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Population aging in Brazil is a fact. Chronic degenerative conditions demand changes in the care process. The training of health professionals, especially doctors, is still fragile. The Federal Council of Medicine (CFM) in 2018 identified that only 1,817 physicians were registered as geriatric specialists. At this time, 165 vacancies were also offered for residency programs in geriatrics in Brazil, with a 50% occupancy rate. In addition to this, there is a network of care that is not articulated and that is further divided with the care of communicable diseases. The continuous and permanent education of professionals working in Primary Health Care (PHC) is essential to developing a care network for the elderly population.  

The matrix support is described as: 

A “Way of producing health in which two or more teams, in a process of shared construction, create a proposal for  pedagogical and therapeutic intervention” 1

A Matrix support is considered an important device for co-responsibility of care and establishment of networks. Two types of teams are identified: the reference and matrix support teams. The reference team: responsible for coordinating and conducting cases, in a longitudinal manner, with health responsibility and building a bond; and, the matrix support: operate as a specialized rearguard, assisting with the handling of cases in a shared and dialogical way, expanding the care repertoire of the professionals of the reference team2

Matrix support works in two dimensions. Assistance is focused on direct actions with service users, based on the demands identified in the shared spaces; and, technical-pedagogical directed to reference teams, of educational support, to expand their technical capacity and shared case management2

Therefore, the matrix support of family health teams (FHS) is a strategy, because of the small number of geriatric specialist professionals and the importance of working with the elderly population in the community. These facilitator actions are described in the Entrustables Professionals Activities (EPAs)3 for the formation of the specialist in geriatrics and contribute to the care of the elderly in the community as proposed in the National Health Policy for the Elderly4

Objective 

To develop co-management care work between primary and specialized care; involve geriatric residents in the process, develop skills to articulate care with the network, identify the network available in the construction of a therapeutic plan; train doctors and residents of the FHS in the care of the elderly with complex cases, seek unique therapeutic plans based on the identified demands. 

What Was Made 

The work started in November 2016 with meetings with the municipal management, unit coordination, and scheduling of team meetings. Their aim was to present the proposal, get to know the teams, raise their problems in caring for the elderly, identify the risk recognition in each team, and schedule shared visits or consultations. Four meetings were held. Home visits and consultations started in January 2017. A questionnaire was proposed to be applied to all the elderly (60 or more) in the territory by community health agents, composed of questions to identify the risk of frailty (PRISMA7)5, and, established participation in one meeting per month with each team, with the objective of discussing and monitoring complex cases, scheduling consultations or home visits, and decide on forward co-management within the geriatric service. 

The recognition of the elderly in the territory (1,501 elderly registered in the unit), identification of fragility risk was carried out (450 questionnaires were applied, with risk identified in 107, also 100 elderly were identified as homebound). 182 consultations were made, 121 of which were home visits (Table 1). 

Table 1: Consultation and Home Visits (HV)Per Year 

Photos by the author 

 

Our visits in Google maps: Figure 1 

On the elderly day of the 2019 vaccination campaign, an active search was carried out with the application of PRISMA 7 among 204 elderly people in the community. 

Photo by the author 

In 2019 we also held a meeting to discuss elderly abuse with community heath agents, because this issue is challenging for them since these professionals’ work involves visiting families in their homes. 

Results 

The demands for building a proposal in conjunction with the teams were identified: the process of identifying elderly people at risk is not clear to the teams, the frequency of visits by professionals does not follow therapeutic planning based on demands and needs, resolvability is compromised by the lack of longitudinal follow-up of cases, and social risks are very significant and require a specific approach. 

The evaluation carried out by the unit's coordination, that was answered by three professionals (from a total of six) where the displacement difficulty, low education, violence in the elderly; and, the lack of knowledge in the area and the short time for consultation are all difficult factors. Positive factors included support for complex cases, an expanded view, and a better understanding of care by professionals. 

In the annual evaluation of the residency training, four students reported. Among these, the importance of the work of community agents and the team in caring for the elderly was pointed out, along with the importance of the formation of home visits, in the understanding of the social and health context, as well as in contact with reality, the overload of the team in their daily practice which makes it difficult to work with the elderly, where priority is not identified along with the outcome of consensual interventions with the teams. 

Conclusion 

This is a rich scenario for the training of specialists and allows for the proposition of strategies for the organization of the care network from Primary Health Care as the organization of the work process, based on the identification of risk, with the establishment of lines of care , based on the identified demands, including planning home visits, proposing criteria for the referral to the geriatric services, and result indicators (vaccination, falls in 12 months, number of medications in use, percentage of elderly mapped in the identification of risk, number of referrals to specialty, number of home visits). 

Works Cited 

1- Guia prático de matriciamento em saúde mental / Dulce Helena Chiaverini (Organizadora) ... [et al.]. [Brasília, DF]: Ministério da Saúde: Centro de Estudo e Pesquisa em Saúde Coletiva, 2011. 

2- Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes /organização Laura Camargo Macruz Feuerwerker, Débora Cristina Bertussi, Emerson Elias Merhy. - 1. ed. - Rio de Janeiro : Hexis, 2016.   

3-Leipzig RM, et al. Geriatric Academic Programs End-of-Training Entrustable Professional Activities for Geriatric Medicine. J Am Geriatr Soc 62:924–929, 2014 

4- Brasil, 2006. Política Nacional de Saúde da Pessoa Idosa.

5- Raîche M, Hébert R, Dubois M-F. Guide d’utilisation du questionnaire PRISMA-7 pour le repérage des personnes âgées en perte d’autonomie modérée à grave.  Dans Hébert R, Tourigny A, Gagnon M.  Intégrer les services pour le maintien de l’autonomie des personnes. Québec, Edisem, 2004; pp 153-175. 

Author bio 

Luciana Branco da Motta M.D, M.Sc, Ph.D. in Public Health is the Geriatric Service and Residency Program Coordinator at the Rio de Janeiro State University Hospital.  She has worked as a geriatrician since 1991and completed her Fellowship in Medical Education from FAIMER Brazil in 2009. Branco da Motta can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..

Summary 

The rate of population aging is growing rapidly across the globe and requiring governments and health care systems to evolve and align with the needs of older populations. Interprofessional education implementations during training and post-training should be executed to produce teams that can best deliver integrated care. All levels of the government, from international entities to local sovereignties, should coordinate for knowledge sharing and delivery, implementation, and the creation of processes and programs to build age-friendly societies.  

Article 

Countries across the world are facing unprecedented economic and sociopolitical challenges caused by a rapidly aging society. According to projections by the United Nations, global life expectancy is projected to increase by 15 years, from 59 years old in 1975 to 74 years old by 2025. The share of the population over 65 years old is growing rapidly. It is estimated that this cohort will overtake the size of the youth (0-14 years old) and younger population groups (15-24 years old) by 2070 (United Nations, 2019). The etiologies of the trend differ depending on the economic status of the country. In low- and middle-income countries, this trend is largely explained by the result of lower infant mortality rates and declining fertility rates. While in high-income countries, the primary factor is largely explained by extended life expectancy due to technological advances.  

There are many issues that result from an aging society: rising demand for a more integrated, high-capacity health care system, along with a long-term care system. The fragmentation between care providers, institutions, and insufficient coordination of care among professionals of different backgrounds leads to a lack of communication and continuity of care, thus resulting in redundancy, high costs, and poor outcomes. Fixing the problem requires coordinating all stakeholders including health care workers, social workers, patients, and their families to provide seamless, person-centered care which can address the patients’ physical and mental health, as well as social needs.  

The implementation of integrated care will require major financing restructuring to support these comprehensive and large programs across different systems. For instance, Japan’s mandatory and public program “Long-term Care Insurance” (LTCI) that went into effect in 2000 provides various long-term care benefits for individuals. Some of these services include nursing homes, home helpers, and day care services with rehab. In this social insurance scheme, people aged 40 and over begin contributing to the system through premiums. Once members reach 65 years of age, they are able to access the benefits of the program. (John Campbell, 2020) Nevertheless, there is a global trend that the share of the working-age population is shrinking rapidly in comparison to that of the growing elderly population. Even with comprehensive and robust programs such as LTCI, the trend may still be a factor that causes national long-term care programs to become imbalanced and unsustainable in the long-term.  

The aging population issue not only requires significant health care and long-term care system reforms, it also requires future developments to create a more age-friendly environment. A major issue confronting the elderly population is social isolation which is consistently prevalent in low-, middle-, and high- income countries across the globe. Research has shown that in the majority of Organization for Economic Co-operation and Development (OECD) countries, social support declines with age, with older people spending less time in social interactions and feeling less support than their younger counterparts (OECD, 2020). These studies suggest that the cause is urbanization and modernization forces that lead to the degradation of the former family structure that has historically provided a safety net of support and care for elderly people. Consequently, the lack of intergenerational living arrangements and family support requires larger societal transformations to supplement these support services.  

This policy action paper aims to address the strategies governments and health care systems need to adopt to create a resilient society for an aging population. We aim to provide a holistic and inclusive framework for all levels of governing power as well as the health care system to solve this growing issue.  

Primary Research Questions 

A “Global Strategy and Action Plan on Aging and Health,” adopted in May 2016 by the World Health Assembly, focuses on strategic objectives to establish a framework for achieving “healthy aging for all.” The strategy calls on countries to commit to developing age-friendly environments, align health systems to the needs of older people, and develop sustainable and equitable systems of long-term care. It also emphasizes the importance of improved data, measurement, and research, and involving older people in all decisions that concern them. The following includes the non-exhaustive list of primary research questions that guided the research process:  

What measures should health care systems adopt for a successful integrated care model -- including social, long-term care, and other services -- that will best serve people living in an aging society?  

How can governments coordinate and lead various industries to support the transformation of communities and the built-environment toward one that is age-friendly and equitable?  

Methodology 

This policy action paper leverages a thorough review of literature, integration of expert lectures, and case studies via the TUFH Aging Society Institute, and in-depth interviews with global experts.  

Analysis/Findings 

The biomedical paradigm of health, which traditionally focused on biological factors as measures of health is an insufficient model to describe well-being. Rather, determinants of active aging and evaluation of well-being among the elderly should include economic, behavioral, personal, social health, social services, and physical environments (WHO, 2015). In addition, Hojman et. al recently published a study that used a novel nationally representative household survey to demonstrate human agency and dignity to also be important predictors of life satisfaction. (Hojman, Daniel & Miranda, Álvaro, 2017) 

Interprofessional Education (IPE) is when “two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.”(WHO, 2010) IPE serves as a powerful tool to provide team-based, value-driven health care that can satisfy the broad and complicated needs faced by the elderly population. Training in higher education and continuing education settings have not been sufficiently responsive enough to develop an adequate interprofessional workforce (Partnership for Health in Aging, 2014). 

Policy Action Recommendations 

The Role of Health care Systems in Building an Aging Society 

Health care systems should adopt certain process reforms in the education and training of their workforce and prepare them to operate in a complex environment. Specifically, within initiatives that can develop effective, multidisciplinary care to best support the diverse needs of an aging society.   

