The programme “PHILOS – Emergency health response to refugee crisis” is a programme of the Greek Ministry of Health, implemented by the Hellenic Center for Disease Control and Prevention (HCDCP). It’s a new approach of the Greek Republic to address on the refugee crisis, by fulfilling the sanitary and psychosocial needs of people living in the open camps. The programme is funded by the Asylum, Migration and Integration Fund (AMIF) of EU’s DG Migration and Home Affairs.
The total budget of the programme is 24,180,928 euros and is funded 100% by the European Union. Since the summer of 2017, PHILOS has expanded its activities to Eastern Aegean islands (Mytilene, Chios, Samos) and to Dodecanese (Kos, Rhodes, Leros, Kalymnos), following the agreement on programme’s extension. It is foreseen to be completed in May of 2018.
For the successful implementation of the programme, a number of health professionals has been recruited such as medical doctors, nurses, midwifes, social workers, drivers/rescuers, as well as scientific and administrative personnel.
The personnel of PHILOS are distributed on seven health districts (YPE) of the National Health System in mainland Greece, including the National Center for Emergency Care (EKAB). Furthermore, a significant part of the financing is closely related to discrete expenditure created by the usage of primary health services from refugees and migrants.
The programme PHILOS introduces a comprehensive approach regarding the provision of health services to refugee’s population and also reinforces the capacity of National Health System to respond to the extra demand of health services as a whole.
Programme PHILOS aims to respond comprehensively to the urgent situation emerged by the refugee crisis in mainland Greece (Attica, Northern and Central Greece) after the closure of the Greek – FYROM borders and the EU – Turkey agreement. This resulted in a large number of refugees being stranded in the country and living in open camps created by the Greek government.
The philosophy of the programme promotes good practices implemented in the European Union concerning the prevention of disease transmission and with respect of the Human Right to health.
The programme is based on:
- the refugee and migrants needs that have already been recorded by the Greek authorities.
- data from Ministries of Migration Policy and National Defense, having the sole responsibility of the refugees’ camps across the country.
- the requirement of additional resources needed by the National Health System and the National Center for Emergency Care (EKAB) in order to respond to the urgent situation, as well as on the increasing needs recorded in the Health Districts (YPE), the accountable public authorities for the health regions of Greece.
Consolidating the urgent needs of the public bodies mentioned above, the main objectives of the programme succinctly are:
- the further reinforcement of the capacity of the public health system and the enhancement of the epidemiological surveillance structures struggling with the stranded migrant population.
- the provision of on-site healthcare and psychological services to the target population through coordinated and well-targeted operational actions.
- the strengthening of NHS task-force, the primary health structures and EKAB, accompanied by a system of recording for hospitalization and health services to nationals of third-countries.
The above-mentioned actions refer to:
- the reinforcement of epidemiological surveillance in the area of public health through the use of mobile medical units.
- the provision of medical and psychological services (elementary health care services) in the refugee camps in the mainland Greece, taking also into consideration the capacity of DG ECHO and DG HOME partners in the field of migration health.
- the immediate reinforcement of the public health system structures (primary healthcare units, hospitals and emergency care spots) on affected regions with personnel equipment/material as well as the coverage of medical costs for patients referred to the services of national health system which will be required to address the extra demand of health services by refugees and migrants.
Management and coordination of the project
Due to the complexity of the issues related to the public health and in order to develop comprehensive interventions for refugees’ and migrants’ benefit, the Hellenic Center for Disease Control and Prevention has recruited specialized scientific and administrative staff.
More specifically, public health professionals, economists, statisticians, administrative personnel and two technical and communication support staff have been hired, respectively. By that means is ensured that the program is fully compliant with the existing EU legislation, and that the health and nursing staff of the program is directly addressed to the needs of the target population.
Migration health surveillance system
Through the creation of an integrated healthcare system inside the refugee camps, the immediate reinforcement of the national health system and the enhancement of epidemiological surveillance, the project will allow the national health system to effectively react to the high number of people received in mainland Greece and subsequently staying temporarily in the country. Thereby the main objective of this action is to safeguard both indigenous population and refugees/migrants.
It will also ensure that people who are in need acute medicine and medical screening will be tackled and people who suffer from a chronic illness/disability, further deteriorated by the harsh conditions of their journey, will be provided with the proper care.
Within the framework of this action, it is foreseen:
- the staffing of each Health District (YPE) with at least one mobile medical unit which it will have all the necessary equipment and the competence to contact medical evacuations, emergency primary health care, as well as to provide public health services. The staff of the mobile unit will be in close cooperation with HCDCP in terms of reporting public health issues, the response to public health emergencies and the risk assessment of potential public health threats.
- the placement of an epidemiologist in each Health District.
- the association of the health districts (YPE) with the public administration by deploying a health inspector in each of the 13 administrative districts of the country.
- the realization of training courses and οn-site visits to refugee/migrant camps.
Risk assessment of public health events
Hellenic Centre for Disease Control and Prevention (HCDCP) is the major public health stakeholder in Greece, responsible for the risk assessment of health threats, the surveillance of communicable diseases and for responding to outbreaks or other major public health events.
