POLICY SEMINAR Barriers to Healthcare Services for Migrants REPORT Background to the event was the recently published study Quality in and Equality of Access to Healthcare Services (HealthQUEST) i. This aimed to identify evidence of the link between poor access to health care and health inequalities and focused on the barriers to healthcare faced by three disadvantaged groups: People with mental disorders; Migrants; Older people with functional limitations. This event was part of a series of three policy seminars ii, each of them focusing on one of the above. This second event addressed the needs of migrants (including legal, undocumented and asylum seekers). The aims of the seminar were as follows: to present the evidence on barriers to healthcare access for people suffering from mental health problems from an EU comparative perspective to present two country studies (Spain and the Netherlands), including evidence of barriers to healthcare services as well as policy initiatives aiming to tackle these barriers to engage speakers and participants in a debate on the (policy-)implications of these findings OPENING The seminar was opened by Jeni Bremner, the director of EHMA and chair of the meeting, who welcomed all participants to the second event highlighting its main aims and objectives. The HealthQUEST study was the introduced in more detail: Despite the different systems in the eight countries studied, many common problems and characteristics has been observed related to (1) cost sharing, (2) coverage, (3) health literacy and (4) supply side responsiveness. Though there were many variations both across countries and different groups, it had become clear that broad policy responses often missed the needs of vulnerable groups. Gaps in information and knowledge, in particular with regards to the effectiveness of policy
responses, were a common problem. This policy seminar therefore aimed at bringing together key stakeholders in the field to help them use the finding of the study and the discussions of this seminar to affect change on the ground. Ms. Bremner s introduction was followed by a brief welcome by Manfred Huber from the European Centre for Social Welfare Policy and Research, Austria who had been the scientific lead of the study. Manfred Huber first and foremost underlined that the research linked to the HealthQUEST study did not start from scratch but was based on existing efforts in the field in a rapidly changing environment. As a result, the HEALTHQUEST study could focus on a number of in-depth case studies involving eight countries that were chosen based on their location (Finland - Spain), size (Poland Greece), history (Germany - Romania) and/or track record in the field e.g. the Netherlands were included in the selection as a reference model in adopting innovative approaches in Healthcare Services for Immigrants. The health quest study was conducted in 2007. Despite a general awareness that the situation within this field was changing rapidly, Mr. Huber stated that some important long-term lessons could be drawn from the study. This policy seminar was an exciting opportunity to debate these findings and discuss any next steps. ACCESS BARRIERS TO HEALTHCARE FOR MIGRANTS Anderson Stanciole (WHO, Switzerland) In the first presentation, Anderson Stanciole aimed to present (1) evidence on health care access barriers for migrants within an EU comparative perspective and (2) country studies, including evidence of barriers to health care as well as policy initiatives aiming to tackle these barriers. He questioned what the magnitude of the problem is, what barriers exist and what conclusion could be drawn from this. Mr. Stanciole argued that migrants were not a homogenous group but could be split into many subgroups including legal migrants and ethnic minorities, undocumented migrants and asylum seekers. These subgroups were often facing very different kinds of barriers. Secondly, the situation in different countries and regions often varied substantially. For example, the HealthQUEST study suggests that Germany has 15.3 million migrants i.e. 18.60% of the population (often from Turkey, FYR and Italy) while Poland had 700000 immigrants i.e. 1.80% of the population. In terms of coverage, migrants in the UK were entitled to the same kind of access as any UK resident while access to the Greek welfare system was limited even for migrants with a resident permit. For immigrants and ethnic minorities, barriers were often related to the need to obtain residency & other permits as for example in Greece where complex administrative processes and a lack of knowledge and fear of authorities was a major hold-up. Secondly, language and cultural barriers could also lead to de facto barriers although migrants might enjoy legal equality on paper. The situation of the Roma population was particularly noteworthy since coverage and health status remained low, and the Roma minority largely remained poorly integrated with the overall population. This was an important issue, particularly in the new member states such as Romania or Poland, which needed to be addressed. Intercultural mediators and local access points could be very useful in deconstructing these barriers. With regards to asylum seekers, it should be noted that asylum requirements had Health Excellence in Health Management which has received funding from the European Union, in the framework of the Health Programme. Sole responsibility lies with EHMA and the Executive Agency is not responsible for any use that may be made of the information
