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Access to Health Care for Undocumented Migrants in - PICUM

Access to Health Care forUndocumented Migrants in Europe


This project has received funding from the EuropeanCommunity under the Community Action Programmeto Combat Social Exclusion 2002 – 2006.The information contained herein is the sole responsibilityof the author, and the Commission declinesall responsibility for the use that may be made of it.This report was made possible with the generous support ofBroeders van Liefde – Frères de la Charité, Caritas International,Cordaid, Gasthuiszusters Augustinessen van Lier,Missionarissen van Steyl, Stichting Liberty and StichtingVrienden Medische Missiezusters.PICUMPlatform for International Cooperationon Undocumented MigrantsGaucheretstraat 1641030 BrusselsBelgiumTel: +32/2/274.14.39Fax: +32/2/274.14.48info@picum.orgwww.picum.orgISBN number: 9789080781399Copyright © 2007 by PICUMCover photo © Sasse/laifLayout: beëlzepub • Brussels • www.beelzepub.com


Access to Health Care forUndocumented Migrants in Europe


2 PICUMPICUM, the Platform for International Cooperation on Undocumented Migrants, is a non-governmentalorganization that aims to promote respect for the human rights of undocumented migrants withinEurope. PICUM also seeks dialogue with organizations and networks with similar concerns in otherparts of the world.PICUM promotes respect for the basic social rights of undocumented migrants, such as the right tohealth care, the right to shelter, the right to education and training, the right to a minimum subsistence,the right to family life, the right to moral and physical integrity, the right to legal aid and the right to fairlabor conditions.PICUM’s activities are focused in five main areas:1. Monitoring and reporting: improving the understanding of issues related to the protection of thehuman rights of undocumented migrants through improved knowledge of problems, policies andpractice.2. Capacity-building: developing the capacities of NGOs and all other actors involved in effectivelypreventing and addressing discrimination against undocumented migrants.3. Advocacy: influencing policy makers to include undocumented migrants in social and integrationpolicies on the national and European levels.4. Awareness-raising: promoting and disseminating the values and practices underlying the protectionof the human rights of undocumented migrants among relevant partners and the wider public.5. Global actors on international migration: developing and contributing to the international dialogueon international migration within the different UN agencies, international organizations, and civilsociety organizations.PICUM has nearly 90 affiliated members and 90 ordinary members in approximately 20 countries inEurope and beyond. PICUM’s monthly newsletter on issues concerning the human rights of undocumentedmigrants is produced in seven languages and circulates to PICUM’s network of more than 2,400 civilsociety organizations, individuals and further.


Access to Health Care for Undocumented Migrants in Europe 3Table of ContentsAcknowledgments .................................................................................................................................................................................................................................................................................................4Introduction ........................................................................................................................................................................................................................................................................................................................5Purpose and structure of this report ..................................................................................................................................................................................................................................111. AUSTRIA ........................................................................................................................................................................................................................................................................................................................122. BELGIUM .......................................................................................................................................................................................................................................................................................................................193. FRANCE ..........................................................................................................................................................................................................................................................................................................................274. GERMANY ...................................................................................................................................................................................................................................................................................................................365. HUNGARY ....................................................................................................................................................................................................................................................................................................................486. ITALY ....................................................................................................................................................................................................................................................................................................................................517. NETHERLANDS ..................................................................................................................................................................................................................................................................................................608. PORTUGAL .................................................................................................................................................................................................................................................................................................................719. SPAIN ..................................................................................................................................................................................................................................................................................................................................7910. SWEDEN ....................................................................................................................................................................................................................................................................................................................8811. UNITED KINGDOM .....................................................................................................................................................................................................................................................................................97Recommendations ...........................................................................................................................................................................................................................................................................................107Bibliography ...............................................................................................................................................................................................................................................................................................................109National legislation ........................................................................................................................................................................................................................................................................................114Index of organizations .............................................................................................................................................................................................................................................................................116


4 PICUMAcknowledgmentsPICUM would like to express its sincere gratitude toSara Collantes, Project Officer, who prepared thisreport, for her thoroughness and commitment toadvancing the rights of undocumented migrants tohealth care throughout the course of this two-yearproject.PICUM is also grateful to the many individuals whoprovided additional support throughout the projectand during the events that helped bring this publicationto fruition: Sabina Appelt, Monica Barona,Tommaso Bicocchi, Isabelle Eitzinger, VeerleEvenepoel, Martina Fava, Ignacio Fernandez, EveGeddie, Angela Gegg, Hélisène Habart, UrsulaKarl-Trummer, Joan Kelly, Christine Lenz, JuanaLopez, Smriti Mallapaty, Birgit Metzler, JohannaNorenhag, Gema Ocaña, Roxanne Paisible, EszterPolgari, Sheila Quinn, Emma Reilly, Baerbel Reissmann,Isabelle Richards, Pablo Sanchez, DianneSifflet, Adinda Van Hemelrijck, Nele Verbruggen andLaurence Verriest.We would also like to thank the members whohave served on PICUM’s Executive Committee fortheir guidance and support throughout this project:Carmelita Barnes, Reyes Castillo, Jos Deraedt,Franck Düvell, Don Flynn, Lisa Gagni, George Joseph,Pede Saya, Thomas Van Cangh, Didier Vanderslyckeand Johan Wets. Thanks also to PICUM membersfor their feedback on the health care situation ofundocumented migrants in their respective countriesthroughout the various stages of this project.Finally, we would particularly like to thank therepresentatives of our nineteen partner organizations:Caritas Europe, Comède, C.P.A.S. Bruxelles(Centre Public d’Aide Sociale de Bruxelles), Eurocities,European Public Health Association (EUPHA),Evangelisches Hilfswerk Österreich, FundaciónProgreso y Salud, Gemeentelijke GezondheidsdienstRotterdam, Hospital Punta de Europa, Jesuit RefugeeService Portugal, Médecins du Monde, Medimmigrant,MediNetz Bremen, Menedék, NAGA AssociazioneVoluntaria di Assistenza Socio-Sanitaria e peri Diritti di Stranieri e Nomadi, Newham Primary CareTrust, Pharos, Rosengrenska and Stelle für interkulturelleArbeit der Landeshauptstadt München. Weare grateful for the valuable time and hard workthese individuals from all across Europe committedthroughout the course of this project to improvingundocumented migrants’ access to health care.Particular thanks also go to those who assisted ourresearch during the field trips and the many expertswho made contributions during our partner meetingsand the final conference.Michele LeVoyPICUM Director


Access to Health Care for Undocumented Migrants in Europe 5Introduction“The exclusion of vulnerable groups from health care brings along majorrisks like individual suffering and exploitation, a risk for public health ingeneral, demand for emergency services which are far more expensive,the creation of backstreet services, ethical dilemmas, problems for theadministration and discrimination against the concerned migrants.”Wayne Farah, Newham Primary Care TrustUndocumented Migrants in EuropeUndocumented migrants are migrants without aresidence permit authorizing them to regularly stayin the country of destination. In its work, PICUMencounters two principle types of undocumentedmigrants:(i) People whose arrival in the country of destinationhas been by a legal route, but who havesubsequently found that the substantial cost oftheir movement cannot be recovered through thevery limited work opportunities permitted underthe official schemes;(ii) People who, though gaining admission by irregularroutes, had been led to that point after along-drawn out process involving a substantialcommitment in time and scarce financialresources, but who had not at the onset of theirjourney necessarily intended ‘illegal’ migration.While it has been estimated that there may be from5 to 8 million undocumented migrants in Europe, 1they largely remain invisible in the eyes of policymakers. This situation puts enormous strain on localactors such as NGOs, health care and educationalprofessionals, and local authorities, who often workwith limited resources to defend undocumentedmigrants’ fundamental rights, including the rightto health care, education and training, fair workingconditions, and housing. These local actors areconfronted on a daily basis with situations confirmingthat irregular legal status is an obstacle for asizeable part of the population in accessing basicsocial services. Professional groups experienceclashes between what their professional ethics tellthem to do and the incriminatory discourse regardingundocumented migrants.Undocumented Migrants and Health CareUndocumented migrants in Europe face seriousproblems in gaining access to health care services.For them, a worsening of their physical and mentalhealth is more likely to occur owing mainly to pooraccess to health care services and/or the continualfear of being discovered and expelled.While numerous international instruments in humanrights law have been ratified by EU member statesand refer to the right of everyone to health care as abasic human right (regardless of one’s administrative1The report by the Global Commission on International Migration (GCIM, Migration in an Interconnected World: New Directionsfor Action. Report of the Global Commission on International Migration, October 2005, (Madrid: Médecins du Monde, 2005),p.32. Available online at: http://www.gcim.org/attachements/gcim-complete-report-2005.pdf) states that the Organizationfor Economic Cooperation and Development - OECD has estimated that “between 10 and 15 percent of Europe’s 56 millionmigrants have irregular status, and that each year around half a million undocumented migrants arrive in the EU.”


