Resource of health system actions on socially determined health inequalities

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Category / Field Definition / Source
1. Country Germany
2. National / subnational / local or mixture Subnational
3. European Union status Member
4. Title of example With Migrants for Migrants - Intercultural Health in Germany (MiMi)
5. Summary

In Germany 18.6% of the population are immigrants. Stress resulting from the social and psychological challenges of integrating into a new culture, together with low socioeconomic status and financial deprivation, can have a negative impact on health. Lack of knowledge about the health care system and cultural and language barriers can also influence the use of health care services. The programme With Migrants for Migrants – Intercultural Health in Germany (MiMi) aims to level unequal long-term health opportunities by making the health system more accessible to immigrants, increasing their health literacy and empowering them through a participatory process, thus promoting their individual responsibility for health and awareness of health issues.

This is being achieved through culturally sensitive interventions in health promotion and prevention, together with the provision (in migrants’ native languages) of information about healthy living, how to deal with the German health system and how to make use of its offers. Some migrants are being trained to become intercultural mediators expert in health issues relevant to them so that they can teach migrant communities about relevant health topics and the German health system. Additionally, health professionals are being trained to improve their awareness and knowledge of migrant communities and migrants’ health issues. Training programmes are carried out in 48 cities in 10 states (Länder) with more than 60 partners, especially municipal health services (15).

6. Why is this example potentially of interest to policy-makers?

The MiMi programme is an example of how a culture-sensitive intervention can be used to enhance the access of a specific population group to existing mainstream health services without the need for a new and/or targeted service.

This is done through two key strategies:

  1. improving migrants’ health literacy and knowledge so as to improve their access to health services; and
  2. building the capacity of health service providers to be responsive to the particular needs of different migrant communities.

The MiMi programme methodology has been evaluated, including the opinions of beneficiaries about the quality and content of the training/information activities and an evaluation of mediator training. A cost–benefit analysis of the entire project will be carried out at its conclusion and will also be an important tool for decision-making in similar interventions. The programme started as a pilot initiative in 4 cities and is today delivered in 48 cities with continuing support (financial and in kind) from an expanded range of partners. Finally, it is an example of how an investment in human resources – funding and training of migrant intercultural mediators and training for health professionals – can contribute to improved responsiveness by the health system and access to care.

7. Description Programme

MiMi works with peer education to improve knowledge of health systems and services, with the aim of building capacity within migrant communities and enabling them to overcome the linguistic and cultural barriers to access to health services. MiMi is based on the principle that there is no need for additional or specialized health services for immigrants. The programme aims to make health systems more accessible to immigrants by increasing their health literacy and knowledge of available health services and their entitlements and empowering them through a participatory process.

To achieve this, MiMi recruits, trains and supports individual migrants to become intercultural mediators in order to work with their communities to increase their knowledge and understanding of the German health system and health topics specifically related to immigrants’ health. Additionally, local public health professionals are trained to increase their knowledge and awareness of issues in the migrant community, including challenges that migrants might face in accessing and using the health system, with the aim of improving health service delivery to the migrant target group.

8. Examples of specific activities
  1. Community group sessions/public information events. These are designed to address a number of core topics, including the German health system (a mandatory topic for all information sessions); nutrition and physical activity; smoking, alcohol and substance abuse; mental health; accidents and injuries; children’s health and the health of the elderly. The public information events take two to three hours and take place in, for example, language schools, religious institutions and refugees’ homes. In 2005, there were 202 such events with a total of 2913 participants, of whom 42% were evaluated as having a low social index (as measured by education, occupation and German language skills), which underlines the objective of achieving equal health care opportunities (2).
  2. Development of the health guide Hand in hand. Hand in hand delivers complementary information in 15 languages on issues such as health insurance and visiting a doctor, dentist, pharmacy and hospital (6).
  3. Training of mediators. This takes place at evenings and weekends for a total of 50 hours on 8 topics (selected from a pool of 17 health-related topics), including the German health system in general and a range of specific issues such as family planning and pregnancy. Official mediators pass a test and receive a certificate. They are paid €150 per community group session conducted alone, or €100 each if conducted in pairs. A session usually lasts three hours, with preparation and reporting taking another six to nine hours.
  4. Training of medical professionals. Training courses for health service professionals have been developed after evaluations found that there was a lack of formal assistance in meeting immigrants’ needs. They take place at two levels. Firstly, health service managers undergo two days training so that they can help staff and are themselves aware of issues. Secondly, longer-term training structured in two to three hour sessions aims to increase intercultural awareness and understanding among medical professionals. This training ensures a theoretical understanding of cultural and communication issues as well as the historical background to migration and the specific health needs of immigrants (1,2).
9. Status of example

MiMi has been in place for six years and has no planned end date (2). The programme was developed by the Ethno-Medical Centre with financial support from the Federal Company of Health Insurance Funds (BKK Bundesverband). It was launched in 2003 as a pilot programme in four cities in the states of Lower Saxony and North Rhine-Westphalia. Since then it has since expanded to 48 cities in Lower Saxony, Hessen, North Rhine-Westphalia, Brandenburg, Baden-Württemberg, Rhineland-Palatinate, Bavaria, Hamburg, Bremen and Schleswig-Holstein. Each city’s implementation phase lasts about 18 months (1,7).

