Analysing health systems responses to forced migration through the complementary lenses of resilience and responsiveness

Biddle LR. Analysing health systems responses to forced migration through the complementary lenses of resilience and responsiveness. Bielefeld: Universität Bielefeld; 2023.Since the “summer of migration” in 2015, there has been renewed interest in how best to integrate asylum seekers and refugees (ASR) in social and welfare systems across Europe, including health systems. The German health system has been slow to learn from previous periods of high in-migration of ASR, such as the early 1990s. In the light of continued migration, it is important to understand factors that can equip health systems for an adequate response. The aim of this thesis is to analyse the German health system response to ASR migration since 2015 using the concepts of health system resilience and responsiveness; assessing its capacity to collect and integrate different forms of knowledge, handle uncertainties and multiple cross-scale dynamics and create trusted and legitimate institutions, and to derive practical policy solutions to improve the resilience of future responses. This thesis derives an analytical approach for assessing health system resilience from a literature review on empirical studies on the concept (paper I). It then follows a structured assessment of resilience following Blanchet et al.’s (2017) four resilience capacities, presenting research from a literature review of ASR and migrant data collection and integration practices across Europe, including Germany (paper II), the results of a state-wide, population-based, cross-sectional health monitoring survey among ASR in collective accommodation centres (papers III and IV) as well as two qualitative studies with health and integration authorities: the first assessing models of care implemented in ASR reception centres (paper V) and the second mapping public health measures taken in response to the Covid-19 pandemic (paper VI). Overall, the analysis shows room for improvement in all four resilience capacities. Substantial health information gaps, inadequate anticipation of potential future challenges, a lack of evidence-based best practices and lack of a dedicated coordination function for ASR health has hampered a resilient response. Locally, several initiatives have demonstrated how resilience capacities may be strengthened through the increased involvement of public health offices in ASR health. Improved guidance and coordination from national institutions could further strengthen the resilience of the system. The responsiveness of services is generally high, but trust could be further strengthened through the institution of accountability mechanisms at patient and community levels. Going beyond health system accessibility, the resilience and responsiveness lens allowed for an analysis of the “system software” of the German health system for ASR. Applying this lens more rigorously in research on ASR health could contribute to a deeper understanding of health system responses, not just in Germany but internationally