The Rise of Categorical Health Care Institutions for Immigrants in the Netherlands

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1 The Rise of Categorical Health Care Institutions for Immigrants in the Netherlands Master Thesis submitted to the Graduate School of Social Sciences in completion of the Master Migration and Ethnic Studies August 2010 Author Mirte de Vries M.Sc Under the Guidance of Prof. W. L. J. M. Devillé Second Reader Prof. J. D. Ingleby

2 Abstract Immigrants and ethnic minorities are becoming a significant group of patients within the Dutch health care system. Although several attempts have been made to interculturalize the regular health care institutions in order to make the health care equally accessible and effective for immigrants, inequalities remain present. The current development within the field of health care for immigrants in the Netherlands displays a rise of categorical health care institutions for immigrants. By means of 11 semi-structured interviews with respondents of the categorical health care institutions and 2 semi-structured interviews with respondents of health insurance companies, this study was set out to identify why the categorical health care institutions for immigrants in the Netherlands were founded and how they need to be positioned within the broader field of health care. The results show that for some of the categorical health care institutions, the difference in beliefs about culturally sensitive health care was the incentive to start these new institutions. But for the majority it were the external processes; the lack of accessible and effective health care for immigrants within the regular health care, the hardening of the governments policies and the implementation of the managed competition within the health care system, that gave rise to the foundation of the categorical health care institutions. The position of these institutions is relatively strong because accessible and effective health care for immigrants appeared to be a niche in the Dutch society in the three investigated sectors of health care: home care, elderly care and mental health care. 2

3 Acknowledgement This thesis was written in completion of the Master Migration and Ethnic studies at the Graduate School of Social Sciences. With a background in Clinical Psychology this research was a great opportunity for me to combine my knowledge and two fields of interest; immigrants in the Dutch society and health care. However, I could not have done this without the support and collaboration of a number of people. To all respondents in the study my special thanks for their collaboration and kindness in receiving me and answering my questions. I am especially thankful to the respondents who generously elaborated about their personal experiences and ideas. I am thankful to my supervisor, Prof. W. L. J. M. Devillé, and my second reader, Prof. J. D. Ingleby, for their advising role, support and time. I am grateful to Kiki for correcting this thesis linguistically. For the technical support I want to thank Klaartje and Niels. Writing a thesis without a computer would have been much more difficult. In addition I would like to thank Rutger for his effort and ideas about the physical appearance of the thesis. I want to thank all the other students that were in this Master for inspiring me and sharing their knowledge. Finally, I am grateful to my friends and family, especially Bart, for their mental support during the whole process. 3

4 Table of Contents Abstract 2 Acknowledgement 3 Table of Contents 4 Chapter I Introductory Chapter Introduction 7 Explanatory Actors and Processes The Total Picture 9 Historical Perspective - The Dutch Case 12 Research Methodology 14 Chapter II The Categorical Perspective on Cultural Sensitive Health Care Introduction 18 Culturally Sensitive Health Care in Theory 19 Results Culturally Sensitive Health Care 21 Adjusting Care 24 Framing Data Conclusion 30 Chapter III External Processes Explaining the Foundation Introduction 33 Theoretical Considerations - Institutional Change 34 Results 37 Institutional Isomorphism in Regular Health Care Institutions 38 Fixed Institutions; the Categorical Solution 40 Cooperation between Categorical and Regular Health Care Institutions 41 Governments Involvement; Managed Competition 44 Framing Data Conclusion 47 4

5 Chapter IV Where Health Care is Changing Positioning the Institutions Introduction 50 Advantages 50 Disadvantages 53 Future 55 Conclusion 58 Chapter V General Conclusions Introduction 60 Foundation 61 Positioning 63 Discussion 63 Limitations and recommendations 64 Bibliography 66 Appendix 1: 69 Categorical Institutions for Immigrants in the Netherlands Appendix 2: 70 Letters to the Categorical Health Care Institutions (in Dutch) Appendix 3: 72 Letters to the Health Insurance Companies (in Dutch) Appendix 4: 74 Interview Scheme Categorical Health Institutions in the Netherlands (in Dutch) 5

