BIE_F_10 Health Care Provision for Marginalized Groups as an Indicator of Social Cohesion

Objectives / Research Questions

Not only the right to physical integrity is a constitutionally guaranteed human right (GG, Art. 2, Para. 2) but physical and mental health can also be considered one of the most fundamental prerequisites for functioning social coexistence in general and social cohesion in particular (e.g. Thoits, 2011; Marmot et al., 2012). Not only the systematic denial, or under-provision, of health care would cut people off individually from a basic need and exclude them from social participation but an often feared and controversially discussed “multiclass medicine” can also be understood as a threat to social cohesion if boundaries between social groups are drawn or reinforced. Significantly, the European Social Cohesion Platform of the Council of Europe recently identified current threats to social cohesion. Among them are the access of vulnerable groups to basic social and participation rights, the impact of economic crises on health care, and the fight against poverty and exclusion. Finally, health care is always embedded in political, cultural, and economic macro-structures, which have to be taken into account in corresponding analyses. The basic thesis of this research project is that the cohesion of a society can be measured also by how well the access of marginalized groups to health care is ensured.

The project examines the extent to which the actual provision of health care to socially marginalized groups in Germany can be considered an indicator of social cohesion. To this end, it first examines how members of very different marginalized groups access health care, what their experiences are, and how this strengthens or endangers cohesion in society or in parts of society. In this project, we thus consider cohesion as a dependent variable shaped by experiences that are in turn embedded into macro-structures. In order to ensure sufficient variance for appropriate conclusions, the project also compares the health care of marginalized groups between federal states or smaller administrative units with differences in indicators of social cohesion or with different policies, for example in the provision of care for refugees (own work on this, e.g. Bozorgmehr, Noest, Thaiss & Razum, 2016; Bozorgmehr& Razum, 2019).

More specifically, the questions for the research project are as following: (1) What exclusionary mechanisms create barriers to access to health care for members of marginalized groups? How do members of marginalized groups perceive access to health care, and how does this relate to perceptions of social cohesion? (2) What strategies can health services use to overcome barriers and thus promote equal health participation for members of marginalized groups? (3) Does the provision of health care to marginalized groups vary as a function of macro-structural indicators or as a function of indicators of social cohesion such as specific legislation, electoral outcomes of populist parties, or other measures of social inequality?

Broadly speaking, the following hypotheses will be tested: (1) Exclusionary mechanisms at the policy level and health system level lead to barriers in access to care for members of marginalized groups. These barriers can contribute to the development of an impaired health status or reinforce pre-existing health impairments. They also represent experiences of discrimination that can threaten social cohesion. (2) Policy as well as organizational forms of health services (e.g. “one catch all” vs. target group–specific services) can either reduce or reinforce social exclusion processes and thus barriers. (3) Exclusion mechanisms on the micro-level (e.g. interactions between patients and doctors) are always framed by macro-structural factors. We expect to find differences between the federal states, which can at least partly be explained by differences in the overall social climate.

The project also looks at the affective component of cohesion on the part of members of marginalized groups in light of their experiences with the health system. Furthermore, it also focuses on the dependent variable of social participation of members of socially marginalized groups, measured as access to health services and dimensions of social participation.

Thematic reference to social cohesion

Potentially exclusionary mechanisms are as diverse as the characteristics of socially marginalized groups that are affected by them. These exclusionary mechanisms can be based on diversity markers such as social status as well as ethnicity, gender, and other characteristics and are applied consciously or unconsciously in areas of life such as school, education, and the labour market, as well as in the field of health care. Here, as a violation of the integrity of the person concerned, they can lead to barriers in access to health care if, for example, a person with a refugee status in Germany is cared for differently than a person with a permanent residence title or with German citizenship. At the same time, or in addition, such experiences can lead to a loss of trust in society or in its institutions on the part of the persons affected, that is to say, a reduction of generalized trust, which is considered an indicator of social cohesion (e.g. Putnam 2001). Experiences of discrimination in particular undermine this trust and can thus contribute to the drifting apart of a society when entire groups are systematically excluded from social participation (e.g. Glanville et al. 2013).

The project is therefore concerned with the micro-dynamics of the interaction between organizational units – in this case the health system, hospitals, doctor’s practices, and so on – on the one hand, and the everyday and living worlds of the members of a society who are dependent on health[JT1]  services, on the other hand (as described in more detail in the application text). We consider social cohesion to be not only the fundamental fit between offers and needs but also, in particular, the access to health offers in line with needs, irrespective of membership of social categories. We assume that a health system can and must, firstly, be able to recognize and remove corresponding barriers (i.e. be inclusive). Secondly, it must be able to take into account the role of these characteristics in user behaviour and in the development of illness. The project thus contributes to strengthening the constructive cohesion of society through the inclusion of socially marginalized groups in the area of health care. At the same time, destructive cohesion should be better understood, which systematically excludes groups marked as not belonging or members of such groups from social participation in health care through individual decisions or system-immanent exclusion mechanisms (institutional discrimination) – thereby further reinforcing pre-existing differences.

With regard to the heuristics formulated in the application text, the project deals with the socioeconomic factors on the micro- and macro-level of societies and focuses in particular on the “participation of all persons in the central areas of social life with as equal opportunities as possible” (SVR 2012). It also looks at structural conditions that create or endanger social cohesion: through the comparative approach, the project aims to provide information on the connections between macro-structural framework conditions (e.g. administrative practices, regional inequality, or election results of populist parties) and the health care of marginalized groups. Finally, by explicitly including the perspective of marginalized groups, the project not only ensures the transfer and anchoring of all research questions in the lived reality of those affected but also takes into account the affective component of cohesion by examining the extent to which one’s own experiences in the health system can endanger cohesion (e.g. through experiences of discrimination) or strengthen it in parts of society (e.g. through shared destinies).

Literature

Bozorgmehr, K., Noes, S., Thaiss, H. M., & Razum, O. (2016). Die gesundheitliche Versorgungssituation von Asylsuchenden. Bundesweite Bestandsaufnahme über die Gesundheitsämter Bundesgesundheitsbl, 59(5), 545-555.

Bozorgmehr, K., & Razum, O. (2019). Negotiating access to health care for asylum seekers in Germany. In WHO Europe (Ed.), Health Diplomacy: Spotlight on Refugees and Migrants (pp. 163-169). Copenhagen: WHO Europe.

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Namer, Y., & Razum, O. (2019). Subgroup-specific services or universal health coverage in LGBTQ+ health care? The Lancet Public Health, 4(6), e278.

Razum, O., & Spallek, J. (2014). Addressing health-related interventions to immigrants: migrant-specific or diversity-sensitive? Int J Public Health, 59(6), 893-895.

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Thoits, P. A. (2011). Mechanisms linking social ties and support to physical and mental health. Journal of Health and Social Behavior, 52, 145–161.