Evaluation and monitoring
Data on ethnic, religious or racialised background is not universally available across European Union member states, although there have been strong claims that only through better data can health inequities that disadvantage groups of migrant origin be effectively tackled (Ingleby, Krasnik, et al., 2012). Ethnic group has proven a controversial categorisation that is rejected as politically unacceptable in some settings but adopted as a means of detecting racialised inequality in others. With respect to superdiverse populations, even if it is available, ethnic group data does not necessarily capture the key dimensions driving health inequalities, which may be age, recency of arrival, migration status, faith-based considerations or gender. Largely missing from the scholarly literature is the systematic evaluation of the effectiveness of the various approaches to healthcare provision for superdiverse populations: whether or not cultural competency training or empowerment initiatives actually improve the poor health outcomes of highly diverse communities remains not only largely unknown but also largely uninvestigated. Health improvement initiatives aimed at diverse populations tend to be driven by conviction and permitted or shut down by local and national political priorities, which, of late, have been increasingly marked by nativism, welfare chauvinism and xenophobia.
In sum, provision is patchy (Rechel et al., 2013) and often constructs migrant and minority health needs as 'special’, requiring temporary intervention to help migrants fit into existing services. Evidence that universal services fail to offer equal access for all (Sundquist, Winkleby & Pudaric, 2001; Westin, Ahs, Brand Persson & Westerling, 2004) has not resulted in the wholesale adaptation of those services. The provision of separate services has, with some notable exceptions, reinforced a model of migrant or minority deficit or even pathology, blaming individuals for their own poor health outcomes (Rocheron, 1988). Emphasis on migrants’ own behaviours avoids consideration of the structural underpinnings of inequality such as racism and discrimination. Furthermore, a ‘politics of austerity’ in many EU countries has emphasised individual responsibility for healthcare access, reducing special measures, while systems continue unchanged, albeit with fewer resources.
The main approaches adopted to meet the needs of an ever-diversifying population focus on cultural adaptation and improved communication within public healthcare services. These approaches developed at a time when significant migratory streams into Europe were thought to be temporary, with the assumption that migrants would either assimilate into the majority population or remrn to their ‘home’ countries. Even when neither radical assimilation and acculturation, nor return migration turned out to be an appropriate characterisation of the migration landscape in the aftermath of World War II, post-colonial migration meant that new arrivals tended to have some knowledge of their new setting. As post-colonial and proximate migration gave way to more globalised migration streams, reliance on coimnon language and shared cultural expectations between new immigrants, old immigrants, local minorities and majority populations became unrealistic. The fragmented superdiverse populations of Europe's cities have enormous pluralism that outstrips the post-colonial multiculturalism and limited proximate and bilateral labour migration streams of the twentieth century. Approaches that target specific groups may have been practical for postcolonial migration when a critical mass of individuals arrived from a few familiar countries. However, the advent of superdiversity, transnationalism and the spread of new communication technologies have rendered such approaches increasingly impractical, as individuals are likely to use multiple health resources from multiple places to respond to their health concerns.
The material that we have outlined indicates a growing recognition that the health needs of highly diverse populations are not adequately met by existing health systems but there does not appear to be a widespread recognition that superdiversity needs to be taken into account if health services are to be responsive to changing population profiles. Given the mobility associated with superdiversity and the ongoing diversification of populations, approaches that constantly seek to identify and then educate mobile groups about how to use local, nationally configured health services seem doomed to failure. What is conspicuously absent from the scholarly literature reviewed here has been not only systematic evaluation of the effectiveness of interventions undertaken, to inform subsequent work, but also radical approaches to developing the responsiveness of healthcare systems. A radically responsive healthcare system that deployed holistic and inclusive strategies to understanding people’s healthcare needs would obviously be appropriate in superdiverse neighbourhoods. It would also be beneficial to other fractions of the general population, not currently well served by the existing public health system, because they are unable to articulate and argue for the services that they need. Such an approach might consider the wider role of the welfare state in healthcare provision. Research to date has overly focused on the public healthcare system and the ways it has been tweaked to meet diverse needs, rather than looking at the ways in which individuals themselves act when they respond to those needs. To develop a responsive system, it is important to understand the actions that individuals take in order to address their health concerns, the kinds of resources they employ, which includes resources from across the welfare state and different types of providers, as well as the way they combine resources. In the final part of this chapter we propose the concept of bricolage to examine the ways in which healthcare needs are tackled by individuals and addressed by a range of health and welfare seivice providers.