Table 2 Key themes, main findings and example quotes

Refugee’s health needs at different migration phases

• At the pre-departure phase, health problems are precipitated by exposure to interpersonal violence, inadequate nutrition, psychological trauma due to hardship, and poor access to healthcare. Healthcare access at this phase is undermined by travel restrictions, lack of infrastructure, persecution and discrimination.

• During travelling phase, health problems are precipitated by inadequate food and nutrition, sub-standard shelter, poor sanitation and hygiene, interpersonal violence, and psychological trauma. Medical care during their journey is usually non-existent.

• Health risks associated with difficult journey and poor health conditions at country of origin often manifest upon arrival at host countries.

• Refugee’s morbidities in Malaysia include communicable diseases, maternal and child health related conditions, malnutrition, psychosocial or mental health disorders, and non-communicable diseases.

“I think it’s throughout the whole journey itself. When they leave the country, back home their condition might not be ideal, so there’s already some history behind it. During the movement, it’s difficult to maintain your hygiene and health. And then when you arrive, it’s a totally new environment.” (I07)

“The conditions on-board were pretty terrible. […] People were packed, couldn’t move, weren’t allowed to move, fed very little – usually just a bowl of rice, a cup of water a day. Sanitary conditions were kind of non-existent […] people were being killed on-board, probably as a way to keep discipline on-board so the people who tried to kind of start trouble or ask for more food or ask to move around would be beaten and sometimes fatally.” (I17)

‘Approachability and Ability to Perceive’: Poor health literacy and the lack of awareness on one’s right to healthcare

• Refugees and asylum-seekers lack information on available health services and face difficulties navigating the health system.

• Refugees and asylum-seekers lack awareness of their right to seek healthcare.

• Refugees and asylum-seekers lack understanding of the treatment and administrative procedures due to language barriers which raises some ethical concerns.

• Refugees and asylum-seekers are highly dependent on their community members as information sources in healthcare seeking.

• NGO clinics play an important role in facilitating the process of navigating the health system through their referral procedures.

“Sometimes, the refugee may not know they actually have the right to access the health facility, so they don’t seek help [...] it is also due to lack of information provided.” (I07)

“There’s a lot of problem with language as well [...] most of the time, even if they signed some document, they do not know what they are signing […] without a proper interpretation or translation available.” (I01)

‘Acceptability and Ability to Seek’: Language difficulties and cultural differences as barriers to access

• Language and communication difficulties are key barriers to access due to the refugee and asylum-seeker’s inability to speak local languages and the lack of translation services.

• Public healthcare services are not tailored to the refugee and asylum-seeker’s culture and traditions. Alternative medicines like traditional medicines based on cultural practices are unavailable.

• During the health seeking process, refugees and asylum-seekers may face prejudices due to differences in their nationality and culture.

“A lot of times, even history taking is a problem. […] They probably just say, ‘Pain’ but when you want to get further history, past medical history or family history, it’s very difficult. [...] Language itself is a big problem.” (I01)

“It’s actually on linguistic and cultural issue […] the staff in that particular facility may have difficulty to cope because they will need more time to use interpreter and more time to adjust on the culture and understanding of each other and belief.” (I07)

‘Availability and Ability to Reach’: Protection barriers to access; and poor healthcare access in immigration detention centers

• Availability of public health facilities is not an issue as Malaysia is a country with one of the highest numbers of healthcare facilities.

• The Malaysian health system should have the capacity to cover the refugee and asylum-seeker population due to its small number relative to the host population.

• Refugees are provided reasonable healthcare treatment despite the legal circumstances for the population in Malaysia.

• Protection barriers are linked to risks of arrest and raids, a lack of documentation, and the set-up of immigration counters at health facilities.

• Availability of NGO-run clinics is limited but these clinics are easy to reach for refugees and asylum-seekers.

• Conditions in IDCs are dire due to the lack of food, water, sanitation and overcrowding. Access to services is poor.

“All in all, the capacity is there and then the quality and quantity of clinics are also there. So, I don’t see an issue about supply and demand but I see an issue of poor accessibility due to the high cost.” (I01)

“You can understand why undocumented migrants won’t go to these clinics because they are worried about being nabbed.” (I12)

“Scabies is now very common there because of the lack of hygiene, and everybody’s coughing and runny nose […] some get injuries […] they have gastric pain, they cannot sleep, they have headaches…the headache is very common among them partly because of no ventilation. The windows are all up-- there’s no window, actually; there’s a gap with some wire netting there, for the air to flow on the top. There’s no window. They can’t look out and when the door is shut, they don’t get to see anything […] the bathrooms are at the end, although the bathrooms are often very dirty bathrooms.” (I06)

‘Affordability and Ability to Pay’: Financial difficulties as a key barrier to access

• Financial challenges are key barriers to healthcare access, primarily due to lack of livelihoods, no healthcare insurance, increased foreigner charges, and no UNHCR documents.

• Travelling to hospital incurs high transportation costs especially for chronic patients.

• Health is not a main priority for refugees because they struggle to meet other basic needs such as shelter and food.

• REMEDI – the health insurance program has great potential in mitigating financial barriers to healthcare but is limited in its coverage and its enrollment is low.

“For accessibility itself just use the cost per se is really very limited because of the very high cost for migrants. Availability is there but the affordability is not there. So, I will say the accessibility is really not there for the migrants.” (I01)

“Like delivery, you know, which they used to be able to afford. But it’s gone up how many times now? From 400 ringgit, after 50% discount, now it’s gone up to, like, what, 2500 after discount? So it’s very unaffordable for many of them, and especially for those without documents […] who are not registered yet, they charge the full price. So it’s really prevented a lot of people from accessing healthcare.” (I09)

“Yes, we have the insurance, but it’s still a challenge […] it will still take some time before people buy on to that idea.” (I09)

‘Appropriateness and Ability to Engage’: Need for access beyond basic essential services; and lack of engagement due to communication difficulties

• Comprehensive health needs are still existent as the refugee and asylum-seeker population is here for a protracted period.

• Access to healthcare should be extended to other areas including antenatal care, health education, preventive care, family planning etc.

• Language difficulties serve as key barriers in enabling refugees and asylum-seekers to engage meaningfully in the healthcare seeking process.

“[…] comprehensive health needs are still existent, being that the population is going to be here for a protracted period of time, we can’t just focus on just access to just basic services; we also need to look at the more comprehensive needs for the long-term, which will then include all the other areas.” (I09)

“I do have patients or refugees in my clinic telling me that sometimes they don’t treat me like a human because they just poke and take blood” or “They will discuss amongst themselves and give me some medicine to take.” (I01)

Negative implications of poor healthcare access

• Negative implications include poor health outcomes among the population, increase in home deliveries, spread of infectious diseases, poorer control of non-communicable diseases leading to secondary complications, loss to follow-up and poorer adherence rates among chronic care patients, and poorer quality of life and psychological health.

• Poor access due to the MoH’s cost-cutting measures could also lead to greater financial cost to the health system in the long term.

“I think we’ve not seen the heights of the consequences of this yet, because we don’t know how many more TB cases may not be getting access to care […] It will eventually encourage people to have home deliveries, which is not a great thing […] it’s a little bit worrisome.” (I09)

“I guess that we are a bit short-sighted to cover for our financial deficit. We cut down unnecessary for all these important vital components which I think, in the long-term, will impact us quite badly […] the long-term impact is quite bad with increase in cost.” (I01)