6 PICUMstatus), the laws and practices in many Europeanstates deviate from these obligations. 2 It is a factthat a high percentage of undocumented migrantsdo not access any kind of health care even if they areentitled.Undocumented migrants mainly seek health carewhen they are severely ill. Health is commonly nottheir main concern because all of their energies areoften exhausted in acquiring the minimum subsistencenecessary for survival.Many undocumented migrants lack informationabout their rights to access medical services in thecountry where they live. On many occasions, they donot seek medical help because they have an enormousfear of being discovered and deported. Theyeasily confuse the levels of administrations andpublic authorities. They also think that hospitalsand health centers will inform the police of theirpresence.There are many vulnerable groups of undocumentedmigrants as regards access to health care, includingchildren, pregnant women and people with severechronic diseases such as HIV/AIDS.Besides these common hindrances, there are manyother practical obstacles in all countries linked toprocedures and administrative conditions, discrimination,language and cultural barriers, medicalfees, etc. In addition, practice shows that manyundocumented migrants are generally unable topay medical fees in those countries where they arerequested to do so. Those undocumented migrantswho do seek health care more frequently favor NGOclinics and hospital emergency units.Improving access to health care for undocumentedmigrants is an urgent priority not only since thelack of it is proven to have serious consequences forundocumented migrants themselves, but also uponpublic health in general. In fact, the effectiveness ofpublic health policies requires the participation ofall residents in health care programmes to protectthe well being of all.The Human Right to Health CareBefore providing an overview of the situationsconcerning access to health care for undocumentedmigrants in the different EU member states examinedin this publication, it is necessary to first elaborateon the international human rights standardsregarding the right to health care. The situation ineach EU member state regarding accessibility tohealth care services for undocumented migrantsshould be weighed against this international standard,rather than against other EU member states.The UN International Covenant on Economic, Socialand Cultural Rights provides the most comprehensiveclause on the right to health in internationalhuman rights law. According to article 12(1), StatesParties recognize:“the right of everyone to the enjoyment of thehighest attainable standard of physical andmental health.”The content of this provision has been further clarifiedby the Committee on Economic, Social andCultural Rights (CESCR), established to monitorthe implementation of the convention in its GeneralComment 14. Accordingly, “States are under theobligation to respect the right to health by, inter alia,refraining from denying or limiting equal accessfor all persons, including prisoners or detainees,minorities, asylum seekers and illegal migrants, topreventive, curative and palliative health services;abstaining from enforcing discriminatory practicesas a State policy…” 32PICUM, Undocumented Migrants Have Rights! An Overview of the International Human Rights Framework, (Brussels:PICUM, 2007).3UN Economic, Social and Cultural Rights Committee, General Comment No. 14 (2000). The right to the highest attainablestandard of health, UN Doc.E/C.12/2000/4. August 2000, para. 34. Available online at:http://www1.umn.edu/humanrts/gencomm/escgencom14.htm


Access to Health Care for Undocumented Migrants in Europe 7The Different Legal Systems in EU Member StatesWhile no EU member state’s legislation specificallyforbids access to health care for undocumentedmigrants, access to publicly subsidized health care,either partially or fully, is not entirely guaranteedin Europe. In some countries, all health care (evenemergency care) is provided only on a paymentbasis and treatments are generally unaffordable forundocumented migrants.The most restrictive member states shield themselvesfrom criticism by asserting that emergencycare is never denied to undocumented migrants.However, it is impossible to seriously speak about“accessibility” to health care when undocumentedmigrants continue to be asked to pay high and unaffordablesums in return, even in situations wheretheir life is at severe risk or when they seek to givebirth, as is occurring in some EU member states.In addition, access to health care is being used as aninstrument of immigration control policies and hasbecome increasingly restrictive in recent years. Forexample, entitlements have been significantly reducedin the UK and France has introduced more conditionsto access publicly subsidized health care.There is a growing tendency in Europe to restrictaccess to health care for undocumented migrantsand to reinforce the link between access to healthservices and immigration control policies. Such policiesnot only undermine fundamental human rightsbut also overburden migrant communities who mayalready be marginalized and living in precarious situations.“Disputes over immigration status frequentlycut across the provision of care and treatment, leavingsick people untreated, supported only by others in themigrant communities who themselves subsist at aminimum wage and minimum social amenity standards.”4The applicable laws and procedures are generallycomplicated and need more publicity. Many relevantactors are unfamiliar with the legislation in forceand have difficulties to accurately describe undocumentedmigrants’ entitlements to health care. Inaddition, it has been observed that having ambiguouslaws with a high degree of uncertainty can bepolitically motivated.When regulating this issue, EU member states usedifferent concepts and generally do not provideclear-cut definitions. There are many terms in use:emergency care, urgent medical care, essentialmedical care, immediate care, immediate necessarytreatment, medically necessary care, etc. Theabsence of clear definitions has brought confusionand failures at the level of implementation but hasalso allowed wide interpretations of the law (as hashappened in the Netherlands where the lack of definitionof the concept of “medically necessary care”has allowed doctors to increasingly expand healthcoverage for undocumented migrants).In some countries, there is no specific legislation onaccess to health care for undocumented migrants.There are only very indirect laws and regulationsapplying (e.g. like the obligation imposed by Swedishlegislation on county councils to provide immediatecare to all persons in need).A Difficult Categorization of CountriesPICUM’s research and the experience of organizationsin its network have shown a wide disparityamongst EU member states concerning legal entitlementsof undocumented migrants to health careservices.Given the different systems existing in Europeconcerning access to health care for undocumentedmigrants, the categorization has been very difficult.We have, however, distinguished five differentsituations:4AIDS and Mobility Europe, You can speak! How HIV-positive people with an uncertain residence status survive in Europe,September 2006, (Amsterdam: AIDS and Mobility Publications, 2006), p.2. Available online at:http://ws5.e-vision.nl/systeem3/images/WG%20IV%20-%20You%20can%20speak.pdf


8 PICUMi.Countries where all care is provided only on apayment basis, such as Austria and Sweden.Nonetheless, there are exceptions for particularlyvulnerable groups or specific medical conditions:Sweden covers the expenses generated for providinghealth care to children of rejected asylumseekers, and Austria allows access to treatmentof contagious diseases such as tuberculosis freeof charge.ii. Other countries offer free health care in verylimited cases, such as Hungary and Germany.In Germany low level entitlements are overriddenby the duty to denounce imposed on publicofficials dealing with undocumented migrants’health care files. The Social Welfare Office isobliged by law to inform the Foreigners’ Officeabout the presence of a patient in an irregularsituation each time they go to a consultation orwhen health care providers ask for reimbursementof medical costs. Consequently, undocumentedmigrants refrain from exercising theiralready limited entitlements.iii. A third category is countries with somewhatwider coverage but whose legislation is ratherrestrictive, ambiguous and with a high degree ofuncertainty. Good examples of countries in thissituation are the UK and Portugal.iv. Other countries, such as France, Belgium andthe Netherlands, have put a “parallel” administrativeand/or payment system in place concerninghealth care services for undocumentedmigrants. However, undocumented migrants arestill treated in the mainstream health system.v. Finally, Italy and Spain provide the widest healthcoverage to undocumented migrants. Althoughthere are certain conditions, gaps and failures,the spirit of the law, particularly in Spain, is toprovide universal access to health care. Thereforefree access to health care is offered to all,including undocumented migrants.The Implementation of the Law at Local andRegional LevelsPICUM’s research has shown that in many countriesthere is high decentralization of competencesfrom the central government to the regional andlocal entities. There are also many gaps betweenwhat the law says and its implementation. Theprocedures concerning implementation of the laware often complicated; there are many conditions,sometimes many administrations involved and a lotof bureaucracy.Many local authorities in charge of implementing thelaw lack information about undocumented migrants’entitlements and thus may illegally deny or refuse torecognize undocumented migrants’ right to accesspublicly subsidized health care.On many occasions, the enforceability of rightsdepends on NGO pressure or mediation. Many problemsthat occur within the administrative systemare solved by NGOs through simple means such astelephone calls. The problem appears to be greaterwhenever undocumented migrants do not seek thehelp of NGOs or in those areas where there are veryfew NGOs working with immigrants (such as in thecountryside in many parts of Europe).Within each country, there are many differences inthe implementation and interpretation of the law.Whilst we find local administrators implementingthe law very generously, organizing informationcampaigns or adopting guidelines to achieveuniformity, there are other administrators discriminatingor introducing illegal additional requirementsto “avoid abuses.”Health Care Providers and HospitalsIt is a constant feature throughout Europe that thosehealth care providers who are more “undocumentedmigrant friendly” (who are more willing to renderservice to undocumented migrants) tend to becomemore overloaded.


