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Australian health policy on access to medical care for refugees and asylum seekers

Australian health policy on access to medical care for refugees and asylum seekers Since the tightening of Australian policy for protection visa applicants began in the 1990s, access to health care has been increasingly restricted to asylum seekers on a range of different visa types. This paper summarises those legislative changes and discusses their implications for health policy relating to refugees and asylum seekers in Australia. Of particular concern are asylum seekers on Bridging Visas with no work rights and no access to Medicare. The paper examines several key questions: What is the current state of play, in terms of health screening and medical care policies, for asylum seekers and refugees? Relatedly, how has current policy changed from that of the past? How does Australia compare with other countries in relation to health policy for asylum seekers and refugees? These questions are addressed with the aim of providing a clear description of the current situation concerning Australian health policy on access to medical care for asylum seekers and refugees. Issues concerning lack of access to appropriate health care and related services are raised, ethical and practical issues are explored, and current policy gaps are investigated. is a complex and rapidly changing field of play. In this Introduction Australian health care policy regarding entitlements to paper, we review current health care policies for refugees medical care for refugees and asylum seekers is complex. and asylum seekers in Australia with a focus on those On the one hand, health care policy for refugees entering areas of policy gaps that result in a lack of access to medi- Australia on the offshore humanitarian program is com- cal and health care for some, and less optimal access to prehensive, entitling refugees to Medicare, early health care for others. We begin by briefly discussing the defini- assessment, specialised torture and trauma services, and tions of who is deemed to be a refugee and who is deemed access to the same services as other Australians. On the to be an asylum seeker, for health care policies vary within other hand, health care policy for refugees and asylum and between these two categories accordingly. Second, we seekers who have entered Australia in an unauthorised describe in some detail, the current health policy for asy- manner, and who are on a range of visa types, is frag- lum seekers and refugees within Australia's onshore pro- mented. About 40% of asylum seekers living in the com- gram compared to health policy for refugees who have munity have no rights to access medical care [1]. come to Australia through the offshore program. Third, we provide a broad comparison of Australian health care pol- Health policy for refugee and asylum seekers is directly icies for refugees and asylum seekers to those of the tied to immigration policy and visa types and this in turn United Kingdom, Canada and New Zealand, countries Page 1 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 Table 1: Australia's immigration humanitarian program Visa categories and subcategories Permanent offshore humanitarian visa Temporary offshore humanitarian visa categories categories Offshore resettlement • Refugee: for people who are subject to persecution in • Secondary Movement Relocation: temporary their home country and who are in need of humanitarian visa (THV) to people who have moved resettlement from a safe first country of asylum to another country •Special Humanitarian Program (SHP): for people before applying to enter Australia (5-year visa) who are outside their home country and are subject to • Secondary Movement Offshore Entry: temporary substantial discrimination amounting to gross violation visa to people who arrived without authorisation in of human rights in their home country Australia at a place outside Australia's migration zone and have moved from a safe first country of asylum (3- year visa) Form of arrival and visas granted Authorised arrivals Unauthorised arrivals Onshore protection Most authorised arrivals who subsequently apply for Unauthorised arrivals are placed in immigration protection receive a bridging visa. The bridging visa detention until granted a Protection Visa or removed allows them to remain in the community while the from Australia. Those who are found to be refugees are Protection Visa application is processed. Those who are granted a 3-year Temporary Protection Visa (TPV). found to be refugees are granted Permanent Protection Visa (PPV). Sources: [9, 48] with comparable public health systems. Finally, we dis- a territory where life or freedom is threatened. Other cuss the current areas where policy on access to health care aspects of asylum law are particularly relevant to the issue is in conflict between States and Territories and the Com- of health policy discussed here. It is important to note that monwealth and where Australian policy may be in breach it is not illegal to seek asylum in any country and that the of various human rights conventions. basic provisions related to humane treatment and basic rights apply to asylum seekers. Additionally, International Who is a refugee or asylum seeker? Human Rights Law recognizes the right of all individuals Under the United Nations 1951 Convention and 1967 to an adequate standard of living [5]. Protocol relating to the Status of Refugees (the Refugee Convention), a refugee is a person who '...owing to a well- At the end of 2004 there were an estimated 19.2 million founded fear of being persecuted for reasons of race, reli- asylum seekers, refugees and other people of concern to gion, nationality, membership of a particular social the UNHCR [6]. In the same year, 676,000 first instance group, or political opinion, is outside the country of his or appeal applications for asylum were submitted in 143 nationality, and is unable to or, owing to such fear, is countries; only 3,276 asylum applications were lodged in unwilling to avail himself of the protection of that coun- Australia, compared to over 500,000 in other industrial- try' [2]. An asylum seeker is a person who has fled their ized countries [6]. In relation to refugee intake, Australia own country and has sought sanctuary in a second state is one of 16 countries currently participating in the [3]. They then apply to be recognized as a bona fide refugee UNHCR-facilitated resettlement program [7]. In 2004, and to receive legal protection and material assistance that 84,809 refugees were resettled in these countries of which that status implies [4]. 13,030 were resettled in Australia [8]. Although the 1951 Refugee Convention does not deal Australian health policy for refugees and asylum specifically with asylum seekers, two of its Articles are par- seekers: Humanitarian program, health ticularly relevant to the issues of access to health care con- screening and health care access sidered in this paper. First, Article 33 (refoulement) states In order to understand health policies for refugees and that no refugee shall be expelled or returned to where his/ asylum seekers, it is important to briefly describe Aus- her life is threatened. Second, Article 31 prohibits punish- tralia's humanitarian program and the current legislation ment or penalties for entry to a state when they come from on visa status and protection. This is because entitlements Page 2 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 to health care vary by visa status, and legislation concern- thorised manner, are required to undergo medical and ing visa status is in a constant state of flux. radiological examinations before the granting of the visa. Australia's humanitarian program According to DIMIA, the only health condition that for- Australia's humanitarian program for refugees and others mally precludes the grant of a visa is active or untreated with humanitarian needs includes two components [9]: tuberculosis (TB) [10]. Those applicants whose TB has offshore resettlement for people overseas, and onshore protec- been treated or those with a previous but currently non- tion for those who are already in Australia, arrived on tem- active TB, are required to make a Health Undertaking. In porary visas (e.g. visitor or student visas) or in an other words, they are required to contact the Health unauthorised manner, and are seeking Australia's protec- Undertaking Service on arrival in Australia, and to report tion. These two components and their visa categories are to State or Territory health authorities for follow-up shown in Table 1. assessment [10]. The Health Undertaking also applies for a pregnant applicant who has not had the chest X-ray as Policy on health screening for offshore and onshore part of the standard health examination (although this is applicants not commonly extended to persons from high risk TB Australia's health policy for humanitarian entrants begins countries). pre-arrival. Those who apply under the offshore resettlement program must satisfy the health requirement [10] speci- All other health conditions are assessed on a case by case fied in the Migration Regulations. This health require- basis taking into account the risk to public health, the esti- ment, which is set by the Department of Immigration and mated costs, and the resource use impact on the Austral- Multicultural and Indigenous Affairs (DIMIA) on advice ian community. The final authority as to whether the from the Commonwealth Department of Health and Age- health requirement is met rests with the Medical Officer of ing, is designed to minimise public health risks to the Aus- the Commonwealth (MOC). The visa processing officers tralian community, regulate public expenditure on health are required to accept the opinion of the MOC. However, and community services, and maintain access to health where there are compelling factors, the Minister's delegate and other services for Australian residents. In general, the processing officer may waive the health requirement for health assessment involves a medical examination, a radi- refugees and other humanitarian visa applicants. If the ological examination to test for Tuberculosis (children applicant or any member of their family fails to pass the under 11 are generally exempt), and HIV/AIDS testing health requirement, the entire family group can be denied (for all applicants aged 15 or older). For some applicants a visa. They may however, be referred to other resettle- screening for Hepatitis B is mandatory. Other tests may be ment countries such as the United States, who have differ- requested by a Medical Officer of the Commonwealth. ent health screening guidelines and selection criteria. For those applying under the onshore protection program, they For those who apply under the onshore protection program, may be denied a protection visa should they fail the the health screening varies depending on their specific cir- health requirement under the same above considerations. cumstances. In general, those who arrive in Australia on a 3-month temporary visa – or less – are not required to Policy on medical care for offshore and onshore applicants have formal health examinations prior to their arrival While Australian policies on resettlement of humanitar- ian refugees are arguably among the best, compared to (some exceptions apply [11]). Those arriving on a greater than 3 months temporary visa may be required to other United Nations High Commissioner for Refugees undergo formal medical and radiological examinations (UNHCR) resettlement countries, its policies on the prior to arrival, depending on the level of health risk of treatment of onshore protection applicants have been their country of origin, their age, and the purpose of their strongly criticised by human rights organisations, schol- stay (e.g. likely to enter a hospital, health care area, class- ars, government members and others for their denial of room, preschool or childcare centres). basic human rights guaranteed under the 1951 Refugee Convention [2]. A brief description of the medical care All unauthorised arrivals who are applying for Australia's entitlements granted to different categories of offshore protection undergo health screening soon after their humanitarian entrants and onshore protection applicants arrival at immigration detention centres. "Where any seri- is given in Table 2. ous communicable diseases are suspected or confirmed, Offshore resettlement program formal notification procedures are followed with Com- monwealth and State/Territory health authorities" [12] On arrival to Australia, all refugees and special humanitar- (p. 2). In general, those who make an onshore application ian program (SHP) entrants under the offshore resettlement for protection, whether arriving on an authorised or unau- program receive all the entitlements granted to Australian permanent residents, including access to social security Page 3 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 Table 2: Health entitlements commonly granted to refugees and asylum seekers in Australia Humanitarian program Circumstances Entitlements Offshore resettlement Refugees who hold permanent offshore humanitarian Same eligibility for Medicare and Health Care Card, visas including Pharmaceutical Benefits