Design, setting and participants: Qualitative study using semi-structured interviews between September and November 2010. Participants were community-based asylum seekers who attended the Asylum Seekers Centre of New South Wales, and health care practitioners and staff from the Asylum Seekers Centre and the NSW Refugee Health Service.
Results: We interviewed 12 asylum seekers, three nurses, one general practitioner and one manager. Asylum seekers’ responses revealed that their access to primary health care was limited by a range of barriers including Medicare ineligibility, health care costs and the effects of social, financial and psychological stress. Limited access contributed to physical suffering and stress in affected asylum seekers. Participants providing care noted some improvement in access after recent government policy changes. However, they noted inadequate access to general practitioners, and dental, mental health and maternity care, and had difficulty negotiating pro-bono services. Both groups commented on the low availability of interpreters.
Conclusions: Access to primary health care in Australia for community-based asylum seekers remains limited, and this has a negative effect on their physical and mental health. Further action is needed to improve the affordability of health care and to increase the provision of support services to community-based asylum seekers; extending Medicare eligibility would be one way of achieving this.
In Australia in the financial year 2009–10, 4534 permanent visas were granted to asylum seekers who had applied onshore for protection, and 8150 protection visa applications were lodged.1,2 The majority of these applicants, having arrived on a valid visa, live in the community while waiting for their claims to be processed.1
Asylum seekers in the Australian community present with a range of health problems including chronic diseases, musculoskeletal conditions, infectious diseases, and psychological illness.3,4 They have reported psychological symptoms, including anxiety, depression, and post-traumatic stress, at a frequency similar to refugees accepted offshore but significantly higher than other immigrants.5 Difficulties for asylum seekers in accessing health care in Australia have been documented.5-9
Work rights and Medicare cover are not afforded to many asylum seekers,10,11 although this number is likely to have decreased after the decision by the Australian Government in 2009 to abolish the “45 day rule”, which restricted the rights of people who had not lodged a protection visa application soon after arrival.10 The health needs of asylum seekers who are ineligible for Medicare cover are met through a mixture of state and federal government policies and programs. The Asylum Seeker Assistance Scheme (ASAS), administered by the Australian Red Cross on contract from the federal government, provides income support and assistance with some health care costs for eligible asylum seekers.1 In 2009–10, this scheme assisted 2802 people.1 However, many do not meet the eligibility criteria (Box 1), and assistance may not be available at certain stages of the asylum application process. Some states have also instituted measures to improve asylum seekers’ access to public health services (Box 2). In New South Wales, this includes fee waivers for emergency care, ambulatory and outpatient care, maternity and antenatal care, and mental health services.14 The remaining burden of providing health care to asylum seekers who are ineligible for Medicare cover falls to charitable and pro-bono services.
We aimed to elicit the views of community-based asylum seekers (referred to throughout as “asylum seekers”), and health care practitioners and staff who provide health care services for them (“stakeholders”), regarding health care access and any impact that barriers may have on asylum seekers’ wellbeing.
We conducted semi-structured interviews with 12 asylum seekers and five stakeholders between September and November 2010. Questions were derived from previous research3,4,8 and through consultation with representatives from organisations working with asylum seekers.
Asylum seekers were recruited from the Asylum Seekers Centre of New South Wales, a charitable service in Sydney that provides services for asylum seekers including casework assistance, social support, and a health care program. Purposive sampling was employed to ensure a range of experiences, participant characteristics and backgrounds. Witnessed oral consent was sought before the interview by a nurse, independent of the investigators. Oral rather than written consent was sought from the asylum seekers, owing to our concerns about asylum seekers’ mistrust of written documents and about written language proficiency. All participants who were not fluent in English (as judged by centre staff and one of us [E S]) were offered the use of an interpreter. Notes were taken during the interviews and later transcribed.
Stakeholders were recruited from the Asylum Seekers Centre and the NSW Refugee Health Service, a state government-funded service, also located in Sydney. Interviews were recorded to tape and transcribed verbatim.
Data were analysed using a combined inductive and deductive approach. A list of initial themes was generated and data were coded by theme. A smaller list of cross-cutting themes was then generated. The data were recoded and charted, and cross-cutting themes were interpreted.
Of the 12 asylum seekers interviewed, four were women (three aged < 40 years, one aged 40–59 years) and eight were men (two aged < 40 years, six aged 40–59 years). Except for one former asylum seeker who had been granted a protection visa in the previous 6 months, all were current asylum seekers. Four came from South Asia, three from sub-Saharan Africa, two from South-East Asia, one from the Middle East, one from East Asia, and one from the Pacific islands. The mean length of time they had spent seeking asylum was 3.4 years. Four were currently eligible for Medicare cover, two of whom had previously been ineligible. The stakeholders comprised three registered nurses, one general practitioner, and one service manager.
A number of asylum seekers reported being unable to see a private doctor at times because they could not afford the consultation fee. Negative experiences of being billed for services made some asylum seekers reluctant to return for health care. Asylum seekers who gained access to doctors through charitable services reported that their options were limited, and many had to wait weeks to see a GP. This resulted in physical suffering, stress and anxiety and, in some cases, serious health risks and deterioration in health status.