Access to Health Care for Undocumented Migrants in Europe 9When talking about undocumented migrants’ entitlements,all interviewed doctors and nursesexpressed a different understanding of the term“urgent” when compared to the one establishedin legislation. For example, these medical professionalsstrongly stressed the urgency of providingmental health care to undocumented migrants(whereas mental health is not considered “urgent”health care in many countries). Highly concernedabout undocumented migrants’ health care needs,they are increasingly involved in advocating forundocumented migrants’ rights. They are normallylistened to by health authorities and they have agreat persuasive power.With regards to hospitals, it is necessary to makesome specific considerations. Medical staff generallyapply professional codes and duties - it is notcommon to find doctors and nurses openly denyinghealth care to anyone. However, hospital administratorsare the first point of call and free from thebinding duty of professional ethics. Administratorsmay not have so many problems to turn away undocumentedmigrants at the hospital reception.The main barriers and problems arising at hospitalsare as follows:• In many cases, undocumented migrants arerequested to prove that they can pay before theyreceive health care. In some countries, hospitalsperceive undocumented migrants as synonymouswith the loss of income and therefore are reluctantto treat them.• Other times, hospitals provide health care andsend the bills to undocumented migrants afterwards.Since undocumented migrants are sometimesunable to pay, many bills remain unsettled.Some of these bills are sent to NGOs if they hadpreviously contacted the hospital concerning aparticular patient.• There is also a lack of information concerningundocumented migrants’ entitlements to healthcare and confusion about target groups (migrants,undocumented migrants, asylum seekers, etc.)and their entitlements.• Hospital administrations sometimes wronglybelieve that their duty to check entitlements isalso a duty to report to immigration authorities.• There are problems with medical history records,many of which are caused by one of the informalstrategies used by undocumented migrants toaccess health care: the use of insurance cardsbelonging to family members or friends.• Also observed is a poor presence of interpretersand cultural mediators in many hospitals.As with health care providers in general, there is aconcentration of undocumented migrants in some“undocumented migrant friendly hospitals” whichare mainly private and religious hospitals (sometimespublicly financed, some other times privatelyfinanced).A last observation about hospitals is that in additionto possessing very relevant information aboutthe health care situation concerning undocumentedmigrants, they also have much information abouttheir living and working conditions but do not implementsystematic data collection.NGOsNGOs are another very relevant actor in this fieldsince they also provide direct health care andhealth care-related assistance to undocumentedmigrants.The main services provided by NGOs to undocumentedmigrants are as follows:• Advice and help to access mainstream medicalservices. This is one of the most common activitiessince most NGOs are interested in making thecommon law system work rather than organizinga parallel charity-based system for undocumentedmigrants.• However, given the gaps and the failures ofthese systems, many organizations (and this is aphenomenon existing in all countries) also providedirect health care assistance through clinics and


10 PICUMmobile units run by volunteer health care providers.These clinics mainly offer primary health careservices but sometimes provide more specializedcare such as gynecological or mental health care.• NGOs also refer patients to health care providerswithin their networks.• Providing medicine (primarily received throughdonations).• They may also pay bills for care, medicine or testsprescribed to undocumented migrants.• Finally, some NGOs implement other initiativesconcerning undocumented migrants, for example,the provision of a small card containing the patient’smedical history and treatments prescribed.Given the gaps and failures of the health care system,there is enormous pressure on NGOs and charities,particularly in countries where legislation is ratherrestrictive. These organizations make a tremendouseffort to fill the gaps and correct the failures of thestate system and on many occasions feel obliged toconstantly improvise solutions.They do this under difficult conditions since theyoften lack human, technical and financial resourcesand, in some countries, they face pressure frompublic authorities given the repressive culture, as isthe case in Germany or Austria. In addition, there area high number of undocumented migrants reliant onthem. In some countries their task is essential sinceNGOs and religious hospitals are the only providersof health care to undocumented migrants.Formal and Informal NetworksThe existing lack or insufficient access to health carefor undocumented migrants has very much boostednetworking at the local level.Many relevant actors rely on informal networks.NGOs, hospitals and individual health care providersmaintain regular contact by telephone and e-mail.They also organize meetings to exchange informationon resolving problems within specific situationsor to plan targeted actions to advocate for undocumentedmigrants’ right to access health care. Publicadministrators and authorities are often involvedin these informal networks as well. Even the policewill sometimes agree to avoid a particular NGO orhospital.There are also frequent examples of formal methodsof cooperation such as partnerships at the locallevel involving cooperation of NGOs, health careproviders, as well as hospitals and local authoritieswith responsibility for public health. Most of thesepartnerships seek to facilitate access to healthcare at the local level for undocumented migrantsin general or for particularly vulnerable groups ofundocumented migrants.Improving Access to Health Care: An UrgentPriorityImproving access to health care for undocumentedmigrants continues to be an urgent priority in Europetoday despite the tremendous efforts made by civilsociety to fill the gaps and guarantee the minimumrespect for human dignity.Nonetheless there are still many undocumentedmigrants in Europe who do not access any kind ofhealth care or access it at a very late and dangerousstage.


Access to Health Care for Undocumented Migrants in Europe 11Purpose and structure of this reportThis report has been the result of a two-year Europeanproject co-funded by the Employment andSocial Affairs and Equal Opportunities DirectorateGeneral of the European Commission. Nineteenpartners from the following EU member statesparticipated in the project: Austria, Belgium, France,Germany, Hungary, Italy, the Netherlands, Portugal,Spain, Sweden and United Kingdom.The main purpose of this publication is to give visibilityto various problems associated with the existinglack of or insufficient access to health care forundocumented migrants residing in Europe.To this aim, we have chosen to present the situationregarding access to health care for undocumentedmigrants in terms of law and practice througheleven country profiles corresponding to the differentmember states participating in this study.Concerning the legal framework, information isprovided on:i)the general health care system;ii) the specific legal entitlements of undocumentedmigrants to access fully or partially publiclysubsidized health care;iii) the procedures and financing of the differentsystems put in place by EU member states to givea response to undocumented migrants’ healthcare needs.Each country profile also gives an overview of thesituation in practice, e.g. the most common problemsand obstacles preventing undocumentedmigrants from accessing health care as well as therole of civil society and local actors in this field.During the first year of the two-year project, fieldtrips and research interviews were carried out. Inthe second year, the information was assimilatedinto report format. Some slight modifications tothe legislative framework may have occurred sincethe research was completed and PICUM has madeefforts to include updates where possible. Althoughthe project has now come to a close, readers maycontact PICUM to include changes in the various EUmember states’ legislation examined in the study.Ultimately, this study seeks to serve as inspirationfor new strategies and actions to continue addressingthe problems associated with insufficient accessto health care for undocumented migrants in Europe.PICUM hopes that the information contained in thispublication will be useful in convincing the governmentsof EU member states to speak more, to domore, and to take on their responsibilities andcomply with international human rights obligationsinstead of continuing to rely upon civil society asan alternative provider of health care for undocumentedmigrants.


12 PICUM1. AUSTRIAA severely ill undocumented Chinese man went to the hospital in Vienna and had aserious but successful stomach surgery. Eighteen days after he left the hospital,another undocumented Chinese man came to the same hospital using the identitycard of the first one. Since the second man had grave stomach problems, the doctorstook him directly to the surgery relying on data from the medical history pertainingto the person mentioned in the identity card presented. During the surgery, the life ofthe patient was in real danger. He only survived thanks to the doctors realizing on timethat the patient did not have the blood group mentioned in the records.» Terms:Länder – states of the Federal Republic of AustriaGENERAL HEALTH CARE SYSTEMAustria has a compulsory statutory health insurancesystem that covers about 95% of the registeredpopulation on a mandatory basis and 2% on a voluntarybasis. 5 Co-insured family members are subjectto a reduced contribution, which in many cases iswaived (e.g. for children). The insured have a legalentitlement to social insurance benefits, whichare financed predominantly by income-dependentcontributions. The financing of the statutory healthinsurance system is always based on contributionspaid in equal shares by employers and employees,accounting for around 7.5% of salaries in 2005, withlimits for maximum contributions. 6People who remain uninsured are mainly unemployednationals and immigrants as well as asylumseekers. In 2003, a study commanded by the FederalMinistry of Health and Women noted that there werearound 160,000 uninsured persons in Austria. 7 Forthem, the state provides health care, medicine5Statutory health insurance is organised according to vocational groups and regional aspects, with some very widevariations in arrangements. Health insurance provides the following benefits: medical aid, medication, hospital care, homenursing and midwives, psychotherapy and clinical-psychological diagnosis, services of the medical-technical professions,mother-child medical card examinations, health examinations and preventive medical check-ups, travel and transportcosts, grants for prosthetic materials and auxiliaries, sickness benefits payments in cases of occupational disabilitythrough illness, maternity benefits, social accident insurance and the nursing care.Additionally, about one third of the Austrian population pays premiums into a private supplementary insurance policyin addition to their social security contributions. Such complementary insurances may grant the insured person betteraccommodation in the hospital (single rooms, for example), coverage of the costs of treatment by a doctor who doesnot have a contract with the particular patient’s health insurance, payment of daily benefits in cases of illness, or theassumption of costs for complementary medical treatment procedures. See Bundesministerium für Gesundheit undFrauen (BMGF), Public Health in Austria, (Wien: BMGF, 2005), pp. 103-107. Available online at:http://www.bmgfj.gv.at/cms/site/attachments/8/6/6/CH0083/CMS1051011595227/public_health_in_austria_2005_internet.pdf6Große-Tebbe S. and Figueras J. (eds.), Snapshots of Health Systems – The State of Affairs in 16 Countries in Summer 2004,(Copenhagen: WHO, 2004), p. 8. Available online at: http://www.euro.who.int/document/e85400.pdf7The Austrian government has traditionally stressed that the whole population residing legally in Austria was insured.Nonetheless, in 2003 it published a report conducted by the European Centre for Social Welfare Policy and Research thatshowed that there were around 160,000 people aged 15 or older living in Austria without any public or private insurance,including foreign students and tourists. See Bundesministerium für Gesundheit und Frauen (BMGF). Quantitativeund qualitative Erfassung und Analyse der nicht-krankenversicherten Personen in Österreich, (Wien: BMGF, 2004),p. 14. Available online at: http://www.bmgfj.gv.at/cms/site/detail.htm?thema=CH0083&doc=CMS1083763194914 andInternational Organisation for Migration (IOM) – National Contact Point Austria within the European Migration Network.Illegal Immigration in Austria. A Survey of recent Migration Research. (Wien:IOM, 2005), p.56. Available online at: http://www.emn.at/modules/typetool/pnincludes/uploads/FINAL_VERSION_ENG.pdf


