Nobody Left Outside (NLO) Checklist: Improving access to healthcare for vulnerable and underserved groups

Introduction: Many marginalised, vulnerable people in Europe who are most in need of healthcare, such as migrants, sex workers, the homeless, people who inject drugs (PWID), prisoners, or LGTBI people, are amongst the least likely to receive it. This is owing to a complex mix of administrative and structural barriers, and often a lack of understanding or unintentional discriminatory practices by service providers. Innovative policy responses and a rethink of health service design, informed by the groups affected, are needed to address these inherent inequities.   Policy context and objective: Sustainable Development Goal target 3.8 emphasises universal access to quality health services. Despite being at elevated risk of poor health, marginalised groups are underserved by health systems. Their exclusion from health service planning results in a misalignment between the service design and the users’ fundamental needs, which limits their uptake and effectiveness. The Nobody Left Behind (NLO) Platform provides a forum for community organisations to collaborate at European level to identify common challenges and solutions to improve access to integrated health and social services. The NLO Platform has developed a Service re-Design Checklist intended for use by health service providers and policymakers to design and deliver targeted services that are accessible to all, particularly underserved, vulnerable people, and for advocacy use by community representatives. Targeted groups: Migrant, homeless, PWID, sex worker, prisoner and LGTBI communities Highlights: The NLO Checklist resulted from project meetings, research and a policy incubation workshop at the European Health Forum, Gastein (2017). It provides a structured series of questions which service providers and policymakers should consider to ensure that health services are accessibie to target groups and to foster engagement with community representatives. Following the World Health Organization Health Systems Framework, the NLO Checklist comprises six sections. A). Service delivery (aiming to design and deliver an easily accessible service that meets the needs of target communities, considering design-stage issues, the range of integrated or linked services provided, accessibility and adaptation measures, and peer support. B) Health workforce (to prevent and address discrimination and ensure the workforce is enabled to deliver the service through education and training). C. Health information systems (to ensure the service is used and meets users’ needs). D. Medical products and technologies (to ensure that all service users have equitable access to care. E). Financing (to ensure the service is adequately sustainably resourced) and F). Leadership and governance (to ensure that community representatives are involved in the governance of a well-organised service). The Checklist is supplmented by an Implementation Guide. NLO Platform members are using the Checklist in ongoing projects. Conclusion: Marginalised groups are often described as ‘hard to reach’ whereas, from the perspective of users, it is frequently the services that are hard to reach. The NLO Platform is a unique collaboration between underserved communities facing common and inter-related healthcare access challenges. The NLO Checklist is a practical tool useful at the policy and local implementation levels to improve access to integrated services, in alignment with the SDGs and universal health equity principles.