Investigating the Role of Intercultural Mediators in Enhancing Asylum-Seeking Migrants’ Access to Health Care Services in Serbia

Abstract

Migrants are especially susceptible to inequitable access to health care services and their access to health care may be further compromised by the tradition of informal patient payments in the Western Balkan countries. As a particularly vulnerable group, this study focused on the asylum-seeking migrants and the role of informal patient payments as an avenue for migrants’ health care access in Serbia. Qualitative interviews were conducted in August and September of 2018 with civil servants (intercultural mediators and information workers, n = 8) and asylum-seeking migrants (n = 6). Data was analyzed using the phenomenological hermeneutical approach. The study showed that intercultural mediators had a pivotal role in shaping better and quicker access to health care services for asylum-seeking migrants in Serbia, which also lowered their exposure to informal patient payments. A commonness in paying informally was found in Serbia, especially due to the high value put into doctors and the lacking resources of the health care system. The asylum-seeking migrants seemed exempted from such payments. Reducing these informal patient payments for health care is highly important to facilitate equity in access to health care

Plain Language Summary

This study seeks to understand the barriers and facilitators of non-western asylum-seeking migrants’ access to health care in Serbia. We have interviewed asylum-seekers themselves and professionals around them to understand this issue. We found that intercultural mediators played a large role in facilitating access to health care of the asylum seekers. The introduction of these mediators could therefore be expanded. For their success, the intercultural mediators however need protection and stability to provide long-term solutions in the migration response. Decision-makers in Western Balkan or European countries should therefore emphasize a systematic and comprehensive position while providing psychosocial support, supervision, and training to the intercultural mediators.

Keywords

migrants intercultural mediators access to health care Serbia informal patient payments

Introduction

Migrants are a vulnerable group that is especially susceptible to inequitable access to health care services (Alexe, 2013; Bozorgmehr et al., 2015; Norredam et al., 2007; Pross, 1998; Starfield, 2001; World Health Organization [WHO], 2010a). People’s vulnerabilities increase during migration; The common risks are compounded by limited access to services that could mitigate or address the impact on health. Vulnerability entails that some people are being more susceptible to harm than others, due to exposure to certain risks. Migrants that are vulnerable are typically exposed to risks such as severe psychosocial stressors, exposure to criminal elements, gender-based violence, or insufficient resources to continue their journey in safety (International Organization for Migration [IOM], 2019a). Vulnerable migrants are therefore typically more exposed to exploitation, violence, and abuse than other groups of society (IOM, 2019b). Migrants further often occupy lower socioeconomic positions, which typically relates to poorer health outcomes (McGary et al., 2018; WHO, 2010b). For many migrants, formal and informal barriers exist when needing access to health care services (Norredam et al., 2007). Formal barriers are for instance legislation or out-of-pocket payments, whereas informal barriers are indicators such as language, psychology (e.g., lacking trust in health care providers), and socio-cultural factors (Norredam et al., 2007).

Being a heterogeneous group of people the definition of “migrants” is varying. The International Organization of Migration’s working definition of a migrant is a person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons (IOM, 2019c). Their status is based on indicators such as the conditions they are in or the reasons for migration (IOM, 2019c). They may thus become an irregular migrant who is traveling without appropriate documentation, environmental migrants who move due to climate or environmental changes, or asylum-seekers who have an undecided claim in a country where they seek international protection (Hannigan et al., 2016; IOM, 2019c). This study focuses on the intended asylum-seeking and asylum-seeking migrants in Serbia since this is a particularly vulnerable group (Mouzourakis et al., 2017). Asylum-seekers are vulnerable to negative health outcomes due to a poor social environment, economic struggles, and difficult living conditions in the asylum centers (Padovese et al., 2014). When accessing health care, they may also face long waiting times, lacking cultural competencies of health care providers, financial and linguistic barriers, while being unfamiliar with the culture, the health care system, and their entitlements (Bhopal et al., 2018; DG Sante, 2019; IOM, 2019b; King et al., 2017; Malmusi et al., 2010; Verrept, 2012; WHO, 2018a).