6 Appendix 5: 77 Interview Scheme Health Insurance Companies in the Netherlands (in Dutch) Appendix 6: 80 Original Quotes (in Dutch) 6

7 Chapter I Introductory Chapter Introduction The multi-cultural character of the Dutch population is becoming more and more reflected in health care. Immigrants and ethnic minorities are becoming a significant group of patients. Although this group keeps on growing (CBS, 2009) and the importance of adressing them effectively in health care becomes inevitable, inequalities remain present. An ongoing discussion concerning the effectiveness and accessibility of health care for immigrants has been present for decades. Research shows that there are differences concerning the immigrants health state and inequalities in their accessibility of the health care. Besides that, their utilisation of the health care and quality of services that is provided for these groups differs from the indigenous population (Ingleby, 2009; Kunst, Machenbach, Lamkaddem, Rademakers & Devillé, 2008; Scheppers, van Dongen, Dekker, Geertzen, & Dekker, 2006; Seeleman, Essink-Bot & Stronks, 2008; Tamsma, 2008). During the last decades there has been much debate and discussion about these topics, and a lot of initiatives have contributed to the process of interculturalization of Dutch health care. Although this process of interculturalization, which refers to the effort to provide services which are equally accessible and effective for immigrants and ethnic minorities as for clients from the cultural majority (Ingleby, 2005), has a long tradition in the Netherlands, inequalities remain present. The Dutch government wants to guarantee essential care for all its citizens and wants to avoid segregation within the health care sector. However, the reforms of the last decade and especially with the recent reform of the health care system in 2006 have changed the field radically. The health care system has been in transition from supply-side-government-regulation towards managed competition (Custers, Arah & Klazinga, 2007; van de Ven and Schut, 2009). The semi-free market has introduced the competition between health insurers and made them important stake-holders in the field. 7

8 Since the entrance of competition among health insurers there is no longer a ban on separate health institutions for specific groups (Mens-Verhulst & Radtke, 2009). As a result of this changing field a niche in the health care market came into being; the immigrant and ethnic minority s health care provision. During the last decade specialized health care institutions were set up to provide health care for immigrants in the Netherlands. This development became especially visible within health care for the elderly, home care and most of all mental health care. Overall it can be stated that categorical institutions in general, whether they are founded for immigrants, women or specific religious groups, are founded out of dissatisfaction with the regular offer (Ingleby & May, 2008). A separate health care for immigrants is inevitable, says the care-manager of the categorical mental health care institution I-psy in Leiden (Langelaan, 2009). The interculturalization of the health care in the Netherlands failed, he says. Although it may not be surprising that after a period of withdrawal of government support and the hardening of the public opinion against immigrants, new specialised health institutions for immigrants are founded, this may not be the complete picture. The actual explanation for this changing field of health care in the Netherlands is absent. A question that remains for instance is: Why are new institutions founded instead of adjusting policies within the already existing health care? This obscurity will be the basis of this thesis, which tries to explore the processes that are fundamental and give rise to these new institutions. A better understanding of processes which may lay at the origin of the foundation and the position of these categorical health care institutions within the broader field of health care in the Netherlands is necessary to get insight in the state-of-affairs concerning health care for immigrants in the Netherlands in general. It may be relevant for policy makers within the government, insurance companies and the regular health care institutions. Besides that, it may contribute, on a more abstract level, to get insight in the 8