Scheme, as other permanent residents. Eligible for Early Health Assessment and Intervention Program and torture/ trauma services. Refugees who hold temporary offshore humanitarian Able to gain access to Medicare and Health Care Cards, visas (THV) including Pharmaceutical Benefits Scheme; eligible for referral to the Early Health Assessment and Intervention Program and torture/trauma services. Onshoore protection Authorised arrivals Authorised arrivals who have been found to be refugees Same eligibility for Medicare and Health Care Card, and are granted permanent protection visa (PPV) including Pharmaceutical Benefits Scheme, as other permanent residents. Authorised arrivals who applied for protection within 45 Eligible for Medicare days of their arrival in Australia and are awaiting primary decision on their application Authorised arrivals who have been in Australia for 45 No access to Medicare days or more before they applied for protection Authorised arrivals who have appealed or are about to No access to Medicare appeal to the Refugee Review Tribunal or the Administrative Appeals Tribunal after their primary protection application has been refused Authorised arrivals who are appealing to the Minister of No access to Medicare Immigration after being found not to be refugees at the review stage Unauthorised arrivals Unauthorised arrivals who have been found to be Access to Medicare benefits and Health Care Card; refugees and are granted temporary protection visa eligibility for torture and trauma counselling (TPV) Unauthorised arrivals who are applying for protection Access to health care through health professionals and are in immigration detention contracted by the private company in charge of the detention centres Unauthorised arrivals who have been in mandatory No access to Medicare detention, are subsequently released into the community, and have an outstanding visa application Others Asylum seekers who hold or held a TPV or a THV, have Eligible for Medicare access through work rights, Health had their application for further protection finally Care Card, including Pharmaceutical Benefits Scheme, refused, have exhausted all legal options to remain in torture/trauma counselling, Maternity Allowance, Australia and are making arrangements for departure maternity immunisation (return pending visa) Asylum seekers who have been held in detention, do not Eligible for Medicare access through work rights, Health have any outstanding visa applications or litigation, who Care Card, including Pharmaceutical Benefits Scheme, cannot currently reasonably be removed from Australia, torture/trauma counselling, Maternity Allowance, and who agree in writing to cooperate with their maternity immunisation removal from Australia when advised that they must leave (removal pending bridging visa) Sources: [15, 49-54] Under certain circumstances, these individuals may be eligible for the Asylum Seeker Assistance Scheme (ASAS) [21] It can apply to both unauthorised arrivals held in detention or authorised arrivals who are in detention after breaching their visa conditions benefits (Centrelink), Medicare, education and training essential services available, accommodation support, (including 510 hours of English language lessons), and household formation support, early health assessment employment services. In addition, they receive settlement and intervention, and community support. The early support through the Integrated Humanitarian Settlement health assessment takes places within the first 12 months Strategy (IHSS), which is carried out by agencies responsi- of arrival, and involves information on available health ble for a range of settlement services. The IHSS includes services, physical health and psychological/psychosocial [13]: initial information and orientation assistance on the assessments, and referral to other health services where Page 4 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 required (including torture/trauma services). A current Case 1 policy gap however, relates to early health screening for Ms Jayawardene and her husband have been living in Australia infectious diseases. as asylum seekers for the past year. They are currently on Bridg- ing Visa E, which allows them to live in the community but In the 1970's and 80's, all new arrivals under the offshore gives them no work rights, no entitlement to Medicare and no program were offered health screening and assessments access to any social security benefits. Ms Jayawardene has which included immunization updates, screening for par- recently given birth. She had no prenatal care. Only after a asitic and infectious diseases. This was more easily accom- caseworker from a community based organisation (CBO) advo- plished as new arrivals spent the first few weeks within a cated on her behalf, was she hospitalised for the birth. She was, migrant hostel. However, in the 1990's Commonwealth however, discharged early because she was unable to pay the policy shifted so that new arrivals were settled directly into fees. The hospital only agreed to waive the fees after much nego- the community along with the expectation that early tiation, carried out on behalf of the couple by the CBO. health assessments would be carried out by local general practitioners. Thus, there is at present no comprehensive Case 2 Mr Hassan sought asylum in Australia two years ago, after hav- policy on health screening for new arrivals. Further, there is considerable debate about the merits of bringing in ing spent several years living in a number of different countries. compulsory health screening or whether this is better car- Mr Hassan spent one year in mandatory detention before he ried out within a more holistic approach allowing people was deemed a refugee and granted a three-year Temporary Pro- to access screening throughout the resettlement period tection Visa (TPV), which confers on him a range of entitle- [14]. ments, including Medicare. He recently consulted a local general practitioner to seek treatment for a stomach ailment, Onshore protection program but was unable to properly communicate about his symptoms Our discussion on Australia's policy on medical care due to his lack of English language skills. Although Mr Hassan within the onshore protection program begins with those is entitled to Medicare benefits, he is not entitled to other set- asylum seekers in detention centres. The immigration tlement services, such as adequate English-language tuition or detention policy, introduced in 1992, has been main- fee-free interpreting services. The lack of access to an interpreter tained with bipartisan support in Parliament [15]. The created a barrier to Mr Hassan receiving a proper health Commonwealth, not the States and Territories, is respon- assessment. sible for the health care of detainees. The private com- pany, Global Solutions Limited (Australia) Pty Ltd, Case 3 contracted by the Commonwealth to manage the deten- Mr Ahmed has a serious chronic heart condition that requires tion centres, is responsible for providing healthcare to all medication. He waited six months for a primary decision on his detainees. It employs nurses, general practitioners and application for protection before he qualified for the Asylum psychologists [16]. According to the Commonwealth Seeker Assistance Scheme (ASAS)-funded by DIMIA- which Government, detained asylum seekers have '24 hour med- assists with basic needs, including health care costs. Two ical services, dental services, culturally responsive physical months ago, however, Mr Ahmed lost access to ASAS because and psychological health services' [15]. Inquiries carried he appealed a negative Refugee Review Tribunal (RRT) deci- out by the Human Rights and Equal Opportunity Com- sion on his application for refugee status. He is now unable to mission (HREOC) into the detention centres, however, pay for essential medication and relies on charitable assistance report serious concerns in terms of the adequacy and qual- to provide his medication. ity of health care services available for the detainees, par- ticularly the failure to diagnose and treat torture/trauma These three case studies illustrate a number of key areas survivors [17,18]. where access to health care is either denied or inade- quately provided to people residing in Australia, and raise Although attention is often focussed on Australia's deten- a number of questions about health policies for onshore tion policies, Australian policy can also be criticised for protection applicants and TPV holders. infringing the rights of asylum seekers through denial of access to appropriate health care and related services [19]. Community based onshore protection applicants The three case studies below illustrate the complexities of Access to health care for asylum seekers living in the com- current policies relating to the provision of health care for munity depends on two elements: the type of bridging asylum seekers and Temporary Protection Visa (TPV) visa they hold and the particular stage of their application holders in Australia (NB: names have been changed). [20]. Until 1997, most onshore protection applicants were granted a bridging visa after their original visa (e.g. a visi- Page 5 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 tor visa or student visa) had expired. With some exemp- minors or elderly persons (over 65 years); parents with tions, this bridging visa conferred work rights, which children under 18 years of age; women with high risk consequently entitled most holders of the visa to Medi- pregnancies; and persons who are unable to work as a care, the Australian Government health insurance result of a disability, illness or torture/trauma [21]. scheme. On 1 July 1997, however, the government intro- duced work rights regulations for asylum seekers who ASAS may also be extended to RRT applicants who are applied for a protection visa (PV) on or after that date. unable to meet their basic needs and who have no ade- According to these regulations, 'a bridging visa with work quate support [21]. There have been a few cases in which rights may be granted to people who have been in Aus- DIMIA has used its discretionary powers to continue pro- tralia for fewer than 45 days in the 12 months before they viding certain asylum seekers, who are experiencing lodge a PV application [21]'. In other words, those asylum exceptional welfare circumstances, with 'special pay- seekers who have been in Australia for 45 days or more in ments' while their cases are at the post-RRT stage [19]. the 12 months before they make the PV application are However, once the RRT makes a decision on the applica- not permitted to work, and therefore, do not have access tion, most asylum seekers cease to be eligible for ASAS to Medicare. It has been reported that this requirement [21]. has resulted in approximately 40 per cent of community based asylum seekers being denied Medicare [1]. Usually, In March 2005, the Minister for Immigration and Multi- these asylum seekers are granted a Bridging Visa E. cultural and Indigenous Affairs announced the creation of the Removal Pending Bridging Visa (RPBV), intended to From 1 January 2001, PV applicants who 'have ever 'provide greater ability to manage the cases of long term applied (on- or off-shore) for a parent visa, irrespective of detainees who are awaiting removal' [22]. The visa allows whether their application is on-hand, finally determined a relatively small number of asylum seekers – those who or withdrawn, have no access to Medicare [21]'. For indi- have exhausted all legal appeals, but who cannot be rea- vidual asylum seekers with no work rights, the 'no work' sonably removed from Australia, and who are willing to condition may only be changed if DIMIA has not made a agree in writing that they will leave Australia when primary decision within six months of the lodgement of instructed to do so by the government – to enter the com- their application and the applicant demonstrates a com- munity. These asylum seekers are eligible for Medicare, pelling need to work [21]. In some circumstances, work through work rights, and have access to Health Care rights and Medicare may also be available to asylum seek- Cards, including the Pharmaceutical Benefits Scheme, ers if they are the spouse, child or parent of an Australian maternity care and torture/trauma counselling. citizen or permanent resident. More recently (21 June 2005) the Federal Government In an attempt to fill this welfare gap, DIMIA administers introduced further changes to detention which will the Asylum Seeker Assistance Scheme (ASAS) through include, among others, the release from detention of contractual arrangements with the Australian Red Cross. children and their families into the community [23]. Operating since 1993, ASAS was designed to financially Under these arrangements, DIMIA is funding the Red assist asylum seekers who were unable to meet their most Cross to develop a national system that will provide mate- basic needs (e.g. food, accommodation, health care). rial and health care support for those asylum seekers ASAS recipients can receive assistance with health care released into the community [24]. costs and referral to counselling services. These recent changes, including the introduction of the Initially, all asylum seekers were entitled to ASAS at the