Caring for Newcomers, Migrants and Refugees

Some newcomers have precarious immigration status that prevents them from accessing public healthcare – these include undocumented migrants (including rejected refugee claimants and tourists who have overstayed their visa), temporary foreign workers without a valid work permit, Seasonal Agricultural Workers (with the exception of those in Manitoba) and some refugees and refugee claimants. Although access to healthcare through the Interim Federal Health Program has been reinstated for most refugees and refugee claimants, there remains confusion that results in some healthcare providers turning away eligible patients and denying them care.

In some provinces (Ontario, Quebec, New Brunswick), immigrants with permanent residence in Canada must wait three months after arrival in Canada to be eligible for provincial healthcare, creating barriers for the duration of the delay, as they must pay for healthcare.

For people in the precarious situations listed above, who don’t have healthcare coverage, a key barrier to accessing healthcare is financial. Many of those living with precarious status can’t legally work, so they are likely to receive low wages when they do work, and are often unemployed. People with precarious status who suffer from chronic illness or mental illness are also likely to be unemployed and therefore have little to no income to pay for health services.

Newcomers may need interpretation to fully understand their healthcare provider and make informed decisions. Even if they speak some English or French, they may not feel comfortable discussing their health in a language they are not proficient in. There are also issues around appropriate interpretation. If a patient’s only option for interpretation is their child for example, they may not be willing to discuss certain health issues, such as sexual and reproductive health issues. Even if there is a professional interpreter, newcomers may hesitate to speak openly out of fear that their personal information may reach others from the same country, particularly if the community is small.

Refugees are often eligible for services under the Interim Federal Health (IFH) Program, in addition to, or instead of, provincial health coverage. In June 2012 major cuts were made to IFH: services covered were narrowed and complex rules were implemented about which categories of refugees were entitled to which services. Many health care providers were reluctant to provide services covered by IFH because of the complicated bureaucracy. Some provincial governments stepped in to provide some of the services cut.

In July 2014, the Federal Court ruled that the cuts were a violation of the Canadian Charter of Rights and Freedoms. To comply with the court order, the federal government added in November 2014 some additional coverage for certain categories of refugees.

The new government elected in October 2015 has committed to restore IFH as it existed prior to the 2012 cuts.

Under the Immigration and Refugee Protection Act, non-Canadians applying to enter or remain in Canada may be inadmissible on health grounds if they have a health condition that is likely to be a danger to public health or safety or might “reasonably be expected to cause excessive demand on health or social services”. This means, for example, that a person living with HIV who applies to become a permanent resident might be refused on the basis of their HIV status, on the grounds that their condition might cause excessive demand.

People applying as refugees or sponsored by a spouse or parent are not subject to the rule about excessive demand. However, they can still be refused if they have a health condition that represents a danger to public health or safety.

Many refugees arrive in Canada with Post-Traumatic Stress Disorder as a result of their experiences of persecution. In addition, the migration experience can cause mental health issues to emerge for any category of newcomer. Yet, mental health services are often not available (whether for newcomers or citizens).

The healthcare system in Canada is different from that in many newcomers’ countries of origin, and newcomers have often not received orientation on what to expect from healthcare in Canada. For example, some people may be used to a system where one only sees a doctor when one is sick or if there is an emergency, or they may be used to going directly to a specialist. This means that the person may not go for preventative care or to talk about healthcare strategies, or they may drop-off after an initial appointment with a general practitioner and not seek further care. It can also be challenging to schedule and keep punctual appointments, due to differences in expectations in the Canadian system.

Some service providers may want to take a participatory approach to healthcare, however not everyone has the same expectations and levels of health literacy, and there may be some patients who want their healthcare provider to be an authority figure.

Lack of access to childcare can also be a barrier for parents wanting to see a healthcare provider without their child present.

Tip: It can help for healthcare providers to be flexible (around scheduling, for example), but also to provide guidance to patients on what the healthcare system here can offer, how it works, and what the expectations of the patient are.

Many people aren’t aware of their sexual and reproductive rights because discussing sex is taboo in their community. For example, some people may not know about the right to not have sex with a spouse. Reticence to talk about sex can make preventative care difficult. On the other hand, some newcomers have plenty of knowledge on this issue.

Tip: Avoid making assumptions about who will or will not be open to talking about sex. Make sure the door is open to talking about sex on a regular basis, with patients regardless of age (young or old). Let your patient know that you’re happy to discuss it and that it’s important. If you are a male practitioner working with a female patient, and discussing with a female practitioner is an option, let them know (and vice versa).