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Direct provision’s enduring health impact

A Government commitment to end the direct provision system is likely to entail a long process, during which time the health of protection applicants will continue to be negatively impacted. Catherine Reilly reports

Mr Lucky Khambule is unequivocal about the greatest health challenge for residents in Ireland’s direct
provision system, which currently accommodates over 7,000 applicants for international protection.

“Mental health,” he tells the Medical Independent (MI). “Mental health is the worst challenge people have and
that is the most ignored part of the fate of people in direct provision.”

Mr Khambule is a former resident of this system and coordinator for the Movement of Asylum Seekers in Ireland (MASI). “There is no formal situation whereby there is support, where you know on this particular day there will be this person who is coming into the centre and will offer their services, there is nothing like that. Nothing. People are
left on their own.”

A spokesperson for the Department of Children, Equality, Disability, Integration, and Youth (DCEDIY) stated that applicants can access all health services through “the same referral pathways as Irish citizens”. They are also entitled to a medical card and a waiver on prescription charges.

“ Recent tender competitions have required contractors to provide social supports to residents to assist them to integrate and have meaningful interaction with the local community, to meet their recreational needs, etc,”
according to the DCEDIY, which took over responsibility for the International Protection Accommodation Services (IPAS) from the Department of Justice in 2020.

A vulnerability assessment pilot commenced in December 2020 and was extended to all new applicants for international protection from the beginning of February 2021.

The Irish Refugee Council had highlighted that the State was legally required since 2018 to implement these assessments under the EU Reception Conditions Directive and it put legal pressure on Government regarding
this matter. Notably, the statutory instrument to implement this Directive also includes a “right to healthcare” provision

According to the DCEDIY, the vulnerability assessment pilot will continue until the end of 2021. “The purpose of these assessments is to determine if, by virtue of a particular category of vulnerability, an applicant is deemed to have special reception needs, what those needs are and what actions are required to address those needs.”

All applicants are advised they can contact IPAS to discuss their needs at any stage, even if a vulnerability assessment has previously been conducted. A resident welfare team was established in IPAS from the beginning of May to oversee the vulnerability assessment process.

System

As of 22 August, direct provision centres (including the Balseskin reception centre) had overall capacity for 7,163 people, with 7,056 accommodation places assigned. The Balseskin centre in Dublin, where applicants stay following quarantine and prior to leaving for an accommodation centre, has capacity for 537 residents, with 382 accommodation
places assigned. A “comprehensive health screening process is afforded to each resident upon entry to Balseskin”.

The direct provision system has been in place since April 2000, when asylum applications were rising significantly. It principally involves provision of full board at accommodation centres run by private companies under State contracts. Most applicants do not have their own cooking facilities.

In 2018 the system cost €78 million and this increased to €175 million in 2020 to cover additional requirements, including provision of Covid-19 response centres for isolation and quarantine and personal protective equipment (PPE) for residents.

A weekly stipend of €38.80 per adult and €29.80 per child is provided. Since 2018, someapplicants have had labour market access following a Supreme Court judgement. In early 2021, the Government widened access to applicants waiting for six months for a first-instance decision on their protection application. Previously, employment permission
could only be sought after nine months.

Applications for international protection fell dramatically in 2020 (1,566) compared with 2019 (4,781) due to the pandemic. Most applicants last year were from Nigeria (208) followed by Somalia (167). In 2021(to 30 June)
there were 728 applicants, with 173 from Nigeria and 70 from Afghanistan.

Over the years, mainstream support has slowly crystallised around scrapping the direct provision system. The Programme for Government included a commitment – instigated by the Green Party – to replace the
system with a new international protection accommodation policy “centred on a not-for-profit approach”.

Staff and management ‘were ill-prepared

as to what was going on. They didn’t know

how to react to a person with

symptoms or even a Covid test result’

“The shortcomings of the current accommodation system for applicants for international protection in congregated settings have been widely recognised and developing a new long-term approach has been a key
priority for this Government,” wrote Taoiseach Micheál Martin in the White Paper to End Direct Provision and to Establish a New International Protection Support Service, which was published in February. It sets out a policy to ‘phase out’ the current system over the next four years.