RPBV, add another significant layer of complexity to an primary and review stages of their application, if a deci- already complicated system. Questions raised by the sion had not been made within six months. The eligibility RPBV visa and its potential implications for asylum seek- criteria for ASAS, however, have been gradually restricted. ers are discussed later in the paper. Currently, to be eligible for ASAS, asylum seekers must be Temporary Protection Visa holders in financial hardship and: have lodged a valid PV applica- tion for which a primary decision has not been made According to current migration regulations, refugees on within six months; not be in detention and must hold a TPV have access to Medicare, are eligible for referral to the bridging or other visa; not have been released from deten- Early Health Assessment and Intervention Program tion on an undertaking of support; not be eligible for (EHAI), and for torture/trauma counselling [25]. TPV either Commonwealth or overseas government income holders, however, face serious challenges when accessing support; and not be a spouse, de facto or sponsored health care services. For instance, those over the age of 18 fiancé(e) of a permanent resident [21]. There are some are not eligible for government-funded English language exemptions to the above criteria, such as: unaccompanied classes. Low levels of English language skills cause social Page 6 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 isolation, unemployment (or low paid employment and These barriers are of particular concern as most refugees therefore inability to afford medications), higher inci- arrive in Australia in poor health and are likely to face par- dence of occupational health and safety issues, and obvi- ticular health challenges in the resettlement period. These ous difficulties when accessing health care services. TPV health challenges stem from previous experiences of tor- holders are not allowed to access the federally funded Tel- ture and trauma and from having lived in poor social and ephone Interpreting Service or the various health inter- economic prior to arrival, all of which impact on their preting services designed to assist health workers who well-being during the resettlement period [14]. treat people from non-English Speaking backgrounds. In addition, amputees on TPV are not able to access the A comparison of health policy for refugees and Commonwealth Rehabilitation Service [26]. asylum seekers across selected industrialised countries In early July 2004, the government introduced new meas- Australia is one of sixteen countries who accept refugees ures for TPV and Temporary Humanitarian Visa (THV) for resettlement under the UNHCR resettlement program holders [27]. Briefly, these changes include a reintegration [29]. Full entitlement to Medicare and additional entitle- assistance package for TPV and THV holders who are pre- ments to health care for special needs, including oral pared to return to their countries, the introduction of a health and mental health, are also provided by the Com- new 'Return Pending Visa', which will allow those TPV monwealth, State and Territory governments [21]. In fact, holders whose applications for further protection has Australian health care policy for newly arrived humanitar- been rejected to stay in Australia for 18 months while they ian entrants is comprehensive and one of the best com- prepare for departure; and changes to enable TPV and pared to other resettlement countries [30]. When it comes THV holders to apply for a range of non-humanitarian to onshore protection applicants, however, at the time of onshore visas to live permanently in Australia. These this writing Australia compares poorly to other resettle- recent developments, however, do not represent major ment countries. changes in health care access and other entitlements to TPV holders. While entitlements to social benefits and health care vary in the other resettlement countries, at the time of this writ- Despite the presence or absence of health policies relating ing, none of these countries deny asylum seekers the right to entitlements to medical care, there are a range of barri- to basic medical care. Indeed, a brief review of the refugee ers to accessing health care services, common to most ref- and asylum seeker health policies of the United Kingdom ugees, independent of their visa status. Some of the (UK), Canada and New Zealand indicates that Australian barriers that have been identified are: policy is comparatively lacking in this respect (See Table 3).  Long waiting times particularly in using Emergency Departments of public hospitals, In Canada, for example, asylum seekers – including those facing deportation – are entitled to primary and  Cost of services, especially for specialist health care and emergency care, essential health services for the treatment in relation to public dental health services, and prevention of serious medical conditions, essential prescription medications, and prenatal and obstetrical  Lack of information and confusion about the health sys- care, among others. Refugees and asylum seekers may also tem, particularly the difference between public and pri- receive secondary and mental health care with prior vate and entitlements, approval [31,32].  Lack of interpreters and female physicians, particularly The UK offers similar coverage for refugees and asylum in rural areas, seekers, providing access to a broad range of National Health Service (NHS) benefits, including primary and sec-  Absence of bulk billing services in rural areas, ondary care, optical and dental care, free prescriptions and coverage of travel costs to/from hospital [33]. It is impor-  Instances of discrimination, tant to note that recent changes to UK law suggest a tight- ening in the NHS' willingness to provide such broad  Other settlement needs taking precedence, particularly services across all asylum seeker categories [34]. Failed in cases where refugees are employed in casual or tempo- asylum seekers who have exhausted all rights of appeal are rary work with no leave provisions, now only eligible for urgent care at no cost [35]. Despite this reduction in the range of available entitlements, the  Lack of specialist care, particularly in regional areas [28]. UK's policy still offers greater medical coverage than that Page 7 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 Table 3: Country comparison of health entitlements for refugees and asylum seekers according to status Australia New Zealand Canada UK Refugee Medicare NZ Health System Provincial Health Cover: NHS Coverage coverage Canada's Federal Health system (comprised of Federal and Provincial contributions) includes comprehensive health cover, including hospital, physician, surgical-dental and specialist cover. Asylum Seeker in Health care through the N/A: Asylum Seekers No overarching coverage: National Health Service detention private company in charge rarely held in detention for individuals are assessed on (NHS) Coverage. a b b of the detention centres longer than 48 hours a case-by-case basis Coverage includes: primary & secondary care, free prescriptions, dental services, coverage of travel costs to/from hospital Asylum Seeker Depends on when visa NZ Health System Interim Federal Health NHS coverage awaiting primary applied for: If application coverage. Coverage (IFH) Program coverage. decision of refugee submitted within 45 days of includes all services, such Coverage includes essential status arrival, then individuals as: Primary & secondary health services for the have access to Medicare care, co-payment of treatment & prevention of but no translating services, pharmaceuticals, specialist serious medical conditions, Early Health Assessment referral and coverage, cost essential prescription and Intervention, and offsets for 'frequent users' medications, torture/trauma counselling, of medical services, contraception, prenatal If application submitted hospital & accident cover, care, obstetrical care, after 45 days of arrival, dental, mental, maternity Immigration Medical Exam, then no Medicare access and sexual health care. emergency dental service. Asylum Seeker No access to Medicare NZ Health System IFH Program Coverage NHS Coverage appealing a negative coverage NB: may take Refugee Review some time to receive Tribunal (or Community Services Card, equivalent) outcome necessary for accessing a General Practitioner (GP) Refused Asylum Seeker No access to Medicare NZ Health System IFH Program Coverage Primary & urgent care only who has exhausted all coverage NB: may take appeals some time to receive Community Services Card, necessary for accessing a GP Sources: [14, 31-33, 36, 37, 49, 55-60] Detention is mandatory for all 'unauthorised arrivals'. Detention is not mandatory for 'unauthorised arrivals'. Under certain circumstances, these individuals may be eligible for ASAS. See: DIMIA, 2003. The majority of individuals in this circumstance will not have Medicare access. A small number of individuals living in the community on 'Removal Pending Bridging Visas' will, however, have access. See: Table 2 for further explanation. Asylum Seekers who are deemed 'hard cases' maintain NHS coverage until a decision has been reached. available to many asylum seekers living in the community example those who are appealing a negative Refugee Sta- in Australia. tus Appeal Authority decision, also have access to PFHD services [37]. New Zealand, Australia's closest resettlement neighbour, provides refugees with the same health services as resi- Grey areas: complexities of the Australian dents through the Publicly Funded Health and Disabili- health care policy for refugees and asylum ties (PFHD) Service. Asylum seekers with applications seekers pending also have access to these services through a Com- The sheer range of diverse and complicated refugee and munity Services Card [36]. Other asylum seekers, for asylum seeker visa types exemplifies the complexity of Page 8 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 Australian health care and health policy for refugees and to access successfully health care, thereby creating even asylum seekers. This complexity often leads to confusion greater gaps between policy and practice. As mentioned among refugees, asylum seekers, community workers and previously, current Commonwealth policy does not pro- health care practitioners alike. Additionally, current vide asylum seekers on Bridging Visas and refugees on TPV health care policy presents numerous grey areas. In partic- access to English language tuition or fee-free interpreting. ular, problems exist around gaps between the legal and Studies from the UK indicate that misunderstandings and practical applications of these policies; lack of policy coor- poor communication between medical practitioners and dination between State and Commonwealth govern- asylum seekers operate as barriers to appropriate health ments; asylum seekers' ability to successfully access care [1]. Clearly, this is also the case for refugees and asy- necessary health care; decisions about granting ASAS; lack lum seekers within Australia, who do not have access to of publicly accessible government data; and implications fee-free interpreting services. of the new RPBV. Transport is often another major barrier to refugees and Significant gaps between legal and practical policy imple- asylum seekers attempting to access health care with many mentation and the lack of coordination between State and lacking the money necessary for public transport or taxis. Commonwealth governments may be best exemplified by Could they access a vehicle, many are ineligible for driv- the issue of access to public hospitals for asylum seekers. ers' licences, unless they can read, write and understand To begin, it is important to distinguish between legal English sufficiently to pass the exam. restrictions and de facto restrictions. Disparities between being eligible to access health care and being able to A key barrier towards improving health policy for refugees access health care epitomise these gaps. In other words, and asylum seekers is the difficulty in obtaining clear asylum seekers with no Medicare can, theoretically, access information from relevant Commonwealth Departments. public hospitals but may not be able to do so because they For example, in relation to ASAS eligibility, it is unclear fear that their lack of income will leave them unable to how DIMIA applies its discretionary powers to extend eli- pay hospital fees. There is growing evidence suggesting gibility to ASAS or similar 'special payments' to some asy- that Medicare ineligible asylum seekers have been turned lum seekers whose cases are at the post-RRT stage. away from hospitals, have not completed their required Similarly there is a lack of publicly available government medical treatment, or have been asked to pay outstanding data on several key issues regarding asylum seeker health hospital bills and this is of significant concern [20]. policy. First, it is unclear how many asylum seekers are liv- ing in the community on Bridging Visa E. This makes it Although some State governments have attempted to difficult for CBOs to assess levels of need and asylum improve asylum seekers' access to health care and welfare seeker populations. Second, there is currently no