Reforms Needed in Training for a Health care Workforce 

Forms of Education and Training 

Health systems should provide opportunities to facilitate and embed team-based values, collaboration, and community mindfulness among practitioners. This includes promoting self-awareness and a deeper understanding of each team member’s role in patient care. These activities can lead to cultivating interpersonal skills such as leadership, communication, accountability, and ethical attitudes. For example, after training activities, facilitators can incorporate a period for reflection on teamwork to further strengthen the development of these skills. Experiential learning practices with reflection help link theories of teamwork and team function with the practical experience: what happens, or what should happen, in the health care practice. 

Contents of Education and Training 

Interprofessional education should not be limited to academic spaces. For it to be an effective tool for better patient management, health care systems should continue the training in the workplace and provide interprofessional continuing education credits. More specifically, specialties such as geriatric medicine should develop specialty-specific IPE curriculum involving common geriatric diseases. This type of IPE curriculum should be included in core geriatric competencies and be a requirement for accreditation standards. Other than IPE initiatives, the use of modern technology as an education tool has been deemed promising. Adaptive technologies such as medical imaging equipment, virtual clinic, and remote patient monitoring are helpful additives to ensure patient and provider well-being. For health care systems to continue the delivery of high-quality care, training opportunities for these technologies should be readily available.  

Receivers of Education and Training 

IPE training and recommendations should include all patient-facing workers, not only physicians and nurses. These members are pharmacists, social workers, nurse practitioners, physical therapists, and family members who also play significant roles in the care process. During the joint training process, caregivers with different positions can develop an understanding and respect for one another. 

Redefine Well-being and Develop Comprehensive Evaluations 

Health care systems should redefine patient well-being by incorporating dimensions beyond traditional economic and financial measurements. The recent report, “How’s Life? 2020,” demonstrates that GDP growth for a country did not always correlate with improved well-being of the population among OECD countries. This emphasizes the need to measure beyond GDP growth as an indicator for progress. Decisionmakers need to shift their understanding of well-being to one that is multidimensional, thus deserving a multidimensional measure. Institutions such as the OECD have already begun some of these efforts. In May 2011, the organization put forward the OECD Better Life Index which included 11 topics -- including both material living conditions and also quality of life. These topics included: housing, jobs, education, civic engagement, life satisfaction, work-life balance, income, community, environment, health, and safety. Each topic is measured with various indices to ensure the multitude of dimensions that truly capture the essence of well-being (OECD, 2011). Systems around the world need to move toward measuring patient outcomes using evaluations of well-being rather than response to medical treatment. Furthermore, it is imperative for patients to be included in the formation of the well-being indicators which can create a sense of empowerment and self-sufficiency.  

The Role of Local, State, National, and International Governance in Building an Aging Society 

As population longevity is extended, patients face a myriad of different forms of disability and functional dependency caused by chronic degenerative diseases. It is a non-discriminatory issue that will affect many sectors of the future economy -- health care, housing, income security, transportation, and recreation. It is important for decisionmakers to realize the obvious, and not so obvious, return on investment society can have when governments invest in enabling the well-being of older people. Some of these benefits include social cohesion, innovation, and workforce participation (WHO, 2015). Building age-friendly societies also ensures the preservation of dignity each individual should be granted throughout the course of their life. Among the many stakeholders, we believe that governments play the essential role of stewardship and guidance for a unified solution to this complex problem.  

Role of Local, State, and National Governments 

Among the governing powers, we propose the responsibilities each level should have to maximize impact. Historically, health-related activities and the delivery of health services have occurred at the local level and regulated at this level. However, because many local governing bodies often lack the technical expertise and resources for evaluation and innovation of new interventions, we believe upstream governing bodies at the state and national level can provide the policy frameworks and resources to lower level administrations.  

How to Incorporate Environmental Development and Design to Protect Aging Populations 

The second critical role in governance is for national governments to incorporate inclusive, age-friendly, community design principles into the city-planning and building process of their cities. 100 Resilient Cities was established in 2013 by The Rockefeller Foundation in response to the growing physical, social, and economic challenges faced by many cities in the 21st century. Countries can reference the 100 Resilient Cities project as they develop their own policies on how to create more age-friendly environments. Through our research, we recommend the following for cities to adopt:  

Implement Robust Public Transportation Networks 

Design public transportation systems (buses, trains, and subways) that are elderly-friendly and will allow for safe travel. Develop alternative local transport systems to augment existing systems to provide the elderly population with access to essential locations such as clinics, rehabilitation centers, community centers, grocery stores and more.  

Build Community Centers 

Community centers can serve as a place of congregation for many different activities to facilitate the well-being of individuals, especially the elderly. They can be tailored to be a multipurpose space for social gatherings, medical, and educational services. One example is the Comprehensive Care Center in Toyama City, Japan which includes “a medical center, culinary school and healthy cafe, a convenience store and pharmacy, public gymnasium, and privately owned sports club” (100 Resilient Cities, n.d.). In addition to improving social wellness, community centers can ensure economic well-being by providing the elderly with a learning center for career training courses. This promotes a culture of life-long learning and develops their skills to enable them to have multiple careers throughout their lifetime -- maintaining this population’s active role in the workforce and protecting mental cognition.  

Promote Social Connectivity Among Local Communities Through Various Volunteer Programs Which Can Be Activated During Pandemics, Natural Disasters, and Other Unexpected ‘Shocks’ 

As climate change produces stress within cities with extreme weather events, proper disaster preparation and response ensures that these natural shocks do not disproportionately affect the most vulnerable individuals. Especially the elderly which many studies have found face more adverse consequences than their younger counterparts (Cherniack, 2008). One example is the creation of the Neighborhood Disaster Prevention Associations which governments can rely on local volunteerism for adequate disaster response while fostering strong social bonds among communities. These associations are composed of local groups who are trained by the state to create community-led emergency plans and convey critical information during a disaster. They can be mobilized during a catastrophe to ensure specific groups are accounting for the elderly within the community.  

Create Financial Mechanisms to Incentivize Community-based Caregiving 

According to a recent report published by the American Association of Retired Persons (AARP) and the National Alliance for Caregiving (NAC), one in five adults are unpaid family caregivers with an increase in this population to 9.5 million adults who have become caregivers within the past five years (Schoch, 2020). As health systems transition to community-based care and more care will be provided in homes, it is important for families, governments, and the private sector to shoulder the growing caregiving burden together. Quebec, Canada has adopted various ambitious policies to adequately address this issue. Vivre et vieillir ensemble is a program in which family members caring for their older family members receive both a tax credit and financial assistance for their care responsibilities in the home (World Health Organization, 2015, p. 220). Governments can encourage the continuation of care to be delivered in homes by creating financial incentive programs that best support this endeavor.  

Role of International Community 

At the international level, we advocate for the creation of platforms that will allow for transnational actors to engage in knowledge sharing, exchange of information, and uniformed data collection of age-related data.  

Conclusion 

The continued drive for development of innovative medical technologies is ubiquitous among modern civilizations. This means that the current aging trend will continue to be a universal and unavoidable challenge. Immediate attention for united action to build an age-friendly society is urgently needed. Health care systems need to move toward offering human-centered and integrated care. However, this challenge is not the sole responsibility of medical communities. Comprehensive and coordinated actions from other industries and sectors are also indispensable. Societies that can successfully adapt to this changing demographic and make the necessary investments to enable individuals to live longer, healthier, and meaningful lives, will create societies that are more resilient and sustainable. 

Works Cited 

Cherniack, P.E. The impact of natural disasters on the elderly (2008) American Journal of Disaster Medicine. pubmed.ncbi.nlm.nih.gov/18666509/.  

Farrell, T. W., Luptak, M. K., Supiano, K. P., Pacala, J. T., & De Lisser, R. (2018). State of the Science: Interprofessional Approaches to Aging, Dementia, and Mental Health. Journal of the American Geriatrics Society, 66 Suppl 1, S40–S47. https://doi.org/10.1111/jgs.15309

Hojman, Daniel & Miranda, Álvaro. (2017). Agency, Human Dignity, and Subjective Well-being. World Development. 101. 1-15 

Organization for Economic Co-operation and Development (OECD). (2011). Better Life Index. stats.oecd.org/Index.aspx?DataSetCode=BLI

Organization for Economic Co-operation and Development (OECD). How’s Life? 2020: Measuring Well-being (2020). www.oecd-ilibrary.org//sites/9870c393-en/1/2/11/index.html

John Campbell. (2020). Japan’s Public, Mandatory Long-Term Care Insurance System [Video]. Retrieved from https://youtu.be/eCjAbgWvC20  

Partnership for Health in Aging workgroup on interdisciplinary team training in geriatrics. Position statement on interdisciplinary team training in geriatrics: An essential component of quality health care for older adults. J Am Geriatr Soc 2014; 62:961–965. 

Resilient Toyama: Toyama Vision 2050 Community, Nature & Innovation. (n.d). Rockefeller Foundation: 100 Resilient Cities.  

Schoch, D. Caregiving in the U.S. 2020. (2020). National Alliance for Caregiving (NAC) and American Association of Retired Persons (AARP).  

United Nations, Population Prospects 2019. (2019). https://population.un.org/wpp/Graphs/

World Health Organization. (2010) Framework for action on interprofessional education and collaborative practice 

World Report on Ageing and Health. (2015). World Health Organization. 

 

EXECUTIVE SUMMARY 

Migrant and Refugee Health experts (WHO) indicate that more people are on the move now than ever before. This rapid increase of population movement has important public health implications, and therefore requires an adequate governmental response. Ratified international human rights standards and conventions exist to protect the rights of migrants and refugees, including their right to health. Nevertheless, many refugees and migrants often lack access to health services and financial protection for health. COMMUNITY HEALTH recognizes that effective approaches to serve and engage remote and rural, indigenous, migrants and refugees, women, and elderly populations, often contrary to mainstream health policy, are often ignored, not included, or recognized in global, national, region policies and practices that inform mainstream practices. The overarching research question driving this policy action is: what are promising practices that can assist governments in implementing initiatives to promote the health of immigrant and refugee populations? The methods we employed are: 1) a review of the literature on best practices, 2) case study analysis of promising practices across two developed and one developing country, and 3) lectures and conversations with experts knowledgeable about such practices. Our findings indicate that initiatives to facilitate sustainable cross-government collaborations and incorporation of immigrants and refugees into the formal workforce including the health care sector are essential for governments to live up to the health as a human right standard. Failure to act will results in human rights violations, loss of economic power, severe strain on health care systems, increases in conditions exacerbated by social determinants of health such as substance use, violence, and infectious disease rates. 