Access to Health Care for Undocumented Migrants in Europe 13and compensation in cases of injury or accident atwork. 8 As for any social service in Austria, undocumentedmigrants are generally excluded from theseprovisions.The Federal Ministry of Health and Women has thegeneral competence in the field of health policy andthe structural planning of the health care system.In addition, this ministry shares responsibility forthe protection of general public health, for preventivemedical measures including preventive medicaltreatment of school-age children, public hygieneand vaccinations, monitoring and combating contagiousand infectious diseases, for matters of hospitals,nursing homes and public social and welfareestablishments. 9The nine Länder governments deliver public healthservices and have strong competences to financeand regulate inpatient care. 10 Additionally, importantresponsibilities are also assumed by social securityinstitutions as self-administered public operations.Access to individual services of the public health caresystem is governed by social law. 11An important contribution to acute medical careis provided by the outpatient clinics of specializeddepartments in hospitals. More than half of Austria’shospitals are so-called “fund-hospitals” which essentiallyencompass the acute-illness sector (exceptaccident and emergency hospitals) and are financedthrough a mix of tax revenues and health insurancecontributions via provincial health funds. 12HEALTH CARE FOR UNDOCUMENTEDMIGRANTS1. Legal Entitlements to Access Fully orPartially Publicly Subsidized Health CareAustrian state discourse related to undocumentedmigrants is marked by a decisive and explicit overemphasison repressive policies, instruments andmeasures. Consequently, there is no public social orhealth care support for undocumented migrants. 13Undocumented migrants are not eligible to accessthe social security system including health, accidentaland pension insurance. Since they cannot obtainpublic health insurance they do not enjoy any legalright to benefit from health care facilities.The only legislation indirectly applicable is theAustrian law on hospitals and sanatoria, whichprovides that every hospital should admit and treatinjured patients whose health is in serious danger. 14This law does not exclude anyone on grounds ofnationality or residence status and thus leaves thedoor open for undocumented migrants to accessthe emergency system in life-threatening situationsbut they will always have to pay for the expenses.Given the costs, it is most likely that undocumentedmigrants will not seek health care or will not be ableto pay the hospital bills.8This system was introduced by the “Basic Welfare Support Agreement” and entitles access to health care and medicinewith some restrictions when compared to the general scheme. The agreement entered into force on 1 May 2004. SeeGroße-Tebbe S. and Figueras J., (2004: 7). Available online at:http://www.euro.who.int/document/e85400.pdf. See also IOM, (2005:34). Available online at:http://www.emn.at/modules/typetool/pnincludes/uploads/FINAL_VERSION_ENG.pdf9See BMGF, (2005: 19f). Available online at:http://www.bmgfj.gv.at/cms/site/attachments/8/6/6/CH0083/CMS1051011595227/public_health_in_austria_2005_internet.pdf10Ibid.11Ibid., p. 15.12See Große-Tebbe S. and Figueras J., (2004:8). Available online at: http://www.euro.who.int/document/e85400.pdf. See alsoBMGF, (2004: 54)13See IOM, (2005:27) and (2005:29-36). Available online at:http://www.emn.at/modules/typetool/pnincludes/uploads/FINAL_VERSION_ENG.pdf14See §§ 22-23 Bundesgesetz über Krankenanstalten- und Kuranstalten (KAKuG) BGBI. Nr. 1/1957, last modified by BGBI. INr. 155/2005.


14 PICUMIn Austria, there are specific laws regarding infectiousdiseases such as tuberculosis and HIV/AIDS thatrequire health care providers to inform the competentauthorities about all new cases. The provisionsare very general and do not make any distinction ongrounds of residence status. The Tuberculosis Actof 1968 stipulates that people suffering from infectioustuberculosis have to receive medical treatmentand the authorities are obliged to provide subsidizedhealth care. 15 In practice, however, it is very difficultto treat undocumented migrants with tuberculosissince they do not normally have the necessaryliving conditions for the continuity and success of thetreatment.Concerning HIV/AIDS, the AIDS law obliges doctorsto inform patients about their disease and the riskof transmission as well as the precautions to avoidinfection of others. 16 The test is free but there is nosubsidized access to treatment for undocumentedmigrants. As a result, some undocumented migrantswith HIV/AIDS seek treatment at places like Aidshilfein Vienna.Aidshilfe Wien offers counseling, anonymoustesting and treatment to people with HIV/AIDS.This organization offers anonymous care andundocumented migrants may thus also receiveretroviral treatment as well as social and psychologicalsupport.http://www.aids.at2.The Situation in PracticeGiven their exclusion from the insurance systemand from the state-funded scheme for uninsuredpersons, 17 undocumented migrants are obliged topay the full cost of treatment when seeking healthcare in Austria. Since treatments are often veryexpensive, in most cases undocumented migrantslack the necessary financial means to pay.Consequently, undocumented migrants only go tohospitals when they have serious diseases thatcannot be treated elsewhere. Even the FederalMinistry of Health and Women seems to acknowledgethis fact in its report about uninsured personsin Austria. This study also stresses that amongthe group of uninsured persons, undocumentedmigrants are one of the most vulnerable due to theirfear of being discovered and sent back to their countriesof origin. 18When ill undocumented migrants cannot find anyother alternative than seeking treatment at thehospital, they usually receive unaffordable billsafter obtaining the treatment. Many turn to NGOsor family members for help with covering the costs.Family members especially face serious difficultiesin paying the incurred medical expenses.Hospitals are not obliged to register the residencestatus of a patient and, as the International Organizationfor Migration (IOM) states, “a patient cannotbe forced to give any reliable data. Sometimes, ithappens that the hospital cannot find out who actuallywas medicated.” 19 As Dr. Gerald Ressi of theorganization OMEGA in Graz reported, “there aremany cases where bills remain unpaid.” Therefore,15See §§ 2 and 10 of the Tuberkulosegesetz, BGBl Nr. 127/1968, last modified by Federal Law BGBl. I Nr. 65/2002.16See Aids-Gesetz BGBI Nr 728/1993, last modified by Federal Law BGBl. I Nr. 98/2001.17International Organisation for Migration (IOM) – European Network for Co-operation and Exchanges on Social Exclusionand Health Issues for Migrants. National Report Austria: Soziale Exklusion und Gesundheit von MigrantInnen in Österreich.(Wien: Ludwig Boltzmann Institut, 2003), pp.30. See also IOM, (2005:27). Available online at:http://www.emn.at/modules/typetool/pnincludes/uploads/FINAL_VERSION_ENG.pdf18BMGF, (2004:90). Available online at: http://www.bmgfj.gv.at/cms/site/detail.htm?thema=CH0083&doc=CMS108376319491419IOM, (2005:27f). Available online at: http://www.emn.at/modules/typetool/pnincludes/uploads/FINAL_VERSION_ENG.pdf


Access to Health Care for Undocumented Migrants in Europe 15the hospital must apply to the District Social WelfareDepartment to cover the budget losses arising fromunpaid bills of uninsured people. 20Unpaid bills may also have consequences for the fewundocumented migrants who manage to regularizetheir stay in Austria. “They will get the residencepermit together with a big debt towards hospitalsthat they will probably have to pay for the rest oftheir lives,” said Gerald Ressi of OMEGA.Even though hospitals may reject an immigrantpatient if their medical condition is not consideredto be an emergency, 21 in practice, the tendency is forhospitals to treat undocumented migrants despitethe potential budget losses, because there are notmany cases arising.3.The Role of Civil Society and Local ActorsTo cope with the above-mentioned practical obstaclesand with the lack of entitlements to publichealth care for undocumented migrants, someorganizations either act as intermediaries, askingfor a cancellation or reduction of the fees, or establishlists of individual health care providers willingto assist undocumented migrants free of charge.Examples of these kinds of organizations areCaritas, Diakonie-AMBER MED, Asyl in Not 22 , VereinUte Bock 23 and Deserteurs- und Flüchtlingsberatung,all based in Vienna.The Deserteurs- und Flüchtlingsberatung(Counseling for Deserters and Refugees) wasfounded in 1992 as a support organization forSerbian and Croatian war deserters. Today itoffers counseling to all refugees and migrants,mostly with regard to questions concerning residenceand asylum. The organization is rooted inthe anti-racism movement. An important part ofits work consists of referring people, includingundocumented migrants, to other facilities andorganizations that are able to provide help.http://www.deserteursberatung.atIn addition, some organizations and hospitals likeDiakonie-AMBER MED, Caritas and Krankenhausder Barmherzigen Brüder in Vienna and OMEGA-CARITAS in Graz also provide direct medical assistanceand medicines to undocumented migrants.AMBER-MED offers health care and medicine foruninsured people in Vienna in cooperation with theAustrian Red Cross. Around 800 patients are treatedevery year by this organization, mostly asylumseekers denied basic care by the state, homelesspeople and undocumented migrants. AMBER-MEDis supported by a network of more than 70 doctorsand institutions such as laboratories and hospitalsthat treat patients for free.20Only the losses of the so-called “fund hospitals” are compensated by the District Social Welfare Department.21IOM, (2005:92). Available online at: http://www.emn.at/modules/typetool/pnincludes/uploads/FINAL_VERSION_ENG.pdf22Asyl in Not (Asylum in Need) is a support committee for people prosecuted for political reasons. For more information,available online at: http://www.asyl-in-not.org.23The Verein Ute Bock (Association Ute Bock) is a refugee project offering counselling, educational programmes andpractical help. More information available online at: http://www.fraubock.at.


