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Possible implications of Inclusion and Exclusion of Migrants in the current Austrian HealthCare Reform Process
Contents
Introduction__________________________________________________________3
Social Determinants of Health and Healthcare Inequalities_______________ _____ 11
Case Study Austria____________________________________________________19
Health Reform Framework Austria________________________________________32
Discussion and Conclusion______________________________________________45
References___________________________________________________________49

Chapter 1: Introduction
Chapter Overview
The chapter introduces the background and objectives of the research study. The background portrays the importance of social determinants of health on health and healthcare parameters across challenged communities. The chapter provides a brief description regarding the health status of migrant communities (referred to as MMH population) in Austria. The chapter also introduces to the methodology and the research questions that are framed for conducting the study.
Background
There has been a global consensus regarding the importance of public health in influencing the socioeconomic status of a nation. Traditionally, public health was viewed as a domain to reduce and control the spread of life-threatening infections across a community. Therefore, efforts like sanitation, implementation of hygienic principles, vaccination, and disease prevention interventions were given priority (Marmot 2008).

Wait! social siences/health care reform,,, integration of migrants into the asutrian Health Care system/reform paper is just an example!

For such purpose, different health promotion programs like lifestyle modifications related with dietary habits, smoking, and physical inactivity have been initiated across the world. Such initiatives have been implemented to prevent the prevalence of cardiovascular and metabolic disorders. Implementation of such initiatives has certainly reduced the prevalence of various life-threatening diseases (Agyemang, et al. 2010). However, the benefits of such initiatives are not equally implemented or perceived by the concerned stakeholders. Such issues stem from the prevalence of healthcare disparities and healthcare inequalities across the inhabitants of any country (Marmot 2005).
Healthcare disparities and healthcare inequalities result from socioeconomic differences, societal discrimination, immigration status, ethnic background, and religion, nature of citizenship, policy discriminations and awareness across concerned stakeholders. Hence, the present focus of public health has shifted towards addressing the SDH (Guijt 2008). It is recognized that healthcare disparities across challenged populations and specific ethnic groups jeopardize the public health initiatives that are implemented by the Government of any country for safeguarding its residents (Borrell et al. 2006). Health inequalities due to SDH (Social Determinants of Health) are evident across Austria (Klimont, Kytir and Leitner , 2007). Social Determinants of Health refers to social and economic conditions that influence health and healthcare across different populations. These conditions influence the risk factors and prognosis for a disease or a set of diseases. Hence, SDH parameters should be considered while framing public health policies.
However, the health statistics of Austria indicate that the average life expectancy of migrant communities is higher than native Austrians (WHO 2014, OECD, 2015). However, health problems are significantly higher in migrant communities compared to Austrian citizens (WHO 2014, OECD, 2015). The prevalence of chronic diseases like diabetes mellitus and obesity are much higher in migrants than native Austrians (WHO 2014, OECD, 2015). The usage of outpatient care is higher in migrant communities (WHO 2014, OECD, 2015). On the other hand, the usage of preventive and specialized care is significantly lower across migrant communities in Austria. Hence, migrant communities are often deprived of quality and preventive health services.
Different strategies are implemented to reduce healthcare disparities across individuals based on ethnicity, race, religion, immigrant status and socioeconomic status (Brown et al. 2006,). The initiatives that are implemented for reducing healthcare disparities include implementation of health education programs/health promotion programs (through the provisions for primary and secondary care) and by improving accessibility to healthcare services (Elliott, McAteer& Hannaford, 2011, Binder-Fritz 2009, 2011, 2014).
It is noted that most health intervention strategies and public health policies endorse downstream interventions to address healthcare disparities amongst challenged individuals, such as preventive health check-ups and nutritional status evaluation. However, such downstream frameworks are not likely to address healthcare disparities holistically (Harris et al. 2006), as they focus mainly on the individual concerned (Borrell et al. 2006). Hence, such health reform strategies or public health policies are not likely to benefit the concerned stakeholders, if such decisions are left to individuals. On the other hand, implementation of upstream frameworks, such as government regulations would likely to benefit concerned stakeholders (BMG 2014). This is because the decision of accepting health care services would not be influenced by individual awareness and perspectives (Brondolo et al. 2008a, 2008b). Such strategies could become the backbone of robust health reform strategies (Noack, 201). The present study would explore the role of health reforms framework in integrating migrant communities in Austria.
Problem Statement
Differences in health outcomes and life expectancy exist not only between different countries but also between different populations within the same country. It is contended that both life expectancy and morbidity are unequally distributed among different social and ethnic groups (Biffl et al., 2012, OECD 2015, WHO 2014). Such disparities are evident in Austria and other European Countries. Most of these disparities stem from different socioeconomic and racial factors. Austria has one of the Europe’s best health care systems, with a statutory social insurance policy. Such policy ensures healthcare coverage across 99% of its population (OECD, 2013(WHO 2014, OECD, 2015)). The quality and accessibility of health care systems in Austria is considered high, compared to other European Union countries (OECD, 2014).
On the other hand, Austria is ranked seventh (amongst 34 OECD countries) based on healthcare expenditure as a component of GDP (OECD, 2013). In spite of ensuring highest standards of care, the average lifespan across Austrians is lesser than their counterparts, residing in other OECD countries. Differences in health outcomes exist not only between different countries but also between different populations within the same country. It is contended that both life expectancy and morbidity are unequally distributed among different social groups (Biff et al., 2012, p. 34; OECD 2015, WHO 2014). The average life span for men and women in Austria are 78.2 years and 83.6 years respectively. These figures were 0.8% and 0.7% higher than the OECD averages across the same population groups during 2013 (OECD, 2015).
However, a gap exists between the average life expectancy and the duration of healthy life years. In 2012, Austria reached just EU’s average lifespan of 61.3 years and 62.3 years for males and females respectively (OECD 2012). Although women are expected not only to live longer, they are also expected to live with a compromised health (WHO, 2014). The key to long and healthy life is distributed along the social hierarchy (Biffl et al., 2012). The social disproportions related with educational attainment (WHO, 2014; OECD, 2015; Klimont, 2008) and level of income (WHO, 2014; Klimont 2008, Statistik Austria 2015) is strongly associated with morbidity and mortality across concerned stakeholders.
It is contended that monetary constraints like poverty and occupational status are some of the major factors that lead to healthcare disparities across Austrian residents (Muckenhuber, Freidl & Rasky, 2011). For example, single-mother households, households with many children, low educational attainment, long unemployment rates and migrant background are not only endangered by poverty and other forms of social exclusion but are more susceptible to worse health outcomes(Biff et al., 2012, OECD 2015, WHO 2014). These individuals are more susceptible to poor health outcomes compared to individuals with higher socio-economic status (Klimont.2008, Till-Tenschert et. al. 2011). Noack (2011) contended that such discrepancies are attributed to the healthcare disparities prevailing across Austria(Biff et al., 2012, OECD 2015, WHO 2014). The authors further contended that health care disparities stem from inappropriate health care reform policies and lack of appropriate implementation of health care services across concerned stakeholders. The current Austrian health care reform process (2013-2016) states that it is based on fairness and equality and “participation of all stakeholders.”
Migrant communities in Austria are referred as Menschen mitMigrationshintergrund (MMH) population. These individuals have their origin in non-EU and non-EFTA countries. However, they have settled in Austria as a consequence of trade agreements between stakeholder nations. These individuals suffer from different inequities and one such inequity includes healthcare disparities. These inequities result from differences in SDH parameters and healthcare policy in Austria. The Austrian Government has introduced a framework of ten health targets. The framework of health targets are popularly denoted as Rahmengesundheitsziele (RGZ). The focus of these targets is to ensure safe and healthy living conditions for its residents (Haas et al., 2013, BMG, 2013). A major target of this framework is to promote fair and equal healthcare opportunities for its residents, irrespective of gender, socioeconomic status, ethnic origin and age. Hence, the framework of health targets (RGZ) is speculated to address healthcare inequities and inequalities across MMH population.
