MEDICAL

TREATMENT

OF ASYLUM

SEEKERS

Co-funded by

the Health Programme

of the European Union

TABLE OF CONTENTS

4 INTRODUCTION,

Franci Zlatar, M. A.

6





PART 1


7


Migrants and Health, Helena Liberšar

18

Social	workers’	field	work	report, Jaka Matičič, Urška Živkovič

32

Project work – Health assessment of asylum seekers, Lea Bombač,

M.D., Špela Brecelj, M.D., Helena Liberšar, dr. Erika Zelko, F.M.M.D.

39

Mental health of asylum seekers, Špela Brecelj, M.D., Lea Bombač,

M.D., dr. Erika Zelko, F.M.M.D.

42

Psychotherapeutic	work	with	refugees, dr. Zuzanna G. Kraskova

44 PART 2

45

Our	experience	with	treatment	of	asylum	seekers

(Health centre Ljubljana, Unit Vič-Rudnik), asst. dr. Neva Kopčavar

Guček, F.M.M.D., Simona Repar Bornšek, M.D., Neli Grosek, M.D.

47

Experience	with	medical	treatment	of	refugees	and	migrants,

prof. dr. Danica Rotar Pavlič, M.D., Ema Vičič, M.D.

55

On	importance	of	implementing	intercultural	mediation	into

Slovenian healthcare institution, dr. Uršula Lipovec Čebron

62 APPENDIX1:

63

Legal framework of Slovenian healthcare system and access to

medical services in Slovenia, Helena Liberšar

70 APPENDIX 2:

71

Medical treatment of asylum seekers – analysis results, Jaka Matičič,

Helena Liberšar

3

INTRODUCTION

Franci Zlatar, M.A., Head of Migration Program

As trends are pointing towards an increasing commercialization of health care, it is be-

coming more and more difficult for certain population groups to access healthcare servic-

es. In that respect, the matter does not only concern a very specific group of vulnerable

people in the field of health care, since constant changes in social circumstances are also

causing structural changes of vulnerable population groups. Years ago, within the frame-

work of partnership of various organizations, we had established a health clinic for people

without health insurance. At that time, homeless people were the group with the most

limited access to health care. The clinic had been established as a temporary solution

until the issue of uninsured individuals had been resolved. Very soon it became clear new

individuals and groups without health insurance or with a limited access to health care

began to appear: homeless people, the erased1, immigrants, and with the emergence of

the economic crisis also many sole traders, who fell into debt with insurance companies.

Consequently, we are not using the term vulnerable people, but are instead talking about

vulnerability in the field of health care. Namely, we must be aware that in particular social

circumstances every individual may experience the loss of access to health care.

Network for decreasing vulnerability in the field of health care, led by international or-

ganization Doctors of the World(Slovene Philanthropy is a partner organization of the

network), established in their report2 that out of 30.000 interviewed patients, who visited

clinics of the organization Doctors of the World and their partner organizations from dif-

ferent European countries, 65,5% of them have no access to regular healthcare system,

1 The term »erased« refers to people, who were born in other republics of the former Yugoslavia, had a Yugoslav citizenship and the citizenship of some other republic of the former Yugoslavia, but had a permanent residency in the former Socialist Republic of Slovenia. In 1991, Slovenia declared its independence. All citizens of the former republics of Yugoslavia, who had their permanent address in Slovenia, had the right to apply for Slovenian citizenship within six months from the declaration of independence. Those who did not obtain their new citizenship, lost their permanent residency status, thus being »erased« from the register of permanent residents. Apart from losing their residency, they also lost other rights (social, economic, etc.).

2 Medecines du monde – Doctors of the World, International network 2016 Observatory Report: Access to the health care for people facing multiple vulnerabilities in health in 31 cities in 12 countries.

4

approximately 40% of women have no access to health care before and after childbirth

and around 40% of children had not been vaccinated. 94% of the interviewees were mi-

grants, most of them were not EU citizens.

Numerous data show that various groups of migrants have a very limited access to health

care. Refugees are especially vulnerable, since they are exposed to different forms of vi-

olence in their home country, on their travel and in the country of their arrival. In Slovenia

as well, certain groups of migrants (undocumented migrants and asylum seekers, with

the exception of children) are entitled to urgent medical treatment and to a limited extent

to some services, covered by supplementary health insurance policy. Needless to say, an

appropriate access to health care, including psychological and therapeutic treatment, is

crucial for a successful integration of refugees. Considering the aforementioned, we must

not only strive for a better healthcare for migrants, but in a broader sense for a universal

accessibility to health care for all population groups.

This publication is a result of work on the project »8 NGO’s for migrants’/refugees health

in 11 countries« and contains findings, suggestions and issues with regard to health care

and in a broader sense psycho-social treatment of applicants for international protection.

5

PART 1

The following articles demonstrate the results and findings on

migrants/refugees’ health in practice and in the field of the project

team including field/project coordinator, social workers, medical

coordinators and assistants, psycho-social referents and interpreters

that formed the so called mixed mobile unit, and other project

members.

The words migrants, refugees are used interchangeably and

include different groups of migrants (migrants, refugees, asylum

seekers). Therefore, the different groups of migrants have different

health rights in Slovenia and we use mainly the term asylum

seekers as this is the population we work most with and as they

have the least rights. We want also to emphasize the fact that

many of asylum seekers may live in Slovenia for a long period of

time without concrete health rights, which may result in poor or

worsened health state with no proper access to health services.

6

MIGRANTS AND HEALTH

Helena Liberšar

- - - SUMMARY - - -

Arrival of large numbers of migrants, such as the one we have

witnessed in October 2015, always causes fear of infectious

diseases, of overload of the national healthcare system and of

bypassing the waiting lists when using medical services.

Two aspects are important with regard to

weather conditions (very low or very

health conditions and health care of mi-

high temperatures, in rain, in snow).

grants in our area:

This is very important, since accessibility of

■ upon their arrival in Europe (by term Eu-

health care and medical services depends

rope we refer to a broader geographic on the status a migrant acquires in the Re-

area with similar characteristics, part of public of Slovenia.

which is also Slovenia), migrants are far

more medically jeopardized than local in-

A person with international protection has

habitants. Namely, it often happens that equal rights as Slovenian citizens.

otherwise healthy people fall ill during

their travel and because of the travel,

Children of asylum seekers have equal

rights as children of Slovenian citizens.

■ health condition of migrants should be

considered in a broader sense, that is, Pregnant women have equal rights as Slo-

from the viewpoint of their refugee ex-

venian citizens - this applies to all services

perience. Many of them were forced to in connection with family planning, child-

leave their homeland because of war birth, childcare, etc.

and in severe conditions. Therefore,

when considering migrants’ health state, In terms of health care, adult asylum seek-

a broader picture needs to be taken into ers and other migrants are in the most dif-

account - not only their current state of ficult position, since they are entitled only

affairs, but their past experience need to urgent medical treatment and there is

to be considered as well: travelling by no alternative status for them to acquire

foot, in closed trucks, on ships, in harsh in the Republic of Slovenia, which would

7

enable them supplementary healthcare ed in the project »8 NGO’s for migrants’/

treatment.

refugees’ health in 11 countries«, which

was meant to serve as a reply to the ar-

According to definition and legal basis, rival of larger numbers of refugees in Eu-

health care of asylum seekers is often re-

rope. Participating in the project enabled

garded as non-urgent. Furthermore, the us to get an insight into health condition

definition of urgency is interpreted in very of refugees, who crossed Slovenian terri-

different ways. From a perspective of their tory, more specifically of those refugees,

overall health condition, their past health who applied for international protection in

conditions and most of all of their refugee Slovenia.

experience (travel, traumas, fear, flight,

life-threatening danger), treating those Main objectives of the program: to ensure

patients is necessary even in non-urgent the newly arrived migrants, especially the

cases. It is also necessary to provide them most vulnerable ones, an easier access to

with an appropriate medical treatment, basic and preventive medical treatment,

which would not make their lives difficult to strengthen the capacity of the nation-

or deteriorate their health condition. Even al health systems of the member states

a simple common cold should be treated to appropriately respond to the medical

as if it was a case of emergency, because needs of refugees, preventing cross-border

nobody knows what affliction a certain in-

health risks.

dividual had to endure on his/her way here

and what might develop out of a seeming-

The project assured three components:

ly non-threatening condition.

health, social and psychological support.

The primary objective of the program was

PROJECT »11 NGO’S

to monitor the health condition of refugees

in transit situation. After the closure of bor-

FOR MIGRANTS/

ders on 9th of March 2016, we focused on

REFUGEES’ HEALTH IN 11 the refugees, who applied for international

COUNTRIES«: OBJECTIVES protection in Slovenia. We thus acquired

AND RESULTS.

an insight into their health condition and

issues through a more consistent and a

longer lasting health assessment.

At Slovene Philanthropy, we had an oppor-

tunity to devote ourselves in a greater detail During the project work we have come to

to issues of health assessment of refugees the following conclusions:

seeking asylum in Slovenia in the year 2016.

■ it is important to consider medical treat-

In co-operation with an international net-

ment of asylum seekers in a broader

work Doctors of the World, we participat-

sense, especially in the context of their

8

long travel and the circumstances, which ■ A physician needs a detailed information

caused them to flee,

on the asylum seeker’s health condition,

his/her previous illnesses and therapies

■ due to language barriers we need to take

he/she might received, in order to be

enough time to explain to the asylum

able to prescribe new therapies for the

seekers, how Slovenian health system

patient.

works and what to expect from the treat-

ment here, since they are accustomed to ■ In medical treatment of asylum seekers,

a different treatment with more rights,

language barriers need to be overcome.

In certain cases, this can be achieved

■ the asylum seekers as well as the med-

with the help of cultural mediators, who

ical personnel should be informed on

are familiar with Slovenian language

asylum seeker's health rights.

and culture as well as the language and

culture of asylum seeker’s country of

origin. It is also important that cultural

PROPOSITION FOR

mediators master the medical terminol-

ogy and are able to translate unbiased,

MEDICAL TREATMENT OF

without implementing their personal

ASYLUM SEEKERS

opinion or altering the information dur-

ing translation.

Asylum seekers are a distinct group of pa-

tients and work of physicians, who treat It is very important for the asylum seekers

them, has its very own specific as well. In to be acquainted with their health condi-

that respect, our findings show it would be tion. Due to language barriers, they do not

sensible for the asylum seekers to have understand most of what the physician

their personal and family physician. In tells them. A further issue is that when they

that case, physician’s work would involve see a doctor, they do not bring their health

treating a particular group of patients (i. record with them, either because they do

e. asylum seekers) instead of focusing on not know they need it or they do not have

treatment of a certain number of patients. it. Consequently, a doctor also has no way

of knowing their medical history and which

Our arguments for this thesis are:

therapies they had received. Due to a lim-

ited scope of their health rights, asylum

■ First of all, a physician needs quite some seekers can be treated only by a doctor

time to provide asylum seekers with a on duty, who also does not monitor their

proper and detailed information on the health condition (this can only be done by a

scope of their health rights, on how the personal or family physician).

Slovenian health system works and on

the range of medical services that they During our fieldwork we established that

are entitled to.

the most important thing is to inform the

9

asylum seekers on their health rights and Offering the asylum seekers a broader

on how the Slovenian health system func-

scope of medical services does not mean

tions. They often do not understand they Slovenian citizens will be deprived of their

will have to wait their turn in order for a rights, since this way the range of rights in

doctor to receive and treat them, since no-

the field of health care would only expand.

body explains that to them prior the treat-

By including asylum seekers into the sys-

ment. Because they are not acquainted tem of health insurance they would also

with the functioning of the health system in be included in the system of waiting lists,

Slovenia, they believe they are not receiv-

which means they would access medical

ing a proper medical treatment and that services under the same conditions as

they are not being properly sought after, everybody else.

which leads to discontent. The issue here

is that asylum seekers are accustomed to As dr. Uršula Lipovec Čebron stated at the

different processes of medical treatment, conference on Medical Treatment of Asy-

since health systems differ from country to lum Seekers, organized by Slovene Phi-

country, and they are simply not familiar lanthropy within the project at the end

with those differences. Basic information of November, the right to urgent medical

on how to act when visiting a doctor would treatment should not be perceived as a

spare the asylum seekers as well as the right, but instead as a foundation, enabling

medical personnel annoyance and numer-

different scope of rights.

ous misunderstandings.

Ali is a 31-year-old man from Afghan-

Burdening of the medical personnel in

istan. He has a wife and two children, is

health centres and rules of the Slovenian

a tailor by profession.

health system with regard to health insur-

ance policies also need to be considered.

In Afghanistan the Taliban threatened

him. When they beat him, his right leg

Health care of migrants is for many a sen-

got broken. Ali went to the hospital be-

sitive subject. Many reproaches had aris-

cause of the injuries, had a surgery, got

en with regard to providing migrants with

osteosynthetic implant and stayed there

more rights while Slovenian citizens are not

for a month. During his stay in hospi-

being appropriately sought after. There are

tal, the Taliban killed his mother.

suspicions on taking advantage of the sys-

tem in order to enable asylum seekers to

Ali came to Slovenia through the

bypass waiting lists while our citizens have

Balkan route. He fled with his family

to wait their turn. One option is to offer

through Pakistan, Iran, Turkey, Mace-

asylum seekers private medical services,

donia, Serbia and Croatia. The exhaust-

which is cruel, considering the fact most of

ing travel lasted for 15 days. His leg was

them have no financial means for survival,

hurting him a lot while travelling.

let alone for medical services.

10

On the journey from Iran to Turkey

events and concerned volunteer, he got

they had to climb the mountains and

an appointment with a surgeon, who

cross the rivers. That is when the leg got

later decided to perform a surgery.

worse. Ali said that this part was really

difficult not only because of his leg but

Migrants without a status or tempo-

also because he has seen frozen bodies

rary/permanent residence in Slovenia,

of those who did not succeed in travel-

such as asylum seekers, are entitled to

ling the same way they did.

urgent medical assistance only, there-

fore many of their health issues are not

The family travelled by boat for five

considered urgent as in life threatening,

hours, crossing the sea between Turkey

but are still necessary for a better qual-

and Greece. When water started enter-

ity of their lives or to prevent a degra-

ing their boat, they had to throw away

dation of their health in the long term.

their luggage. At the same time, they

were watching in despair how the boat

Many times organizations working

behind them was sinking.

with and for migrants are faced with

challenges to find solutions and even

His problems with the leg escalated in

more often we need to take unbeaten

the last six months. On 1st of April he

paths to find help.

went to see the nurse in asylum home,

because of the pain and because the os-

Working closely with vulnerable peo-

teosynthetic material was already com-

ple who refugees always are, regard-

ing out of his knee. She said that she

less of their gender or situation, gives

cannot do anything, since he does not

one a different perspective on life itself

have a health insurance. Once he will

and people offering services to them,

have a status, he will be allowed to visit

whether they are medical personnel,

the doctor for non-life-threatening sit-

social workers or volunteers, should

uations as well. Our translator insisted

always consider migrant’s situation,

on sending him to the ER, where she

not as current, but as a whole, taking

sent him and where they scanned the

in consideration his or her history, the

leg. The doctor said that the quality

months and kilometres they travelled

of osteosynthetic material in his leg is

to come to current destination and ev-

really good (the same they are using

erything that happened to him or her

here), the only problem is that it is too

during all this time. To treat him/her as

long. Since his situation was not life

a human being and equal.

threatening (literally: he is not dying

from the pain), he couldn’t do anything.

Nearly 4 months after the operation,

Ali is now happy and pain free. He can

This is one of the stories that end-

now enjoy his days walking and sport-

ed well. Through a series of fortunate

ing, which wasn’t possible before. His

11

condition didn’t impact only his life but

Urgent medical treatment involves CPR,

also the life of his family. His wife was

services necessary for preservation of vital

before very stressed and passive and the

functions and prevention of drastic deteri-

children were behaving badly. Now also

oration of health condition of the injured,

his family is happier and more content.

chronically ill or suddenly ill. The servic-

They are more optimistic and children’s

es are provided until stabilization of vital

behaviour changed significantly since functions or until a patient begins treat-

they have his father “back”.

ment at the appropriate institution. Urgent

medical transport is provided as a part of

Including asylum seekers into the system of urgent medical treatment services.

health insurance only solves one part of the

issue, with which the asylum seekers and Urgent medical treatment and unpostpon-

the medical personnel have to confront (i. e. able medical services include:

a right to basic health care). Yet unresolved

would remain the issue of overcoming lan-

■ immediate treatment after an urgent

guage barriers and intercultural differenc-

medical treatment (if necessary),

es between various health systems of the

countries of asylum seekers’ origin.

■ treatment of wounds, prevention of

sudden and fatal deterioration of chron-

On the whole, the refugee situation should

ic diseases and medical conditions that

not be considered from a single stand-

could lead to permanent damage of

point and the issues should not be solved

specific organs and of their functions,

one-sidedly, but instead on all levels, be-

ginning with respect for human dignity.

■ treatment of sprains, fractures and inju-

ries acquiring specialist treatment,

URGENT MEDICAL

■ treatment of poisoning,

TREATMENT

■ services for prevention of spread of

infections, which might cause a septic

Every person has the right to urgent med-

shock in a patient,

ical treatment. Urgent medical treatment

includes unpostponable medical services, ■ services or treatment of diseases, which

CPR, life support and prevention of dete-

are mandatory by law and are not fund-

rioration of medical condition of an ill or

ed by the state, employer or the insured

injured person. The treatment urgency es-

person,

timation is given by a personal physician

or a medical commission in charge, in ac-

■ subsidized prescription drugs, needed

cordance with general acts of the Health

for treatment of illnesses and conditions

Insurance Institute.

listed in previous paragraphs,

12

■ instruments needed for treatment of

into the hospital in the following two

conditions, listed in previous paragraphs

weeks. He didn´t manage to arrange it.

(to extend and according to standards

This was postponed until Mohammad

and norms, defined by the Article 103 of

gave up.

Health Insurance Rules).

Asylum seekers in Slovenia are entitled

Mohammad is 34 years old, he has a

to emergency health treatment exclu-

wife and two children. Few days before

sively. In examples like Mohammadś,

their journey to Europe, his problems

a social worker must hand the refer-

with kidney stones began. Doctor told

ence letter of a general practitioner to

him that a kidney stone is moving to-

the special commission working with-

wards his bladder and prescribed him

in asylum home in charge for granting

a 10-day drug treatment. They im-

additional health services. They are the

proved his condition until their arrival

ones making the decision, whether the

in Greece, where due to stress he lost

asylum seeker is entitled to a specialist

the medicines together with the docu-

check or not.

ments. On the way, he got various pain-

killers, which made the journey bear-

Two weeks ago Mohammadś blood

able, even though he knew the problem

was examined, which proved that

still exist.

something is not right (his calcium lev-

el was higher than usual).