16 PICUMThe Diakonie Evangelisches Hilfswerk is theRefugee Service of the Protestant Church inAustria. In 2004, it started the project AMBER;an important contact point for undocumentedmigrants who would not dare to consult a doctorfor fear of being arrested. AMBER-MED tries toguarantee anonymity and protects the data of allthose who seek medical help.AMBER-MED’s main areas of activity are regularand preventive health care, neurological careand psychotherapeutic crisis intervention. Theyalso have a dispensary of drugs. In cases wherethe organization cannot provide further help tothe patients, they are referred to its networkof cooperating health care providers that treatundocumented migrants free of charge. Thefollowing is one such case:A 40-year old undocumented man from Serbiawas suffering from Carpal tunnel-syndromeand had lost the use of his right hand due to astrong deformation. He had been undocumentedin Austria for a number of years and employedwithout a work permit. As he did not have healthinsurance, he sought free medical treatment atAMBER-MED. One of the AMBER-MED surgeonsfound a private surgical practice where he wasable to do the necessary surgery (cutting asinew). The aftercare as well as physical regenerationwas assured by AMBER-MED. Due to thetreatment, the man was able to use his hand andto return to work after a short recovery timehttp://www.amber.diakonie.at/AMBER-MED, along with other organizations andinstitutions, such as Caritas Graz and Krankenanstaltdes Göttlichen Heilande (a religious hospital inVienna), also offer possibilities for anonymous prenatalcounseling, gynecological examinations andchildbirth for women without insurance coverage. 24Since its foundation in 1991, the Louise Bus-CaritasMobile Unit has provided medical assistance toaround 5,200 homeless and uninsured people everyyear. In 1993, Caritas St. Josef took over the organizationand responsibility of the Louise Bus whichoffers medical assistance five days a week at sevendifferent places in Vienna – places where homelesspeople can primarily be found. Doctors and unsalariedassistants ensure professional medical care forpatients without health insurance. The mobile unitallows contact with people afraid of going to a doctorto deal with their problems and confiding in them.At times this mobile unit as well as the other organizationsproviding direct medical assistance toundocumented migrants in Vienna find themselvesin situations where the patients require specializedhelp that only hospitals can provide. In these cases,most refer the patients to the Krankenhaus derBarmherzigen Brüder, a private religious hospitalwhere undocumented migrants are treated for free.This hospital is today one of the most importantcontact points for undocumented migrants in Vienna.Free medical care is guaranteed to approximately20,000 to 30,000 uninsured patients every year, ofwhich about 1,000 to 5,000 are hospitalized. Undocumentedmigrants largely rely on the Krankenhausder Barmherzigen Brüder, which provides all typesof inpatient and outpatient care with the sole exceptionof HIV/AIDS and accident-related treatments.24See IOM, (2005:94). Available online at: http://www.emn.at/modules/typetool/pnincludes/uploads/FINAL_VERSION_ENG.pdf


Access to Health Care for Undocumented Migrants in Europe 17The Krankenhaus der Barmherzigen Brüder(Hospital of the Brothers of Saint John) wasfounded more than 400 years ago, based onChristian principles of charity. A major project ofthe hospital is the so-called “new hospitality” thatincludes a mobile unit for deaf people, a separateunit for stationary treatment of detainees as wellas a special mobile unit for those without healthinsurance and unable to pay for treatment,particularly homeless people or undocumentedmigrants. Through this form of charity, thehospital applies its mission and indiscriminatelyoffers medical treatment to people regardless oftheir social or national background or religiouscommitment.http://www.barmherzige-brueder.at/Medication is provided for some undocumentedmigrants by the Pharmaceutical Depot of theAustrian Red Cross in Vienna. In 2000, this organizationprovided pharmaceutical support worldwidefor an amount exceeding two million Euros. In addition,the Red Cross Pharmaceutical Depot offersprescribed medication to uninsured people forfree. However, some medicine is not always availablesince the depot only has a limited quantity at itsdisposal.Apart from the initiatives based in Vienna, othersexist in different Austrian cities. For instance, inthe city of Graz, Caritas Graz and the organizationOMEGA jointly work on the Marienambulanz, amobile unit which provides health care in severalpoints of the city once a week to uninsured homelesspeople. Undocumented migrants constitute asignificant part of this group.The Marienambulanz is a project carried outjointly by Caritas Graz and OMEGA with the aim ofproviding primary health care to people withoutinsurance as well as to homeless people in Graz.Undocumented migrants represent a large partof the target group.In 2004, 5,061 medical treatments were provided.25 Since 2001, a mobile unit has traveled todifferent areas in Graz once a week to providehealth care. In January 2006, the Marienambulanzwas granted the legal status of an officialoutpatient clinic, according to the Hospital Lawof the Styrian region.http://www.marienambulanz.caritas-graz.at/Omega Gesundheitsstelle (Omega HealthCenter) is a non-profit association which aimsfor the promotion, support and treatment ofindividuals who are affected by organized formsof violence and gross systematic violations ofhealth and human rights by employing a familyorientedapproach.http://www.omega-graz.atIn a country such as Austria where the state takes noaction to solve the problems arising from the lack ofaccess to health care for undocumented migrants,the role of civil society organizations and privateinstitutions is crucial to keep these migrants alive.This reality has also been acknowledged by theMinistry of Health. 2625Ibid.26See BMGF, (2004: 90). Available online at: http://www.bmgfj.gv.at/cms/site/detail.htm?thema=CH0083&doc=CMS1083763194914


18 PICUMIn big cities like Vienna, the existence of informalnetworks and privately funded initiatives allowsundocumented migrants to receive most medicaltreatments free of charge. However, this seems notto be the case in rural areas with less immigrantpopulation. 27 For example, according to FrauenhausTirol (Tyrol Battered Women’s Shelter), thereare very few doctors in Tyrol willing to treat peoplewithout health insurance.Many undocumented migrants are uninformed aboutthe possibility of receiving medical treatment andare continually very reluctant to seek health carein any venue, as they fear discovery. As Dr. Pichlerfrom the Krankenhaus der Barmherzigen Brüdersaid, “Here in Austria, undocumented migrants onlycome to hospital when they are in an extreme situation.Some of them come only to die.”27Ibid.


Access to Health Care for Undocumented Migrants in Europe 192. BELGIUMConsuelo was an undocumented woman from Ecuador who had lived in Belgiumfor seven years. During her stay, she lived in constant fear due to her irregular status and neverwent to the doctor, even when she started having health problems. She finally decided to goto the hospital when her situation became very serious, and at that point she was diagnosedwith cancer. Her treatment was only partially covered by the state through the “urgent medicalassistance” scheme. Since she could not afford the remaining cost of the treatment, shereturned to her native country of Ecuador, where she died shortly afterwards.» Terms:CPAS/OCMW (Centre public d’aide sociale/ Openbaar centrum voor maatschappelijkwelzijn) - social welfare centreINAMI (Institut national d’assurance maladie-invalidité) - National Institute for Health andDisability InsuranceSPP-IS (Service public de programmation de l’Intégration sociale) – Public service forprogramming and social integrationGENERAL HEALTH CARE SYSTEMBelgium has a system of compulsory national healthinsurance that covers the whole population and has avery broad benefits package. Health care is privatelyprovided. Health insurance is organized through sixprivate non-profit health insurance funds.Membership is obligatory but there is a freedom tochoose between health insurance funds. The healthcoverage and the social contribution rates levied arethe same for all funds. Nonetheless, reimbursementby individual health insurance funds dependson the nature of the service, the legal status of theprovider and the status of the insured. There is adistinction between those who receive standardreimbursements and other vulnerable social groupswho obtain higher reimbursements.Patients in Belgium participate in health care financingvia co-payments, for which the patient pays acertain fixed amount of the cost of a service, withthe third-party payer covering the balance of theamount; and via co-insurance, for which the patientpays a certain fixed proportion of the cost of aservice and the third-party payer covers the remainingproportion.Private health insurance remains very small in termsof market volume but has increased as compulsoryinsurance coverage has been reduced.The Belgian health system is organized on twolevels: federal and regional. The federal governmentregulates and supervises all sectors of thesocial security system, including health insurance.However, responsibility for almost all preventivecare and health promotion has been transferred tothe communities and regions.The federal government is responsible for regulatingand financing the compulsory health insurance;determining accreditation criteria; funding hospitalsand so-called heavy medical care units; legislationcovering different professional qualifications;and registration of pharmaceuticals and their pricecontrol. The regional governments are responsiblefor health promotion; maternity and child healthservices; different aspects of elderly care; theimplementation of hospital accreditation standards;and the financing of hospital investment. 2828Große-Tebbe S. and Figueras J., (2004:11-14). Available online at: http://www.euro.who.int/document/e85400.pdfSee also “Belgium: Health System Review”, in Health Systems Review Vol.9 No.2, 2007. Available online at:http://www.euro.who.int/document/e90059.pdf,