In 2015 the number of migrants turning toward European Union (EU) borders reached a high point with 1,2 million asylum-seekers, while approximately 500,000 asylum-seekers applied for protection in 2020 (European Commission, 2022). The Western Balkan countries became transit countries for many of these migrants, and when closing the “Balkan route” in 2016, many migrants became stranded in these countries (Lukić, 2016; Pusztai et al., 2018). It is difficult to estimate the exact number of migrants residing in the Western Balkan countries, as there are many repeated border crossings of migrants who have been in the region for some time in an attempt to reach their target destination (e.g., EU). In Serbia for instance, undocumented migrants may merely register themselves as asylum seekers to get access to asylum centers.

Asylum-seeking migrants, traveling from crisis and war come from countries with weak health systems (Laverack, 2018), while they face hardships through their journey that may lead to physical and mental health illnesses (Kristiansen et al., 2016; Pavli & Maltezou, 2017; Scholz, 2016; WFP; IOM, 2020). When re-settling in the EU, the migrants are further susceptible to non-communicable diseases (Apt, 2017; Pavli & Maltezou, 2017; Scholz, 2016). Even though all EU member states have formally recognized the right to the highest attainable standard of physical and mental health (European Parliament, European Council, & European Commission, 2017), migrants are often met with several barriers to access health care services in this region (Verrept, 2012). The EU countries are therefore faced with pressing needs and challenges to address these public health consequences and adequately address migrants’ health (care) needs (Apt, 2017; King et al., 2017; Kristiansen et al., 2016; Pavli & Maltezou, 2017; Scholz, 2016; WHO, 2017). Being in the stage of entering the EU, the Western Balkan countries are committed to providing equal access to health care (European Council, 1993). Most of these countries have however been reluctant in providing health care services to some migrants, such as irregular migrants or asylum-seekers (UNHCR, 2016). These migrants’ legal status, therefore, becomes a barrier to access health care (Fang et al., 2015; WHO, 2015). Serbia initially provided mainly emergency care services to asylum-seeking migrants (Pusztai et al., 2018), though due to the border closures and closing of the “Balkan Route” in 2016, the health system needed to respond to the changing circumstances (Lukić, 2016; Pusztai et al., 2018). Several initiatives were taken to provide better access to services and better-quality care for migrants, for instance, the opportunity to register as an intended asylum-seeker (receiving the same rights to accommodation and (health care) services as asylum-seekers) and the mobilization of intercultural mediators when accessing services (Pusztai et al., 2018).

Intercultural mediators are intermediaries who improve the communication and understanding between migrants’ patients and health care providers, by reducing issues of linguistic and sociocultural differences (Chiarenza, 2014; Pérez & Martin, 2014). In the current paper, the focus is on the formal (trained and hired) intercultural mediators that assist ethnic minority patients and health care providers during encounters with the health care system or other social services. These are therefore not informal mediators such as family members or friends (Verrept, 2019). Evidence on the use of intercultural mediators shows that they may diminish barriers in health care access by bridging different cultural viewpoints on health (care) and building trust while providing information and guidance on services (Verrept, 2012, 2019). As a facilitator to health care access and quality, the intercultural mediators may further increase the level of trust between health care providers and asylum-seeking migrants (Betancourt et al., 2002; Robertshaw et al., 2017; Verrept, 2019). This may for instance be by increasing the cultural competency of health care providers and providing language interpretation for migrants to understand their treatment and diagnosis (Verrept, 2012).