He arrived in centre for asylum seek-

ers in Ljubljana four months ago. Ev-

Mohammad is really tired and desper-

ery day for 15 days he visited a nurse,

ate at the moment. He is sitting with

who was giving him painkillers, until at

his arms crossed around his torso. At

some point he earned her attention –

first I thought he is uncomfortable be-

she sent him to hospital. The same day

cause of the interview, but he explains

the family was transferred to different

that he is like this because of the pain.

unit of centre for asylum seekers and he

He refuses to visit dr.C, social worker

didn´t manage to get to the hospital.

or any other organisation representa-

tives. He said: ˝ I am not going to both-

In the new location Mohammad went

er them until my kidneys stop working. I

to a social worker three times to get the

made friends with the pain. ˝

painkillers, dr.C wrote two reference

letters to the social worker to send him

One negative aspect of urgent medical

to the hospital for a kidney scan. She treatment in practice is that the medical

said she took him there, which was not

personnel decides on the spot, whether

true. When dr.C wrote the third refer-

certain medical condition requires urgent

ence letter, he gave it to a NGO social

medical treatment or not. If the personnel

worker, who said he will try to get him

estimates a patient is not entitled to an

13

urgent medical assistance, they may re-

extent, defined by provisions of the com-

ject the application for the treatment. The pulsory health insurance), they are only

urgency of the treatment may also be es-

entitled to an urgent medical treatment as

tablished subsequently. In case it had been defined by Act 86 of the International Pro-

established the condition was not urgent, tection Act from 16th of March 2016.

a patient must pay the bill for the services.

Urgent medical treatment of asylum seek-

ers includes the right to:

ACCESS TO MEDICAL

TREATMENT OF ASYLUM

1. urgent medical assistance and

emergency transport (in accordance

SEEKERS

to prior decision of a physician) as well as

emergency dental medical treatment;

Health care of asylum seekers is defined

by the International Protection Act. The act 2. urgent medical treatment in accord-

also defines health care of asylum seekers

ance with the decision of the treat-

is financed from the state budget.

ing physician, which includes:

With regard to understanding asylum seek-

■ preservation of vital functions, cessa-

ers’ rights in the field of health care and

tion of bleeding and prevention of ex-

in medical treatment, first issue that ap-

sanguination;

pears here is the access to a physician,

since Slovenian health system is based on ■ prevention of sudden deterioration of

the Health Care and Health Insurance Act.

medical condition, which could result in

The medical personnel also relies on those

permanent damage of individual organs

provisions, since they are in a dilemma on

or vital functions;

who will fund the service and to what ex-

tent they may even treat the patient every ■ treatment of shock;

time they provide a treatment.

■ treatment of chronic diseases and con-

The second issue are long-running asylum

ditions which, if left untreated, could

procedures during which asylum seek-

directly and in a short time-span cause

ers may wait several months, even years

disability, other permanent health dam-

without being able to claim their health

age or death;

insurance. No matter how long they must

wait for the asylum procedure to come to ■ treatment of febrile conditions and pre-

a conclusion (one possible solution to the

vention of spreading of infections, which

issue could be that after 6 months of their

could cause septic shock;

stay in Slovenia, asylum seekers would be

given the right to a basic health care to the ■ treatment/prevention of poisoning;

14

■ treatment of fractures and sprains as work permit as soon as possible. Many of well as other injuries, which require the them are highly educated or have specific

intervention of a physician;

skills. That way, they would be able to work

and pay for their health insurance, which

■ subsidized and partly-subsidized med-

would significantly unburden the state

ication in accordance with the list of budget.

interchangeable drugs, which are pre-

scribed for treatment of illnesses and

I would like to feel useful and do

conditions, listed in previous paragraphs;

something

3. health care of women: contracep- An applicant approached the social

tion, abortion, health care during

worker and started a conversation

pregnancy and after childbirth.

about the possibility of work.

Asylum seekers may claim their health insur-

Asylum seeker: Could you help me? I’d

ance when they become employed. After 9

like to do something, something use-

months of their residency in Slovenia (in case

ful, to help somebody and use the skills

they had not yet obtained decision regarding

that I’ve got. I can’t go to work because

their application for international protection),

I haven’t been here for nine months yet,

asylum seekers may acquire their working

but I’d like to occupy myself somehow

permit in accordance with conditions, defined

for the time to pass and for me to do

by Act 87 of International Protection Act:

something good for the community.

(1) The asylum seeker has the right Social worker: Yes, it’s really a problem

to free access to the labor mar-

that you can’t work until you’ve been

ket nine months after submission of the

here for at least nine months. Maybe

application, if he at that time was not

you could try some volunteer work?

served with the decision of the competent

Would that be OK with you?

authority and this delay cannot be attribut-

ed to the asylum seeker.

Asylum seeker: Sure, anything. It’s a

nonsense that I’m forced to become

(2) The asylum seeker shall after the idle and feel useless. Why wait when

expiration of nine months after

I can be active and do something for

the submission of an application have ac-

others?

cess to vocational training courses in ac-

cordance with the rules set out in the fourth

Social worker: OK, I’ll check the op-

paragraph of Article 78 of this Law.

tions for volunteer work. What would

you like to do? What can you do best?

It would be sensible to consider the possi-

bility for the asylum seekers to receive their

Asylum seeker: As a matter of fact,

15

I don’t rely mind doing whatever, I rights, or because language improficiency

can do physical work, I can teach and communication barriers.

dancing and skating, I can help with

industrial work, which is what I was

Samira is in her late twenties from a

also trained for. The important thing

Persian speaking country. She arrived in

for me is to become of use for the

Slovenia with her husband, in her early

community and to occupy myself, so

pregnancy, seven months ago. After her

that I can get rid of all the negative

arrival in the centre for asylum seekers,

thoughts filling my head while I’m

she asked for a doctor examination be-

waiting and waiting.

cause she had minor pain in her stom-

ach. The nurse told her this is normal

Social worker: OK, I’ll check the op-

and that they will make an appoint-

tions and we’ll discuss them.

ment for a sonography examination, for

which she waited two months. Luckily,

Act 86 of International Protection Act also

everything went well, but the waiting

defines:

period was very stressful for her.

■ A vulnerable person with special needs,

The volunteer Ana, a mother of two,

exceptionally, each asylum seeker is

helped her with preparations on la-

entitled to additional health services,

bour. She explained (with help of an

including psychotherapeutic assistance

interpreter) to Samira what is going to

approved and established by the Com-

happen, how it will look like. They even

mission in the fourth paragraph of Arti-

watched the video of a labour together.

cle 83 of this Law.

Today, the baby boy is 20 days old. She

■ Children of asylum seekers and asylum

remember that the labour was really

seeking unaccompanied children, are

long, difficult and very painful, because

entitled to healthcare to the same ex-

she got appendicitis after the labour and

tent as children who have compulsory

had to stay in hospital for a longer pe-

health insurance as family members. To

riod than is usual. Samira recalls: ˝I did

the same extent of health care are also

not have an interpreter who could help me

entitled schoolchildren under 18 years

express my wishes, concerns about baby’s

of age, and by the end of training, but

health. The baby had a small outgrow on

only up to the age of 26.

his finger, which was later removed. I was

not able to ask the doctor about the proce-

Children and women with regard to re-

dure, what I am supposed to do, nor how

production and contraception have equal

to take care of it. Soon after the birth, the

rights as Slovenian citizens. Nevertheless,

baby had a disease I could not understand

in practice difficulties often arise, either be-

(jaundice), nor was I able to ask medical

cause doctors are not familiar with those

professionals what was happening. ˝

16

When a midwife came to explain her COMMISSION FOR

about how to take care of the baby, they

GRANTING ADDITIONAL

couldn´t talk because of the language HEALTH RIGHTS

barrier. Here Ana stepped into the sto-

ry and told and showed her everything

Within the Ministry of the Interior, a special

once again.

commission is in charge of granting addi-

tional health rights to adult asylum seek-

In terms of health insurance, the asylum

ers, who only have rights to urgent medical

seekers who are children and pregnant

treatment. The commission may ensure

women are entitled to a full coverage. access to additional healthcare services

This is the information the majority of

in cases, when urgent medical treatment

them don´t have. Uncertainty about the

does not suffice and a broader medical

babyś health, the pregnancy after the treatment is necessary (see section Access

journey they made, is a tremendous-

to Medical Treatment of Asylum Seekers).

ly stressing factor, which keeps many

mothers-to-be awake at night.

The commission is composed of the repre-

sentatives of the Ministry of Interior, Minis-

The language barrier is one of the big-

try of Health, a doctor and a representative

gest obstacles in situations such as the

of a non-governmental organization.

one described above. Having a first

child in an unknown country, in an un-

known health system, medical proce-

dures, without the possibility to speak

up in a language health professionals

could understand and the uncertain-

ty of the childś foreseeable future is

a challenge, which could be facilitated

with an accompanying interpreter and/

or cultural mediator.

A special commission may help the asy-

lum seekers to acquire a broader scope of

rights in the field of health care.

17

SOCIAL WORKERS’

FIELDWORK REPORT

Jaka Matičič, Urška Živkovič

- - - SUMMARY - - -

This article presents observations of social workers, partaking

in the project work, and contains summaries of weekly reports

on conditions in asylum centres, admittance of asylum seekers in

asylum home and acceptance of asylum seekers by the local pop-

ulation. The purpose of those reports is detection and following

special circumstances and needs of asylum seekers. The structure

of the article follows the content and structure of the reports.

The integral medical treatment of asylum PSYCHO-SOCIAL

seekers includes numerous service provid-

ASSISTANCE AND

ers: social and other services of Ministry of

the Interior, non-governmental organiza-

INTEGRATION ACTIVITIES

tions, local community and others. At the

Slovene Philanthropy, we organized a spe-

The greatest challenge in psycho-social

cial service, the so called mobile unit, which assistance and integration activities is lack

also included services of social workers. In of personnel for a concrete work with this

general, we have addressed mostly psy-

particular vulnerable group. Challenges in

cho-social aspects of health assessment psycho-social assistance and integration

processes, which contributed to a broader activities are namely connected with exe-

conception of health and general health cution of concrete activities, since various

condition of asylum seekers. Our work in-

aspects need to be considered here, such

cluded following the situation of asylum as life situation, flee from their country of

seekers, gathering information on their ba-

origin, long journey and traumatization as a

sic needs, assistance in medical referrals consequence of violence, which many were

and providing information on their health exposed to in their homeland or on their

rights.

travel. At the same time, psycho-social

assistance and integration activities would

18

help them to overcome cultural and lin-

It would be necessary to provide continu-

guistic differences in the new environment ous psychological and/or psychotherapeu-

while they are waiting on their internation-

tic assistance and environment in which

al protection.

the asylum seekers would feel safe and

accepted. This is namely the basis for a

Long-lasting procedures and rejections of person’s well-being and development of a

their applications for international protec-

state of mind, needed for initiation of inte-

tion have an additional negative effect on gration process, which can only be success-

the already unpleasant situation in which ful if an individual is motivated enough

the asylum seekers are in, and on their to become an independent member of

general wellbeing and health.

a community as soon as possible and to

access services, which the asylum seeker

Such state of affairs may be attributed to needs in his/her everyday life. The biggest

the fact that the approach towards con-

issue is the access to medical treatment

crete integration is bad. Integration should services, since according to the Internation-

have been implemented while asylum al Protection Act and the Health Care and

seekers wait for their international pro-

Health Insurance Act, asylum seekers are

tection, which would alleviate the future only entitled to urgent medical treatment.

integration of persons with international This also means, they do not have the right

protection, since Integration in fact begins to choose a personal physician, but instead

not until a person acquires the status of a may only be treated by a doctor on duty. In

refugee or status of subsidiary protection.

addition, in order for them to be more inte-

grated and to be able to manage their life

During our work, we have noticed that situations, asylum seekers would need to

many health issues within the asylum be familiar with Slovenian legislation and

seekers population in fact arise from gen-

their rights.

eral ill-being, fears and traumas they carry

within themselves. While treating asylum If there is nobody to help them in receiving

seekers, most often we noticed they have basic medical treatment in the beginning

a need for conversation and mental relief. and later in case of more complex medical

Social workers offered a psychological first issues to help them receiving a specialist

aid due to traumas and fear the conver-

examination or admittance to the hospital,

sations were often demanding. In provid-

this may lead to complications in their psy-

ing a broader psychological support, the chophysical condition and to deterioration

presence of a psychotherapist and a psy-

of their well-being, as this is very often the

chologist working on the project proved to case at the moment.

be very valuable, since apart from that,

psychi-atrist (contracted by MoI) is only At the moment, there is one social worker

present 2 hours once a week in the asylum working in one shift at units of Asylum home

home in Vič.

in Kotnikova and Logatec, where there are

19

between 50 and 70 asylum seekers (the lum seekers’ health situation. It often hap-personnel is being provided by the Ministry pens the medical record stays with social

of the Interior). In the asylum home in Vič workers in the asylum home and that asy-

the situation is no different. In comparing lum seekers visit a doctor without bringing

this to other programs, funded in the field it with them. A more systematic informa-

of social care in 2016, we may establish tion flow would ensure a better medical

that the programs require one social work-

treatment as well as any further treat-

er to continually work with 8 to 25 regular ments of the asylum seekers’ condition.

users of the service. During our work with

asylum seekers, we have come across

Specialist examination, July 2016 - is-

cases, which can be categorized into sev-

sues with transfer of information

eral different groups of vulnerable people,

therefore, for the purpose of working with

After a girl has been examined by a

asylum seekers, we propose professional

specialist, the nurse stepped up to her

staff, skilled in the field of social work with

family and shared the information

asylum seekers and with vulnerable groups

about the girl’s condition with her fam-

to be provided to 20 persons at the most in

ily and a social worker accompanying

order to ensure successful work in the field

the family.

of psycho-social assistance and prevention

of health and social risks. We believe the

Nurse: There, the girl has been exam-

suggested ratio (i. e. one social worker pro

ined. So far the doctor hasn’t noticed

20 asylum seekers) to represent the max-

any risks with regard to her condition.

imum possible efficiency, considering the

If her condition deteriorates, come

complexity of work with such vulnerable

again, otherwise you have your next ap-

group, which includes not only trauma-

pointment in two weeks.

tized individuals, but also other vulnerable

groups, such as physically impaired, the el-

Social worker: So the doctor couldn’t

derly, victims of violence, children, etc. Of

find anything wrong with her?

course, difficulties in communication due

to language and cultural differences, which

Nurse: Yes. Next time bring another

demand additional time and engagement

reference letter because this one was

by the professional worker, also need to be

urgent and is only valid for 24 hours.

taken into consideration.

Try to get a reference letter, which will

be valid for a longer time period. Oh,

Information flow is also of key importance,

that’s right, she won’t be able to get it

although it is generally impeded, because

because she isn’t entitled to it.

most of the information on the health of

asylum seekers remain in hands of one

Social worker: Really? I didn’t even

professional worker, while an efficient work

know this one is valid for such a short

requires a complete knowledge of the asy-

time. But we can get a reference letter,

20

which will be valid for a longer time pe-

pediatrician in Logatec and let this

riod, because children of asylum seekers

doctor call him, if he will need the in-

have equal medical rights as children of

formation.

Slovenian citizens.

Social worker: Thank you and good-

Nurse: I’m not sure if this is true, they

bye.

are not Slovenian citizens.

Social worker: Miss, this is definitely

true. It is defined by the International

REPRESSED EMOTIONS

Protection Act.

AND PASSIVENESS

Nurse: Boy, you sure are fervent. Why

We have heard many sad and painful sto-

don’t you wangle me some good spe-

ries during our work. Conversations with

cialist check for my problems ...

asylum seekers revealed to us their emo-

tional condition. In the beginning they told

Social worker: What about the results?

us their stories with tears in their eyes,

How are we to inform the doctor on thinking about their home, family and

the findings?

friends, who were left behind. Some of

them did not and still do not know, what

Nurse: Hold on a second, we’ll ask the

happened to their relatives, if they are alive

doctor.

and whether their cities and homes are still

standing. They are deeply worried, because

ENTRANCE INTO

they have not received this information,

THE DOCTOR’S OFFICE

which adversely affects their general and

health condition. Some of them received

Social worker: Doctor, what about the

the information on their families and home

girl’s results? The doctor in the asylum

some time later. If the information they re-

home will want to know, what’s her ceived was encouraging, their health con-

condition like, because he’s monitoring

dition greatly improved. The opposite was

her health.

true for those, who received information on

the death of their friends and family. The

Doctor: We will send the results there.

most difficult find it the ones, who know

something had happened, but are not sure

Social worker: Do you have any ad-

about the outcome of the events.

dress? It is our first time here, so we ha-

ven’t managed to exchange any contact

Let me go home, please - illustration

data.

of mental state of asylum seekers due

to long wait

Doctor: We’ll send the results to the

21

Unpredictability of the situation in Long-running procedures of assessment of

which asylum seekers in Slovenia find

eligibility of their request for international

themselves in is starting to eat away protection drives these people into pas-

their well-being. Some of them were siveness. Even those, who were convinced

forced to apply for international pro-

nothing can break them and showed opti-

tection one way or the other, since the

mism and shared some creative insights

system did not offer any other solution.

on the matter, later became very passive.

When they are disappointed to see that

Their motivation for activities in- and out-

the situation in the country of their ref-

side of asylum home had dropped signif-

uge is not any better for them then in

icantly. Participation in activities, which

their homeland, many asylum seekers could at least to some extend avert their

resign themselves to their fate and ac-

negative thoughts, is less and less effective

cept the fact they will not have it any

and is dropping in spite of initial interest.

better here than at home. They also feel

unsafe and in the end many decide to

It’s my birthday, but I’m not happy

return home despite the danger. Nev-

ertheless, the procedure for returning

Social worker ran into one of the asy-

is equally lingering and leaves a person

lum seekers and started a conversation

uncertain, just the same as people are

with him, since they have a good rela-

insecure and worried when waiting for

tionship and like to talk to each other.

their application for international pro-

tection to be resolved. One of such was

Social worker: Hey, how are you today,

the case of a man, sitting outside alone

good?

and gazing into distance. When a so-

cial worker approached him, the man

Asylum seeker: It’s my birthday, but

addressed him.

I’m not happy.

Asylum seeker: Everything is the same

Social worker: Happy birthday! What

as it was six months ago. Children are

is troubling you, can I help in any way?

playing like they played six months ago

and I received a telephone call that my

Asylum seeker: My wife is crying be-

mother died. What am I even doing

cause everybody here received their

here? I am ill myself, my father back at

status and are leaving the asylum home.

home is also very ill and there is no one

All acquaintances we made here are

that could help him. I am stuck here.

leaving, while we are still here waiting,

Let me go home as soon as possible.

not knowing what will happen to us.