Synopsis of Health Targets (RGZ)
The Austrian Government has introduced a framework of ten health targets (Rahmengesundheitsziele – RGZ). The synopsis of the same is tabulated below:
Target 1: To provide health-promoting living and working conditions for all population groups through cooperation of all societal and political areas
Target 2 “To promote fair and equal opportunities in health, irrespective of gender, socio-economic group, ethnic origin and age“
Target 3: To enhance health literacy in the population
Target 4: To secure sustainable natural resources such as air, water and soil and healthy environments for future generations
Target 5: To strengthen social cohesion as a health enhancer
Target 6: To ensure conditions under which children and young people can grow up as healthy as possible
Target 7: To provide access to a healthy diet for all
Target 8: To promote healthy, safe exercise and activity in everyday life through appropriate environments
Target 9: To promote psychosocial health in all population groups
Target 10: To secure sustainable and efficient health care services of high quality for all
Purpose of the Research
The Austrian Healthcare Reform process acknowledged the healthcare needs and healthcare inequalities of ethnic groups in Austria. The paper will evaluate the social disparities or social determinants of health for portraying health disparities within Austrian residents. It would then examine the impact of health care disparities on the health status of migrants. The focus would be on social disparities because its effect on health and well-being is much greater than biological determinants. Moreover, social disparities or social determinants of health are avoidable and need to be addressed (AGES 2013).
Appraising the social determinants of health is essential for designing effective educational interventions and public policies for managing the healthcare disparities across ethnic groups residing in Austria.(Biff et al., 2012, OECD 2015, WHO 2014) It would be unwise to place the responsibility for poor health outcomes solely on concerned individuals (AGES 2013). Moreover, it should not also be expected that programs aimed to address healthcare disparities would be adopted by the concerned individuals. Hence, health reform programs should be so designed so as to engage different individuals belonging to diverse ethnic groups (WHO, 2014; OECD, 2015; Klimont, 2008). Policymakers should implement stringent health reform programs and must ensure an inclusive environment for redressing healthcare disparities across concerned stakeholders. Such strategies might address social determinants of health prevailing in Austria.
Research Questions
The present study investigated the main research question which was stratified into various sub-questions. The main question that was explored in this study was:
What findings from literature review could be adopted for addressing healthcare inequality amongst MMH [Menschen mitMigrationshintergrund] population of Austria?
The sub-questions that were explored in this study were:
What are the SDH parameters in the MMH [Menschen mitMigrationshintergrund] population (belonging to non-EU and non-EFTA countries) of Austria?
How well does the Austrian Health Care Targets (RGZ) address the health issues of the MMH population (as per the WHO “Health 2020” policy framework), with a particular focus on target 2?
What are the challenges in promoting fair and equal opportunities in health for MMH population of Austria?
Methodology
Study Design
The present study was based on a literature review conducted with relevant keywords (Barbour 2001). The literature review was arranged under different headings ((Ritchie, Spencer & O’Connor, 2003, Lucas 2014): socioeconomic status, healthcare, and demographic data of Austria and other European countries.
Procedure of Literature Review
The literature review was based on “keyword search strategy.” Different keywords and Boolean connectors were used to select the appropriate articles, and include “Social Health Determinants” or “Healthcare disparities” or “Healthcare Deprivation” AND “immigrants” or “ethnic minorities” or “racial communities” or “socioeconomic status” AND “Health Reform” or “Public Health Policy” or “Health Governance” AND “European Union” or “Austria” AND “OECD countries” or “Global” or “Europe”.
The different websites include Pubmed Central, Medline, OVID online, Cochrane Database and Google Scholar. Google Scholar was used for validating the reliability of different articles retrieved from four other websites. Moreover, health statistics data was obtained from Statistik Austria (2008, 2015, 2016). The relevant studies were appraised based on socioeconomic, healthcare, and demographic findings. OECD reports andStatistik Austria were also searched for retrieving necessary data.
There is a significant difference in health status and state of healthcare between Austrian residents and individuals belonging to MMH population. The study also contended that the Framework of Health Targets (RGZ) could effectively integrate MMH population of Austria based on the philosophy of ‘Health-2020”. The study explored the benefits of the RGZ frameworks based on the Health 2020 framework. “Health 2020” is the new health policy framework that has been adopted by European nations. This framework is implemented or analysing the perspective of healthcare of MMH population in Austria. The “Health 2020″ framework acts as a guide and roadmap for policy-makers in ensuring public health. It also helps to ensure vision, mission, strategic goals and priorities for policymakers, those who are responsible for framing public health policies. Hence, policymakers should adopt such frameworks in their public health policies for improving health, for addressing health inequalities and for ensuring the health of future generations. Hence, it is contended that the RGZ would have the provisions of Health 2020 in its health targets. Inclusion and alignment of RGZ with Health 2020 may reduce healthcare inequity and inequality amongst MMH population in Austria.
Structure of Dissertation
The first chapter introduces the background and objectives of the research. The second chapter of the dissertation would portray the SDH and its impact on healthcare inequity. The specific focus would be on Ethnic minorities and migrant communities. It would analyze the SDH and the health systems that are implemented for aiding healthcare reform of the target communities. The chapter would also discuss the key challenges and healthcare needs of such communities. The chapter would reflect the importance of integrating migrant communities in the health reform system. The third chapter would specifically focus on SDH and health inequity amongst migrant communities (migrating from non-EU and non-EFTA nations). The chapter would also focus on the Austrian Health system and portray the OECD economic survey results. The chapter would then focus on Healthcare status of Austrian citizens and migrant communities in Austria. Finally, the chapter would highlight the limitations of the Austrian health system in addressing healthcare inequity and healthcare discrepancy amongst migrant communities. It would also portray the SDH parameters of migrant communities in Austria that predisposes them to health care inequity. Therefore, Chapter 3 would explore the challenges in promoting fair and equal opportunities in health for MMH population. Chapter 4 would highlight the health reform strategies in Austria with reference to health targets (RGZ). The chapter would explore the role of health reforms framework in integrating the migrant communities. Finally, the chapter would portray the findings that could be adopted for addressing healthcare inequality across migrant communities in Austria. The final chapter would end with a discussion and conclusion on the dissertation.
Chapter 2: Social Determinants of Health and Healthcare Inequalities
Chapter Overview
This chapter would portray the SDH parameters and its impact on healthcare inequity. The specific focus would be on ethnic minorities like the migrant communities. This section would analyze the SDH parameters and the health systems that are implemented for aiding healthcare reform across target communities. The chapter would also discuss the key challenges and healthcare needs of migrant communities. Finally, it would reflect the importance of integrating migrant communities in the health reform system.
Social Determinants of Health
Social Determinants of Health (SDH) refer to the different non-clinical factors, which impact the average health of a population (Agudelo-Suarez, et al. 2009, Agudelo-Suarez et al., 2011,). Labonte and Schrecker (2007, p.12) mentions that ” Social determinants of health, broadly stated, are the conditions in which people live and work that affect opportunities to lead healthy lives. Good medical care is vital, but unless the root social causes that undermine people’s health are addressed, the state of well-being would not be achieved”. SDH include various distal determinants and proximal determinants that influence the administration of public health policies or public health initiatives (WHO, 2014; OECD, 2015; Klimont, 2008). The distal determinants of health include the political, legal, organizational and cultural framework in a society or a nation. On the other hand, proximal determinants of health include socioeconomic status, demographics, physical environment, working conditions, employability, personal and social networks and lifestyle behaviours/habits (Marmont 2005, ,Thapa &Hauff 2005). It is contended that social determinants of health should be optimized before implementing healthcare reform programs (Agudelo-Suarez, et al. 2009, Agudelo-Suarez et al., 2011,). Every individual resident of a country should be eligible to receive the highest standards of care irrespective of their demographics and should not be discrimination (DeVito et al. 2015).