Migrants’ challenges to access health care in the European region may be further compromised in the Western Balkan countries due to the persistent tradition of patients paying informally for health care services (Colombini et al., 2012; Krupic et al., 2015). Current evidence on migrants’ access to health care and informal patient payments in the Western Balkan countries is mainly focused on Roma people and Bosnian immigrants (Bradby et al., 2015; Hannigan et al., 2016; Priebe et al., 2016; UNHCR, 2016). Evidence on the recent influx of non-western migrants is scant, while the role of informal patient payments as an avenue for migrants’ health care access in these Balkan countries is further lacking in the literature. These payments constitute a financial barrier to access health care as they are highly likely to discourage consumers to utilize health care services (Gupta et al., 2001; Nekoeimoghadam et al., 2013). Informal patient payments are defined as “a direct contribution which is made in addition to any contribution by the terms of entitlement, in cash or in-kind (gratitude gift), by patients or others acting on their behalf, to health care providers for services that the patients are entitled to” (Gaal et al., 2006). Informal patient payments thus encompass bribes or gifts that are offered to service providers for services that patients are naturally entitled to (Arsenijevic et al., 2014a; Stepurko et al., 2015).

Currently, evidence is scarce on the intercultural mediators’ role in the protection against informal patient payments. With the large influx of migrants in Serbia, it may be challenging to control informal patient payments, while migrants should be ensured in accessing health care services equally to others. Using intercultural mediators may be one way to protect migrants from paying informally, as they provide interpretation, share information, offer services, or help refugees and migrants connect to services (Venables et al., 2021; Verrept, 2019). The aim of this paper is therefore to explore the role of intercultural mediators on the facilitators and barriers to access health care services in Serbia. The focus is mainly on whether asylum-seekers pay informally and how intercultural mediators may build trust and bridge the gaps between asylum-seekers and health care providers in Serbia.

Methods

Data Collection

The data for the current paper rests on a larger data collection about informal patient payments and facilitators and barriers to access care in Serbia (Buch Mejsner et al., 2021). Qualitative interviews were conducted in August and September of 2018 with civil servants (intercultural mediators and information workers, n = 8) working with various types of migrants. The role of the intercultural mediators was to provide interpretation and guide migrants to (health care) services, whereas the information workers informed migrants about their entitlements and rights as migrants in Serbia, for example, the option to apply for intended asylum. Among these migrants were the intended asylum-seeking or asylum-seeking migrants that were also interviewed in the present study (n = 6). These migrants resided in an asylum center near Belgrade. The asylum-seeking migrants and intended asylum-seeking migrants will in the rest of the paper be mentioned in combination as asylum-seeking migrants. The civil servants were aged between 25 and 53 (five men and three women) and were interviewed in English. Six were further Serbian citizens and two were from other European countries. The asylum-seeking migrants were aged between 19 and 62 (three men and three women) and were interviewed with an intercultural mediator, who translated questions and comments to and from their local languages (Farsi, Dari, Persian) into English. Four were from Afghanistan and two were from Iran. Respondents with different background were chosen to have multiple perspectives on the migrants’ access to health care services in Serbia, increasing the validity of findings.

Inclusion criteria were either being a migrant from an asylum center or being a civil servant in the field of migration. The asylum-seeking migrants further needed to have previous experiences with the Serbian health care system. The University of Belgrade assisted in getting access to the asylum center. The migrants were invited by the staff at the center to participate in the interviews. Interviews lasted approximately 1 hr. To generate a meaningful analysis, only the non-western asylum-seeking migrants were included and not the internally displaced or regional Western Balkan migrants. The interviewed migrants had lived in an asylum center for a period of 3 months up to 3 years. A local researcher from the University of Belgrade also assisted during the interviews of migrants with organizational tasks, such as correct completion of informed consent forms or directing migrants to the interview room. Before beginning the interviews with migrants, the roles of the researcher, the intercultural mediator, and the assistant researcher from the University of Belgrade were clarified to the migrants.

Data Analysis

From the entire dataset on informal patient payments and facilitators and barriers to access care in Serbia, the issues connected to intercultural mediators were firstly extracted using Nvivo. The naïve reading, based on the phenomenological hermeneutical approach (Lindseth & Norberg, 2004), was the first step in the analysis. The transcripts were therefore initially read several times to get an overall understanding of the data. This understanding guided the subsequent thematical structural analysis, where themes and sub-themes were identified in the text. Quotes of respondents that matched a particular theme or sub-theme were put together. After initial categorization, further reflection was done on the themes and sub-themes and reorganized into final themes and sub-themes.

