Author
Primary health care
Applicants are entitled to health care. However, the LITP prescribes that health care includes emergency care and necessary treatment of illnesses and serious mental disorders.[1]
In 2020, an Ordinance on health care standards for applicants for international protection and foreigners under temporary protection entered into force regulating, amongst other, initial and supplementary medical examinations and the scope of health care for applicants of international protection.[2] Additionally, the Ordinance lists the different vulnerable groups entitled to health care as follows: persons deprived of legal capacity, children, unaccompanied children, elderly and infirm persons, seriously ill persons, persons with disabilities, pregnant women, single parents with a minor children, people with mental disabilities and victims of human trafficking, victims of torture, rape or other psychological, physical and sexual violence, such as victims of female genital mutilation. These categories of persons have a right to psychosocial support and assistance in appropriate institutions A pregnant woman or a parturient woman who requires monitoring of pregnancy and childbirth is entitled to health care to the same extent as insured person from compulsory health insurance. Children up to the age of 18 are guaranteed the entire right to health care in accordance with the legislation governing the right to health care from compulsory health insurance.[3]
Medical assistance is available in the Reception Centres for Applicants for International Protection in Zagreb and Kutina. While no information is available for the period from 2019 until the end of 2022. At the beginning of 2019, the Ministry of Interior reported that health care is also provided by the health care institutions in Zagreb and Kutina designated by the Ministry of Health.[4] In the Health Centre, a competent ambulance (family medicine) has been designated for the provision of health care from the primary health care level for chronic and life-threatening illnesses. A specialist ambulance for vulnerable groups has been appointed by the Ministry of Health and Local Health Centres. This includes: paediatric ambulance, gynaecological ambulance, school medicine ambulance, neuropsychiatric ambulance at the Hospital of Kutina, ambulance for addiction treatment; dental ambulances and Psychiatric Hospital in Zagreb.
In addition, applicants are referred to local hospitals i.e. in Sisak for those accommodated in Kutina, and the Hospital of Zagreb. The competent pharmacies, one in Zagreb and one in Kutina, have also been determined. Vaccination is performed by doctors in health centres or by specialists of school medicine.
A medical team of MdM was present at the Reception Centre in Zagreb every working day.
Due to outbreak of COVID 19, after being accommodated in Reception Centres for Applicants of International Protection, applicants for international protection were placed quarantine.
Until June 2021, the self-isolation period lasted 14 days for all newcomers who arrived from Bosnia and Herzegovina, Serbia and other high-risk countries, while from June 2021 the self-isolation period was shortened to 10 days (except for persons returned under the Dublin Regulation, whose duration of self-isolation remained at least 14 days).[5]
In May 2022, the mandatory preventive isolation rules for the newly arrived applicants in the Reception Centre for Applicants of International Protection were lifted, and a smaller isolation area was maintained only for patients who were SARS CoV-2 positive and their contacts.[6]
At the beginning of the COVID-19 pandemic, the Croatian Institute for Public Health issued Protocol related to testing for COVID-19 / SARS-CoV-2.[7] The protocol states that, among others, applicants for international protection and refugees belongs to priority groups for testing.
Information posters and/or leaflets on COVID 19 and hygiene were prepared by the Croatian Institute for Public Health and Ministry of the Interior,[8] Médecins du Monde (MdM),[9] and the Croatian Red Cross.[10]
Multilingual info-prevention posters and flyers for applicants were displayed in the Reception Centre for Applicants for International Protection.
In July 2021, the government decided to provide access to COVID-19 vaccination both to Croatian citizens and other persons who hold foreign citizenship and who do not have status of insured persons in the Republic of Croatia.
In 2022, in cooperation with IOM Slovenia and Croatian Ministry of Interior, posters and brochures on vaccination against COVID-19 were developed in several languages and distributed, among others, to the Reception Centre for Applicants of International Protection. The brochures list the benefits of vaccination against COVID-19, explain how applicants and beneficiaries of international protection can approach vaccination, and present the currently available vaccines and their possible side effects. Information on the validity of the vaccination certificate against COVID-19 and general protection measures can be also found in the materials. A total of 1,300 brochures and 25 posters were distributed. Furthermore, an awareness video for applicants and beneficiaries of international protection was developed to raise awareness of the importance of vaccination against COVID-19 and support informed decisions about vaccination against COVID-19. The video which is available in 5 language versions can be found on the website of IOM Croatia, as well as brochures.[11] In addition, it was distributed to key stakeholders for their use in future prevention activities involving migrant communities.[12]
In 2022, as in 2021, MDM-BELGIQUE’s team also further informed applicants for international protection about the possibility of vaccination and organised transportation with interpreters to the main public vaccination centre in Zagreb.