Guidelines for Framing Policies for Addressing SDH: Commission for Social Determinants Health
WHO’s Commission for Social Determinants of Health (CSDH) (2008) identifies health inequalities based on psychosocial factors, social production of disease/political economy of health and social parameters. The psychosocial framework contends that “perception and experience of personal status in unequal societies lead to stress and poor health.” The social production of disease and the political economy framework emphasizes that economic and political factors are major health determinants. The approach tends to integrate biological causes and social causes for the genesis of health management and health outcomes. CSDH contends that the major social pathways and mechanisms that affect the health of an individual are social selection/social mobility, social causation and life course issues.
Monitoring, Evaluation, and Measurement of Policy Changes
Different health target frameworks are recommended for implementing healthcare policies across the target populations. Such targets are generated through the stringent criteria of policy research. For example, Steven (2007) pointed out the eight monitoring and evaluation areas for policy research. Monitoring and evaluation of policies are essential for appraising the policy changes about a specific problem or a specific domain (Stachowiak 2013). The process of monitoring and evaluation helps to inculcate changes in the policy framework for ensuring its success (Tsui, Hearn & Young, 2014). The eight monitoring and evaluation areas for policy research are:
Attitudes of key stakeholders to get issues onto agenda: This domain helps to evaluate the intent and interests of the concerned stakeholders in implementing a specific policy. Moreover, it is contended that the stakeholders would be interested to implement a policy change based on evidence (Young et al. 2014).
Public Opinion: This domain represents the perception of the general community and society towards the proposed policy change (Gujit 2008).
Capacity and Engagement of other actors: This domain represents the individuals who are engaged in the policy change and the support system which drives such policy changes(Hovland 2007).
Change in discourse among policy actors and commentators: It represents the opinion of the policy makers regarding such changes (Hovland 2007).
Improvements in policy making procedure/process: This domain represents the individuals consulted during policy changes. Appropriate stakeholders should be focused in implementing such changes (Jones 2011).
Change in policy content: Specifies the new legislations, budgets and strategies that need to be incorporated in the policy (Beynon 2012).
Behaviour change for effective implementation: This domain explores whether the concerned stakeholders have the necessary skills, relationships, and motivation to incorporate policy changes (Keck and Sikkink 1998).
Networks and systems supporting delivery: This domain implicates the infrastructural support in aiding the policy changes (Cameron, Mishra & Brown 2015).
Evaluating the Effectiveness of Public Health Policy Frameworks
Nutley, Walter & Davies (2007) have specified the different dimensions for analyzing public policies. Such framework or dimensions broadly evaluate the effects of a specific policy change and the status of implementation of such policy/s (Milio 2001, Peters 2002, Salamon 2002, Pawson 2006, NCCHHP 2012). The dimensions for analyzing public policies are represented in Table 1.
Effects Effectiveness of a policy (Morestin et al. 2010) Represents the effects of the policy on the target population
Unintended effects of the policy(Rein & Schon 2005) Focuses on the undesirable effects of a policy or policy change
Equity (Swinburn, Gill & Kumanyika 2005) Effects of the policy on different groups
Implementation Cost factors Represents the financial cost of the policy
Feasibility (Oxman, et al. 2009) Explores the technical feasibility of the policy
Acceptability status of the policy (Lavis et al. 2009) Whether the relevant stakeholders feel that the policy /policy changes are acceptable
Social Determinants of Health and Healthcare Inequality
Healthcare discrimination and healthcare inequalities not only impact the physical health of certain strata of society but also affects the socioeconomic development of a country (Faltermaier 2001). Healthcare inequalities are witnessed even across developed and developing countries. Policy makers have a major role in addressing the social determinants of health (Smedley 2006). The Government of all countries should implement a stringent framework for ensuring and safeguarding the health of its citizens (Franke, 2006). The residents of any country should be extended highest standards of care. Unfortunately, different populations or specific ethnic groups are deprived of receiving quality and standard healthcare interventions. Such disparities stem from ineffective government policies, lack of appropriate governance, ignorance of policy makers and social/cultural taboos imposed on concerned stakeholders (Kapilshrami, Hill & Meer., 2014).
Healthcare disparities may result from the biological differences between different racial communities or special ethnic groups and also from the social disparities to which these individuals are exposed. Social disparities represent the domain of SDH and encompass issues related to housing, transportation, communication, education, awareness, criminal behaviour. All such factors have been implicated to interact with each other and also with the biological determinants that influence the health status of an individual (Biffl, Altenburg & Bjourngren-Caudra, 2012,). It is accepted that most ethnic or racial communities fail to achieve the full potential for a healthy life. The inequalities imposed by social determinants are unjust, unjustifiable and avoidable (Agudelo-Suarez, et al. 2009, Agudelo-Suarez et al., 2011). Healthcare disparities lead to poor and negative health outcomes in this class of individuals (Hofmarcher & Quentin, 2013).
SDH and Healthcare Inequality amongst Migrants
Every individual resident of a country should be eligible to receive the highest standards of care irrespective of their demographics and should not be discrimination (Sujoldzic et al. 2006, p. 707, United Nations 2002). Healthcare disparities are also witnessed in residents with immigrant status. Immigrants are deprived of quality and safe healthcare across the globe. The major reasons for such disparities are attributed to their status of citizenship and social taboos within policy makers and governance (WHO, 2014,Wamala, Bostrom & Nyqvist et al. 2007).
Governments of various countries are reluctant to designate appropriate citizen status to immigrants. Some of the major reasons for such pitfalls are the financial constraints and the likely burden that would be imposed by the respective Governments. Moreover, political appeasement of the residents (who are citizens by birth) and security threats to a country are also important in the genesis of healthcare disparities amongst immigrants. Health inequalities due to the social determinants of health (SDH) are long known both internationally (Bachinger, Monika & Klaudia 2004, Karl –Trummer, Ursula & Sardavar 2009) and in Austria (Klimont 2008).
Healthcare Disparities in Migrant Population
Healthcare disparities are also witnessed in residents with immigrant status (Hunte &Williams 2009). Immigrants are deprived of quality and safe healthcare across the globe (Bachinger, Monika & Klaudia 2004, Karl –Trummer, Ursula & Sardavar 2009a, Karl –Trummer, Ursula & Sardavar, 2009b, Karl –Trummer, Ursula & Sardavar 2012a, Karl –Trummer, Ursula & Sardavar , 2012). The major reasons for such disparities are attributed to their status of citizenship and social taboos within policy makers and governance. Governments of various countries are reluctant to designate appropriate citizen status to immigrants (HLS-EU 2012). Some of the major reasons for such pitfalls are the financial constraints and the likely burden that would be imposed upon the respective Governments (Hoffmann et al. 2013). Moreover, political appeasement of the residents (who are citizens by birth) and security threats to a country are also important in the genesis of healthcare disparities amongst immigrants (Karlsen & Nazroo 2002, WHO 2014).
Carta et al. (2005, p. 13) reported that addressing the social determinants of health could reduce poor health outcomes in children by almost 70%. Moreover, the authors implicated that advances in medical sciences could prevent 1, 76, 633 deaths in African-Americans during the period 1991 to 2000. On the contrary, the authors also implicated that if social disparities had been addressed during the same period, the number would have reached 8, 86, 202. Hence, Carta et al. (2005, p. 13) clearly implicated the impact of social disparities on public health status. De Majo & Kemp (2010, p. 471) reported that healthcare disparities across African-Americans, Hispanic and White resulted in an additional burden of 24 billion U.S dollars. Hence, it is evident that SDH could impact the physical health of an individual as well as the economic health of a country (Donovan et al. 2013, Edge & Newbold 2013,). Healthcare anomalies and healthcare disparities are observed all across the globe and Austria is no exception to such phenomenon.