Validity and Reliability Control

To address potential bias in the analysis and coding of data (Burla et al., 2008; Hruschka et al., 2004), we conducted an Intercoder Reliability test (ICR). The NVivo software was applied to complete the ICR test that resulted in a Kappa’s coefficient (K), ranging from below 0 (no agreement) to 1 (total agreement). Results below .41 were regarded as poor, whereas values from .50 were solid agreements, and values above .80 were nearly perfect agreement (Burla et al., 2008; Hallgren, 2012). Two researchers conducted the test on 10% of the data and initially met to discuss and agree upon the pre-selected categories to be coded, that were selected by the main researcher (Zenk et al., 2007). The results were discussed after coding the first categories, and the codes were revised to reduce misunderstandings in categorization and to reach a higher level of agreement. The final test was done with the resulting mean Cohens Kappa .585 indicating satisfactory agreement and coding consistency.

Results

Our results have shown that intercultural mediators facilitated the access to health care services for asylum-seeking migrants and protected them against informal patient payments in Serbia (see Figure 1). One of several strategies adopted to respond to the increasing flow of migrants in Serbia, was the mobilization of intercultural mediators, which appeared to increase the migrant’s utilization of care and their experiences of quality. Overall, our findings revealed that intercultural mediators were believed to bridge some of the sociocultural gaps, increase trust, and decrease prejudices through information and advocacy. Some of the barriers in access to health care, such as paying informally, appeared to be minimal for the asylum-seeking migrants when intercultural mediators were involved. Overall, the study found that migrants received more timely access to care and experienced better-quality care when in the system. In the following, we describe these two elements from the viewpoint of implementing intercultural mediators, their ability to bridge gaps and build trust, and their capability to reduce informal patient payments.

Figure 1.

Intercultural mediators role in migrants’ access to health care.

Ease of Access and Better-Quality Health Care Services with Intercultural Mediators

It was evident from the data of the current study that waiting times for appointments were long in Serbia, creating barriers to accessing health care services. However, several of the interviewed civil servants believed that asylum-seeking migrants had better access to health care than other migrants and locals residing in Serbia. The intercultural mediators were in that regard perceived to play a crucial role. Migrants without local language skills and knowledge about the Serbian health care system had difficulties to access health care services without an intercultural mediator. The mobilization of intercultural mediators to facilitate access to the health care system contributed to shorter waiting times, revealing possible inappropriate behavior from health care providers (such as migrants being spoken to rudely or provided improper treatment) and preventing informal patient payments. The intercultural mediators were, therefore, important actors in providing support to both parties.

All interviewed civil servants believed that asylum-seeking migrants received better quality care because of intercultural mediators. The mediators not only addressed the language barriers but accompanied these migrants in emergency cases.

“They just call me like around midnight (…) and I went (…). The ambulance came and we went to the hospital right then. Later I was there for some hours, and I came back to camp and tomorrow again I went again to the hospital to finish the job” (Civil Servant 3)

The informants pinpointed, however, that there were too few intercultural mediators available, and that they had an overburden of responsibilities. Most of them were in an uncertain work and life situation, where they possessed other jobs besides being an intercultural mediator. They were therefore unavailable to assist all migrants in need of their services.

Bridging Sociocultural Gaps and Building Trust to Influence Health Care Access and Quality

Generally, the respondents claimed that asylum-seeking migrants were sometimes hesitant to access health care services because of lack of trust in the health care system, lack of money to pay for services, their own personal or cultural beliefs on modern health care systems, or a fear of being detained in Serbia. The majority of the civil servants believed that it was crucial to establish trust between asylum-seeking migrants and intercultural mediators. Lacking empathy to the migrants’ situations or asking questions directly for administrative purposes may be counter-productive, creating a distance. Several civil servants claimed that establishing trust is an art that requires patience and regular, empathetic conversations.