CONTEXT 

The world’s immigrant population is on an unprecedented rise. Today, approximately one seventh of the world’s population, or 1 billion, is composed of immigrants (World Health Organization 2020). A primordial motivation for immigration is search for a better life which includes securing an education, employment, housing, and human rights protections (Klinger, 2020). The unprecedented rise of immigration around the globe is here to stay as it is fueled by the increased globalization and conflict, climate change, economic instability, and infectious disease seen in many countries around the world. As a result of the ubiquitousness of immigration, the profile and demographic characteristics or immigrants are changing. For example, in the U.S., which receives approximately 40% of the world’s immigrants, today’s immigrants are more likely to be educated, women, older adults, children, and refugees compared to a decade ago (Radford & Krogstad, 2019).  These changes in trends signify a need for national governments to shift their policies and approaches to accommodating immigrants and refugees in order to abide by the human right to health. Immigrants and refugees intersect with every aspect of society including the economy, education, health care, and policy sectors 

(National Academies of Sciences, Engineering, and Medicine, 2017).  It is important to consider the evidence indicating that immigrants, if given the opportunity, are important contributors to the economy of nations. In the U.S., it is estimated that immigrants contribute approximately $2 trillion to Gross Domestic Product by working at higher rates, supporting the elderly, and raising children who in great proportions exhibit upward social mobility (U.S. Department of Labor, Bureau of Labor Statistics, undated). 

Unfortunately, immigrants and refugees are often disproportionately impacted by social determinants of health as they face many challenges that place them at high risk of morbidity and mortality severely limiting their potential economic contribution. Many face treacherous journeys from their country of origin to the new destination and at the new destination face hostile immigration laws, policies and procedures that expose them to increased discrimination, violation of human rights, violence, detention, incarceration, lack of integration and access to health care services, unemployment, and lack of affordable housing (Casillas, 2006). 

The purpose of this policy/action paper is to highlight the initiatives that promote the priorities set forth by the WHO at a regional and local level underscoring how state and Local governments are ideally positioned to implement policies and practices that will most immediately contribute to the well-being of immigrants and refugees as they are at the frontlines. Promising partnership initiatives by South Africa (developed country), Mexico (a developing country) and two U.S. states (a developed country): New Mexico and Texas, on the U.S.-Mexico border will be discussed. Recommendations made are supported by a review of the literature and conversations with experts facilitated by the TUFH Migrant and Refugee Institute.  

PRIMARY RESEARCH QUESTIONS 

The following includes the non-exhaustive list of primary research questions driving our review of the need for Migrant and Refugee Health, and a recommended path for integration with health and education policies: 

  1. What are best practices to build and/or strengthen bi-national infrastructure and collaborations?
  2. How can bi-national initiatives support Refugee Doctors and Health Care Professionals in the care of refugee and migrant communities?
  3. How can Community Health Workers or other Health Professionals be trained and integrated into the care of immigrant and refugee communities?
  4. What complementary strategies can be incorporated into existing health policies? Can economic empowerment contribute to the reduction in vulnerabilities to communicable diseases for immigrants?
  5. How can the private sector be attracted to participate in initiatives protecting immigrants’ health?
  6. What facilitates the sustainability of initiatives to promote a long-term impact on targeted populations?

METHODOLOGY 

To explore the primary research questions, the development of this policy action paper included the establishment of terminology; a review of literature; integration of expert lectures and case studies via the TUFH Migrant and Refugee Institute; and content from interviews with global content experts. 

ANALYSIS/FINDINGS 

Literature Review Findings/Analysis 

Our literature review yielded information about innovative practices and indicated that bi-national agreements, coalitions, community-academic partnerships, and harnessing the power of technology are powerful tools that can bring sustainable capacity across systems to address the health needs of immigrants. In particular, building an informatics infrastructure seems essential to build capacity in the cross-sector collaborations within countries. Five components are proposed by Bakken as the building blocks of a solid infrastructure: 1) standardized terminologies and structures, 2) digital sources of evidence, 3) standards that facilitate health care data exchange among heterogeneous systems, 4) informatics processes that support the acquisition and application of evidence to specific clinical situations, and 5) informatics competencies. Presently, major barriers to data sharing are present including differences across countries in the provision and enforcement of laws that protect the confidentiality of patient medical information. Today, powerful technological innovations may facilitate the confidential exchange of information. However, political will and implementation of practices to facilitate trusting collaborations may be a precursor to data sharing.   

Case Study Examples/Findings/Analysis 

Initiatives, lessons, and recommendations from two case studies are discussed below. In the following section, promising practices to promote cross country collaborations and their implications for actions/strategies to promote the health of immigrants and refugees are discussed.  

Case Study: The U.S.-Mexico Border, United States 

The U.S.-Mexico border, a land stretch of 2,000 miles is the largest binational border crossing in the world. Four U.S. states including California, Arizona, New-Mexico, and Texas border six Mexico states. In 2019 alone, 610,000 undocumented immigrants crossed this border. The U.S.-Mexico border is an area characterized by diversity in terms of culture, economy, and disease profiles of residents as a developed nation meets a developing one. There is high cross-border mobility due to the economic interdependence yet sharp distinctions in the demographic characteristics of U.S. and Mexican residents.  

The area is also a primary destination for immigrants. For example, in 2019, approximately 300,000 immigrants from Central America arrived to border cities with the intention to cross into the U.S. This region of the world, as many others, is seeing an unprecedented increase in the number of immigrants fleeing conflict and extreme poverty.  As stated above, the demographic characteristics of immigrants are changing and this trend is reflected in the profile of recently arrived immigrants to the U.S.-Mexico border. Estimates indicate that a greater percentage of women and individuals > 60 years, than a decade ago, make up the migrant population. In 2018, 29% of migrants entering Mexico bound for the U.S. were women compared to < 10% a decade ago (Franco & Alcantar, 2019).  

The primary challenges that the U.S.-Mexico border faces include binational health care use, a high proportion of uninsured or underinsured individuals, and a high proportion of families with members who have mixed immigration statuses, migrant laborers, farmworkers, recent immigrants and undocumented immigrants. Public health issues are broad but reproductive and sexual health epidemiologic profiles suggest this is a health issue of special concern. For example, there is a very high birth rate coupled with high rates of unwanted pregnancies, reproductive cancers, gestational diabetes, and sexually-transmitted diseases.  Although each country has initiatives to promote sexual and reproductive health, efforts to address the needs of a binational/bicultural population that accommodates the needs of each country’s epidemiological and cultural profile is needed. Despite these challenges, several U.S. states and Mexico are devising and implementing initiatives, strategies to learn about the best efforts each country is leading and set objectives to strengthen the local infrastructure to improve the health and well-being of immigrants. This part of the world is not unlike other border crossings around the globe. Several initiatives and strategies put forth by U.S.-Mexico border entities can serve as an example of potential strategies that can be employed by nations around the globe in a concerted effort to improve the health of immigrants and refugees. Several initiatives undertaken will be described with implications for initiatives to safeguard the health of immigrants and refugees around the world and in the settings described including strengthening the capacity of health care systems which in many parts of the world are already strained.   

The U.S.-Mexico Border Health Commission (USMBHC (Southern African Development Community, undated) is a premier example of a binational collaborative grounded in the human right of individuals to health created by medical health providers and advocates. The main goal of this collaborative is to provide leadership in developing and implementing initiatives to optimize the health of U.S.-Mexico border residents, including immigrants and refugees. On July 2000, the United States and Mexican governments entered into a formal agreement to establish the USMBHC motivated by the recognition that the lives and health of border residents is intertwined. The USMBHC operates from four offices across four U.S. states and six corresponding offices across the six Mexican states that make the U.S.-Mexico border. Each office has a close collaboration with the corresponding state health departments and funding is provided by the U.S. Department of Health and Human Services and the Mexican Ministry of Health. A primary objective of the commission is to identify health priorities and target such priorities with a variety of initiatives to address infectious disease (e.g., the U.S.-Mexico border Tuberculosis Consortium); chronic diseases such as type 2 diabetes prevention (e.g., Binational Obesity and diabetes prevention and awareness campaigns); and Health insurance Education and Marketplace initiatives (e.g., Workshops to educate residents on insurance options based on the affordable care act). Three important initiatives set forth by the USMBHC include: 1) The Healthy Border 2020: A Prevention and Health Promotion Initiative; 2) Establishment of a local surveillance system to generate data specific to the binational border population to enable the planning and assessment of targeted initiatives; 3) Training community-health workers to strengthen the local health care infrastructure and workforce; and 4) Building sustainable coalitions and academic-community partnerships bringing together key stakeholders, community based and governmental organizations, and politicians to engage in mobilize action, promote strategic planning, research, and collaboration. The USMBHC is an example of a successful binational collaboration that has assisted in the planning and implementation of several initiative to improve the health of border residents. The four key initiatives named above will be expanded upon below along with implications and recommendations for extending the reach of initiatives to improve the health of immigrants and refugees.    

The Healthy Border 2020: A Prevention and Health Promotion Initiative. The USMBHC began to formalize its collaboration beyond signing of an agreement by forming a commission: The U.S.-Mexico Border Binational Commission. The commission was directed to develop a framework to advance public health goals in the region and actions to promote these. The result was a comprehensive report titled: The Healthy Border 2020: A Prevention and Health Promotion Initiative .  The report provides detailed information about the demographics of the region highlighting the social determinants of health impacting residents and guidance on priority health areas to address. Information also includes baseline data and specific strategies to improve health and advocate for resources and facilitating collaborations across governments. This framework represented an important step in formalizing collaborations as it provides specific directions and measurable targets facilitating the engagement of a variety of actors in initiatives. Potential interested entities include governmental, non-governmental, academic, and other stakeholders. The initiatives discussed below are the result of priorities highlighted in this report and initiatives being undertaken by a variety of actors and entities.

A review of the document suggests that although the report is sufficiently general to promote the health and well-being of border residents in general including immigrants and refugees, the inclusion of a specific section to guide initiatives to promote their health may be particularly useful to guide strategic planning in this realm. The USMBHC can assemble a task force composed of academics and other key stakeholders knowledgeable about immigrant and refugee health and the specific needs and problems immigrants face in the region. Similarly to the existing report, the section can contain information about the demographics and health priorities of recently arrived immigrants and refugees, including the social determinants of health likely to impact the health and well-being of immigrants and refugees in the region. The endorsement of the USMBHC is likely to promote the dissemination and implementation of initiatives described as this has been the case in the past.  

Local Surveillance Capacity Building Initiative. The USMBHC (Nicholas, Mfono, Corless, Davis,  O’Brien,  Padua, & Fortinsky, 2016).   began a surveillance program to remove the barrier of inexistence of local information to guide policy efforts including assessment. Such information is necessary to develop and implement policies, initiatives and programs and evaluate them. Without such information an evidence-based approach to public health cannot be practiced. Although each country has mature surveillance systems, the data collected was considered insufficient to address the varied, culture-specific, complex needs of border region residents which include a large number of recently arrived immigrants and refugees. The sister cities of Brownsville, Texas and Matamoros, Tamaulipas implemented a local surveillance system by engaging community members in collecting and analyzing epidemiological information to improve the health care of women of reproductive age and their children. Importantly, the information generated consisted of risk factors at the physical, behavioral, and emotional levels for the most prevalent diseases (WHO, 2018).  For example, through this initiative it was unveiled that low contraceptive use was a primordial barrier to decreasing rates of pregnancy and STIs. The information obtained was used to develop health educational materials addressing the most prevalent barriers evidenced in the population living on the U.S-Mexico border (International Labour Organization, undated).  Furthermore, data about cervical cancer 3-year screening, HIV testing during pregnancy, and HIV lifetime testing rates of the Brownsville-Matamoros border residents indicated a much lower prevalence of 68.2% for cervical cancer, 60% for HIV testing during pregnancy, and 36.1% for lifetime HIV testing rates compared to national averages of both countries (International Labour Organization, undated). The collection and exchange of this information assisted the commission in recommending course of action specific to the area surpassing strict confidentiality policies on information exchange and non-standardization of measures that have prevented information sharing between countries.   