My home is in my country. Please, don’t

All I wish for my birthday is for my

let my father die while I’m waiting here

family to be happy. I’m very grateful

to be able to get back home.

for everything you do for us. But I also

wish for the sadness and crying to stop.

22

Social worker: Things will get better, which does not ensure any privacy. The you’ll see. Today is your birthday - use

rooms are not suitably equipped for winter

it for making your family happy, you are

cold or summer heat, since the building it-

good at that.

self is not sound- and heatproof and there

is no air-conditioning. Heat in the sum-

Asylum seeker: I’m trying, but it mer and cold due to insufficient heating

doesn’t help and I’m also worried peo-

in the winter is having a stressful impact

ple sometimes understand us the wrong

on the residents. Such factors often have

way. Everybody says how lively and dis-

a negative influence on a broader aspect

obedient my daughter is, but nobody of psychophysical well-being and health.

knows how was it like in my country. The same applies to lack of privacy, which

There she couldn’t play the way she can

causes numerous cultural clashes and dis-

here - outside the house, playing with

agreements between sexes.

other children. Because of the danger

she couldn’t leave the house and be-

The location and the structure of the build-

came very passive. Here she can go out

ing of Asylum home and its units has a

and play all kinds of children’s plays. significant influence on the social exclusion

Here she can experience childhood, she

of the asylum seekers, resulting in poor

hadn’t had before. That’s why she is so

integration in the local community as well

vivacious, because she couldn’t be like as access to services, needed for a quality

that before we came here. But some living - clinics, schools, etc. In the Asylum

people don’t understand that.

home in Vič and in the unit in Kotnikova

those issues are not as prominent as they

Social worker: Then take a rug and go

are in the unit in Logatec, where accessi-

outside with your family. Go for a walk

bility to public infrastructure is poor. The

and make a picnic in a glade. Have a lit-

same applies to access to medical facili-

tle celebration. You’ll feel much better

ties, which can be especially problematic in

when you’ll be together, you’ll see.

winter when cold and respiratory disease

rates are higher than usual, which can

Asylum seeker: I’ll try, you’re probably

present a higher risk for their health.

right, this could help.

INFORMATION AND

ACCOMMODATION

COMMUNICATION

The rooms are too small for the number of Upon their arrival, asylum seekers very

accommodated asylum seekers. In some often had a limited access to information

cases there are different families living in and appropriate means of communica-

the same room, divided in half by a curtain, tion. Translations of official procedures and

23

guidelines for understanding their situation impact on their well-being. Participating in are improving, nevertheless the asylum community services, in which asylum seek-seekers are still not receiving enough infor-

ers sincerely wish to partake in, would ena-

mation for them to function independent-

ble them to feel they are doing something

ly without the help of others. Despite the purposeful. At the same time, this would

attempt of local residents to provide them improve the public conception of them,

with internet access asylum seekers, resid-

which is mostly based on prejudices and

ing in asylum home in Kotnikova, obtained fear.

their internet access late this year. Besides

costly cross-border telephone charges, in-

Poorly informed local population and vari-

ternet represents the only means of com-

ous public services are having an impact on

munication with their relatives. When inter-

access to different services, such as access

net access had not been available to them, to pharmaceuticals, medical treatment or

asylum seekers felt severely frustrated simply living in the community. Asylum

and helpless, since they did not know what seekers are living in a closed institution,

was happening to their family. Visits to the separated from the local population. Such

doctor were more frequent. It is difficult to state of affairs leads to misconception of

describe those kinds of issues, but due to the local population with regard to their sit-

uncertainty of their condition and the situ-

uation and status, making asylum seekers

ation of their family, which stayed at home frequent targets of verbal abuse, occasion-

or were still on their way to Europe, asylum ally also of physical violence. A conception

seekers were in need of intensive psycho-

of asylum seekers’ situation is created by

therapeutic or other form of treatment. In the public opinion, which is in one way or

most cases, such treatments are very dif-

the other manifested in form of a negative

ficult for those implicated due to various perception.

issues, such as language barriers, cultural

and other differences.

Visiting the pharmacy, May 2016 -

example of expressing contempt in

Communication with the local communi-

public

ty is also impeded, because institutions

in which they reside are dislocated and

A volunteer went to the pharmacy

closed, forcing the residents into a slum-

with one of the asylum seekers to show

like lifestyle, associating only with their

him around so that he would be able

kind and not being able to come in touch

to find it by himself the next time. She

with reality outside their four walls. This

led him to the counter to buy medicine

hinders the possibility of integration and

he needed. Because the whole situation

independency within the local community.

was entirely new for him, the volun-

teer explained him how the health and

Contact with the »real« world and mobility

pharmaceutical system works in Slove-

within the local community have a positive

nia. Meanwhile, the pharmacist stated

24

that Hitler knew how to handle such instance tick-borne diseases in Logatec,

specimens when he wiped them out of

with which they are not familiar at all)

Europe, because this is not a place for

and on local medical standards hygiene,

them. Upon receiving the medicine, the

illnesses rates, treatment, operative proce-

volunteer and the asylum seeker indig-

dures and medication therapies. Receiving

nantly left the pharmacy.

those information would significantly less-

en the possibility for additional medical

Within the institutional system, asylum complications.

seekers are subjected to numerous com-

plications due to poor information and Complete and concrete information is also

non-communication, developing as a result needed for breaking stereotypes of asylum

of cultural differences, which we are not seekers and for dispersing fear of the local

sufficiently familiar with as we perceive population from accepting asylum seekers

them as a standard practice. In reality it into the local community. Very often, lack

is evident that precisely because of those of information on the asylum seekers leads

differences asylum seekers are exposed to to a negative public opinion, due to which

unnecessary rule restriction and mobbing, the local population has a negative and

which in the long turn negatively effects hostile disposition towards them. This is

their well-being. For instance, complica-

making the integration in the community

tions with regard to use of bathrooms, difficult and has a negative impact on the

kitchens and other public surfaces often asylum seekers’ well-being.

lead to a state, when nobody explains to

what is the appropriate way of using them

and then due to incorrect use the rules

get restricted, which results in prohibition POLICE SURVEILLANCE

of using the kitchen, cancelling separate AND SAFETY SERVICES

meals in time of fasting, sometimes the

rules are being restricted simply due to bad Although the asylum seekers are relative-

mood and hard feelings for which asylum ly free to move around the territory of the

seekers are being blamed, because they Republic of Slovenia, they have often been

did not use toilets according to our stand-

accompanied by police forces. In Logatec,

ards with which they themselves are not where only families are accommodated,

acquainted with.

we have several times witnessed police

patrols escorting the asylum seekers on

Other information is insufficient and is not their walk through the village from the

complete as well. At the moment, asylum place of their encounter right up to their

seekers still do not have sufficient informa-

intended destination. At times the asylum

tion with regard to access to medical treat-

seekers tell us about such events. In oth-

ment, on dangers and possibilities of infec-

er locations the police forces are exercis-

tions, present in the EU and Slovenia (for ing continuous control. Such occurrences

25

leave unpleasant feelings and surely do they went to school, juveniles and children not contribute to integration of asylum expressed their fear several times about

seekers into the local environment. Safety what their peers will think of them if they

services in charge for providing security of will see them wearing unfit clothing. There

asylum seekers and visitors of the Asylum are also several seniors, who used ropes

home are sometimes exhibiting violent be-

and similar accessories instead of belts in

havior towards the asylum seekers, which order to be dressed at least roughly decent

indicates an overload of security services, for them to be able to walk in public, but

since it is evident that the current situa-

the unsuitable clothing nevertheless had a

tion exceeds staff efficiency needed for a negative impact on their self-image. Cloth-

quality work of the personnel and for the ing, which does not meet social standards,

treatment of asylum seekers. We have causes fear of contempt, stares of amaze-

also witnessed cases of minor mobbing ment and social exclusion.

and inappropriate treatment by the secu-

rity guards when this was unnecessary and Asylum seekers have no umbrellas, unless

when the asylum seekers could have been they buy them themselves, and are practi-

treated differently. Although this is a minor cally forced to stay indoors in case of bad

part of the whole situation, such actions weather. Such a small matter is the cause

never the less have a negative impact on of their increased social exclusion and at

the well-being of asylum seekers, who are the same time is preventing them from

already in a unenviable situation.

attending activities outside the asylum

home, which could beneficially influence

their well-being. That way, rainy days are

ASSURANCE OF

even harder to overcome.

APPROPRIATE DWELLING

STANDARDS AND BASIC

NEEDS

DIET

Asylum seekers are entitled to three meals

Clothing for asylum seekers is mainly ac-

a day, with the exception of children, who

quired through donations, which are most receive five meals a day. The food they

welcome but do not always provide what get is not suitably adjusted to their dietary

they truly need. In asylum homes, some habits, which results in numerous health

asylum seekers were frequently given issues and gastric disorders. Appeals for

clothes that did not entirely fit them. Some introducing foods which suit their dietary

of them did not manage to acquire clothing habits (more rice and spices they are ac-

and footwear suitable for wearing outside customed to use) bore some fruit, although

the asylum home in spite of many months in time the situation worsened again. With

of searching through the donations. Before the appropriate diet numerous health and

26

dental issues could have been avoided, for SYSTEMIC ARRANGEMENT

instance constipation, diarrhea, abdominal OF MEDICAL TREATMENT

pain, gingivitis, toothache, malnourish-

IN COMPARISON TO

ment, anemia and other conditions, which

are troubling children and young mothers MEDICAL PRACTICE

and are very common. Examples of inap-

propriate nourishment are the so called In practice, there are issues appearing with

lunch packages, given to them at week-

the administrative treatment of asylum

ends (during the week asylum seekers re-

seekers within the health institutions, even

ceive cooked meals), which mostly contain in treatment of pregnant women and chil-

foods with high content of sugar and salt dren, who according to the law have equal

- chips, sweets.

rights as Slovenian citizens.

Most of the asylum seekers would like to Asylum seekers card is used for identifica-

cook for themselves and be able to pre-

tion and also serves as health card. Due

pare food best suited for their dietary hab-

to disorganization of the system (which is

its and digestion. In asylum homes, there probably a result of interministerial dis-

is some possibility of food preparation, but crepancies between the Ministry of Health

the kitchens are small and not suitable and the Ministry for Foreign Affairs, which

for food storage or meal preparation for is in charge for managing the functioning

a larger number of people. From the food of the asylum home), there are cases when

they receive, mostly they express the need upon visiting a medical institution, asylum

for rice, vegetables, black tea and spices, seekers do not know how to acquire med-

which they are accustomed to use.

ical examination and the medical person-

nel, responsible for administrative treat-

Cooking would also enable them to main-

ment prior to the examination, does not

tain their everyday activities, which would know how to record them into the system,

have a beneficial effect on the general which is constantly up-dated and designed

well-being, health and family care. Insti-

for registering patients with a health insur-

tutional arrangement of the accommoda-

ance. Due to lack of information on asy-

tion and diet dispossessed them of their lum seekers’ health rights, it also happens

everyday-life activities. Such state of af-

that their request for medical treatment is

fairs forces the asylum seekers to become denied. Most frequent issue is misunder-

passive, unmotivated and helpless, which standment and disinclination of the med-

additionally increases their concerns and ical personnel, who does not know how to

anxiety.

treat asylum seekers and which services to

provide to them.

Appointment for a specialist exam-

ination, June 2016 - issues with ad-

27

ministrative treatment

plaining this to you, because the minis-

try ensured us to pay for the treatment.

Caller: Hello, I am a social worker call-

ing on behalf of a boy from the family

Nurse: Listen, I know nothing about

of asylum seekers. I would like to ap-

that. Let me put you through to a doc-

point the boy on a specialist examina-

tor.

tion at your clinic, where he had been

referred to by a pediatrician from a lo-

PUTTING THROUGHTO

cal health centre.

THE DOCTOR

Nurse: His health insurance number

Doctor: Hello.

please.

Caller: Hello, the nurse has put me

Caller: Miss, since he is an asylum

through to you to discuss the appoint-

seekers, he has no health insurance.

ment for a specialist examination of a

boy from the asylum home, whose fam-

Nurse: Mister, we cannot make an ap-

ily is applying for international protec-

pointment if he hasn’t got his health

tion in Slovenia. He needs a specialist

insurance. This is impossible. Does he

examination, for which he received a

even have a medical card? Who is the

reference letter by a pediatrician from

obligor in this case?

a local health centre.

Caller: Miss, he is a minor and an asy-

Doctor: Yes, yes, talk to the nurse about

lum seeker and as such he is by law

that.

entitled to the same medical rights as

Slovenian citizens. He has an interna-

Caller: But the nurse have put me

tional protection applicant card, which

through to you, because she doesn’t

is an ID and a medical card at the same

know how to arrange this matter and

time. He also received a reference letter

told me to talk to you and ask you, if

by a pediatrician, where it states that

this is possible, which it is since chil-

the obligor in this case is the Ministry

dren of asylum seekers have equal med-

of Health, which is obliged to pay the

ical rights as Slovenian citizens.

expenses of the treatment.

Doctor: Yes, this is true. Tell the nurse

Nurse: But how am I supposed to know

to make an appointment.

this? We haven’t received any notice on

the matter. We called the Ministry, but

Caller: Thank you.

nobody answered.

Doctor: Goodbye.

Caller: This is precisely why I am ex-

28

Caller: Goodbye.

cause it is easier to get transportation in

the morning.

PUTTING THROUGH

BACK TO THE NURSE

Nurse: OK. He should come on the

chosen date and make sure he brings

Caller: Hello, the doctor said you may

his reference letter and please enclose

arrange an appointment for the boy.

that number of the person from the

ministry you were talking about. We

Nurse: But sir, I don’t know which

will somehow deal with that later on.

number to enter into the record. I can’t

make an appointment if I have not got

Caller: We will. Thank you for your

his number.

time and kindness. Goodbye.

Caller: Miss, I am not familiar with

Nurse: Goodbye to you too.

how the system in the health centre

functions, but that boy really needs this

During our project work, we have also come

examination.

across complex issues of patients with chronic

diseases. They require regular medical treat-

Nurse: I understand, but we received ment and access to medication (in cases of

no instructions on how to act in this patients with heart disease or diabetes), but

situation.

the system is not allowing it, which may lead

to deterioration of the patients’ medical con-

Caller: Then contact the ministry, I dition and feeling of well-being. Every further

have already told you what to do, but if

visit to a doctor in order to acquire medication

you like we can give you the number of

is demanding and in certain cases even im-

the ministry in charge.

possible without the help of social and other

workers, who offer help in mediation, logistics

Nurse: No, no, let the doctor deal with

and other activities for preventing the worst

that.

case scenario.

Caller: Have you made the appoint-

Cronical problems and lack of regular

ment then?

medical tretement

Nurse: I don’t know, I’ll just make a

Vladimir is 56-year-old Russian man

separate notice somewhere and we will

who lives in Slovenia for five months

keep him in mind. When would you

now.

like me to make an appointment, in the

morning or in the afternoon?

He has chronical cardiovascular problems.

Doctors at home prescribed him daily us-

Caller: If possible in the morning, be-

age of medicines for the rest of his life.

29

His problems started six years ago due to

sistent medical treatment which needs

his highly stressful profession and adren-

to be monitored. He also doesn‘t have

aline sports activities. It all started with a

the right to choose a personal phisician,

heart attack, which was followed by an-

who would monitor his condition reg-

other. His friend who is a doctor advised

ularly and appoint him to a specialist.

him a surgery, which he had in Moscow.

He can only visit doctors on duty and

every time this can be a different per-

In Slovenia he has problems with ac-

son. His treatment starts from scratch

cess to urgently needed medicine. If he

every month and is based only upon on

notices that he is slowly running out of

his words, not on a specialist's opinion,

them, he has to go to a nurse in another

which may result in unnoticed slowly

unit of asylum centre who appoint him

progressive changes in his condition.

to a doctor on duty. He never knows

At the same time, it is highly possible

how long will he have to wait to see

that he will run out of his medication

a doctor – it happened before that he

before he will get a new prescription,

had to wait for two weeks. Since doc-

which just adds to the the overall in-

tors on this position are changing on a

consistency of the treatment.

daily basis, he has to explain what he

needs and why he needs it to every one

All this, together with his highly un-

of them. Also, the doctor is a general

predictable life situation while waiting

practitioner not a specialist and does

for the answer regarding his interna-

not follow his condition. Vladimir had

tional protection, is definitely not im-

a specialist check eight months ago and

proving his health.

if his health doesn‘t deteriorate in the

meantime, he should see a specialist no

Vladimir recalls how it was in Austria,

sooner than in one year‘s time. He is

where he got an appointment at a spe-

worried how this will be possible here,

cialist right away and got the prescrip-

if even getting the medicines is com-

tion for the medicine for a longer time

plicated.

period. It would be a good idea to learn

from their example of good practice.

His story is a good example of insuf-

ficient health care available to asylum

seekers in Slovenia. Asylum seekers

are entitled to a specialist visit only in

DENTAL TREATMENT

case of life threatening condition or if

a special commission in asylum centre

In asylum seekers population, there is a

approves their written request. This prevalence of dental problems, which is

procedure can be long, which is a prob-

a result of various factors, improper diet

lem especially for people with chronical

being one of them. With persons, treated

conditions who need a regular and con-

as long-running asylum seekers (on aver-

30

age 6 months, sometimes one year), the

in labour. I took six painkillers (4 Lekadol

biggest issue is they are only entitled to

and 2 Nalgesin), but told the nurse next

an urgent dental treatment, which means

day that I only took two. My baby, whom

that either a tooth is extracted, or a dental

I breastfed, slept for two days. I am certain

drill is being made without filling the tooth

that this is because of the medicines. I went

afterwards. The exposed tooth presents a

to the dentist, who pulled the tooth out. I

possibility for development of further den-

had to sign that I agree with the proce-

tal problems and a general deterioration of

dure, even though I didn´t understand

asylum seeker’s health condition.

what I was signing."