Integrating Migrants in the Health Reform System
Different strategies are implemented to reduce healthcare disparities across individuals based on ethnicity, race, religion, immigrant status and socioeconomic status (Brown et al. 2006). The initiatives that are implemented for reducing healthcare disparities include administration of health education programs/health promotion programs (through the provisions for primary and secondary care) and by improving accessibility to healthcare services (Elliott, McAteer & Hannaford, 2011, Binder-Fritz 2009, Binder-Fritz , 2011, Binder-Fritz, 2014). Government stakeholders and private agencies partner with one another for improving access to healthcare services for concerned individuals (Berg et al. 2011). One such partnership involves the implementation of healthcare insurance amongst uninsured individuals (Haas, 2013).
Healthcare insurance provides secondary and tertiary prevention to concerned stakeholders (Green et al. 2001). It is noted that most health intervention strategies and public health policies are endorsing on downstream interventions to address healthcare disparities amongst challenged individuals. However, such downstream frameworks are not likely to address healthcare disparities holistically (Harris et al. 2006). This is because such downstream strategies depend on the individual concerned (Borrell et al. 2006). Hence, health reform strategies or public health policies are not likely to benefit the concerned stakeholders, if such decisions are left to individuals. Implementation of such upstream frameworks would likely to benefit the concerned stakeholders (BMG 2014). This is because the decision of accepting health care services would not be influenced by individual wishes and wills (Brondolo et al. 2008a, Brondolo et al., 2008b). Rather, such strategy could become the backbone of robust health reform strategies (Noack, 2011).
Health Inequalities and Social Exclusion amongst MMH Population
Jackson (2005, p. 64) reported that health inequalities are caused by the “paradigm of intersectionality”. It captures the multiple causes of discrimination based on gender, socioeconomic status, religion and background of migration. These factors interact with each other and contribute to the genesis of healthcare inequality. The interactions are speculated to be more subjective in nature compared to objective parameters (Jackson 2005). Jackson (2005, p. 63) argued that these factors affect health outcomes in an individual as well as the community to which he or she belongs (Jackson 2005,).
Hence, the cause of social exclusion happens to be multidimensional in nature (Bhalla and Lapeyre 1997). Multidimensional aspects of social exclusion include “insufficient access to social rights, material deprivation, limited social participation and a lack of normative integration (within the greater community)” (Vrooman and Hoff, 2013). Factors like ethnicity, gender, health status, age, socioeconomic status, societal norms, political initiatives and labour market dynamics can be considered to influence the risk of social exclusion (Bhalla and Lapeyere, 1997,; Vrooman and Hoff 2013). Hence, social exclusion could be prevented by addressing healthcare needs of MMH population (Östlin et al. 2011). Therefore, an integrative approach that ensures social rights, educational attainment, an extension of health care facilities and social participation across MMH community would be desirable. Such initiatives might be helpful in reducing the healthcare disparities across the MMH population of Austria (Goeg 2014).
Jackson (2005) also highlighted that both institutional and individual-level discrimination may lead to the genesis of health inequalities amongst MMH population. Healthcare disparities occur, according to Smedley et al. (2006, p12) due to “the operation of health care and its legal and regulatory climate”. Smedley et al. (2003) elaborated that factors like linguistic barriers, lack of interpreters and inappropriate distribution of the healthcare system leads to the genesis of healthcare disparities and social exclusion. Hence, social exclusion is not always driven by socioeconomic determinants of health.
Smedley et al. (2003) explain that discrimination may occur from the uncertainty of a physician’s encounter with a migrant individual. They contend that physicians often face clinical dilemmas in addressing healthcare needs in migrant populations arising from the lack of knowledge about patient’s history and ethnographic factors that may determine the health of an individual. Moreover, such dilemmas are also influenced by stereotypes and prejudices about migrants. Smedley et al. (2003) endorse that these multi-factorial issues lead to social exclusion and healthcare disparities across migrants. Dauvrin et al. (2012) reported an elaborate framework is required to address healthcare disparities. Dauvrin et al. (2012, p. 726) proposed that health targets must be appropriately elaborated and cultural competence of health care professionals must be ensured for preventing healthcare inequality across migrants.
Implementation of Health Policy Frameworks
The framework aims to integrate governments and the society for significantly improving the health of different populations. The broad perspective of the framework ensures the well-being of different populations, reduction in health inequalities and healthcare disparities, strengthening public health and ensuring people-centric health systems. Moreover, the framework also endorses that people-centric health systems should be universal, sustainable, and equitable and must ensure high-quality care. “Health 2020” is both evidence-based and peer-reviewed. It is based on the philosophy that good health is beneficial for the entire society. This is because a healthy society is strongly mandated for socioeconomic development of the nation. Moreover, good health also stimulates economic recovery. The “Health 2020” framework acts as a guide and roadmap for policy-makers in ensuring public health. It also helps to ensure vision, mission, strategic goals and priorities for policymakers, those who are responsible for framing public health policies. Hence, policymakers should adopt such frameworks in their public health policies for improving health, for addressing health inequalities and for ensuring the health of future generations.
Chapter 3: Case Study of Austria
Chapter Overview
The chapter would explore the challenges in promoting fair and equal opportunities in health for MMH population in Austria. The chapter incorporates statistics on migrant health and the healthcare needs in them. Moreover, it paves the roadmap for health policy frameworks.
Migration in Austria: Historical Background
Austria has been a favourite destination for migrant communities across the world. Census indicates that there are around 5, 46, 000 official migrants from non-EU and non-EFTA countries. On the other hand, there are around 40, 000 illegal migrants in Austria. Historically, Austria has witnessed a high influx of migrants. During 1960, the bilateral agreements with Turkey and Yugoslavia paved the way for migrant communities to settle in Austria (Statistik Austria, 2014, 2015, 2016). Such agreements were undertaken to facilitate temporary guest-workers ( who are accepted as contractual workers) in Austria. Moreover, the oil crisis during 1975 stimulated the implementation of “Alien Employment Act” which further encouraged migration in Austria. During 1988 and 1993 Austria witnessed the highest influx of migrants (Statistik Austria, 2014, 2015, 2016). The increase in migration during that period is attributed to the civil war in Yugoslavia.
Status of Migration in Austria and EU
Austria has an estimated population over 8.5 million inhabitants, out of which 21.8% (approximately 1.8 million people) reside in Vienna (Statistik Austria 2016). In Austria, demographic classification is based on nationality and migrant background (Statistik Austria, 2016). The classification is also made between the first generation of migrants (who were born abroad) and second generation of migrants (both parents have been born abroad). In Austria, 1.8 million individuals have a migrant background, accounting for almost one- sixth of the entire population. In Vienna itself, 41% of the population have a migrant background (Statistik Austria 2016). The majority of migrants in Austria are from Germany, Yugoslavia, Serbia, Croatia, Bosnia and Turkey. On the other hand, migrants have also come from non-EU countries like Afghanistan, Syria, Iran, China, Iraq, Philippines and India (Statistik Austria 2008, 2013a, 2013b, 2014a, 2014b, 2015, 2016). Hence, the migrant population in Austria is diverse. Migrant communities in Austria are referred as Menschen mitMigrationshintergrund (MMH) population. Most of these individuals have their origin in non-EU and non-EFTA countries.

Fig 1: represents the number of new migrants over the last two decades. The statistics indicate that there is a notable increase in the number of new migrants in Austria (Statistik Austria, 2014).