In a similar vein, a surveillance system can be set in place to assess demographic characteristics, disease profiles, and the most pressing barriers to health that immigrants and refugees experience in a new destination. Such a system is likely to yield information that is locally relevant, easily accessible across countries, and quick to generate and analyze to guide the development of specific public health evidence-based strategies. Presently, it is not known if the surveillance system in place at the Brownsville-Matamoros border has the capacity to devote concerted efforts at assessing recently arrived immigrants. Building capacity to focus efforts here can guide strategic efforts at improving the health of immigrants across nations. 

Training of Community Health Workers Initiative. The USMBHC has embarked in another system change initiative to strengthen the health care infrastructure of the region: the training and support of community health workers (CHWs). CHWs assist in developing and implementing health care initiatives in the under resourced and medically underserved U.S.-Mexico border region. This initiative is the result of the strategic priority of improving residents’ access to health care and strengthening the under resourced public health infrastructure of the region. CHWs are trusted, knowledgeable community members who are trained to link individuals to the health care system. Furthermore, CHWs perform health care roles including delivering health preventative information and strengthening the health behavior skills of individuals to facilitate the enactment of health promoting behaviors (Arvey & Fernandez, 2012).  Research indicates that CHWs are effective at linking immigrants into systems of care in developed countries such as the U.S. were policies such as the affordable care act allows legal immigrants to obtain health insurance coverage (Findley & Matos, 2015).  Research also suggests that CHWs perform other key roles beyond linking individuals into care to conducting outreach and delivery of public health education programs in places where immigrants live and work (Findley & Matos, 2015). In the case of the USMBHC initiative, the CHW model being implemented includes training and support for CHWs to serve as health educators and advocates. It is estimated that approximately 3,500 CHWs are working in the U.S.-Mexico border region (Foster-Cox, Torres, & Adams, 2018).  A key role that CHWs perform in the U.S.-Mexico border region is that of advocate and a bridge to service provision. Many U.S.-Mexico border residents, particularly immigrants and those living in settlements lack essential services including water, electricity, and stable housing. CHWs are in a position, through trainings and extensive networking with distinct service providers, where they can become immediately aware of the most pressing needs and mobilize action. In 2014, an unprecedented number of unaccompanied child immigrants arrived at different points of the U.S.-Mexico border. The USMBHC immediately asked CHWs assistance and evidenced how in a matter of a small span of time CHWs mobilized their networks to set in place processes and systems to link minors to services that would be able to assist them safely. The USMBHC provides training on a variety of topics including chronic and infectious diseases, environmental health, and maternal and child health. Importantly, credentialing is a fundamental part of the support provided by the commission and it entails supporting CHWs to attend professional development opportunities through online educational trainings, conference attendance, and other educational opportunities. This latter endeavor is extremely important to promote the credibility of CHWs and their integration into the formal healthcare workforce and enhances sustainability (Torres, Balcazar, Rosenthal, et al., 2017). 

A key aspect of implementing and sustaining a CHW program that can be sustainable and truly strengthen binational collaborative efforts is developing a binational system for credentialing. Although CHWs have been involved in the provision and linkage to health care services for centuries around the world, one of the biggest barriers to sustainability is lack of credibility, respect, and integration of CHWs into the formal health care workforce. The USMBHC is actively working on formalizing the CHW trade. As discussed above, immigrants are more likely to be educated than before. Many have a professional degree, including a health-related degree, from their country of origin. Recruiting immigrants who hold professional degrees in health to work as CHWs can assist with their integration and eventual re-credentialing while strengthening the capacity of the health care system in the country of arrival.  

Coalition, and Community-Academic Partnership Building Initiative. Another major initiative embarked by the USMBHC to mobilize action, increase advocacy capacity and inter-sectoral collaboration among multiple entities is community health coalitions and community-academic partnerships. Several partnerships have formed in the region to address a variety of health conditions including teen pregnancy (Red de Coaliciones Comunitarias, 2020) and the success and accomplishments of such are reported in the academic and non-academic literatures. Furthermore, entities such as The United States Department of Anti-Narcotic Affairs and the US Embassy in Mexico have provided funding for 5-year initiatives to tackle complex health problems. For example, one such initiative consists of a partnership to develop a network of community coalitions across the border region to promote substance abuse prevention by tackling structural, interpersonal and individual level factors. Nine coalitions across four border communities: Ciudad Juarez, Nogales, Agua Prieta, and Tijuana that varied on urbanicity have been implementing actions to prevent substance abuse. Specific actions include cleaning of public parks to increase access to alternative drug-free recreation spaces, family level interventions to prevent high school drop-out, community level interventions to provide information about the causes of substance use, and promotion of physical activity among individuals at high risk of substance abuse. A coalition is composed of community members who are residents of a specific neighborhood. Several publications reporting on the work and goals accomplished have been produced (Red de Coaliciones Comunitarias, 2020). An analysis of such documents reveals that a framework to encourage engagement and collaboration has been employed including community-based participatory research (CBPR) principles which call for capacity building for engagement including building a sense of community (Brown, Chilenski, Ramos, Gallegos, & Feinberg, 2016). We wish to emphasize the necessity of grounding collaborations on principles that will facilitate the sustainability of partnerships. There is vast literature alluding to such practices which have been delineated to remove the most persistent barriers to partnership building including asymmetries in power. 

Analysis from this initiative makes it clear that facilitating community-academic partnerships and the assembly, direction, and sustainability of coalitions to address specific health issues is a powerful tool to bring about grass root sustainable change. Although coalitions are addressing issues that affect immigrants and refugees at unprecedented rates such as substance abuse, there is a need for a network of coalitions to solely address the high priority needs that immigrants face. A network of coalitions working across neighborhoods in a particular region can plan actions to promote the participation of immigrants and refugees in the formal workforce, to increase their access to legal and health care services, and to increase their integration and relocation from detention centers. In the U.S. state of California, such an effort has begun with the purpose of 1) bringing awareness that immigration status is a social determinant of health that can be modified, 2) establishing immigration-informed care in health care settings, 3) building medical-legal partnerships, and 4) harnessing the power and knowledge of local stakeholders and politicians by including them as part of the partnership to advocate for resources (Saadi, Cheffers, Taira, et al., 2017). A review of the literature yielded an innovative strategy that is being implemented in certain countries which is block chaining (Karanja, et al., 2019).  This practice is harnessing the power of technology to promote the rapid training and certification of immigrants to increase their participation in the formal workforce. Coalitions can be particularly effective at implementing a strategic plan and ensuing actions and political will to encourage and facilitate adoption of this strategy.  

Case Study: South Africa  

The number of international and internal migrants are continually increasing in South Africa. According to Mid-Year Population Estimate by Statistic South Africa in 2019, the international migrant population, on average, increases 15,000 every five years since 2006. And the statistics for domestic migration is more significant. It is important to realize that migration is a determinant of health. With the growing migrant population in South Africa, the local government and health system should take action to address health inequalities and increase access to health care for migrants.  

It’s acknowledged that South Africa has a high prevalence of communicable diseases such as HIV and Tuberculosis. Migrants are more vulnerable to these diseases due to various reasons including poverty, poor living conditions, and limited access to medical treatment caused by language barriers, and discrimination (Nicholas,  Mfono,  Corless, Davis, O’Brien,  Padua,  & Fortinsky, 2016).  In order to help mobile and migrant populations prevent and mitigate the impact of HIV along major transport corridors and cross border areas in Southern Africa, International Labour Organization has initiated a regional program called The Corridor Economic Empowerment Project (CEEP). This project focuses on the economic empowerment of men and women working in the informal economy and it requires collaboration between government, trade unions and employers. Different activities are carried out. At the institution and corporate level, it provides funds for small enterprises to run businesses and helps to expand employment opportunities for the migrant population. Besides, it has trained 128 cross border institutions like customs agencies and 76 transport companies to deliver essential knowledge on HIV and AIDS and periodically distribute condoms to the workers (WHO, 2018).  By doing so, it builds the competency of enterprises and employers in mitigating the impact of HIV at workplaces. Secondly, it contributes to the agreement signed by ASSOTSI and customs authorities, ensuring that informal workers are not excluded from access to HIV services at border areas.   On the migrant worker’s level, the project encourages them to start their own businesses and offers training to improve their business skills (International Labour Organization, undated). This helps to strengthen their economic power and thus reduces their vulnerability to HIV to some extent.  

Overall, the program is successful. It reaches more than 164,603 stakeholders and policymakers and leads to the change of national and regional HIV policies towards addressing issues from an economic perspective. Besides, it has supported nearly 9,000 businesses and created 11,554 jobs until 2014. Moreover, Beneficiaries reported that they had improved socio-economic status and living conditions. And they increased their knowledge about HIV and corrected their risky sexual behavior, all of which reduces their vulnerability to HIV (Southern African Development Community, undated).  However, the program still has aspects that need to be paid attention to. First of all, it’s commendable to have collaboration between nations and interactions among government, NGOs and private sectors. However, from the national level, due to economic, political and cultural differences, some countries may not have the capacity to implement the project as expected, which, in turn, results in a less satisfying outcome. Therefore, it’s critical to build a structural coordination system, so that the program could be adjusted based on local conditions and resources could be freely mobilized and fully utilized. Secondly, the institutional capacity for coordination of informal sector activities is also very important. As a multi-party collaboration program, it needs to provide clear guidance on what each sector should do and it should think about how to attract the private sector to participate in the program. Thirdly, it’s useful to have monitor and evaluation in all aspects of project implementation, so that the project can change directions whenever it finds out a problem, which leads to a better result. Currently, the monitor and evaluation system is semi-manual, making the work laborious, slow, and time-consuming. Therefore, technology is required. A new system makes the data collection and analysis process more efficient. 

Lessons are learnt from the case study of South Africa. Economic empowerment could be useful complementary strategies incorporated into current health policies. Using the economic framework, we can tackle the problem from another angle, making the total impact greater than before. Moreover, the cross-border collaboration and cooperation between institutions are encouraged. No matter what level of collaboration it is, the coordination is very important. In addition to it, different responsibilities and goals should be assigned to each participant accurately based on their own condition. Lastly, it’s a trend to apply informatics infrastructures and blockchain technology to evidence-based practices. 

RESULTING POSITION 

This Group expresses our support for actions to promote cross-government collaborations, cross-sector collaborations within governments, and to assemble and sustain strategic long-term partnerships creating communities of practice among professionals across disciplines. 

