The European Network to reduce vulnerabilities in health brings together NGOs and academic partners from 23 European countries. Its goal is to contribute to the reduction of EU-wide health inequalities and to improve the response from better equipped health systems so as to deal with vulnerability factors. The Network advocates in favour of better access to healthcare for people facing vulnerabilities through solid quantitative data collection among the partners and advocacy towards European institutions and stakeholders. The members work in different fields of health and social care provision and support a variety of target groups, from the homeless and sex workers to people in poverty and migrants. This creates the potential for rich exchanges on good practices and an opportunity for more effective common advocacy activities across Europe.

2017-last year of a three-year project (2015-2017) - will focus on capitalising on the lessons learned over the three years and enlarging ambitions for future collaboration. This implies designing tools that can be used in the longer run such as a toolkit on best practices and two webinars on data collection and patient empowerment. Dialogue between the members will continue, sharing knowledge about activities and expertise by organizing exchanges between peers and workshops on advocacy and empowerment.

The Network will continue to work on the data collection process in 14 European countries. Medical and social surveys conducted in free clinics receiving people facing vulnerabilities (EU citizens and migrants) enable to identify their health status and social determinants, including obstacles to access to care, in order to inform health policy makers and obtain positive changes. More particularly, the Network’s joint data collection and advocacy on refugees’ health needs will help create a more balanced public discourse within which policy makers can commit to abide by their international obligations towards refugees.

The 'European Network to reduce vulnerabilities in health' (hereafter ‘the Network’) brings together NGOs and academic partners from 23 European countries. The members work in different fields of health and social care provision and support a variety of target groups, from the homeless, drug users, sex workers, Roma to migrants. This diversity creates the potential for rich exchanges on good practices and an opportunity for more effective common advocacy activities across Europe. For three years, the Network's overall goal is "to contribute to the reduction of EU-wide health inequalities and to improve the response from better equipped health systems so as to deal with vulnerability factors".

The experiences of our patients must be addressed within the context of a series of policy decisions that were the result of a lack of political will to achieve universal healthcare and a lack of desire to respect the right to healthcare, both at a national and European level. The WHO Director-General has made universal healthcare coverage a priority: “It is ultimately a political choice. It is the responsibility of every country and national government to pursue it”. But in 2016, universal access to health is experiencing significant declines in Europe, especially for people facing vulnerabilities. The rise of populism appears to have resulted in a move away from a discourse of austerity in Europe. However, member states’ restrictive accounting measures, particularly in the area of health, continue to weigh on vulnerable populations, including migrants. In 2017, the European Commission recommended the health sector be reformed to reduce public deficits by ensuring cost-effectiveness and safeguarding fiscal sustainability. The main measures member states should be concerned with are: outpatient rather than inpatient care; improving governance; more primary healthcare and integrated care; and rationalisation of prescriptions. But these relate to more budget cuts that actually increase health inequalities that can affect the needs of the most vulnerable such as staff reductions; health privatisation; reduced hospital stay; and reduced benefits.

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 for three years (2015-2017), the 23 European Network members (19 in 2015 and 23 in 2016, 23 in 2017) 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 ce

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 (first half of the year): 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 in November 2016 in Brussels. A political event with all partners and stakeholders in 2017 will take place to launch the report and capture the lesson learnt of those past three years.

• Every year: intensive learning moments (workshops, seminars, exchanges of practices) for Network members’ teams, on one of the

2015 was about laying the foundations of the Network, 2016 about consolidating activities and 2017 enlarging the ambitions and thinking about the future of the network after 3 years of work together. Even though, the Network did not succeed in a follow grant with Chafea for 2015-2017, the Network is currently looking into alternatives to not lose the momentum and maintain our efforts on fighting against health inequalities.
2017 was seen as a transition year within the MdM International Network now called the Network empowerment team (NET). At European level, building on the work initiated by MdM France and the International Network Secretariat (DRI) for several years, MdM UK took over the management of the Observatory for one year (2017). The main output was the production of the 2017 Observatory report on access to healthcare in 14 European countries and its wide dissemination.
The launch of the Observatory report in Brussels (11/2017) was attended by about 100 participants from all over Europe. The conference were structured around two panels. The first panel introduced the findings of the Observatory report while the second one opened a discussion on the political role of the EU in leading the right to health for migrants in Europe.
This year, we organized two exchanges of practices between members. This year was about empowerment issue and access to healthcare for the EU mobile citizens. Those workshops were co-organized by our partners based in Austria and Hungary. Following the workshop in Hungary on empowerment, a review of practices on empowerment was undertaken by an independent consultant to obtain a better understanding on which specific cases MDM’s staff and partners are capable of effectively empower users.
In term of communication, MdM Network members have been kept up to date with a regular internal EU updates on activities/ events that occurred during the year and a quarterly newsletter sent to more than 500 EU stakeholders (NGOs and civil society platforms, researchers, health professionals, EU Permanent representatives, EU representatives).
In line with our objective 4, the Network engaged the political dialogue with key EU institutional stakeholders about vulnerabilities in health (see quarterly EU updates) at EU and national level. We had the opportunity to meet several times with the DG Justice Commissioner Vera Jourova to discuss the issue of children in migration and their access to healthcare, regular exchanges with DG HEALTH/CHAFEA, several MEPs (bilateal meetings with Network Members or regular meetings with for instance Cecilia Wistrom).