20 PICUMHEALTH CARE FOR UNDOCUMENTED For the remaining situations, undocumentedMIGRANTSmigrants have the right to access “urgent medicalassistance” free of charge. 311. Legal Entitlements to Access Fully orThe Royal Decree regulating “urgent medical assistance”does not provide a concrete definition of thisPartially Publicly Subsidized Health CareSince undocumented migrants cannot officially concept, however it clearly states that:work, they do not have access to the social securitysystem. There are however some exceptions.i) the assistance provided should be exclusively ofUndocumented migrants can get insured if one ofa medical nature;the following conditions is met:ii) the “urgent” character must be certified by ai) their parents, children or spouses are entitled todoctor;health insurance;iii) health care provided can be preventive andii) they were once documented and had a declaredcurative;job (paying all social contributions), but at aiv) the medical help given can be both mobile orcertain moment lost their legal status, whileprovided in a health centre;the employer kept on paying the contributions(in these cases the employee will continue to be v) the assistance cannot consist of financial help,insured for a while, since there is a run-off of housing or any other provision of service inseveral years);kind. 32iii) they had previously held health insurance but The terminology used has brought on confusion. Thehave lost their legal status;word “urgent” gives the impression that only accurateor emergency cases are taken into account.iv) they are studying at a recognized school forHowever, the concept is much broader and encompassesa wide variety of care provisions, such ashigher education. 29The most recent case approved was that of unaccompaniedminors (documented and undocu-medical examinations, operations, childbirth, physiotherapy,medications, tests and exams, etc. Themented), who since January 2007 have been entitledonly exceptions are medical materials such as dentalto receive health insurance in Belgium. 30 prosthesis, wheelchairs, etc., as well as some typesof medicine.29PICUM, Health Care for Undocumented Migrants – Germany, Belgium, the Netherlands and United Kingdom, (Brussels:PICUM, 2001), pp.22. Available online at: http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdf.30See National Health Law of 13 December 2006 (Loi du 13 Decembre 2006 portant dispositions diverses en matière desanté). Although the law stipulates that insurance for separated children would come into force on 1 January 2007,according to the organisation Medimmigrant, it will effectively only apply from 1 January 2008. See Medimmigrant, Laloi du 13 décembre 2006 portant dispositions diverses en matière de santé, (Brussels: Medimmigrant, 2006d). Availableonline at: http://www.medimmigrant.be/mm.legislation.fr.htm31See Organic Law on Social Welfare Centers (Loi organique des Centers Publics d’Action Sociale) of 8 July 1976 andRoyal Decree of 12 December 1996 on state medical assistance (arrêté royal relative à l’aide médicale urgente, M.B. du31.12.1006).32See Article 1 of Royal Decree of 12 December 1996.


Access to Health Care for Undocumented Migrants in Europe 21In an official document, the administration explainsthat urgent medical care even includes “assistancethat it is necessary to avoid a health situation thatis dangerous for a person or his/her circle.” 33 Asreported by Médecins Sans Frontières (MSF), “the‘urgent’ character must not be interpreted as amatter of life or death. It is rather a notion intendingto protect physical and mental integrity. Therefore,a person who is ‘simply’ ill has the right to accesshealth care.” 34The government has never adopted provisions thatclearly specify those medical services that undocumentedmigrants are entitled to under this scheme. Itis left to the health care provider to decide on a caseby case basis what is to be considered “urgent.”The concept of “urgent medical assistance” applyingto undocumented migrants has been largelyconfounded with the concept of “emergency care”which is the care required immediately in case of anaccident or a sudden illness. This type of care, whichis defined very restrictively, is regulated by a differentlaw and is granted free of charge to everyone,including undocumented migrants. 35Apart from this, undocumented migrants can, atleast in theory, also get private health insurance thatgives full reimbursement of medical costs. However,since these premiums are always very expensive,few undocumented migrants can afford this kind ofinsurance. 362.The Procedure and Financing of the SystemThe authorities managing the procedure – the socialwelfare centers (CPAS/OCMW) - have a high degreeof autonomy in the implementation of the applicablelegislation, to such an extent that there exists nosole procedure to receive “urgent medical assistance”but many different ones.Most commonly, undocumented migrants first goto the CPAS/OCMW in the municipality where theylive. The CPAS/OCMW then initiates a social inquiryfor verifying if the applicant is residing irregularlyin their local area and if they are in a precariouseconomic situation. The CPAS/OCMW has to makea decision in thirty days as to whether to agree onpaying medical assistance. 37 They will also specify ifthe validity of the document is just for one consultationor for a longer but determined period of time.If the decision is positive, the applicant can visit ahealth care provider recognized by both the NationalInstitute for Health and Disability Insurance (INAMI -Institut national d’assurance maladie-invalidité) andthe respective CPAS/OCMW. The doctor will thenexamine the patient and send the bill to the CPAS/OCMW together with an “urgent medical assistancecertificate.”The CPAS/OCMW will pay the health care providerand be reimbursed by the state. Only if the socialwelfare office receives this certificate attesting theurgent character of a particular provision of health33“Même l’aide nécessaire pour éviter une situation médicale dangereuse pour une personne ou son entourage relève del’aide médicale urgente.” See Circulaire of 20 May 1997 clarifying the Royal Order on urgent medical assistance.34Médecins Sans Frontières. Accès aux soins en Belgique: Rapport d’activité 2005, (Bruxelles: MSF, 2006), p. 1935See Act on urgent medical assistance of 8 July 1964 (Loi relative à l’aide médicale urgente du 8 Juillet 1964).36PICUM (2001), p.22. Available online at: http://www.picum.org37This decision can be challenged before the labour court (Tribunal de travail).


22 PICUMcare, will the social welfare centre be reimbursedby the SPP-IS – Service public de programmationde l’Intégration sociale. The reimbursement procedureis a lengthy process, often lasting up to ninemonths.The amount for reimbursement will always relate toa fixed list established by the INAMI. Nonetheless,the CPAS/OCMW is always free to go beyond andassume the extra cost for those care services notcomprised within this list.The procedure is different in cases where undocumentedmigrants need immediate medical assistance.In these circumstances, undocumentedmigrants bypass the social welfare center and godirectly to the hospital. It is then the responsibility ofthe health care provider in the hospital to completean inquiry and issue the “urgent medical assistancecertificate” which will be sent to the respectiveCPAS/OCMW, which in most cases located in thehospital area. Very frequently however, the socialwelfare centers request an additional social inquiryto ensure that the house visit is completed. 38The CPAS/OCMW must oversee that “urgent medicalassistance” is available and accessible to undocumentedmigrants. To this aim, it must facilitate thefirst consultation and the access to medicine aswell as monitor the whole procedure. Many CPAS/OCMW also make urgent medical care agreementswith particular care providers and hospitals (usuallypublic hospitals) to make access to health careeasier for undocumented migrants.Finally, the law guarantees that any informationwhich appears on medical certificates will be treatedconfidentially and will not be used for any purposeother than repayment. Members of the (para)medical profession are bound by a duty of professionalconfidentiality. 393.The Situation in PracticeThe existence of a parallel administrative systemwith a highly complex and long procedure determinesthat in many cases the right to access healthcare is not effectively guaranteed. In addition, thereare many differences between the provisions of thelaw and the situation in practice due to the lack ofawareness regarding entitlements and about howthe system works.There are difficulties in determining the competentCPAS/OCMW, particularly when undocumentedmigrants do not have a fixed address. In addition,administrators are often overworked and socialworkers do not always have a sound knowledge ofthe “urgent medical assistance” scheme. This hasconsequences on the quality of the social inquiryundertaken. 40While in principle they are obliged to do so, manyCPAS/OCMW refuse to reimburse costs made in aprivate hospital. This can lead to problems if peopleare taken to a private hospital by an ambulance afteran accident. In addition, sometimes undocumentedmigrants are simply not well informed and go to aprivate hospital instead of a public one approved bythe CPAS/OCMW.38For more information about the application procedure for the “urgent medical assistance certificate”, Medimmigrant,Manuel Aide Médicale Urgente pour personnes en séjour illégal. Manuel pour des collaborateurs de CPAS et prestatairesde soins. (Brussels: Medimmigrant, 2006a), pp.4. Available online at: http://www.medimmigrant.be/mm.publications.fr.htm and Medimmigrant, Urgent Medical Care for Illegal Residents, (Brussels: Medimmigrant, 2006c). Available onlineat: http://www.medimmigrant.be/mm.publications.fr.htm39See Article 4 of Royal Order of 12 December 1996.40See Médecins Sans Frontières, (2006: 19)