POLICY ACTION RECOMMENDATIONS 

Our policy action recommendations based on the literature, case studies reviewed, lectures by experts, and conversations with them are delineated below: 

  1. Binational Collaborations are a strong tool to promote the health of vulnerable populations including immigrants and refugees. However, trust and capacity building are necessary elements to promote the sustainability and effectiveness of complex collaborations.
    a. Trust and commitment at a local level is instrumental. The success of the implementation of a surveillance system and sharing of information by the USMBHC was possible due to the effort invested in relationship building and commitment of individuals and organizations involved to the achievement ofestablished goals.  As a result of the activities implemented through strategic planning, research, and academic-community partnerships, other important organizations, such as the Centers for Disease Control and Prevention and the Pan American Health Organization have contributed to the sustainability of the USMBHC by providing support and funding.  
    b. The active implementation and assessment of methods of community engagement to mobilize communities to participate in initiatives to improve their own health is of utmost importance to sustain binational collaborations. The literature reviewed included examples of successful community-academic partnerships including the efforts exerted to improve collaboration and relationship building through capacity building.
    c. It is absolutely necessary to implement principles that will remove barriers to sustainable collaborations. Principles have been devised, implemented in a variety of forms, and refined. We strongly encourage the use of practices delineated in the literature to promote trust, true collaboration, and power sharing (Israel, Eng, Schulz, & Parker, 2013; Wallerstein, et al., 2020).
  2. There is a need to strengthen the health care infrastructure of immigrant receiving communities, especially in resource constrained settings and settings where the majority of health care investments go to disease treatment and cure rather than prevention. For example, the U.S.-Mexico border has an already fragile health care infrastructure that risks collapse if additional strains are imposed. The initiatives described in the case studies can strengthen the health care infrastructure of immigrant receiving communities and include:
    a. Community health workers are another form of strengthening the health care infrastructure and provide services and advocacy to change social determinants of health. The incorporation of CHWs into the health care workforce is fully endorsed by the World Health Organization’s Alma-Ata Declaration.
    b. Advocacy for the rapid training and incorporation of immigrant health care professionals through block chaining is a promising strategy. As argued above, coalitions can set in place actions to facilitate the adoption of this initiative.
    c. Training health care workers on immigrant-informed care, an initiative that can build upon trauma-informed care, can bring awareness to practicing health care providers who may interact with immigrants about their specific needs. Furthermore, it can promote the will to implement specific screening practices and facilitate collaborations across sectors to bring needed services. According to the literature reviewed, coalitions are also a mechanism to spark change in this domain.
  3. Identifying and addressing health issues from an economic perspective can attract the investment of different sectors and increase intersectoral collaborations to change a fundamental social determinant of health.
    a. Economic empowerment can be integrated into existing policies protecting and improving migrant’s health rights. A better financial status helps migrants improve their living conditions. Furthermore, it increases their chances of visiting a doctor and getting in-time medical treatment, all of which reduce their vulnerability to certain diseases.
    b. The economic empowerment program must be sustainable. The effect of only providing funding to small enterprises is short-lived in nature. And thus, programs should combine funding with business and financial skills training, not only giving participants enough capital to start the business but also developing their entrepreneurship abilities to run the business in the long term.
  4. Intersectoral collaboration is a key element for achieving the policy goal. The efforts from the private sector are especially meaningful. Therefore, policymakers should create economic incentives such as microcredit with a low-interest rate and business subsidies, encouraging enterprises to work with other institutions and make contributions to protecting migrants’ health. Actions taken by companies include raising salaries, improving the working environment, providing private insurance, and delivering health education to workers.
  5. The implementation and management process should incorporate the application of technology. A better-automated monitor and evaluation system- a larger space to store data, a stronger capability to deal with data, supports the development of the program. Furthermore, devising a collaborative agreement for data sharing that will abide by the laws of respective countries can facilitate data sharing.

CONCLUSION 

The consequences of failure to promote collaborations across governments, strengthening the health care workforce, and promoting intersectoral collaborations to promote the health and well-being of immigrants and refugees can be dire. Consequences are multi-level and include human rights violations, loss of economic power, increases in crime and violence, and other conditions that exacerbate substance use and infectious disease rates, and collapse of health care systems. Unfortunately many barriers prevent implementation of collaborations, however, the literature we discussed and the specific case studies illustrate that with political will creative ways of promoting collaboration are possible.  

BIBLIOGRAPHY 

Arvey, S. R., & Fernandez, M. E. (2012). Identifying the core elements of effective community health worker programs: a research agenda. American Journal of Public Health, 102(9), 1633–1637. 

Brown, L. D., Chilenski, S. M., Ramos, R., Gallegos, N., & Feinberg, M. (2016). Community prevention coalition context and capacity assessment: Comparing the United States and Mexico. Health Education & Behavior, 43(2), 145-155. 

Casillas R., R. (2006). Una vida discreta, fugaz y anónima; los transmigrantes centroamericanos en México. Recuperado el 5 de septiembre de 2016, de Centro de Documentación sobre Migraciones para América Latina, Organización Internacional para las Migraciones: http://cimal.iom.int/es/authors/rodolfo-casillas-r

Findley, S., & Matos, S. (2015). Bridging the gap: How community health workers promote the health of immigrants. London: Oxford University Press. 

Forster-Cox, S., Torres, E., Adams, F. (2018). Essential roles of Promotores de Salud on the U.S.-Mexico Border: A U.S.-Mexico border health perspective. Global Journal of health Education and Promotion, 18(1), s4-s18.

Franco Sanchez, L. M., & Granados Alcantar, J. A. (2019). Características de la migración internacional en la actualidad en Mexico. Universidad Autónoma de Mexico. Accesses at ru.iiec.unam.mx/2-032-Franco-Granados.pdf on June 2, 2020. 

International Labour Organization. (n.d.). Economic Empowerment and HIV Vulnerability Reduction Along Transport Corridors in Southern Africa. Retrieved June 8, 2020, from www.ilo.org/africa/countries-covered/index.htm

Israel, B. A., Eng, E., Schulz, A. J., & Parker, E. A. (2013). Methods for Community-Based Participatory Research (2nd ed.). San Francisco, CA: Josey-Bass. 

Karanja, R., et al. (2019). Blockchain-based digital ID platform for Refugee camps in Kenya. World Economic Forum. 

Klinger, D. E. (2020). Migration and Immigration. Public Integrity, 1-5. 

National Academies of Sciences, Engineering, and Medicine. (2017). The Economic and Fiscal Consequences of Immigration. Washington, DC: The National Academies Press. 

Nicholas, P. K., Mfono, N., Corless, I. B., Davis, S. M., O’Brien, E., Padua, J., . . . Fortinsky, S. (2016). HIV vulnerability in migrant populations in southern africa: Sociological, cultural, health-related, and human-rights perspectives. International Journal of Africa Nursing Sciences, 5, 1-8. doi:10.1016/j.ijans.2016.09.003 

Radford. M. & Krogstad, R.  (2019). Recently arrived U.S. immigrants, growing in number, differ from long-term residents. Pew Research Center. Accessed at www.pewresearch.org/recently-arrived-u-s-immigrants-growing/ on May 27, 2020. 

Red de Coaliciones Comunitarias (2020). Network of Community Coalitions. Alliance for Border Collaboratives accessed at http://www.coaliciones.org/es/publicaciones

Saadi, A., Cheffers, M. L., Taira, B., et al. (2017). Building immigration-informed, cross-sector coalitions: findings from the Los Angeles County Health Equity for Immigrants Summit, 3(1), Health Equity, 431-435. 

Southern African Development Community. (n.d: A Prevention & Health Promotion Initiative. Available at www.borderhealth.org, accessed 5/20/20. 

Southern African Development Community. (n.d.). Innovative HIV Prevention Practices and Programmes for Long Distance Truck Drivers and Sex Workers: Global Lessons and Opportunities in the SADC Region. Retrieved June 8,2020, from www.msh.org/sadc_fact_sheet_dec_4_2015_jp_final.pdf

Torres, S., Balcazar, H., Rosenthal, L. E., et al. (2017). Community health workers in Canada and the US: Working from the margins to address health equity. Critical Public Health, 27(5), 533-540.  

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EXECUTIVE SUMMARY 

Prior to COVID-19, the #The MeToo movement took the world by storm, exposing the extreme suffering of women at the hands of abusers. The United Nations (UN) has described Violence Against Women (VaW) as “perhaps the most shameful human rights violation”1 VaW is a longstanding global public health problem which has been ignored despite the efforts of many. Survivors of VaW are facing disproportionate consequences due to COVID-19 and resulting lockdowns and economic hardship worldwide. As a result of COVID-19, the reality of significant morbidity and mortality is gaining more attention, particularly as VaW is increasing. In this policy brief, we address issues related to VaW and COVID-19 through a social justice lens that applies a feminist anti-racism analytical framework. 

We argue that this critical time period can be used to catalyze long lasting changes to prevent and mitigate VaW through comprehensive short and long term policy measures related to education, research, media coverage, legislation, policing, social work and so forth. It is urgent that governments everywhere make women and children safety an immediate priority through the provision of safe housing, food security, healthcare and retraining for livelihoods. The pandemic of VaW must never be silenced again and movements such as #MeToo ought to be supported to promulgate effective human right changes that lead to systemic and institutional justice. Because of the intensification of VaW during this time, Covid-19 offers the world the opportunity to eradicate VaW once and for all. 

Eradicating VaW is a complex endeavor which requires buy-in from all sectors. Here, we consider the complex intersection of issues creating the current climate of heightened violence against women during Covid-19. Global leaders in government, business, and other sectors, in addition to local community members, ought to make efforts to protect women’s lives and shift the public narrative related to VaW. Empowering boys and men to prevent and combat VaW is a critical part of this work. Toxic masculinity, which is defined as widely accepted gender norms about men’s authority and men’s use of violence to exert control over women, is one of the deadly roots of VaW.  Everyone on the gender spectrum has a role to play in ending the deadly pandemic of VaW.    

FOCUS OF THIS PAPER 

This brief policy note provides insight on the global context about VaW during Covid-19 and makes recommendations which we sincerely hope will be taken up around the world. 

CONTEXT 

Around the world, the pandemic has already disproportionately impacted women (United Nations, 2020).  One major impact of COVID-19 is related to the stay at home orders. The home is not safe for women entrapped with their abusers. Moreover, regular escape routes that women typically utilize, such as staying with friends and family during acute episodes of violence, have evaporated as many people are fearful of viral contamination. To make matters worse, in some women’s shelters, a negative COVID test result is needed before women are granted safety. Additionally, because courts in many countries are closed, it is more difficult to obtain a restraining order against perpetrators of violence and in some cases, these orders have been canceled (Hurtas, 2020).