proce- [38], the Catholic Commission for Justice Development dure for recording asylum seekers' access to health care and Peace reports that State governments have failed 'to which has lead to a lack of knowledge to inform policy provide clear instructions to their departments and agen- and practice. Third, there are no available data for analys- cies to protect the human rights of asylum seekers in the ing the numbers of refugees and asylum seekers using areas of housing, health, transport and education' [39]. public hospital services and, finally, there are no data on Additionally, State and Territory governments do not have what they are being treated for. These issues, in turn, make clear policies concerning Medicare ineligible asylum seek- it virtually impossible to estimate rates of and reasons for ers. In New South Wales (NSW), for example, an assur- admission. Thus, we are left with case studies and docu- ance of payment is required before treatment will be mentation carried out by the already strapped CBOs work- provided. If, however, that assurance is not available, then ing in the sector. patients will 'receive only the minimum and necessary medical care to stabilise their condition' [1]. The recent introduction of RPBV only complicates these grey areas further. In particular, the RPBV creates dispari- Strategies and practices for the provision of care to this ties between bridging visas, presents significant human population also vary widely across public health care serv- rights issues and has the potential to lead to further men- ices. While a few services provide ease of access to asylum tal health issues for these asylum seekers. First, the RPBV's seekers, many CBOs report that the majority deny access provision of Medicare raises significant issues around the or attempt full fee recovery after providing the services. levels of health care access for asylum seekers on other Commonly, access to these services, including waiving of types of Bridging Visas. For example, what is the rationale fees, is dependent on long term advocacy from CBOs [19]. behind the decision to grant Medicare rights to this Bridg- ing Visa, when existing Bridging Visas offer no similar Other factors, such as English language skills and ability rights? Why has the provision of greater rights under this to access transport, also influence asylum seekers' ability Bridging Visa not translated to other, similar visa catego- Page 9 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 ries? That is, if Medicare has been deemed necessary for There are two key areas where policy reforms are urgently these Bridging Visa holders, why has this not been required. First, Commonwealth and State and Territory extended to other Bridging Visa holders? health care policy for asylum seekers needs to be coordi- nated to remove the current gaps which result in little or The RPBV also raises great concern about potential denial no access to health care for a proportion of the asylum of human rights. Currently, the RPBV requires asylum seeker population [14]. Second, serious consideration seekers to agree in writing that they will cooperate with should be given to extending medical care to all asylum their removal from Australia when the government deems seekers residing on Australia soil, regardless of their visa it is safe to do so. Thus, there is the very real potential for status. This medical care should include at least primary the promise of release from detention to lead to asylum medical and psychological health care and care that can- seekers relinquishing their legal rights and future oppor- not be postponed [45]. While there has been no rigorous tunities for visas. The written agreement may also facili- economic analysis of the potential costs of extending tate involuntary return – individuals will have no say Medicare to the entirety of this population, a small study about the safety of their return, once the government indicates that the costs would be about A$ 2.9 million per deems it should happen [40]. year for NSW [46]. A similar analysis conducted by one of the authors (I C-V) estimated that the expected health care The RPBV may also have significant effects on the mental costs for asylum seekers living in the Victorian community health of asylum seekers. There is a growing body of evi- would be about A$1.5 million per year. This figure repre- dence on the negative mental health impacts of detention sents about 0.009% of the total annual health care on asylum seekers [41,42]. Releasing these already trau- expenditure in Victoria in 2000–2001 [47]. These two ini- matised individuals into the community without immedi- tiatives would go a long way towards health policy reform ate and ongoing access to counselling, and with no for this vulnerable, high need but numerically small pop- definite return date, no guaranteed visa term and no rights ulation residing in Australia. of appeal, could lead to further mental health issues, such as depression, feelings of isolation and anxiety. List of abbreviations ASAS: Asylum Seeker Assistance Scheme Filling the Gaps: the need to adopt minimum CBO: Community based organisation standards Current Australian health policy on access to medical care for refugees and asylum seekers has two faces. On the one DIMIA: Department of Immigration and Multicultural hand, health care access for resettling refugees is compre- and Indigenous Affairs hensive and one of the best compared to other resettle- ment countries. On the other hand, health policy for EHAI: Early Health Assessment and Intervention Program asylum seekers is less than adequate to ensure a minimum standard of health care. Moreover, the gaps between Com- HIV: Human Immunodeficiency Virus monwealth policy and State and Territory policy has pro- duced a climate of confusion especially in regards to who HREOC: Human Rights and Equal Opportunity pays. Commission As Taylor argues, current Australian policy for asylum ICESCR: International Covenant on Economic, Social and seekers is 'insufficient to assure them of an adequate Cultural Rights standard of living', and in breach of the International Cov- enant on Economic, Social and Cultural Rights (ICESCR) IFH: Interim Federal Health [43]. The current policy context may also leave Australia in breach of other 'international legal conventions and IHSS: Integrated Humanitarian Settlement Strategy recommendations regarding its obligations toward asy- lum seekers living in its territory' [19] (p.16). Expanding MOC: Medical Officer of the Commonwealth on the human rights perspective, Dwyer argues that refu- gee and asylum seeker health care is also an issue of social NHS: National Health Service justice and social responsibility [44]. In order to meet its basic human rights, social justice and social responsibility PFHD: Publicly Funded Health and Disabilities requirements, therefore, Australian health policy for asy- lum seekers needs significant and immediate change. PPV: Permanent Protection Visa PV: Protection visa Page 10 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 Human Services. Melbourne, Victorian Foundation for Survivors RPBV: Removal Pending Bridging Visa of Torture; 2004. 15. DIMIA: Fact Sheet 82: Immigration Detention. Canberra, RRT: Refugee Review Tribunal Department of Immigration and Multicultural and Indigenous Affairs; 16. Smith MM: Asylum seekers in Australia. eMJA 2001, 175:587 SHP: Special Humanitarian Program -5589. 17. HREOC: Those who've come across the seas: Detention of unauthorised arrivals. In Report Sydney, Human Rights and Equal TB: Tuberculosis Opportunity Commission; 1998. 18. HREOC: Immigration Detention: Human Rigths Commis- sioner's 1998-1999 Review. Canberra, Human Rights and Equal THV: Temporary Humanitarian Visa Opportunity Commission; 1999. 19. McNevin A: Seeking Safety, Not Charity: A report in support TPV: Temporary Protection Visa of work-rights for asylum-seekers living in the community on Bridging Visa E. Melbourne, Network of Asylum Seeker Agen- cies Victoria; 2005. UNHCR: United Nations High Commissioner for 20. Asylum Seeker Project Hotham Mission: Welfare issues and immigration outcomes for asylum seekers on Bridging Visa Refugees E. In Research and evaluation paper Melbourne, ; 2003. 21. DIMIA: Fact Sheet 62: Assistance for asylum seekers in Aus- Competing interests tralia. Canberra, Department of Immigration and Multicultural and Indigenous Affairs; 2003. The author(s) declare that they have no competing 22. Minister for Immigration and Multicultural and Indigenous Affairs: interests. Broader Powers for Immigration Minister to Manage Long Term Detainees. [http://www.minister.immi.gov.au/ media_releases/media05/v05046.htm]. Authors' contributions 23. Commonwealth of Australia: Migration Amendment (Detention All authors contributed equally to this paper. Arrangements) Bill 2005 - Explanatory Memorandum. Can- berra, The Parliament of the Commonwealth of Australia; 2005. 24. Aristotle P: Changes to detention arrangements. Melbourne, Acknowledgements Victorian Foundation for Survivors of Torture; 2005. The authors would like to thank: Paris Aristotle, Mardi Stow, Jenny Mitch- 25. DIMIA: Temporary protection visas. Fact Sheet [http:// www.immi.gov.au/facts/64protection.htm]. ell, Jo Szwarc, and Robyn Sampson for their helpful comments on initial 26. Pickering S, Gard M, Richardson R: "We're working with people drafts of the paper; the anonymous reviewers for their valuable comments. here" : The impact of the TPV regime on refugee settlement service provision in NSW. Report 2003. References 27. DIMIA: New measures for temporary protection and tempo- 1. Harris MF, Telfer BL: The health needs of asylum seekers living rary humanitarian visa holders. In Report Canberra, Department of Immigration and Multicultural and Indigenous Affairs; 2004. in the community. eMJA 2001, 175:589 -5592. 2. UNHCR: Convention Relating to the Status of Refugees. 28. Marston G: Temporary protection permanent uncertainty : The experience of refugees living on temporary protection Geneva, UNHCR; 1951. 3. UNHCR: UNHCR Guidelines on Detention of Asylum visas. In Report Melbourne, Centre for Applied Social Research RMIT University; 2003. Seekers. [http://www.rcmvs.org/investigacion/Asylum.htm]. 4. UNHCR: Refugees by Numbers. Volume 2005. Geneva, United 29. UNHCR: New Resettlement Programs. [http://www.unhcr.ch/ cgi-bin/texis/vtx/protect?id=3bb2e1d04]. Nations High Commissioner for Refugees; 2004. 5. UNHCR: Global Consultations on International Protection: 30. UNHCR: Resettlement Handbook. Geneva, Department of Internal Portection, United Nations High Commissioner for Refugees; Report of the Meetings within the Framework of the Stand- ing Committee (Third Track). [http://www.unhcr.ch/cgi-bin/ 2004. 31. Citizenship and Immigration Canada: Interim Federal Health Pro- texis/vtx/excom/opendoc.pdf?tbl=EXCOM&id=3d3fb35a4]. 6. UNHCR: 2004 Global Refugee Trends. Geneva, Population and gram Information for Health Professionals. [http:// www.cic.gc.ca/english/applications/guides/5568ea.html]. Geographical Data Section, Division of Operational Support, United Nations High Commissioner for Refugees; 2005. 32. Citizenship and Immigration Canada: Interim Federal Health Pro- gram. [http://www.cic.gc.ca/ref-protection/english/infocentre/set 7. UNHCR: Protecting Refugees: New resettlement pro- grammes. Geneva, United Nations High Commissioner for tlement-etablissement/comm-prof/appendix_i.htm]. 33. National Health Service UK: Health Services. Meeting the Needs of Refugees; 2005. 8. U.S. Committee for Refugees and Immigrants: World Refugee Sur- Refugees and Asylum Seekers in the UK: An information pack for health care workers [http://www.london.nhs.uk/newsmedia/publications/ vey 2005. Washington, U.S. Committee for Refugees and Immigrants; 2005. Asylum_Refugee.pdf]. 34. Hinsliff G: Hutton Announces Crackdown on Health Cheats. 9. DIMIA: Fact Sheet 60: Australia's Refugee and Humanitarian Program. Canberra, Department of Immigration and Multicultural In The Observer London, ; 2003. 35. Statutory Instrument 2004, No. 614: The National Health and Indigenous Affairs; 2005. 10. DIMIA: Fact Sheet 22: The Health Requirement. Canberra, Service (Changes to Overseas Visitors) (Amendment) Regu- lations 2004. 2004. Department of Immigration and Multicultural and Indigenous Affairs; 2004. 36. Minister of Health: Refugee Health Care: A Handbook for Por- fessionals. [http://www.moh.govt.nz/moh.nsf/wpg_Index/Publica 11. DIMIA: Health requirement for temporary entry to Australia. Canberra, Department of Immigration and Multicultural and Indige- tions-Refugee+Health+Care:+A+Handbook+for+Health+Profes- sionals]. nous Affairs; 2005. 12. DIMIA: Fact Sheet 75: Processing unlawful boat arrivals. Can- 37. Department of Labour: Refugee Voices: Interim Report: A Jour- ney Towards Resettlemetn. [http://www.immigration.govt.nNR/ berra, Department of Immigration and Multicultural and Indigenous Affairs; 2004. rdonlyres/88DD11F7-107C-45A8-889F-AAD0E01C6CA0/ RefugeeVoicesInterimReportDecember2002.pdf#search='refu 13. DIMIA: Australia's support for humanitarian entrants. Can- berra, Department of Immigration and Multicultural and Indigenous gee%20voices%20interim%20report%20nz]. 38. Minister for Community Services: Brack's Government Helps Affairs; 2003. 