In 2022, MDM-BELGIQUE’s team developed info-prevention posters/leaflets on three different topics: “How I feel matters”, “Everyone has the right to birth control” and “There is no room for violence in the family”; as well as a brochure on mental health.[13]
In 2023, MdM issued the publication “Physical and mental health of applicants for international protection in the Republic of Croatia – new trends, observations, challenges and recommendations”.[14]
Complementary services by NGOs
In 2022, the MDM- BELGIQUE’s team consisted of one general practitioner, one nurse and interpreters (4-6 interpreters throughout 2022 – for Arabic, Farsi, Russian, Spanish and French languages).[15]
The MDM-BELGIQUE team provided health care for applicants for international protection in the Reception Centre for Applicants for International Protection and facilitated their access to public health institutions in order to gain access to the primary health care, specialist-consultative and diagnostic examinations and treatment. This included conducting initial health examinations of newly arrived applicants and providing continuous health consultations in the premises of the Reception Centre (work with patients: 6 hours every working day) in order to facilitate access to a general practitioner of the Ambulance for applicants for international protection at the local Health Centre. These activities enabled the MDM-BELGIQUE medical team to assess the health status of applicants for international protection and to organise appropriate treatment and additional health care following the recommendation of a general practitioner of the Ambulance for applicants for international protection (if referral is required).
In order to provide comprehensive support and care to patients, the community worker / social worker and interpreters/cultural mediators provided practical support to applicants for international protection in terms of interpretation, provision of information and counselling, transport of patients to health care facilities. MDM-Belgique arranged the dates of examinations in health care institutions, organised the transport schedule and patient transportation (including the transport schedule for the Croatian Red Cross) and accompanied patients to their appointments with the help of interpreters.
Regular vaccination of children and medical visits for pre-school/school enrolment were carried out continuously in 2022 through the cooperation with the Health Centre and Andrija Štampar Teaching Institute of Public Health. Transportation of children to relevant health institutions and hospitals and other health centres with paediatric clinics was conducted regularly.
In 2022, the MdM’s medical team carried out 3,076 medical consultations with applicants for international protection, out of which 2,342 were initial medical examinations of newly arrived applicants. Out of the 3,076 medical consultations: 44.7% were organized with women and 33.1% with children. The most represented nationalities were Kurdish population from Iraq and Türkiye (25.9%), Afghans (16.7%) and Cubans (13.6%). In addition, a total of 380 transports of 250 applicants for international protection to health care facilities for the necessary specialist and diagnostic treatment were performed (including 27 transports for children to paediatricians/vaccinations/school medicine specialists).
Furthermore, in 2022, between 2 and 11 pregnant women were accommodated at the same time at the Reception Centre in Zagreb (total of 101 during the entire year). MDM-BELGIQUE’s team provided them with comprehensive healthcare services in cooperation with the Outpatient Clinic Zagreb – Centar (including gynaecological examinations and necessary tests) and accompanied them to the Clinical Hospital for Women’s Diseases and Obstetrics of the University Hospital Centre Zagreb, or to the „Sveti Duh” Hospital.
In 2022, the MDM team also held info prevention workshops for women and girls. The workshops were held on the topic of mental health and psychosocial support, and took place, on average, once a week in the Reception Centre in Zagreb.
Given the specific conditions of the migration route, which include poor nutrition and limited possibilities for maintaining oral hygiene, a significant number of beneficiaries needed dental services. Through cooperation with “Health Centre Zagreb – Centar“, MDM-BELGIQUE tried to provide the necessary care to applicants who needed dental services in order to prevent the number of emergency dental treatments and complex interventions. For this purpose, communication was established with 12 dental medicine specialists, and successful cooperation was established with 8 of them. Regular organisation of dental care services presented the additional workload of organising transportation and interpretation, for MDM-BELGIQUE’s team.