10. Equity categorization Not specified (Remedying Health Disadvantage)

The programme’s health equity categorization is not specified. Although one outcome of its activities might well be to remedy health disadvantage, this is not specifically stated as an aim and is not evaluated. However, the Ethno-Medical Centre (which developed the programme) notes that one of the aims of the project is in the long term to contribute to the reduction of inequities regarding health opportunities through offering equal access to health services and information (6).

11. Type of health systems action Addressing inequalities in access to health services

The programme can be categorized as addressing inequalities in access to health services by removing potential barriers to access to health services and seeking to improve the responsiveness of the health system. This has been done through:

(i) providing information and education on health topics and services;

(ii) training staff both in the health sector and in social and integration services (see Section 22 on capacity-building for details) to increase their awareness of the legal, cultural and socioeconomic challenges faced by migrant communities and thus provide a more responsive service.

12. Health systems functions addressed by the example Combination (Creating Resources + Service Delivery)

The MiMi programme addresses a combination of health system functions, namely service delivery, creation of resources and stewardship/governance.

  1. Creation of resources. Improved responsiveness by the health system is achieved through training medical professionals to be aware of the cultural and socioeconomic challenges faced by migrants in gaining access to appropriate health care and to respond better to the needs of this population group. Through this continuing long-term training at all levels of health personnel, resources are generated in the form of improved quality and capacity of staff. The health system itself has benefited from the programme. Service professionals have become more aware of (and attuned to) the needs of the immigrant population, allowing them to address immigrants’ needs in culturally appropriate ways (1).
  2. Service delivery. The heightened awareness resulting from capacity-building for health service professionals will have contributed to improved service delivery as they become more aware of (and attuned to) the needs of the immigrant population, which increases their capacity to address this population’s needs in culturally appropriate ways.
  3. Additionally, in building coalitions between sectors (health and social/integration) to achieve the objectives of health systems to be effective, responsive and fair, MiMi expands the range of non-financial resources available to improve existing services and their ability to respond appropriately to the particular needs of the migrant community.
13. Critical features of the health system that address health inequity Participation and engagement

The critical features of health systems that the MiMi programme reflects are primarily participation and engagement, although intersectoral action is used to a certain extent as a vehicle to deliver the goals of such participation and engagement. Social inclusion is a promising potential outcome of the programme. The idea is that those who are traditionally disadvantaged socially due to low education, income and occupation status should be enabled to participate in and integrate into the German health system in the first instance, and hopefully society as a whole in the long term through improved health.

One way in which the programme aims to achieve this is by demystifying the health system, through educating migrants about health services and other health topics and enabling them both to make informed decisions regarding their health and to access appropriate health services.

Activities to meet this educational goal largely revolve around:

(i) community group sessions and public information events, where specially trained mediators from the migrant community provide information on health topics and access to services;

(ii) development of educational brochures targeted at the migrant community.

The training and use of mediators solely from the migrant community is a particularly noteworthy and important step towards their participation and engagement in the German system and society.

The programme further seeks to assure this through training for health and social professionals at all levels in issues relating to the migrant community and the challenges they face, as well as through public relations, communication and networking to raise awareness of these same issues in general at local and regional levels.

14. Other principles

The social inclusion of migrants is a key principle in this programme’s activities. The longer-term overall goal is to integrate migrants socially, economically and politically. It aims to achieve this through starting at the local (health) level, educating and enabling migrants to understand the German health system and thus to access health services, ultimately becoming familiar with and participating in this sector of society. In using mediators from the migrant community, the programme recognizes the dynamics and individual needs of this particular group. Likewise, by training health, social and integration services staff in the particular requirements of and challenges faced by the migrant community, the programme aims to include their needs in the mainstream and works towards a more responsive system of universal coverage.

15. Implementation

The project is currently being implemented and there are no plans to end it. The Ethno-Medical Centre (EMZ) is still responsible for overall coordination of the project.

The programme was developed by the EMZ in 2003 and launched with the financial support of the Federal Association of Company Health Insurances (BKK Bundesverbund) as a pilot programme in four cities in 2004-2005. Initially, partnerships were formed with the local health and integration services. These first partners played a critical role in implementing the programme and their commitment helped to encourage other partners such as local authorities, nongovernmental organizations, insurance companies and educational institutions to join the MiMi collaborative effort. A round of meetings to bring together health services, integration offices and recently recruited potential partners led to the formulation and signature of a contract defining the role and responsibilities of each partner in the implementation process after they had committed themselves to the programme. Once MiMi had enjoyed substantial success and become well known there was no need to seek out partners; rather, interested potential partners now often contact EMZ directly.