Ayesha is a mother of a few-months

Wih regards to dental problems, the

old baby boy and has problems with her

stories are mostly all similar, as asylum

teeth. She was reporting her problems

seekers have rights only to urgent dental

to the nurse in asylum centre since she

care. This influences the asylum seekers‘

arrived in Slovenia, which was approx-

personal life in a broader sense. They are

imately eight months ago. All she re-

aware that they will be given only pain-

ceived were painkillers. When the pain

killers until the pain is so strong, that the

worsened, she went to see a dentist, for

tooth has to be pulled out.

which a nurse notified the health cen-

tre. Because the asylum seekers do not

In Slovenia, healthcare insurance for

have their personal dentist, she had to

asylum seekers covers only life-threat-

go to the dentist that was on duty that

ening conditions. Toothaches, no mat-

day. The volunteer accompanied her.

ter whatthe cause or strength of it, are

treated in the same procedure: ˝ Itś

Teeth problems are one of the most

always the same.The dentist opens and

common health problems reported by

cleans your tooth, does the temporary fill-

asylum seekers. One of the challenges

ing, which falls out in few days. When the

of providing adequate dental services

pain returns, you visit the dentist again,

is communication. Not everyone has

who pulls it out. ˝

the chance of being accompanied by

an interpreter. If they are lucky, the vol-

Health problems add additional challeng-

unteer can go with them. In Ayesha‘s

es and stress to the long waiting for in-

case this resulted in treatment of the

ternational protection decision. The basic

wrong tooth. She was too embarrassed

healthcare insurance with a basic preven-

to speak up, the volunteer was also very

tive and curative health treatment would

angry, but she didn´t do anything.

make numerous lives easier.

"When the next toothache began, the pain

Note: The stories and testimonies in the

was tremendous. I was crying, I couldn´t

publication were collected by social work-

sleep – the pain was strong as when I was

ers on the project.

31

PROJECT WORK - HEALTH

ASSESSMENT OF ASYLUM SEEKERS

Lea Bombač, M.D., Špela Brecelj, M.D., Helena Liberšar,

dr. Erika Zelko, F.M.M.D.

- - - SUMMARY - - -

This article introduces an insight into project work, during which

we have offered health assessment to asylum seekers, whose rights

to medical services in Slovenia are limited. We will present our

personal opinions on dilemmas and possible improvements of cur-

rent medical treatment available to asylum seekers.





INTRODUCTION


chronic non-infectious diseases, which are

not considered emergency cases.

With closure of Balkan route in March 2016, At the moment, there are approximately 300

medical needs of refugees have changed. asylum seekers in Slovenia, which counts 1

This also applies to methods of medical refugee on 7000 Slovenian citizens. Asylum

treatment and attendance to migrants’ seekers are accommodated in the Asylum

medical needs. Those who stay in our coun-

home and its units. As a team of medical

try and apply for international protection are coordinators participating in the project

treated as asylum seekers, which means work, executed by Slovene Philanthropy and

they have limited rights to medical servic-

Doctors of the World (8 NGO’s for migrants/

es. Before the closure of migrant routes, refugees’ health in 11 countries), we strived

there was an increased need for treatment to provide a more extensive health assess-

of wounds, injuries and dehydration. Such ment to asylum seekers, since according

cases are seldom at the moment, instead to law they have a very limited access to

a need for a more extensive medical treat-

medical treatment. The team consists also

ment has appeared, including treatment of of 3 medical coordinators, we communicate

32

with asylum seekers with help of Farsi and time of working hours or made an appoint-

Arabic interpreters and an medical assistant ment with staff who provides information

ensures that the work is carried out without regarding work of the medical staff in the

complications. We work in all three units of institution. In case of language proficiency

asylum home: in Vič and Kotnikova (Ljublja-

(Slovenian, English, Croatian, Serbian), asy-

na) and in Logatec.

lum seekers come and talk to us by them-

selves. In case of communication barriers

We provide 26 hours of health assessment and language improficiency, a translator is

a week, asylum seekers are assessed in an present at the visit (exceptionally we use

improvised rooms, we have only basic in-

translation services via telephone or inter-

struments at our disposal. Assuring health net). Work is very diverse. We assess every-

assessment is a demanding task, especially one in need of medical attention by listen-

since it involves treating a distinct popula-

ing, assessing them with basic instruments

tion, vulnerable people, who require a more and discussing their issues.

attentive approach. Our work often demands

a great deal of improvisation and flexibility.

Before directing a patient in need of lab-

oratory examination, further diagnostics or

As the project is coming to its end, so does further referrals to a health centre, we con-

a more extensive health assessment and a tact the doctor on duty or a nurse in health

more efficient communication with the asy-

centre and arrange an appointment for fur-

lum seekers in sense of providing for their ther diagnostics and appropriate therapy in

health needs while they are waiting for their case this is needed and is considered part

status acquisition. Number of asylum seek-

of urgent treatment.

ers is increasing and a new wave of refu-

gees is anticipated, therefore we would wish With help of translators we prepared a re-

to contribute to an effective and continuous cord of asylum seekers’ health condition in

medical treatment of asylum seekers in the order to avoid language barriers during the

future, as well as ensure that treating asy-

examination in the health centre. It is pref-

lum seekers in community health centres erable for asylum seekers, undergoing an

wouldn’t cause any complications, delays examination at the general practitioner or

of examinations due to solution seeking at the specialist, to return with all results

and would at the same time enable asylum and to be acquainted with the type and

seekers a proper medical treatment.

characteristics of their disease.

We help asylum seekers to receive their

WORK PROCESS

medicine as soon as possible. In case when

they need further examination outside the

asylum home, a transport to health institu-

Asylum seekers in need of health care tion has to be organized and a translation

first go to a clinic in the asylum home in service needs to be provided (when trans-

33

lators are available). Translators usually al-

WHY IT WOULD BE

leviated work, but communication barriers SENSIBLE FOR ASYLUM

nevertheless remain an issue, mostly with SEEKERS TO HAVE A

regards to understanding asylum seekers’

health state.

PERSONAL PHYSICIAN

■ Since his arrival trough Austria to Slove-

MEDICAL TREATMENT AND

nia, a 37-year-old man is complaining

of a recurring abdominal pain. He was

HEALTHCARE OF ASYLUM

examined by different doctors in differ-

SEEKERS AS DEFINED BY

ent locations, there are no records of

LAW

his medical treatment. One evening he

was brought to the ER due to unbear-

able pain. Since there were no medical

In the Official Gazette, Article 78 of Inter-

documents and records of his existing

national Protection Act (chapter Rights and

treatment available, medical staff in

Obligations of Applicants for International

the ER treated him without any knowl-

Protection) states that an asylum seeker

edge of his medical condition. Language

has the right to urgent medical treatment

barrier was an issue as well. His treat-

in place of his/her admission. Free medi-

ment had to once again start from the

cal services available to asylum seekers

very beginning. He underwent different

are defined in Article 86 of International

medical imaging, but results showed no

Protection Act. Children of asylum seekers

signs of disease. Upon his discharge,

(up to age 18) and asylum seeking women

he received instructions for a diet for

have somewhat more rights, regarding spe-

irritable bowel syndrome. We explained

cific medical conditions. Children of asylum

the instructions in detail to his wife. His

seekers have equal rights as children of

condition improved considerably. If the

Slovenian citizens. Pregnant women have

asylum seeker had a personal physician,

equal rights as pregnant Slovenian citizens,

he would have received instructions for

the same applies to breastfeeding women.

the diet sooner and the costs of expen-

Female asylum seekers have equal rights

sive medical treatment could have been

as Slovenian citizens in field of family plan-

avoided.

ning and reproductive health. Measures of

ensuring health care of asylum seekers are ■ 35-year-old asylum seeker is suffer-

defined in Rules on the Rights of Asylum

ing from nasal congestion. At first it

seekers, measures for ensuring patient

seems as if he has a cold, since he is

care of asylum seekers are defined in Arti-

always wearing lot of warm clothes,

cle 17 (according to statutes, valid in time

but assessment of his health condition

of project execution, new regulations are in

showed symptoms similar to that of hay

preparation -Ed.).

fever. The asylum seeker tried different

34

treatments (nasal irrigation, vitamin C

his condition and if needed to arrange

supplements), but his condition did not

referrals for a specialist examination,

improve. Different doctors recommend-

appropriate therapy and obtainment of

ed a different therapy, according to their

a wheelchair. It would be much easier

knowledge and information they re-

for the boy, his family and doctors, if

ceived from the asylum seeker. It is not

the boy would be monitored by a single

known which medicine the patient took.

physician. This way his family would not

He was not referred to a further exam-

need to explain his condition to different

ination, since his condition is chronic,

translators and doctors all the time.

supposedly lasting for several months

now, possibly even several years, but ■ 29-year-old asylum seeker is suffering

we do not know for sure due to com-

from rectal pain and is experiencing

munication barriers, because there is no

bleeding from the rectum, presumably

interpreter available for the language he

due to haemorrhoids. Until now, he vis-

speaks.

ited different clinics and received haem-

orrhoid treatment, but his condition did

■ 20-year-old asylum seeker is suffering

not improve. He did not know which

from migraine headaches for approxi-

medicine he received, he had no med-

mately 12 months now. Headaches ap-

ical results and was not referred to a

pear weekly, last for several days and

further examination, since his condition

disappear spontaneously. His last head-

was not considered urgent. A proctology

ache lasted for five days, analgetics did

examination showed no signs of haem-

not seem to relieve the pain. His mental

orrhoidal disease, instead he was diag-

state was altered, he was referred to a

nosed with intertrigo (i. e. inflammation

health centre and from there further to

of skin folds). The affected area is pain-

a hospital treatment, where additional

ful, bleeding and gives false impression

examinations showed he was having a

of haemorrhoids. To improve quality of

migraine attack. A personal physician

the life, skin folds ought to be surgical-

would have been able to monitor his

ly removed. The skin folds are now en-

condition and would have known that his

larged and chronically inflamed, the pa-

attacks usually begin with these symp-

tient cannot sit, walk or lie down, but the

toms, therefore he could have treated

inter-ministerial commission declined

him with an appropriate anti-migraine

the request for funding the operation.

therapy and costs of additional treat-

ment could have been avoided.

■ 8-year-old child is suffering from cere-

bral palsy and epileptic seizures since

his second year of age. He would re-

quire a personal pediatrician to monitor

35

DILEMMAS AND

seekers. It would be significantly more suit-

PROPOSALS FOR

able to establish co-operation with nearby

CHANGES IN TREATMENT Health Centre Metelkova, where asylum

seekers would be treated by doctor on duty,

OF ASYLUM SEEKERS

in accordance with prior appointment.

Limited rights to medical treatment put Currently, entire management and execu-

asylum seekers in an unenviable posi-

tion of medical activities is being run by a

tion, especially because it may take many nurse in unit of asylum home in Vič, which

months or even years for them to obtain is inconvenient for those who are accom-

international protection. They might live in modated in other units of asylum home -

Slovenia for several years and during that asylum seekers from unit in Kotnikova or

time they will only have rights to urgent from unit in Logatec cannot use services,

medical assistance, with the exception of provided by the nurse in Vič. If an asylum

children and particular categories of wom-

seeker from unit in Logatec falls ill, he/she

en. Another issue is there are no rules, will not go to see a nurse in Vič and after

official procedures or guidelines on how that a doctor in Logatec. Consequently, the

to provide medical treatment of asylum responsibility for managing medical affairs

seekers. In order to make admission and falls on shoulders of staff, unqualified for

treatment of asylum seekers more trans-

administrating medical activities - most of-

parent, ministry and health centres made ten on social workers. Definition of urgent

an agreement, according to which a referral medical assistance, as defined by law, is

is to be made for an asylum seeker prior to inexplicit and therefore enables various in-

an examination, or a doctor on duty is to be terpretations. Furthermore, in comparison

informed of the asylum seeker’s arrival. So-

to Slovenian citizens, in the first 9 months

cial worker or healthcare professional from after their arrival asylum seekers are una-

the Asylum home can call and appoint ble to engage in substantial gainful activ-

asylum seeker to appointed health centre. ities, which would enable them to pay for

Asylum seekers from unit of asylum home health insurance or medical services. Asy-

in Vič are referred to Health centre Vič-Rud-

lum seekers would require at least a basic

nik, asylum seekers from unit of asylum health insurance. This is not about granting

home in Logatec are referred to Health asylum seekers above-standard treatment,

centre in Logatec. However, it is more dif-

unavailable to Slovenian citizens - it is

ficult to establish a suitable co-operation about the importance of providing a basic

for asylum seekers from unit of asylum health care and human dignity to asylum

home in Kotnikova - they are being referred seekers in need of medical services. A more

to the General Urgent Medical Assistance extensive medical treatment of asylum

(GUMA), which provides an urgent medical seekers would also unburden the system,

assistance and is therefore not the most for instance on-duty services. In executing

convenient location for treating asylum requests, the inter-ministerial commission

36

(see page 17) focuses solely on urgency services will be approved. The current legis-factor, nevertheless the quality of asy-

lative does not explicitly define, whether a

lum seekers’ lives is greatly diminished by patient who was referred to further exam-

non-urgent medical states as well. Sec-

inations by a general practitioner needs a

ond issue is that even when the commis-

reference letter (reference letters are being

sion grants additional medical treatments, managed by Health Insurance Institute of

there are no clear criteria for selecting a Slovenia).

service provider.

4. to define, whether asylum seekers

Therefore, it would be necessary:

whose referral have been approved

by the commission ought to be placed on

1. to employ a medical coordinator at a waiting list (waiting lists are being man-

national level to ensure continuous aged by the Health Insurance Institute of

medical treatment and supervision of asy-

Slovenia).

lum seekers’ health conditions. The coordi-

nator would also manage the information 5. to set deadlines for issuing request

flow between different services, function-

approvals by the commission, e. g.

ing at different levels and participating 7 days. Current system of informing is not

in health care of asylum seekers and - in functioning well. Some asylum seekers can

broader sense - of migrants;

wait up to several months for an answer,

during which time nobody knows, when the

2. to employ a family practitioner, in- commission will have been in session.

tegrated in the system, qualified

for working with refugee population, with 6. to ensure an active participation of

a suitably equipped clinic, a basic medi-

the inter-ministerial commission.

cal team and a translator. Such treatment The commission should establish clear

would offer asylum seekers a primary distinction between urgent and non-ur-

health care and in particular cases a spe-

gent medical services - the latter should

cialist examination if approved so by the be financed by the Ministry of Health. The

commission, provided the asylum seekers commission should asses the requests

are not already entitled to specialist treat-

prudently, namely if the commission would

ment (pregnant women, breastfeeding approve every request, there would be no

women, children).

need for its services in the first place.

3. to improve referral system. In case 7. to establish a systematic method

a general practitioner issues an ur-

of informing asylum seekers of pa-

gent referral, a patient uses the service as tients’ rights and obligations, concerning

a citizen. In case a general practitioner is-

different possibilities for their treatment,

sues a cursory or regular referral, inter-min-

possible complications and functioning of

isterial commission assesses, whether the our health system. This is crucial, since dur-

37

ing medical treatments there is not enough CONCLUSION

time to acquaint asylum seekers with all

the information they need.

In the course of our work and project ex-

ecution, we established good connections

8. to prepare clinical pathways for tak- between our team and medical teams in

ing measures in case of infectious community health centres. In the future it

diseases (e. g. tuberculosis, HIV, hepatitis, would be necessary to determine meas-

STD).

ures and activity procedures as well as to

define guidelines for medical treatment

9. to define guidelines and methods and patient care of asylum seekers, since

for treating mental illnesses, includ-

there are none to follow at the moment.

ing addictions.

10. to prepare simple leaflets in lan-

guages asylum seekers under-

stand. The leaflets should contain explana-

tion on how our medical system functions

and which rights and obligations in terms

of medical are available to them.

11. to employ a nurse in all units of

asylum home (for a full-time or

at least part-time position). For instance, a

nurse would execute preventive measures,

educate asylum seekers, distribute and

store medicine, attend to non-complicated

health issues, maintain contacts with phy-

sicians and arrange referrals.

12. to enable asylum seekers to

choose a personal physician, pedi-

atrician and/or gynaecologist at their local

health centre - this is crucial, since some

asylum seekers live in the asylum home for

many months or even years. Such measure

would ensure monitoring their health con-

dition, storing their medical documentation,

referring and supervising all in one place.

38

MENTAL HEALTH CARE

OF ASYLUM SEEKERS

Špela Brecelj M.D., Lea Bombač M.D., dr. Erika Zelko F.M.M.D.

- - - SUMMARY - - -

This article introduces our personal opinions with reference to

dilemmas, regarding mental health care of asylum seekers, and

discusses some suggestions for its improvement. During our

project work of providing health assessment to asylum seekers

some of the most common health issues we noticed were depres-

sion, insomnia, anxiety and somatic symptom disorders, such as

headaches, unexplained pain and nausea.

Insomnia and nightmares

lationship with his wife and son. The

child started waking up from night-

Even the strongest men can break when

mares in the middle of the night. While

they see asylum seekers, who had been

an adult, receiving appropriate psycho-

transferred to the Republic of Slove-

therapeutic treatment, might recover

nia under yearly quota, receiving a re-

from the traumas, it is much harder

ply with regard to their application for

for a child, witnessing discontent of

international protection in one month.

their parents and experiencing stress-

When some must wait several months

ful events in the most sensitive years

for first interviews in order for the pro-

of their personal development, to over-

cedure to even begin, the feeling of in-

come these long-term consequences in

security does nothing but increase. In-

the coming life situations. We may only

somnia is just one of the consequences.

guess, what will happen to this family

in the future.

One of the asylum seekers regularly

went out in the middle of the night, Situation in which they found themselves

since he could not stop thinking about

in (state of war or state of crisis in their

what will happen to him. Bad mood homeland, death of family members and

and insecurity started affecting the re-

friends, exposure to violence, torture and

39

terrorist attacks, loss of home, family and

ates a sense of collective co-creation of

social network, exhausting journey, uncer-

dwelling conditions in the asylum home,

tain future) makes mental state of asylum

enables the opportunity to prepare

seekers one of the most critical aspects of

meals in fashion of their traditional cui-

health. Accommodation in country of their

sine (in order to avoid malnutrition due

arrival and applying for asylum does raise

to loss of appetite as well as weight

some hope in the beginning, nevertheless

gain due to disproportionate intake of

during their stay in the asylum home asy-

carbohydrates) and thereby acts as a

lum seekers encounter new stressful situa-

prevention measure to avoid diseases

tions, for instance social isolation, financial

linked to improper diet (vitamin defi-

insecurity, loss of their role in society and

ciency, obesity, diabetes, hypertension,

family, limited access to health care, work

gastrointestinal diseases etc.).

and activities, which give one a sense of

dignity, purpose and hope. According to ■ Actively involve asylum seekers in

experience we acquired during our work

processes of sanitation of bedrooms

with asylum seekers, we believe applying

and common rooms. Taking care of

measures for preservation and improve-

the rooms in which they dwell creates

ment of mental health of this popula-

a sense of intimacy, homeliness and re-

tion is one of the most crucial preventive

sponsibility towards self - that is a foun-

measures in field of health care. To prevent

dation of feeling of dignity. As already

secondary traumatization and develop-

mentioned in the previous paragraph,

ment of mental illnesses, »self-treatment«

such activities create a daily and weekly

with psychoactive substances, as well as

rhythm.

somatic symptom disorders, developing

as result of imbalance in the psycho-neu-

■ Providing opportunity to work (paid or

ro-endocrine-immune system, we propose

voluntary) in the vicinity of the asy-

to those responsible for organization of

lum home. Purposeful work reestablish-

dwelling conditions in asylum homes the

es a sense of capability and self-worth.

following measures (substantiated with

Providing work opportunities in outdoor

recommendations of European project

maintenance and community assistance

called EUR-HUMAN):

(raking leaves, shoveling snow, mowing

lawns etc.) would in our opinion attribute

■ Enabling asylum seekers a full or at

to prevention of general drop in morale

least partial active participation in

and mental health deterioration of in-

meal preparation. This proved to have

habitants of asylum home. Should the

numerous positive effects on physical

work provide a source of extra income

and mental well-being: it creates a dai-

(for those who have been waiting for 9

ly rhythm of purposeful activity and a

months or more) and a possibility to con-

sense of responsibility, it gives individ-

nect with social surroundings, that would

uals a role in their new community, cre-

be even more so valuable.