9 inclusion of immigrants in a health care system in general, with the Netherlands as a case study. In order to answer the question why these categorical health care institutions for immigrants are founded in the Netherlands and how they need to be positioned within the larger field of health care, this study will focus mostly on the perception of the new institutions themselves. How do the policy makers and health practitioners in these institutions perceive their own institution and how do they position themselves in the larger field of health care provision? In addition the perspective of the health insurance companies will be included. Explanatory Actors and Processes - The Total Picture The goal to achieve equally accessible and effective health care for immigrants in the Netherlands has been a goal for many years. In order to understand the recent development of the categorical health care institutions, it is necessary to analyze this development in the light of its historical, integral perspective. These new institutions are founded within an already existing field, an existing environment with its influencing actors and processes. In order to understand the foundation of these institutions, insight in their position in the broader field of health care and their vision on immigrants health care, is required. However, the only literature that is available on these categorical health care institutions presents the fact that they are founded and the assumption that they are (partly) founded as a result of the reform in the governments regulation and the lack of efficient health care provision in the regular health care institutions (Ingleby & May, 2009; Kerkhof, 2005; Mens- Verhulst & Radtke, 2009). No proper research has yet been done on these new institutions and the previously mentioned causes for their foundation have only been presumed. No literature exists on the position of these institutions in the broader field of health care provision in the Netherlands, the dynamics between the different stake-holders or the outcomes of the health care provision of these institutions. This current research will cover a modest part 9

10 of these obscurities, as it will only focus on the perspective of the institutions themselves and the health insurance companies. The integral perspective, the presumed actors and the presumed processes influencing this development, are presented in the following explanatory model. The presence of immigrants as patients within the health care system makes all the actors presented in the model responsible for solving the issue (Ingleby, 2009; Kunst, Machenbach, Lamkaddem, Rademakers & Devillé, 2008; Scheppers, van Dongen, Dekker, Geertzen, & Dekker, 2006; Seeleman, Essink-Bot & Stronks, 2008; Tamsma, 2008; Knipscheer & Kleber, 2005). The model has not yet been evaluated and the arrows do not suggest any tested significant association. The model is developed in order to give insight in the complexity of the situation and the variety of stake-holders, actors and processes, involved. 10

11 This model presents the broader field in which the categorical health care institutions are founded including the processes giving rise to this foundation. The changed influence of the government by implementing the process of managed competition shifted the responsibility for the integration of immigrants in the Dutch health care system towards the trinity of insurance companies, health providers and patients. The interaction between patients and health providers and its inequalities and inadequate outcomes are presumed to be the incentive to the process of interculturalization on the one hand and on the other hand a direct incentive to found the categorical health care institutions. The process of managed competition and the process of interculturalization of the regular health care are presumed to be fundamental in the rise of the categorical health care institutions and therefore will be the main focus in this study. In this explanatory model a distinction was made between the influence of the government and the Dutch society. Due the complexity and the lack of literature on the political discourses concerning immigrants in the Dutch health care system and the immigrant integration in the Dutch health care system, these two processes are excluded from this study. The process of adjusting the health care provision to its changing population in order to make the health care equally accessible and of equal quality for immigrants as well as for the native population is tied to the process of integration (RVZ, 2000). While integration puts its emphasis on the full-fledged participation of immigrants in society in its institutions, interculturalization emphasizes the acknowledgement of ethnic diversity in the offered provisions. The goal of this process is to make organizations stop taking the Western culture and ethics as the starting point, but extend its vision towards cultures, values and norms. It is not only about revising the policy of the health care institutions; it is also about contemplating the common vision within these institutions. It is more concerned with a reassessment of procedures, an increased sensitivity to cultures and the establishment of intercultural policies for the health care professionals. 11

12 Besides this process of interculturalization, the process of managed competition between health care institutes and health insurance companies is presumed to be of influence in the foundation of the categorical health care institutions for immigrants. Major reforms of the health insurance system and reimbursement systems for care providers are currently taking place in the Netherlands (Custers, Arah & Klazinga, 2007). These reforms aim to forge a more efficient system in terms of costs as well as quality. Market forces may be a key driver in achieving this, with service providers, health insurers and patients as main players in that market. Client-centeredness is another key issue underpinning the reforms. As health service clients, patients are to make informed choices on a transparent market. Meanwhile, the same patient is expected to develop more cost-awareness and accept more individual responsibility for his or her own situation and health. In spite of the emphasis on client choice, the health insurers ultimately may be the main negotiator on the market (Tamsma, 2008). Therefore they may be of great influence in the foundation of these categorical health care institutions for immigrants. Historical Perspective - The Dutch Case This process of adapting health care towards a new population with different cultural backgrounds is tied to the other developments within the country like political discourse and institutional situations, as presented in the explanatory model. The foundation of the Dutch case that will be presented below lays in the dissertation of Sander Kramer (2009). He wrote a discourse analysis on the process of interculturalization of the health care in the Netherlands in the period 1972 to In the Netherlands this process started most obviously from the time that the guest workers were recruited. In the period between 1972 and 1983, the Netherlands was officially an emigration country but it was obvious that there was a major shift towards becoming an immigration country. The emphasis in this period was on the preservation of language and identity of the immigrants in order to be able to send them back to their home country during economic downfalls. The 12