The capacity to detect a public health event is one of the core mandates of HCDCP, directly connected to the capacity to respond by investigating the event and proposing control or prevention measures. As regards the current migration crisis, HCDCP is already in the process of developing and implementing a surveillance system targeting this population.
The main objectives of this action are:
- to ensure the early detection of a) a public health incident demanding an intervention b) possible disease outbreaks or other public health events in refugee/migrants camps that operate in the country.
- the standardization of timely medical screening procedures in order to ensure the free access of refugees/migrants to public health system, whilst avoiding the additional burden for the local hospitals with incidents that could be handled on-site.
- the development of an electronic platform to foster the submission of epidemiological surveillance data from the refugee/migrant camps.
Additionally, a series of seminars concerning the use of rapid diagnostic tests will be conducted for the personnel of the mobile medical units as well as for the health professionals working on-site.
Support of the surveillance system from refugees’ points of care (POC)
The main aim of the action is the improvement of the surveillance system operated in the refugee camps (submission time, validity, completeness and acceptance of data) as well as the diffusion of data collected to the stakeholders for immediate response.
Furthermore, the response time to public health incidents is expected to be diminished since it is envisaged the creation of:
- response protocols adapted to refugee’s needs and taking into account the living conditions in open camps.
- response protocols in case of disease outbreaks in refugee/migrant camps (various scenarios)
Strengthen diagnostic capacity of hospitals and reference laboratories
Accurate diagnosis is required both for clinical and public health reasons. Taking into consideration the total number of refugee camps operating all over the country, the aim of the action is the handling of an infectious disease incident to be managed on-site and if serious then to be referred to the nearest tertiary care facility or reference laboratory centre.
Roughly 57,000 refugees/migrants are stranded in Greece at this point of time, assigned to 48 open camps. A system of epidemiological surveillance from migrant health points of care is under development by the Hellenic Centre for Disease Control and Prevention. Based on the preliminary data already available, the most common reported syndromes include respiratory infections and gastroenteritis, follow by suspected scabies.
For the Organization it is crucial to be able to detect and diagnose clusters of syndromes in order to advice on appropriate control measures and prevent larger outbreaks.
Reinforcement of reference laboratory diagnostic capacity
The framework for reference laboratories is currently under review in Greece and the specialized laboratories operating this period still require reinforcement. Examples of such testing belonging to the level of a reference laboratory include: N.menigitides subtyping, PCR and genotyping for malaria, genotyping for Salmonella and Shigella, antibody testing for inactivating antibodies for flaviviruses, viral cultures, etc.
In addition, the capacity to diagnose and perform specialized testing for rare pathogens and toxins in Greece is limited, as in many EU countries. Examples include, but are not limited to, tests such as: detection of diphtheria toxin, detection of botulism toxin in human or environmental samples, culture of hemorrhagic fever viruses, detection and culture of rabies virus in human samples.
Following a consultation with laboratory experts, HCDCP will undertake the:
- provision of reagents to the reference laboratories
- agreement for international assistance from EU’s laboratories for rare pathogens or testing and necessary financing for said testing (e.g. international transport of biological material, testing fees)
As the whole population of refugees and migrants is expected to remain in Greece for a long period, health issues related to all the above-mentioned diseases will emerge, requiring further diagnostic testing and treatment. Diagnostic capacity for several groups of disease will need support for reagents of:
- tropical diseases (malaria, taenia, schistosoma, etc) to the reference laboratory of the Department of Entomology, Tropical Diseases and Parasites of the National School of Public Health
- mycobacteria (Reference centre for Mycobacteria)
- respiratory viruses and influenza (Pasteur Virology and Microbiology, Aristotle University of Thessaloniki)
- arboviruses (1st Microbiology, Aristotle University of Thessaloniki)
- public health laboratories for Environmental samples connected to outbreaks (Central Thessaly)
Strengthening the capacity to organize and conduct mass vaccination campaigns
The main objective of this action is the immunization coverage of the target – population to reach at such a level that it will be totally prevented the appearance of vaccine preventable diseases (VPDs) among the refugee/migrant population. Our goal is all children and teenagers living in the open camps to be fully vaccinated according the recommendations of the National Immunization Advisory Committee in Greece.
In accordance with UNHCR data, 38% of the total refugee/migrant population in Greece is children under 15 years old, plus 2.5% newborn babies and pregnancies, i.e. 25,000. Taking into consideration the risk assessment, the recommendations of the National Immunization Advisory Committee in Greece and the available vaccines in the european market, the number of vaccines needed per population group include:
- Hexavalent DTaP-IPV–Hib-HepB for children 2 mos-<8 years (estimated quantity: 47,000 doses).
- Tetravalent adult type Tdap-IPV for children 8-<15 years (estimated quantity: 34,000 doses).
Furthermore, a sufficient number of doses for other diseases guarantees the total immunization coverage of the target population who is facing a higher risk of exposure to wildlife.