Access to Health Care for Undocumented Migrants in Europe 23Some other problems arise from the fact that theterm “urgent” is not defined. Local actors, in particularlocal authorities, complain about the ambiguityof the concept used within legislation. “It is crucialto clarify the term ‘urgent medical assistance’ andachieve greater convergence among the differentCPAS/OCMW. Access to health care not onlydepends on the law but also on the internal organizationand policy of the respective CPAS,” said SophieMagnée of the Brussels-Capital Social WelfareCenter.Furthermore, health care providers are oftenconfused regarding this process (a serious concerngiven that they are responsible for deciding theurgency of a particular situation), as are undocumentedmigrants themselves who have the tendencyto think their entitlements are limited to very urgentcases or to care provided in the emergency units ofthe hospitals. Addressing this problem, Medimmigrantissued a recommendation that the governmentshould start by deleting the word “urgent” from theexpression “urgent medical assistance.” In theiropinion, this will avoid a lot of misunderstanding.The procedure to access health care is lengthy andconsists of numerous steps. Belgian organizationsdeny that these circumstances may have unfortunateconsequences upon undocumented migrants’health status.It takes a long time for the social welfare centersto gather all the information they need to decidewhether to refund costs for the care provided. In themeantime, the medical expenses remain outstanding.This is particularly problematic in cases wherethe patient has an urgent need to visit a doctor. AsMédecins Sans Frontières has reported, certainsocial workers at the CPAS/OCMW choose to sendundocumented migrants directly to the emergencyunit: “They know well that the administrativeprocedure and the social inquiry will take too long.This example shows that the current procedure isnot in accordance with patients’ needs, needs thatare often quite urgent.” 41In practice, many undocumented migrants in needof medical assistance first go to the doctor withoutthe previous agreement of the CPAS/OCMW. Theproblem arising in these kinds of situations is thatthe cost of the first consultation is usually paid bythe patient since the doctor is often not one of thehealth care providers recognized by the competentsocial welfare center.There are many health care providers in Belgiumwho are not aware of the existence of a law on“urgent medical assistance” or do not understand themeaning of the concept used by the legislation. Othersare unwilling to cooperate and follow the administrativeprocedure due to their own ideological reasons orbecause they fear that they will not be reimbursed orthat if they are reimbursed, it will be too late.Certain CPAS/OCMW have made agreements withspecific general practitioners. Most NGOs look atthis practice very positively as it is an efficient wayto solve the problem: facilitating access to healthcare for undocumented migrants as well as makingdoctors feel more confident about the reimbursementof medical costs.There are many differences in the implementationand interpretation of the law given the high degreeof autonomy that the respective authorities (CPAS/OCMW) have to manage the procedure. The resultis that accessibility to health care largely differsfrom municipality to municipality. In Brussels alone,there are nineteen municipalities, each with theirown requirements and procedures. Whilst some arerather restrictive and ask for a lot of documentation,others are willing to agree more easily.41Ibid., p. 17.


24 PICUMSome CPAS/OCMW in Brussels (e.g. BrusselsCapital and Molenbeek municipalities) have developeda good practice that has gained governmentrecognition. 42 It consists of providing undocumentedmigrants with a “medical card” which secures theirtreatment or receipt of medicine for a certain perioddepending on their specific health care needs, thussaving the undocumented migrant from passingthrough the whole procedure each time they becomeill or require more medication. Nonetheless, thereare still many municipalities that continue providingagreements on a case by case basis.Even if this practice is very positive and appreciatedby NGOs, undocumented migrants are forced to gothrough the procedure again and again, especiallyif they have severe chronic diseases. “To be able tocontinue my long-term treatment, I have to go everythree months to the general practitioner and ask himto send the ‘urgent medical assistance certificate’ tothe CPAS/OCMW. It is always a matter of back andforwards. That is painful for somebody who is seriouslyill. There is excessive bureaucracy. They playwith the patients, they play with us,” explained JuanManuel, a Colombian undocumented migrant whohas been living in Belgium for five years.Undocumented migrants face serious difficultieswith the social administration in Belgium. However,this is not the only problem arising. Undocumentedmigrants are often fearful of visiting a social welfarecenter because they think that the immigrationauthorities will be informed about their irregularpresence in Belgium. This constitutes a growingproblem in the current context of increasingrepression. 43 Undocumented migrants are particularlysensitive about establishing contact with theCPAS/OCMW because the social worker normallycompletes a house visit as a part of the social investigation.In this sense, Medimmigrant thinks thatsocial workers should regularly reassure undocumentedmigrants that no link to the immigrationauthorities exists.In reality, many undocumented migrants do notknow about the existence of this right or are badlyinformed about it. Rejected asylum seekers seemto be the most informed group when comparedto recent arrivals or those who have never legallyresided in Belgium. 44As a result, undocumented migrants use variousinformal strategies to try to obtain medical assistance,such as borrowing documents from familymembers or friends who are documented; paying thefull cost of medical services by themselves (whichoften leads to the accumulation of debts) or with thehelp of others like religious communities; negotiatingwith doctors about the cost of health care; andgoing to organizations delivering medical assistancefree of charge.4.The Role of Civil Society and Local ActorsGiven the fact that undocumented migrants’ accessto health care is still very limited and that there aremany practical obstacles preventing them fromaccessing medical treatment, organizations suchas Médecins Sans Frontières (MSF) and Médecinsdu Monde 45 provide free health care to ill undocumentedmigrants.MSF’s “Access to Health Care” project seeks tofacilitate access to health care, in particular primarycare. This organization provides social, health andpsychological assistance in Brussels and Antwerpto vulnerable populations including undocumentedmigrants. Firstly, the social department collectsnecessary data in order to give advice for accessingsocial services. After that, a doctor examines the42See Circulaire of the Ministry of Social Integration of 14 July 2005.43See Médecins Sans Frontières, (2006 : 20)44See PICUM, Book of Solidarity: Providing assistance to undocumented migrants in Belgium, Germany, the Netherlands andthe UK. Vol. 01, 2002, (Brussels: PICUM, 2002), pp. 21-22.45http://www.medecinsdumonde.be


Access to Health Care for Undocumented Migrants in Europe 25patient, takes the necessary measures according totheir health status and if necessary, refers them toa psychologist.Many undocumented migrants go to MSF for an initialconsultation, especially if they live in an area wherethe municipality asks for an “urgent medical assistancecertificate” issued by a doctor before startingthe procedure.Médecins Sans Frontières (MSF) is an internationalhumanitarian aid organization whichprovides emergency medical assistance topopulations in danger in more than 70 countries.In Belgium, MSF focuses on improving accessto health care for the disadvantaged and mostvulnerable populations. They provide informationabout the health system as well as directmedical assistance through two clinics locatedin Brussels and Antwerp.In 2005 alone, MSF provided 8,140 consultations.Up to 80% of the patients treated were undocumentedmigrants and asylum seekers.http://www.msf.beMedimmigrant, an organization based in Brussels,provides information to undocumented migrantsabout their rights and the procedure to access“urgent medical assistance” in Belgium. Medimmigrantalso acts as an intermediary between thepatient and the CPAS/OCMW and refers migrants toparticular health care providers or other organizationsif necessary.During contact hours, Medimmigrant answers questionsregarding access to health care as well as aboutresidence permits for medical reasons. Given thattheir assistance is mainly provided via telephone,appointments are exceptional, e.g. when the case isvery complex or there are language barriers, etc.Medimmigrant also has a fund to pay the first consultationor medicine in exceptional circumstances, e.g.if the procedure is failing or during the time that thesocial welfare office is deciding whether or not toprovide medical services free of charge.The organization Medimmigrant seeks to ensurethe right to health care for undocumentedmigrants and people with a precarious residencestatus embedded in the legislation and have itconcretely implemented by social services andother public institutions.Besides providing information about entitlementsto access health care, Medimmigrant actively mediatesto speed up the procedure to access healthcare. Their assistance is specifically addressed toresidents or organizations located in the BrusselsCapital Region.Medimmigrant also works at the structural level.To this aim, it takes part in numerous platforms andinitiatives at the national level and makes regularrecommendations to the government in the fieldof access to health care with the aim of achievingbetter implementation of the law as well as raisingawareness amongst the different stakeholders.Part of this work also focuses on residence permitsfor medical reasons. This organization is committedto uphold the right to stay and the right to socialservices for people who are unable to return totheir country of origin as a result of their illness.It also lobbies for the establishment of a Europeanmedical database with information covering theaccessibility and availability of necessary treatmentsand medicine in the countries of origin.http://www.medimmigrant.beBelgian organizations also carry out significantadvocacy work. They witness barriers in accessinghealth care and make frequent recommendations tothe government in relation to the procedure to grant“urgent medical care” in Belgium.


