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 2019until the end of 2021, 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.[5]
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).[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]
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.
Complementary services by NGOs
In 2021, the MDM-Belgique team consisted of a medical doctor, a nurse and interpreters for Arabic and Farsi (4 interpreters in total). [11] 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 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, and organised the transport schedule and patient transportation (including the transport schedule for the Croatian Red Cross).
Regular vaccination of children was carried out continuously in 2021 through the cooperation with Health Centre, Andrija Stampar Teaching Institute of Public Health and the Croatian Institute of Public Health and MDM-BELGIQUE.
In 2021, the MdM’s medical team carried out 1,603 medical consultations with applicants for international protection, out of which 211 initial medical examinations. Out of the 1,603 medical consultations: 44.3% were performed with women and 21.6% with children. The most represented nationalities were Afghans (42.1%) Iranians (10.3%) and Iraqis (8.2%). In addition, a total of 588 transports of 310 applicants for international protection to health care facilities for the necessary specialist and diagnostic treatment were performed (including 93 transports for children to paediatricians/vaccinations/school medicine specialists). In addition, 53 transports / escorts to public health facilities were also provided for the purpose of vaccination against the virus SARS CoV-2.
Applicants for international protection were informed about the maintenance of hygiene, health care and protection primarily during medical consultations and health examinations, especially during the initial medical examinations of newly arrived applicants and during organised preventive health workshops. A total of 10 workshops were held in 2021 for 91 applicants.
Two MdM’s psychologists conducted initial psychological assessments and individual psychological counselling sessions every working day for 6 hours and emergency interventions as needed. An external associate- psychiatrist visited the Reception Centre in Zagreb three times a month. Compared to 2020, there was an increase in the number of reports on sexual and gender based violence (SGBV) during 2021, i.e. violence experienced within the Reception Centre, during transit or in the country of origin. MDM-BELGIQUE psychologists offered adequate psychological help and support and, if necessary, included them in adequate psychological and / or psychiatric treatment.
The MdM team provided 657 individual psychological counselling sessions and 136 specialist psychiatric examinations in the course of 2021. Moreover, 7 informative-preventive workshops on mental health care were held with the participation of a total of 54 applicants for international protection as well as 6 workshops for a total of 72 women and girls.
All children who stayed in the Reception Centre upon arrival and for whom it was possible to obtain an appointment for specialist examination, were examined and vaccinated if necessary by a paediatrician at the Health Center Zagreb – Center or „Andrija Stampar“ Teaching Institute of Public Health. MDM-Belgique provided transportation of children to relevant health institutions and hospitals and other health centers with paediatric clinics.
Pregnant women who stayed upon arrival in the Reception Centre were examined by a gynaecologist at the Health Center and at the hospital. The MDM – Belgique team coordinated the transport of pregnant women for examinations, as well as visits of the nurse after childbirth. During 2021, 58 pregnant women were accommodated in the Reception Centre.
During the initial medical examination, applicants for international protection with a possible problem of addiction to psychoactive substances were referred to an MDM’s psychiatrist (subspecialist in addiction) or to „Andrija Stampar“ Teaching Institute of Public Health and MDM – Belgique team ensured transportation as well as the subsequent supervision and issuance of prescribed pharmacotherapy in cooperation with the doctor of Health Center on a daily basis.
MdM noted that the proportion of women, children, families, patients with chronic or serious illnesses, as well as people with disabilities, continued in 2021 among applicants. In addition, during 2021, there were five accidents in which foreigners were seriously injured while some of them died. (see more under Access to the territory and pushbacks). The victims suffered severe bodily injuries, which required daily care in conditions which were not intended for the treatment of such injuries. In addition, applicants needed adequate psychological assistance in the form of crisis interventions, individual psychological counselling group work and psychiatric care in order to try to overcome the trauma experienced, develop and strengthen psychological resilience and adequate coping mechanisms with traumatic experience, and maintain and / or improve functionality after a traumatic experience. All of the above required additional efforts from the MDM-BELGIQUE team.
Since March 2020 and during the whole 2021 the MDM-BELGIQUE team was also in charge of health protection and prevention of spread of COVID-19 disease among applicants for international protection accommodated in the Reception Centre in Zagreb and provision of health care to applicants who were affected by COVID-19. From March 2020 onwards, the MDM-Belgique team implemented a number of preventive measures and recommendations i.e. ensured hand disinfection in several places in the Reception Centre, carried out daily temperature measurement of all applicants, distributed protective masks, disseminated and translated info-preventive material and established telephone and e-mail communications of applicants who were isolated with psychologists and a psychiatry specialist as needed. Specific info-materials were also produced and distributed to applicants in self-isolation. MDM-BELGIQUE developed a Protocol on the treatment and testing strategy when there is suspicion of COVID infection, which has proved necessary in coordinating the work of all services and organisations working within the Reception Centre. The Protocol is regularly updated in accordance with official instructions.
