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Commmon Approach for REfugees and other migrants' health [CARE] [717317] - Project
Project abstract

Since 2011 the geopolitical instability in the Middle East and North Africa has been contributing to exceptional flows of migrants to South European countries. According to IOM estimates, 769,399 refugees and migrants crossed the Mediterranean Sea to reach Italy, Greece and Malta during the period 1 January - 6 November 2015. WHO does not recommend obligatory screening of refugee and migrant populations for diseases, because there is no clear evidence of benefits but strongly recommends offering and providing health checks at the entry points to ensure access to health care for all refugees and migrants in need of health protection, specific population groups (children, pregnant women, elderly) included. But migrant’s health deserves to be profoundly understood and clinical attitude accordingly adapted. That’s why migrants’ health needs are at the very centre of the today discussion and multidisciplinary teams identified as the most appropriate approach to tackle them. This model results to be effective particularly in approaching even more fragile subgroups, such as minors, pregnant women and victims of violence. The project, which can count upon the endorsement of 5 MS governments experiencing strong migration flows, deploys its potential throughout 8 WPs, all tailored addressing different aspects of migrant’s health, with a view to hosting societies. Among them, three WPs are horizontal, namely coordination, results dissemination and evaluation. Other WPs do sustain the health of migrants within the hotspots and migrants’ centres, produce evidence based instruments to manage health threats and syndromic surveillance, offer a way for tracking migrant’s health on the move, produces training and information material for health staff and general public as well as intervene into the public/private relationships to promote a new governance model for migration public policies.

Summary of context, overal objectives, strategic, relevance and contribution of the action

The aim of CARE project was to promote and sustain a good health status among migrants and local populations in five Member States experiencing strong migration pressure: Italy, Greece, Malta, Croatia and Slovenia. Its partnership consisted of a broad and highly skilled consortium of public health authorities and civil society organisations, all with solid scientific, policy and public health background. In particular, the public partnership would make sure that results and outcomes are taken on board by their governments, by improving their current policies and actions in a sustainable way. They are the Italian Institute for Health, Migration and Poverty (INMP), as project coordinator, the AOU Meyer Paediatric Hospital (Italy), the Bambino Gesù Paediatric Hospital (Italy), CMT Prooptiki (Greece), the Croatian Institute of Public Health, the Hellenic Center for Disease Control and Prevention (KEELPNO), the Istituto Superiore di Sanità (Italy), the Italian Ministry of Health, the Italian Red Cross, the Ministry for Health of Malta, the National Institute of Public Health (Slovenia), the National School of Public Health/ESDY (Greece), Oxfam Italia (Italy), Praksis Ngo (Greece) and SYN-EIRMOS Ngo of Social Solidarity (Greece).
The CARE project addressed the Challenges and General objectives mentioned in “The Third Health Programme 2014-2020: Funding Health Initiatives”. In particular, it addressed the first two general objectives of the programme:
• promote health, prevent diseases and foster supportive environments for healthy lifestyles taking into account the 'health in all policies' principle;
• protect Union citizens from serious cross-border health threats.
But it also fitted explicitly the Thematic Priority ”Support Member States under particular migratory pressure in their response to health related challenges”, which was recently included as an amendment of the Workplan 2015 of the Programme itself.
The important outputs obtained at the end of the project have been further valorised by sustainability actions undertaken by the National authorities, particularly the Italian one. In fact, concerning the health tracking and monitoring system, it has been used after the end of the project into the hotspots of Trapani Milo and Lampedusa, by the multidisciplinary teams of INMP. Such a system has also been requested in several other migrants’ centers as a reference health record tool. The Italian Ministry of health has then proposed to the Sicily Region to adopt such system as a standard tool for health record. Another sustainability success of the project was the protocol on unaccompanied minors’ age assessment, which has been spread over other centres and hotspots in Italy and has constituted the ground test for the incoming national Law (47/2017) on age assessment determination. As a whole, the project has positively contributed in creating a “culture” of preparedness in the participating countries, also those where the changed context has demanded an adaptation of the instruments.

Methods and means

The CARE project implemented a common approach to the promotion of the good health of migrants/refugees and the local populations in the above mentioned 5 participating countries.
The common approach has been promoted through 3 main streams:
- strong collaboration among all partners involved in each Project’s Work Package
- development and implementation, with adjustments on different local contexts, of common new tools for migrants’ health assistance, CDs monitoring, training of health and non-health operators and, finally, migrants and general public information
- identification and engagement of relevant institutional stakeholders in the project activities.