Austria has a long tradition of immigration. It is estimated that approximately 16% of the Austrian population is born abroad. Around 11% of the Austrian population holds the citizenship of another country. Out of such individuals, 36% belong to EU countries, while 64% belong to other countries. Amongst the first generation migrants, 53% hold permanent residence of Austria, 23% holds the right of domicile, 4% holds the right for short term stay and 16% are asylum seekers and 4% are illegal immigrants. Asylum seekers and illegal immigrants are prevented from right to employment. Hence, the target population of migrants (MMH) indicates that 20% (16% and 4%) are directly socially excluded from the Austrian mainframe system.
Migration in Austria could be attributed to various reasons. On the one hand, the major driving factor for migration was a need for skilled labour(Statistik Austria 2008, 2013a, 2013b, 2014a, 2014b, 2015, 2016). On the other hand, migration also took place to seek political refuge. Hence, the socio-demographic and socioeconomic attributes in migrants are diverse and multi-factorial (OECD, 2013, 2014).Migration is recognized as an important instrument for sustaining the functioning and economic growth of European countries. Austria is facing the adverse effects of demographic transition due to the ageing population. Without migration both the young people and the part of the population in “active” working age would decrease (Binder-Fritz, 2014, p. 1037).
However, the migration influx shifts this trend into the next decades rather than reversing it (Statistik Austria, 2015, 2016). The share of people at retirement age will, therefore, continue to grow (and young population would decrease) over the next decades if migration is prevented in Austria.

Fig 2: Average life expectancy in Austrian residents and migrants according to gender. The data suggests that the average life expectancy in migrant communities (MMH) is significantly higher than Austrian residents.

Fig 3: Indicates that self-perception of good healthcare accessibility and facility is lower in migrants compared to individuals born in Austria(Statistik Austria, 2015, 2016).
The disparity shown in Fig 2 and Fig3 clearly indicate that although average life expectancy is higher in migrants, they do not perceive the Austrian Health System to be competent in addressing their healthcare needs. These assessments of the same are represented in figure 4.

Fig 4: Represents the objective measures of social determinants of health across Austrians and migrants(OECD 2013).
The data represented in Fig 4 clearly imply that healthcare disparities are prevalent between migrants and Austrians. Moreover, the figures also indicate that social determinants of health are the key drivers of healthcare disparities across migrants. The attainment of secondary education was significantly lower amongst migrants compared to their Austrian counterparts. On the other hand, vaccination rate against pneumonia was significantly lower in migrants, the prevalence of chronic diseases (like obesity) was significantly higher across migrants compared to their Austrian counterparts, indicating a lower use of preventive health services. The data is in line with literature review, where it was found that migrants (whether first-generation or second-generation) generally have lower educational attainment than Austrian residents(WHO, 2014, Haas et al., 2013).
The health statistics of Austria indicate that the average life expectancy of migrant communities is higher than native Austrians. However, health problems are significantly higher in migrant communities compared to Austrian citizens (Ajrouch et al. 2010). The usage of outpatient care in hospitals is higher in migrant communities. On the other hand, the usage of preventive and specialized care is significantly lower across migrant communities in Austria (Ajrouch et al. 2010, p. 417). Hence, migrant communities are often deprived of quality and preventive health services. Therefore, RGZ has appropriately focused on enhancing the accessibility of quality and preventive health services across migrant communities in Austria (Haas et al., 2013).
SDH and Migrant Status in Austria
Reports indicate that the demand for low-qualified jobs shows a downward trend, while the need for high-skilled jobs is increasing in Austria. Austria is facing acute shortages in skilled labour in the field of healthcare, information technology, engineering services and financial sectors. The SDH parameters that are associated with MMH population include poverty, low income, poor occupational status and low educational attainment (Statistik Austria 2008, 2013a, 2013b, 2014a, 2014b, 2015, 2016). The interdependent framework of poverty, low income, poor occupational status and low educational attainment on poor health outcomes is evident in Austria. In 2014, 19.2 % (1.6 million) Austrian residents were at-risk of poverty or healthcare deprivation (Statistik Austria 2015). The risk factor was attributed to low educational attainment, single-women family, households with several children or low occupational compensation (Statistic Austria 2015). According to the World Health Organization (WHO 2014), the risk of healthcare deprivation of non-EU migrants (including legal and illegal migrants in Austria is almost double than that of Austrian citizens. Legal migrants are those who were incorporated in Austria due to trade treaties, while illegal migrants are those that stemmed from trafficking.
Because of the diversity of the MMH population, it is contended that the risk of healthcare deprivation is reduced in immigrants originating within the EU (Statistik Austria, 2015). Because educational attainment is one of the major causes of healthcare disparities across migrant communities in Austria, it is contended that non –EU migrants (whose country of origin is outside the EU) have less educational attainment compared to their EU counterparts (OECD 2013, 2014). Moreover, educational attainment in parents strongly influences educational attainment in their offspring. Hence, social determinants of health across migrants are largely driven by educational attainment (Bjorngren 2012,). Migrants originating outside the EU exhibit worse educational and social mobility across their successive generations. Moreover, children belonging to migrant families attend fewer preschool services than rest of the Austrian population (BMG 2012). Social status (including social mobility) deeply affects the heath outcome of migrants and ethnic minorities. It is reported that both social determinants of health and social exclusion are responsible for healthcare disparities across MMH population of Austria(BMG 2012).
Healthcare disparities in the MMH community are strongly influenced by ethnicity (Bhopal 2007). Epidemiological findings indicate that the relative health risk of certain diseases is higher in migrants compared to natural residents of Austria. For, example the relative risk of diabetes mellitus is significantly higher in women belonging to MMH population compared to women compared to natural residents of Austria (Statistik Austria, 2013a, 2013b). However, health promotion services do not differentiate between migrants and natural residents for reporting epidemiological data(Bhopal 2007, Agyemang et al.2010).
Following Agyemang et al. (2010), it is contended that epidemiological data should be collected and reported based on ethnicity, socioeconomic status, immigration status, and educational attainment. Such categorization is essential for framing appropriate healthcare reform strategies for the Austrian population for distributing healthcare facilities (Agyemang et al., 2010). However, it is speculated that evaluating epidemiological data based on ethnicity and socioeconomic status (SES) might be inadequate in addressing the healthcare disparities across MMH population of Austria. This is because, as Ingleby (2002., p.332) argued, healthcare disparities in the MMH population are not only dependent on SDH. Rather, marginalisation and social exclusion are also significant contributors to such disparities. Such assumptions were based on the healthcare inequalities found across the European population as a function of socioeconomic status only. Hence, Ingleby (2012, p.331) recommended that healthcare inequalities across MMH population could be addressed through three major initiatives. First of all, marginalised and socially excluded individuals should be identified and extended unprecedented support. Secondly, the causes of social exclusion and marginalisation should be identified and addressed. Thirdly, the interaction between different causes that leads to social exclusion and marginalisation must be evaluated (Ingleby 2012).