“That kind of trust takes time, and it takes regular conversations with the person. It doesn’t have to be always about something important. You can just drop by for 10 to 15 minutes to say hi and how was their day. (…) after that, they will feel more comfortable telling you whatever you need to know.” (Civil Servant 2)

The interviewed civil servants and some of the interviewed migrants explained that socio-cultural gaps were a barrier in access to health care services by asylum-seeking migrants. Largely, they believed, this was because the migrants came from different socio-cultural backgrounds and their understanding of health and disease were often different than the contemporary understanding of that in Serbia. Most of the civil servants believed that some migrants ignored clear symptoms of disease or medical emergency and continued their journey toward Europe. The migrants’ cultural constructs might further make their access to health care services difficult, the informants expressed. The informants reported, for example, that female migrants would sometimes refrain from being attended by male intercultural mediators or being treated by male doctors. They would further have preconceived ideas that western health care providers did not understand migrants’ culture, priorities, and needs. These ideas of stigma were often accumulated by other migrants in the area, reporting stories of improper or unfair treatment which made them hesitant to seek health care services. The intercultural mediators in that regard seemed to play a pivotal role in dealing with such hesitation, in that they may bridge the cultural gaps and guide the migrants to better utilize health care services.

Reducing Informal Patient Payments Due to Facilitation Function of Intercultural Mediators

Most of the respondents perceived that informal patient payments were quite common in Serbia, although they were believed to decrease in intensity compared to the past.

So you have some layers of society who are more powerful than others. Doctors now have power over life and death, like the clergy did before. And just a way to honour this power. So, it is something like a tradition basically. (Civil Servant 1)

The interviewed asylum-seeking migrants reported that they could generally access universal health care in Serbia, though in some instances they needed to pay out-of-pocket for certain medicines or services. They experienced that this created a barrier in their utilization of services, as it was impossible for them to raise money. Generally, it was further believed that paying informally for services, in the form of gifts or money, was not either optional for these migrants, since they did not have the assets to purchase such things even if they wished to. None of the civil servant respondents recalled the asylum-seeking migrants being asked to pay informal fees for their health care services.

“No, No. Migrants don’t do that. Really. Really. I have never heard anything similar from the side of migrants. Although, I know that it is present.” (Civil Servant 4)

However, several of the civil servants reported that other vulnerable groups in Serbia, such as other migrants, who were unable to pay extra, for example, maternity care, were exposed to poorer access or poorer quality care if they refused to pay extra. Due to the lacking resources, and consequently poor access and poor-quality care, several civil servants believed that Serbians would rather pay out-of-pocket for private health care services or would make informal patient payments for those they were entitled to.

If you have money, that is. You would never really go to the public institutions. You would choose the private because they are just better. (Civil Servant 1)

Several of the respondents perceived the gratitude gifts as acceptable, while some opposed, calling it corruption. The interviewed migrants mentioned that they were, from their home country, familiar with the practice of informal patient payments or utilizing private health care services. In that sense, they believed that doctors should be recognized for their work through informal patient payments, especially to motivate them and to continue their positive work with other future patients. The organized mechanism for the newly arrived migrants to access health care, along with the presence of intercultural mediators, however, made it difficult for informal patient payments to take place, even if it was a cultural norm in Serbia. Few migrants mentioned that they were unfamiliar with this custom in Serbia, which they reported to be a reason for them to not give gifts or money.

Discussion

This study explored asylum-seeking migrants’ access to health care in Serbia when assisted by intercultural mediators. The analysis of the data indicated that access to health care was easier when these mediators were involved. The intercultural mediators further played an important role in reducing the risk of migrants paying informally.

Similar to the work by the World Health Organization’s Health Evidence Network (Verrept, 2019), the present study found that the main roles of the intercultural mediators were interpreting, bridging socio-cultural gaps, promoting migrants’ health in guiding them to (certain) health care services, and bridging access to the health care system through, for example, information and advocacy. The intercultural mediators thus had a pivotal and invaluable role in paving the way for asylum-seekers’ access to health care services. Though, for example, Venables et al. (2021) and Robertshaw et al. (2017) point out that not all migrants wish an intercultural mediator to be present, as speaking their native language during treatments may raise traumatic memories. The interviewed migrants of the present study expressed a high degree of trust toward the intercultural mediators that were included. According to earlier evidence, migrants being assisted by intercultural mediators however need information about the assistance of the mediators and reassurance on codes of conduct and confidentiality when accepting this assistance (Venables et al., 2021). All migrants of the present study were asked whether they wished an intercultural mediator to be present and all accepted their assistance.

