees initiated by the 2012 retrenchments. The 2012 and 2014 IFHP changes have led to the deterioration of health for some refugees, as the reforms prevented access to comprehensive and continuous care. Stakeholders emphasized that the negative political discourse and increased financial burden prevented refugees from accessing health care. Overall, the reforms to the IFHP in 2014 and 2012 transferred refugee health costs and responsibility from federal to provincial authorities, resulting in bureaucratic strains, inefficiencies and overburdened administration, which contributed to confusion. Canada's experience may provide other nations considering similar regulations with insights into the impacts of retrenching refugee health policy. Given the global refugee crisis, Canada's newly elected government has renewed its focus on welcoming refugees and in 2016 reinstated the coverage provided through the pre-2012 IFHP. This was a crucial step forward by the nation to remedy some of the consequences endured by refugee populations, to reverse some of the costs incurred by Canadian provinces and to provide an equitable response to refugees seeking asylum during these troubled times.

doi: 10.17269/CJPH.108.5553

APPENDIX A Table A1. Policy-maker and government official stakeholders Stakeholder Description Influence Position Policy-maker 1 Works at the policy, Moderate Opposed research and consulting level regarding immigration and refugee policy; former government official Policy-maker 2 Government official High Opposed involved in health at the federal level Policy-maker 3 Works at the policy Moderate-low Opposed and research level regarding refugee and refugee claimant immigration and health policy Policy-maker 4 Works at the policy Low Not disclosed and public awareness level of immigrant and refugee policy Policy-maker 5 Government official Moderate-low Opposed formerly involved in immigration and refugee policy at the provincial level Table A2. Civil society organization stakeholders Stakeholder Description Influence Position Organization 1 Provides leadership programs, Moderate Mixed training and employment opportunities for refugees and claimants Organization 2 Provides settlement services Moderate Mixed and primary health care for refugees and refugee claimants Organization 3 Provides legal services in Low Mixed counselling, immigration, refugee and family law, and aid for refugees and refugee claimants Organization 4 Provides primary health care, Moderate Opposed employment and housing services for refugees and refugee claimants Organization 5 Provides legal services for High Mixed refugees and refugee claimants, and public legal education and law reform work Organization 6 Provides settlement and Moderate Opposed integration services for refugee claimants Table A3. Professional and practitioner stakeholders Stakeholder Description Influence Position Professional 1 Provides health care to Moderate Mixed refugees and refugee claimants Professional 2 Provides health care to High Opposed refugees and refugee claimants Professional 3 Provides settlement Low Mixed services to refugees and refugee claimants Professional 4 Provides legal services Low Opposed to refugees and refugee claimants Professional 5 Provides legal services High-moderate Mixed to refugees and refugee claimants Professional 6 Provides settlement Low Mixed services to refugees and refugee claimants Table A4. Refugee and refugee claimant stakeholder characteristics Stakeholder Description Influence Position Refugee 1 Refugee since February 2014 Low Supportive from designated country of origin * Refugee 2 Refugee claimant since 2011 Low Supportive from non-designated country of origin ([dagger]) Refugee 3 Refugee claimant since 2009 Low Supportive from designated country of origin Refugee 4 Refugee claimant since 2012 Low Mixed and current Convention refugee ([double dagger]) from non-designated country of origin Refugee 5 Failed refugee claimant in Low Mixed 2012, applied for humanitarian and compassionate consideration. Convention refugee since 2015 May from designated country of origin Refugee 6 Convention refugee since Low Supportive December 2013 from designated country of origin * Designated countries of origin are countries deemed by the Federal Government to be places that do not normally produce refugees, and that respect human rights and offer state protection. Refugees from DCOs are subjected to shorter claim processing timelines, prohibited from appealing failed refugee claims and, if their claim for refugee status is denied, cannot reapply invoking humanitarian and compassionate grounds for up to one year. ([dagger]) Non-designated countries of origin include countries that are not deemed safe for return by refugees. ([double dagger]) Convention refugees are persons "owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, due to such fear, is unwilling to avail him/herself of the protection of that country; or who, not having a nationality and being outside the country where he/she normally lives, is unable or, due to such fear, is unwilling to return to it." (19)

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Received: March 1, 2016

Accepted: April 21, 2017

Valentina Antonipillai, MSc, [1,2] Andrea Baumann, PhD, [2,3] Andrea Hunter, MD, [4] Olive Wahoush, PhD, [2,3] Timothy O'Shea, MD [5]

Author Affiliations

[1.] Health Policy PhD Program, McMaster University, Hamilton, ON

[2.] Global Health, McMaster University, Hamilton, ON

[3.] School of Nursing, McMaster University, Hamilton, ON

[4.] Paediatrics, McMaster University, Hamilton, ON

[5.] School of Medicine, McMaster University, Hamilton, ON

Correspondence: Valentina Antonipillai, Health Policy PhD Program, McMaster University, Department of Health Research Methods, Evidence and Impact, 1280 Main Street West, Hamilton, ON L8S 4L8, Tel: 905-525-9140, E-mail: antoniv@mcmaster.ca

Conflict of Interest: None to declare.

* Designated countries of origin (DCOs) are countries deemed by the Federal Government to be places that do not normally produce refugees and that respect human rights and offer state protection. Refugees from DCOs are subjected to shorter claim processing timelines, prohibited from appealing failed refugee claims and, if their claim for refugee status is denied, are unable to reapply invoking humanitarian and compassionate grounds for up to one year.

Non-designated countries of origin are countries that are not deemed safe for return by refugees.

Caption: Figure 1. Health care access and provision barriers

Caption: Figure 2. Stakeholder map: Influence vs. position Table 1. Types of coverage associated with the 2014 reforms to the IFHP 2014 Interim Federal Health Program reforms Type of coverage Population receiving What does this mean? coverage Type 1: Basic, * Government assisted All health coverage supplementary, and refugees: Resettled benefits provided prescription drug refugees who are or coverage were receiving monthly income support through the Resettlement Assistance Program * Children (below 19 years of age) * Victims of human trafficking * Individuals who resettle in Canada under the Citizenship and Immigration Minister's humanitarian and compassionate considerations Type 2: Basic and * Pregnant women Lack of supplementary prescription drug coverage (vision and coverage * Rejected refugee dental care) claimants from non- deportable countries (Iraq, Afghanistan, Congo, South Sudan, Gaza, Somalia and Syria) Type 3: Basic and * Privately sponsored Lack of supplementary Public Health and refugees coverage and limited Public drug coverage Safety (PHPS) * Active refugee prescription drug claimants currently coverage awaiting a claim decision * Protected persons Type 4: PHPS basic * Ineligible refugee Lack of supplementary coverage and PHPS claimants coverage, limited prescription drug drug coverage and coverage * Suspended refugee limited basic claimants coverage * Rejected refugee claimants who can be deported to country of origin * Refugee claimants eligible to apply for pre-removal risk assessment Type 5: Coverage for * Individual detained Not specified persons detained by the Canadian under the Immigration Border Services and Refugee Agency Protection Act Type 6: Coverage for * All individuals who Only immigration the immigration enter the country medical examination medical examination without permanent is covered resident status and are provided with temporary or no immigration status