Healthcare Inequality across MMH community in Austria
Sardadvar (2014) contended that the debate regarding health inequalities usually pivot around the interaction between socioeconomic status and health. Moreover, the author also acknowledged that SES influences the health of individuals. Sardadvar (2014) concluded that certain migrant communities in Austria are disadvantaged on health. Such disadvantages stemmed from the lack of awareness, low accessibility to healthcare provisions, reduced provisions for primary care and outpatient care, and low educational attainment. Moreover, the study also indicated that the influence of migrant status on health was stronger for women. On the other hand, health status in their male counterparts is strongly influenced by interactions between migrant and occupational status (Sardadvar, 2014). Reports suggested that the proportion of Austrian population below the age of 20 years was 23.7%. On the other hand, the proportion of Austrian population above the age of 65 years and 75 years was 14.6% and 6% respectively. These figures were much lower than the EU average and the averages existing in other OECD countries. However, the average age of the Austrian population is expected to rise over the past three decades (Statistik Austria 2013a, 2013b, 2015, 2016).The life expectancy in Austria (reported to be 81.2 years in 2013) has increased in last 11 years, but is still lower than other OECD countries (like Japan, Spain and Switzerland)where average life expectancy is 83 years and more(Statistik Austria 2013a, 2013b, 2015, 2016). In fact, Austria has already witnessed increased survival rates over a span of 15 years (1997 to 2012). In 1997, the average life span at birth in Austria was 80.2% in across females and 73.9% of males, while the average life span at birth in Austria in 2013 was poised at 81.2%. For this reason, the Austrian Government has kept an achievable target of increasing the average life span of Austrians by at-least two years during 2011 to 2033 (Statistik Austria 2013a, 2013b, 2015, 2016). The life-expectancy of MMH communities is more than Austrian residents. However, the quality of health and quality of life is lesser than the Austrian residents.
OECD (2015) indicated that potentially avoidable hospital admissions were much lower in Austria compared to other EU and OECD countries. Such issues confirmed the poor status of primary care in Austria. Moreover, the number of hospital admissions for individuals affected with chronic conditions like asthma, COPD (chronic obstructive pulmonary disease), congestive heart failure (CHF) and diabetes mellitus were much higher in Austria compared to other EU and OECD countries. Such statistics also confirmed the poor status of primary and preventive healthcare in Austria. OECD (2015) endorsed that greater efforts must be implemented by the Austrian Government for ensuring continuity of care in individuals suffering from chronic disease conditions. The mission could be achieved with increased focus and infrastructure for facilitating primary and preventive health care services in Austria (WHO, 2014).
Healthcare Status in Austria
According to the OECD (2015) reports, Austrian health system provides better accessibility to healthcare facilities across the EU and other OECD countries. However, the quality of care is questioned in the management of cancer and different chronic diseases. Moreover, the rate of hospital admission for chronic disease conditions is also higher in Austria compared with other EU and OECD countries. The status of primary health care is another area of concern in Austria. It is noted that the Austrian health system tends to have a stronger focus on in-patient care, but the country lags behind EU and other OECD countries in the rate of ambulatory surgeries (performed in outpatient settings)(OECD 2013, WHO 2014).
The life expectancy in Austria (reported to be 81.2 years in 2013) has increased in last 11 years. The report further stated that Austrian health services provide better accessibility to healthcare facilities. However, unplanned medical expenditure (as a share of total household consumption) was significantly more than other OECD countries. On the other hand, a relatively small proportion of the population shares that they do have unmet healthcare needs. Such issues stem from financial reasons, increased wait times in health care organizations for accessing healthcare services and communication problems in accessing healthcare facilities(WHO, 2014).Reports suggested that the proportion of Austrian population below the age of 20 years was 23.7%. On the other hand, the proportion of Austrian population above the age of 65 years and 75 years was 14.6% and 6% respectively. These figures were much lower than the EU average and the averages existing in other OECD countries. However, the average age of the Austrian population is expected to rise over the past three decades(Statistik Austria 2013a, 2013b, 2015, 2016).Austria has addressed acute emergencies much better than other EU and OECD countries. On the contrary, acute care for patients admitted with a heart attack or acute myocardial infarction in Austria is significantly lesser than the OECD average. It is acknowledged that the success of colorectal surgery is better in Austria (Villadsen et al. 2010). However, the survival rates for individuals affected with cervical cancer and breast cancer is significantly lower than other EU and OECD countries. Moreover, the report also established that the decreased survival rates for individuals affected with cervical cancer and breast cancer were attributed to delayed diagnosis (Villadsen et al. 2010). The status of primary care in Austria is significantly lower than other EU and OECD countries. Due to lower socioeconomic status migrant communities may not access hospital care unlike Austrian residents. Hence, lesser provision for primary care and ambulatory surgeries would impact healthcare accessibility by MMH population.

Fig 3: Indicates that self-perception of good healthcare accessibility and facility is lower in migrants compared to individuals born in Austria(Statistik Austria, 2015, 2016).
The disparity shown in Fig 2 and Fig3 clearly indicate that although average life expectancy is higher in migrants, they do not perceive the Austrian Health System to be competent in addressing their healthcare needs. However, these reports are based on subjective responses from individuals. These assessments of the same are represented in figure 4.

Chapter 4: Health Reform Framework Austria
Chapter Overview
This chapter highlights the health reform strategies in Austria with reference to health targets (RGZ). The chapter would explore the role of health reforms framework in integrating the migrant communities. Finally, the chapter would portray the findings that could be adopted for addressing healthcare inequality across migrant communities in Austria.
Concept of Health Targets
Recently, the Austrian government has committed itself to a health target framework in line with the WHO’s initiatives “Health-for-all” and “Health-in-all.” These policies help to ensure health and well-being of individuals across the world. WHO endorses that “Health-in –all” and “Health -for –all” could be ensured by implementing appropriate primary health care across individuals. The primary health care strategy embarks to promote health, dignity, and quality of life amongst prospective healthcare consumers. WHO envisions “health as a personal state of well-being and not just the availability and accessibility of healthcare services” (BMG 2013). The state of well-being is essential for an individual to lead a socially and economically productive life. “Health-for-all” aims to remove the obstacles that lead to negative health outcomes across all individuals. The “Health-for-all” program endorses on the elimination of malnutrition, ignorance on health literacy, contaminated drinking water and unhygienic lifestyle through the implementation of appropriate healthcare reforms. Various countries have adopted the health reform process for ensuring the objectives framed by the WHO (BMG 2013).
Domain of RGZ: Alignment of 2nd Target with Other Targets
Appraisal of the health targets indicate that the 2nd target is aligned to almost all the other targets. Hence, the dissertation emphasised on the 2nd target. The first target is to ensure safe working and healthy living conditions for promoting quality health for its residents. Moreover, such conditions should be ensured through appropriate cooperation between societal and political stakeholders (Haas et al., 2013, BMG, 2013). The second target is to promote fair and equal healthcare opportunities irrespective of gender, socioeconomic status, ethnic origin and age and is the main focus for discussion of this dissertation. It is contended that the second target could be met if issues like educational disparities, hostile environments, social injustice and social security are addressed by policy makers. Moreover, this target could be only ensured if social, and food security is ensured across concerned stakeholders (Haas et al., 2013, BMG, 2013). The 2nd target indicates that promoting health equity might ensure uniform and safe working condition for everyone (1st target).
The third target is to promote appropriate health literacy amongst its residents. Health literacy indicates the knowledge and awareness regarding health and healthcare provisions existing in the society. Once again, the underpinning logic of the 3rd target is imbibed in the 2nd target. This is because equal and fair healthcare (2nd target) could be only achieved by increasing health literacy amongst stakeholders (3rd target). Hence, it is important that challenged communities (like MMH) should be health literate for accessing healthcare facilities in the society. Moreover, the objective also endorses that at-risk individuals should be appropriately sensitized regarding the importance of complying with healthy behaviours and healthy lifestyles. The fourth target aims to secure sustainable natural resources like air, water, and soil for its future generations (Haas et al., 2013, BMG, 2013). The 4th target seems to be aligned with the 2nd target. This is because the natural resources (4th target) would be only sustained through the prevention of hostile environments (2nd target). The fifth target embarks on strengthening social cohesion for improving health outcomes across its residents. Social cohesion (5th target) would lead to social equity (2nd target). Social equity is one of the predetermining factors for addressing healthcare inequality (2nd target). The sixth target endorses that children and adolescents should always thrive under healthy conditions (Haas et al., 2013, BMG, 2013). Ensuring healthy condition for children (including that of MMH population) would promote fair and equal healthcare irrespective of age and ethnicity (2nd target). The seventh target aims to ensure a healthy diet for all of its residents. Hence, provision of healthy diet (7th target) would provide social security (2nd target). The tenth target is to secure sustainable and efficient healthcare services to ensure the highest standards of care (Haas et al., 2013, BMG, 2013). Highest standards of care (10th target) would ensure fair healthcare (2nd target) across concerned stakeholders.