VaW is thus a pandemic within a pandemic (Gwenn, 2020). Without the layer of COVID-19, about 50,000 women worldwide are killed annually due to VaW” (Gwenn, 2020). Additionally, one in three women around the world will experience physical or sexual violence in their lifetime (Godin, 2020). VaW, which is an issue of gender inequity, is fueled by social norms and structures. Male-dominated societies tend to undervalue women and authorize men to treat women as second-class citizens. This begins in early childhood when girls receive unequal treatment compared to boys in matters of household chores, access to education and other opportunities. Girls are often forced to stay at home, while boys are encouraged to have active lives inside and outside the home. 

Survivors of VaW face immense social, physical, and mental health consequences because of the violence they have faced. Survivors are more likely to experience depression, heavy alcohol and substance use, PTSD, anxiety, increased stress, chronic disease, injuries, and physical disability. (Wilkes, 2018). Aggravating factors include low socioeconomic status, inadequate social supports, low education, substance abuse, mental illness, and employment status (Bradley, DiPasquale, Dillabough, & Schneider, 2020). Unemployment for men, drug abuse, owning a firearm, and previous instances of abuse are factors that increase the risk that VaW will result in femicide (Campbell, Webster, Koziol-McLain, Block, et al., 2020). Social and cultural norms related to gender, specifically hegemonic toxic masculinities, patriarchy, and oppressive cultural practices contribute to social environments that perpetuate VaW. In cultures where “macho” attitudes are highly valued, there is a higher association of violence against women (Weldon, 2002). Advancing women’s rights and gender equity, will improve women’s safety and decrease the impacts of VaW.  

Because of COVID-19, the underlying issues contributing to VaW are more prominent. COVID-19 introduced uncertainty, heightened economic pressure, layoffs from work, increased stress, and stay at home orders, resulting in survivors isolating themselves with perpetrators of abuse. This creates a perfect storm where survivors face an increase in violence without being able to access appropriate services due to government mandated shutdowns and periods of isolation (Taub, 2020).  Exacerbated by COVID-19, many women have found themselves taking on the role of unpaid caregivers to family members (Lewis, 2020). Additionally, oftentimes perpetrators of violence control or withhold financial resources (Godin, 2020). The interruption of source of income has placed both financial and psychosocial burdens on breadwinners who are mostly men (United National Population Fund, 2020). Without the economic means to provide for their families, heightened tension and lack of resources in the household can lead to VaW. Furthermore, women who are economically independent have a heightened ability to leave VaW situations, where those who do not are often left with few options (WHO Fact Sheet, 2017).

Correlating data suggest that VaW is acting like an “opportunistic infection” flourishing in the conditions created by COVID-19 (Taub, 2020).  With families in lockdown worldwide, hotlines are lighting up with abuse reports (Taub, 2020). Perpetrators of violence, who may have suffered a job loss or an increase in stress, have greater opportunities to incite violence due to stay at home orders allowing for more access to victims (Taub, 2020). Perpetrators of VaW typically isolate their victims in order to maintain control and power over them; stay at home orders inadvertently reinforce control and abuse perpetrated by abusers, and thus by their very nature create environments where survivors of violence are inherently more vulnerable. Additionally, women face negative economic consequences that can last for years after the violence ends, as the mental and emotional reverberations of violence impact job stability, economic well-being and livelihood (Wilkes, 2018). Finally, systems and services designed to support survivors have historically been poorly funded worldwide, because this issue has been relegated to the sidelines (United Nations Agency for International development, undated). 

An increase in femicides implies that VaW poses an increasingly significant and lethal threat to women worldwide under COVID-19 lockdowns (Bradbury-Hones & Isham, 2020; Prusa, Garcia,& Soledad, 2020; Jeltsen, 2020). In responding to the pandemic, there has been a general lack of intentional thought related to stay at home orders and VaW, stemming from a global lack of commitment to addressing VaW.  

By changing public opinion on VaW, specifically around social values as related to women’s rights, women’s movements expand public imagination around what is possible for women (Weldon, 2002). The #MeToo Movement, in particular, led by Tarana Burke, has been a force for effective change that has gained a great deal of momentum from high profile actors, leaders and others, in many countries. This movement, and affiliated movements such as #timesup, has connected gender, ethnocultural, income and intersecting issues as they relate to VaW and child abuse. Changing public sentiment has the larger effect of influencing politics and the legal system because politicians and local leaders feel pressure from their constituents about what the current social problems are (Weldon, 2002). 

Furthermore, having more women in office allows for an increase uptake in government action against issues against women, like VaW (Weldon, 2002). Conversations to demystify and destigmatize VaW should be ensured between policy makers and other relevant stakeholders in order to prioritize an understanding and any association of shame/disgrace related to VaW with the adoption to mainstream practices. Effective approaches, which are at times contrary to regional or national policies and practice, could be enhanced by women’s movement advocates worldwide, maintaining pressure on policy makers or relevant stakeholders. 

POLICY ACTION  

Here we examine VaW and policy actions as related to VaW throughout COVID-19 with lens of social justice. Women’s movements worldwide, such as #MeToo, have been responsible for getting VaW to be recognized as a social issue rather than being considered a private affair, forcing VaW to be introduced as a government and public agenda.9 Global women’s movements have shifted public discourse, social values around VaW in addition to prompting systemic government action in support of survivors of VaW (Weldon, 2002). 

In India, for example, “the Battered Women’s Movement (BWM) and the ADVM (Anti-Dowry Violence Movement attempted to challenge the hegemonic ideology that family was a private sphere, not subject to state interests or action, and that the state had no interest in family”(Weldon, 2002). In the United States, the #MeToo movement transformed public opinion around VaW by providing a platform for women survivors of VaW to share their stories and by unearthing how prevalent the horrific terrors of VaW that permeated the American society. The #MeToo movement used a popular tactic employed by women’s movements worldwide of latching on to high profile cases that bring to light the issue of VaW to mainstream media and public awareness. 

In order to change public sentiment and policy, including boys and men is essential, since in many places men are the majority of decision and policy makers (Ramsey, 2019). Social values that shape intolerance of violence against women are shaped during childhood (The National Academy Press, 2018). Additionally, in many places around the world, natural socialization of boys acts as a barrier to becoming male social justice allies (Minieri, 2014). Therefore, it is essential to begin teaching children, especially boys, to be social justice allies early on in life. Additionally, this education should include how VaW affects men and boys, in addition to the local economy and community. This education would support boys and men to take ownership of the decisions made in their own community and would ensure that the women and girls in their community are well supported and valued (Oxfam, 2020).

Policy Recommendations 

  1. During COVID-19, governments and other sectors ought to prioritize women and children through well-resourced programs aimed at the provision of housing, food security, and training programs for women survivors’ livelihood.
  2. Researchers, educators, and decision makers ought to draw attention to the pandemic of VaW within and alongside the pandemics of Covid-19, racism, opioid overdoses, climate injustices, and nuclear arms. Media outlets ought to cover the reality of multiple pandemics.
  3. A spectrum of educational programs that are aimed at prevention of VaW should be adopted and supported by local and national governments. This spectrum should include a model similar to the Australian Spectrum of Prevention, which includes “strengthening individual knowledge and skills, promoting community education, educating providers, fostering coalitions and networks, changing organizational practices, and influencing policies and legislation”(Flood, 2010).
  4. Curriculum development of training in primary and secondary schooling should focus on how to educate men and boys to unlearn hegemonic masculinity socialization and to become male social justice allies. Running services and schooling with how to educate men and boys to prevent VaW, understand hegemonic masculinity. Working with men and boys to consider the importance of their own role in the work fosters self-efficacy, leading to men understanding their own role in preventing VaW and educating other men about the importance of preventing VaW. 
  5. In the context of healthcare education and professional development:
    a. Further training in supporting VaW is essential. Specific training for the providers’ role in supporting survivors is essential, especially for those localities where healthcare providers are more likely to be men than women. The internet provides a safe learning and training platform within the context of COVID-19. Online training and workshops for healthcare providers serve to help identify, empathize, ask, and listen to survivors of VaW. The WHO clinical book on Domestic Violence should serve as a guide in training. Adoption of SAFE technique by the American College of Surgeons, which puts emphasis on four major questions including stress/safety, afraid/abused, friends/family and emergency, should be incorporated in various training programs.
    b. Healthcare providers must decenter patriarchal masculinity. Any form of stigmatization and trauma attached to those providing care to VaW survivors must be eradicated through community-based education since the culture in most communities encourage acts of discrimination resulting in women having less privilege and power. Health providers must question survivors where they suspect VaW using a trauma informed and women-centered lens.
    c. Health care providers must maintain awareness of VaW, see opportunities for self-education, develop strategies for discussing VaW, and become familiar with currently available local resources for patient referral. Furthermore, VaW screening tools must be readily accessible in healthcare settings (Boserup, Mckenney, & Elkbuli, 2020).
  6. In the event of future crises, government policies and responses must consider the intersection of issues and the economic and social implications these crises have on women, specifically survivors of VaW. Governments must prioritize funding to VaW services and hotlines.18 Governments should consider direct cash grants to survivors who must leave their home due to violence and abuse.21 Governments should be prepared to think innovatively and creatively about solutions.
  7. Legislation that supports the human rights of women to safety ought to be enshrined in all jurisdictions. Enforcement of this legislation, with appropriate resourcing, ought to be a high priority for all governments.  This includes retraining police forces, social work staff, communities, and others.
  8. Supporting movements such as #MeToo to continue their important work in drawing attention to VaW for a long lasting systemic and  institutional change.

Conclusion 

There are no easy resolutions to VaW worldwide. Our recommendations above begin to address the underlying issues causing VaW. Decreasing VaW during a crisis, such as COVID-19, requires changes to the root causes of VaW, including toxic masculinities, patriarchy, and oppressive cultural practices.17 Social justice movements such as #MeToo, along with the widespread impact that they have, promise to usher change in this arena.i 

References

Boserup, B., Mckenney, M., & Elkbuli, A. (2020). Alarming Trends in US Domestic Violence During the COVID-19 Pandemic. The American Journal of Emergency Medicine. doi:10.1016/j.ajem.2020.04.077.  

Bradbury-Jones, C., & Isham, L. (2020). The Pandemic paradox: The consequences of COVID-19 on domestic violence. Journal of Clinical Nursing, 29(13-14), 2047-2049. doi:10.1111/jocn.15296. 

Bradley, N., DiPasquale, A., Dillabough, K., & Schneider, P. (2020, May 01). Health Care Practitioner's Responsibility to Address Intimate Partner Violence Related to the COVID-19 Pandemic. Retrieved from www.cmaj.ca/cmaj.200634.full.pdf

Campbell, J., Webster, D., Koziol-McLain, J., Block, C., Campbell, D., Curry, M., . . . Laughon, K. (2003, July). Risk Factors for Femicide in Abusive Relationships: Results from a Multisite Case Control Study. Retrieved May 15, 2020, from www.thetrace.org/FemicideDr.Campbell.pdf. 

