This submission is provided by cohealth, one of Victoria’s leading refugee and asylum seeker health services. cohealth welcomes the opportunity to contribute to the Department of Home Affairs review of the management and composition of Australia’s Humanitarian Program and would be keen for decision makers at the Department to meet with past and present cohealth clients with lived experience.
Individuals and families from refugee backgrounds demonstrate extraordinary resilience and strength as they adapt to life in Australia. They contribute to the rich diversity of the Australian community and bring with them a wealth of skills and expertise. Despite their incredible resilience, people who are refugees face a range of disadvantages and challenges throughout their resettlement journeys in Australia. This includes barriers to accessing essential services such as health care, mental health supports, employment, education, housing, and other social services that are fundamental to connecting with community and rebuilding their lives in Australia. Not only do these stressors exacerbate experiences of mental ill-health, but they have prevented Australia from taking advantage of the rich diversity of skills and knowledge that refugees contribute to the broader community.
The following sections of this submission provide an overview of cohealth, cohealth’s Refugee and Asylum Seeker Health Program, barriers to accessing essential services experienced by refugees receiving settlement assistance and key recommendations for the improvement of Australia’s Humanitarian Program.
cohealth is one of Australia’s largest community health organisations, delivering care from over 30 locations across the inner, north, and west of Melbourne as well as statewide services across Victoria. cohealth provides integrated general practice, medical specialist, dental, allied health, mental health, alcohol and other drug, counselling, family violence, and social support services to more than 50,000 people each year.
People using cohealth services typically experience social disadvantage and are consequently marginalised from mainstream health services or require a higher level of care and support – such as people who are experiencing homelessness, mental illness, people who use alcohol and other drugs, Aboriginal and Torres Strait Islanders, refugees and asylum seekers, recently released prisoners, LGBTIQ communities and people with chronic and complex health conditions.
cohealth’s Refugee and Asylum Seeker Health Program delivers affordable, high quality, and comprehensive health services to people seeking asylum or from refugee backgrounds in Victoria. cohealth’s specialised refugee health nurses and care coordinators assess each person’s physical and mental health needs to connect people to the right health and social services. This includes:
- Facilitating referral, and coordinated care of clients between health, settlement, and community programs
- Providing person centred, therapeutic services such as counselling and women’s health
- Building internal, external and community partnerships and programs to promote health and enhance service delivery
- Sector capacity building and advocacy in relation to refugee and asylum seeker health principles and practice
- Supporting the development of health literacy of individuals, communities and contributing to service system improvements that support health literacy
This program is funded by the Victorian Government’s Refugee Health Program and plays a vital role in improving the health and wellbeing of people from refugee and asylum seeker backgrounds.
Settlement assistance to Humanitarian Program entrants
According to the discussion paper, settlement services delivered by the Department of Home Affairs aim to provide early, tailored and intensive support to refugees and humanitarian entrants in the first five years after their arrival in Australia. Whilst cohealth acknowledges the Australian Government’s stated commitment to the wellbeing of migrants and refugees settling in Australia, significant improvements in the current settlement assistance provided to Humanitarian Program entrants are required to ensure their specific needs are met and they are empowered to be independent and participate in the Australian community.
The following sections outline key challenges experienced by people engaged in the Humanitarian Program in navigating and accessing essential services and supports.
Barriers to accessing health and mental health services
People who are refugees experience poorer physical and mental health than the broader Australian community due to experiences of war, civil unrest, extended periods in refugee camps, interrupted access to healthcare in countries of asylum and experiences of mandatory detention. Many have experienced traumatic events and losses and have undergone hardship during journeys of escape. These experiences often result in complex health needs related to:
- nutritional deficiencies
- immunisation coverage that does not meet the Australian immunisation schedule
- poor dental and eye health
- poorly managed chronic disease
- delayed development and growth in children
- chronic parasitic infections
- communicable disease
In addition to experiencing poorer physical health, people who are refugees also experience higher levels of psychological distress and increased risk of mental illness, including post-traumatic stress disorder, depression and anxiety. More than 50 per cent of people who sought asylum prior to being granted permanent protection are estimated to be living with major depression or post-traumatic stress disorder. Early access to culturally safe, holistic and accessible health care is therefore paramount to enabling positive health and mental health outcomes for humanitarian entrants.
Whilst everyone has the right to high quality and accessible health care, individuals and families from refugee backgrounds in Australia often experience significant barriers in accessing these services, including:
- Delayed access to Medicare
- Inadequate access to language services and interpreting services (ie. TIS is not available for optometry services)
- No or low income so unable to meet out of pocket costs of health care, medications and/or cover the cost of transport to attend health appointments
- Limited access to disability aids and equipment on arrival
- Limited familiarity of the public transport system and how to access health services
- Experiences of trauma and torture that may have ongoing impacts on access to care
- The competing demands of settlement, such as attending English language classes and obtaining work, impacting capacity to attend health and mental health appointments
- Lack of familiarity with Australian healthcare systems
- Social, cultural and environmental factors such as experiences of racism and discrimination in the community as well as the lack of access to culturally safe health services
The COVID-19 pandemic has added additional pressure on already under resourced primary health care services. Subsequently, GP clinics have reduced capacity to take on new patients as well as a notable decrease in the number of GP practices offering bulk-billing services. This has made it more difficult for refugees and people seeking asylum to access affordable health and mental health services in both metropolitan and regional areas.