The overall objective of this health reform framework is to enhance the average lifespan of Austrian residents by at least two years from its present status. The second health target endorses on improving the socioeconomic status and social status of challenged communities by ensuring provisions for employment and food security. Such perspectives would lead tothe generation of a healthy lifestyle and increased lifespan across target population (including MMH community). The health reform policy was adopted in 2011 by the Federal Health Commission, Austria and is to be pursued for the next 20 years (BMG, 2013). The health reform policy speculates that the reform strategies would ensure the affordability, accessibility and quality of Austria’s Health System to Austrian residents irrespective of gender, racial, ethnic and socioeconomic status. Moreover, the reform policy states that health systems in Austria should prevent healthcare inequalities, should maintain transparency and should take a patient-centric approach while extending healthcare services to Austrian residents(Haas et al., 2013, BMG, 2013), which supports the attainment of the second target.
RGZ and “Health 2020”
The “Health Policy Framework” (RGZ) is aligned with “Health 2020”. This is because the primary objective of RGZ is to address health inequalities and healthcare disparities, strengthening public health. Moreover, the RGZ also endorses that people-centric health systems should be deployed in addressing such inequalities and improving the health of the society (Statistik Austria, 2015). On the other hand, RGZ mandates that the public health system in Austria should be universal, sustainable, and equitable. The standards and quality of healthcare are already high in Austria. Hence, RGZ strongly focuses on the accessibility of health care services and equitable health care for its population (Haas et al., 2013, BMG, 2013). This clearly implicate that Health 2020 is oriented to address the health inequities and inequalities across challenged populations in Europe.
The guiding philosophy of RGZ strongly suggests an inclusive approach for the migrant communities in Austria. The policy framework (RGZ) aims to address social determinants of health for migrant communities in Austria. Hence, different health and health care priorities are undertaken. Such priorities are integrated with the social determinants of health. The different targets of RGZ clearly suggest that educational attainment, reduction in poverty and accessibility of healthcare are the major priorities for migrant communities in Austria (WHO, 2014, BMG, 2013). Implementation of such measures would help to generate a stronger workforce in the Austrian community. Moreover, addressing the educational and health care needs of migrant children would encourage their mothers to be a part of the Austrian workforce. Hence, the RGZ framework not only seems to address the health inequities across migrants but also promises to integrate the migrant communities in the Austrian community The guiding philosophy of Austrian Health Policy Framework (RGZ) is also supported by the findings of Sardadvar (2014), which was portrayed earlier.
Monitoring, Evaluation, and Measurement of Policy Changes
The health targets framework would be appraised based on Steven’s (2007) framework of policy research. Monitoring and evaluation of policies are essential for appraising the policy changes about a specific problem or a specific domain (Stachowiak 2013). The framework for such policy changes and the Health 2020 framework would be considered for appraising the target 2 of the RGZ.
Attitudes of key stakeholders to get issues onto agenda Similar to CSDH (2008) and WHO (2013/14), the WHO Health 2020 framework envisions “an increase in life expectancy and well-being, a reduction of premature mortality and health inequalities, along with universal coverage and the right the highest attainable level of health, framed by national goals and targets for health” for every European Country. These words bear similarities to the stated principles and objectives of the RGZ (BMG 2013). Thus it is aligned with the ideology of target 2 as because the stakeholders rightly considered the issue of social equity for addressing healthcare discrepancies in challenged individuals.
Public Opinion The four priorities of “Health 2020” which are “a lifelong approach and empowerment in health, the focus on the burden of diseases and the strengthening of people-orientated health systems, and the building of resilient and supportive capacities” (WHO 2013), bear resemblance to the targets, objectives and measures of the Austria’s Health Reform framework.
Capacity and Engagement of other actors The Austrian health reform framework seeks the support of educational systems and social security systems to aid in the policy changes for the improvement of health in MMH population.
Change in discourse among policy actors and commentators The main challenges for the future of healthcare in MMH have been appropriately identified in the Framework of Health Targets: 1. 2/3rd of mortality are attributed to non-communicable diseases that can be influenced through life-style interventions outside the health sector (OECD, 2016). 2. Health outcomes are affected by socioeconomic aspects, and these are unequally distributed among the social disadvantaged individuals 3. The socioeconomic disadvantage affects children (Statistik Austria 2015) which lead to poor health outcomes in migrant children (Statistik Austria, 2014, 2015). Such issues lead to poor health and socioeconomic outcome in migrant adults 4. Given the projection of an increasing in the ageing population (Statistik Austria 2016), an increase in dependence on care and prevalence of chronic disease is anticipated. This will lead to increased need demand for care and social assistance.
Improvements in policy making procedure/process The policies should be improved based on action research. The RGZ framework (target 2) seems to have been framed after apprising health and healthcare data across Austrian residents.
Change in policy content The Health reform policy endorses on the development of a welfare state. The policy change envisages developing educational attainment in migrants and ensuring an atmosphere of reduced insecurity.
Behaviour change for effective implementation Prevention of stress, health, and insecurity of migrants (legal) at the workplace. On the other hand, measures should be implemented to prevent exploitation in asylum seekers or illegal migrants in the workplace. Social stigma amongst physicians should be discouraged, and legal framework should be imposed for extending safe and quality health care in migrants
Networks and systems supporting delivery Social organizations should be deployed to prevent school drop-outs across migrant children. Moreover, they should be asked to report discrimination against MMH population.
Integrating Migrants in the Health Reform System of Austria
Reports have indicated that the trust in people, proactive helpfulness, and perception of solidarity in Austria, have weakened from its relatively high values in the past (Bertelsmann, 2014). Although Austria’s overall ranking in social cohesion is still high, the acceptance of diversity has weakened over the past 10 years. These issues notably seem to hint towards the tensions on integration of immigrants. The Austrian Government has launched several initiatives to attract foreign workers amidst low fertility and growing shortages of skilled labour. In 2011, the Red-White-Red (the Austrian national colours) and EU blue cards were introduced for facilitating immigration.
Austria has one of the largest population groups with immigrant origin among OECD countries. The major shift of migrants is from Yugoslavia and Slovakia due to the civil war. Such shifts were expedited due to trade treaties and the economic affluence of Austria. Education and labour market characteristics of some of these groups are clearly weaker than those of native Austrians. Most immigrants exhibit lower levels of skills, lower employment rates, and higher unemployment rates. Recent reports indicate that the Austrian Education System tends to perpetuate differences in educational outcomes between socioeconomic groups across generations (Sardadvar, 2014). In particular, the socioeconomic characteristics of students attending the same school are less diverse than in other OECD countries. This means there is a class distinction in different academic institutions in Austria. Such differences are perpetuated by socioeconomic status and admission criteria on domiciliary status. Such strategies have hindered the educational mobility of immigrant groups in Austria. As a result, different immigrant groups have generated weak human capital to the Austrian Society (WHO, 2014, Statistik Austria, 2015).