The evidence further suggests that intercultural mediators are often in precarious and temporary positions, while they lack sufficient training and formal certification (Verrept, 2012, 2019). The present study also found these mediators to be in uncertain work and life situations, which consequently made them accept the overburden of responsibilities and do their job based on private wishes to help others in need. Intercultural mediation programs are in that regard typically implemented in a non-systematic and short-term manner, which increases the mediators’ precarious situation (Verrept, 2019). This is also the case with the migrants’ response in Serbia (Lukić, 2016; Pusztai et al., 2018). Being migrants themselves, the intercultural mediators of the present study may also be vulnerable by likely carrying traumatic events that could have surfaced during their assistance (Venables et al., 2021; Verrept, 2019). Strengthening their position more comprehensively and systematically could give them better tools in assisting other migrants (Verrept, 2019). Venables et al. (2021) suggest that psychosocial support, supervision, and the training of intercultural mediators are highly important tools for the long-term sustainability of their services, and for them to, for example, establish a proper objective and professional distance in their work. Similarly, the WHO continuously emphasizes the culturally sensitive and linguistically appropriate health care systems in Europe, by for instance providing interpretation services, guiding, and providing information on health care entitlements, and training health care providers in culturally sensitive health care services (WHO, 2016, 2018a).

Bridging Sociocultural Gaps in the Treatment and Access to Health

In the current study, asylum-seeking migrants would be hesitant to access health care services due to preconceived ideas about how they may be treated by health care providers when in the system. For instance, fear of prejudices about migrants, mental health not being understood, their needs not being met, or poor-quality treatment. When in the system, the asylum-seeking migrants further needed the intercultural mediators’ presence to understand their diagnosis or treatment. Other studies (Bartolomei et al., 2016; Hassan et al., 2015; Kiselev et al., 2020; Shannon et al., 2016; Wohler & Dantas, 2017) similarly found that the perceived mismatches between the western systems of treatment and diagnosis and migrants’ needs, resulted in the fear of mistreatment, misunderstandings in culturally based explanations of mental illness, and lack of trust in doctors and the health care system. Especially the vulnerable migrants may be apprehensive about engagement with the health care system (Duncan, 2015; Peterson et al., 2011). In the current study, the intercultural mediators seemed to potentially impact the timely access to care, increasing the trust toward the health care system and providers, and reducing migrants’ hesitation. Researchers (B. Murray & McCrone, 2015; Robertshaw et al., 2017) also find that enhancers of trust between health care providers and migrants’ patients rely on continuity of the provider, time, interpersonal skills, assisting migrants with their wider needs, and taking an active interest in migrants’ language, background, and culture. Although the intercultural mediators seemed to be pivotal in facilitating such relationships, they were during our study often highly busy and sometimes unavailable to the migrants, as there were not enough of them. When having no intercultural mediators available, evidence suggests that language barriers create situations where (mental) health care providers need to terminate the treatment completely (Kiselev et al., 2020; Müller et al., 2018). The positive relationship between health care providers and migrants that is facilitated by the intercultural mediators is thus invaluable when tackling migrants’ equal access to health care services (Phelan & Martín, 2010; McGary et al., 2018).

