Australia prides itself on having one of the world’s best universal healthcare systems. Medicare is often held up as a defining national achievement – comprehensive, equitable, and available to all who need it.

But for many women from refugee and asylum-seeking backgrounds, particularly when it comes to sexual and reproductive health, the promise of universality does not always translate into lived experience.

A growing body of Australian research suggests we could do more for women who most need preventive sexual and reproductive healthcare, including contraception, cervical screening and human papillomavirus (HPV) vaccination, during the critical early years of resettlement.

Dr Natasha Davidson has conducted qualitative research studies with women from refugee and asylum-seeking backgrounds that consistently shows that preventive care is poorly understood, inconsistently offered, and often delayed until illness or pregnancy prompts contact with the health system.

In one study among resettled Karen women in Melbourne, preventive sexual and reproductive healthcare was frequently perceived as unnecessary unless symptoms were present, reflecting both pre-migration experiences and limited post-arrival health education. As one woman suggested:

“If I’m not sick, I’m not going to see the doctor.”

Similar patterns emerge in a recent study with women from Iraq and Syria. Women in the study described limited available information, fragmented care, confusion about eligibility, and reliance on informal information networks rather than clinicians. As one woman explained:

“But because I don’t know about it, that’s why I haven’t done it.” 

Structural barriers

Beyond gaps in knowledge and health literacy, women seeking asylum face layered structural and relational barriers that further constrain access to timely care.

Structurally, precarious visa status and shifting eligibility rules create ongoing uncertainty about entitlements, Medicare access and out-of-pocket costs.

For many women, fear that seeking care could affect immigration outcomes discourages engagement, even when services are technically available.

Complex referral pathways, long wait times in overstretched public systems and limited availability of bulk-billing or low-cost services compound delays.

“Well, I didn’t have a Medicare for one year and I was given Medicare only two months ago...We are still on a bridging visa so the department of immigration is quite strict and the Medicare used to be valid for one or two years. But they are valid for only six months at the moment.”

Practical barriers including insecure housing, social isolation and primary caregiving responsibilities make attending appointments difficult. Language access is also inconsistent. Although interpreter services are funded through programs such as the Translating and Interpreting Service, women frequently report not being offered professional interpreters or being expected to rely on family members, which undermines confidentiality and quality of care.

Missed opportunities

Even when women had regular contact with primary care, preventive sexual and reproductive health was rarely raised proactively by providers.

This is not simply a matter of “low health literacy”. Provider-focused research highlights significant structural and professional barriers that shape these missed opportunities.

A national survey of Australian primary healthcare providers found wide variation in clinicians’ knowledge, confidence and practices when it came to delivering preventive sexual and reproductive care to women from refugee and asylum-seeking backgrounds.

Many providers reported uncertainty about screening guidelines, concerns about cultural appropriateness, time pressures and a reluctance to raise sexual health unless women explicitly requested it.

One general practitioner described how funding structures actively constrain equitable care:

“The current funding system whereby long consultations are financially penalised and where there is no additional funding to cover the time and resources spent on interpreters, time spent on low-health-literacy patients, and complexity, means that the standard of care these patients receive is vastly inferior to the care received by their English-speaking counterparts.  Opportunistic and preventive care is difficult.  Culturally-appropriate care is difficult, too; I am a male GP and we are often lucky to have an interpreter at all, let alone a female one.  The standard of care provided to these vulnerable patients is a national disgrace.”

These findings echo international research showing that well-intentioned clinicians often default to a “treat everyone the same” approach.

While seemingly equitable, this can inadvertently disadvantage women whose prior experiences of health care, trauma and displacement mean they’re less likely to initiate conversations about sexual and reproductive health.

HPV vaccination: A case study

Vaccination for HPV provides a stark example. Despite Australia’s world-leading HPV vaccination program, qualitative research shows that awareness of HPV and its link to cervical cancer is low among refugee and asylum-seeking women, and access pathways are poorly understood.

“Yes, I know about that, my children had an immunisation when they were Year 7, but I don’t know what the immunisation was for, but I just let them do that.”

Women overwhelmingly expressed willingness to vaccinate their children once informed, but many had simply never been told.

“If I know about it, of course I would give my son and daughter.”

In a universal system that relies on opportunistic delivery, limited access to information can be as powerful a barrier as cost.

Looking forward: Where can improvements be made?

What these studies collectively reveal is a system that assumes knowledge, confidence and continuity that many newly-arrived women do not yet have.

Universal coverage, while essential, isn’t sufficient on its own. Equity requires active engagement, not passive availability.

The consequences of these gaps are not abstract. Women from refugee and asylum-seeking backgrounds experience higher risks across a range of sexual and reproductive health outcomes, shaped by social determinants, access barriers and delayed care. Preventive care is a critical but underutilised lever for reducing these inequities.

None of this reflects a lack of commitment from clinicians or the health system. Rather, it points to the need for structural support – longer consultations, routine use of interpreters, clearer guidance for providers, and proactive, culturally-safe models of preventive care embedded into early settlement and primary health services.

Australia’s universal health care system remains a national strength. But if universality is to mean equity, we must ask harder questions about who the system is truly working for, and who’s still being left to navigate it alone.