Since the beginning of September 2020 until 1 March 2021, the staff of MDM-BELGIQUE operated in two teams, which rotated every 14 days due to the increase in the number of COVID -19 patients in Croatia, and in accordance with the instructions of the Ministry of Interior. Given the need for a doctor to be present in each team, another doctor was hired. The total number of persons in preventive quarantine reached 2,797 persons in 2021. Out of the total number of persons in quarantine (2,797), 420 persons were tested during the year, out of which only 48 were tested positive on COVID-19.
In the self-isolation premises, the health of the applicants was monitored daily and the measurement of the body temperature was carried out. Applicants that showed symptoms were immediately referred for coronavirus testing. In situations of suspicion of COVID 19, MDM-Belgique has fully taken over the organisation of testing in cooperation with „Andrija Stampar“ Teaching Institute of Public Health.
MDM-BELGIQUE supported the organisation of vaccination of applicants for international protection against COVID-19, which was carried out in the Reception Centre by the Croatian Institute of Public Health team on two occasions- i.e. on 19 July 2021 (79 applicants vaccinated) and on 28 December 2021 at the Shelter in Zagreb (67 applicants vaccinated). As of August 2021, regular transport / escorts to public health facilities for vaccination against COVID-19 were provided on regular basis.
However, MdM reported that the coronavirus pandemic continued to be a challenge for their team and required flexibility in line with recommended preventive epidemiological measures.Nevertheless, the long-term exposure of MdM staff to the significantly increased workload in the Reception Centre that is not sufficiently equipped and does not have enough staff to organize and maintain an efficient and safe quarantine space has caused high levels of stress and a sense of disproportionate responsibility among their employees.
A guide called “I want to be healthy” with general guidelines and preventive measures for physical and mental health was created in Arabic, English, Farsi, French and Croatian in October 2019, and a poster of the same name in November 2019.
In 2020, MdM has produced the publication “Everyone has the right to healthcare: A model of healthcare mediation/support intended for asylum seekers in Croatia – outline, challenges & recommendations”.[12] The publication describes various components of the health care model, as well as the results in terms of facilitating access to health care for applicants of international protection in Croatia. The publication was published in Croatian and English.
Since 1 August 2020, the possibility of continuous, individualised, language-adapted and culturally aware monitoring of health and health care has been ensured within the Reception Centre for Applicants for International Protection through a new project implemented by MdM,.
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.[13] 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 will end on 31 December 2022.
Mental health
Psychological counselling and support was provided by MdM during 2021.[14] Two MdM’s psychologists conducted initial psychological assessments and provided individual psychological counselling sessions every working day for 6 hours, as well as emergency interventions as needed. An external associate- psychiatrist visited the Reception Centre in Zagreb three times a month. The MdM team provided 657 individual psychological counselling sessions and 136 specialist psychiatric examinations in the course of 2021. MDM reported that the organisation of preventive and treatment interventions related to the mental health of applicants for international protection is working well thanks to the established and improved interdisciplinary cooperation of MDM – BELGIQUE with a general practitioner, psychologist and psychiatrist, as well as due to referrals to psychiatric hospitals, Institute for Child and Adolescent Psychiatry and Psychotherapy of the University Hospital Centre Zagreb and the Child and Youth Protection Center of the City of Zagreb, which are supported by interpreters and MDM staff as needed.
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.[15] 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).[16]
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.
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” .[17] 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, 19 January 2022.
[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] Information provided by MdM, 19 January 2022.
[12] MdM, Everyone has the right to healthcare: A model of healthcare mediation/support intended for asylum seekers in Croatia – outline, challenges & recommendations, 2020, available at: https://bit.ly/3sEwEIH.
[13] Ministry of Interior: Decision on the allocation of financial resources 31 July 2020, available in Croatian at: https://bit.ly/3eiRKat.
[14] Information provided by MdM, 19 January 2022.
[15] Article 57(2) LITP.
[16] Official Gazette 28/2020, available in Croatia at : https://bit.ly/2QKE3ZK.
[17] Information provided by MdM, 17 January 2021.