Barriers to health care
For years, people in Europe have been calling for an improvement to health care for irregular migrants and people seeking asylum. Only a small number of European countries give these people access to national health insurance – and where insurance is available, there are serious barriers to accessing treatment.
The International Organisation for Migration (IOM) has published a detailed report on access to health care for irregular migrants in the European Union (EU). The report reveals an urgent need to improve health outcomes for some of the most vulnerable groups in the EU. It makes recommendations to immediately expand universal health coverage.
Most irregular migrants in Europe arrive lawfully, and are ‘overstayers’ who no longer meet the conditions of their visa, or are ‘transit migrants’ on their way to a different country where they may intend to apply for asylum. Even people born in the EU may be considered irregular migrants if they are in breach of a condition of their movement within the region, such as maintaining work or being able to financially support themselves.
Implications for health care
People who do not have health insurance their country of origin or in their host state have very limited access to health care in Europe. The impact of this is made much worse by social and employment disadvantages experienced by most irregular migrants.
Unemployment rates in the EU are generally high. This means many irregular migrants can only support themselves through dangerous or demeaning work, or work that involves unsocial hours or low pay. Many migrants and people seeking asylum also cannot get formal employment contracts, making it very common for them to be exploited.
There are often major health and safety risks associated with the kind of work that irregular migrants are willing to accept. They also often have little or no protection against loss of income.
Health care needs
Despite what people might believe, migrants on average tend to be in better health when they come than those already there. However, their health tends to get worse the longer they live there – often because of precarious work, poor housing, low income and social exclusion.
The daily health needs of irregular migrants do not differ from those of the rest of the population. However, their living and working conditions often create hardships and health risks. Overcrowded and unhygienic housing, poor nutrition and a lack of health education can increase the likelihood of disease. Social disadvantage tends to increase the risk of work-related illnesses and injuries, sexual and reproductive health problems and mental health issues.
Availability of services
Despite the high quality of health care in rich EU countries, most migrants cannot afford services if they are not covered by insurance. Health insurance often requires documents which can be difficult or impossible for irregular migrants or displaced persons to get.
IOM’s research into the entitlement to health services in EU nations found irregular migrants were covered for around 35% of the full coverage enjoyed by nationals. The services which are are available tend to relate to emergency care. However, the definition of an ‘emergency’ is extremely unpredictable. As a result, irregular migrants may be deterred from seeking medical assistance that they urgently require.
The limitations of entitlements
Limiting health care coverage to emergency situations completely contradicts the consensus that prevention, early intervention and continuity of care promote health and reduces costs. The obligation to ‘rescue’ a person in a life-threatening situation does not justify refusing help to those who have ongoing health concerns.
Restrictions on non-emergency services are sometimes lifted for patients who are pregnant or who have an infectious disease. However, health outcomes are still severely undermined by a lack of continued treatment. Although a pregnant woman may be entitled to free hospital delivery, the risk of complications is greatly increased if they cannot get check-ups during the pregnancy. Similarly, detecting a communicable disease early may stop it from spreading further.
Barriers to access
Even where a person is entitled to some services, irregular migrants may often be stopped from using them because they don’t know how to use the health care system.
IOM’s report cited numerous studies which found that health care workers in the EU are poorly informed about which services should be provided to irregular migrants.
Interpreters or ‘navigators’ are not readily available to those who are unfamiliar with the system. Most EU nations have no process in place for distributing information to migrants about health care to which they are entitled.
When irregular migrants do come for medical treatment, they are not necessarily protected from being reported to immigration authorities. This not only discourages migrants from seeking care, but may also be part of a government’s strategy for monitoring and/or penalising migrants.
A key reason for countries to improve access to health care is their international human rights obligations. The right to health is enshrined in the Universal Declaration of Human Rights and other instruments.
European instruments such the European Social Charter and the Maastricht Treaty also emphasise the importance of health. However, the obligations are often vaguely defined and refer to citizenship or national practice. As a result, there is is generally no legal remedy for irregular migrants if their rights to health care are violated.
IOM’s report strongly recommended that countries should interpret their human rights obligations more broadly.