The white paper proposes that applicants will stay in a reception and integration centre for “no more than four months”. These centres will be “newly built to a high specification and will be operated by not-for-profit organisations on behalf of the State”. During this “orientation period”, people will receive integration supports including English language tuition and “employment activation supports”

After the first four months, people whose protection claims are still being processed will move to accommodation in the community. “This will be own-door or own-room accommodation, for which they will pay a means-tested rent

“Applicants will be entitled to seek paid work after six months, and they will be encouraged and supported to do so. Integration supports will continue to be available to people who need them.”

The transition to the new system will be led by the DCEDIY, which envisages that it will be “fully operational by December 2024”. The model is based on an assumed 3,500 new applicants per annum and applications being largely processed to decision at first instance within six months and on appeal within a further six months.

Delays

Currently, the application system is “fraught with administrative delays and a substantial backlog” despite the commencement of the International Protection Act 2015 and the introduction of a single application procedure
in 2017, according to a recent report from the Irish Refugee Council.

Applications for international protection are made to the International Protection Office (IPO) in the Department of Justice, while appeals are handled by the International Protection Appeals Tribunal (IPAT), a statutory independent body.

The Covid-19 pandemic had “further slowed the decision-making process” with public health restrictions reducing the processing capacity of the IPO and IPAT, as well as family reunification decision-making, stated the Council’s report Hanging on a Thread: Delays in the Irish Protection Process. In 2020 the median processing time for international protection applications, processed to completion at first instance at the IPO, was 17.6 months, a Department of Justice spokesperson informed MI.

The median processing time for all applications, processed to completion at first instance at the IPO in quarter two 2021, was 26.9 months. The median processing time for applications at appeal in 2020 was 31 weeks.

Last year the median processing time for cases decided in the Ministerial Decisions Unit (which processes recommendations from the IPO and decisions of the IPAT) was 1.6 months and seven days for cases processed to completion in quarter two 2021.

“The white paper proposes that the new system should be phased in and operational by 2024 and that the intervening period should provide an opportunity to progress improvements in the overall processing times for international protection,” the Department of Justice spokesperson stated.

“Work is under way in the Department towards identifying mechanisms which will assist with this. For example, additional ICT resources have been secured for this year, and detailed practical work, including the end-to-end review of relevant international protection processes by a multidisciplinary team from within the Department, has now been completed.”

Health in new model

The white paper states that a health assessment will be provided for all new international protection applicants in phase one of the process. A vulnerability assessment process will be in place “building on the current pilot vulnerability screening and assessment process with which the HSE is supporting DCEDIY”.

Community healthcare teams will develop a “comprehensive and efficient model of care for applicants for international protection”.

Under the white paper, the DCEDIY has committed to developing wellbeing indicators for international protection applicants, to be assessed by an independent body at regular intervals.

The DCEDIY spokesperson said the development of wellbeing indicators will commence “at a later stage in the implementation process”. As set out in the white paper, “an independent body of experts will work with the
Department to develop these indicators. The process to appoint this independent body of experts has not yet commenced.

Pandemic

In the meantime, campaigners say the pandemic has exposed and exacerbated the impact of direct provision on people’s health. Data from the Health Protection Surveillance Centre (HPSC) shows from August 2020 to December 2020, there were 19 reported outbreaks in direct provision centres.

According to Mr Khambule of MASI, the authorities responsible for managing and overseeing the system did not respond appropriately to the emergence of the Covid-19 pandemic.

“The issue of Covid in direct provision has been a concern from day one…. Our concern, even before the outbreaks, were the overcrowding and lack of opportunity for people to social distance in accordance with the health guidelines.
“All the health guidelines which we were seeing from the HSE were non-existent when it comes to direct provision…. Initially there was no plan in terms of the sanitisers, the gloves, masks, that was not provided.”

Staff and management “were ill-prepared as to what was going on. They didn’t know how to react to a person with symptoms or even a Covid test result.” “Our calls at that time were simple, to reduce the number of people in the centres” to a maximum of two people per room “instead of three or four”

MASI also advocated for people at high risk of Covid-19 to be identified and moved from centres promptly, so as not to be exposed to overcrowding. He maintained these calls “fell on deaf ears” at the time, but he acknowledged there have been some improvements. “The longer this pandemic stayed with us, it meant that they also had to up their game. They now started to put the sanitisers in visible areas, which was good to see happening.”

However, overcrowding has remained a concern and social distancing is often not being managed by authorities when moving residents between different centres and locations, he maintained.

Aside from infection control, the close cohabitation of people from vastly different backgrounds can lead to interpersonal tensions. “This question of mixing people of different races, religions, countries, they don’t really care about the fact that some of these people cannot get along because of the differences of countries people come from….

