Healthcare for people from refugee backgrounds and people seeking asylum

Position

The Royal Australian College of General Practitioners (RACGP):

1. Supports equity of access to confidential, quality healthcare for all people from a refugee background, including people seeking asylum.
2. Recommends increased funding for improved access to interpreter services for all healthcare providers including allied health providers and oral health.
3. Supports a policy of providing full access to both federally and state funded health services for people seeking asylum once they have lodged a claim for protection.
4. Does not condone or support immigration detention and acknowledges the evidence that immigration detention and prolonged visa uncertainty causes physical and mental harm to people seeking asylum. The RACGP endorses the UNHCR’s global strategy to end the detention of asylum-seekers and refugees.
5. Supports the collection of key data in all health care systems and recommends that the Australian Institute of Health and Welfare (AIHW) develop a minimum dataset that enables annual reporting on the health and healthcare needs of people from refugee backgrounds and people seeking asylum.
6. Recommends the establishment of a National Refugee Health and Wellbeing Framework to support a consistent, equitable and integrated approach to the delivery of refugee health care across Australia.
7. Recommends that education and training in caring for people from a refugee background, including those seeking asylum, should be included in all undergraduate, postgraduate, and professional medical education programs.
8. Supports a more inclusive and diverse health workforce and recommends identification of recognised pathways for International Medical Graduates (IMGs) from a refugee background to enter the Australian health workforce.

Definitions

An asylum seeker (person seeking asylum) is a person who has fled their own country and applied for protection as a refugee.
According to the United Nations Convention relating to the Status of Refugees, as amended by its 1967 Protocol (the Refugee Convention), a refugee is a person who is outside their own country and is unable or unwilling to return due to a well-founded fear of being persecuted because of their: race; religion; nationality; membership of a particular social group; or political opinion.¹
All people who are granted refugee status according to the United Nations Convention start this process by seeking asylum.

Background

As a signatory to the United Nations Refugee Convention,¹ Australia commits to resettle a proportion of humanitarian entrants every year as part of its Humanitarian Settlement Program. In addition, under the same Convention, Australia has obligations to protect the human rights of all asylum seekers and refugees who arrive in Australia regardless of how or where they arrive and whether they arrive with or without a visa. As a party to the Convention, Australia has agreed to ensure that people who meet the United Nations definition of a refugee are not sent back to a country where their life or freedom would be threatened, a principle known as non-refoulement. 

People from refugee backgrounds often have higher rates of long-term physical and mental health issues compared with other migrants. This is, due in large part to the refugee journey which may expose them to deprivation, persecution and human rights violations as well as post-migration stressors of resettlement. General practice is uniquely positioned to offer the incremental, person-centred, and trauma-informed approach recommended for recovery and long-term care of people from refugee backgrounds².

Refugees and humanitarian entrants

Each year many thousands of people from refugee backgrounds settle in Australia as part of the nation’s Humanitarian Settlement Program^3.4 This program supports humanitarian entrants and other eligible visa holders in the early resettlement period, with a strong focus on learning English, gaining employment and accessing education and training. The number of refugee and humanitarian entrants welcomed to Australia since World War II passed 950,000 in the first half of 2023⁵.

It is recommended that a comprehensive post-arrival health assessment is offered to all newly arrived people from a refugee background, preferably within one month of arrival.⁶ This assessment commonly takes place in general practice and involves a comprehensive history and physical examination, pathology screening, catch up immunisation, further management, and referrals as appropriate. Comprehensive primary care that is responsive to the diversity of backgrounds and experiences people have had in their refugee journeys offers an essential first step to addressing many immediate and long-term healthcare needs.

People seeking asylum

Under the UN Convention, it is not illegal to cross a border for the purpose of seeking asylum. Protection visa applications are processed and assessed by the Australian Department of Home Affairs. Over recent years there have been multiple changes to how this processing occurs and to the policies that inform these processes. Depending on the mode and date of arrival, different groups of people seeking asylum have been and continue to be processed under different systems, with different entitlements.

People seeking asylum face additional stressors to those experienced by humanitarian entrants arriving in Australia. These are related to the often prolonged, process of seeking asylum and make them particularly vulnerable to long-term physical and psychological health problems. Their migration journey may have included time in immigration detention and periods of sustained uncertainty. The negative health impacts of immigration detention are expanded on below. Additionally, Australian temporary protection visas have been shown to be associated with worse mental health status when compared to permanent protection visas, due to restrictions on family reunion, access to employment, Medicare, and exposure to ongoing uncertainty.⁶

Discussion

The RACGP recognises the complexity of health care needs of people from refugee backgrounds. The higher rates of long-term physical and psychological problems experienced by this population are in part due to their pre-immigration experiences but are often exacerbated by post-migration factors. While many will have similar health concerns to Australian-born patients, they may also have health issues specific to their country of origin and their migration and settlement experience. For these reasons it is important to understand each individual’s unique migration journey and the system barriers experienced in accessing care. 