Work performed during the reporting period

During the 12-months duration of the project, activities were first of all addressed towards promoting migrants and refugees’ access to appropriate health care, within the Italian hotspots of Lampedusa and Trapani Milo and the Greek hotspots of Kos and Leros. The healthcare model encompassed targeted clinical protocols and procedures. In particular, it included the development and implementation of the following tools for the health management of migrants and refugees: a) clinical protocols for cases of scabies and for cases of fever associated with skin rash, and b) holistic age assessment protocol for unaccompanied minors.
Protocols and procedures have been implemented by multidisciplinary teams, composed of health professionals, social workers and transcultural mediators. It is important to note that Croatia was initially included in the implementation of the healthcare provision activities of the project, but, due to the closure of the Balkan migratory route, the targeted Slavonski Brod centre was closed and the few refugees and migrants present in the country were transferred to different migrants’ centres. Notwithstanding, the health professionals and non-health operators working into the above-mentioned migrants’ centres benefited from the training provided, in order to be prepared in case the Balkan migratory route open again.
Moreover, an integrated electronic system to record and monitor the health status of migrants and refugees has been developed and tested at the hotspots. The system consists of: 1) an electronic healthcare management software - complying with all applicable privacy regulations - installed on the computer used by the doctors into the hotspot, and 2) a portable device (USB card) to be delivered to each migrant, who has undergone clinical examinations at the hotspot. The USB card contains the personal medical history of the migrant as well as information on any subsequent healthcare provided.
In fact, for each migrant visited the first time, the system generates a “token”, which is integrated by records each time he/she receives a further examination. The application allows doctors to access records stored into the card even when outside the hotspot, and to integrate them with new records, thus providing continuity in the assistance. The system maintains on the PC into the hotspot a copy of each electronic health record generated in the same centre, feeding a resident database that allows the extraction of health data for epidemiological evaluation.
Also a syndromic surveillance system to monitor potential spread of communicable diseases has been piloted/simulated in the 5 participating countries as well as in Portugal in order to enhance the early detection of communicable disease outbreaks or single cases of very severe conditions among migrants hosted in dedicated reception centres, which could flag potential public health emergencies. The rationale of implementing syndromic surveillance in migrant reception/detention facilities is that these facilities in Europe are institutional settings that typically host closed/semi-open communities. As in other institutional settings, also migrant holding facilities face specific challenges in preventing and controlling the transmission of communicable diseases.
An inclusive survey on vaccinations offered to newly arrived migrants in the CARE participating countries was also conducted, based on primary data collection. Lastly, the activities developed under the framework of monitoring of communicable diseases, involved the design and the pilot implementation of an information service model on endemic and currently epidemic diseases in the countries of origin and transit of migrants and refugees, addressed to frontline healthcare professionals, guiding them in conducting clinical examinations. The information service model provided the sending of target information dispatches to professionals on a weekly and monthly basis.
Moreover, the actions

The main output achieved so far and their potential impact and use by target group (including benefits)

The results achieved by the CARE project focused on 2 main domains:
- how to take care of migrants’ health into hotspots and other migrants’ centers
- how to make countries invest either on their own communities and on their health systems’ preparedness.
In this two areas, the CARE project has achieved significant results, essentially based on the production and adoption of common tools for migrants’ health assistance, monitoring of CDs, training of health and non-health operators and, finally, for migrants and general public information.
In the participating countries, these tools have been used by the CARE partners for the implementation of actions based on a common strategy, clearly with adjustments to the different local contexts. Many of these tools may be further used in other contexts at European level.

The healthcare provision model of the CARE project has successfully addressed the challenge of providing effective and targeted healthcare services to the needs of migrants hosted into the hotspots and migrant centres targeted by the project, on the basis of an integrated model for proper healthcare provision, encompassing targeted clinical protocols and procedures. In Italy, medical support provision for migrants/refugees has been assured by CARE multidisciplinary teams in Lampedusa and Trapani Milo hotspots for 6,149 patients, while 804 patients received psychosocial support and 799 paediatric clinical examinations. Moreover, 2,621 cases of scabies and 116 cases of fever associated with skin rash have been managed using the CARE clinical protocols. Finally, 75 age assessments were performed through the protocol developed in the framework of the project.
In Greece, CARE teams the multidisciplinary teams managed more than 12,000 cases, while the psychosocial units dealt with more than 1,300 cases. Referrals were made for a high number of demanding psychiatric cases that needed further psychiatric and psychological support. Moreover, the clinical protocol for scabies has been implemented in 145 cases in Leros and 387 in Kos. No cases of fever plus skin rash were reported. Finally, age assessments according to the CARE holistic protocol have been conducted on 20 migrants as complementary to the one envisaged by the Greek Law. Moreover, thanks to the holistic approach, both invasive diagnostic exams and mistakes were minimized.

