Access to health care
Mirte Sprengers
The right to the highest attainable standard of health is a bundle of obligations on states and others and the challenge is to hold the duty-bearers to account.
Paul Hunt, UN-expert on the right to health. (April 2008)
When you read these words of Paul Hunt, you might immediately think of poor people in Africa not being able to get health care. But don’t forget the vulnerable groups in your own societies! There are approximately 5 to 8 million undocumented migrants (UDMs) in Europe who often remain unseen by policymakers. Although every person has the right to health care regardless of their legal status, appropriate care is not always provided. The problem often lies in their access to, not in the quality or availability of health care. This article reviews that problem.
Undocumented migrants
UDMs are people, often refugees, who do not have (or did not apply for) a residency permit for the country to which they have fled. These people cannot return to their homelands for several reasons: it is simply too dangerous, they do not have passports or they are too ill to travel. Often the serious problems the refugees would encounter upon return to their own countries are not recognized by the host country. Heavily traumatized refugees might also fail to tell a consistent story, and this can lead to denial of a permit. In each case the reason for escape is important enough for the individual to risk remaining illegally in the host country.
 Health problems
UDMs often cope with multiple and serious health problems, acquired before or after migration, or both. Refugees often come from countries with poorer health facilities than in Western countries. Often there are no vaccination programmes in the individual’s homeland, and the prevalence of communicable diseases (e.g. TB, HIV) and psychological problems (Post Traumatic Stress Syndrome resulting from experiences during war, torture and loss of relatives) is higher. Secondly, the way refugees typically travel, hidden in trucks or packed by the hundreds into tiny boats, can lead to health problems.
Once they arrive at their destination, they face new problems: finding shelter, coping with unemployment, keeping their illegal status from being discovered. This often leads to depression and other psychological problems.
Right to health care
If UDMs get ill, they should be able to find health care, even if they do not have a place in the regular system. This is an issue of human rights that has been recorded in several important international documents. According to the UN commission on Economic, Social and Cultural Rights (UNESCR), states are under the obligation to respect the right to health by refraining from denying or limiting equal access for all persons, including [...] asylum seekers and illegal immigrants, to preventive, curative and palliative health services.
The right to health is also secured in the Universal Declaration of Human Rights (UN, 1948). This means it applies to every human being, including people without legal status. Several codes on medical ethics help health workers in taking decisions. The main thrust of such codes is to ensure that physicians consider the health of the patient as their first and most important consideration:
A doctor must have complete clinical independence in deciding upon the care of a person for whom he or she is medically responsible. The doctor’s fundamental role is to alleviate the distress of his or her fellow men, and no motive, whether personal, collective or political shall prevail against this higher purpose (Tokyo Declaration, World Medical Association).
Access to health care: the problem
But law and ethics mean nothing if not properly implemented. Still, only one third of the UDMs in Europe with a chronic disorder receive treatment. Governments forget too easily the obligations imposed upon them by international human rights conventions.
In Europe, different policies are in place. All of them however fail, some more so than others, to provide UDMs with the necessary accessibility to health care.
Stories from refugees
One night, I had to go to the hospital. I had been in pain for a long time and thought I might be bleeding internally. I think I waited too long, because I was
afraid of getting arrested by the police. I didn’t know exactly what to do. An ambulance would be too expensive for me. I eventually took a cab to the hospital around noon the next day. I had to make an arrangement with the hospital about the payment. Today I feel fine but I’m very worried about the costs.
(Testimony of an undocumented woman, Médecins du Monde, case from The Netherlands)
G is an Arab man whose nationality is disputed. He suffers from bowel cancer, and was admitted because of uncontrollable bleeding. The clinicians in A&E (accident and emergency departments) scheduled him for an operation as soon as the bleeding stopped. However, once the hospital discovered G was a refused asylum seeker, he was given a bill for many thousands of pounds and his operation was cancelled. He was discharged from hospital and told to come back ‘when his condition deteriorated’. (Case from United Kingdom)
A severely ill undocumented Chinese man went to the hospital in Vienna and had a serious but successful stomach surgery. Eighteen days after he left, another undocumented Chinese man with grave stomach pain, came to the hospital using the identity card of the first one. Immediately, he was taken to surgery, the treating physicians relied on the medical history from the first patient. During surgery, the patient’s life was in real danger. Luckily, the doctors realized in time that the patient’s blood type did not match the blood type mentioned in the records. This saved his life.
