Department of International Development, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK.
Soc Sci Med. 2023 Feb;319:115385. doi: 10.1016/j.socscimed.2022.115385. Epub 2022 Sep 21.
High-income countries (HICs) which are said to have "reached" universal health coverage (UHC) typically still have coverage gaps, due to both formal policies and informal barriers which result in "hypothetical access". In England, a user fee exemption has in principle made access to treatment for post-traumatic stress disorder (PTSD) and other mental health conditions thought to be caused by certain forms of violence universal, regardless of immigration status. This study explores the everyday governance of this mental health coverage for forced migrants in the English National Health Service (NHS) and NGO sector. Fieldwork was conducted in two waves, in 2015-2016 and 2019-2021, including six months of participant observation in an NGO and 21 semi-structured interviews with psy professionals across 16 NHS and NGO service providers. Further interviews were conducted with mental health commissioners and policymakers, as well as analysis of grey literature. Despite being formally covered for certain types of mental health care, in practice asylum seekers and undocumented migrants were often excluded by NHS providers. Undocumented migrants were also often excluded by NGO providers. Several rationalities linked discursive fields to practices developed by psy professionals and other street-level bureaucrats to govern coverage, in a process of "managing failure". These rationalities are presented under three paired themes which draw attention to tensions and resistance in the governance of coverage: medicalisation and biolegitimacy; austerity and ethico-politics; and differential racialisation and decolonisation. Rationalities were associated with strategies and tactics such as social triage, clinical advocacy, obfuscation, evidence-based advocacy and silencing critique. The concept of "health coverage assemblage" is introduced to explain the complex, unstable, contingent and fragmented nature of UHC policies and programmes. Misrecognition and underestimation of the everyday work of health professionals in promoting, resisting and reproducing diverse rationalities within the assemblage may lead to missed opportunities for reform.
高收入国家（HICs）被认为已经“实现”了全民健康覆盖（UHC），但由于正式政策和非正式障碍，仍然存在覆盖差距，导致“假设性获得”。在英国，原则上免除了用户费用豁免，使得因某些形式的暴力而导致的创伤后应激障碍（PTSD）和其他心理健康状况的治疗获得普遍覆盖，无论移民身份如何。本研究探讨了英国国民保健制度（NHS）和非政府组织部门中强迫移民获得这种心理健康覆盖的日常治理。实地工作分两波进行，分别在 2015-2016 年和 2019-2021 年进行，包括在一家非政府组织进行了六个月的参与式观察，以及对 16 家 NHS 和非政府组织服务提供商的 21 名心理专业人员进行了半结构化访谈。还与心理健康专员和政策制定者进行了进一步访谈，并对灰色文献进行了分析。尽管在某些类型的心理健康护理方面得到了正式覆盖，但在实践中，NHS 提供者经常将寻求庇护者和无证件移民排除在外。无证件移民也经常被非政府组织的提供者排除在外。几个理性主义将话语领域与心理专业人员和其他基层官僚机构制定的实践联系起来，以管理覆盖范围，这是一个“管理失败”的过程。这些理性主义在三个配对主题下呈现，这些主题提请注意覆盖范围治理中的紧张和抵制：医学化和生物合法性；紧缩和伦理政治；以及不同的种族化和非殖民化。理性主义与社会分诊、临床倡导、模糊化、循证倡导和沉默批评等策略和策略相关联。“健康覆盖组合”的概念被引入，以解释 UHC 政策和计划的复杂、不稳定、偶然和支离破碎的性质。对卫生专业人员在组合中促进、抵制和复制各种理性主义的日常工作的误解和低估，可能会错失改革的机会。