Flood, M. (2010). Where Men Stand: Men's roles in confronting violence against women. Retrieved June 15, 2020, from www.ncdsv.org/WR_WhereMenStandMen'sRolesInEndingVAW_Long_2010.pdf

Godin, M. (2020, March 18). How Coronavirus Is Affecting Victims of Domestic Violence. Retrieved from time.com/coronavirus-domestic-violence-victims/

Gwenn, C. (2020, April 07). The Pandemic Within the Pandemic: We Need to Offer HOPE. Retrieved from www.allianceforhope.com/the-pandemic-within-the-pandemic/

Hurtas, S. (2020, March 31). Turkey's Femicide Toll Soars Amid Coronavirus Lockdowns. Retrieved June 24, 2020, from www.al-monitor.com/turkey-women-domestic-violence-soars.html

Jeltsen, M. (2020, April 12). As Nation Stays Home, Early Indicators Suggest Rise in Domestic Violence Killings. Retrieved May 1, 2020, from www.huffpost.com/increase-domestic-violence-killings-coronavirus

Lewis, H. (2020, April 01). The Coronavirus is a Disaster for Feminism. Retrieved June 1, 2020, from www.theatlantic.com/feminism-womens-rights-coronavirus-covid

Minieri, A. M. (2014). Not Just a Women's Issue: How male undergraduate students understand their development as social justice allies for preventing men's violence against women (Order No. 10143577). Available from GenderWatch; ProQuest Dissertations & Theses Global. (1824398400). Retrieved from proxy.library.upenn.edu/1824398400?accountid=14707

Oxfam. (2020, March 30). How to Confront the Coronavirus Catastrophe. Retrieved May 15, 2020, from www.oxfam.de/fuenf-punkte-plan_coronakrise_englisch.pd

Prusa, A., García Nice, B., & Soledad, O. (2020, May 15). Pandemic of Violence: Protecting women during COVID-19. Retrieved June 24, 2020, from reliefweb.int/pandemic-violence-protecting-women

Ramsey, M. (2019, October). Dramatically Reduce Gender-Based Violence and Harmful Practices. Retrieved June 1, 2020, from womendeliver.org/2019-5-D4G_Brief_GBV.pdf

The National Academies Press. (2018, April). Addressing the Social and Cultural Norms that Underlie the Acceptance of Violence. Retrieved June 24, 2020, from https://www.nap.edu/read/25075/chapter/1

United Nation. “Policy Brief: The Impact of COVID-19 on Women". April 2020. www.un.org/policy-brief-the-impact-of-covid-19-on-women.pdf

United Nations Population Fund. (2020). Socio-economic and Health Impact of COVID-19 on Sexual and Gender-based Violence (SGBV) in Ghana. Retrieved June 20, 2020, from ghana.un.org/en/43329-socio-economic-and-health-impact-covid-19

.UN Women. “Review and Appraisal of the Implementation of the Beijing Platform for Action: Report of the Secretary-General". United Nations Department of Public Information. May 2000. www.un.org/presskit/fs4.htm.  

Weldon, S. L. (2002). Protest, policy, and the problem of violence against women : A cross-national comparison. Retrieved from ebookcentral-proquest-com.proxy.library.upenn.edu

Wilkes, N. (2018). Violence Against Women as a Social Justice Issue. Routledge Handbook of Social, Economic, and Criminal Justice, 3-10. doi:10.4324/9781351002707-1. 

WHO fact sheet: violence against women’ November 2017. www.who.int/violence-against-women

Summary 

Elderly tribal women in villages suffer with disorders which affect their everyday life due to the lack of awareness of the circumstances of living in extreme poverty, the lack of desired health services and social support systems, although their disorders can be easily treated. Objectives were to know the burden of disorders in rural tribal elderly women, their perceptions in a low resource region with extreme poverty .Overall 65% of women had complaints that included vision related 52%, hearing 23%, joints and muscles 19%,, high blood pressure and elevated blood sugar was present in 18% of women, and there were two cases of breast cancer diagnosed. After receiving medical advice and help, 80% of the women took action to improve their health. Overall, 77% of women said that they were satisfied with their life even with extreme poverty. By task, services were shifted to provide sustainable support. Women were apathetic about problems which affected their everyday life in the villages. Many stake holders were involved to help. In this era elderly women in remote villages live with problems where simple solutions are possible to improve their quality of life. It is essential to find ways to support women facing these health needs. 

Background 

The elderly suffer more, and women even more so due to various reasons globally yet this is much more prevalent in developing countries. Elderly tribal women in villages suffer with disorders which affect their everyday life, although their disorders can be easily treated. It seems to be due to lack of awareness, extreme poverty, lack of desired health services, and a dearth of social support system, although there may be other reasons too. 

Objectives 

Our objective was to better understand the burden of health disorders among rural tribal elderly women, and their perceptions in a low resource region with extreme poverty. 

Material and Methods 

In some remote villages in the Melghat region of the Amravati district of Maharashtra province of India, community-based mother-and-child services were started in view of high maternal, Perinatal, and child mortality. When nurse midwives visited families to provide maternal care in the villages, elderly women, mothers-in-law, mothers, and the grandmothers of pregnant women of the community also approached them for services. The Elderly women had problems, but healthcare was neither sought and nor provided. They lived with disorders without medical testing done, and naturally without support. Women could not see but had no glasses to improve their vision. Some women had difficulty hearing and others could not even walk as they had joint and muscle problems but did not have proper sticks, canes or walking support or hearing aids. Some women used tree branches that are dangerous due to the risk of the stick breaking and causing the woman to fall. Many others had various other complaints for which some consultations were done but they lived with whatever problems they had. Yet, upon seeing the nurses in their villages, they actually asked for help, so it was decided to first find out the problems the elderly women faced and then try to provide service if appropriate services were to be provided it was essential. Funding could be procured from Global Health Through Education Training Services USA to enable researching the 30 villages. Nearing the end of research in 30 villages, it was realized that it was essential to try to find actual positions in 100 villages, the mother-and-child service area, where services were being provided. Locally available resources of mother and childcare were shared, and information was collected about the problems of women in the 100 villages. It was obvious that the elderly women were suffering from disorders for which care was possible with having them make simple movements and without the use of any high-tech equipment. Nearby Metropolitan Civil Society was approached for assistance as they have a commitment to social corporate responsibility. Funding was procured to help the women have a better quality of life by providing the women whatever health care and support was essential. Once information about their problems was available services were planned. Kasturba Health Society, Sevagram in the nearby district which started the mother and child health services, supported refraction checking in the villages. For sticks women were identified and provided with walking sticks and canes and for other illnesses women were helped with getting the proper diagnosis and related therapy. The mission was to provide doable services. Women could be provided with glasses, walking sticks and canes, and hearing aids right in their villages. Only some needed help through work ups and when this was needed the same supports were provided in hospital setting in the village or referral institute in a nearby district.  

Findings 

Overall, 65% of women had health complaints, vision 52%, hearing 23%, joints and muscles 19%, dental 14%, gynecological complaints 12%, urinary 11%, two cases of women with lumps in their breasts were identified (with some overlap with the other health conditions), and 18% of women had high blood pressure and elevated blood sugar levels. After receiving medical advice and help, 80% of women took action. Overall, 77% of women said they were satisfied with their life in the villages although they live in extreme poverty. 

Those with Diabetes and hypertension were provided drugs for a few days from the base hospital in the village which provided care and services 24-7, and then later these women were linked to the special public health system under Aayushat Primary Health Centers that was created for non-communicable disorders by the Government of India. The women who had cataracts were brought to the hospital and helped through the Prevention of Blindness Programme of the Government of India under which they were able to receive free cataract surgery. For other illnesses women were guided to seek services from the base hospital. Two women had breast cancer and were helped through free cancer treatment initiatives at the main referral institute which had responded to the needs of remote rural communities living with extreme poverty. 

Overall, the beginning of community services began for mother and children services but ultimately led to elderly women seeking assistance and research was done to find about their disorders and provide comprehensive services to rural communities. By shifting services, we were able to provide help and create a system of doable and sustainable care. Women were apathetic about their health problems which affected their everyday life and they expected a special system for their care in the villages. In addition to apathy, there were issues of social support and sometimes transportation. In addition, for some disorders there are at this time no initiatives available through the government. Therefore, it would be necessary to seek support through civil society. When new problems arose, we worked together to develop new solutions so that the elderly rural tribal women living in extreme poverty could have an improved quality of life. Many stakeholders were involved to bring about the help needed by the elderly women. 

In the modern era new knowledge is becoming available, like polycystic ovarian syndrome in adolescences could be responsible for coronary artery disease, hypertension, and endometrial cancer during aging. Hypertensive disorders in pregnancy could be an indication of CAD during aging among others, while preterm birth could be an indication of various problems in later life. More information is emerging about the disorders in female reproductive health which could lead to many disorders as women age. In this era, elderly women in remote villages live with problems where simple solutions are possible that can greatly improve their quality life. It is essential to find ways. However, certain illnesses like cervical cancer, bowel disorders, and others require more research. 

Acknowledgements 

Acknowledgements are due to the Global Health Through Education Training and Services of USA for providing funds through the Elderly Task Force of the Network Towards Unity for Health (TUFH) for research in 30 villages and also the Jan Kalyan Trust, Mumbai and Kasturba Health Society, Sevagram, Wardha, Maharashtra, India for the expansion of their research and support services.   

Authors

S. Chhabra, Emeritus Professor, Obstetrics Gynecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Officer on Special Duty, Dr. Sushila Nayar Hospital, Ucayali, Melghat, Amravati, Chief Executive Officer, Aakanksha Shishir Sevagram, Kasturba Health Society, Sewagram, Wardha, Maharashtra, India, and teams 

Summary 

Refugees are at high risk of experiencing limited health access and being exposed to diseases prevalent in conditions where there is poor sanitation, hunger, poverty, and over crowdedness. Despite these challenges refugees deserves full access to health services. Refugees in Rwanda experience these problems to various degrees. The government, refugees’ agencies, and nonprofit organizations have been responding accordingly to improve the well-being of refugees living in Rwanda. 

Along the lines of expanding refugees’ access to health care, the UNCHR and the Rwanda Social Security Board have initiated a program to incorporate refugees into the Community-based Health Insurance (CBHI) initiative. The CBHI applies in all health care facilities around the country and covers all health services ranging from primary to tertiary health services.(1) 

Introduction and Background 

Rwanda hosts more than 172,000 refugees living in six camps around the country, most refugees are from neighboring countries. Around 53% of the refugees are from Burundi, while the rest are from the Democratic Republic of Congo and other African countries. The Government of Rwanda has put into place several measures to incorporate refugees into normal life as real citizens of the country. Refugees in Rwanda are granted the right to work and the government has a policy to progressively integrate refugees into the national health and education system.(2) 

Refugees in Rwanda access basic health services from their camps with the help of humanitarian staff. When there is a need, refugees are referred to secondary and tertiary health services in local public and private health institutions.(3) Under collaboration with several national and international agencies that have refugee wellbeing as part of their mission, health centers and other facilities have been established to ensure improved health care among refugees in Rwanda. Water and sanitation facilities, environmental and healthy sources of energy, and community basic health education programs have been launched in various camps under the support of various agencies and nonprofit organizations. 