Economic accessibility
Generally speaking, undocumented people do not have a steady income and are not allowed to have medical insurance. Since medical procedures are very expensive, this poses a serious financial problem for UDMs in countries where health care is only provided on a cash-payment basis, as in Austria and Sweden. The tragedy is that regular medical care is often vastly cheaper than the emergency treatment that results when regular medical care has been unattainable, and ironically, emergency treatment is always covered by the government.
Physical accessibility
In some countries, as in the Netherlands, certain hospitals or health centres are appointed to take care of UDMs. Although this system might be characterized by improved quality of care offered to UDMs by experienced health professionals, it might also be characterized by problems of accessibility, as it requires patients to travel to a particular location, and travelling costs may be prohibitive for sick people.
Health care as a tool for the immigration office
Right wing politicians argue that providing free health care would attract even more immigrants and would encourage people to stay in their countries illegally. Research, however, concludes that health care is not a pull factor for migrants, nor is the denial of medical care a push factor. But some countries take it even further. In Germany, all public institutions, including hospitals, are obliged to report any and all encounters with undocumented persons to the Foreigners Office. The Foreigners Office will then take action and start the deportation procedure. As a result, undocumented persons are afraid to seek health care.
Lack of information
Even if the policies are reasonable, they often fail to provide good access to health care because health workers and UDMs do not know about them. A receptionist might not know what to do when a person comes without an insurance card; a doctor might not be sure whether to report the patient to the Foreigners Office; the patient might not know his rights and entitlements. Because policies in neighbouring countries are so different, the situation becomes confusing for the UDMs.
The Netherlands
In the Netherlands, health insurance is obligatory. Although this is not possible for UDMs, Dutch law ensures that they have access to necessary medical care too. Only a doctor can decide whether medical procedures are necessary.
Access to health care for UDMs in the Netherlands is generally good, although there is also a lack of knowledge about policy guidelines. For example, a small study showed that 68% of uninsured patients were refused care by non-medical personnel, like receptionists, in 2007.
Recently, the Dutch government adopted a new law, which provides more funding for the health care of UDMs than was previously provided. The downside of this law is that only 80% of treatment costs will be subsidized, leaving 20% for the patient to cover. In expensive cases, these costs might be covered by the treating health care organization.
 Conclusion
Access to health care is a problem in many countries hosting UDMs. These people have the right to health care and doctors should treat them according to their ethical codes. Governmental policies differ between countries, but none leaves enough room for doctors to provide good care. These policies influence access to health care by creating financial, physical and informational barriers. We should hold the duty-bearers to account, as Paul Hunt said.
Get involved!
Many NGOs are working on this issue. You can join them or set up your own project. Lobby to change policies, inform fellow students, doctors, other health workers and even UDMs by writing articles, making leaflets, organizing debates or garnering attention for these issues in the curriculum! You can join the network on projects on UDMs of IFMSA (International Federation of Medical Students’ Associations) and IPPNW (International Physicians for the Prevention of Nuclear War) by sending an empty email to
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. Don’t hesitate to ask for help or inspiration!
References
- Merlin, ‘right to health’ discussion with Edward Stourton and Paul Hunt, London, April 18th 2008. http://www.merlin.org.uk/Lists/News-Detail.aspx?id=684
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Report by the Global Commission on International Migration; “Migration in an Interconnected World: New Directions for Action” October 2005, p. 32
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United Nations International Covenant on Economic, Social and Cultural Rights, article 12 (1966)
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General Comment no. 14, The United Nations Commission on Economic, Social and Cultural Rights (2000)
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Tokyo Declaration, World Medical Association. Guidelines for Physicians Concerning Torture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment.
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Médecins du Monde (september 2007), European survey on migrants’ access to health care
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Romero-Ortuno, R (2004). Access to health care for illegal immigrants in the EU: should we be concerned? European Journal of Health Law, 11: 245-272.
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PICUM (Platform for International cooperation on Undocumented Migrants) Report; Acces to health Care for Undocumented Migrants in Europe, 2007, p.39
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Rapport Commissie Klazinga 2008; Arts en Vreemdeling, Rapport van de commissie Medische zorg aan (dreigend) uitgeprocedeerde asielzoekers en illegale vreemdelingen (Commissie Klazinga)
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Dokters van de Wereld; Zorg, recht en plicht, resultaten van getuigenissen januari-juli 2007
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Modification Health Care insurance Law (ZvW)
Photos by Ivana Jurcic and Sarah McD, shared under Creative Common License
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Global Medicine 5