Since March 2020 and throughout 2021 and 2022, MDM-BELGIQUE’s team was also in charge of health protection and prevention of SARS CoV-2 among the population of applicants for international protection accommodated in the Reception Centre for Applicants in Zagreb in close cooperation with Andrija Štampar Teaching Institute of Public Health, Ministry of Interior, Croatian Red Cross and other relevant stakeholders.
In early May 2022 and in agreement with the epidemiologist of the Andrija Štampar Teaching Institute of Public Health”, the mandatory preventive isolation rules for the newly arrived applicants were lifted, and a smaller isolation area was maintained only for patients who were SARS CoV-2 positive and their contacts. Patients with symptoms were further tested and received appropriate treatment/medical follow-up when tested positive for SARS CoV-2.
MDM-BELGIQUE’s team further also informed applicants for international protection about the possibility of vaccination and organised transportation with interpreters to the main public vaccination centre in Zagreb. Lastly, multilingual info-prevention posters and flyers for applicants were displayed at the facility.
In 2022, 1403 persons went through preventive isolation area of the Reception Centre for Applicants for International Protection (which was removed in May 2022), 199 persons were tested, 48 persons who tested positive for SARS CoV-2 received appropriate treatment/medical follow-up and 125 persons were supported to access vaccination against SARS CoV-2.
In total, in the period between March 2020 and December 2022, 5,569 persons went through an isolation area in Reception Centre for Applicants for International Protection in Zagreb (removed since May 2022), 799 persons were tested; 122 persons who tested positive for SARS CoV-2 received appropriate treatment/medical follow-up; 321 persons were supported to access vaccination against SARS CoV-2.
Two MDM-BELGIQUE’s psychologists further conducted initial psychological assessment and individual psychological counselling (working with beneficiaries for 6 hours every working day), as well as emergency interventions when needed in 2022. Alongside permanent team members, MDM-BELGIQUE continued to cooperate with an external associate (psychiatrist) in 2022, who was conducting psychiatric examinations of asylum seekers in Zagreb three times per month. Compared with previous years, in 2022, MDM-BELGIQUE observed additional increase of sexual and gender-based violence cases (SGBV) – with a total of 66 cases. MDM-BELGIQUE offered adequate psychological assistance and/or psychiatric treatment to all survivors as well as assistance with other necessary referrals – in cooperation with relevant service providers.
Main challenge encountered by MDM throughout 2022 was the large surge in the numbers of applicants for international protection in Croatia as well as further intensification of transit migration levels (at the beginning of 2022, applicants were staying in Croatia for, on average, 30 days, while during August and September for an average of 3 days).
Besides particularly complex cases (which included post-operative care after reconstructive foot surgery, cases of severe PTSD, suicidality, severe chronic diseases and acute conditions), increasing arrivals resulted in a large surge in the number of first health examinations that needed to be conducted by the team (up to 110 newcomers per day; with some weeks with around 500 arrivals), but also additional administrative work of ordering diagnostics tests, specialist examinations and planning transport schedules – that often needed to be cancelled because applicants left Croatia before scheduled appointments. The increased workload resulted in high level of stress and fatigue for the origination’s staff.
In July 2020, the Directorate for European Affairs, International Relations and European Union Funds issued a decision on the allocation of financial resources for the implementation of the project to be implemented by MDM.[16] The aim of the project is to protect the health and prevent disease among applicants of international protection through improved access to first examinations and medical consultations in Reception Centres for applicants for international protection. The project lasts until 31 December 2022.
Due to lack of funding, MdM had to temporary suspend their activities inside the reception centers for applicants for international protection from 22 May 2023.[17]
Mental health
Psychological counselling and support was provided by MdM during 2021.[18]
Two MdM’s psychologists conducted initial psychological assessments and individual psychological counselling sessions every working day for 6 hours, as well as emergency interventions when needed. Cooperation with an external associate – psychiatrist continued in 2022 who was visiting the Reception Centre in Zagreb three times a month. An increase in the number of reported cases of sexual and gender-based violence (SGBV) (as well as the number of applicants) compared to the previous year was noted in 2022. A total of 66 cases were reported. MdM’s psychologists offered adequate psychological help and support and, if necessary, included them in adequate psychological and/or psychiatric treatment. During 2022, 665 individual psychological consultations were carried out by two psychologists, and 96 specialist psychiatric examinations were conducted by one psychiatrist.