Barriers to accessing safe and affordable housing
Secure, affordable housing is particularly critical to provide the foundation from which individuals and families can establish themselves and engage with community, work, education and health care. However, the ongoing rising cost of living, limited public and social housing stock, and lack of affordable, accessible, and safe housing in the private rental market is contributing to the dramatic increase in the numbers of people from refugee backgrounds experiencing homelessness and housing instability. These families and individuals are sleeping rough; living in severely overcrowded dwellings; cycling through periods in emergency accommodation, often in unsafe and unsuitable settings; and having to move frequently to keep a roof over their heads. Some people are currently being placed in housing which exacerbates existing trauma by bringing back memories of containment and imprisonment (e.g. bedsits with limited space and windows).
These housing stressors can result in deteriorating mental health, unmet health needs, delayed school start for children, homelessness and frequent moves which disturbs children’s education and stability. A consequence of this can be an increase in the number of services involved in care who have limited influence on the housing outcome (such as GPs and refugee health nurses). Not only does this create further service fatigue for people who are refugees, but it also adds pressure on under resourced and time constrained health care services. Despite their presenting health needs, people from refugee backgrounds are often unable to focus on their health goals with health professionals due to their housing needs and experiences of housing crisis taking priority.
A notable gap in Australia’s Humanitarian Program is the insufficient case management support to access affordable, safe accommodation at arrival and in the first five years of settlement and beyond. Existing housing support initiatives such as the National Rental Affordability Scheme and Private Rental Assistance Program (PRAP) are not readily accessible for linguistically diverse community members and there are no community-based case management support services that specialise in supporting culturally and linguistically diverse community members to navigate the public and private housing sectors.
Service navigation and community connection challenges
The duration and amount of case management support funded by the Humanitarian Program is not adequate to support refugees in familiarising with Australian service systems, navigating social supports, using public transport and developing connections with the community. While the standard period of support is between 6 and 18 months, groups with more complex support needs such as single parent households and individuals and families with disability or chronic physical or mental health conditions may require support for a longer period of time. Improved access to flexible service navigation assistance and case management support, particularly for individuals and families experiencing increased vulnerability, throughout the settlement experience would ensure they can access support when it is needed, reduce risk and prevent crises.
In addition to increased case management support, greater cultural orientation and service navigation training opportunities (including using public transport) are required. This training is often delivered as a one-off information session, and not revisited at different points in the resettlement journey. cohealth recommends that bi-cultural workers (including people who have lived experience as a humanitarian entrant) are employed to deliver this training, and for there to be multiple training opportunities throughout the first ten years of resettlement.
It is best practice for programs delivering support to culturally and linguistically diverse communities, including people who are refugees, to work in collaboration with the communities they are engaging, and employ bi-cultural workers. Bi-cultural workers improve access to services as they provide a vital cultural bridge between mainstream services and their communities, ensuring both greater engagement with communities, and improved delivery of services to diverse communities. They are employed to use their cultural knowledge, language skills, lived experience and community connections to work with people who they share a lived experience with and mainstream organisations. Bi-cultural workers elevate community voices, advocate for their needs, co-design and deliver programs, share information and facilitate cultural safety.
cohealth calls on the Federal Government to:
- Provide all humanitarian entrants (regardless of their means of arrival to Australia and/or whether it was granted onshore or offshore) access to settlement assistance and support.
- Increase the amount of settlement case support available for people accessing the Humanitarian Program to ensure that their health and psychosocial needs are holistically met.
- Provide more flexibility for people to access case management beyond the first five years of arrival with consideration for an extension for some case to ten years of arrival.
- Increase the amount of direct case support related to securing safe and appropriate housing, including practical support to view properties and negotiate with real estate agents.
- Ensure that people who are refugees with complex support needs or increased vulnerability are provided access to highly skilled, experienced and professional case managers and are not solely supported by community volunteers employed by the Community Refugee Integration and Settlement Pilot (CRISP).
- Increase the resourcing to community services delivering supports funded by the Humanitarian Program to employ bi-cultural workers to provide comprehensive systems navigation support, public transport training and cultural orientation (including provision of support over time rather than a one-off single event).
- Fund the provision of settlement health coordinators or advisors to support settlement worker capacity building in relation to health, health pathways and the provision of secondary consultation for emerging health crisis such as the previous model trialled in Victoria.
- Provide full funding for humanitarian arrivals with a disability to access appropriate aids and equipment on arrival. Funding must also be provided for the assessment of the client needs via relevant Allied Health such as Occupational Therapy or Physiotherapy.
- Ensure interpreting and translating services are available to all health, mental health, disability and social support related appointments (including optometry)
- Ensure community volunteers engaged in CRISP receive comprehensive training on service navigation, trauma informed care, culturally safe practice, boundary setting, using interpreters and child safe practice.
- Work in partnership with the State Government to increase the capacity of the health system to meet the physical, psychological, cultural, linguistic, and social needs of people from refugee backgrounds in both metropolitan and regional areas. All health care providers must receive comprehensive training on issues facing people of refugee backgrounds, including use of interpreters and culturally safe practice. This also includes increasing the capacity of general practices (GPs) to provide care to new families on arrival by providing training, incentives, support and resourcing (such as the Victorian Refugee Health Nurse Program) to enable GPs to engage and appropriately respond to refugee health.
- Work in partnership with the State Government to develop a strategy to address the current housing crisis (increasing rental costs, low vacancy rates across metro and rural areas, a shortage of public housing stock) and offer intensive housing support to newly arrived refugees and people seeking asylum to secure safe and affordable housing.
- Work in partnership with the State Government to develop a strategy relating to anti-racism initiatives that focus on amplifying the voices of people from refugee backgrounds and enable them to share their diverse stories.
 cohealth (2022), Position Statement: Refugee and Asylum Seeker Health
 Department of Home Affairs (2022), Discussion Paper Australia’s Humanitarian Program 2022-23
 DHHS (2019), Refugee and Asylum Seeker Health Services: Guidelines for the Community Health Program
 cohealth (2019), Bi-cultural work program