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European network to reduce vulnerabilities in health [Vulnerability NW] [671366] - Operating Grant
Project abstract

The proposal creates a new, open ‘European network to reduce vulnerabilities in health’, bringing together NGOs and academic partners from 17 EU Member States and 2 EFTA/EEA countries. Our goal is to contribute to decreased EU-wide health inequalities and to more responsive health systems that are better equipped to deal with vulnerability factors that increase health inequalities.The economic crisis has demonstrated that everyone could be ‘vulnerable’ at a given moment in their life. Many members of ‘vulnerable groups’ such as (undocumented) migrants or asylum seekers, sex workers, drug users, Roma, the homeless etc. are actually quite resilient. Consequently, the concept of 'vulnerability' is more useful, inclusive and more precise than the term ‘vulnerable groups’. In order for health systems in Europe to be sustainable and resilient, they need to be able to cover the whole population without any gaps and effectively deal with multiple vulnerabilities.The founding members of the Network seek to gain greater capacity and skills through mutual learning about how to improve health service delivery, patient empowerment, common data collection and advocacy. As a result, people facing multiple vulnerabilities will get access to higher quality care in the health programmes run by Network members and the skills and knowledge they need to get easier access to good quality care in mainstream healthcare systems. The Network will undertake a common data collection process to generate robust data, analysed and validated by a leading epidemiologist. This data will be valuable for academics to review and acquire greater understanding about how vulnerabilities contribute to health inequalities. It will also be a new resource for local, regional, national and EU health authorities, enlarging the evidence base on reducing vulnerabilities in health and identifying ways that health systems could become more responsive and adapted.

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

While the economic crisis and austerity measures have resulted in an overall increase in unmet health needs in most countries, the most destitute- including an increasing number of EU nationals-have been hit the hardest. Austerity policies have left almost a third of the population without healthcare coverage (OECD 2014). People experiencing numerous vulnerability factors were already facing major health inequalities before the crisis hit Europe, and continue being easily overlooked in health policy debates. 62, 9 % of the people seen by MdM in Europe in 2014 had no health coverage. More than half of the pregnant women had not had access to antenatal care before they came to MdM (54,2%). And yet less than half of the children seen in MdM consultations were properly immunised against tetanus (42.5%) or measles, mumps and rubella (34.5%) – although these vaccinations are known to be essential throughout the world and the vaccination coverage for measles at the age of two years is around 90% in the general population in Europe.

In order for health systems in Europe to be sustainable and resilient (overall objective), they need to be able to cover the whole population without any gaps and effectively deal with multiple vulnerabilities. Thanks to the support of CHAFEA, the 23 European Network members (19 in 2015 and 23 in 2016) seek to gain greater capacity and skills through mutual learning about how to improve health service delivery, patient empowerment, common data collection and advocacy (objective 1). As a result, people facing multiple vulnerabilities will get access to higher quality care in the health programmes run by Network members. In addition, they will get the knowledge they need to get easier access to good quality care in mainstream healthcare systems (objective 2). The Network undertakes on a yearly basis a common data collection process to generate robust data, analysed and validated by a leading epidemiologist (objective 3). This data are valuable for academics to acquire greater understanding about how vulnerabilities contribute to health inequalities. It is also used as an evidence based advocacy tool to influence policy makers in further supporting health protection for all (objective 4). The project activities primarily contribute to specific and operational objective 3 of the EU Third Health Programme 2014-2010 (innovative, efficient and sustainable health systems) and also support specific and operational objective 4 (facilitate access to better and safer healthcare).

The quantitative and qualitative data collection proposed by the network can provide a bottom up perspective on health inequalities and help build policies that will effectively tackle health inequalities. Similarly, collecting relevant data about social determinants of health can certainly contribute to reduce them. The Third Health Programme mentions mental health problems as a source of vulnerability and a significant contributor to health inequality. Improved mental health is clearly included in the Network members’ service delivery, data collection and awareness raising activities.