Intercultural Mediators’ Role in Diminishing Informal Patient Payments

The present study found that informal patient payments were common, mainly due to the perceptions of gift-giving and the lacking resources of the Serbian health care system. However, asylum-seeking migrants seemed to be protected from informal patient payments in the Serbian health care system, mostly due the role of intercultural mediators. These mediators would consequently guide and inform migrants on health care entitlements and local customs in Serbia, while advocating for the best quality of treatments. Most of the respondents recognized the motivation of doctors through informal patient payments. Others believed it to be corruption that should be eradicated. Such beliefs resemble the academic discussion in the area, on whether they are forced or voluntary, whether they are a fee-for-service or out of gratitude, and what it constitutes when they are paid out of money or from gifts (e.g., drinks, flowers, sweets) (Aasland et al., 2012; Buch Mejsner & Eklund Karlsson, 2017; Gaal et al., 2006; Gaál et al., 2010; Gaal & McKee, 2005; Grødeland, 2013; Khodamoradi et al., 2018; Lewis, 2002; Polese, 2014; Stepurko et al., 2013; Vian, 2008, 2020). Regardless of the positive intention of patients, the informal patient payments are regarded as out-of-pocket payments and should be viewed as detrimental for the equal access to health care of vulnerable groups (WHO, 2000, 2019). Other evidence similarly finds that the Serbian health care system faces several challenges of constrained resources, informal patient payments, and high levels of out-of-pocket payments (Arsenijevic et al., 2014b, 2015; Bjegovic-Mikanovic et al., 2019) meanwhile having a health insurance coverage of 98% (Bjegovic-Mikanovic et al., 2019). Thus, the private out-of-pocket payments for health care services have been levelled at approximately 40 % of total health expenditure over the past years (WHO, 2018b).

Vulnerable groups, such as the migrants of the current study, however, need financial protection to not be pushed further into poverty (WHO, 2019). The introduction of intercultural mediators and the organized way to access health care services for the asylum-seeking migrants in Serbia, appeared to reduce the chances of paying informally for this group. Other evidence from Serbia suggests that the lower educated or those with lower income, report higher levels of unmet needs such as financial barriers, long waiting times, or transportation difficulties when seeking health care services (Bjegovic-Mikanovic et al., 2019). Some civil servants of the current study also emphasized the high utility of private health care services or the informal patient payments for public health care services, to receive faster or better-quality care. Evidence on informal patient payments similarly shows that those with money are more likely to pay informally (Arsenijevic et al., 2015; Pourtaleb et al., 2020; Tomini et al., 2012; Vian et al., 2006) illustrating the overall inability of vulnerable groups to pay out-of-pocket. In the current study, asylum-seeking migrants seemed to be protected from these challenges in the Serbian health care system. Though, when integrating into society they would most likely be faced with high unmet needs.

Methodological Considerations

Recruiting asylum-seeking migrants for the study was challenging, as they lived in precarious situations and were often too occupied with their current situation to participate. Migration researchers suggest creating a multicultural team to build trust between researchers and migrants and conducting snowball sampling (Fête et al., 2019; Ingleby, 2009). To access, recruit, and interview the migrants a team of intercultural mediators, researchers from the University of Southern Denmark and the University of Belgrade was created. The researchers worked together on obtaining approvals needed for interviewing migrants in the asylum centers. The interviewed migrants were selected by the management at the asylum centers, potentially giving selection bias. The recruitment of respondents was generally a long process in the study and sampling bias may be present.

Those migrants selected for interviews had previous experience with the health care system in Serbia and were willing and able to participate. Interviewing vulnerable migrants may however present several limitations, such as their willingness to participate due to for instance language barriers, religious beliefs, or educational level (Gabriel et al., 2017; Reiss et al., 2014). Intercultural mediators were therefore included. Intercultural mediators providing interpretation during interviews may create challenges in the flow of the conversation, making it less spontaneous and disjointed (Plumridge et al., 2012). The researcher may further face challenges in prompting and losing control whether questions are phrased in a non-leading and neutral way (Plumridge et al., 2012). Since the responses from the migrants were translated, misunderstandings of questions might have occurred, potentially harming the validity of the data (C. D. Murray & Wynne, 2001). Question marks raised by the respondents were, however, taken into great consideration before, during, and after the interviews. The intercultural mediators were further briefed before the interviews. These mediators could also provide information to the researchers and migrants on for instance the (Serbian) social context or the migrants’ situation, reducing misunderstandings. Only interviewing the asylum-seeking migrants in the present study, may however provide limited data about the highly heterogenous group of migrants and their barriers and facilitators to access health care. Barriers in access to health care services could be further investigated with other methodologies and in various migrant groups. In the present study, observing the asylum-seeking migrants could have provided different insights into their stories, while giving other more complex understandings of their encounters with the health care system in Serbia.