14. VFST: Towards a health strategy for refugees and asylum Victoria's Asylum Seekers. Melbourne, Victorian Government; seekers in Victoria: Report to the Victorian Department of Page 11 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 39. Schwartz L: Government visa policies a 'sin', say rights advocates. In The Age Melbourne, ; 2004. 40. Asylum Seeker Resource Centre: Proposed Release of Long Term Detainees Does Not Go Far Enough. [http://back end.ewock.com/ewocksql3/ asindex.asp?ID=166&Action=News&IDNews Item=504&IDSub=Null&IDItem=Null]. 41. Steel Z, Silove DM: The mental health implications of detaining asylum seekers. eMJA 2001, 175:596 -5599. 42. Sultan A, O'Sullivan K: Psychological disturbances in asylum seekers held in long term detention: A participant-observer account. eMJA 2001, 175:593 -5596. 43. Taylor S: Do on-shore asylum seekers have economic and social right? Dealing with the moral contradiction of liberal democracy. Melbourne Journal of International Law 2000, 1:70 -796. 44. Dwyer J: Illegal immigrants, health care, and social responsibility. Hasting Center Report 2004, 34:34-41. 45. Council of the European Union: Laying down minimum stand- ards for the reception of asylum seekers. Brussels, Council of the European Union; 2003. 46. Kardamanidis K: Tangible and intangible costs of the 'no work - no Medicare' policy for community based asylum seekers in New South Wales Australia. In School of Public Health Sydney, University of Sydney; 2004. 47. AIHW: Health system expenditure on disease and injury in Australia, 2000-01. Canberra, Australian Institute of Health and Welfare; 2004. 48. DIMIA: Fact Sheet 65: New Humanitarian Visa System. Can- berra, Department of Immigration and Multicultural and Indigenous Affairs; 2002. 49. DIMIA: Form 1024i: Bridging Visas. Canberra, Department of Immigration and Multicultural and Indigenous Affairs; 2003. 50. Australian Attorney-General's Department: Migration Regula- tions 1994. Canberra, SCALEplus, Commonwealth of Australia; 51. DIMIA: Seeking asylum within Australia. Fact Sheet [http:// www.immi.gov.au/facts/61asylum.htm]. 52. Brotherhood of St Laurence: Seeking Asylum: Living with Fear, Uncertainty and Exclusion. Melbourne, BSL; 2002. 53. DIMIA: Fact Sheet 64c: Return Pending Visa. Canberra, Department of Immigration and Multicultural and Indigenous Affairs; 54. DIMIA: Fact Sheet 85: Removal Pending Bridging Visa. Can- berra, Department of Immigration and Multicultural and Indigenous Affairs; 2005. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 12 of 12 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

Australian health policy on access to medical care for refugees and asylum seekers

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Publisher
Springer Journals
Copyright
Copyright © 2005 by Correa-Velez et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Social Policy
ISSN
1743-8462
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1743-8462
DOI
10.1186/1743-8462-2-23
pmid
16212674
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See Article on Publisher Site

Abstract

Since the tightening of Australian policy for protection visa applicants began in the 1990s, access to health care has been increasingly restricted to asylum seekers on a range of different visa types. This paper summarises those legislative changes and discusses their implications for health policy relating to refugees and asylum seekers in Australia. Of particular concern are asylum seekers on Bridging Visas with no work rights and no access to Medicare. The paper examines several key questions: What is the current state of play, in terms of health screening and medical care policies, for asylum seekers and refugees? Relatedly, how has current policy changed from that of the past? How does Australia compare with other countries in relation to health policy for asylum seekers and refugees? These questions are addressed with the aim of providing a clear description of the current situation concerning Australian health policy on access to medical care for asylum seekers and refugees. Issues concerning lack of access to appropriate health care and related services are raised, ethical and practical issues are explored, and current policy gaps are investigated. is a complex and rapidly changing field of play. In this Introduction Australian health care policy regarding entitlements to paper, we review current health care policies for refugees medical care for refugees and asylum seekers is complex. and asylum seekers in Australia with a focus on those On the one hand, health care policy for refugees entering areas of policy gaps that result in a lack of access to medi- Australia on the offshore humanitarian program is com- cal and health care for some, and less optimal access to prehensive, entitling refugees to Medicare, early health care for others. We begin by briefly discussing the defini- assessment, specialised torture and trauma services, and tions of who is deemed to be a refugee and who is deemed access to the same services as other Australians. On the to be an asylum seeker, for health care policies vary within other hand, health care policy for refugees and asylum and between these two categories accordingly. Second, we seekers who have entered Australia in an unauthorised describe in some detail, the current health policy for asy- manner, and who are on a range of visa types, is frag- lum seekers and refugees within Australia's onshore pro- mented. About 40% of asylum seekers living in the com- gram compared to health policy for refugees who have munity have no rights to access medical care [1]. come to Australia through the offshore program. Third, we provide a broad comparison of Australian health care pol- Health policy for refugee and asylum seekers is directly icies for refugees and asylum seekers to those of the tied to immigration policy and visa types and this in turn United Kingdom, Canada and New Zealand, countries Page 1 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 Table 1: Australia's immigration humanitarian program Visa categories and subcategories Permanent offshore humanitarian visa Temporary offshore humanitarian visa categories categories Offshore resettlement • Refugee: for people who are subject to persecution in • Secondary Movement Relocation: temporary their home country and who are in need of humanitarian visa (THV) to people who have moved resettlement from a safe first country of asylum to another country •Special Humanitarian Program (SHP): for people before applying to enter Australia (5-year visa) who are outside their home country and are subject to • Secondary Movement Offshore Entry: temporary substantial discrimination amounting to gross violation visa to people who arrived without authorisation in of human rights in their home country Australia at a place outside Australia's migration zone and have moved from a safe first country of asylum (3- year visa) Form of arrival and visas granted Authorised arrivals Unauthorised arrivals Onshore protection Most authorised arrivals who subsequently apply for Unauthorised arrivals are placed in immigration protection receive a bridging visa. The bridging visa detention until granted a Protection Visa or removed allows them to remain in the community while the from Australia. Those who are found to be refugees are Protection Visa application is processed. Those who are granted a 3-year Temporary Protection Visa (TPV). found to be refugees are granted Permanent Protection Visa (PPV). Sources: [9, 48] with comparable public health systems. Finally, we dis- a territory where life or freedom is threatened. Other cuss the current areas where policy on access to health care aspects of asylum law are particularly relevant to the issue is in conflict between States and Territories and the Com- of health policy discussed here. It is important to note that monwealth and where Australian policy may be in breach it is not illegal to seek asylum in any country and that the of various human rights conventions. basic provisions related to humane treatment and basic rights apply to asylum seekers. Additionally, International Who is a refugee or asylum seeker? Human Rights Law recognizes the right of all individuals Under the United Nations 1951 Convention and 1967 to an adequate standard of living [5]. Protocol relating to the Status of Refugees (the Refugee Convention), a refugee is a person who '...owing to a well- At the end of 2004 there were an estimated 19.2 million founded fear of being persecuted for reasons of race, reli- asylum seekers, refugees and other people of concern to gion, nationality, membership of a particular social the UNHCR [6]. In the same year, 676,000 first instance group, or political opinion, is outside the country of his or appeal applications for asylum were submitted in 143 nationality, and is unable to or, owing to such fear, is countries; only 3,276 asylum applications were lodged in unwilling to avail himself of the protection of that coun- Australia, compared to over 500,000 in other industrial- try' [2]. An asylum seeker is a person who has fled their ized countries [6]. In relation to refugee intake, Australia own country and has sought sanctuary in a second state is one of 16 countries currently participating in the [3]. They then apply to be recognized as a bona fide refugee UNHCR-facilitated resettlement program [7]. In 2004, and to receive legal protection and material assistance that 84,809 refugees were resettled in these countries of which that status implies [4]. 13,030 were resettled in Australia [8]. Although the 1951 Refugee Convention does not deal Australian health policy for refugees and asylum specifically with asylum seekers, two of its Articles are par- seekers: Humanitarian program, health ticularly relevant to the issues of access to health care con- screening and health care access sidered in this paper. First, Article 33 (refoulement) states In order to understand health policies for refugees and that no refugee shall be expelled or returned to where his/ asylum seekers, it is important to briefly describe Aus- her life is threatened. Second, Article 31 prohibits punish- tralia's humanitarian program and the current legislation ment or penalties for entry to a state when they come from on visa status and protection. This is because entitlements Page 2 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 to health care vary by visa status, and legislation concern- thorised manner, are required to undergo medical and ing visa status is in a constant state of flux. radiological examinations before the granting of the visa. Australia's humanitarian program According to DIMIA, the only health condition that for- Australia's humanitarian program for refugees and others mally precludes the grant of a visa is active or untreated with humanitarian needs includes two components [9]: tuberculosis (TB) [10]. Those applicants whose TB has offshore resettlement for people overseas, and onshore protec- been treated or those with a previous but currently non- tion for those who are already in Australia, arrived on tem- active TB, are required to make a Health Undertaking. In porary visas (e.g. visitor or student visas) or in an other words, they are required to contact the Health unauthorised manner, and are seeking Australia's protec- Undertaking Service on arrival in Australia, and to report tion. These two components and their visa categories are to State or Territory health authorities for follow-up shown in Table 1. assessment [10]. The Health Undertaking also applies for a pregnant applicant who has not had the chest X-ray as Policy on health screening for offshore and onshore part of the standard health examination (although this is applicants not commonly extended to persons from high risk TB Australia's health policy for humanitarian entrants begins countries). pre-arrival. Those who apply under the offshore resettlement program must satisfy the health requirement [10] speci- All other health conditions are assessed on a case by case fied in the Migration Regulations. This health require- basis taking into account the risk to public health, the esti- ment, which is set by the Department of Immigration and mated costs, and the resource use impact on the Austral- Multicultural and Indigenous Affairs (DIMIA) on advice ian community. The final authority as to whether the from the Commonwealth Department of Health and Age- health requirement is met rests with the Medical Officer of ing, is designed to minimise public health risks to the Aus- the Commonwealth (MOC). The visa processing officers tralian community, regulate public expenditure on health are required to accept the opinion of the MOC. However, and community services, and maintain access to health where there are compelling factors, the Minister's delegate and other services for Australian residents. In general, the processing officer may waive the health requirement for health assessment involves a medical examination, a radi- refugees and other humanitarian visa applicants. If the ological examination to test for Tuberculosis (children applicant or any member of their family fails to pass the under 11 are generally exempt), and HIV/AIDS testing health requirement, the entire family group can be denied (for all applicants aged 15 or older). For some applicants a visa. They may however, be referred to other