13 government even spoke about a categorical policy towards the incorporation of the immigrants. A specific health policy and separate health provisions for immigrants were presumed to be needed; especially within the elderly care this approach was implemented. The tendency of this starting process of interculturalization was characterized by a mild tone and optimism. This discourse changed in the period between 1983 and The Netherlands admitted in the Minority Report of 1983 (Minderhedennota 1983) that it was an immigration country. With this acknowledgement the government stated that they had to make up the arrears of the immigrants and an actual incorporation policy became required. Incorporation of immigrants on the labour market and incorporation concerning housing and education was getting the most attention; whereas the incorporation within health care lagged behind. The problems and inequalities in the health care were attributed to the lack of expertise of the health providers and to the lack of empathy for this new group of patients. Sympathy for this problem was still present, however the support for categorical institutions declined. The immigrants were presented as a homogeneous group. The vision towards transcultural health care was based on the acknowledgement of different world-, religious- and behavioural perspectives. The idea of a special therapist for immigrants came into being, especially in the field of mental health care. This therapist was not only capable of bridging the language difficulties, but had the competence to bridge also the cultural differences. The following period, from 1993 till 2002, was an important period for the process of interculturalization of the health care. The health care provision during this period was characterised by a lot of active regular health care institutions providing care for immigrants, sometimes in separate teams. Only refugees and asylum seekers had their own categorical institutions, but there was little collaboration between migrant health care and refugee health care. The migrant population was still perceived as a homogeneous group. In 2000, the Council for Public Health and Health Care (RvZ) published two highly critical reports (Wennink, Boomstra & Meeuwisse, 2000; RVZ, 2000) 13

14 highlighting the health problems of migrants and ethnic minorities, as well as the problems of accessibility and quality in service provision. In response to these criticisms, the Minister of Health set up a Project Group to work out a strategy for interculturalizing health care. This was the first time that there was real support from the government to contribute to the process of interculturalization on a structural level. In these plans, emphasis was placed on mental health the sector which had campaigned most vigorously for improvements (Ingelby, 2005). From 2002 onwards the climate towards immigrants changed radically and with that change, the integration policies were becoming characterized by the demand towards immigrants to adapt to the Dutch standards. The preservation of ones different cultural identity was becoming perceived as a failure of ones integration. The discourse on incorporation of immigrants saw no justification for specific attention for immigrant health care services. The responsibility of fitting in was placed back at the immigrants themselves and the governmental support triumph of the year 2000 vanished as quick as the political discourse changed. The only possible reason to think of separate health care provisions or adjustments was if there was economic gain. From the year 2005 onwards, categorical institutions slowly became visible. The economic motivation seems to be one of the reasons to start these institutions. Nevertheless, this explanation has no justification and the broader field of health care in which the new institutions are founded contains more stake-holders and processes that might be of influence on the foundation. Research Methodology The aim of this study was to investigate why the categorical health institutions for immigrants in the Netherlands were founded and how they need to be positioned within the larger field of health care. In order to explore and explain the obscurities concerning the foundation a combination of different qualitative research methods was used. The research started with a 14