40

Proposed changes should not be perceived

simply as a financial burden, but instead

should be considered as a reorganization

of dwelling and work processes in the asy-

lum home, which shouldn’t function as an

authoritative institution. A common goal

of all of us who work with asylum seekers

is to enable them to become actively in-

volved in taking care for and providing for

themselves, which would greatly contribute

to their recovery from previous traumatic

experiences. An opportunity for asylum

seekers to prove themselves as orderly in-

dividuals, who are capable of work and are

being actively included into the society (as

opposed to e.g. idle alcoholics, which they

may very well become, considering the sit-

uation they are in at the moment), would

also contribute to breaking the stigma and

fear of this population as well as alleviate

the acculturation process, to which asylum

seekers from various environments and

cultural backgrounds may richly contribute

to.

41

PSYCHOTHERAPEUTIC

WORK WITH REGUGEES

Dr. Zuzanna G. Kraskova

- - - SUMMARY - - -

I perform psychotherapy on clients, who in the past were victims of war vi-

olence or violence in general. The users are asylum seekers in the Republic of

Slovenia or those who already acquired international protection. Those indi-

viduals suffered deep traumas, affecting their personality structure, emotion-

al, behavioral and thinking patterns. In most cases they come from war zones

or had fled from perils of war and violence and after toilsome journey came to

find their refuge in Slovenia. In the majority of this population group, conse-

quences of fear, tension and anguish result in form of mental disorders.

Cognitive behavioral therapy, which I per-

appear. I practice psychodynamic approach

form on clients, is the most appropriate with all clients; it is appropriate for uncov-

therapy for treating mood disorders, since ering deep thinking patterns, personality

the symptoms of those clients show unad-

structure as well as for establishing the cli-

justed thinking and consequently feelings ent’s psychological profile, needed for per-

of unease or discomfort. In its secondary forming psychotherapy treatment.

form they show symptoms of obses-

sive-compulsive disorder and several types I perform creative psychotherapy on all cli-

of phobia. Keeping journals, which clients ents, since the creative approach to ther-

bring to the therapy sessions, help us dis-

apy offers the clients a divergent way of

cover when, why and to what extend a dis-

thinking, enabling them a broader view on

order appears in everyday life. Cognitive the issue and the surrounding environment.

behavioral therapy is based on identifica-

It helps the clients to achieve a higher level

tion and alteration of unadjusted thinking, of thinking and enables them to achieve a

originating from an incorrect basic pat-

higher level of consciousness. Occasional-

terns. By modifying this basic pattern, the ly, I combine creative psychotherapy with

level of emotional ill-being decreases and cognitive behavioral therapy.

during psychotherapy treatments even dis-

42

Mindsight - this therapy is based on intro-

spection and is suitable for clients, showing

symptoms of anxiety disorder, especially

generalized anxiety disorder. With those

clients, this approach is optimal since it

involves dwelling deep into a specific trau-

matic event from childhood or youth; the

client is absorbed into the traumatic event

and internalizes it. This way, the client con-

fronts the event and sees its mirror image,

which helps to discover unconscious pat-

terns that preserve the trauma in state of

active thought dynamics - mindsight ther-

apy helps to disintegrate the trauma until

it finally fades away completely.

I perform the acceptance and commitment

therapy (Socratic method) on the majority

of clients; this method enables a direct con-

frontation with a traumatic event on a lev-

el of comprehension, internalization of the

trauma and modification of basic patterns.

In the past the clients namely experienced

specific traumatic events and this type of

therapy, which is also based on questions

(also from the aspect of the answer), helps

the clients to accept the frustration, ena-

bles them to change their thinking pattern

and when they remember the traumatic

event this helps them to use a new, fresh

thinking pattern, which will alleviate the

level of unease and discomfort.

43

PART 2

Asylum seekers and migrant medical treatment is not a completely

new practice in Slovenia. Some doctors, working in health

centres that receive migrants, and those working voluntarily

in the Health clinic for persons without health insurance, are

constantly dealing with difficulties of treating migrant population,

nevertheless there is no systematic approach to migrants/refugees’

medical treatment in sense of collaboration between all subjects

included in the process: ministries in charge, health institutions,

researchers and NGO’s working closely with the migrant

population. It is necessary for all practices to be linked in order to

ensure the best medical treatment for refugees and migrants.

In the following we introduce three perspectives on migrants/

refugees’ health treatment that exemplify that all practices are well

in line with regard to what is needed and what obstacles need

to be overcome for a proper and successful medical treatment of

migrants.

44

OUR EXPERIENCE

WITH THE TREATMENT

OF ASYLUM SEEKERS

asst. dr. Nena Kopčavar Guček, F.M.M.D.,

Simona Repar Bornšek, M.D., Neli Grosek, M.D.

Health Centre Vič Ljubljana and Health clinic

for persons without health insurance

cally, without a prior consultation and ap-





INTRODUCTION


pointment by the authorized person from

the asylum home. Frequently, they are not

In Health Centre Ljubljana-Vič, we are treat-

acquainted with their rights and possibili-

ing asylum seekers from the Asylum Home ties for their treatment, since in most cases

for several years now. During our work we asylum seekers are only entitled to urgent

acquired a great deal of experience, which medical treatment - consequently, any ad-

we tried to sum up in several notes on draw-

ditional treatment is unavailable to them.

backs of the existing system and added our

proposals for its improvement.

2. Communication barriers are pro-

longing and hindering the treatment.

In Health Centre Ljubljana-Vič, asylum

seekers are mostly admitted by a doctor on 3. Migrants often do not have any in-

duty as unappointed patients. Patients are

formation on their (chronic) health

treated by a different doctor each time - condition and medicine they take, they

this results in issues with record keeping, also have no record of their previous treat-

decreased continuity and unnecessary pro-

ments.

longation of treatment.

4. Due to unorganized and unappoint-

ed arrivals and treatments of asy-

DRAWBACKS OF EXISTING lum seekers, rights of insurants of Republic

of Slovenia are often violated.

SYSTEM

1.

5. Treatments are dispersed and in-

It is not uncommon for asylum seek-

coherent - as a consequence, such

ers to visit health centres sporadi-

treatments are not only incomplete, but

45

can also be hazardous for individual asy-

a decrease (see »Table 1«) in number of

lum seekers.

asylum seekers visiting the health centre,

apart from that, when they visit a doctor,

6. Occasionally we come across ethi- they bring a reference letter from a medi-

cal issues, for instance when wom-

cal coordinator.

en refuse to take off their clothes during a

clinical examination, or when men refuse 6. We support the possibility of asy-

to be examined by a female doctor.

lum seekers being able to choose

a personal physician. Such measure would

simplify and standardize treatments, en-

PROPOSALS FOR

able continuity and increase the overall

quality and safety levels of the treatment.

IMPROVEMENTS

1. Prior to a medical treatment, indi-

vidual asylum seeker should visit

MONTH

Number of

an authorized person in the asylum home,

patients treated

who would consult the doctor prior to the

January

16

treatment.

February

25

2.

March

23

If possible, a translator should be

present at the examination (if there

April

29

are no professional translators available, a

May

26

layman native-speaker should suffice).

June

9

July

4

3. If possible, patients should bring August

15

their complete medical record to September

22

each treatment.

October

11

4. Notice on visits to the clinic should November

5

be given at least several hours be-

Table 1: Number of migrants treated in

forehand - epidemiological aspects are im-

Health Centre Vič (according to months in

portant (e. g. due to necessity of a quaran-

2016)

tine when facing a suspicion of infectious

diseases).

Most visits were made due to following

requirements: drug prescriptions, medical

5. Since project »8 NGO’s for migrants’/ tests, wound care, first medical examina-

refugees’ health in 11 countries« tion.

started (executed by Slovene Philanthro-

py in units of Asylum home), we noticed

46

EXPERIENCE WITH MEDICAL

TREATMENT OF REFUGEES

AND MIGRANTS

prof. dr. Danica Rotar Pavlič, M.D., Eva Vičič, M.D.,

Department of Family Medicine

Faculty of Medicine Ljubljana

- - - SUMMARY - - -

The importance of communication between a patient and a doctor lays the

groundwork for a successful treatment and is therefore a part of under-

graduate as well as postgraduate medical studies. Ability to communicate is

particularly important in intercultural treatments. Apart from overcoming

language barriers, medical doctors must also consider patient’s socio-cultural

and religious beliefs and different prevalence of certain illnesses in patients

from different cultures and minority groups. In a doctor-patient interaction,

communication must each time be accustomed to the patient’s needs - this

applies to treatment of the majority population as well as to treatment of

ethnic minorities and refugees. Although interpreters generally alleviate

patient-doctor communication, researches showed they may also have a neg-

ative influence. Regardless of the patient’s cultural background and language

barriers, doctors, medical technicians, psychologists and other experts must

build a confidential relationship, which must be based on mutual respect since

the very beginning of treatment.





INTRODUCTION


stantly increasing (1). Migration flow con-

sists not only of Syrian refugees, but also

Since the beginning of crisis in Syria, a of migrants from other war zones and eco-

number of refugees in Slovenia is con-

nomically underdeveloped areas. In 2015,

47

Slovenia needed to face the refugee crisis. REFUGEE AND MIGRANT

As a part of the Balkan route, it was an im-

CRISIS

portant so called »transit state« for immi-

grants, which brought forth not only politi-

Refugee and migrant health crisis can be

cal and social, but also community health divided into different segments:

issues (2,3).

■ accessibility to medical treatment;

In Europe there is no fixed and standard-

ized method of evaluating medical needs ■ means for treatment of migrants and

of migrants and refugees, many of whom

treatment related costs;

experienced several weeks and months of

different methods of transportation and had ■ communication with migrants and ref-

differently appropriate access to food, wa-

ugees;

ter and accommodation. Due to numerous

factors, they were more exposed to risks for ■ diversity of illnesses, appearing within

suffering injuries or developing diseases, at

this population;

the same time they had various possibilities

of access to medical treatment.

■ possibility of further hospital medical

treatment;

In some EU states, primary triage and

medical examinations of newly arrived mi-

■ psychological support.

grants, economic migrants and refugees

are compulsory, in some they are not. Fur-

In countries, where issues with refugees

thermore, the methods of such evaluations are present for some years now (e. g. Nor-

are not standardized in all EU states - for way, Sweden etc.), different researches (4,

instance, in most states the so called re-

5) showed that individual approach is cru-

ferral letters or results are not issued upon cial for a quality medical treatment. Name-

the treatment. Consequently, upon their ly, refugees and other migrants come from

first contact with newly arrived refugees various environments (urban as well as ru-

or migrants, medical staff in certain states ral), they had different upbringing, received

cannot evaluate and consider information different education and have different cus-

of previous medical treatment.

toms. As communication needs to be ad-

justed during the treatment of the »local«

This article introduces general findings on population, so too it must be adjusted to

the refugee crisis in Europe with the em-

every particular individual in treatment of

phasis on communication and describes refugees and migrants - language is an

issues, concerning interpreters and transla-

additional issue in this case. Although the

tors. In conclusion, the article puts a special presence of interpreters and cultural me-

focus on the often underestimated aspect diators usually alleviates patient-doctor

of refugees’ mental health.

communication, researches showed (6)

48

they may also have a negative influence. sional assistance as well as appropriate Firstly, it must be assured that they are the psychological support, co-operation of dif-right gender (e. g. female interpreters in ferent professional services (psychiatrists,

treatment of female patients - the same psychologists, social workers, etc.) and an

applies to doctors). When interpreters or integral approach to treatment of patients

translators are related to patients, they are crucial. For refugees, the travel alone

may also be biased while interpreting the has been extremely difficult and stressful,

information; relatives may regard a spe-

in addition, many of them endured atroc-

cific symptom as more important than for ities of war, abuse and trauma in their

instance a person, who is taking medical homeland. We have to consider this fact

history of a patient, and may therefore and we need to actively encourage them

present the information differently due to to seek help, because some of them are

their emotional involvement. Apart from not accustomed to openly discuss those is-

that, feelings of shame and unease may sues due to ethnic and/or religious reasons.

appear in the presence of an official inter-

Children in particular will need special help,

preter, which affects the accurateness of in addition we need to enable them the

the given information that may be of vital possibility of being included into the edu-

importance for the medical staff.

cational system.

Access to medical treatment is another is-

It should not take us by surprise if the

sue. Slovenia was foremost a transit state, migrants will expect the kind of medical

therefore an essential part of treatment of treatment that they are accustomed to and

refugees was that doctors were available in have received in their home country. Their

all accommodation centres - that way, mi-

perception and interpretation of diseases

grants knew where to go in case of health may be completely different as well (4).

problems. It is entirely different with refu-

Consequently, some may put doctors under

gees, who wish to stay, because they have more pressure, since they have different

to be acquainted with the principles on expectations with regards to the treatment.

which our health system functions (where

and how to acquire health insurance, where

to go in case of emergency and where to

go in case of acute and chronic conditions, COMMUNICATION

locations of clinics of family physicians,

working hours of medical institutions etc.).

Appropriate communication promotes the

development of a satisfying relationship

From a medical perspective, it is important between a patient and a medical profes-

for a doctor to be educated on illnesses sional, enables an adequate exchange of

that are more prevalent in other parts of information, determines the plan and ef-

the world and less common in our region. ficacy of the treatment and ensures the

In order to provide refugees with a profes-

patient’s co-operation in the treatment

49

process (9). The ability to communicate SPECIFICS OF

is especially important in intercultural en-

COMMUNICATION

counters. Apart from overcoming language WITH PATIENTS FROM

barriers, medical doctors must also consid-

er the patient’s socio-cultural and religious DIFFERENT CULTURAL

beliefs, as well as variable prevalence of BACKGROUND

some of the most common illnesses in pa-

tients from different cultural backgrounds When working with individuals from differ-

(10).

ent cultural background, it is good to be fa-

miliar with »culturally related syndromes«,

Satisfactory communication leads to de-

which define interactions and communica-

velopment of trust. Refugees have a pos-

tion between a patient and medical staff.

sibility to convey important and sensitive Some refugees respond to health issues in

information that enable the doctor to ac-

a very emotional way. Misunderstanding

curately assess their condition and take their way of expression, medical experts

further decisions. That way, refugees have may mistakenly declare them neurotic.

a greater sense of autonomy and they Some economic migrants may present

estimate that they contribute their auton-

their health issues less grave then they re-

omy to the process of treatment, there-

ally are because of fear for their employ-

fore they are more motivated for changes ment, which may unintentionally mislead a

and co-operation in the treatment. With doctor to other diagnostic algorithm (12).

regards to the communication, some ref-

ugees have negative experiences, which Communication with individuals from dif-

may be summed up into four categories: ferent cultural background should include

mistrust, low-quality treatment, excessive the following principles:

or insufficient use of medical resources,

consequently dissatisfaction with non-in-

■ communication should be a »two-lane

volvement in the treatment process. When

highway«, where both participants

refugees are dissatisfied with communica-

should listen and be listened;

tion, they look for second or third opinion,

they seek health care elsewhere and are ■ efficient

communication

demands

avoiding further contact with medical ser-

qualification, which means using sim-

vice providers. Consequence of negative

ple words that are easy to understand,

experiences is the feeling of frustration and

speech should be intelligible, instruc-

rejection. Because they feel they have not

tions short and simple;

been taken into account, their motivation

for further treatment is diminished (11).

■ doctor should be flexible and for the pur-

pose of efficient communication various

means of communication should be

used;

50

■ doctor should have patience while com-

be at the doctor’s disposal all the time,

municating with a patient.

the latter should of course approach each

patient individually. Web service Google

A doctor should learn to accept diversity Translate and non-verbal communication

and should therefore get educated on spe-

(which many healthcare professionals had

cifics of refugee’s culture by asking the ref-

to use during our Schengen research) may

ugee about his/her knowledge and notion serve as an additional help, but this should

of the disease, about his/her expectations not be a primary means of communication,

and what would he/she like to know with since vital information may get lost during

regards to his/her health state. Most of all, the process.

a doctor should be empathetic.

Co-operation between cultural mediators

and translators differs from case to case. In

TRANSLATORS,

official procedures (e. g. filing applications

for international protection), a translator

INTERPRETERS AND

is to be present at all times. Those proce-

CULTURAL MEDIATORS

dures and translation services are arranged

by the Ministry of the Interior. In such cas-

Refugees, who came to Slovenia, are not es, official interpreters should provide the

one homogenous group of people, neither services, however, two issues appeared

can they be divided to several minor ho-

regarding that matter: firstly, it is difficult

mogenous group, e. g. to »Syrians«, »Af-

to acquire official interpreters for certain

ghans«, »Somalis« etc. There is a plurality languages, since there are few available

of social, cultural, socio-economic, ethnic or none at all; secondly, interpreters are

and religious factors existing within this generally paid considerably more when

population. A new research has been made providing court interpreting services, than

in the Schengen area (Slovenia, Croatia), when providing services for the Ministry,

which confirmed results of previous re-

therefore they usually refuse to participate

searches, namely that poor communica-

in official procedures and services of official

tion is the biggest issue in treatment of translators must be used instead.

refugees. Communication issues caused

medical experts to be under considera-

In cases when presence of an official trans-

bly greater stress due to the possibility of lator is not compulsory (e. g. medical treat-

making incorrect diagnosis and/or giving ment procedures), majority of doctors turn

incorrect treatment, since in order to pro-

for help to people, who speak one of the

vide a high quality medical treatment, it is languages of the refugees/migrants. In

important to take the medical history of a translating, one should always aim towards

patient correctly - this applies to all medi-

objectivity, which is not always the case

cal fields and the treatment of migrants is with non-professional translators, since

no exception. A qualified interpreter should they often interpret statements of health-

51

care professionals in their own way and tries, gender violence and mutilation of

often to the patients’ detriment. Therefore, female genitalia is still allowed (14). Apart

Slovene Philanthropy strives for introducing from the abovementioned, upon their arriv-

a profile of so called »cultural mediators« al in a new country refugees might realize

(research of practices and introduction of their expectations and ideas on developed

the term, carried out by dr. Uršula Lipovec world differ from actual circumstances and

Čebron, will be presented in continuation all their hopes of a better life vanish in-

- Ed.). Cultural mediators should be fluent stantly (15). Consequently, states of deni-

in both languages, they should be familiar al, negativism, excessive irritability and de-

with both cultures and should receive ap-

pression might develop (16, 17). In migrant

propriate education.

population the prevalence of posttraumat-

ic stress disorder counts for 20-40% and

prevalence of a major depressive episode

UNDERRATED

for 30-70%. In comparison to a gener-

al population, the prevalence of mental

IMPORTANCE OF MENTAL illnesses in refugee population between

HEALTH IN REFUGEE

men and women is comparable (18).