recently become more severe e.g. in the UK and Germany. Measures were often very limited for failed asylum seekers e.g. full access to the NHS had been possible until 2004, when it was made subject to charges unless immediately necessary. In Germany, income assistance often took the form of tokens but geographical barriers were immense (asylum seekers were limited in their ability to move around the country freely). Thirdly, the magnitude of undocumented migrants was by definition difficult to judge. The highest amount is likely to be found in Greece, while the lowest number is in Finland. The main problem connected to healthcare service is that undocumented migrants are not entitled to access (except emergency and medically necessary care). As a result, non-urgent care (e.g. diabetes, vaccinations etc.) was often severely neglected leading to serious health concern at a later stage. Moreover, access was further complicated by fear of extradition. For example, public providers in Germany were obliged to report to the immigration office In conclusion, Mr. Stanciole explained that migrant groups were relatively more affected by certain health problems (e.g. TB, CVD, CHD, depression) but that this 'Health migrant effect was decreasing over time. Reducing healthcare service access hurdles for undocumented migrants represented however the most difficult challenge currently. Migrants remained at risk of poverty and social exclusion; addressing health access needs was an important aspect thereof. As a result, it was essential that services were responsive (awareness of service availability, translation / interpretation services, combating discrimination) and that administrative hurdles were consciously reduced especially related to the obtainment of official documents (e.g. birth certificates, residence and work permits and health insurance papers) COUNTRY CASE STUDIES 1. Spain: Ines Garcia Sanchez (Andalusian School of Public Health, Spain) started her presentation with an explanation of the Spanish Healthcare system: Spain is split into 17 autonomous communities and 2 autonomous cities, overall health status is good with female life expectancy at 82 years and male life expectancy at 74.6 years. The right to the protection of health and health care for all citizens is anchored in the constitution of 1978, and the general law on health (14/1986), which allows for public financing, universal and free health services, specific rights and duties for citizens, political decentralisation of health to the communities and integration into a national health system. Coverage is very high (approx. 99.5%) for all Spanish citizens, legal immigrants and residents (via agreements with third countries). Only a small percentage of the Spanish population is not covered by the Public Health System, and they often turn to the private one. Illegal immigrants have the right to emergency care, mother and child attendance. In 2007, Spain had approx. 4.526.522 immigrants coming from other EU members (33%), Africa (17%), Latin America (8.2%) and Asia (4.8%). Numbers are on the rise. They are not equally distributed in Spain as most of them live in the richest regions that are Cataluña, Comunidad de Madrid and
some seaside areas. After this general introduction, Ms. Sanchez elaborated on the migrants that are currently living in Spain and the barriers they face: In terms of coverage, health care for non EU member immigrants is covered by Immigration Law. Consequently, those registered as residents can obtain a health card and have full right to complete health care (as Spanish citizens). In addition, all people have the right to emergency health care regardless of their legal situation. Asylum seekers are covered by Red Cross & Social Work Unit while EU member immigrants are covered by EU Maastricht Treaty & other regulations. As mentioned in the previous presentation, it is often very difficult to obtain the necessary documentation (e.g. personal identification & residence verification) given the lack of knowledge of the immigration law and fear of the police. While the health basket is officially the same as for Spanish citizen, major differences can be observed with regards to irregular use of the healthcare system, predominant use of emergency and specialised services only and a lack of follow-up care. While most general services are free of charge, dental care is only handled by private doctors and thus comes with substantial barriers for migrants who often do not have the necessary funds. A NGO-subsidized system exists on the other hand for medicines that may also fall under a co-payment mechanism though barriers and delays can arise. The existence of waiting list continues to be a problem in all of Spain as users are often forced to turn to private hospitals for treatment. In addition, health centres opening hours are often not tailored to the migrants needs, social conditions or employment hours reducing the Access rate further. A lack of mutual recognition and understanding caused by cultural shock is a fundamental problem in