The multidisciplinary teams working into the hotspots have also tested the system developed for migrants’ health tracking and monitoring, with excellent results in terms of usability, effectiveness and user-friendliness. The strong point of the system was the total compliance with privacy applicable regulations, Nationally and Internationally. In fact, health data generated during the clinical examination are recorded by the doctor into a local pc (not connected to cloud or external databases) where the written consent from the patient is also digitally stored. Then, at the time of departure from the hotspot, the migrant is given his own health data written into a digital card (portable digital device), which is handy and wallet fitting. Again, health data are kept by their owner and therefore no infringement to privacy regulations is conceivable. However, we decided to encrypt the data recorded into the card just not to allow other possible unauthorized persons to maliciously modify them and therefore jeopardize entire effort. Furthermore, the system received positive evaluation in terms of capability to register relevant information in real time with the possibility to increment them in a later moment as well as to cover the health needs over the entire transfer of the migrant until a registration on the NHS occurs.

In the field of monitoring of communicable diseases, relevant specific objectives were met through the following results: 1) development and piloting/simulation a syndromic surveillance system, that can facilitate the detection of infectious disease outbreaks and contri

Achieved outcomes compared to the expected outcomes

By implementing the project, more appropriate health care provision to migrants and an increased knowledge/control of infectious disease threats among them in the centers have resulted as fully achieved.
The multidisciplinary team has shown itself as appropriate in terms of health and social competencies, which make it capable both to ensure treatment of the most common diseases of migrants and to provide them with access to proper care. Morbidity patterns of migrants/refugees are in fact mainly characterized by the proportional high occurrence of communicable and parasitic diseases. Experience suggests that the CARE health model contributes to keep communicable diseases under control, to avoid outbreaks and achieve effective treatment of patients. The electronic health tracking and monitoring system is also an essential tool in this model. It does contribute to better monitoring and following up patients’ health and thus, certainly allow the continuity of care. Therefore, syndromic surveillance, clinical protocols and operation procedures as well as the health tracking and monitoring system constitute essential components of the CARE health model and can play a key role in ensuring appropriate and effective management of migrants/refugees’ health.

Dissemination and evaluation activities carried out so far and their major results

The CARE project considered the dissemination activities as a continuing process and a Care partners’ shared responsibility, strategically planned to accompany the whole project’s duration. A specific project Work Package has been devoted to the dissemination of information about the project’s activities, achievements and relevant outputs/outcomes through the use of different channels/tools implemented on the basis of the strategy set out in the project’s Communication and Dissemination Plan:
- a CARE logo
- an extensive dissemination list
- a project leaflet in English and in the national languages of the participating countries
- the project’s official website, which has been developed under the address, and continuously updated, to serve as main information hub for the CARE activities. It includes a download section, where the project folder and leaflet, the press releases and the training and information materials produced in the framework of project’s WP7 are downloadable.
- three e-newsletters for the promotion of the project as well as its progress during its twelve-month implementation were also created.
- five Info Days, which took place between February and March 2017 in Malta, Croatia, Slovenia, Greece and Italy respectively and gave great visibility to the CARE project. These events were devoted to present and disseminate project objectives, results and achievements and to engage all relevant institutional stakeholders in a constructive discussion on policy recommendations and future actions at national level.

As for the results achieved, it must be highlighted the importance of the use of multiple dissemination channels and tools, and, among them, the pivotal role played by both the project website and the Info Days.
Concerning the evaluation activities, the performance of the project was assessed at mid-term (Internal interim evaluation report), providing feedback to the project coordinator. Then, an overall performance of the project has been conducted as part of the final internal evaluation report, as well as an external evaluation, focusing on the health impact of the healthcare provision model of the project, as well as its transferability and sustainability. Both internal and external evaluations were based on targeted evaluation plans, which were developed during the first months of the project.

Thus, based on the summative assessment of the project, the internal final evaluation reported that the CARE project has managed to reach its general and specific objectives to a large extent. In addition, all Grant Agreement indicators resulted from the change of the context have been reached. Additional indicators have been added during the implementation and detected as achieved. Therefore, the CARE project has been implemented to a large extent as planned overall, with adaptations in some cases, due to the external context changes.

The external evaluation focused on three aspects of the project activities: (1) Health impact of the healthcare provision model (2) Sustainability of the healthcare provision model (3) Healthcare provision model transferability.
Concerning the health impact of the healthcare provision model, both morbidity data and assessments of frontline health workers support the view that the model meets the health needs of migrants/refugees and may have a significant contribution in improving their health outcomes.
Regarding the sustainability of the healthcare provision model, both technical data and professionals’ assessments suggest that the model meets many sustainability requirements. Despite the adaptation problems or implementation obstacles, the model as a whole, as well as most of its components, have been successfully piloted in at least two different countries –with some differences - providing evidence that the model is feasible, functional and acceptable. The multidisciplinary approach, the use of clinical protocols and the int