Refugee health clinic thrives amid bulkbilling shortage

(L-R) Dr Amireh Fakhouri, Dr Lester Mascarenhas and interpreter Francis work in refugee health. (James Ross/AAP PHOTOS)

When Dr Amireh Fakhouri asked her patient about her chest pain, she did not expect to hear about her being raped by the Myanmar military or her husband being killed right in front of her.

The refugee woman from the persecuted ethnic Karen minority in Myanmar is one of hundreds of patients who frequent the Utopia Refugee and Asylum Seeker Health clinic in Melbourne.

"I guess I wasn't expecting that to come from a consult about chest pain," Dr Fakhouri, who has been working at the clinic for over a year, told AAP.

Dr Amireh Fakhouri
Dr Fakhouri's experiences as a refugee and her fluency in Arabic helps her to connect with patients.

"That was something that kind of probably startled me a little bit."

"It's a very different skill when you work in refugee health because you have to be able to differentiate is this from a psychological aspect or is this from an actual physical aspect to know which treatment pathway do I take," she explained.

Dr Fakhouri, the daughter of Palestinian refugees, said it has been a steep learning curve for her transitioning out of mainstream clinics to a more holistic, bio-psycho-social model.

The one of a kind clinic founded by Dr Lester Mascarenhas opened its doors in December 2019, a few months before the coronavirus pandemic, with the aim of providing GP services at little or no cost to refugees and asylum seekers regardless of their Medicare status. 

"I wanted to design a health service where we're maximising bang for buck so for every dollar invested in Medicare, we really wanted to make sure we're not having any wastage," he said.

Bulk-billing is a mainstay of the clinic amid a nationwide shortage.

A report by online health directory Cleanbill in January found the rate of bulk billing nationally had dropped by more than 11 per cent from around 35 per cent in 2023 to 24 per cent in 2024.

It also found that out-of-pocket costs for patients have risen to $41.69 on average across Australia.

At Utopia, patients have a private consult costing $80 once a year and for the rest of the year no matter how many times they come, it is completely bulk-billed.

Consults are longer ranging from 20-40 minutes, which is about double the mainstream average, to allow for full-time interpreters from various refugee communities to be present with patients.

"When I see a new arrival you don't just say here's your prescription and five repeats... you tell them to keep the yellow receipt from the pharmacist to give you more, so very simple things like that need to be explained," Dr Mascarenhas said.

Dr Lester Mascharena
Dr Lester Mascarenhas found the one of a kind clinic in Melbourne in 2019.

He described Utopia's practice of refugee health as "slow medicine" by providing a more comprehensive service delivery model that uses bi-cultural health workers.

About a third of the staff, whether in an administrative or health role, are of refugee background.

"So if someone comes in to request a pap smear we would try and get them in with a women's health nurse. It costs a lot less for the government and for us than seeing a doctor," Dr Mascarenhas said.

"The same service is being provided but the item number and the fee for the nurse will be quiet different.

"We're keeping the costs of delivery care down."

For Philip Moo Eh, a refugee from Myanmar's Karen ethnic minority who has been in Australia for a decade, the clinic has created a relationship built on trust with his community.

"The main thing is trust and then the second thing is kindness," he said.

"Most of the Karen people feel like he (Dr Mascarenhas) is family because he knows about our conditions."

They represent about 70 per cent of the patients who come to the clinic with the rest coming from Horn of Africa, Middle East and South Asia particularly Afghanistan and Pakistan.

Mr Moo Eh, who is diabetic, escaped to Malaysia in 2010 after his village was torched by the army as well as his rice farm and home were looted.

He said a common issue for the Karen community in Australia is post-traumatic stress disorder, which other refugees from various backgrounds also suffer from.

"The doctors try to know about our refugee background, about the Karen community and the situation of fleeing from military attacks - and especially our stress," he said.

Apart from PTSD, Dr Mascarenhas said blood-borne viruses such as Hepatitis B and C and latent tuberculosis are common diseases that patients present with.

For Dr Fakhouri, her experiences as a GP, as a refugee and her fluency in Arabic enables her to connect at a deeper level with her patients to deliver culturally appropriate care.

"I sometimes compare my patient that's sitting in front of me with what if that was my mom and dad because of their similar language barrier and health literacy," she said.

"For example, when I see Syrian refugees and try to explain to them that their migraines or their headaches are related to the trauma that they've experienced in their life."

"I kind of put myself in their shoes sometimes and that kind of helps me understand their situation and their concerns about their health."

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