Health should be regarded as not just an individual right, but as a collective project that maintains the strength of a community.
This principle is often outweighed by other goals such as economic interests or public perceptions of what people ‘deserve’. IOM points out however that the threat posed to the wider society creates a strong incentive for policy-makers to make health care more inclusive.
IOM’s report strongly emphasised that poor health care for irregular migrants is in fact more expensive for countries. There are indirect costs of ill health for both the patient and for the wider community, such as the loss of earning capacity and the higher costs of providing care over the long term.
IOM proposes that primary care should be increased to prevent diseases at early states and facilitates overall health. This would reduce the need for more expensive hospitalisation and emergency care. This would also reduce the strain on emergency resources and improve access for the wider community.
IOM found that this approach will always save costs, reducing the direct and indirect costs of medical care by at least 49% and up to 100%.
Addressing public opinion
Health policies are decided by governments, who are in turn elected by voters. This means that before any changes can be made, it is vital to address popular misconceptions about irregular migrants in Europe. In particular, the IOM have called for better education about the nature and causes of irregular migration, as well as the costs and consequences of providing adequate health care.
IOM’s report suggested that nations often restrict access to services to pressure migrants to leave or to deter others from arriving. Often, this agenda is justified by stigmatising irregular migrants in the media, and by associating them with crime, disorder and disease. As a result, there is often strong public support for policies which are harsh, but also self-defeating.
IOM found that national policies that increase hardships have little or no effect on migration flow. This is because for most irregular migrants, returning to their home country is either impossible or so dangerous that it is still better to stay in Europe.
IOM was also unable to find any evidence that more generous health care would attract people to come.
There is also a risk of increasing public hostility if people perceive that migrants have better access to health care than nationals. This is often related to the assumption that irregular migrants are not subject to the taxes which indirectly fund universal health care.
Updating models of coverage
IOM has noted that means testing is necessary in all health care systems. It recommends that irregular migrants should be placed under the same obligation as nationals to disclose their income to receive free or low-cost health care.
It notes however that current methods of means testing create a barrier to treatment for irregular migrants, who are often unable to get the documents required to qualify for health coverage (such as tax returns).
As well, national health insurance systems need to prohibit reporting patient details to immigration authorities. IOM underscored that migrants, as well as health care providers, would need to be informed about this prohibition, and that it must be strictly enforced.
For irregular migrants to participate fully in any national health insurance scheme, there also need to be provisions for ‘health literacy’ and the breaking down of linguistic and cultural barriers to receiving care.
National projects to reduce these obstacles would assist not only irregular migrants, but other marginalised groups in the wider community.
- The principle of universal and equitable health coverage should be applied to everyone residing in a country, regardless of their legal status.
- Governments should honour their obligation to ratify or implement treaties committing them to uphold health-related rights. More prominence should be given to the health-related rights of irregular migrants and more legal action should be undertaken to defend these rights.
- States should grant full access for irregular migrants to all forms of primary care available to nationals.
- Governments should consider the evidence that restricting access to primary care costs more money than it saves.
- Reporting of irregular migrants by health workers or service provider organisations to police or immigration authorities should be explicitly prohibited and strictly enforced. Irregular migrants should be reassured that such reporting will not take place.
- Special attention must be paid to protecting the health-related rights of particularly vulnerable groups such as children, pregnant women and trafficked persons.
- Increased research is needed to identify the health problems for which irregular migrants are particularly at risk. Existing knowledge about their help-seeking behaviour should be improved, while sound epidemiological methods should be used to estimate the health risks affecting them.
- There should be urgent funding and research to remedy the serious shortage of reliable and up-to-date information about irregular migrants.
- There should be increasing effort to combat myths and misunderstandings about irregular migrants,
- Access to health services for irregular migrants should be accompanied by contribution arrangements that will not be perceived as unfairly privileging this group
- It is essential to ensure that health services are responsive to their special needs and to remove other barriers to reaching care.
Governments, intergovernmental and non-governmental organisations, experts and researcher must join forces to support the health-related rights of irregular migrants. The aim should be to integrate irregular migrants fully into mainstream service provisions.