Spain as exemplified by difficulties with handling situations such as bigamy & clitoral excision. Communication difficulties may also arise due to language difficulties although many immigrants are from Spanish-speaking countries and progress had been made with multi-language leaflets and flyers targeted at immigrants from other countries. Health literacy, on the other hand, remains a crucial problem when addressing access barriers for migrants in Spain. Lack of understanding with regards to the Spanish system, the administrative steps, employment-related mobility, cultural misunderstanding and/or fear of foreign methods hampers access to a great extent. Moreover, a lack of knowledge on the extent of the problem further complicates any further step aimed at tackling these barriers. Important policy initiatives such as specific programmes and methods to prepare health care personnel and advise them on services related to minorities groups, the introduction of multi-language leaflets and clinical records, as well as translator and mediator services were making a difference. Religious organisations and NGOs were also playing a fundamental role in the provision of health services to the illegal immigrants and asylum seekers, particularly with regards to the provision of direct health care, health promotion, and advice on social integration or help with completing forms. Finally, the Strategic Citizen & Integration Plan (2007-2010) further guaranteed the rights of immigrants to effective access to health care underlining that it was essential to not only treat the illness but the wider social environment and quality of life. Health Excellence in Health Management which has received funding from the European Union, in the framework of the Health Programme. Sole responsibility lies with EHMA and the Executive Agency is not responsible for any use that may be made of the information
2. The Netherlands Nicoline Tamsma (National Institute of Public Health & the Environment, the Netherlands) also started her presentation with a short introduction to the Netherlands, where overall poverty risk and unemployment is low and the life expectancy lies above EU average. Recent Dutch reforms have resulted in a system that allows for comparatively little co-payments, small regional differences, good overall accessibility and only small differences in access across population groups. On the other hand, poor health is a key driver of social exclusion. Non-western immigrants represent 10% of the population but 23% of minimum income households. Further attention was needed on volume and nature of health problems marginalised groups as well as the persistent under-utilisation of care for some subgroups and services. The Netherlands are often cited as reference example given their good track in dealing with migrants health, including Peer education, Information in many languages, Health monitoring and National expertise centres, such as PHAROS (refugees, illegal immigrant, asylum seekers health), Mikado (migrant health) and Lampion (illegal immigrant health). However, it needs to be noted that standards have recently dropped. In terms of coverage, there is a legal safeguard ensuring that all applicants accepted for the basic insurance package but the residence criterion practically excludes illegal immigrants. 1.5% of the Dutch population is uninsured and 4% of immigrants are uninsured. First generation immigrants are eight times more likely (6.6%) than natives (0.8%) to be uninsured; second generation twice more likely (1.6%). In addition, additional cover is usually taken out for physiotherapy, dental care, ambulant mental health but lower educated groups are characterised by a lower uptake of dental services, mental health counselling, cervical cancer screening. Moreover, migrants are three times more likely to fail premium payment for more than 6 months; Aruban, Dutch Antillean and Surinamese even nive times more likely than the average population. Particularly non-western immigrants are at high poverty risk though suffering from a poorer health status mainly caused by socioeconomic factors. For example, evidence suggests older Turkish and Moroccan migrants are at a higher risk for depression (especially Turkish women) but help-seeking behaviour is influenced by external factors such as the education level; length of residence, employment status. As a result, specialist services and hospital care is less used, and migrants often rely on informal care due to these barriers for formal care. Looking at the interplay of risk factors, older migrants should not be forgotten. Given their lower health status, high health needs, more unemployment, lower income and pensions, they were likely to represent a serious challenge to the system, which was already under pressure from the ageing population. Asylum seekers are to be covered by a specific law (pending decision procedure) that foresees a scope similar to standard health/long term care package but does not allow for free choice of physicians. The relatively low utilisation of mental health services may also be a problem here. Frequent relocation and linked rebuilding of trust/patient record transfer creates further barriers to effective care. Ms Tamsma further outlined what may help when addressing barrier in access to health care for asylum seekers such as Community Health Services that allow for special training targeted at complex needs, and more culturally sensitive, preventative services and a