Intercultural mediators and information workers were also interviewed, to have multiple perspectives on the migrants’ situation and to increase the validity of findings. These professionals were able to provide perspectives of the new coming migrants as professionals and as local Serbians. The inclusion of these interviewees may create ethical dilemmas when ensuring migrants’ integrity (Leaning, 2001). The intercultural mediators were therefore interviewed after the migrants’ interviews were completed. Further, the roles of the intercultural mediator and the researchers were clarified before the interviews began and migrants were continuously made aware of their rights to withdraw at any time. Comparing the information workers and intercultural mediators with the asylum-seeking migrants is also difficult. They were in different positions to access health care and had different legal entitlements. One group further resided locally, whereas the other intended to leave Serbia. Interviewing both groups, however, gave an interesting dynamic and the possibility to uncover aspects of informal patient payments from both sides.

Conclusion

Intercultural mediators were found to have a pivotal role in shaping better and quicker access to health care services and to reduce the risk of informal patient payments for asylum-seeking migrants in Serbia. The result of the present study indicated that the strategies taken to provide health care for the asylum-seeking migrants seemed to be successful in increasing trust in the health care system, bridging socio-cultural gaps and reducing informal patient payments. These initiatives could be translated to other Western Balkan countries, which face barriers in migrants’ access to health care. The intercultural mediators however need protection and stability to be able to provide long-term solutions in the migration response. Decision-makers in Western Balkan or European countries should therefore emphasize a systematic and comprehensive position while providing psychosocial support, supervision, and training to the intercultural mediators. In line with other evidence, other vulnerable groups living in Serbia seemed to be at risk to private spending on health care and high levels of unmet needs. When integrating into the Serbian society, the asylum-seeking migrants will thus be part of that group. Based on these results, decision-makers in Serbia might mobilize intercultural mediators to all vulnerable groups when accessing health care services.

The evidence from the current study may provide information on facilitators, barriers, and gaps in the equal access to health care services of asylum-seekers, to those mobilizing migration responses in Serbia or other European countries.

The below specific implications for research, policy, and practice rely on the key findings of the study in promoting migrants’ and equitable access to health care. They are based on the evidence in the area and the perceptions of the respondents in the current study and may be directed toward societies in Serbia or other countries employing the assistance of intercultural mediators.

Future research could be done on the intercultural mediators’ role on informal patient payments in other vulnerable groups, for instance other migrant populations in European or Western Balkan countries.

Better and easier access to health care for vulnerable populations could be given by translating the structural factors implemented for the asylum-seeking migrants in Serbia, for example, mobilizing intercultural mediators and easier access to health care services through for example patient timeslots.

The accessibility and quality of health care services to migrants could be increased through more organized and longer-term conditions for the intercultural mediators. Research in this field could also be done.

Socio-cultural gaps between migrants and health care providers could be bridged by increasing the cultural competencies of health care providers

Awareness could be given to the detrimental effects of private spending on health care, by emphasizing the cultural and structural constructs of gift-giving when providing health care services.

Footnotes

Acknowledgements

None.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

Ethical approval was given by the Faculty of Medicine at the University of Belgrade (Number: 2650/VI-12). In Denmark an ethical approval was received from the University of Southern Denmark (SDU) (Number: 18/33066 CEAN) and the South Regional Committee on Health Research Ethics (Number: S-20182000-84). We further followed the SDU Data Protection Guidelines, based on GDPR, ensuring data confidentiality, and safeguarding of data files.

ORCID iDs

Sofie Buch Mejsner

Maša Davidović

Leena Eklund Karlsson

Data Availability Statement

Data may be available upon request to corresponding author.

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