With the aid of the community-based health insurance, Rwanda has advanced universal health coverage. With this type of health insurance, all targeted populations contribute according to their social economic status as arranged in the Ubudehe categories I, II, III and IV.(4) 

Community-based Health Insurance 

Normally Rwanda has a community-based health insurance initiative that has significantly expanded health access to all Rwandans despite inadequate financial capacity. As of January 2016, CBHI subscriptions are reported to have increased by 79%, and this program is voluntary and requires the family to contribute for all of its members. The CBHI pays 90% of all hospital bills and the patient is required to pay only the remaining 10% which can be provided by most of Rwandans.(5) 

It has been a long while since refugees were not able to benefit from this risk pooling. This means that previously they had to carry all their medical bills despite terrible financial vulnerability and high risks for developing diseases. Under the policy of integrating refugees into the national health and educations system, the Ministry In Charge of Emergency Management (MINEMA), the UNHCR, and the Rwanda Social Security Board signed an memorandum of understanding to ensure that refugees could also benefit from the community-based health insurance the same way nationals do.  

Knowing the cost and gaps in health care for urban refugees, and the fact that only the most vulnerable were supported by UNHCR, UNHCR has financially supported and pushed forward this project as a more cost-effective and sustainable approach to meeting the health needs for urban refugees and refugee students who are away from their camp-based families. Refugees are considered as a special category, but pay the same premium rate as nationals do. 

Since September 2019, 18% of refugees in Rwanda began to benefit from the CBHI. Benefiting refugees are mainly students in high school and refugees living in urban areas. Currently, more than 50% of the target refugees are enrolled and the rest are being progressively enrolled subject to the verification and issuance of national documentation. The CBHI covers all health costs described under primary, secondary, and tertiary health care within government health facilities across the country.(1)  

This program involves several partners to support its success and sustainability. The MINEMA, Rwanda Social Security Board (RSSB), Africa Humanitarian Action (AHA-health partner), and the United Nations High Commissioner for Refugees (UNHCR) are current partners working to provide unlimited health access to refugees in Rwanda.(1) 

Outcomes  

With the community-based health insurance, refugees in urban areas and students can access any government health care facilities wherever they live or work as Rwandan nationals. This helps refugees to focus on their daily activities, studies for students, and paves a way for a good future and strong human capital production.(1) 

Conclusion 

Refugees are prone to experiencing poor health access and diseases that favor their living conditions. Initiatives aimed at boosting refugee access to health services by overcoming barriers should be supported. Governments,  nonprofit local organizations, and international agencies which have the aim of improving access to health among refugees are called to join this battle to ensure refugees in Rwanda are enjoying access to health services the same as nationals.  

This project of incorporating refugees in the community-based health insurance will continue to evolve and be enhanced. The MoU will be revised before its validity ends.(1) 

Works Cited 

1. Community-based health insurance for urban refugees and refugee students in Rwanda | The Global Compact on Refugees | Digital platform [Internet]. [cited 2020 Jun 29]. Available from: globalcompactrefugees.org/community-based-health-insurance-urban-refugees

2. UNHCR - Rwanda [Internet]. [cited 2020 Jun 29]. Available from: https://www.unhcr.org/rwanda.html

3. Rwanda Country Refugee Response Plan 2019-2020 - Rwanda | ReliefWeb [Internet]. [cited 2020 Jun 29]. Available from: reliefweb.int/rwanda-country-refugee-response-plan

4. Universal Health Coverage: How Rwanda is moving forward with healthcare for all | Innovations in Healthcare [Internet]. [cited 2020 Jun 29]. Available from: www.innovationsinhealthcare.org/universal-health-coverage-how-rwanda

5. USAID. Health insurance profile: Rwanda. African Strateg Heal. 2013;8–11.

EXECUTIVE SUMMARY 

Despite progress made to reduce maternal mortality rates, roughly 300,000 women worldwide still die due to pregnancy-related complications every year, with significant variation by the country’s income level showing 180 deaths/100,000 live births in middle-income countries 

(Seale, 2020). In Egypt, the Maternal Mortality Ratio (MMR) is estimated to be 37 per 100000 live births in 2017 (WHO, UNICEF, UNFPA, World Bank Group, and UN Population Division, 2019). 

Maternal sepsis remains one of the major causes of maternal deaths worldwide, presenting 11 percent of the recorded deaths, and up to 15 women per 1000 births are affected in low- and middle-income countries (Alkema, Chou, Hogan, Zhang, Moller, Gemmill, Fat, et al., 2016). It is defined by the World Health Organization (WHO) as a life-threatening condition that arises when the body’s response to infection that causes injury to its organs during pregnancy, childbirth, after abortion, or during the post-delivery period (Leaper & Edmiston, 2017).  

Our team believes that at the most basic, women deserve the fundamental right to live a healthy and safe life. And at the core of this is access to quality healthcare during pregnancy and childbirth. We believe that if we implement the right practice through the awareness of the health workers who need to be adequately trained, we can achieve change and witness a drop in MMR (Seale, 2020).  

The ‘2016 WHO Global guidelines for the prevention of surgical site infection’ (SSI) were the leading effort against maternal sepsis, they developed evidence-based guidelines based on systematic reviews and present additional information in support of actions to improve practice, aiming to achieve standardization in practice addressing the issue (Leaper & Edmiston, 2017).  However, recently in 2020, the WHO Global Maternal Sepsis Study (GLOSS) launched the STOP SEPSIS! awareness campaign. Studies show that its implementation was effective with regard to the recognition of respondents. There were significant changes in maternal sepsis identification and management (Brizuela, et al, 2020). 

THE INNOVATION 

Our team decided to integrate the 2016 recommendations into our facility standard practice, evidence-based practices have been highlighted as effective innovations. The emphasis has been on the rigor of the research methods used to produce evidence in support of innovation (Peterson, Haidar, Fixsen, Ramaswamy, Weiner, & Leatherman, 2018).  

To select an innovation for use, there needs to be some steps: co-development of implementation capacity guided by the principles of Active Implementation.  Our team was formed at the Ain Shams University Maternity Hospital (ASUMH) a tertiary hospital in Cairo, in collaboration with the ‘WHO Collaborating Center for Research Evidence for Sexual and Reproductive Health, the Department of Maternal and Child Health, and the Department of Health Policy and Management, Gillings School of Global Public Health, Department of Obstetrics and Gynecology, School of Medicine, and the Public Health Leadership Program, the University of North Carolina at Chapel Hill’, North Carolina USA.  

ASUMH serves patients from all over Cairo & also referrals from other governorates in Egypt. We receive a heavy workload, with an average of about 16,000 deliveries per year. Four women health personals volunteered to join the Active Implementation team to study Implementation science from October 2018 till November 2019 and form the Implementation team.  

From March 2019 till March 2020, our implementation project took place, the team worked on applying frameworks effectively and efficiently to affect change in practitioner behavior and organization’ system functioning to directly improve benefits to recipients. Our focus was directed towards our staff practice and behavior; our objective was to implement a new set of activities that we believe they can reduce the rate of maternal sepsis in our facility. We decided that educating our staff would be the best and most effective innovative solution (Horner, Sugai, & Fixsen, 2017). 

We started by conducting a baseline observation to track our staff practice by recruiting independent observers from our volunteering medical students, who were given a detailed checklist on how to implement evidence-based practice in the labor and delivery setting (Leaper & Edmiston, 2017). Using the WHO 2016 recommendation model, we created a simple checklist to see how accurate our staff performance is. (Table 1) We also conducted a baseline online survey; asking the staff directly about their practice and their knowledge about the same set of recommendations (Leaper & Edmiston, 2017).  

Looking into the results of the baseline observations, our team formed a couple of focus groups to start working on innovations that match the core components of an effective innovation; to be teachable, learnable, doable, and assessable in practice; and promote consistency across practitioners at the level of actual service delivery based on the need of the healthcare providers in our facility (Fixsen, Blasé, & Van Dyke, 2011).  

Adopting the implementation mindset of continuous monitoring of multiple components as; staff selection, training, performance evaluation; facilitative administration; systems intervention. Our implementation team moved from the exploration phase into the staff training phase.1 We organized a couple of orientation meetings where we talked about our implementation goals, we clarified the gaps in our practice and what change we want to see happen. We designed a series of wall posters with the evidence-based recent recommendations that we placed in our facility to serve as a constant guide. (Figure 2) 

OUTCOMES 

Following the research implementation methods, our team used multiple-baseline designs (MBD) (Horner, Sugai, & Fixsen, 2017) to evaluate the efficacy of our intervention. The MBD, shown here, used to produce reliable information rapidly about the problems and solutions we subjected to research.  

The data show changes in outcomes in each baseline before and after the introduction of an innovation. It allows simultaneous comparisons of post intervention scores with pre-intervention scores in the remaining baselines, thus controlling for general trends as practice effects and time-related events. 

 Figure 1  August 2019  March 2019

Figure 2 shows a collective summary of the posters the team designed to serve the innovation in our facility. 

Table 1

 

 

Total observations: 34  

Using:  Chi-square test; 

p-value >0.05 NS; *p-value <0.05 S; **p-value <0.001 HS

Table 1 shows highly statistically significant improvement in after innovation observations compared to before innovation in compliance to WHO global guidelines for the prevention of surgical site infection 2016.

Comparing the data from our secondary observation; we see a significant change in staff performance. Referring to one guideline (Guideline 1 in Table 1); Surgical antibiotic prophylaxis (SAP) should be administered within 120 minutes before skin incision in operational Caesarian section delivery (Horner, Sugai, & Fixsen, 2017) - 60% of the total observed staff (34 personal) were accurately following the guideline before the innovation, while 88% followed it after the innovation. In contrast with Guideline 2 in Table 1, concerning the recommendation against hair removal before delivery (Horner, Sugai, & Fixsen, 2017), 23% of our staff were not aware of this guideline then 92% changed their practice after the innovation.  

In attempting to use our innovation, the goal is to use its essential components with high fidelity thus change the organization as needed to fit the innovation. The status quo is powerful; fidelity is a lever for change (Horner, Sugai, & Fixsen, 2017).  

Our implementation team support practitioners as they attempt to use innovations with fidelity first but we faced many challenges in that matter: we received minimal support from our organization leaders and other disciplines. Our improvement cycles were constantly interrupted by the resistance to change.  

CONCLUSION 

Our team planned to begin an improvement initiative, we are prepared to manage the change process and never lose sight of the original goal. When attempting to use an innovation in practice the expectation is that changes in related activities and routines will be required in ex-pected and unexpected ways. We believe that through learning and education, our staff can maintain the improvement cycles and constructively deliver the best-practice methods to our recipients. Our team is still working on keeping the improvement cycle; Plan, Do, Study, Act (PDSA) active in our organization. The PDSAC methods are helping us act in creative new ways to sustain our innovation. We look forward to new improvement strategies to contend with the acknowledged complexity inherent in our attempt to use innovation in practice.  

Acknowledgments 

This study was conducted by a group of volunteers; staff practitioners and medical students. We are very grateful to our mentors at UNC, Chapel Hill. 

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