Issues Limiting Health Reform
The Healthcare Reform system would be unable to address healthcare disparities across migrants because the core target group (asylum seekers and illegal migrants) have not been identified. Hence, the Framework of Health Targets should aim to target asylum seekers and illegal migrants amongst the MMH population before addressing SDH parameters (Sardadvar, 2014). Hence, the RGZ should keep provisions for addressing and integrating asylum seekers and illegal migrants in the health reform initiative to abide by the philosophy of “Health-for-All” and “Health-In-All”. This is because the second target of the RGZ is to promote fair and equal healthcare opportunities irrespective of gender, socioeconomic status, ethnic origin and age of its residents (BMG, 2013). Hence, the Austrian Government might include certain initiatives for incorporating asylum seekers and illegal immigrants in the health targets framework. These individuals could be enrolled with social care services or religious institutions for ensuring healthcare and addressing healthcare discrepancies in them.

Chapter 5: Discussion & Conclusion
Chapter Overview
This chapter summarizes the study and focuses on the future actions that could be initiated for addressing healthcare inequities amongst MMH population in Austria. The discussion is based on the policy changes and the health targets that should be incorporated in public health policies. Moreover, the chapter also elucidated the strengths and limitations of this study. Finally, the chapter includes certain concluding remarks that may be useful in conducting further studies on policy research in migrants.
Summary
Health inequalities due to the social determinants of health (SDH) are well recognized. Healthcare disparities and healthcare inequalities result from socioeconomic differences, societal discrimination, immigration status, ethnic background, religion, the nature of citizenship, policy discriminations and awareness across concerned stakeholders (BMG, 2012, 2013). Hence, social determinants of health are the key drivers of healthcare disparities across migrants in Austria (Sardadvar, 2014). The attainment of secondary education was significantly lower amongst migrants compared to their Austrian counterparts. Moreover, the prevalence of chronic diseases (like obesity) was significantly higher across MMH compared to their Austrian counterparts (WHO, 2014).
The data is in line with literature review, where it was speculated that migrants (whether first-generation or second-generation have lower educational attainment). Moreover, as suggested by Tanahashi and CSDH framework, migrants might be socially excluded to receive appropriate healthcare facilities like vaccination. The data analysis could finally relate that social determinant of health parameters (education) and social exclusion (vaccination status) influences the healthcare disparity (prevalence of obesity) across migrants in Austria (WHO, 2014).
CSDH) (2008) focuses on health inequalities based on psychosocial factors, social production of disease/political economy of health and social parameters. According to the psychosocial framework it is contended that perception of personal status leads to stress and poor health. Hence, the health target framework (RGZ) accommodates these aspects as it tries to address inequities and inequalities amongst target population. Such initiatives might change the perception of concerned stakeholders and may lead to positive health outcomes. On the other hand, the social framework emphasizes that economic and political factors are major health determinants. In that regard, the Austrian government has already embraced migrants from non-EU and non-ETFA countries (except asylum seekers and illegal migrants) by providing social security. CSDH contends that the major social pathways and mechanisms that affect the health of an individual are social selection/social mobility, social causation and life course issues. The health target framework (RGZ) does incorporate the philosophy of CSDH framework and Health 2020 guidelines for addressing healthcare issues across MMH population.
Historical evidence suggests that attainment of educational levels and attainment of skills were still low in second generation immigrants. Hence, there is an absolute necessity to integrate and support second generation and third generation immigrants in Austria. Such steps are essential to address the growing shortage of skilled human capital. Moreover, integration of such immigrants could reduce the socioeconomic tensions (related with mistrust) in the Austrian society. Moreover, policies to increase the inflow of skilled workers could be reframed upon the availability of skilled labour amongst the second generation and third generation immigrants (OECD, 2014). Opening up the educational tracks to disadvantaged groups and making schools more inclusive would foster social inclusion. While local programs like “Mama lernt Deutsch” (Mum learns German) or “FEM. Frauen Gesundheitsinititiative” (Women’s health initiative) exist, explicit targeting requires multiple and profound dedications of all institutions encouraging and empowering MEMs to participation within society (Haas et al. 2013).
On the other hand, provisions for social partnership platforms should be extended to the immigrants. Such platforms would enhance their awareness and ability to address health issues, educational issues, and economic issues for themselves and their offspring (OECD, 2013a). More importantly, such provisions would help them to feel inclusive in the Austrian society. Hence, the Austrian Government needs to include, integrate and empower second and third generation immigrants for ensuring the socio-economic development of Austria (Haas et al.2013).
A critical step in this regard would be to increase the participation of immigrant children in early childhood education (before the compulsory pre-school age of five). Reports suggest that enrolment to early childhood education in second and third generation immigrants is still low. Educational attainment during childhood and engagement in academics would provide space for women belonging to immigrant families to participate in the Austrian labour market (Haas et al. 2013). Hence, an integrative and inclusive approach is desirable for ensuring social rights, educational attainment, an extension of health care facilities and social participation across MMH community of Austria (BMG, 2013, Sardadvar, 2014). Such initiatives would be certainly helpful in reducing healthcare disparities across the concerned stakeholders in Austria. Moreover, increasing educational mobility and addressing healthcare inequalities across migrant groups would lead to the genesis of strong human capital for the Austrian Society.
Strength and Limitations
The present study incorporated different historical, social and healthcare data for analyzing healthcare inequities amongst migrant communities (MMH). Hence, the analysis could be considered robust and backed with various objective and subjective facts. Moreover, these facts complemented each other and helped to identify the key issues that underpin policy research. However, the study did not include any experimental subjects and the subjective responses of the target community were not captured. This might limit the understanding on cause-and-effect of healthcare discrepancies across MMH community.
Way Forward
It is contended that the second target could be met if issues like educational disparities, hostile environments, social injustice and social security are addressed by policy makers. Moreover, this target could be only ensured if social and food security is ensured across concerned stakeholders. Hence, the Framework of Health Targets (RGZ) would effectively integrate MMH population of Austria based on the philosophy of ‘Health-for-All”. However, it should be modified to ensure social health security across asylum seekers and illegal immigrants. Moreover, asylum seekers should be provided employment opportunities and must be integrated into the social structure of the Austrian society.
In fact, the “Target 2” of RGZ has emphasized to eradicate hostile environment, social injustice and social security amongst MMH population. The major challenges in promoting fair and equal opportunities in health for MMH population of Austria include social stigma of healthcare professionals regarding migrants, insufficient social rights, material deprivation, low social participation and lack of integration within the greater community. Therefore, an integrative approach such as the CSDH framework would be effective in ensuring social rights, educational attainment, an extension of health care facilities and social participation across MMH community. Such initiatives might be helpful in reducing the healthcare disparities across the MMH population of Austria (BMG, 2013).
It was contended that physicians often face clinical dilemmas in addressing healthcare needs in migrant populations. Such difficulties arise from the lack of knowledge on patient’s history and ethnographic factors that determine the health of an individual. Hence, healthcare professionals should be sensitized on the importance of healthcare in migrant communities, and they must remove their stigma before extending healthcare to the concerned stakeholders (Sardadvar, 2014, Statistik Austria, 2013). Austrian health system ensures better accessibility to healthcare facilities, and in-patient care is best in the European Union. Hence, Austrian health system guarantees that healthcare discrepancies in migrants could be addressed adequately, provided these migrants are covered under the social security system (Statistic Austria, 2012, 2014).
However, the Austrian Health System should enhance ambulatory care services and long-term care facilities for addressing chronic health problems of Austrian citizens and migrants. Austria does have the support of various social organizations (like Austrian Red Cross Society) to extend supportive healthcare services in MMH population (BMG, 2013).
Concluding Remarks
The study appropriately reviewed the status of health of MMH community in Austria. Moreover, the study appraised the framework of health targets (RGZ) in alignment with Health 2020 for addressing healthcare discrepancies across MMH community. Hence, the analysis incorporated a standard framework for comparing the health targets. Such standardization is useful for ensuring uniformity of healthcare initiatives across differently challenged communities in Europe (including Austria). However, future studies should evaluate the subjective responses of the target communities for understanding the cause-and-effect relationship for their healthcare discrepancies.

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