POPULATION

After being exposed to atrocities of war CONCLUSION

and to stressful events, refugees are at

risk of developing mental health problems. Migrations and globalization cause chang-

Extent of mental health problems varies es in structure of patient population. When

(from 75% to less than 5% of posttraumat-

communicating and treating patients from

ic stress disorder in refugee population). different ethnic and cultural backgrounds,

Systematic reviews of research results doctors and medical staff must consider

(research included children and adults) specifics of cultural environments from

showed children recover from traumatic which the patients originate. They should

events better than adults (13).

overcome language barriers with the help

of interpreters and cultural mediators.

Refugees often leave their homeland after Treatment of patients from a different

they have been exposed to life-threatening cultural environment demands a doctor’s

situations, for instance war conflicts and vi-

self-reflection and awareness of his/her

olence. By becoming refugees they might own norms and values, which are brought

get exposed to perilous situations and risk in interaction with a patient.

prison sentence or death of their beloved.

They can become victims of persecution

and oppression due to their ethnicity, reli-

gion or sexual orientation. In some coun-

52

REFERENCES

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White, M., Ruston, D. C., Lo, B.

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(2004). Patient-centered Communi-

Asare, P. (2016). Syria: The story of the

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zdravstvene oskrbe ljudi iz drugih

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kultur. Učinkovito sporazumevanje

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v medkulturnih srečanjih med

al. (2011). Good practice in health care

bolnikom in zdravnikom. U: Kersnik,

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3. Rechel, B., Mladovsky, P., Deville,

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W., Rijks, B., Petrova-Benedict, R.,

Systematic Review of Patients Ex-

McKee, M. (2011). Migration and he-

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Encounters and a Balance between Vul-

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4. Wachtler, C., Brorsson, A., Troein,

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M. (2006). Meeting and treating cul-

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12. Zelko, E. (2016). Sporazumevanje z

alitative interview study. Fam Pract;

osebo iz drugega kulturnega okolja.

23: 111-115.

U: Petek, D., Švab, I. Sporazumevanje

v družinski medicini. Ljubljana: Ka-

5. Van Wieringen, V. C. M., Harmsen,

tedra za družinsko medicino Medi-

J. A. M., Bruijnzeels, M. A. (2002).

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Panter-Brick, C., Stein, A. (2012).

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6. Ferguson, W. J., Candib, L.M. (2002).

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middle-income countries: risk and pro-

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353-61.

14. Thomas, S., Nafees, B., Bhugra, D.

7. Bhatia, R., Wallace, P. (2007). Expe-

(2004). ‚I was running away from

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in general practice: a qualitative study.

unaccompanied asylum seeking children

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in the UK. Child Care Health Dev;

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(2011). Migrant participation in

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16. Slobodin, O., de Jong, J.T. (2015).

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matized asylum seekers and refugees:

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21-28.

54

ON IMPORTANCE

OF IMPLEMENTING INTERCULTURAL

MEDIATION INTO SLOVENIAN

HEALTHCARE INSTITUTIONS

dr. Uršula Lipovec Čebron,

Department of Ethnology and Cultural Anthropology, Faculty of Arts

WHAT IS INTERCULTURAL (Bowen 2000: 8). Cultural mediator is not

simply a person, who speaks a language of

MEDIATON?

a certain community, but is instead some-

one who is acquainted with and »speaks«

Intercultural mediation is an international-

the culture of a user. Language proficiency

ly established concept and practice, used should thus not be equated with cultural

for reducing inequality and ensuring quality proficiency. Cultural mediator is a profes-

treatment in healthcare and other institu-

sionally qualified individual, who acts as a

tions (EQUAL EP TransKom 2012; Verrept third party in a relationship between a user

2008, 2012). It is intended for overcoming and provider. In healthcare institutions, cul-

misunderstandings that emerge because tural mediator represents a bridge between

of linguistic, cultural, social and other dif-

health care providers and health care us-

ferences between users and providers in ers (Bofulin, Farkaš, Lainščak, Gosencaand

public and private institutions. In this con-

others 2016).

text, the term culture does not only refer

to ethnicity of an individual, but also to

other economic and social aspects of life

that influence the occurrence of different WHY IS CULTURAL

misunderstandings. In such context, me-

MEDIATION NEEDED?

diation surpasses linguistic interpretation,

since it includes translation of different no-

In today’s modern world of fluidity and fast

tions and practices. If interpretation refers social changes, communities are becoming

to translation of language, then mediation increasingly more culturally and socially di-

refers to translation of cultural meanings verse - this phenomenon is also present in

55

environments, which appear internally ho-

tients from different cultural and so-

mogenous. Slovenia is no exception here. cio-economic environments are on a daily

In such altered environments, it is not only basis. Those users do not speak or under-

important to consider the existence of var-

stand Slovenian and/or have experienced

ious population groups, but also the fact different medical practices, they have a

that differences inside those groups might different notion of body, pain, disease and

be even greater than differences between health and are not appropriately acquaint-

the groups themselves. Migration and oth-

ed with the Slovenian healthcare system.

er social trends reveal a multifaceted di-

Since there are no cultural mediators and

versity of population - not only because of interpreters available to them at the mo-

increasing numbers of members of differ-

ment, healthcare professionals are left to

ent »ethnic groups«, but also because of their own resources while treating those

social stratification and numerous other patients. This very often makes their work

factors that are influencing on inclusion or difficult, causes numerous misunderstand-

exclusion of population (Standards for Eq-

ings and reduces the quality of healthcare

uity in Health Care for Migrants and other services. Consequently, healthcare service

Vulnerable Groups 2013; Chiarenza and users from different environments often

others 2016). Those changes in general experience unequal, low-quality services,

population are traversing to the healthcare which results in less successful treatment

system and represent challenges, which while the patients themselves are exposed

the healthcare system needs to address in to greater health risks (Bofulin, Farkaš

order to provide quality healthcare servic-

Lainščak, Gosenca and others 2016; Chi-

es.

arenza and others 2016).

In context of health care, cultural and so-

In many countries, such issues have been

cial differences manifest for instance as resolved by implementing interpreters

differences in social position, differences and/or cultural mediators and by qualify-

in understanding health and disease, dif-

ing healthcare professionals to develop

ferences in practices of health care and their cultural competence. Experience from

responses to health issues. Differences abroad shows such methods of problem

between users and providers of medical solving can bring numerous obstacles and

services are not only limited to differences dilemmas (Kleinman and Benson 2006;

in education, language proficiency etc., but Gregg and Saha 2006) when health institu-

are present in all aspects of medical treat-

tions seek hasty, unprofessional and short-

ment. Those differences are not always term solutions and do not address issues3

evident, nevertheless they always have that need to be resolved in order to ensure

relevant clinical implications.

3 Those issues are, for instance: how to ensure the

independence of cultural mediators, who is to set

In Slovenia, an increasing number of

the criteria for cultural mediator’s work, who in

healthcare professionals istreating pa-

how will be in charge for their education, how to

fund their work, etc.

56

an efficient co-operation of cultural medi-

they can follow the prescribed therapies

ators in health institutions. The opposite is

easier as well as respond better to pre-

true in cases, when introduction of cultural

ventive programs);

mediators was thoughtfully planned, reg-

ularly evaluated and profesionally man-

■ decreases costs (due to presence of cul-

aged while at the same time it served as

tural mediator, healthcare professionals

a complement of long-term development

spend less time for overcoming misun-

of cultural competence among healthcare

derstandings during the treatment; a

professionals (Verrept, 2008, 2012). In

greater quality of treatment results in

cases when cultural mediation has been

improved health state of the users and

appropriately implemented, it is considered

at the same time they use medical ser-

as an example of good practice that signif-

vices more rationally (less visits to the

icantly increases the quality of healthcare

ER, less hospitalizations, etc.). (Verrept

services and in that regard, the reasons for

2008, 2012).

implementing cultural mediators can be

summed into following paragraphs:

■ it decreases inequality in medical OUTSET OF

treatment (because they understand IMPLEMENTATION OF

patients‘ needs better, healthcare pro-

CULTURAL MEDIATION IN

fessionals are able to ensure not only COMMUNITY HEALTHCARE

formal but actual, equal, impartial and

quality treatment, prevent unwanted IN SLOVENIA

discrimination and manage risk factors

for its emergence);

In Republic of Slovenia, there are sever-

al provisions, which can be used as legal

■ it increases the quality of medical treat-

basis for implementation of cultural me-

ment (presence of a cultural mediator diation into the system of health care, for

ensures a greater accuracy of conveyed example Patients’ Rights Act and Code

information and therefore enables an of Ethics on Medical Treatment and Pa-

establishment of a more accurate di-

tient’s Care, nevertheless, guidelines for

agnosis, also the patients are able to implementation of cultural mediation into

understand instructions for taking med-

the healthcare system have not been de-

icine and following other therapies and termined yet. Apart from that, cultural me-

preventive measures);

diators have not been officially included

into Slovenian healthcare system.

■ it increases responsiveness of users

(due to improved communication with One exception is a recent trial implemen-

healthcare professionals, the users de-

tation of a cultural mediator for inhabitants

velop trustful relationship with them, of the Albanian community in Celje. The

57

trial implementation was carried out with-

temic measures for decreasing inequality

in the framework of a project »For better in health care (Chiarenza and others 2016:

health and decreasing inequality in health 18–19) and translated the handbook Stan-

care - Together for health«. This project dard for Assurance of Equality in Health

was carried out during 2013 and 2016 by Care of Vulnerable Population Groups and

the National Institute for Public Health4. Tool for Self-evaluation of Health Institu-

Special emphasis was placed on decreas-

tions (Chiarenza and others 2016). As pre-

ing inequality in health care and including viously mentioned, one of the most crucial

various vulnerable groups of people into programms of the project were services,

preventive health care. During the project, provided by the cultural mediator (Sep-

a qualitative research has been conducted tember - December 2015) in Health Centre

by researchers in different parts of Slove-

Celje6, which proved to be very successful

nia. Researchers established, which pop-

and necessary for healthcare professionals

ulation groups are the most marginalized as well as Albanian users of healthcare ser-

with regards to health care, what are the vices (Jazbinšek in Pistotnik 2016). Ground-

most common obstacles, regarding access work for this trial implementation of cultural

to health care services and what are some mediation was set with the Declaration of

possible options for solving those issues Necessity for Implementation of Cultural

(Farkaš Lainščak 2016: 14-25). The findings Mediation in Health Care Institutions in

revealed, refugees/migrants are the most Republic of Slovenia, prepared by co-work-

vulnerable group in system of health care ers of the project »Together for Health« in

- they must face numerous obstacles (ex-

co-operation with various non-governmen-

clusion from health insurance system, lim-

tal organizations7. The declaration includes

ited access to health insurance and urgent the following proposals for implementation

medical assistance, etc.), many of which are of intercultural mediation into the system of

also linguistic and cultural in nature (ibid.). health care in Slovenia:

As a response to those findings, co-workers

on the project carried out 20-hour education 1. Intercultural mediation should not

project for developing cultural competence

be a spontaneous and unprofession-

in healthcare professionals5 and prepared al activity.

a handbook titled Cultural Competence

and Health Care: Handbook for Develop-

6 More precisely, in the Centre for Health En-

ing Cultural Competence in Health Care

hancement in Health Centre Celje and in the

Reference Clinic in Health Centre in Vojnik.

Professionals (Lipovec Čebron 2016). 7 Non-governmental organizations, which pre-

In the course of the project, the team of

pared and together with the National Institute

for Public Health signed the declaration are:

co-workers prepared a proposition of sys-

Association Mozaik, Association for Awareness

and Protection - Anti-Discrimination Center,

4 The project was funded by the Norway Grants

Slovene Philanthropy, Association for the de-

program 2009-2014.

velopment and integration of social sciences and

5 The education project took place in Health Cen-

cultures – Relation, Institute for Multicultural

tres in Celje, Sevnica and Vrhnika from January

Research, The Peace Institute, The Association of

to June 2016.

Free Trade Unions of Slovenia.

58

The function and significance of cultural c) professional qualification of cultural me-mediation cannot be replaced by a spon-

diators must be executed by an interdis-

taneous or an unorganized form of support

ciplinary group of experts.

(for instance relatives and others) when

solving cultural misunderstandings.

Qualifying cultural mediators should not

be a one-time and generalized passing

2. Intercultural mediator should be of information on a theoretical level, but

professional and should be bound should instead include a complete and in-

to secrecy.

depth qualification, carried out by an inter-

disciplinary group of experts.

Organized and professional work binds the

mediator to secrecy.

4. Funding of cultural mediator should

ensure the independence of his/her

3. Intercultural mediator should be ap- work.

propriately qualified:

Funding services of a cultural mediators

a) he/she must originate from the same should be provided by an institution, which

linguistic and cultural environment as ensures impartiality and respects the prin-

the user or must at least be very famil-

ciples of cultural mediator being an inde-

iar with the language and culture of that pendent expert in his/her field.

environment.

5. Intercultural mediator should strive

Proficiency in language of the user is a

for a co-operative relationship with

necessery but insufficient skill to work as a all parties, especially the users of health-

cultural mediator, since cultural mediation care services.

also includes a good knowledge of the us-

er’s culture.

He/she should function consistently with the

interest of all parties, never against the in-

b) he/she must be familiar with the ba-

terest of the user or against the user’s will.

sics of medical discipline and how the

healthcare institutions function.

6. Intercultural mediator should be fa-

miliar with his/her local environment

Cultural mediator must receive basic and should have a solid network of con-

knowledge on medical discipline and tacts (governmental and non-governmen-

healthcare institutions. At the same time, tal organizations, contacts with initiatives he/she must master the medical termi-of inhabitants, etc.), with whom he/she

nology in the language of the user as well may co-operate if necessary.

as in the language of the medical service

provider.

All governmental and non-governmental

organizations as well as individual orga-

59

nized groups of people, working in the field 10. Healthcare professionals must be of protecting vulnerable groups of people

qualified for co-operating with an

and ensuring their rights for treatment are intercultural mediator.

relevant for cultural mediator’s work.

Because intercultural mediation is a new

7. Intercultural mediator should be ac- practice in our environment, healthcare

tive in different community health professionals should acquire skills on how

institutions and services.

to co-operate with third parties during the

treatment.

Cultural mediator should mediate in health

centres, hospitals, rehabilitation centres 11. Intercultural mediator must re-

and other medical institutions. If neces-

ceive appropriate payment for his/

sary, he/she should also engage in field-

her work.

work (home nursing care), home visits and

other forms of medical assistance, execut-

Work should not be voluntary. A stable,

ed outside medical institutions.

appropriate and quality intercultural medi-

ation can only be assured by appropriate

8. Intercultural mediator should be payment and a good work plan (Farkaš

aware of positions of power in the Lainščak in Lipovec Čebron 2016: 93 -96).

medical environment.

Cultural mediator should intervene in the

relationship between medical service pro-

REFERENCES

vider and user only if he/she detects any Bofulin, M., Farkaš Lainščak, J., Gosenca,

unequal treatment. At the same time, he/

K., Jelenc, A., Keršič Svetel, M., Lipovec

she should be aware of the consequences Čebron, U., Škraban, J.. 2016. Komu-

of unequal positions in medical treatment niciranje. V: Kulturne kompetence in

and should pay special attention to them.

zdravstvena oskrba: priročnik za razvijanje

kulturnih kompetenc zdravstvenih delav-

9.

cev. Ljubljana: Nacionalni inštitut za javno

It is sensible to implement a cultural zdravje. Retrieved from: <http://www.sku-

mediator only if healthcare profes-

pajzazdravje.si/media/prirocnik.kulturne.

sionals are being simultaneously educated kompetence.2016.pdf>, 1. 12. 2016.

on cultural competence.

Bowen, S.. 2001 Language Barriers in

Access to Health Care. Ottawa: Health

Intercultural mediation, together with a Canada.

cultural competence of healthcare profes-

Chiarenza, A., Farkaš Lainščak, J., Li-

sionals, is an integral solution to under-

povec Čebron, U.. 2016 Standard za za-

standing intercultural and social differenc-

gotavljanje enakosti v zdravstveni oskrbi

es and overcoming obstacles that arise as »ranljivih« skupin. Ljubljana: Nacionalni

a consequence of those differences.

inštitut za javno zdravje.

60

EQUAL EP TransKom. 2012 Compa-

2013. Copenhagen: The Task Force on

rative Study on Language and Culture

Migrant-Friendly and Culturally Com-

Mediation in different European coun-

petent Health Care. The International

tries. Wuppertal: EQUAL EP TransKom Network of Health Promoting Hospitals

– gesund & sozial.

and Health Services..Retrieved from:

<http://hphnet.org/index.php?option=-

Farkaš Lainščak, J., ed. 2016 Ocena

com_content&view=article&id=291:mig-

potreb uporabnikov in izvajalcev preven-

rant-friendly-a-culturally-competent-he-

tivnih programov za odrasle. Ljubljana:

alth-care&catid=20&Itemid=3>, 2. 12.

Nacionalni inštitut za javno zdravje.

2016.

Retrieved from: < http://www.nijz.si/

sl/publikacije/ocena-potreb-uporabni-

Verrept, H.. 2008 'Intercultural Media-

kov-in-izvajalcev-preventivnih-progra-

tion: an Answer to Health Care Dispari-

mov-za-odrasle>, 1. 12. 2016.

ties?.' V: Crossing borders in community

interpreting. Definitions and dilemmas.

Gregg, J., Somnath, S.. 2006 Losing

Culture on the Way to Competence: The Verrept, H. 2012 'Notes on the em-

Use and Misuse of Culture in Medical

ployment of intercultural mediators and

Education. Academic Medicine 81 (6):

interpreters in health care.' Facts Beyond

542–547.