15 literature review followed by a search on the Internet. The main research method in this study however was the semi-structured interview. Internet Search The first step in this research was to get an overview of the currently existing categorical health care institutions for immigrants in the Netherlands. There was no existing data base in which these institutions were listed; therefore a search by the use of the Internet was done. The difficulty in obtaining this information on the one hand was the fact that not all categorical health care institutions were visible on the Internet. On the other hand, in the time that this research was executed new categorical health care institutions were founded. In addition, a definition of categorical health care institution for immigrants was required because none of the categorical health care institutions seemed to exclude non-immigrants from health care provision. As a definition, health care institutions that had a special focus on the immigrant population were chosen. An overview of this snap-shot of the situation at the start of this research is presented in appendix 1. Respondents The focus in this study was on two actors, respondents of the categorical health institutions themselves and the health insurance companies. Within the categorical health institutions a distinction was made between the management /the policy makers and the health practitioners. The aim was to get a sample of at least one or two interviewees within each type of categorical health care institution; mental health care, home care and elderly care. In addition, the goal was to get in contact with the insurance companies that were mentioned in the interviews with the categorical health care institutions. The insurance companies that were most mentioned by the categorical health care institutions were approached. In order to get the richest sample, all the categorical health care institutions for immigrants that were found on the Internet search were 15

16 approached for participation by letter and . After the first interviews, two health insurance companies were mentioned most by the respondents; both of them were approached by letter and . This letter addressed to potential respondents, explained the nature of the research, the interviews and formulated the request for them to participate. The letters are presented in appendix 2 and 3. After a week these institutions and companies were approached by phone in order to check whether they received the letter and/or and audit their participation. In total, 17 categorical health care institutions were approached, of which 7 were willing to participate in the study. Both of the approached insurance companies were willing to participate. The institutions that refused the request to participate had varying arguments of which the lack of time was the most popular. Eventually this strategy brought up a sample of 11 interviews with respondents of the categorical health care institutions and 2 interviews with health insurance companies. This makes 13 interviews in total of which 12 of them were single interviews and one of them was an interview involving two respondents. This amounts to a total of 14 respondents. Six of these interviews were with the categorical mental health care institutions containing three interviews with the management and three with the health practitioners. Two interviews were with categorical home care institutions, both of them with the management. And three interviews with respondents of the categorical elderly care, also all of them with the management. Unfortunately only within the mental health care a distinction between the health practitioners and management was possible. Exactly half of the respondents were from migrant descent; the other half was native Dutch. In addition, there was a little underrepresentation of women, 4 of the 14, within the sample. Semi-structured Interviews The interview outline was semi-structured. By the use of an interview scheme (see appendix 4 and 5) different themes were addressed. Besides the general information the themes contained the merits and the functioning of the 16

17 institutions, a comparison with the past and with the regular health care institutions and the future perspective. By using semi-structured interviews as opposed to more structured interview methods, respondents had more freedom to talk about their experiences regarding the interview topics. Not having a strict structure also amounted into an informal atmosphere during the interview which increased the possibility for respondents to feel at ease. The location of the interview varied depending on the respondent. The length of the interviews varied between 30 and 85 minutes and were all recorded. Afterwards, all interviews were transcribed and sent back to the respondent in order to check their accuracy. All respondents were fully aware of the content, goal and method of the research. Due to the confidentiality of the results no names of the participating institutions or respondents will be displayed in this thesis. All the quotes in this thesis only display the type of institution the respondent was representing. The quotes have been translated from Dutch to English, the original quotes are listed in appendix 6. All data were saved anonymously and are only accessible by the researcher for the proposed research. After the research was finished, all the co-operating institutions received the results. Analysis After transcribing, all the interviews were coded. Central themes were identified and a coding scheme, made by hand, was set up to code all the transcripts. During the coding process, new themes emerged, which were updated in all the transcripts. 17