resettle- screening for Hepatitis B is mandatory. Other tests may be ment countries such as the United States, who have differ- requested by a Medical Officer of the Commonwealth. ent health screening guidelines and selection criteria. For those applying under the onshore protection program, they For those who apply under the onshore protection program, may be denied a protection visa should they fail the the health screening varies depending on their specific cir- health requirement under the same above considerations. cumstances. In general, those who arrive in Australia on a 3-month temporary visa – or less – are not required to Policy on medical care for offshore and onshore applicants have formal health examinations prior to their arrival While Australian policies on resettlement of humanitar- ian refugees are arguably among the best, compared to (some exceptions apply [11]). Those arriving on a greater than 3 months temporary visa may be required to other United Nations High Commissioner for Refugees undergo formal medical and radiological examinations (UNHCR) resettlement countries, its policies on the prior to arrival, depending on the level of health risk of treatment of onshore protection applicants have been their country of origin, their age, and the purpose of their strongly criticised by human rights organisations, schol- stay (e.g. likely to enter a hospital, health care area, class- ars, government members and others for their denial of room, preschool or childcare centres). basic human rights guaranteed under the 1951 Refugee Convention [2]. A brief description of the medical care All unauthorised arrivals who are applying for Australia's entitlements granted to different categories of offshore protection undergo health screening soon after their humanitarian entrants and onshore protection applicants arrival at immigration detention centres. "Where any seri- is given in Table 2. ous communicable diseases are suspected or confirmed, Offshore resettlement program formal notification procedures are followed with Com- monwealth and State/Territory health authorities" [12] On arrival to Australia, all refugees and special humanitar- (p. 2). In general, those who make an onshore application ian program (SHP) entrants under the offshore resettlement for protection, whether arriving on an authorised or unau- program receive all the entitlements granted to Australian permanent residents, including access to social security Page 3 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 Table 2: Health entitlements commonly granted to refugees and asylum seekers in Australia Humanitarian program Circumstances Entitlements Offshore resettlement Refugees who hold permanent offshore humanitarian Same eligibility for Medicare and Health Care Card, visas including Pharmaceutical Benefits Scheme, as other permanent residents. Eligible for Early Health Assessment and Intervention Program and torture/ trauma services. Refugees who hold temporary offshore humanitarian Able to gain access to Medicare and Health Care Cards, visas (THV) including Pharmaceutical Benefits Scheme; eligible for referral to the Early Health Assessment and Intervention Program and torture/trauma services. Onshoore protection Authorised arrivals Authorised arrivals who have been found to be refugees Same eligibility for Medicare and Health Care Card, and are granted permanent protection visa (PPV) including Pharmaceutical Benefits Scheme, as other permanent residents. Authorised arrivals who applied for protection within 45 Eligible for Medicare days of their arrival in Australia and are awaiting primary decision on their application Authorised arrivals who have been in Australia for 45 No access to Medicare days or more before they applied for protection Authorised arrivals who have appealed or are about to No access to Medicare appeal to the Refugee Review Tribunal or the Administrative Appeals Tribunal after their primary protection application has been refused Authorised arrivals who are appealing to the Minister of No access to Medicare Immigration after being found not to be refugees at the review stage Unauthorised arrivals Unauthorised arrivals who have been found to be Access to Medicare benefits and Health Care Card; refugees and are granted temporary protection visa eligibility for torture and trauma counselling (TPV) Unauthorised arrivals who are applying for protection Access to health care through health professionals and are in immigration detention contracted by the private company in charge of the detention centres Unauthorised arrivals who have been in mandatory No access to Medicare detention, are subsequently released into the community, and have an outstanding visa application Others Asylum seekers who hold or held a TPV or a THV, have Eligible for Medicare access through work rights, Health had their application for further protection finally Care Card, including Pharmaceutical Benefits Scheme, refused, have exhausted all legal options to remain in torture/trauma counselling, Maternity Allowance, Australia and are making arrangements for departure maternity immunisation (return pending visa) Asylum seekers who have been held in detention, do not Eligible for Medicare access through work rights, Health have any outstanding visa applications or litigation, who Care Card, including Pharmaceutical Benefits Scheme, cannot currently reasonably be removed from Australia, torture/trauma counselling, Maternity Allowance, and who agree in writing to cooperate with their maternity immunisation removal from Australia when advised that they must leave (removal pending bridging visa) Sources: [15, 49-54] Under certain circumstances, these individuals may be eligible for the Asylum Seeker Assistance Scheme (ASAS) [21] It can apply to both unauthorised arrivals held in detention or authorised arrivals who are in detention after breaching their visa conditions benefits (Centrelink), Medicare, education and training essential services available, accommodation support, (including 510 hours of English language lessons), and household formation support, early health assessment employment services. In addition, they receive settlement and intervention, and community support. The early support through the Integrated Humanitarian Settlement health assessment takes places within the first 12 months Strategy (IHSS), which is carried out by agencies responsi- of arrival, and involves information on available health ble for a range of settlement services. The IHSS includes services, physical health and psychological/psychosocial [13]: initial information and orientation assistance on the assessments, and referral to other health services where Page 4 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 required (including torture/trauma services). A current Case 1 policy gap however, relates to early health screening for Ms Jayawardene and her husband have been living in Australia infectious diseases. as asylum seekers for the past year. They are currently on Bridg- ing Visa E, which allows them to live in the community but In the 1970's and 80's, all new arrivals under the offshore gives them no work rights, no entitlement to Medicare and no program were offered health screening and assessments access to any social security benefits. Ms Jayawardene has which included immunization updates, screening for par- recently given birth. She had no prenatal care. Only after a asitic and infectious diseases. This was more easily accom- caseworker from a community based organisation (CBO) advo- plished as new arrivals spent the first few weeks within a cated on her behalf, was she hospitalised for the birth. She was, migrant hostel. However, in the 1990's Commonwealth however, discharged early because she was unable to pay the policy shifted so that new arrivals were settled directly into fees. The hospital only agreed to waive the fees after much nego- the community along with the expectation that early tiation, carried out on behalf of the couple by the CBO. health assessments would be carried out by local general practitioners. Thus, there is at present no comprehensive Case 2 Mr Hassan sought asylum in Australia two years ago, after hav- policy on health screening for new arrivals. Further, there is considerable debate about the merits of bringing in ing spent several years living in a number of different countries. compulsory health screening or whether this is better car- Mr Hassan spent one year in mandatory detention before he ried out within a more holistic approach allowing people was deemed a refugee and granted a three-year Temporary Pro- to access screening throughout the resettlement period tection Visa (TPV), which confers on him a range of entitle- [14]. ments, including Medicare. He recently consulted a local general practitioner to seek treatment for a stomach ailment, Onshore protection program but was unable to properly communicate about his symptoms Our discussion on Australia's policy on medical care due to his lack of English language skills. Although Mr Hassan within the onshore protection program begins with those is entitled to Medicare benefits, he is not entitled to other set- asylum seekers in detention centres. The immigration tlement services, such as adequate English-language tuition or detention policy, introduced in 1992, has been main- fee-free interpreting services. The lack of access to an interpreter tained with bipartisan support in Parliament [15]. The created a barrier to Mr Hassan receiving a proper health Commonwealth, not the States and Territories, is respon- assessment. sible for the health care of detainees. The private com- pany, Global Solutions Limited (Australia) Pty Ltd, Case 3 contracted by the Commonwealth to manage the deten- Mr Ahmed has a serious chronic heart condition that requires tion centres, is responsible for providing healthcare to all medication. He waited six months for a primary decision on his detainees. It employs nurses, general practitioners and application for protection before he qualified for the Asylum psychologists [16]. According to the Commonwealth Seeker Assistance Scheme (ASAS)-funded by DIMIA- which Government, detained asylum seekers have '24 hour med- assists with basic needs, including health care costs. Two ical services, dental services, culturally responsive physical months ago, however, Mr Ahmed lost access to ASAS because and psychological health services' [15]. Inquiries carried he appealed a negative Refugee Review Tribunal (RRT) deci- out by the Human Rights and Equal Opportunity Com- sion on his application for refugee status. He is now unable to mission (HREOC) into the detention centres, however, pay for essential medication and relies on charitable assistance report serious concerns in terms of the adequacy and qual- to provide his medication. ity of health care services available for the detainees, par- ticularly the failure to diagnose and treat torture/trauma These three case studies illustrate a number of key areas survivors [17,18]. where access to health care is either denied or inade- quately provided to people residing in Australia, and raise Although attention is often focussed on Australia's deten- a number of questions about health policies for onshore tion policies, Australian policy can also be criticised for protection applicants and TPV holders. infringing the rights of asylum seekers through denial of access to appropriate health care and related services [19]. Community based onshore protection applicants The three case studies below illustrate the complexities of Access to health care for asylum seekers living in the com- current policies relating to the provision of health care for munity depends on two elements: the type of bridging asylum seekers and Temporary Protection Visa (TPV) visa they hold and the particular stage of their application holders in Australia (NB: names have been changed). [20]. Until 1997, most onshore protection applicants were granted a bridging visa after their original visa (e.g. a visi- Page 5 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 tor visa or student visa) had expired. With some exemp- minors or elderly persons (over 65 years); parents with tions, this bridging visa conferred work rights, which children under 18 years of age; women with high risk consequently entitled most holders of the visa to Medi- pregnancies; and persons who are unable to work as a care, the Australian Government health insurance result of a disability, illness or torture/trauma [21]. scheme. On 1 July 1997, however, the government intro- duced work rights regulations for asylum seekers who ASAS may also be extended to RRT applicants who are applied for a protection visa (PV) on or after that date. unable to meet their basic needs and who have no ade- According to these regulations, 'a bridging visa with work quate support [21]. There have been a few cases in which rights may be granted to people who have been in Aus- DIMIA has used its discretionary powers to continue pro- tralia for fewer than 45 days in the 12 months before they viding certain asylum seekers, who are experiencing lodge a PV application [21]'. In other words, those asylum exceptional welfare circumstances, with 'special pay- seekers who have been in Australia for 45 days or more in ments' while their cases are at the post-RRT stage [19]. the 12 months before they make the PV application are However, once the RRT makes a decision on the applica- not permitted to work, and therefore, do not have access tion, most asylum seekers cease to be eligible for ASAS to Medicare. It has been reported that this requirement [21]. has resulted in approximately 40 per cent of community based asylum seekers being denied Medicare [1]. Usually, In March 2005, the Minister for Immigration and Multi- these asylum seekers are granted a Bridging Visa E. cultural and Indigenous Affairs announced the creation of the Removal Pending Bridging Visa (RPBV), intended to From 1 January 2001, PV applicants who 'have ever 'provide greater ability to manage the cases of long term applied (on- or off-shore) for a parent visa, irrespective of detainees who are awaiting removal' [22]. The visa allows whether their application is on-hand, finally determined a relatively small number of asylum seekers – those who or withdrawn, have no access to Medicare [21]'. For indi- have exhausted all legal appeals, but who cannot be rea- vidual asylum seekers with no work rights, the 'no work' sonably removed from Australia, and who are willing to condition may only be changed if DIMIA has not made a agree in writing that they will leave Australia when primary decision within six months of the lodgement of instructed to do so by the government – to enter the com- their application and the applicant demonstrates a com- munity. These asylum seekers are eligible for Medicare, pelling need to work [21]. In some circumstances, work through work rights, and have access to Health Care rights and Medicare may also be available to asylum seek- Cards, including the Pharmaceutical Benefits Scheme, ers if they are the spouse, child or parent of an Australian maternity care and torture/trauma counselling. citizen or permanent resident. More recently (21 June 2005) the Federal Government In an attempt to fill this welfare gap, DIMIA administers introduced further changes to detention which will the Asylum Seeker Assistance Scheme (ASAS) through include, among others, the release from detention of contractual arrangements with the Australian Red Cross. children and their families into the community [23]. Operating since 1993, ASAS was designed to financially Under these arrangements, DIMIA is funding the Red assist asylum seekers who were unable to meet their most Cross to develop a national system that will provide mate- basic needs (e.g. food, accommodation, health care). rial and health care support for those asylum seekers ASAS recipients can receive assistance with health care released into the community [24]. costs and referral to counselling services. These recent changes, including the introduction of the Initially, all asylum seekers were entitled to ASAS at the RPBV, add another significant layer of complexity to an primary and review stages of their application, if a deci- already complicated system. Questions raised by the sion had not been made within six months. The eligibility RPBV visa and its potential implications for asylum seek- criteria for ASAS, however, have been gradually restricted. ers are discussed later in the paper. Currently, to be eligible for ASAS, asylum seekers must be Temporary Protection Visa holders in financial hardship and: have lodged a valid PV applica- tion for which a primary decision has not been made According to current migration regulations, refugees on within six months; not be in detention and must hold a TPV have access to Medicare, are eligible for referral to the bridging or other visa; not have been released from deten- Early Health Assessment and Intervention Program tion on an undertaking of support; not be eligible for (EHAI), and for torture/trauma counselling [25]. TPV either Commonwealth or overseas government income holders, however, face serious challenges when accessing support; and not be a spouse, de facto or sponsored health care services. For instance, those over the age of 18 fiancé(e) of a permanent resident [21]. There are some are not eligible for government-funded English language exemptions to the above criteria, such as: unaccompanied classes. Low levels of English language skills cause social Page 6 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 isolation, unemployment (or low paid employment and These barriers are of particular concern as most refugees therefore inability to afford medications), higher inci- arrive in Australia in poor health and are likely to face par- dence of occupational health and safety issues, and obvi- ticular health challenges in the resettlement period. These ous difficulties when accessing health care services. TPV health challenges stem from previous experiences of tor- holders are not allowed to access the federally funded Tel- ture and trauma and from having lived in poor social and ephone Interpreting Service or the various health inter- economic prior to arrival, all of which impact on their preting services designed to assist health workers who well-being during the resettlement period [14]. treat people from non-English Speaking backgrounds. In addition, amputees on TPV are not able to access the A comparison of health policy for refugees and Commonwealth Rehabilitation Service [26]. asylum seekers across selected industrialised countries In early July 2004, the government introduced new meas- Australia is one of sixteen countries who accept refugees ures for TPV and Temporary Humanitarian Visa (THV) for resettlement under the UNHCR resettlement program holders [27]. Briefly, these changes include a reintegration [29]. Full entitlement to Medicare and additional entitle- assistance package for TPV and THV holders who are pre- ments to health care for special needs, including oral pared to return to their countries, the introduction of a health and mental health, are also provided by the Com- new 'Return Pending Visa', which will allow those TPV monwealth, State and Territory governments [21]. In fact, holders whose applications for further protection has Australian health care policy for newly arrived humanitar- been rejected to stay in Australia for 18 months while they ian entrants is comprehensive and one of the best com- prepare for departure; and changes to enable TPV and pared to other resettlement countries [30]. When it comes THV holders to apply for a range of non-humanitarian to onshore protection applicants, however, at the time of onshore visas to live permanently in Australia. These this writing Australia compares poorly to other resettle- recent developments, however, do not represent major ment countries. changes in health care access and other entitlements to TPV holders. While entitlements to social benefits and health care vary in the other resettlement countries, at the time of this writ- Despite the presence or absence of health policies relating ing, none of these countries deny asylum seekers the right to entitlements to medical care, there are a range of barri- to basic medical care. Indeed, a brief review of the refugee ers to accessing health care services, common to most ref- and asylum seeker health policies of the United Kingdom ugees, independent of their visa status. Some of the (UK), Canada and New Zealand indicates that Australian barriers that have been identified are: policy is comparatively lacking in this respect (See Table 3).  Long waiting times particularly in using Emergency Departments of public hospitals, In Canada, for example, asylum seekers – including those facing deportation – are entitled to primary and  Cost of services, especially for specialist health care and emergency care, essential health services for the treatment in relation to public dental health services, and prevention of serious medical conditions, essential prescription medications, and prenatal and obstetrical  Lack of information and confusion about the health sys- care, among others. Refugees and asylum seekers may also tem, particularly the difference between public and pri- receive secondary and mental health care with prior vate and entitlements, approval [31,32].  Lack of interpreters and female physicians, particularly The UK offers similar coverage for refugees and asylum in rural areas, seekers, providing access to a broad range of National Health Service (NHS) benefits, including primary and sec-  Absence of bulk billing services in rural areas, ondary care, optical and dental care, free prescriptions and coverage of travel costs to/from hospital [33]. It is impor-  Instances of discrimination, tant to note that recent changes to UK law suggest a tight- ening in the NHS' willingness to provide such broad  Other settlement needs taking precedence, particularly services across all asylum seeker categories [34]. Failed in cases where refugees are employed in casual or tempo- asylum seekers who have exhausted all rights of appeal are rary work with no leave provisions, now only eligible for urgent care at no cost [35]. Despite this reduction in the range of available entitlements, the  Lack of specialist care, particularly in regional areas [28]. UK's policy still offers greater medical coverage than that Page 7 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 Table 3: Country comparison of health entitlements for refugees and asylum seekers according to status Australia New Zealand Canada UK Refugee Medicare NZ Health System Provincial Health Cover: NHS Coverage coverage Canada's Federal Health system (comprised of Federal and Provincial contributions) includes comprehensive health cover, including hospital, physician, surgical-dental and specialist cover. Asylum Seeker in Health care through the N/A: Asylum Seekers No overarching coverage: National Health Service detention private company in charge rarely held in detention for individuals are assessed on (NHS) Coverage. a b b of the detention centres longer than 48 hours a case-by-case basis Coverage includes: primary & secondary care, free prescriptions, dental services, coverage of travel costs to/from hospital Asylum Seeker Depends on when visa NZ Health System Interim Federal Health NHS coverage awaiting primary applied for: If application coverage. Coverage (IFH) Program coverage. decision of refugee submitted within 45 days of includes all services, such Coverage includes essential status arrival, then individuals as: Primary & secondary health services for the have access to Medicare care, co-payment of treatment & prevention of but no translating services, pharmaceuticals, specialist serious medical conditions, Early Health Assessment referral and coverage, cost essential prescription and Intervention, and offsets for 'frequent users' medications, torture/trauma counselling, of medical services, contraception, prenatal If application submitted hospital & accident cover, care, obstetrical care, after 45 days of arrival, dental, mental, maternity Immigration Medical Exam, then no Medicare access and sexual health care. emergency dental service. Asylum Seeker No access to Medicare NZ Health System IFH Program Coverage NHS Coverage appealing a negative coverage NB: may take Refugee Review some time to receive Tribunal (or Community Services Card, equivalent) outcome necessary for accessing a General Practitioner (GP) Refused Asylum Seeker No access to Medicare NZ Health System IFH Program Coverage Primary & urgent care only who has exhausted all coverage NB: may take appeals some time to receive Community Services Card, necessary for accessing a GP Sources: [14, 31-33, 36, 37, 49, 55-60] Detention is mandatory for all 'unauthorised arrivals'. Detention is not mandatory for 'unauthorised arrivals'. Under certain circumstances, these individuals may be eligible for ASAS. See: DIMIA, 2003. The majority of individuals in this circumstance will not have Medicare access. A small number of individuals living in the community on 'Removal Pending Bridging Visas' will, however, have access. See: Table 2 for further explanation. Asylum Seekers who are deemed 'hard cases' maintain NHS coverage until a decision has been reached. available to many asylum seekers living in the community example those who are appealing a negative Refugee Sta- in Australia. tus Appeal Authority decision, also have access to PFHD services [37]. New Zealand, Australia's closest resettlement neighbour, provides refugees with the same health services as resi- Grey areas: complexities of the Australian dents through the Publicly Funded Health and Disabili- health care policy for refugees and asylum ties (PFHD) Service. Asylum seekers with applications seekers pending also have access to these services through a Com- The sheer range of diverse and complicated refugee and munity Services Card [36]. Other asylum seekers, for asylum seeker visa types exemplifies the complexity of Page 8 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 Australian health care and health policy for refugees and to access successfully health care, thereby creating even asylum seekers. This complexity often leads to confusion greater gaps between policy and practice. As mentioned among refugees, asylum seekers, community workers and previously, current Commonwealth policy does not pro- health care practitioners alike. Additionally, current vide asylum seekers on Bridging Visas and refugees on TPV health care policy presents numerous grey