Interim Federal Health Program: Administrative Burdens Compromise Refugee Health Care Access

By Sonal Marwah

This is the first in Sonal Marwah’s series on the Interim Federal Health (IFH) Program.

Canada has signed up to many international agreements and covenants, and some it routinely ignores. This is the case with the International Covenant on Economic, Social and Cultural Rights which recognizes that everyone has the right to the highest attainable standard of physical and mental health, and that states have a duty of non-discrimination in the realization of that right. Since the Federal government introduced changes to the Interim Federal Health (IFH) program on 30 June, 2012, there are different levels of health care coverage to different refugee categories, with several categories having minimal to no health insurance. Consequently, the IFH cuts have negatively affected the health outcomes for refugees and claimants, some more disproportionately than others, such as claimants’ belonging to the Designated Country of Origin (DCO) list. The DCO list includes countries by the Government of Canada considered to be “safe” which typically do not produce refugees, respect human rights and offer state protection.

An exploratory study was conducted with front-line staff, including health providers, refugee lawyers and health policy analysts to assess the immediate impact of the cuts. In addition, the study examined provider responses and recommendations to mitigate the negative health outcomes on refugees.

In addition to the negative health impacts on refugees and claimants, a key finding in the study is that a significant unintended and unaccounted for consequence of the IFH cuts are the new administrative burdens for health facilities and the confusion faced by providers in terms of navigating the revised IFH program. This confusion can lead to misdiagnosis and misuse of interventions, under-diagnosis, and the under-utilization of treatment and services. Evidence documented by the Refugee Health Outcome Monitoring and Evaluation System tells us there were two young children with multiple hospitalizations for asthma who could not get access to their inhalers, leaving them at risk for increased need for emergency department visits. In another case, a woman was unable to get prenatal screening because she was waiting for the initiation of IFH program coverage. The baby would be a Canadian citizen.

IFH administrative hurdles and public health contradictions

“The new IFH is a painful bureaucratic maze to work through! No one is still clear on what exactly our patients are covered for or not! And this is not the reason why I became a doctor.” 

The IFH administrative maze can be attributed to the use of ambiguous terminology in the IFH regulations and the new refugee categories. Refugee claimants (consisting of DCO and rejected refugee claimants, which combined constitute a larger share of the refugee applicants as compared to the number of Government-Assisted and Privately sponsored refugees) receive public safety health care coverage, where health assistance is provided only if the health condition is deemed to be a public health risk. Yet there is no clear definition on how to determine the public danger, or the degree of risk which warrants treatment, or who is qualified to make the decision.

Providers have stated that the IFH program’s definition of public health is far too narrow and inconsistent with their professional work and medical training, as public health encompasses preventive primary care, and not only treatment for diseases like tuberculosis, for example. In addition, providers fear that health facilities receiving uninsured patients may be forced to take a conservative approach in deciding what constitutes a life-threatening medical problem. This dilemma arises from concern about whether the health facility will be reimbursed by the government.

There are also ironic inconsistencies within the revised IFH regulations. In order for providers to properly assess the presence of health problems and risks, they require blood work, ultrasounds, and referrals, yet these services are not included in the public safety coverage basket. For example, a young girl from a country with widespread malaria had a high fever but could not be referred to the tests needed to rule out malaria as she awaited her IFH program coverage to be initiated.

The Hamilton Centre for Newcomer Health describes this as a catch-22 situation, as refugees might be afflicted with a disease like HIV, but cannot visit a medical centre to get tested due to costs that they may not be able to personally cover. In other cases, some refugees qualify for the Ontario Drug Benefit Program but providers are unable to order the lab work and x-rays required to evaluate their patients properly and prescribe drugs.

In response, a minority of providers offer their services for free at certain clinics and strive to provide the best care possible within existing IFH policy constraints. In addition, health facilities are working collaboratively to assemble creative solutions to make efficient use of limited resources for the increasing number of non-status uninsured persons. So far, only Quebec and Manitoba have committed to covering medication and most medical services for all refugee and claimants without distinction to help fill in the health care gaps.

 

* The next in this blog series will be on the compromised care being received by refugees, economic costs of denying care, and dilemmas facing health providers.  

Sonal Marwah is a MSc candidate in Global Health at McMaster University, carrying out research in refugee health care access and health equity in the student practicum program at the Wellesley Institute. Alongside, she is Project Coordinator at the Small Arms Survey, Geneva working on armed violence issues. She has an MA in International Affairs from the Graduate Institute, Geneva.