“IPAS is supposed to be the caring part of this whole process, but they care less, honestly they do care less.”

Mr Nick Henderson, CEO of the Irish Refugee Council, told MI that pandemic measures in the direct provision system
“gradually improved, but there were still significant outbreaks”

A report published by the Council in August 2020, titled Powerless, found 55 per cent of people in the system felt unsafe during the pandemic; 50 per cent were unable to socially distance from other residents; 42 per cent shared a bedroom with a non-family member; and 46 per cent shared a bathroom with a non-family member.

One respondent to the survey commented: “We share the same canteen, a lot of people share bathrooms and toilets. The truth of the matter is we are at risk of dying more than anyone else.”

Mr Henderson said there were efforts by authorities to cocoon the vulnerable. “But I think the State never got away from the fact that people were ultimately in congregated settings, they were in close proximity to each other, and therefore there was always going to be a higher degree of risk of transmission”.

A pressing concern for support organisations is the “real deterioration in people’s mental health”, he added. The pandemic has impacted people’s health and wellbeing, in addition to the associated delays in processing applications. “That manifests itself in drastic actions that includes suicidal ideation and actual suicide attempts as well.”

Mr Henderson said that, more generally, residents can face difficulties getting on GP lists, while access to dentistry has emerged as an issue. “People can get linked to really good health and appropriate support, but in our experience, people can also just be lost within a system.”

He noted wider problems around access to mental healthcare in Ireland. “If it is absent for mainstream society, it will definitely be absent for people in this process.”

‘High priority’

The DCEDIY spokesperson maintained that the health and wellbeing of all residents during the pandemic “remains the highest priority for this Department”.

“To that end, a wide range of measures have been put in place across the accommodation network to address any Covid-19 related issues, should they arise. These measures were implemented in collaboration with the HSE and informed by regional public health officials and infection control teams.”

According to the Department, the measures are kept under regular review by a joint HSE/DCEDIY monitoring group. These measures include “provision for self-isolation facilities in centres and offsite self-isolation at HSE and IPAS isolation facilities”; increased capacity to support physical and social distancing; “enhanced” cleaning regimes and provision of PPE; regular communications on public health advice to residents and centre managers; provision of a free, confidential and independent support line for residents operated by the Jesuit Refugee Service; cocooning of all medically vulnerable residents and those aged over 65; and the HSE accommodation scheme for healthcare workers.

The spokesperson said Covid-19 vaccination of residents was a matter for the HSE.

“However, IPAS fully supports all information sessions and/or vaccination clinics where the HSE have chosen to implement a clinic on-site; supports access to GP/pharmacy vaccinations, and in many cases, supports residents’ transport requirements to national vaccination centres.”

As there are a number of routes by which residents can access vaccinations, the HSE had indicated it would not be able to measure vaccine uptake in an accommodation centre with accuracy.

Meanwhile, the DCEDIY spokesperson said it is engaged in consultations with the Department of Health and HIQA to establish an independent monitoring mechanism for IPAS accommodation centres, where overall conditions are often criticised by advocacy groups. “The aim is that HIQA will be able to commence roll-out of its monitoring strategy shortly. Centres will be required to address any issues arising from the inspections.”

According to Mr Henderson, HIQA inspections “will be really important because ending direct provision isn’t going to
happen overnight”. “If you read HIQA inspection reports [of health and social care services] and compare them to current inspection reports [of direct provision], they are chalk and cheese, so to have their teeth could really make an
impact in the short-term.”

While an end to the direct provision system has been promised, Mr Khambule of MASI remains sceptical about whether it will be fully realised or just repackaged. Mr Henderson also acknowledged that this is a worry and that the Council, as a member of the programme board overseeing the process, shares a responsibility to ensure the
full reforms are implemented.

“I think what they are trying to do is find a fancy term they are going to come with, but the operation will still be the same, from what I can see,” noted Mr Khambule. He said a core problem remains the length of time that people are required to stay under State care, whatever form that may take. He underlined that the operators of accommodation centres were not financially impacted by the pandemic.

“They still overcrowd people, because overcrowding means money to them as they are paid per head, not per bed,” he maintained.

“During the pandemic, everyone, every sector, suffered, but I can tell you, any owners of direct provision did not suffer an inch in terms of their profits…. They are smiling all the way to the bank while everyone else is trying to recover.”

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