In addition, three info-prevention posters/leaflets concerning mental health, protection of reproductive health and violence-prevention were distributed: “How I feel matter”, “Everyone has the right to birth control” and “There is no room for violence in the family””, as well as a brochure on mental health. Additional info-prevention workshops for women and girls on the topics of mental health and psychosocial support were also conducted on average once a week in the course of 2022.
Additional issues related to trauma and mental health of applicants for international protection are further described in Screening of vulnerability.
Special health needs
Applicants who need special reception and/or procedural guarantees, especially victims of torture, rape or other serious forms of psychological, physical or sexual violence, shall be provided with the appropriate health care related to their specific condition or the consequences resulting from the mentioned acts.[19] However, this type of specialised health care has been lacking for years in practice. According to the Law on Mandatory Health Insurance and Health Care for Foreigners in the Republic of Croatia, an ordinance which defines the scope of the right to health care for applicants who has been subject to torture, rape or other serious forms of violence and as well as for those with special health care needs, should have been adopted in previous years, however the Ordinance on health care standards for applicants for international protection and foreigners under temporary protection was finally adopted in 2020 and entered into force in March 2020 (see Primary health care for more information).[20]
According to national legislation, the procedure of recognising the personal circumstances of applicants shall be conducted continuously by specially trained police officers, employees of the Ministry of Interior and other competent bodies, from the moment of the expression of the intention to apply for international protection until the delivery of the decision on the application. However, according to CLC’s knowledge there is still no further detailed guidance available in the law, nor an early identification mechanism in the form of internal guidance. According to the Croatian Law Centre’s insights, less evident vulnerabilities such as those relating to victims of torture are much less likely to be identified in current practice (see Identification).
However, in 2020, as part of the project implemented by MDM-Belgique entitled: “Empowering Women and Children in the migrant population to take ACTion against sexual and gender-based violence (We ACT)”, Guidelines for dealing with cases of sexual violence against women and children were prepared. The content of guidelines was incorporated in the Standard Operational Procedure in Cases of Sexual and Gender-Based Violence in the Reception Centres for Applicants of International Protection” .[21] The Standard Operational Procedure was developed in cooperation with the Ministry of Interior, UNHCR, IOM, MDM-BELGIQUE, the Croatian Red Cross and the Croatian Law Centre. It entered into force in April 2021.
[1] Article 57(1) LITP.
[2] Official Gazette 28/2020, available in Croatia at: https://bit.ly/3asTWel.
[3] Article 9 (1) (4) Ordinance on health care standards for applicants for international protection and foreigners under temporary protection
[4] Information provided by the Ministry of Interior, 28 January 2019.
[5] Information provided by MdM, 19 January 2022.
[6] Information provided by MdM, 14 February 2023.
[7] Croatian Institute for Public Health: Protocol related to testing for COVID-19 / SARS-CoV-2, 21 March 2020, available in Croatian at: https://bit.ly/3nbDDYz.
[8] Croatian Institute for Public Health and Ministry of Interior leaflets available in Croatian at: https://bit.ly/3aotkeH; in Farsi at: https://bit.ly/2P9cf0V.
[9] MdM, ‘Washing hands poster’, 2020, available in severl langauges at: https://bit.ly/3vfZJw1.
[10] Croatian Red Cross information on available sources of information on COVID-19, available in Arabic at: https://bit.ly/3avMuPT.
[11] See: https://croatia.iom.int/improving-access-covid-19-vaccinations
[12] Information provided by IOM, 18 January 2023.
[13] Information provided by MdM, 14 February 2023.
[14] Available in Croatian at: https://bit.ly/3IQ6ZI7; and in English at: https://bit.ly/3C4pO6r.
[15] Information provided by MdM, 14 February 2023.
[16] Ministry of Interior: Decision on the allocation of financial resources 31 July 2020, available in Croatian at: https://bit.ly/3eiRKat.
[17] Information provided by MdM, 19 June 2023.
[18] Information provided by MdM, 14 February 2023.
[19] Article 57(2) LITP.
[20] Official Gazette 28/2020, available in Croatia at: https://bit.ly/2QKE3ZK.
[21] Information provided by MdM, 17 January 2021.