Approximately 62,000 asylum seekers and refugees have arrived in Greece since 2015 and are not able, or choose not to, move to another European country. While many of those now stranded in Greece intend to continue their journey to Europe, others are faced with the reality of long-term residence in the country. The Greek government and UNHCR state that they are committed to integrating asylum seekers and refugees who will be living in Greece into local society, improving self-reliance and long-term access to services and improving cohesion with the host communities.
Health services are not predominantly featured in the discussion around integration, but health and well-being are integral to new arrivals’ ability to participate in society. In a country with a struggling health service as a result of years of austerity, and as donors move away from emergency funding for asylum seekers and refugees, this is an important time to focus on strengthening the Greek health system. Integrating asylum seekers and refugees into the public health system can serve as a platform to strengthen the health system in general, benefitting asylum seekers, refugees and the host community, and leading to more equitable and inclusive health care.
The Greek Ministry of Health (MOH) has taken steps to highlight and put into practice its political commitment to providing streamlined health care for asylum seekers and refugees in the country. As of April 2016, access to health care is no longer linked to employment-based health insurance, a move towards universal health coverage (UHC) across the country. A joint ministerial decision states that asylum seekers and refugees along with other uninsured populations are now eligible for free health care in the country through the provision of a social security number.
But the long-term structural changes in the health system which are needed do not happen overnight. While the new law goes a long way to ensuring UHC, it is clear that there are still barriers to implementing an integrated approach to health care for asylum seekers and refugees. The financial flows and structural functioning of health care in Greece indicate that the European Commission and Greek government still view asylum seeker and refugee health as part of an emergency response, rather than an integral part of health sector planning that is central to the work of the MOH.
Money for health care provided by the European Commission has largely been assigned to NGOs providing primary health care in clinics in urban areas or in camps and reception centres. This model was appropriate when the government was unable to manage the high numbers of asylum seekers and refugees in the country and lacked the technical capacity to conduct an emergency response. As the situation in the country has changed and people are now living primarily in urban areas for longer periods of time, this model is inefficient. It can often lead to an increased burden on the health sector through over-referral of patients by NGOs to public health centres and hospitals, often meaning a duplication of efforts.
This model is representative of a focus on short-term solutions for asylum seekers and refugees as a distinct community, which is contrary to the cited political commitment by the Greek government and UNHCR to a move towards integrated government-funded and -run health care. Funding for long-term structural reforms, as opposed to funding NGOs, would mean a move away from emergency response to allow the MOH to address key challenges such as chronic understaffing and a lack of material resources that would improve the health care of Greeks as well.
While the existence of NGOs in the country perpetuates the government's reliance on them, it is not just a matter of all NGOs pulling out of the country and the MOH taking over; this should be a gradual process in order for the government to develop the capacity for a strong health system which can cater for the needs of populations facing distinct challenges. Currently there are no tailored services for asylum seekers and refugees in the mainstream health system; the development of such services needs to be reflected in the funding approach by donors such as the European Commission and collaboration between NGOs and the MOH. NGOs also have a distinct role to play in emergency preparedness and ensuring that mechanisms are in place to respond to a potential increase in arrivals if, for example, the EU–Turkey deal were to collapse.
Another challenge is political decision-making and tussles over which government department has the responsibility for asylum seeker and refugee health. Within the MOH, the Secretariat-General for Public Health is responsible, but it is the National Health Operations Centre (a body of the MOH intended to address public health crises) that manages the everyday response, further segregating the health of asylum seekers and refugees.
In addition, access to health care is dependent on many different ministries. The Ministry of Migration Policy is responsible for the health and well-being of those living within Reception and Identification Centres on the islands, and which until May had been providing funds to NGOs to provide medical and psychosocial care. The Ministry of Labour is responsible for issuing social security numbers, on which a refugee's ability to access free health care within the Greek health service depends. It is imperative that these ministries, with the MOH, work closely together to align their policies and practice and ensure that integration in health care on the islands and the mainland is not seen as distinct from the ultimate goal of overall social integration.
Focusing on integrating health care services is an important step towards wider social integration and requires strengthening of the health system, streamlined policies by the MOH and other relevant ministries, increased structural funding and a move away from emergency service provision. In order to integrate asylum seekers and refugees, everyone involved needs to ensure that the services provided are appropriate for people who face multiple barriers.
Lenio (Eleni) Capsaskis, Academy Stavros Niarchos Foundation Senior Fellow, Centre on Global Health Security.