I just find it very hard when I’m sick, I can’t afford to pay for a doctor. When I was pregnant I didn’t have letters to see a GP so it was very, very hard. It was my first child, I was in pain always, I was pregnant for 6 months before I saw a GP. [asylum seeker A4]
You want to know what’s wrong, otherwise you start imagining stuff, you want someone to tell you this is wrong. Sometimes I would have these headaches that were so severe, but Panadol didn’t work so you just lie there and listen to your body in pain. [asylum seeker A5]
Asylum seekers reported difficulties with paying for prescription and over-the-counter medications, and items such as spectacles and blood-glucose test strips. One asylum seeker with a history of serious heart disease who was ineligible for Medicare cover reported stopping his blood pressure medications because they were unaffordable. Asylum seekers covered by the ASAS reported delays in organising GP and specialist appointments and in payment of medical bills.
Stakeholders reported that negotiating pro-bono care for their clients, including medications, investigations, and access to specialists, was time consuming and difficult. Dental, mental health and maternity care were identified as areas of concern, even after the NSW fee-waiver policy was introduced.
Post-migration stressors reported by asylum seekers included financial hardship, the immigration process, accommodation insecurity, an inability to work, social isolation, separation from family, illness, and poor access to health care. Many reported feelings of anxiety and/or depression. Negative emotions appeared to be strongest in those who had been waiting longer for their claim to be resolved.
Too much thinking, about how to pay rent, how to buy food, what about visa situation, and illness. So many problems. [asylum seeker A9]
Stakeholders believed that post-migration stress and psychological illness places asylum seekers in a vulnerable social position, increasing their reluctance to access health care and decreasing their assertiveness in dealing with health care services. Unlike refugees accepted off shore, asylum seekers do not have access to government casework assistance, and may be unaware of relevant services. Many asylum seekers felt their access to health care was limited by a lack of information, particularly when they were newly arrived.
Stakeholders noted that access to hospital-based and maternity care had improved since the NSW policy directive14 was given in 2009. However, its implementation was impaired by a lack of awareness among hospital administration staff.
Although there were large gaps in access to GPs, asylum seekers were generally positive about their experiences with them. Some complained that the private GPs they saw did not give them sufficient time or use interpreters.
Most of the times [the doctor] couldn’t find what I said to him and most of the time I didn’t understand what he said to me. He take me for a few minutes and another patient he take. [asylum seeker, A6]
Ineligibility for health care cards prevented asylum seekers from accessing non-emergency dental care. Stakeholders also expressed concern that GPs are not authorised to have free access to the Commonwealth-funded Translating and Interpreting Service for consultations with Medicare-ineligible patients.
The reported experiences of community-based asylum seekers needing health care in NSW, and the experiences of those working for organisations that aim to make care available, suggest that access to health care among community-based asylum seekers in NSW remains problematic.
Our study was limited by its small sample size and recruitment of asylum seekers from a single support centre in NSW. The findings are not necessarily representative of asylum seekers in other states or those who do not access support services. Most interviews were conducted in English, which may have limited the expression of some participants.
Overall, state government policies have improved asylum seekers’ access to hospital-based care, however, gaps remain in primary care access, mainly due to Medicare ineligibility. Lack of access to GPs reduces access to specialist and other services that are provided through the state health care system and that generally require a referral from a GP. The impact of inadequate access reported in our study includes physical suffering, considerable anxiety, and a risk of deterioration in health status.
Limitations of the ASAS include eligibility barriers, delays in organising GP and specialist appointments, and delayed payment of medical bills. As shown by an earlier Australian study,6 dental health needs of asylum seekers are poorly met. The high mental health needs that exist among community-based asylum seekers may also be undermanaged.
Asylum seekers reported experiencing a range of post-migration stressors that may impede their access to health care, in line with previous Australian research.5,7 Moreover, inadequate access to health care emerged as a stressor in itself, consistent with research identifying it as a stressor and a significant predictor of depression and anxiety among asylum seekers.22
Access to primary care would be improved by extending Medicare eligibility to all asylum seekers. This is unlikely to add significantly to the cost of the health care system, and would bring Australia’s policy into line with that of similar countries.23,24
Access to primary health care in Australia remains limited for some community-based asylum seekers, contributing to physical and psychological suffering. Principles of disease prevention and the right of every person to health care should drive measures to improve the availability and affordability of general practice care and health support services for these asylum seekers.
1 Australian Government Asylum Seeker Assistance Scheme (ASAS) eligibility criteria12
have lodged a valid protection visa application more than 6 months ago unless exempt
not be in detention
hold a bridging or other visa
not be eligible for either Commonwealth or overseas government income support
not be a partner or sponsored fiancé of a permanent resident
unaccompanied minors, elderly persons or families with children under 18 years
persons unable to work as a result of a disability, illness, care responsibilities or the effects of torture and/or trauma
persons experiencing financial hardship resulting from a change in circumstances beyond their control since their last arrival in Australia
2 Australian state health policies related to Medicare-ineligible community-based asylum seekers
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