Challenges in health care services for refugees in Cologne, Germany: A providers' perspective using a mixed-methods approach

Since the peak of refugees arriving in Germany in 2015, existing health care structures have faced major chal-lenges. The city of Cologne developed ad-hoc new structures to address these challenges, including a separate department for refugee medicine. We examine the processes of health care provision and perceived challenges in the health care of refugees in Cologne. We used a mixed-methods approach using 20 semi-structured interviews and analyzed descriptively a database including 353 datasets with socio-demographic, health-related and resource-related information to link with the results of qualitative data. Our qualitative data revealed several challenges in providing health care to refugees. Challenges included receiving approval of health care services and medical aids by the municipality, communication and cooperation between the actors in care of refugees, undersupplies in mental health care and addictive disorders as well as improper housing conditions for refugees with mental health issues, psychiatric disorders or elderly persons. Quantitative data confirmed the challenges in approving health care services and medical aids, but no valid statement could be made about communication and cooperation. Undersupplies for mental health issues were confirmed, the gap for treatment of addictive disorders shows a divergence within the database. Improper housing conditions for mentally ill persons were reflected, for elderly persons this did not appear in data. In conclusion, analyzing the challenges in care can stimulate necessary changes to improve health services for refugees locally, while others are beyond the control of the local authority and require legislative and political action.