How to improve the health and access to care of uninsured migrants in Montreal?

Starting in 2013, researchers from different universities and backgrounds and Doctors of the World Canada, committed to a participatory process for developing the protocol of an intervention research on migrants without health insurance. The first phase of the research allowed for an understanding of the intervention by Doctors of the World, an assessment of available knowledge and the identification of research objectives. For details see the research notes and posters.

Canada has very few studies specifically focusing on access to healthcare by people without medical insurance. Most previous studies aim to assess the level of access to healthcare by migrant pregnant women without medical insurance or study a specific group of migrants such as asylum seekers.

Since 2011, immigration policies in Canada have become increasingly restrictive. Consequently, it has become harder to obtain permanent resident status and access Medicare (RAMQ). The number of migrants with temporary, incomplete and/or expensive health insurance has risen exponentially. However, there is no statistical data available to verify the situation observed in the field. It is also noteworthy that a lot of migrants with precarious status are uninsured for long periods of time. Once again, this information has not been documented. This means that in case of illness, these future Canadians have to pay for their care and often pay fees that are higher than those paid by Canadian residents. On the other hand, for some, it becomes impossible to have access to healthcare whilst ill or seriously ill. In Montreal, the Doctors of the World clinic is the only place where people without health insurance can have access to free healthcare. This clinic is able to provide care for a specific health problem only. Doctors of the World is unable to offer all the services needed due to limited resources.

1. To study the health status and access to care of uninsured migrants.
2. To understand the development, implementation and sustainability of health initiatives for this population throughout Canada, in order to create strategies applicable in the Montreal context.
3. To understand the viewpoints and decisions of stakeholders at all decision-making levels within the health system.
4. To generate results that are widely applicable, as well as to contribute to social change and development of policies that may in turn favor improving the population’s access to healthcare.

Our study includes: all migrants with no public or private health insurance. People without a RAMQ card, the Interim Federal Health Program (IFHP) for asylum seekers, or private health insurance at the time of the study. Participants should be over 18 years old, live or have the intention of living in Quebec for at least 6 months. Those excluded from the study are permanent residents who do not have healthcare due to their RAMQ card having been stolen or lost. Those who await the receipt of the RAMQ card, i.e. within in the three months delay, are also not included in this study.

A quantitative survey will be carried out on uninsured migrants. It will be focused mainly on access to care, health, work and living conditions. The participants will be partly recruited at the Doctors of the World clinic (Total=500) while others will be selected from within the community (Total=400). The questionnaire will be prepared in French, English, Spanish, Haitian Creole, Mandarin.

Qualitative interviews will be conducted with 30 participants who have experienced illness whilst lacking health insurance to find out about their life trajectory and access to health services during this period.   The interviews will include those who easily accessed care, as well as others who did not access healthcare services so as to compare both groups’ life and health trajectories.

About health initiatives

Qualitative interviews will be carried out with people working on health initiatives (including health and social work professionals, administrators, etc) in Montreal (Total=20), Toronto (Total=8) and Vancouver (Total=8). We will try to understand how the initiatives were developed, their goals and the way through which have they have become sustainable (or not).

About policymakers

Qualitative interviews will be conducted with 20 policymakers and administrators working as part of Quebec’s professional associations and the public health system. We are going to analyze the decisions and recommendations made regarding uninsured migrants as well as the factors that influenced them. We will also analyze their knowledge of this complex problem.

For an overview of the project, read the summary section at the top.

Co-researchers:

• Josephine Aho,  Epidemiologist, Director of Public Health Montreal.
• Patrick Cloos, Associate Professor at the School of Social Work, University of Montreal.
• Jill Hanley, Associate Professor at the School of Social Work, McGill University.
• Elhadji Mbaye, Postdoctoral Researcher at the Institute Beauvoir, Concordia University.
• Maria Muñoz-Bertrand, Doctor, Director of Public Health Montreal, Clinical Lecturer at the Department of Family Medicine and Emergency Medicine, University of Montreal.
• Marie-Jo Ouimet,  Doctor, Director of Public Health Montreal, Clinical Lecturer at the Department of Social and Preventive Medicine (DMSP) at the School of Public Health, University of Montreal (ESPUM).
• Marie France Raynault, Medical Advisor, Director of Public Health of Montreal, Professor at the School of Public Health, University of Montreal (ESPUM).

Students:

• Jessika Huard
  Master’s student in public health, global health option, in the School of Public Health of the University of Montreal (ESPUM). Her traineeship is on the development of recruitment strategies in community organizations and places of worship. Her interests are: Reproductive health, HIV in developing countries, access to care for vulnerable populations, immigrants’ health and social inequalities in health.
• Ke Zhou
  Master’s student in public health at the School of Higher Studies in Public Health (EHESP) from Rennes, France. His traineeship is on the development and implementation of recruitment strategies in hard-to-reach communities. He is particularly interested in socio-ecological interventions, integrating elements of epidemiologic and economic evaluation.
• Solène Lagrange
  Trainee with the research coordinator. She is a pharmacist by training and holds a Master’s degree in public health from the Institute of Public Health, Epidemiology and Development of Bordeaux, France. She is particularly interested in issues of access to health care and population health, and the links between public health policies and societal issues. She chose to associate her medical knowledge with the management, evaluation, organization of health care and the health welfare of the populations.
• Veronica Torres
  Master’s Degree in Public Health, Global Health Option at the School of Public Health of Université de Montréal. She is a specialist in ENT with several years of professional practice in the public and private sectors. She works on health initiatives for precarious migrants in Montreal, Toronto and Vancouver. She mainly focuses on vulnerable populations, universal access to care and social inequalities in health.
• Ekta Kumar
  Trainee in social work at McGill University. She is concerned with the protection of human rights and universal access to health services. In addition, she wants to better understand the issues facing migrants. She focuses on raising awareness among South Asian clients and building relationships with community organizations in Montreal.

Research Coordinator:
Magalie Benoit, Msc, Public Health Research Institute of the University of Montreal (IRSPUM)