From 1987 onwards the New Zealand Government has offered resettlement places to the most vulnerable refugees in refugee camps. These include women at risk, those with medical conditions and disabilities, and those categorised by the United Nations High Commission for Refugees (UNHCR) as having "poor integration potential"; for instance, those who are pre-literate, women-led households with large numbers of children and long-stayers in refugee camps. The changes to refugee resettlement policy have significantly increased the number, dependency and cultural, religious and ethnic diversity of the refugees settled since 1992. However, while specifically prioritising refugees with high health and social needs, New Zealand has not yet developed the institutional means to include diverse ethnic groups in policy, strategy and service planning. This article looks at the role of public institutions in New Zealand, in this case the public health system, in the integration of refugees. The study shows that, for refugee groups, the health sector has developed responses to local needs and demands in highly specific health care settings that are often poorly resourced. Of interest in the study are the interactions between the health practitioners and provider organisations advocating for better services for refugee groups, and the institutional responses to the issues raised by health providers.
New Zealand does not bar any refugees or asylum seekers on the grounds of medical conditions or disabilities (UNHCR 1998:126). Quota refugees are New Zealand residents on arrival and have the same entitlements as all New Zealanders to publicly provided health and disability services, and to subsidised primary health care (Minister of Health 2003). However, for refugees, entitlement to health and disability services does not mean these services are being accessed. A study of health and disability services in the Auckland region, conducted between 2002 and 2006, shows that in practice access for refugee groups is limited and inequitable.
The findings of the qualitative field study indicate that the public health system needs to be "activated" (Penninx 2004) from the "top down" in order to provide accessible and equitable services for refugees, and for their first- and second-generation ethnic communities. The concept of activation is used in the sense that public institutions are important actors in the integration of refugee groups. Penninx's (2004:4) theoretical perspective on the role of institutional "opportunity structures" provides a means of analysing refugee participation in the health system. In this view, public institutions determine the nature and quality of refugee integration through social, cultural, religious and linguistic accommodations.
The public institutions of receiving societies strongly determine the settlement outcomes for refugee groups by either promoting opportunities to participate, or limiting access and equal outcomes for refugee groups. The study draws on theoretical models of newcomer integration in order to promote the development of a more inclusive public health system for refugees. In health and related social policy, the issue of including refugee groups must take into consideration cultural and religious diversity on the one hand, and socio-economic inequality on the other.
In 1987 the New Zealand Government undertook a comprehensive review of the Refugee Quota Programme and increased the number of refugees arriving to an annual quota of 750 places. The review authorised the Minister of Immigration to set numbers for specific high health and social needs categories within the quota (Department of Labour and New Zealand Immigration Service 1994). The review removed preferences for specific national, ethnic and religious groups. In the last two decades the refugee groups settled in New Zealand have come from Iran, Iraq, Afghanistan, Sri Lanka, Bosnia, Kosovo, Somalia, Eritrea, Ethiopia, the Sudan, Burma, Bhutan, Burundi, Rwanda, the Democratic Republic of Congo, Brazzaville, Sierra Leone, Zimbabwe, Palestine, Algeria and Colombia. The profile of refugees settled in New Zealand from 1987 has been characterised by ethnic, cultural and religious diversity, and by the number of complex health, disability and psycho-social cases requiring specialised intervention and management.
Approximately 1,500 refugees are settled in New Zealand every year, 60% of whom will reside in the Auckland region (New Zealand Immigration Service 2004:44). This number includes the annual quota of 750 refugees, family reunion members, and convention refugees (former asylum seekers). The Auckland District Health Board (ADHB) estimated in 2002 that a population of 40,000 people from refugee backgrounds was resident in the greater Auckland region (ADHB 2002b). While these are small numbers, refugee groups present cumulatively significant high-health-needs populations. Refugee groups demonstrate health disparities and a unique set of health needs in New Zealand health populations (Ministry of Health 2001, Solomon 1999). Poor health on arrival in New Zealand reflects the population health patterns of countries of origin; the refugee experience of trauma, flight and deprivation; the conditions in refugee camps; and little or no previous access to health care (Hamilton et al. 2001, Hobbs et al. 2002, McLeod and Reeve 2005, Ministry of Health 2001). In the longer term, the indications are that the same patterns of poor health that are occurring in other low socio-economic groups, particularly those of Pacific peoples, are being replicated in refugee groups, including diabetes, obesity, cardiovascular disease, poor mental health and oral health, and high smoking rates (Solomon 1997, 1999).
The study, which was undertaken between 2002 and 2006, used a qualitative research methodology. A critical social theoretical approach was taken to the interpretation of the data used in the study. The method of analysis used is critical hermeneutics. The study takes a multi-method approach, using historical and social policy analysis to set the structural context for the interpretation of data from participant interviews. A variety of empirical materials informed the study, including the findings of quantitative and qualitative research studies, historical material, health and social policy, interviews, media analysis and personal observations.
Because over 60% of the refugees settled in New Zealand are resident in the Auckland region, it was decided to focus this study on health and disability services in this region. During field work, 28 in-depth semi-structured interviews were conducted with service providers in community, primary and secondary health care sectors, in both governmental and non-governmental agencies. The services approached were either known to have significant numbers of clients from refugee backgrounds, or to be located in areas where refugee communities were settled. The services that participated in the study included: primary health, child and family health, public health, disability support services, mental health, women's health, HIV/AIDS services, drug and alcohol services, hearing and vision services, health promotion providers and not-for-profit community care agencies. Those interviewed included nurses, doctors, midwives, health educators and health promoters, nutritionists, social workers, community health workers, hearing/vision testers, reception staff and managers. In addition, three focus groups were held: two for those working in child health services and one for a health promotion service. The study received ethics approval in December 2002 from the Massey Human Ethics Committee, the Auckland Health and Disability Ethics Committee, and the Plunket Society Ethics Committee. (When participants are quoted in this paper, pseudonyms are used.)
The process of analysis used to interpret data in the study is called the "hermeneutical circle" (Kincheloe and McLaren 2005). The critical hermeneutic tradition holds that in qualitative research there is only interpretation. The hermeneutic act of interpretation involves making sense of what has been observed in a way...