Methods and means

Everyone is likely to be vulnerable at a given moment in his or her life. Our theory of change is that to make vulnerability factors visible and to hold policy makers and health systems accountable for meeting their stated objectives of universality of coverage, we first need comparable quantitative and qualitative data as well as appropriate messages. When information is generated about the reasons for such obstacles, and brought to the attention of health authorities, advocacy can achieve changes in the system. Another – parallel – way to obtain change is to empower service users that are facing vulnerability factors, e.g. there are several examples throughout Europe where groups of sex workers, drug users or undocumented migrants have obtained access to better quality healthcare services once they knew how to successfully engage with authorities.
The members of the Network are all organisations reaching out to marginalized populations and with complex physical, mental and social problems. These teams are specialised in appropriately responding to urgent social and health needs in complex situations, but most of them lack experience in data collection, advocacy or policy making. This is why our network building activities and mutual learning are oriented towards starting or improving data collection and in how to engage in civil dialogue processes.

The 3 year work plan (2015-2017) is characterised by a cyclical rhythm…
• Every year in February: an annual network meeting and an advocacy training. The Annual meetings cover discussions on the state and governance of the Network, evaluating progress made in several areas and discussing strategy, validating new membership applications, etc. The advocacy training is about sharing successes and failures concerning advocacy and civil dialogue activities.

• In addition to continuous dissemination activities, a European Observatory Report is published on a yearly basis featuring the results of the data collection, legal analysis and other information gathering. It was launched with a press conference in May 2015 in London and will be launched at a dissemination event in the European Parliament in 2016 and a high-level political event with all partners and stakeholders in 2017.

• Every year in October: an intensive learning moment (workshops) for Network members’ teams, on one of the four objectives (quality of service delivery, patient empowerment, gathering data or advocacy).

Work performed during the reporting period


2015 was about laying the foundations of the Network whereas 2016 and 2017 are respectively about consolidating activities and enlarging the ambitions and thinking about the future of the network after 3 years of work together.

The kick off meeting in Amsterdam (02/2015) was attended by about 70 participants from 19 countries, plus MdM Canada, MdM Japan and MdM USA. It set the first rules of work for the enlarged network in order to collaborate for high quality common data collection and build a strong basis for a common advocacy plan.

MdM Network members have been kept up to date with a regular internal newsflash on activities/ events that occurred during the year and a bi-monthly newsletter.

The network published three key reports in 2015:
• A user-friendly 48 page European Observatory report in 3 languages (English, French and Spanish). The survey is based on 41,238 face-to-face medical and social consultations with 22,171 individuals in nine European countries (BE, FR, DE, EL, NL, ES, SE, CH, UK) in 2014. It is meant for a general audience and a wide variety of national and European policy makers;
• An epidemiological report version in English with full analysis of the data (9 European countries, Turkey and Canada). As it includes data on infectious deseases, it is meant for reasearchers and health profesionnals;
• A legal report on access to healthcare in 12 countries (BE, CA, FR, DE, EL, LU, NL, ES, SE, CH, TR and UK).

In line with our objective 4, the Network engaged the political dialogue with key EU institutional stakeholders about vulnerabilities in health. We organized a meeting with the Health Commissioner Vytenis Andriukaitis, regular exchanges with DG HEALTH/CHAFEA, the health attachés of Permanent Representations (e.g. a meeting took place with the Dutch Perm Rep in March 2015 concerning their Presidency priorities) and MEPs and provided relevant input to parliamentary work (e.g. in April, the Network sent a report to the PACE Committee on Social Affairs, Health and Sustainable Development with a subsequent hearing about children’s access to healthcare).

Implementing high-quality comparable data collection is a heavy process that takes a long time. Therefore, we planned a 1,5 day workshop in October 2015 in Paris. It allowed people from 10 countries who directly collect data, to exchange on their practices and challenges and to acquire a deep understanding of the medical and social questionnaires. A video available on our blog is a useful tool to train national team when collecting data with patients.

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

The expansion of data collection by the end of 2015 seems to have enhanced the ‘power’ with which MdM can advocate. Five more Network members (MRCI from Ireland, MdM Luxembourg, Health Centre for Undocumented Migrants in Norway, Carusel in Romania and Slovene Philanthropy from Slovenia) – impressed about the advocacy power of data collection – have joined the quantitative data collection in 2016 and 2017. This brings the total number of members collecting data to 16 European members in 2016 (including Canada and Turkey) instead of 9 members in 2015. Materials were made available to the network members: written data collection guidelines on how to use the medical and social questionnaires and testimonies guidelines were shared and disseminated to those collecting the data. The aim of the guidelines was to make sure all salaried and volunteer staff working in first line social and medical consultations understand why specific questions are asked, and use the questionnaires appropriately.