better coordination of care and specialist mental health services. Finally, illegal immigrants are not allowed to have access to the public services except to legal aid, education and acute emergency care. Preventive health care is not covered, and the fear of the authorities and extradition further limites the use of any kind of emergency care. No or very little additional empirical data on health care for illegal immigrants is available, which further hinders any policy initiatives in this field. On the other hand, some good practice examples do exist, e.g. pregnant women/women with babies can access the early year service and immunization programme without leaving an address. Pediatricians have signed a code of behaviour concerning the emergency care. Both initiatives have led to an increase in utilization numbers. In addition, there are various volunteer initiatives aimed at supporting homeless people (especially in Amsterdam), which have proven to be quite successful in affecting change on the ground. In summary, while the Dutch system is more progressive than others in Europe, many challenges remain: Health literacy has grown in importance. Ms. Tamsma outlined that the Dutch system is designed for the informed and well educated citizens and thus likely to cause problems for more vulnerable groups. Moreover, there has been a renewed focus on mainstreaming that would negate any funding for specialist services and likely ignore the needs of particular groups. It was nonetheless essential that the differences between various groups were recognized to be able to tailor services to the needs of a target group and affect real change. DISCUSSION During the moderated discussion on potential further actions to tackle access barriers to healthcare for migrants, Mr. Stanciole affirmed there is a wider discussion whether the access to documents for migrants should be facilitated or legitimated or whether it should be limited further. The interplay with immigration rules is essential in this regard. Both the Spansih and Dutch case study raised questions about the role of legal documents in limiting or promoting access to health care. For example, there were many peculiarities related to refugees and asylum seekers in Spain, who needed certain papers to access to the Spanish healthcare services but which were becoming increasingly difficult to obtain (even when they were not afraid to contact the authorities in the first place). Moreover, the economic crisis could potentially have a disastrous effect on the current status-quo since immigrants needed to renew their residence permit regularly. With many jobs being lost in the construction sector, it was questionable if migrants were likely to receive another permit if they were unemployed. Without the residence permit they would not be considered legal and therefore would not be entitled to Spanish healthcare services. Participants compared the question of legal permits in Spain with the situation in the Netherlands. In contrast to the Spanish case, Ms Tamsma explained that even though legal permits are important documents in the Netherlands, the healthcare system pivots on private insurance schemes, which are by law allowed to insure a person who does not own a residence permit. Health Excellence in Health Management which has received funding from the European Union, in the framework of the Health Programme. Sole responsibility lies with EHMA and the Executive Agency is not responsible for any use that may be made of the information
CONCLUSIONS The conclusions of this policy seminar underlined that there continues to be a lack of understanding and a gap of evidence concerning the access to healthcare services. A common point for the three target groups of the policy seminars (people with mental disorders, immigrants and older people) is the lack of impact assessment for country experimentations. We still do not know enough about what works, what does not work, what can work in other countries or for other vulnerable groups. Much still needed to be done with regards to access barrier for migrants in Europe even in countries such as the Netherlands with a generally good track record and ambitious aims that works for educated middle-class citizens but is less successful at targeting other specific groups. The findings of the HealthQUEST study and the discussions of the seminar clearly remain valid for national and European policy-making, and should be developed further by key stakeholders in the field. More information on HealthQUEST(i) and the Access Policy Seminars(ii) can be found on the EHMA website. Participants are strongly encouraged to access the presentations and reports of this and the previous seminar on mental health under http://www.ehma.org/index.php?q=node/216 to disseminate these findings further. We also hope to see many of you at the forthcoming Access policy seminar. The next seminar focusing on older people will take place in early September. i Financed by the European Commission, DG EMPL and led by EHMA. ii Financed by the European Agency for Health and Consumers (EAHC) through an Operating Grant titled PHeTEHM