18 Chapter II - The Categorical Perspective on Culturally Sensitive Health Care Introduction Preceding the foundation of a new type of institution, there is always a reason, a motivation to start with. There is always an idea, a vision or a perspective on what this new institution should contain. Likewise, there was an idea preceding the foundation of the categorical health care institutions in the Netherlands. The founders as well as the employees attracted to these institutions may have a certain idea or perception on what the institutions offer. They have a certain vision on health care for immigrants; they have an idea about the operationalization of culturally sensitive health care. The goal of culturally sensitive health care may be clear: offering health care that is accessible and effective for a cultural diverse population. However, the operationalization of this concept is still an issue of debate. What does the process of interculturalization, making the organisations more culturally sensitive, imply? This process can be interpreted and translated in various ways. In order to answer the question why these categorical health care institutions are founded, some insight in their perspective on culturally sensitive health care is required because the perspective may have given birth to the idea of founding these new organisations. In this chapter first culturally sensitive health care and especially the different approaches on how culture is embedded in health care provision as it is described in theory will be discussed. After that, this chapter will present the results of the interviews concerning the perspective of the respondents of the categorical health care institutions for immigrants. Their vision on accessible and effective health care for immigrants will be presented as well as the way they operationalize this within the categorical institutions. The chapter will be concluded by framing these results in the light of the theory. To what extent 18

19 does the theory contribute to the explanation why these categorical health care institutes for immigrants are founded and how they should be positioned in the broader field of health care? Culturally Sensitive Health Care in Theory Lately, the process of interculturalization is more often referred to as the process of making health care more culturally sensitive, culture-specific or culturally competent. The changing conception of this process displays the development it is going through. The process is not yet crystallized and is dependent on the societal context and policies. This concept can be, and is, interpreted in varies ways as it may include different outcomes of the contradiction of universalism versus relativism and may be defined differently into different types of organizations. For the intelligibility of the research I will use the term interculturalization in order to refer to this process of making the health care for immigrants as accessible, effective and of equal quality as for the native population. In addition I will use the term culturally sensitive to refer to the desired outcome of this process. This process of interculturalization is not a goal in itself; it is the means to an end. But what the actual end result is, what real culturally sensitive health care contains continues to be a debatable topic. The evident variable within the process of interculturalization in the Dutch health care system is the position of culture. The universalist relativist contradiction includes two different perspectives concerning symptoms, health problems and diseases. The first approach, universalism presumes symptoms and diseases to be universal, culture is of no influence and importance and a specific cultural approach or treatment is therefore unnecessary. The second approach, relativism, presumes that every culture also Western needs to be interpreted as a separate whole with its own norms and abnormal behaviours. This makes it necessary to interpret symptoms and diseases within their cultural context, with its own people (Wennink, Boomstra & Meeuwisse, 2000). 19

20 As discussed before in the introductory chapter, research shows that immigrant experiences of health, behaviour connected to illness and helpseeking processes are frequently unfamiliar to care providers in the Netherlands and often collide against their expectations. Therefore they hinder the care, limit the access and contribute to an increased probability of problems (van Dijk & van Dongen, 2000). This suggests that culture may in fact be a significant actor and in order to overcome these differences culture needs to be included in the health care provision. A process of interculturalization seems inevitable. Obviously, the universalist approach is not the basis for this process of interculturalization whereas the relativist approach may be. However, there is also a combination of these approaches possible. This third combined approach contains the belief that there are universal symptoms and diseases; nevertheless, there are social and cultural factors that influence the intensity, frequency and most of all the appearance of the symptoms. Universal symptoms and diseases are present in all cultures; nevertheless, the manifestations of them are variable. Each of these two approaches, the combined and the relativist approach, or better phrased these two different beliefs, may translate into a different form of organization. The combined approach may translate into regular health care institutions in which interculturalization means that all the therapists and health practitioners need to be able to help all patients equally, taking into account their various cultural backgrounds. The cultural diversity of the patients will become a self-evident aspect of the overall quality policy in the institutions. Every patient will be treated the same, whereas the cultural aspect becomes incorporated in the general approach. A possible disadvantage of this strategy may be that the attention for relevant cultural differences may weaken, become unnoticed, and will be dominated by the uniform, dominant approach of the cultural majority. The relativist approach may be translated differently; it may form the basis for the categorical health care institutions that form the unit of analysis in this 20

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