Figures: Communi-Care for Migrants

and Ethnic Minorities. 4th Conference

Jazbinšek, S., Pistotnik, S.. 2016 'Eval-

on Migrant and Ethnic Minority Health

vacija pilotnega uvajanja medkulturne

in Europe, Università Bocconi, Milano,

mediatorke za albansko govorečo skup-

Italija.

nost v Center za krepitev zdravja (CKZ)

ZD Celje in v referenčno ambulanto ZD Valero-Garcés, C., Martin, A., ur. Am-

Vojnik.' Neobjavljeno poročilo projekta

sterdam/Philadelpia: Benjamins Tran-

Skupaj za zdravje. Ljubljana: Nacionalni

slation Library. b.n.l.

' Intercultural

inštitut za javno zdravje.

Mediation at Belgian Hospitals.' Online

reference: http://mfh-eu.net/public/files/

Lipovec Čebron, U., ed. 2016 Kulturne

conference/mfh_paper3_Hans_Verrept.

kompetence in zdravstvena oskrba: pri-

pdf, pregledano 5. 8. 2015.

ročnik za razvijanje kulturnih kompetenc

zdravstvenih delavcev. Ljubljana: Nacio-

nalni inštitut za javno zdravje. Retrieved

from: <http://www.skupajzazdravje.si/

media/prirocnik.kulturne.kompeten-

ce.2016.pdf>, 3. 12. 2016.

Kleinman, A., Benson, P.. 2006 Anthro-

pology in the Clinic: The Problem of

Cultural Competency and How to Fix it.

PLoS Medicine 3 (10): 1673–1676.

Standards for Equity in Health Care for

Migrants and other Vulnerable Groups.

Self-Assessment Tool for Pilot Imple-

mentation.

61

APPENDIX 1

62

LEGAL FRAMEWORK

OF THE SLOVENIAN HEALTHCARE

SYSTEM AND ACCESS TO MEDICAL

SERVICES IN SLOVENIA8

Helena Liberšar

In continuation, we will present the Slovenian healthcare system in order to

better illustrate the difficulties which accessing healthcare services imposes on

the asylum seekers and healthcare professionals.

8

STRUCTURE AND

ry health insurance and non-compulsory or

PROVISION OF FUNDING

supplementary health insurance.

FOR HEALTHCARE SYSTEM Compulsory health insurance is defined by

IN SLOVENIA9

the Health Care and Health Insurance Act

and by the Compulsory Health Insurance

Slovenian healthcare system consists of Rules.

two types of health insurance: compulso-

For covering the difference between the

8 Report on legal framework of access to health-

total costs of health services and the

care in Slovenia was prepared within the project

European Network to Reduce Vulnerability in costs of services covered by the compul-

health in cooperation with Medecins du Monde.

sory health insurance, an insured person

9

For more information on organization and may take out supplementary health in-

funding of the Slovenian health care system see

WHO report 2009 http://www.euro.who.int/__

surance, provided by insurance compa-

data/assets/pdf_file/0004/96367/E92607.pd-

nies in accordance to the Insurance Act

f?ua=1, pages 17-61, and the webpage of Health

Insurance Institute of Slovenia http://www.zzzs.

and the Health Care and Health Insur-

si/zzzs/internet/zzzseng.nsf/o/F233938E2AD0

ance Act.

AAA3C1257BB000452FD9.

63

Institution in charge for providing compul-

and a clearer demarcation between

sory health insurance is the Health Insur-

public and private healthcare services

ance Institute of Slovenia.

(abolition of the supplementary health

insurance).

The health sector is provided at the prima-

ry, secondary and tertiary level. Healthcare ■ Ensuring the financial sustainability

services at the primary level comprises

of the compulsory health insurance

primary health care and pharmacy. Health-

scheme by way of achieving greater

care services at the secondary level com-

solidarity in terms of users’ contributions

prises specialist outpatient and inpatients

and the greatest possible preservation

activity. Healthcare services at the tertiary

of existing rights.

level comprises the occupation clinics, clin-

ical institutes or clinical departments and ■ Implementing a transparent and uni-

other authorized healthcare institutions

form public procurement system in

(Article 2 of the Health Services Act, 13.

healthcare in order to ensure efficient

2. 1992, final provisions at February 15. 2.

procurement of medicinal products,

2013).

medical devices and other equipment

for the needs of healthcare services.

Primary healthcare services are provided

by public healthcare centres (62 health ■ Reorganizing the management opera-

centres across Slovenia10).

tion and supervision of public health in-

stitutions and increasing the liability of

the directors and councils thereof11.

INSTITUTIONS IN CHARGE Health Insurance Institute of Slove-

FOR REGULATING HEALTH nia: Implementation of compulsory health

CARE IN SLOVENIA

insurance is a public service performed by

the Health Insurance Institute of Slovenia

Ministry of Health: Ministry of Health is as a public institute. The headquarters of

the highest body in the field of health care the Institute are in Ljubljana. The Institute

in Slovenia. Its areas and priorities are:

is organized in such a way that the servic-

es are available to insured persons in the

■ Strengthening public healthcare, taking proximity of their place of residence or

into account its financial sustainability, permanent address. The Institute sets up

with an emphasis on maintaining the organizational units for specific sectors and

right to compulsory health insurance areas (Article 69 of Health Care and Health

that is as comprehensive as possible, Insurance Act).

10 For more information see Public network of Pri-

mary healthcare services, September 2013, Min-

11 See

http://www.mz.gov.si/si/delovna_podroc-

istry of Health, page 8.

ja_in_prioritete/.

64

Health insurance companies: There by the insured persons, employers and oth-

are four health insurance companies in er persons as defined by the Health Care

charge for providing supplementary health and Health Insurance Act. With regards to

insurance. Their functioning is defined by the status of the insured person (retirees,

the Insurance Act (17. 1. 2016). Insur-

unemployed etc.) also other institutions are

ance companies may only provide supple-

bound to pay the contributions (Pension

mentary health insurance to persons with and Disability Insurance Institute of Slove-

compulsory health insurance or other sup-

nia, Health Insurance Institute of Slovenia,

plementary health insurance (for instance, the state budget, Employment Service of

above-standard medical services). Supple-

Slovenia, municipalities).

mentary health insurance cannot replace

compulsory health insurance.

Medical services are funded by the compul-

sory and supplementary health insurance.

National Institute of Public Health: A person insured only with the compulsory

National Institute of Public Health (NIPH) is insurance is obliged to pay the costs of dif-

a central national institution in charge of ference between the total costs of health

research, protection and increase of health services and the costs of services covered

of the population of the Republic of Slo-

by the compulsory health insurance. The

venia through raising awareness and other costs must be covered from own or other

preventive measures. Apart from its cen-

sources if a person meets the criteria for

tral role in the Slovenian public healthcare the costs to be paid by the third party.

system the NIPH also participates in inter-

national projects, covering various areas of In some cases costs of medical services

healthcare and general public healthcare are covered by the state budget of the Re-

issues. The NIPH also represents an expert public of Slovenia:

assistance for resolutions of the state on

the national and local level with direct or ■

emergency treatment of persons of

indirect influence on health12.

unknown residence, foreigners from

countries which have not concluded

an international agreement, as well as

FINANCING OF THE

foreigners and citizens of the Republic

of Slovenia with permanent residence

PUBLIC HEALTHCARE

abroad who temporarily reside in the

SYSTEM

Republic of Slovenia or are travelling

through the country and they were un-

Funding for compulsory health insurance

able to obtain payment for medical

are provided through contributions paid to

services, as well as other persons who,

the Health Insurance Institute of Slovenia

under the provisions of this Act, are not

included in compulsory health insurance

12 For more information see http://www.nijz.si/sl/

nijz/predstavitev/osebna-izkaznica.

and are not insured with a foreign health

65

insurance (Article 7 of the Health Care tients to a particular physician, medical and Health Insurance Act).

commission or invalidity committee; refers

the patient to a specialist examination16;

prescribes medication; provides services of

ACCESS TO HEALTHCARE

ambulance and other transportation (Arti-

cle 81 of the Health Care and Health In-

IN SLOVENIA

surance Act).

The insured person acquires access to medi-

The aforementioned does not apply for

cal services with the health insurance card13. cases of urgent medical assistance17.

The health insurance card is an official iden-

tity document of persons insured under the Every person with a compulsory health in-

compulsory health insurance scheme. The surance in the Republic of Slovenia is enti-

card is issued by the Health Insurance In-

tled to medical services to an extent and in

stitute of Slovenia. An insured person must the way as it is defined by the compulsory

submit the health insurance card when visit-

health insurance procedure.

ing a doctor, or when that person claims and

enforces his/her health-related rights.

According to the stipulations and proce-

dures of the current regulations insured

Every resident of the Republic of Slovenia persons have a right to healthcare servic-

should have health insurance and access es. These are a right to: primary healthcare

to medical services. Every insured person services, dental medical services, services

chooses his/her personal physician14. Ac-

in specialized social institutions, special-

cess to medical service is possible only ist medical treatment, hospital medical

through personal physician and by having a treatment and tertiary medical treatment,

health insurance card. A personal physician health resort services, restorative care and

is also in charge for referring the patients rehabilitation, transportation with am-

to a specialist examination or to a hospital bulance and other vehicles, prescription

treatment. The same applies to gynecolo-

medication, medical accessories, health-

gist and dentist15.

care services while traveling and residing

abroad. With particular groups of people

Personal physician: decides on the tem-

(children, school-age youth and students)

porary incapacity for work; refers the pa-

or insured persons with specific medical

conditions specific medical services are en-

13 For more information see http://www.zzzs.si/

tirely covered by compulsory health insur-

zzzs/internet/zzzs.nsf/o/667843302118EB9C-

C1256E8B003135E0.

ance (as defined by Article 23 of the Health

14 See Zakon o zdravstvenemvarstvu in zdravstven-

emzavarovanju, 1. 9. 2015, Articles 80-85, and 16 For more information see http://www.zzzs.si/

Pravilaobveznegazdravstvenegazavarovanja, 17.

zzzs/internet/zzzseng.nsf/o/711DAD33F7FB-

11. 2014, Articles 161-180.

1CB8C1257BB000456695.

15 Article 80 of the Law on Health Care and Health 17 See Article 179 of Compulsory Health Insurance Insurance.

Rules.

66

Care and Health Insurance Act. The article 5. persons on the territory of the Re-

also defines which medical services cov-

public of Slovenia engaged in an

ered by the compulsory health insurance economic or professional activity as their

ought to be paid for entirely or partially in a sole or main occupation;

certain percentage, i. e. specific percentage

of the full price).

6. the members of a partnership,

members of limited liability com-

panies and founders of institutions if they

INSURED PERSONS

are shareholders of the companies or insti-

tutions founders managerial persons per-

forming managerial function as the sole or

Insured persons are the insurance holders main occupation;

and their families.

7. farmers, members of their holdings

Insured under this Act (as defined by Article

and other persons in the Republic of

15 of the Health Care and Health Insurance Slovenia who perform agricultural activity

Act) are:

as their sole or main occupation;

1. persons who are employed in the 8. top sportsperson and chess players

Republic of Slovenia;

- members of sports and chess or-

ganizations in the Republic of Slovenia who

2. persons employed by an employer are not insured somewhere else;

based in the Republic of Slovenia,

and sent to work or for professional training 9. unemployed persons receiving the

abroad, if they are not subject to compul-

employment compensation;

sory insurance in the country in which they

were sent;

10. persons with permanent resi-

dence in Slovenia who receive

3. persons employed by foreign and pension according to the regulations of

international organizations and in-

the Republic of Slovenia or receive alimony

stitutions, foreign consular and diplomatic according to the regulations of the Liveli-

representative offices based in the Repub-

hood Protection of Farmers;

lic of Slovenia, unless otherwise specified

by an international treaty;

11. persons with permanent residence

in Slovenia who receive pensions

4. persons domiciled in the Republic from foreign pension insurance carrier, un-

of Slovenia, and employed by a for-

less otherwise specified by the internation-

eign employer, who are not insured with a al agreement;

foreign health insurance;

67

12. persons domiciled in the Republic 18. persons domiciled in the Republic

of Slovenia insured with a foreign

of Slovenia who are recipients of

health insurance during their stay in the financial assistance under the regulations

Republic of Slovenia cannot use the rights on the protection of participants in the war,

in this respect;

if they are not insured somewhere else;

13. family members of a person in- 19. military servicemen residing in the

sured with a foreign health insur-

Republic of Slovenia in the civil

ance with permanent residence in Slovenia service and military service allowances;

who are not insured as family members

with foreign health insurance;

■ conscripts residing in the Republic of

Slovenia during his military service or

14. foreigners who are educated or during training for reserve composition

refined in the Republic of Slovenia

of the police;

and are not insured somewhere else;

15.

20. persons domiciled in the Republic

persons domiciled in the Republic

of Slovenia, if they do not quali-

of Slovenia who are recipients of fy for insurance under one of the points of

disability benefits under the regulations this paragraph and decide on their own pay

on military invalids and civilian war inva-

contribution;

lids, the rights under the regulations on the

protection of war veterans, victims of war 21. citizens of the Republic of Slove-

and other was participants and users of the

nia and foreigners with perma-

republic of financial assistance, if they are nent residence permits who are under the

not insured somewhere else;

law, which regulates the exercise of rights

from public funds, granted the right to pay-

16. persons with permanent residence ment of contributions for compulsory insur-

in Slovenia who receive compen-

ance;

sation under the law on social protection

for mentally and physically handicapped 22. detainees who are not insured

adults, if they are not insured in any other;

somewhere else until the mo-

ment of occurrence of detention, or whose

17. persons domiciled in the Republic insurance is terminated at the time of de-

of Slovenia receiving permanent tention, convicts serving prison sentences

social assistance in cash and the persons in juvenile prison, juveniles serving the ed-

to whom the Republic of Slovenia granted ucational measure of placement in a cor-

refugee status or subsidiary protection in rectional facility, the person to whom it is

accordance with the rules on international a security measure of compulsory psychi-

protection if they are not insured some-

atric treatment and custody in a medical

where else;

institution and compulsory treatment of

68

addiction to alcohol and drugs. Detainees SUPPLEMENTARY HEALTH

in the insurance application Institute pris-

INSURANCE

ons in which detainees serving detention,

the other persons referred to in this section,

institution or organization in which they are Supplementary health insurance covers the

present, no later than the next working day difference between the total costs of health

after receiving such persons;

services and the costs of services covered

by the compulsory health insurance. In

23. persons who acquired the right case, when an insured person takes out

under the law governing parental supplementary insurance, the difference

protection, namely:

between the total costs of health services

and the costs of services covered by the

■ beneficiaries of parental benefits to compulsory health insurance is covered by

which employment was terminated for the health insurance company, with which

the duration of parental leave,

the insured person took out the insurance

policy.

■ one of the parents, who by virtue of

their activities paid social security con-

Supplementary health insurance covers the

tributions for at least 20 hours a week expenses of healthcare and all the con-

and cares for a child under three years cerned services, provision of medication

of age,

and medical instruments.

■ one parent who leaves the labor market Compulsory and supplementary health

in order to care for four or more children;

insurance are a part of social security of

insured persons.

24. children under 18 years of age

who are studying and are not in-

sured as family members, because their

parents do not care for them or because

their parents do not qualify for inclusion in

the compulsory insurance;

25. family assistants under the law

governing social security.

69

APPENDIX 2

70

MEDICAL TREATMENT

OF ASYLUM SEEKERS

Jaka Matičič, Helena Liberšar

Within the framework of the project, we have conducted

a research on medical treatment of asylum seekers and on

knowledge of their rights in the field of health care by health-

care professionals. With this research, we have tried to gain

a deeper insight into the process of admittance and medical

treatment of asylum seekers in the Republic of Slovenia, and

tried to establish how well the medical staff in public health

centres is informed on the matter, whereby we focused on

medical doctors and nurses/medical technicians, who are

directly involved in the treatment of those patients.

ANALYSIS RESULTS

We have addressed our survey to the management and the personnel in 56 different

health centres as well as some general hospitals across Slovenia. Total reach of the sur-

vey counted 449 persons (i. e. 449 persons clicked on the link to the survey and skimmed

the questions without answering them), 187 persons answered the survey questions (i. e.

respondents). The survey has been conducted during 5th and 31th of August 2016.

71

REGIONAL PLACEMENT OF RESPONDENTS AND THEIR

EXPERIENCE WITH TREATMENT OF ASYLUM SEEKERS

We wished to include in our survey all the regions and their major cities in Slovenia, with

the intention to examine the knowledge of healthcare professionals on the subject of

treatment of asylum seekers, in case one of those regions could become a hosting region

for a new unit of asylum home, should migrations continue in the future, as it was the case

with Logatec. The basis for our survey was the notion of necessity for a health centre in

charge to be appropriately informed on rights of asylum seekers, admittance procedures

and procedures of medical treatment for a purpose of efficient and undisturbed work

in treating asylum seekers. The majority of respondents comes from Ljubljana (44%),

followed by Celje (15%) and Maribor (12%). The smallest percentage of the respondents

come from Nova Gorica (1%), Kranj (3%) and Murska Sobota (5%).

Koper

Maribor

Murska Sobota

Celje

Ljubljana

Novo mesto

Nova Gorica

Kranj

0 %

5 %

10 %

15 %

20 %

25 %

30 %

35 %

40 %

45 %

50 %

Image 1: Regional placement of respondents (n=185)

The reason for a large percentage of respondents from those regions may well be the

fact those are larger regions with the largest number of health centres and with some of

the largest hospitals in the country. Reasons for such structure are that the addressees

did not respond to the survey, since they have not had any contact with the asylum seek-

ers thus far, namely, because asylum seekers and refugees, who already acquired their

international protection, are primarily accommodated in broader areas around Ljubljana

and Maribor.

72

Of all the respondents, who stated what their function in a public health centre was, almost half of them (44%) are medical doctors (M.D. or D.M.D.), followed by medical

technicians (28%), nurse practitioners and physician’s assistants (14%) and other medi-

cal professionals such as therapeutists, dental assistants, radiology engineers and other

(15%). The majority of respondents (69%) acquired a higher education (graduate level),

a fifth of the respondents acquired secondary education and the rest a tertiary education

(post-graduate level).

Medical doctor or Doctor of Dental Medicine

Medical Technician

Other

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Image 2: Function in a public health institution (n=110)

FREQUENCY OF TREATMENT

We were interested in knowing, how often and where the respondents treated asylum

seekers. Two thirds of the respondents have never been included in the treatment of asy-

lum seekers. A little less than a fifth of the respondents (18%) treated the asylum seekers

at least once in the past six months. The rest of the respondents (14%) have treated

asylum seekers at least once a month. The reason for such low percentage of treatments

may be attributed to the fact that asylum seekers are accommodated in units of Asylum

home in Vič, Kotnikova and Logatec.