areas. In partic- access to English language tuition or fee-free interpreting. ular, problems exist around gaps between the legal and Studies from the UK indicate that misunderstandings and practical applications of these policies; lack of policy coor- poor communication between medical practitioners and dination between State and Commonwealth govern- asylum seekers operate as barriers to appropriate health ments; asylum seekers' ability to successfully access care [1]. Clearly, this is also the case for refugees and asy- necessary health care; decisions about granting ASAS; lack lum seekers within Australia, who do not have access to of publicly accessible government data; and implications fee-free interpreting services. of the new RPBV. Transport is often another major barrier to refugees and Significant gaps between legal and practical policy imple- asylum seekers attempting to access health care with many mentation and the lack of coordination between State and lacking the money necessary for public transport or taxis. Commonwealth governments may be best exemplified by Could they access a vehicle, many are ineligible for driv- the issue of access to public hospitals for asylum seekers. ers' licences, unless they can read, write and understand To begin, it is important to distinguish between legal English sufficiently to pass the exam. restrictions and de facto restrictions. Disparities between being eligible to access health care and being able to A key barrier towards improving health policy for refugees access health care epitomise these gaps. In other words, and asylum seekers is the difficulty in obtaining clear asylum seekers with no Medicare can, theoretically, access information from relevant Commonwealth Departments. public hospitals but may not be able to do so because they For example, in relation to ASAS eligibility, it is unclear fear that their lack of income will leave them unable to how DIMIA applies its discretionary powers to extend eli- pay hospital fees. There is growing evidence suggesting gibility to ASAS or similar 'special payments' to some asy- that Medicare ineligible asylum seekers have been turned lum seekers whose cases are at the post-RRT stage. away from hospitals, have not completed their required Similarly there is a lack of publicly available government medical treatment, or have been asked to pay outstanding data on several key issues regarding asylum seeker health hospital bills and this is of significant concern [20]. policy. First, it is unclear how many asylum seekers are liv- ing in the community on Bridging Visa E. This makes it Although some State governments have attempted to difficult for CBOs to assess levels of need and asylum improve asylum seekers' access to health care and welfare seeker populations. Second, there is currently no proce- [38], the Catholic Commission for Justice Development dure for recording asylum seekers' access to health care and Peace reports that State governments have failed 'to which has lead to a lack of knowledge to inform policy provide clear instructions to their departments and agen- and practice. Third, there are no available data for analys- cies to protect the human rights of asylum seekers in the ing the numbers of refugees and asylum seekers using areas of housing, health, transport and education' [39]. public hospital services and, finally, there are no data on Additionally, State and Territory governments do not have what they are being treated for. These issues, in turn, make clear policies concerning Medicare ineligible asylum seek- it virtually impossible to estimate rates of and reasons for ers. In New South Wales (NSW), for example, an assur- admission. Thus, we are left with case studies and docu- ance of payment is required before treatment will be mentation carried out by the already strapped CBOs work- provided. If, however, that assurance is not available, then ing in the sector. patients will 'receive only the minimum and necessary medical care to stabilise their condition' [1]. The recent introduction of RPBV only complicates these grey areas further. In particular, the RPBV creates dispari- Strategies and practices for the provision of care to this ties between bridging visas, presents significant human population also vary widely across public health care serv- rights issues and has the potential to lead to further men- ices. While a few services provide ease of access to asylum tal health issues for these asylum seekers. First, the RPBV's seekers, many CBOs report that the majority deny access provision of Medicare raises significant issues around the or attempt full fee recovery after providing the services. levels of health care access for asylum seekers on other Commonly, access to these services, including waiving of types of Bridging Visas. For example, what is the rationale fees, is dependent on long term advocacy from CBOs [19]. behind the decision to grant Medicare rights to this Bridg- ing Visa, when existing Bridging Visas offer no similar Other factors, such as English language skills and ability rights? Why has the provision of greater rights under this to access transport, also influence asylum seekers' ability Bridging Visa not translated to other, similar visa catego- Page 9 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 ries? That is, if Medicare has been deemed necessary for There are two key areas where policy reforms are urgently these Bridging Visa holders, why has this not been required. First, Commonwealth and State and Territory extended to other Bridging Visa holders? health care policy for asylum seekers needs to be coordi- nated to remove the current gaps which result in little or The RPBV also raises great concern about potential denial no access to health care for a proportion of the asylum of human rights. Currently, the RPBV requires asylum seeker population [14]. Second, serious consideration seekers to agree in writing that they will cooperate with should be given to extending medical care to all asylum their removal from Australia when the government deems seekers residing on Australia soil, regardless of their visa it is safe to do so. Thus, there is the very real potential for status. This medical care should include at least primary the promise of release from detention to lead to asylum medical and psychological health care and care that can- seekers relinquishing their legal rights and future oppor- not be postponed [45]. While there has been no rigorous tunities for visas. The written agreement may also facili- economic analysis of the potential costs of extending tate involuntary return – individuals will have no say Medicare to the entirety of this population, a small study about the safety of their return, once the government indicates that the costs would be about A$ 2.9 million per deems it should happen [40]. year for NSW [46]. A similar analysis conducted by one of the authors (I C-V) estimated that the expected health care The RPBV may also have significant effects on the mental costs for asylum seekers living in the Victorian community health of asylum seekers. There is a growing body of evi- would be about A$1.5 million per year. This figure repre- dence on the negative mental health impacts of detention sents about 0.009% of the total annual health care on asylum seekers [41,42]. Releasing these already trau- expenditure in Victoria in 2000–2001 [47]. These two ini- matised individuals into the community without immedi- tiatives would go a long way towards health policy reform ate and ongoing access to counselling, and with no for this vulnerable, high need but numerically small pop- definite return date, no guaranteed visa term and no rights ulation residing in Australia. of appeal, could lead to further mental health issues, such as depression, feelings of isolation and anxiety. List of abbreviations ASAS: Asylum Seeker Assistance Scheme Filling the Gaps: the need to adopt minimum CBO: Community based organisation standards Current Australian health policy on access to medical care for refugees and asylum seekers has two faces. On the one DIMIA: Department of Immigration and Multicultural hand, health care access for resettling refugees is compre- and Indigenous Affairs hensive and one of the best compared to other resettle- ment countries. On the other hand, health policy for EHAI: Early Health Assessment and Intervention Program asylum seekers is less than adequate to ensure a minimum standard of health care. Moreover, the gaps between Com- HIV: Human Immunodeficiency Virus monwealth policy and State and Territory policy has pro- duced a climate of confusion especially in regards to who HREOC: Human Rights and Equal Opportunity pays. Commission As Taylor argues, current Australian policy for asylum ICESCR: International Covenant on Economic, Social and seekers is 'insufficient to assure them of an adequate Cultural Rights standard of living', and in breach of the International Cov- enant on Economic, Social and Cultural Rights (ICESCR) IFH: Interim Federal Health [43]. The current policy context may also leave Australia in breach of other 'international legal conventions and IHSS: Integrated Humanitarian Settlement Strategy recommendations regarding its obligations toward asy- lum seekers living in its territory' [19] (p.16). Expanding MOC: Medical Officer of the Commonwealth on the human rights perspective, Dwyer argues that refu- gee and asylum seeker health care is also an issue of social NHS: National Health Service justice and social responsibility [44]. In order to meet its basic human rights, social justice and social responsibility PFHD: Publicly Funded Health and Disabilities requirements, therefore, Australian health policy for asy- lum seekers needs significant and immediate change. PPV: Permanent Protection Visa PV: Protection visa Page 10 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:23 http://www.anzhealthpolicy.com/content/2/1/23 Human Services. Melbourne, Victorian Foundation for Survivors RPBV: Removal Pending Bridging Visa of Torture; 2004. 15. DIMIA: Fact Sheet 82: Immigration Detention. Canberra, RRT: Refugee Review Tribunal Department of Immigration and Multicultural and Indigenous Affairs; 16. Smith MM: Asylum seekers in Australia. eMJA 2001, 175:587 SHP: Special Humanitarian Program -5589. 17. HREOC: Those who've come across the seas: Detention of unauthorised arrivals. In Report Sydney, Human Rights and Equal TB: Tuberculosis Opportunity Commission; 1998. 18. HREOC: Immigration Detention: Human Rigths Commis- sioner's 1998-1999 Review. Canberra, Human Rights and Equal THV: Temporary Humanitarian Visa Opportunity Commission; 1999. 19. McNevin A: Seeking Safety, Not Charity: A report in support TPV: Temporary Protection Visa of work-rights for asylum-seekers living in the community on Bridging Visa E. Melbourne, Network of Asylum Seeker Agen- cies Victoria; 2005. UNHCR: United Nations High Commissioner for 20. Asylum Seeker Project Hotham Mission: Welfare issues and immigration outcomes for asylum seekers on Bridging Visa Refugees E. In Research and evaluation paper Melbourne, ; 2003. 21. DIMIA: Fact Sheet 62: Assistance for asylum seekers in Aus- Competing interests tralia. Canberra, Department of Immigration and Multicultural and Indigenous Affairs; 2003. The author(s) declare that they have no competing 22. Minister for Immigration and Multicultural and Indigenous Affairs: interests. Broader Powers for Immigration Minister to Manage Long Term Detainees. [http://www.minister.immi.gov.au/ media_releases/media05/v05046.htm]. Authors' contributions 23. Commonwealth of Australia: Migration Amendment (Detention All authors contributed equally to this paper. Arrangements) Bill 2005 - Explanatory Memorandum. Can- berra, The Parliament of the Commonwealth of Australia; 2005. 24. Aristotle P: Changes to detention arrangements. Melbourne, Acknowledgements Victorian Foundation for Survivors of Torture; 2005. The authors would like to thank: Paris Aristotle, Mardi Stow, Jenny Mitch- 25. DIMIA: Temporary protection visas. Fact Sheet [http:// www.immi.gov.au/facts/64protection.htm]. ell, Jo Szwarc, and Robyn Sampson for their helpful comments on initial 26. Pickering S, Gard M, Richardson R: "We're working with people drafts of the paper; the anonymous reviewers for their valuable comments. here" : The impact of the TPV regime on refugee settlement service provision in NSW. 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Australian Attorney-General's Department: Migration Regula- tions 1994. Canberra, SCALEplus, Commonwealth of Australia; 51. DIMIA: Seeking asylum within Australia. Fact Sheet [http:// www.immi.gov.au/facts/61asylum.htm]. 52. Brotherhood of St Laurence: Seeking Asylum: Living with Fear, Uncertainty and Exclusion. Melbourne, BSL; 2002. 53. DIMIA: Fact Sheet 64c: Return Pending Visa. Canberra, Department of Immigration and Multicultural and Indigenous Affairs; 54. DIMIA: Fact Sheet 85: Removal Pending Bridging Visa. Can- berra, Department of Immigration and Multicultural and Indigenous Affairs; 2005. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 12 of 12 (page number not for citation purposes)

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Australia and New Zealand Health PolicySpringer Journals

Published: Oct 9, 2005

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