Equity and access to services

The UN Committee on Economic Social and Cultural Rights recognises that health is a fundamental human right indispensable for the exercise of other human rights⁷. Every human being is entitled to the enjoyment of the highest attainable standard of physical and mental health conducive to living a life in dignity. The RACGP supports equity of access to healthcare for all people from a refugee background, including people seeking asylum. This care should be consistent with the Australian Charter of Healthcare Rights, and the relevant set of healthcare standards, for example, the RACGP Standards for general practices (5^th edition), or the RACGP Standards for health services in Australian immigration detention facilities (2^nd edition).^8,9,10

Some of the relevant standards included in these RACGP resources relate to:

• the need for interpreter and other communication services (criterion C1.4)
• the provision of respectful and culturally appropriate care (criterion C2.1)
• patients receiving appropriately tailored information and health promotion, illness prevention and preventative care (criterion C4.1)
• confidentiality and privacy of health and other information (criterion C6.3)
• maintenance of patient health summaries that include past health history, immunisations, health risk factors, social history including cultural background, and preferred language and interpreter services (criterion QI2.1B)

People from refugee backgrounds can experience a range of barriers when accessing primary care and other services. These may be related to the way the health system responds to factors such as trauma associated with the refugee experience, language, culture, health system literacy, and socioeconomic disadvantage, as well as policies that restrict eligibility to health and other services.^2,3

Language services

General practices have a responsibility to deliver care that is culturally responsive and in so doing, to help address the barriers to equitable healthcare that exist for people from refugee backgrounds. This includes providing access to resources that are culturally appropriate, translated, and/or in plain English. The Health Translations directory provides health practitioners with access to translated health information if they are working with CALD communities. 

Working with professional interpreters is another essential component of this care. Initiatives are needed to increase the uptake of interpreter services by general practitioners, for example, increased funding for longer, complex, consultations. In addition, more resourcing is needed to improve the numbers and training of interpreters. All primary healthcare providers, including allied health providers need access to funded professional interpreter services. In particular, access to interpreters for psychological services would assist in meeting the mental healthcare needs of people from refugee backgrounds with low English proficiency.

In June 2022 the Department of Health and Aged Care published a fact sheet which provides information on how to account for time taken to communicate with patients when claiming time-tiered MBS items.  The fact sheet is available on MBS online.

Continuity of care

Primary care is ideally suited to providing, patient-centred, long-term care and recovery for refugee background patients. Enabling continuity of care for patients from refugee backgrounds can be promoted by a whole-of-practice approach with attention to culturally responsive, trauma-informed care. A whole of practice approach can include having bilingual staff; waiting spaces with information in local refugee community languages; clear signage about the availability of interpreters, contact details of the patient’s settlement worker; availability of long appointments; and inclusion of in-language appointment reminders.² 

Patients with complex needs will benefit from integrated support from settlement, specialist refugee and medical services, mental health, and trauma services.² It is essential that there is effective clinical handover and communication between services.  Primary care plays a vital role in coordinating these services.  
 

Immigration detention

The RACGP does not condone or support the use of immigration detention. There is a significant body of evidence that demonstrates the adverse mental and physical health impacts of immigration detention, particularly prolonged detention, on people seeking asylum. The impacts of detention can be profound, particularly for the most vulnerable, including children and adolescents, pregnant women, and individuals with previous experiences of torture and trauma. The mental and physical health impacts of detention on children,^11,12,13  and prolonged detention on all individuals, are well documented.^14,15,16 The RACGP acknowledges that, within the constraints of the current legislative framework, there needs to be a quality and safety standard to optimise delivery of healthcare to those detained in immigration detention facilities.  The RACGP has therefore developed the Standard for health services in Australian immigration detention facilities (2^nd Edition) to help ensure all people in these facilities have access to safe and quality healthcare.

The RACGP supports the UNHCR’s global strategy to end the detention of asylum-seekers and refugees.¹⁷

Access to Medicare

An additional barrier for many people seeking asylum is lack of continual access to Medicare. Multiple changes to the processing of Protection visa applications and the policies that inform these processes mean that depending on the mode and date of arrival, different groups of people seeking asylum have been and continue to be processed under different systems, with different entitlements. It is important to recognise that individuals’ circumstances may change (e.g. from detention facilities to community detention programs or onto a bridging visa) and that eligibility for certain services (including Medicare) can fluctuate during the visa determination process.² Consistent access to Medicare, and therefore consistent access to affordable healthcare, reduces uncertainty, improves engagement with health services, and reduces the high economic costs of delayed access to care, particularly to preventive care. While some states provide access to state funded services for people seeking asylum ineligible for Medicare this is inconsistent across the country. The RACGP supports a policy of providing full access to both federally and state funded services for people seeking asylum once they have lodged a claim for protection.

Research and Evaluation

There is a growing body of evidence pointing to the specific health care needs of people from refugee backgrounds and people seeking asylum. However, more research is required to expand our knowledge of healthcare needs and best practice primary healthcare for people from a refugee background.