The current implementation status is that MiMi is operational in 48 cities in 10 federal states and with numerous partners, especially municipal health partners. By November 2009, 1098 mediators had been trained. There is some variation in implementation and the partners’ contributions. For example, some provide monetary funds whereas others provide resources in kind through making facilities and human resources available to the programme without charge.

Evaluation of training and community group sessions is continuous. A more systematic evaluation, including cost-effectiveness, was to be undertaken by the University of Applied Medical Sciences of Hanover in 2007-2008 (results not yet published) (1).

Partnership, networking and public relations were an essential part of gathering support for the establishment of the project in the initial stages and continue to play an important role. Public relations are undertaken jointly by the EMZ and the BKK through the internet, media and regular newsletters. Networking aims to sensitize health and social institutions to the needs of the migrant community and includes annual programme review meetings bringing together policy-makers, mediators and health and social workers (5).

16. Monitoring and evaluation

The programme is under continuous evaluation for its capacity-building within the migrant population. This is done through written queries, questionnaires and group discussions during and after training events and community health sessions, in which sociodemographic data are also collected and comments are solicited from lecturers, mediators and participants on the quality and content of the sessions and information. The results from these evaluations in 2004-2005 show that the number of immigrants accessed has steadily increased from 1105 in 2004 to 7441 in 2008, as did the number of nationalities reached – from 34 in 2004 to 104 in 2008. Each year, more than 92% of migrants who participated in public information campaigns felt they had learnt something new at the event, and the vast majority each year agreed they would review their attitudes towards health (>90%) and look after their health more in the future (>95%).

Additionally, project conferences provide a forum for exchange of experience between cooperation partners as well as the chance to provide feedback on the organization of the programme and on information events. A cost-benefit analysis of the entire project is due to be carried out at its conclusion.

Since 2007, annual evaluation reports have been available for state-wide programmes, which indicate that the programme has facilitated the formation of important links between immigrant communities and the health system.

A systematic programme evaluation is underway by the University of Applied Medical Sciences in Hanover to expand the current concept of evaluating capacity-building and health determinants of the target population, and to describe qualitatively the use and benefits of MiMi to all actors (1,2).

17. Health systems context Insurance-based

Germany spends about one tenth of its gross domestic product on health, one of the highest proportions among the European Union and Organisation for Economic Co-operation and Development countries.

The health care system is characterized by a predominance of mandatory statutory health insurance (SHI) with multiple competing sickness funds and a private/public mix of providers (Bismarck model). Some 90% of the population are covered by comprehensive SHI (8,9). This is complemented by co-existing schemes of health security coverage, most importantly private health insurance or governmental schemes.

The package of benefits covered by SHI is defined in Social Code Book V and is highly comprehensive, although since 2004, funeral benefits, patient transport, over-the-counter medications, lifestyle medications, glasses and a few other medical aids have been excluded. It is available to almost everybody who is insured. Empirical data, however, show that socially disadvantaged people and those with an immigrant background make less use of preventive services. In other words, there are social inequalities in access to (parts of) the health care system.

Contributions for SHI are not dependent on risk and are proportional to income from gainful employment. They include non-earning spouses and children, without any surcharges. Since 1949, contributions have been shared equally between the SHI-insured employees and their employers. Contribution rates vary between sickness funds.

Complementary sources of financing include statutory retirement insurance (mainly for medical rehabilitation of employees) and statutory (work-related) accident insurance. Private households increasingly contribute to health expenditure, including direct payments and co-payments (8,9).

18. Context for development of example

In 2007, 15.3 million people with an immigrant background were living in Germany, of whom approximately half (8 million) had become German citizens or were Germans formerly living abroad, while the other half (7.3 million) were non-German citizens. Immigrants thus accounted for 18.6% of the population, more (just under a third) in the case of children aged under five years. Immigrants can be broadly categorized as guest-workers and their families from the 1960s-1970s, asylum-seekers and refugees from the 1980s-1990s, and native Germans returning from the countries of the former Soviet Union from the 1990s-2000s.

Immigrants are generally disadvantaged in terms of socioeconomic status. The incidence of unemployment and precarious work tends to be higher in this group. Despite improvements, children with an immigrant background still have a lower educational status.

The Cross-Sectoral Working Group on Migration and Public Health has been working since 1997 with the aim of improving public health services for migrants. This is particularly important, as it has been shown that health status tends to decline with length of stay owing to socioeconomic disadvantage and lack of access to the health system. A step towards systematically embedding health-related measures in a general strategy to promote the social inclusion of migrants is currently addressed within the framework of the National Integration Plan, which deals with integration in politics and society (1).