73

several times a week

app. once a weak

app. once a month

at least once in past six months

never

0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

Image 3: Frequency of treatment up to the present day (n=184)

INFORMATION FLOW AND ACTUAL METHODS FOR

TREATMENT OF ASYLUM SEEKERS

In health centres, locally in charge for medical treatment of asylum seekers, one issue is

a lack of adequate information that would enable an appropriate treatment of asylum

seekers when needed and without additional complications. There were cases when due

to inadequate information at their disposal and unadapted tools, necessary for adminis-

trative treatment of asylum seekers (for instance, asylum seekers do not have a health

insurance card and they use their asylum seeker card instead), the personnel did not have

the knowledge or the means to appropriately treat asylum seekers. Consequently, their

work as well as asylum seekers’ access to medical treatment were impeded and the asy-

lum seekers would not have been able to seek medical assistance without the help of so-

cial workers or volunteers. In the survey, we posed a question on whether the respondents

were given any information or instructions with regards to treatment of asylum seekers

by the departmental ministry or the institutions in charge. Slightly less than half of the

respondents (45%), who answered the question, knows for a fact that the departmental

ministry did not provide any information or guidelines on the subject, while a fifth of the

respondents (25%) does not know, whether such instructions were given.

74

I DON’T

KNOW

25 %

NO

45 %

YES

31 %

Image 4: Have you been informed by the departmental ministry or the institutions in

charge on the methods for treatment of asylum seekers? (n=183)

To those, who received information on methods of treatment of asylum seekers (30%)

by the departmental ministry and the institutions in charge, we posed a supplementary

question regarding the content of instructions. Different answers were possible. The ma-

jority (84% of those who replied YES) stated, they received instructions for administrative

treatment and 53% of those, who answered YES, stated, they received a protocol for tak-

ing measures in case of outbreak of infectious diseases and conditions, 39% respondents,

who answered YES, stated, they received information on rights of asylum seekers and

27% of respondents, who answered YES, stated they received information on referential

personnel and clinics for treatment of asylum seekers.

Adresses of referntial physicians and clinics

for treatment of asylum seekers

Rights and limitations in health care

of asylum seekers for international protection

Protocol for taking mesures in case of outbreaks

of infectious diseases and conditions

Instructions for administrative

treatment of asylum seekers

0 %

20 %

40 %

60 %

80 %

100 %

Image 5: What information did the respondents receive from the departmental ministry

and the institutions in charge? (n=51)

It is an interesting fact, that the respondents from Ljubljana region, where the majority

of asylum seekers are accommodated, stated they did not receive information on asylum

seekers’ rights. The conclusion is, that the medical personnel, employed at public health

75

centres, included in the treatment of asylum seekers and regularly working with them,

must also face challenges regarding lack of information needed for their work. Practice

showed that lack of information leads to stress and discontent of healthcare profession-

als as well as asylum seekers. It has also been noticed that administrative as well as

medical treatment of asylum seekers was more efficient, if healthcare professionals were

appropriately informed on how to admit, treat and refer asylum seekers to further exami-

nations. Therefore, our further activities included focusing on providing the asylum seekers

as well as the medical personnel the needed information on asylum seekers’ rights.

I DON’T

KNOW

25 %

NO

37 %

YES

38 %

Image 6: Information given to the medical personnel by the departmental ministry and

institutions in charge in LJ region (n=82).

We wished to establish how well the institutions are acquainted with and are ready for

treatment of specific health conditions, that could appear within the population of asy-

lum seekers. Considering the fact that certain illnesses have been rooted out or do not

appear in Slovenia at all, health condition of patients from parts of the world, where such

illnesses still appear, could drastically deteriorate if health institutions would not receive

proper instructions or guidelines for an efficient medical treatment and procedures for

treatment of such diseases. One of the questions in the survey was, whether the medical

personnel is informed on existence of protocols/guidelines, used within their institute for

treating diseases and medical conditions, which asylum seekers might have contracted in

the country of their origin (listed in the image below).

76

Typhus

Tetanus

Rabies

Hepatitis B

Malaria

Yellow fever

Hepatitis A

Child paralysis

Meningococcal

meningitis

Japanese

Encephalitis

Tuberculosis

HIV

Other

0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

We have...

We dont’t have...

I dont’t know

Image 7: For treatment of which infectious diseases did your institute provide a protocol/

guidelines? (n=102)

For most diseases, the medical personnel was acquainted with instructions/guidelines for

treatment of individual diseases, with the exception of typhus, malaria, yellow fever, child

paralysis and Japanese encephalitis (the respondents stated they have not received any

instructions or that they do not know, whether such instructions are available). In case

when patients with any of those diseases were admitted into their institution, the treat-

ment process would be compromised, since treatment procedures would have to be addi-

tionally verified and in case of inappropriate treatment or prolonged waiting the patients’

health condition might deteriorate. Past practice showed that at the outbreaks of certain

illnesses, health institutions acquire appropriate treatment procedures only when they

treated a sufficient number of such cases, which allowed them to develop the suitable

treatment procedures. Our estimation is based on the fact that when we gathered infor-

mation prior to conducting our survey, we have not managed to acquire those instructions

and preventive measures from the National Institute of Public Health. It was interesting

to find that in most cases the respondents, who answered I DON’T KNOW, stated they do

not know whether there are any instructions/protocols available for treatment of certain

other illnesses, such as Ebola, Zika virus or measles.

77

EVALUATION OF THE SITUATION OF ASYLUM SEEKERS

AND RELATIONSHIP OF MEDICAL PERSONNEL

TOWARDS TREATMENT OF ASYLUM SEEKERS

Due to numerous system impediments, which are hindering appropriate medical treat-

ment of asylum seekers in various ways, we wished to establish whether the difficulties

with treatment of asylum seekers develop as a consequence of administrative obstacles,

interministerial inconsistencies and improper legislation realization, or by inappropriate

understanding of the current situation with regards to rights of asylum seekers in the

process of ensuring medical treatment within the public healthcare system.

We also wished to determine what is the relationship of the respondents towards asylum

seekers, respectively, whether they are favorably inclined towards treating asylum seek-

ers or not. The majority of the respondents remained undecided. 21% of the respondents

replied, they have no issues with treating asylum seekers, while 20% of the respondents

replied they do. It can be concluded that in general, healthcare personnel is favorably

inclined towards the asylum seekers, nevertheless the percentage of those uninclined is

rather high as well.

45 %

40 %

35 %

30 %

25 %

20 %

15 %

10 %

5 %

0 %

1 - NOT TRUE

2

3

4

5 - TRUE

RS

LJ

Image 8: I do not mind treating asylum seekers (n=177 - on a national level, n=80 - in

Ljubljana region)

In continuation, we also focused on the analysis, in which we examined this statement

from the aspect of the location, in which the majority of asylum seekers is accommo-

78

dated at the moment (i. e. Ljubljana). Propensity towards treatment of asylum seekers is slightly higher in Ljubljana than on a national level - 26% of respondents who are inclined

towards treatment of asylum seekers come from Ljubljana. 11% of respondents from

Ljubljana are partially inclined towards treatment of asylum seekers and 40% of respond-

ents are undecided on the matter. 18% of respondents from Ljubljana are not inclined

towards treatment of asylum seekers and 5% of the respondents are partially uninclined.

It is evident that the region with the highest level of exposure to treatment of asylum

seekers is more welcoming towards them. The possible reason for such state of affairs

may reside in the frequency of treatments and in a better interpersonal dialogue between

asylum seekers and medical personnel. It is necessary to understand that a constructive

intercultural dialogue will enable citizens of the Republic of Slovenia to understand asy-

lum seekers’ problems better and help the asylum seekers to accept and to live by the

social norms of our country and, in broader sense, the EU. This way, the integration of

asylum seekers into the society will be easier and their treatment in all levels of society,

including health care, will be better.

We also analyzed the age aspect. Results showed older respondents are less inclined

to the treatment (25%), while in younger generation the percentage of those uninclined

is lower (12%). In general, younger respondents are in favor of treating asylum seekers.

35 %

30 %

25 %

20 %

15 %

10 %

5 %

0 %

1 - NOT TRUE

2

3

4

5 - TRUE

younger (21-40)

older (40 +)

Image 9: Treatment of asylum seekers with regards to age structure (n- younger= 48,

n- older=59).

79

Considering their function within the institution, there is a distinct difference between medical doctors and doctors of dental medicine, and medical technicians and nurses -

according to survey results, we may conclude that nurses and medical technicians are

more inclined to treatment of asylum seekers than medical doctors and doctors of dental

medicine. We can only speculate on the reasons for such state of mind. Perhaps one of

the reasons is that medical doctors and doctors of dental medicine are the ones respon-

sible for the treatment and are well aware of the possibility of additional problems such

treatments may bring.

We would need to acquire additional information for a more detailed analysis. It would

be interesting to establish those reasons in the future, but a more accurate method of

research would need to be used, e. g. interviews.

45 %

40 %

35 %

30 %

25 %

20 %

15 %

10 %

5 %

0 %

1 - NOT TRUE

2

3

4

5 - TRUE

doctors (M.D:, D.M.D.)

Medical technicians/nurses

other

Image 10: Treatment of asylum seekers with regards to the function in the institution

(n-doctors (M.D., D.M.D.), r=46, n- medical technicians/nurses=47, n- other=10).

We wished to examine, whether the medical personnel in general hospitals and health

centres is informed on the current refugee situation. Results showed that respondents

were well informed on the actual state of affairs.

80

0 %

20 %

40 %

60 %

80 %

100 %

101-300

50-100

301-1000

več kot 2000

1001-2000

Image 11: Estimation of number of asylum seekers in Slovenia (n=103).

We were also interested in the opinion of the respondents on what illnesses do they

expect to encounter when treating asylum seekers. They stated: acute diseases and con-

ditions, infections, malnutrition and various forms of deteriorated mental state, but in fact

the biggest issue is a limitation of a continuous access to medical treatment for patients

with chronic diseases, since without regular treatment, their condition is not improving or

is even deteriorating on a daily basis.

Furthermore, we also posed a question, regarding how well the respondents know the

rights and the extend of rights of particular groups of asylum seekers. According to the

legislative of Republic of Slovenia in connection to treatment of asylum seekers, they are

entitled to urgent medical treatment, while children, pregnant women and breastfeeding

women have the same rights to medical treatment as Slovenian citizens. Nevertheless,

practice showed that healthcare professionals often need an additional explanation on

that matter or need to be made aware of that fact. Survey results showed that a very high

percentage of the respondents, who answered that question (80%), are well informed on

the rights of asylum seekers. It is evident that experience from practice and survey results

show eventual improvement of understanding those rights. It may also be that the med-

ical personnel is familiar with those rights, but does not implement them into treatment

processes, possibly due to reasons of personal nature or due to unadjustment of the sys-

tem for treatment of asylum seekers with those rights. As already mentioned, in certain

cases we have witnessed complications in administrative treatment of patients that puts

both healthcare professional as well as the asylum seekers into an unpleasant situation.

81

Pregnant and

breastfeeding woman

Minors

Victims of violence

People with special needs

Elderly

0 %

20 %

40 %

60 %

80 %

100 %

Image 12: Opinion on equalization of rights of asylum seekers with rights of citizens of

Republic of Slovenia (n=103).

From a perspective of a complete treatment of asylum seekers, we were also interested

in how the medical personnel perceives the treatment of patients with international pro-

tection. As previously mentioned, asylum seekers are entitled only to treatment in case of

emergency, therefore, the treatment they receive is limited to urgent medical treatment.

In practice, this means that when they are referred to a further examination without an

urgent referral (except in case of self-funding of medical treatments, which is not possible

for most asylum seekers), asylum seekers find themselves in a situation, where they re-

ceive a reference letter for a specialist examination for treatment of their particular health

condition, but at the same time the reference letter is of no use to them, since they are

not entitled to a specialist examination unless they are in a state of emergency. This may

lead to additional aggravating circumstances, because asylum seekers are unable to pay

for the services. Such complications also affect the work of the medical personnel, who is

also put under additional pressure by the measures, imposed onto them by the system.

82

Diseases and condtitions

in pregnancy

Abdominal problems

Injuries

Chronic diseases

Respiratory diseases

Stroke

Childhood diseases

and conditions

Anxiety

Dental problems

0 %

20 %

40 %

60 %

80 %

100 %

Rehabilitation

Hospitalization

Refferals

Visit...

Urgent treatment

Image 13: Rights for different levels of treatment in case of certain health conditions

(n=105).

It is evident from the answers that medical personnel is well aware of the fact that by

the law, asylum seekers are entitled to urgent medical treatment. At the same time, a

percentage of respondents, who agree that asylum seekers should have a right to a spe-

cialist examination, is also quite high. Nevertheless, in the beginning such examinations

have proved difficult to be performed due to personnel shortage.

With the purpose of improving the existing system, which is unkind to the asylum seekers

as well as to medical personnel, we posed a question regarding evaluation of current con-

dition of treatment of asylum seekers, the relationship of the medical personnel towards

the existing treatment system and possibilities for a change in the future. The available

answers were listed in a table and the respondents evaluated them on a scale from 1

to 5, where 1 meant NOT TRUE and 5 meant TRUE. The answers and the respondents’

evaluations are listed in the table below:

83

Statement/Evaluation

1

2

3

4

5

n

I believe that public health system

8%

8%

33% 21% 30% 106

efficiently covers the medical needs

of asylum seekers.

Asylum seekers should have the

21% 21% 29% 16%

3% 105

right to a specialist examination in

non-urgent cases as well.

In case of increased medical needs

17% 15% 28% 15% 25% 103

of asylum seekers, I would be willing

to partake in treatment processes

more intensely (pro bono clinics,

voluntary work in my own clinic).

Treatment of asylum seekers

2%

3%

20% 28% 47% 100

demands more effort and imposes a

burden on health institutions.

System-wise, a better organization

2%

4%

20% 24% 50% 101

of treatment of asylum seekers is

necessary.

Table 1: Evaluation of statements referring to treatment of asylum seekers.

It is evident from the answers that in general, the respondents believe the system already

efficiently covers the medical needs of asylum seekers and that 42% of the respondents,

who answered the question, do not agree with the statement on the right to a specialist

treatment in non-urgent medical cases. The same applies for those respondents, who

remained undecided (29%). As we noticed during our work, the issue with rights for a spe-

cialist examination in non-urgent cases is a complex matter, since the health condition of

patients (the same also applies to patients with chronic illnesses) may deteriorate to the

point, when their condition requires an urgent medical treatment. When this happens, it is

difficult to treat people without having access to a record of their medical history, which

could be easily resolved by giving asylum seekers the right for a specialist examination

and the right to choose a personal physician. Precisely this kind of deterioration of their

health has a profoundly negative influence on the patients’ psychophysical state, which is

evident from the occurrence of conditions, that require an intensive psychosocial or even

psychotherapeutic interference. Waiting for the asylum seekers’ health condition to de-

velop into a state of emergency brings forth other issues in different areas and at the end

leads to development of serious problems, which could be avoided if the asylum seekers

had the right to a specialist examination in the first place.

On the question on voluntary work and offering free medical services, 40% of the re-

spondents replied they are willing to provide medical treatment free of charge. A high

84

percentage still remains undecided on the matter.

Voluntary work in form of pro bono activities already provides the majority of help, of-

fered to vulnerable groups (individuals without health insurance). Positive replies of the

respondents with regard to the question whether they are willing to work voluntarily are

an encouraging information for organization of medical treatment of asylum seekers,

nevertheless, final conclusions cannot be made yet, since distribution of answers is very

disproportionate and as such does not allow a more concrete inference.

A relatively high percentage of the respondents (75%), who answered the questions on

whether they perceive the public health institutions to be burdened by the current system

for treatment of asylum seekers and whether they perceive the system of treatment of

asylum seekers to be efficient, agree that health institutions are overloaded and that

medical treatment of asylum seekers should be organized more efficiently system-wise

(74%).

Based on results of the survey, we may conclude that on behalf of the medical personnel,

employed in public healthcare institutions, as well as on behalf of the asylum seekers, it

is necessary to reconsider how to reorganize the system of medical treatment of asylum

seekers in a way it would best serve the asylum seekers’ interests. It would be necessary

to ensure a system, in which asylum seekers could use medical services as independently

as possible and without additional complications. It is also crucial to ensure that the med-

ical personnel would not perceive those changes as an additional burden to their work and

that the change in the system would administratively enable them to appropriately treat

asylum seekers without encountering major difficulties, additionally burdening their work.

85

60 %

50 %

40 %

30 %

20 %

10 %

0 %

1 - NOT TRUE

2

3

4

5 - TRUE

I belive that public health system efficiently covers the medical needs

of asylum seekers.

Asylum seekers should have the right to a specialist examination in

non-urgent cases as well.

In case of increased medical needs of asylum seekers, I would be willing to

partake in treatment process more intensely (pro bono clinics, voluntary work

in my own clinic).

Treatment of asylum seekers demands more effort and imposes a burden on

health institutions.

System-wise, a better organization of treatment of asylum seekers is

necessary.

Image 14: Agreement/disagreement with the statement on treatment of asylum seekers

and distribution of answers.

86

87

MEDICAL TREATMENT

OF ASYLUM SEEKERS





Introduction


Franci Zlatar, M.A.

Authors

Helena Liberšar



Jaka Matičič



Urška Živkovič



Lea Bombač, M.D.



Špela Brecelj, M.D.



dr. Erika Zelko, F.M.M.D.



dr. Zuzanna G. Kraskova



asst. dr. Nena Kopčavar Guček, F.M.M.D.



Simona Repar Bornšek, M.D.



Neli Grosek, M.D.



prof. dr. Danica Rotar Pavlič, M.D.



Eva Vičič, M.D.



dr. Uršula Lipovec Čebron

Editor

Helena Liberšar

Publisher

Slovenska filantropija, Združenje za promocijo prostovoljstva,

Ljubljana, december 2016

Translation

Helena Cehner

Design

Tadej Trkman

This publication has been issued within the 8 NGO’s for Migrant/Refugees’ for health in

11 Countries project with subsidy from the European Union and the Directorate-General

for Health and Food Safety.

88

CIP - Kataložni zapis o publikaciji

Narodna in univerzitetna knjižnica, Ljubljana

614.2:341.43-051(082)(0.034.2)

MEDICAL treatment of asylum seekers [Elektronski vir]

/ [authors Helena Liberšar ... [et al.] ; editor Helena Liberšar ;

translation Helena Cehner]. - El. knjiga. - Ljubljana : Slovenska

filantropija, Združenje za promocijo prostovoljstva, 2017

ISBN 978-961-94217-0-3 (pdf)

1. Liberšar, Helena

289998848