Improving health outcomes requires better reporting of cultural and linguistic diversity¹⁸. Five data fields; country of birth, year of arrival, language spoken, need for interpreter, and cultural background (eg Polynesian or North African), have been identified as essential to the delivery of safe, quality care to people of culturally and linguistically diverse (CALD) backgrounds.¹⁹ Collecting this data is not only essential to the delivery of effective care, but it also enables important aspects of care delivery to be measured, facilitating evidence-based policy development, resource allocation, and service planning. The RACGP recommends that the Australian Institute of Health and Welfare (AIHW) leverages current data linkage projects to ensure the collection of a minimum dataset that enables annual reporting on the health and healthcare needs of people from refugee backgrounds and people seeking asylum. 

It is recommended that all healthcare services (in both primary and secondary care) are supported to collect this data to inform local health needs assessments effectively as well as providing national data that is current and relevant. To enable this, it is essential that all healthcare software supports collection of this data and to work with the Australian Digital Health Agency to ensure CALD data is incorporated.
Having the correct datasets in primary health care will enable GPs in each practice to gather more meaningful data about their patients by ensuring that the demographic data provide a cultural and linguistic lens that is key to addressing many of the community's health care issues. The RACGP sample registration form shows how this information could be selfreported by new patients²⁰.
 

Coordination of Services and a National Refugee Health and Wellbeing Framework

Improved coordination between relevant Commonwealth and State agencies and peak bodies with expertise in refugee health is also required to enhance outcomes for people from refugee backgrounds and people seeking asylum. Current issues include:

• a lack of consistency in how refugee health services are structured and funded across the states and territories.
• variability in how quickly newly arrived refugees can access the health services that they need.
• significant wait times and obstacles to accessing the National Disability Insurance Scheme (NDIS) and no access for people seeking asylum.
• limited capacity to provide coordinated and consistent ‘surge responses’ to emergent health and humanitarian crises, for example the COVID pandemic, the Afghan evacuation, and the war in Ukraine.

People from a refugee background should experience a continuum of care from their initial Immigration Medical Examinations (IME) (generally performed overseas), through to their Departure Health Checks (DHC) and ultimately linkage with local refugee health services/general practitioners after arrival in each state and territory. Appropriate clinical handover (including prompt transfer of demographic and health information) across this continuum provides optimal opportunity for completion of a timely comprehensive health assessment post arrival. This will enable people from a refugee background to access recommended healthcare including screening and catch-up immunisations and facilitate early linkage with other health services where appropriate. 

For those seeking asylum, healthcare may also have been delivered through immigration detention health services. Appropriate clinical handover and transfer of care is equally important in this setting.

The RACGP recommends the creation of a National Refugee Health and Wellbeing Framework to support a more consistent, equitable, responsive, and integrated approach to the delivery of healthcare for refugees across Australia. The RACGP supports work done by The Refugee Health Network of Australia (RHeaNA) in identifying key considerations which would underpin the framework and support a more strategic approach to refugee health and wellbeing. 

In 2022 the Queensland Government published the updated Refugee Health and Wellbeing Policy and Action Plan 20222027 for Queensland.  A national framework would bring consistency across the States and Territories and help clarify the roles of the Commonwealth and State governments and inform policy and funding decisions across all government spending.

Training and support for healthcare providers

The RACGP strongly recommends that education and training in caring for people from a refugee background, including those seeking asylum should be included in undergraduate, postgraduate, and professional medical education programs. The 2022 RACGP curriculum and syllabus contains a contextual unit on migrant, refugee, and asylum seeker health and the RACGP has endorsed the Migrant and Refugee Women’s Health Partnership Competency Standards Framework to guide Culturally Responsive Clinical Practice.

The RACGP has structures to support general practitioners interested in becoming more involved in migrant, refugee, and asylum seeker health. For information on RACGP Specific Interests Migrant, Refugee, and Asylum Seeker Health please contact RACGP Specific Interests.
Alongside the RACGP Standards already mentioned, the RACGP also has resources on its website to assist GPs in providing healthcare for people from a refugee background. GPs may also find useful resources from organisations such as the Refugee Health Network in your State, State Governments, PHNs, and the Australian Refugee Health Practice Guide.  It’s important that up to date evidence-based resources continue to be available to guide GPs and other healthcare professionals.  The RACGP supports continued investment in the development of up-to-date, evidence-based guidelines.

The RACGP recognises the importance of a diverse workforce in responding to the diverse needs of all Australians and supports a more inclusive and diverse health workforce through identification of recognised pathways for International Medical Graduates from a refugee background to enter the Australian medical workforce.  

Conclusion

It’s essential that refugees and people seeking asylum have access to high-quality care which is responsive to the diverse needs of this group.  This care must be coordinated, comprehensive, culturally responsive, and trauma-informed.

General practitioners have a key role to play in supporting this group, but they need to be supported through access to interpreters, appropriate education and training, evidence-based research, a coordinated approach between health services, and guided by a national strategy.

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Author:                   RACGP Specific Interests
Contact:                 gpsi@racgp.org.au   
Review date:         2026