Table 3.

Barriers and facilitators affecting the implementation of TB, HIV and hepatitis B and C services to refugees and migrants, stratified by systems level

Systems level	Barriers	Facilitators
Macro
Policy	Restrictive immigration and health policies Data sharing Charging Complex entitlement regulations	Political commitment Integration into government plans/strategies Separation of health and legal systems Universal, affordable healthcare
Transnational	Lack of cross-border collaboration Poor quality data	Robust data collection, monitoring and evaluation Patient confidentiality and data protection Transnational continuity of care Cross-border collaboration and policy Cross-sectoral initiatives
Population	High mobility/dispersal	Voluntary testing
Meso
Community	Lack of community support Stigma Racism Multiple discriminations Lower social status	Clear health information and messaging Involvement and engagement of affected communities Peer-support/community champions Public education and awareness-raising
Service	Structural discrimination Fragmentation/lack of joined-up care Knowledge and attitudes of health professionals Lack of provider awareness of entitlements Limited opening hours Inconsistencies in testing, treatment and charging across services Distance to services Time constraints of servicesa	Multi-disease services Locally tailored interventions Availability of community-based services Health insurance/free at the point of care Training to ensure services are inclusive, diversity sensitive and culturally relevant Health service flexibility Broad range of screening and treatment services
Micro
Structural	Limited knowledge of health and social care services, entitlements or protections Insecure legal status Fear Lack of trust	Patient involvement in healthcare decisions and delivery Patient and community ownership Clear patient pathways Holistic approach/improving overall health and health-seeking behaviour Patient-centred approaches Awareness of rights and entitlements
Sociocultural	Language Religion Health belief models Social and emotional isolation Low self-perceived risk	Social support networks Access to interpreting/translation services Culturally relevant pre- and post-testing counselling
Socio-economic	Social and economic insecurity from high-risk living conditions and poor working conditions Lack of health insurance Insecure housing Limited transportation	Convenient, patient-friendly outreach settings

Table adapted from Table 8, WHO Health Evidence Network synthesis report 74.²⁴

^aResulting from limited opening/appointment times and a high demand for services.