19. Related policies, background documents and initiatives

Recent policy initiatives have sought to improve the health and social inclusion of immigrant populations. MiMi relates to several strategies in particular, which all support the integration of immigrants and the reduction of health inequities (5):

  • the National Framework for Prevention Strategy highlights health inequities and encourages action for socially disadvantaged populations, including immigrants;
  • the Integration Strategy promotes the equal participation of immigrants in social, political and economic life;
  • the Immigration Act of January 2005 (the legislative base of the Integration Strategy) makes available integration courses on, for example, German language, law, history and culture, and special measures for women and girls;
  • the National Action Plan for Poverty and Social Inclusion considers the government’s commitments to strengthening the integration of immigrants.
20. Funding and resources

The health and social services both allocate part of their financial budgets and human resources to the operation of MiMi. Partners contribute according to the availability of resources. Some contribute financially, some in kind, for example, by making available existing physical infrastructure and human resources; 30% of all partners offer materials and rooms for training and community group sessions.

In the first year of the programme when there were only four pilot cities, the Federal Association of Company Health Insurance Funds financed the programme. Today, after a process of engagement with key stakeholders and new partners in the programme which has yielded a sustainable funding structure, there are three main sources of funding for the implementation of each project: the city, the state and the insurance companies (1).

21. Capacity-building, existing skills, etc.

Capacity-building takes place at three levels.

  1. Migrant community. First and foremost, the migrant community is educated about relevant health issues, the German health care system in general and how to access local health services. Thus they become aware of health issues and learn how to take responsibility for their own health in accessing health care including, for example, preventive measures, disease management and early diagnosis.
  2. Training of mediators. Members of the migrant community are trained to teach other immigrants, particularly those who are at a socioeconomic disadvantage, about basic health issues and the German health system. It takes over 50 hours to obtain a certificate to teach, with follow-up sessions.
  3. Training of social and health/medical professionals. There needs to be a greater degree of institutionalization of the social integration of immigrants. For this to happen, social workers and medical professionals need to be trained in issues relating to immigration so that they can help the migrant community more effectively and display a greater awareness of challenges relating, for example, to culture and socioeconomic disadvantage that affect the migrant community.
  4. Public relations and networking. At the institutional level, public relations are undertaken jointly by the Ethno-Medical Centre and the Federal Company of Health Insurance Funds through the internet, media and regular newsletters. Networking aims to sensitize health and social institutions to the needs of the migrant community.
22. Source(s) of example

The following is the main source used for this summary profile.

One of the series of case studies developed as part of the follow-up to WHO Regional Committee for Europe resolution EUR/RC52/R7 of 2002 on Poverty and Health. The objective of the case studies was to profile a programme or intervention to increase the performance of health systems for one or more of the following groups: immigrants facing poverty and social exclusion, under- and unemployed people, children living in poverty and Roma exposed to poverty and social exclusion. Of the 22–24 case studies, 8 are profiled in this web-based resource. These case studies have been through a process of external peer review and editing.

23. Contact details for technical officer

Ramazan Salman
Executive Managing Director
Ethno-Medical Centre e.V.
Königstraße 6
30175 Hanover
Germany

Telephone: +49 511 16841022
Fax: +49 511 457215
Email: ethno@onlinehome.de
Web site: www.ethno-medizinisches-zentrum.de

24. Other information

References

  1. Salman R, Weyers S. Germany: With Migrants for Migrants. In: Poverty and social exclusion in the European Region: Health systems respond. Copenhagen, WHO Regional Office for Europe.
  2. With Migrants for Migrants - Intercultural Health in Germany . DETERMINE EU Consortium for action on the socio-economic determinants of health, 2009 (accessed 6 December 2009).
  3. South West Public Health Observatory, United Kingdom [web site]. With Migrants for Migrants - Intercultural Health in Germany (accessed 6 December 2009).
  4. Cities of Migration [web site], 2009 (accessed 6 December 2009).
  5. Socioeconomic determinants of health. With Migrants for Migrants, Germany [web site]. Copenhagen, WHO Regional Office for Europe, 2009 (accessed 6 December 2009).
  6. Health – hand in hand. Essen, BKK Bundersverband, 2005 (accessed 6 December 2009).
  7. Migration Service Gesundheit [web site]. Ethno Medizinisches Zentrum e.V., 2009 (accessed 6 December 2009).
  8. European Observatory on Health Care Systems.Health care systems in transition: Germany. Copenhagen, WHO Regional Office for Europe, 2000 (accessed 6 December 2009)
  9. European Observatory on Health Systems and Policies. Health care systems in transition: Germany – HiT summary. Copenhagen, WHO Regional Office for Europe, 2004 (accessed 6 December 2009).

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