The action also foresees:
- the registration of indicators with regard to the rapid diagnostic tests for use in the ambulatory clinics in refugee camps
- the calculation of indicators concerning carried out vaccinations
- the calculation of indicators as regards the immunization coverage (per vaccine, population group, sex, nationality)
Primary health care provision at the refugee camps
The action is related to the establishment and function of an entire network of primary health care provision services (medical, nursing and psycho-social) that will operate at the refugee camps, accommodating migrants, asylum seekers, people in need of international protection and members of vulnerable groups. For this reason, it is foreseen the creation of health professional teams each of them consisted of a physician, a nurse, a psychologist, a social worker, a midwife and a cultural mediator.
The network is supervised by the Emergency Operations Centre (EOC) of HCDCP, which is in contact with the field coordinators on daily basis and handles organizational problems that may occurred.
EOC is responsible for:
- the qualifications and the provision of the necessary medical and domestic equipment to emergency health centers
- the receipt of prescribed medicines daily forms as well as the logistics management of emergency health centers
- the communication on daily basis with the field coordinators and health professionals in refugee/migrant camps
HCDCP’s proposal is the creation of a Geographic Information System (GIS) for the provision of data in real time.
Health professionals training programmes
The National Public Health School (ESDY) applied a short-term intense in-service training programme for the health professionals placed in refugee camps. The domain of training included cultural competencies, detection signs and therapy of sex trafficking and war victims, age assessment to unaccompanied minors, psychosocial and medical tests for communicable diseases, vaccinations, etc.
Reinforcement of national health system structures on affected regions
This action is implemented with a view to decreasing the reporting additional workload of the national health system that has become excessive particularly on the affected regions. Refugees and migrants remaining on the country unavoidably originate an additional burden on the public health system structures (public hospitals, primary health centers, etc) as well as on the operation of the National Centre for Emergency Care (EKAB).
On the basis of the experience gained during the last months, a significant part of the refugee/migrant population living in open camps, is transferred daily to public health system structures in order to deal with emergent as well as with chronic health issues.
Furthermore, a large number of refugees/migrants is children, needed a special and scientifically complete treatment especially in cases where the identification of a minor is compelled. The age identification is strongly related to the manner of treating an asylum application as well as to the type of support provided in the reception country.
Moreover, health professionals must be aware of the refugees’ age in order to determine the appropriate treatment as to report the case if necessary to the corresponding public health structures.
At the same time, they will gather demographic data in order to record the educational and psychosocial needs of each minor refugee/migrant while referring the most severe cases to the appropriate psychologists and social workers of each camp.
The National Center for Emergency Care (EKAB) is expected to be further reinforced with additional personnel for being able to carry out transports from the refugee camps to the public health structures.
PHILOS expansion in Eastern Aegean and Dodecanese
Since the summer of 2017, PHILOS has expanded its activities to Eastern Aegean islands (Mytilene, Chios, Samos) and to Dodecanese (Kos, Rhodes, Leros, Kalymnos), following the agreement on programme’s extension. It is foreseen to be completed in May of 2018.
It foresees the direct support either of the refugee reception and identification centres and/or of the national health system structures (hospitals and health centers) of the above mentioned islands with medical and nursing personnel.
Due to the complexity of the specific sub-action, more than two hundred individuals are recruited, including a large number of specialties such as doctors, midwives, nurses, health visitors, psychologists, social workers, intercultural mediators, medical lab technicians, drivers/rescuers, etc.
From the data collected so far from PHILOS programme, it appears that the newly employed personnel will aid both programme’s beneficiaries and the public health system and the epidemiological surveillance structures of these islands.
As the above mentioned islands are the first accommodation places for refugees/migrants, it is being implemented for the first time in the refugee reception and identification centres the medical protocol on vulnerability created under PHILOS programme. The protocol on vulnerability addresses issues related to sexual and reproductive health, trafficking, gender based violence, as well as to the recognition, clinical management and treatment of victims of torture and of vulnerable group’s members.
Financing from Internal Security Fund (ISF)
During the last two years, the Greek Ministry of Health in cooperation with the Hellenic Centre for Disease Control and Prevention received a total financing of 27 million euros for confronting the emerging needs created in the country by the refugee/migrant crisis. Therefore, a formal application for financing was submitted to the Directorate General Migration and Home Affairs, supervised by Commissioner Dimitris Avramopoulos.
The financing cost of the programme for 2015 was funded entirely by the Internal Security Fund (ISF), and its main actions were related to the immediate enhancement of NHS’s structures in specific areas as well as the reinforcement of National Centre for Emergency Care’s fleet with new vehicles. For this purpose, a total of 139 health professionals were recruited for nine months including physicians, midwifes, drivers/rescuers, cultural mediators and administrative personnel.
A significant part of the medical costs (including hospitalization, clinical tests, drugs, vaccinations, etc.) concerning refugees and migrants referred to public hospitals and emergency care services, was regarded as eligible expenditure and therefore covered a big part of hospitals’ budget located in Eastern Aegean. The project is considered as successfully completed since it presented an exceptionally high absorption rate (around 98%).
The Ministry of Health is in consultation with the relevant authorities of the European Commission to allocate additional funding for the above-mentioned region.