The annual Observatory Report is produced by the European Network to Reduce Vulnerabilities in Health, which brings together MdM programmes, partner NGOs and academics who seek to reduce EU-wide health inequalities. It is an observational study of people who are excluded from mainstream healthcare services. The purpose of the report is to present data, analysed and validated by a leading epidemiologist, on people who are excluded from mainstream healthcare services, alongside testimonies and photos collected in programmes run by MdM and partner NGOs. It is aimed at policy makers at local, regional, national and EU level, providing them with the evidence base on reducing vulnerabilities in health and identifying ways that health systems could become more responsive and adapted. It is also valuable for academics to acquire greater understanding about how vulnerabilities contribute to health inequalities, and vice versa.
This 2017 Observatory Report includes data, testimonies and photographs collected from thirteen programmes from January to December in 2016. The programmes are both medical and non-medical, collecting the social and medical data. There was a total of 110,277 medical and social consultations. The report was produced in partnership with the Institute of Global Health, University College London. With over 160 staff and access to expertise of over 200 staff from across UCL, the Institute collaborates across disciplines to find solutions to global health problems with cross-disciplinary approach at the heart of its research and teaching.

This Observatory Report: • provides a brief look at the political, policy and legal context whilst the data and testimonies were being collected; • describes what we saw from the data relating to the demographics and country of origins; • observes what vulnerabilities in health and healthcare access patients faced; • records levels of healthcare coverage and barriers patients faced when accessing healthcare; • describes the diagnosed health conditions and health status reported by patients; • provides an overall discussion on the key findings; and • presents recommendations to the relevant institutions, national governments, and organisations to improve access to healthcare for people facing multiple vulnerabilities in health.

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 November 2016. 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 (09/2016) and the annual EUPHA conference (11/2015), PACE Committee session of the Council of Europe (MdM presented its conclusions on medical age assessment), United Nations General Assembly and the summit on migration in New York (09/16), the European Forum on the the rights of the child (11/16).

The Network was visible at several high level academic meetings and gave lectures at medical faculties. The Network was consulted by DG Justice for its particular relevant field expertise in access to healthcare for unaccompanied minors. 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 Network participated in the “EU Border Care Annual Conference” organized by the European University Institute in Florence the 27-28 June 2016. The Network talked about the Legal Norms and Actual Practices That Determine Undocumented Women's Access to Maternity Care in the Destination or Transit European Countries. EU BORDER CARE is a comparative anthropological analysis of undocumented women’s access to maternity care in European borderlands, with a specific focus on South and South-Eastern European borders, and ultra-peripheral regions.
The European Network wrote an article as well for a book entitled “Santé des populations vulnérables” (Health of vulnerable populations) edited by Claire Adam and V. Faucherre (Auteur). This book – education focus- is intended for medical students. The book will therefore focus on pragmatic aspects that respond to the needs of these populations. Click here to read the Network Contribution

The following materials were disseminated according to a dissemination plan provided by each Network members:
• The European Observatory report on access to healthcare
• the Legal report on access to healthcare in 16 countries
• The quartely newsletter (sent widely)
• The EU internal update (within the Network)

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 (as in 2015 and 2016), we have also asked all our members to establish national dissemination plans.

The Data Collection Manager created a practical monitoring tool and a manuel on data collection- at the disposal on dropbox for the Network member collecting the data – to follow how the dissemination of the Observatory report whether it is electronically (websites, media) or events.
We faced several constraints in term of lack of ressources and delays in producing the Obsevatory report, therefore we have decided to prioritize the updates the medical and social questionnaires to collect data in 2017 and further support members in their daily work and when collecting data and less focus this year on the dissemination.