Our main activity was producing, releasing and disseminating our three newest reports (in Brussels, London, Paris, Strasbourg, at national and local level, online etc.) mentioned above. The 48 page report had a print-run of 5,000 hard copies (2,500 in English, 2,000 in French and 500 in Spanish). A 1 page infographic was also helpful in getting the key messages across to the media.

Now, it is more difficult for policy makers to ignore statistics thanks to the development of a common advocacy strategy in the Network. The data collected seems therefore to have served as a tool that has allowed MdM to achieve further outcomes and impacts. We also created opportunities for members to speak out through written contribution to European Parliament work and political decision makers and raise visibility of the issue of access to healthcare (articles written and published, media coverage). By representing the Network at conferences and stakeholder meetings, Members achieved a better understanding of European decision making processes, while bringing direct testimonies about what is going on in the field to high-level policy makers.

Achieved outcomes compared to the expected outcomes

The influence on EU public Health has largely come about through social and other media (e.g. newspapers), particularly following the yearly launch of the European Observatory report in May 2015. Thanks to the Network’s advocacy and awareness raising activities, information from the European Observatory Report was widely picked up by the European and National media (see section dissemination).
EU institutions and Members States further expressed support for health protection for all as highlighted in several events/conferences such as the European Health Forum Gastein (09/2015) and the annual EPHA conference (09/2015). The Network have seen as well growing evidence based statements in EU public health and healthcare policy as illustrated in the EU Fundamental Rights Agency study “Cost of exclusion from healthcare – The case of migrants in an irregular situation.

The network collaborated with many academics in 2015. The Centre for Health and Migration (C-HM) in Austria and MdM Belgium worked on a thematic study on cost-analysis of health care provided to migrants and ethnic minorities. The Network was visible at several high level academic meetings, gave lectures at medical faculties and at the Italian Congress of Paediatrics, and was consulted for specific EC funded research projects (PISCE). The long version of the network’s report was published on Research Gate and was disseminated among more than 145 academics with a track record of interest in vulnerabilities in health. MdM UK co-authored an article in Int. J. Health Service. Our data were cited in a BMJ article (“Restricting access to the NHS for undocumented migrants is bad policy at high cost”). A full article “Obstacles to access to care for migrants, children and pregnant women in Europe” was published in the WHO PHAME newsletter. The results of the Network’s data collection and legal analysis was presented at the 2015 French Public Health Society (SFSP) and European Public Health Association (EUPHA) annual conferences.

The importance of working with healthcare professionals, and empowering them to treat undocumented migrants, received particular attention in 2015 and was one of the main discussion points at the meeting in Amsterdam (which kicked-off the new DG SANCO-funded project). MdM has developed special leaflets for healthcare professionals which have been distributed at events and conferences.

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


The following materials were disseminated according to a dissemination plan provided by each Network members:
• The 48 page European Observatory report
• The epidemiological Observatory report
• the Legal report on access to healthcare in 12 countries
• Production of 4 nationally / locally adapted leaflets targeting health professionals
• The bi-monthly newsletter and internal updates on the migrants reception crisis
• The Newsflash (internal update)

The mapping of European stakeholders that preceded the release of the 2015 European Observatory report has been turned into a segmented mailing list, with relevant European civil society contacts (about 400), academics (145), Health Attachés, EC staff (about 40) and about 170 of the most relevant MEPs (i.e. health professionals, or members of ENVI, LIBE, EMPL or FEMM committees). This year, we have also asked all our members to establish national dissemination plans.

In presence of the MEP Jean Lambert and the President of the Royal College of Midwives, the launch of the European observatory report received quite substantial media attention during the press conference in London (May 2015). Moderated by Fiona Godlee, Editor in Chief of the prestigious British Medical Journal, the event was attended by at least 12 journalists (BBC, AFP, Spanish National Radio, Onda Cero Radio and Telecino (Spain), British Journal of Midwifery, Nursing Times, etc.) and generated 128 articles across Europe. Major media outlets such as The Guardian and The Independent in the UK, De Standaard in Belgium, the NOS in the Netherlands published article and interviews on the subject.