28 PICUMaccess to health care for most people and, exceptfor some cases in certain parts of the country, theabsence of waiting lists for treatment. In recentyears, a number of reforms have transformed itsoriginal characteristics by increasing parliament’srole, replacing employees’ wage-based contributionswith a contribution (tax) based on total incomeand basing universal coverage on residence ratherthan on employment. 50HEALTH CARE FOR UNDOCUMENTEDMIGRANTS1. Legal Entitlements to Access Fully orPartially Publicly Subsidized Health CareFree access to health care for the poorest groupsof society irrespective of administrative status wasguaranteed in France until 1999, when the UniversalHealth Coverage Act (CMU) removed entitlementsfor those without regular residence. 51A new parallel administrative system created specificallyfor undocumented migrants was however putin place. The system, called “State Medical Assistance”(Aide Médicale de l’Etat - AME), allows undocumentedmigrants and their dependants to accesspublicly subsidized health care upon compliance ofcertain conditions.The AME entitles undocumented migrants who havebeen residing in France for more than three monthsand are below a certain economic threshold (576.13EUR for one-person households in 2007) to access allkinds of health care free of charge (including abortion).However, there are limitations to the amountscovered on the official reimbursement scheme,preventing access to dental prosthesis and correctivelenses for example impossible. 52 Undocumentedmigrants do not have to make co-payments althoughthere has been an attempt by the French Parliamentto reduce AME coverage from 100% to 75% . 53For undocumented migrants who do not comply withthese conditions, only emergency care is covered bythe state with the exception of children who are entitledto access all kind of health care free of chargeregardless of their eligibility for AME.According to the applicable legislation, “emergencycare” (soins d’urgence) means not only care in lifethreateningsituations but also treatment of contagiousdiseases (necessary to eliminate a risk forpublic health), all types of health care for children,maternity care and abortion for medical reasons.The treatment of chronic diseases is excluded. 54In addition, all undocumented migrants also haveaccess to public centers providing screening ofsexually transmitted diseases and HIV/AIDS, family50Große-Tebbe S. and Figueras J., (2004:21-23). Available online at http://www.euro.who.int/document/e85400.pdf andSandier S., Paris V. and Polton D., Health care systems in transition – France 2004. Available online at:http://www.euro.who.int/document/e83126.pdf51Article 3 of the Universal Health Coverage Act (Loi n°99-641 du 27 juillet 1999. Loi portant la création d’une couverturemaladie universelle, Journal Officiel de la République Française of 28 juillet 1999).52For full details of the AME see COMÈDE, Migrants/etrangers en situation precaire: Prise en charge medico-psychosociale,(Paris : Comède, 2005), p. 211-216.53Article 31-1 of the Loi n° 2002-1576 of 30 December 2002, Journal Officiel de la République Française of 31 December2002, p. 22070. The AME reform requires its beneficiaries to pay the ‘forfait hospitalier’ in case of hospitalisation and the‘ticket modérateur’ for out-patient consultation. The reform is however not in place yet since the implementing regulation(décret) has not yet been published due largely to great opposition by NGOs, health care providers, trade unions andacademics. For more information, see Da Lomba S., “Fundamental social rights for irregular migrants: the right to healthcare in France and England”, in Bogusz B., Cholewinski R., Cygan A. and Szyszczak E., (eds.) Irregular Migration andHuman Rights: Theoretical, European and International Perspectives, (Leiden: Martinus Nijhoff Publishers, 2004), pp. 370-371. Concerning the general legal framework, see Act No 92-722 of 22 July 1992 as amended, which created a right to theAME and Article L251-1 of the Code of Social Action and Families (Code de l’Action Sociale et des Familles).54See Articles L 254-1 and L254-2 of the Code of Social Action and Families; See also Circulaire DHOS/DSS/DGAS n°141du 16 mars 2005 relative à la prise en charge des soins urgents délivrés à des étrangers résidant en France de manièreirrégulière et non bénéficiaires de l’Aide médicale de l’Etat.


Access to Health Care for Undocumented Migrants in Europe 29planning, vaccinations and screening and treatmentof tuberculosis. None of these centers require anykind of identification to provide services. 55Undocumented migrants who have been living inFrance for at least three years are also eligible for“home medical assistance” (assistance médicale àdomicile). This allows them to consult general practitionersfree of charge. Nonetheless, this right isundermined by difficulties in supplying evidence of athree-year continuous residence in France. 56Finally, it is important to mention the specific situationof migrants who lost their status of documentedresidency. If, during the period of regularstay in France, they were affiliated to social securityunder the compulsory scheme, they have the rightto keep their health insurance for four more years.The complementary CMU will be enjoyed during thefirst year of irregular stay and the AME will be thecomplementary scheme applying for the remainingyears. 572. The Procedure and the Financing of theSystemUndocumented migrants can obtain the AME beforethey get ill, therefore they do not need a medicalcertificate to get the AME.To this aim, they have to fill in an official form andsubmit it to one of the entities established underlaw (most commonly the centers de sécurité socialede quartier - CSS but also hospitals and someNGOs). 58 The files are then transmitted to the publicbody which holds responsibility for managing theAME at departmental level: the Caisses primairesd’assurance maladie des travailleurs salariés. 59There are several requirements that they have tocomply with in order to get the AME. They mustprovide:a) an identification document of the applicants andtheir dependents such as passport, ID card, birthcertificate, expired resident permits, etc; 60b) an address; if they do not have any, they have toprovide the address of an approved public institutionor organization;55CIDAG (Center d’Information et de Dépistage Anonyme Gratuit), IST (Infections Sexuellement Transmissibles), Centersde Vaccination, PMI (Protection Maternelle et Enfantile), CDO (Consultations Dépistage et Orientations), CLAT (centers delutte anti-tuberculeuse). For more information see COMÈDE, La guide de Comède 2006, (Paris 2006). Available at http://www.comede.org.56See Article 38-I(4) of Loi Pasqua of 1993 (Loi n° 93-1027 of 24 August 1993 relative à la maîtrise de l’immigration etaux conditions d’entrée et de séjour des étrangers en France, Journal Officiel de la République Française of 29 August1993 and Article L 111-2 of Code of Social Action and Families; See also Da Lomba S., “Fundamental social rights forirregular migrants’’ , p. 369 ; See also Fassin D.,, Carde E.,, Ferré N., and Musso-Dimitrijevic S., Un traitement inégal. Lesdiscriminations dans l’accès aux soins, p. 58.57Groupe d’Information et de Soutien des Immigrés Accès à l’Espace Privé (GISTI), Sans-papiers mais pas sans droits. June2006. Available online at: http://www.gisti.org/doc/publications/2006/sans-papiers/index.html58See Article L252-1 of Code of Social Action and Families.59According to the law, the decisions are made by the government representative in the department, who can delegate thispower to the director of the caisse primaire d’assurance maladie des travailleurs salariés. See Article L252-3 of the Codeof Social Action and Families.60For details, see Article 4(1) of the Décret n° 2005-860 of 28 July 2005 relative aux modalités d’admission des demandesd’aide médicale de l’Etat and Article 2(2) of Circulaire DGAS/DSS/DHOS/2005/407 of 27 September 2005 relative à l’aidemédicale de l’Etat.


30 PICUMc) evidence that they have been residing in Francefor more than three months showing documentssuch as expired visas, asylum rejection notifications,hotel bills, school registrations, electricitybills, gas bills, telephone bills in the name ofthe applicant or of the host. It is also possibleto submit a document signed by a health careprovider or by a knowledgeable organization; 61d)information and identification of their dependants;e) information about their economic resourcesduring the previous twelve months to prove thatthey are under the economic threshold set by thelaw on the basis of the number of persons in thehousehold (598.23 EUR/month for a one-personhousehold in 2007). If this is not possible forthem, the law provides the possibility of makinga sworn declaration (declaration sur l’honneur),but this is rather rare in practice.The AME is initially granted for one year but can berenewed and has to be shown every time undocumentedmigrants seek care, tests or medicine. 62Once renewed, some caisses primaires use the termAMER (Aide Médicale d’Etat Renovée).When giving medical assistance to undocumentedmigrants in possession of the AME certificate, healthcare providers have to specify in the files or bills thatthe services have been rendered to a beneficiary of theAME and that no payment has been requested. Thecost incurred for providing health services under thisscheme are finally covered by the state. 63To cover expenses incurred by hospitals for providinginpatient and outpatient emergency care toundocumented migrants not eligible for the AME,a special fund was created in 2004: the “fonds desoins d’urgence.” This fund is paid on a case by casebasis by the state to hospitals and is managed by thenational caisse nationale d’assurance maladie andthe departmental caisses primaries d’assurancemaladie. Hospitals have to prove that the patients donot have any other coverage and inform about theemergency character of the care provided. 64Access to emergency care for undocumentedmigrants is organized through the “health carecenter offices” (Permanences d’Accèes aux Soins deSanté - PASS) that are in charge of providing medicaland social support to underprivileged persons andthus facilitate their access to health care in publichospitals. Nonetheless, it is still rather difficult tofind these kinds of units in most public hospitals. 65 Inaddition, there are great differences among hospitalsas regards the existence and organization ofthis service for socially excluded patients.3.The Situation in PracticeA high percentage of undocumented migrants residingin France who are in principle entitled to AME donot receive it for various reasons.In 2005, the report of the observatory on access tohealth care of Médecins du Monde France revealedthat 93.7% of undocumented migrants assisted in61See Loi de finances rectificative pour 2003 (n° 2003-1312) of 30 December 2003; See also Article 4(2) of the Décret n° 2005-860.62Article L252-3 of the Code of Social Action and Families.63Article L253-2 of the Code of Social Action and Families and Article 44 of the Decree No. 2005-859 of 28 July 2005 on statemedical assistance (Décret n° 2005-859 du 28 juillet 2005 relatif à l’aide médicale de l’Etat, J.O. n° 175 du 29 juillet 2005, p.12353).64See Circulaire DHOS/DSS/DGAS n°141 du 16 mars 2005.65See Fight Against Exclusion Act of 29 July 1998 (Loi n° 98-657 du 2 juillet 1998 d’orientation relative à la lutte contre lesexclusions) and Circulaire DH/AF 1/DGS/SP 2/DAS/RV 3 n° 98-736 of 17 December 1998 relative à la mission de luttecontre l’exclusion sociale des établissements de santé participant au service public hospitalier et à l’accès aux soins despersonnes les plus démunies.


Access to Health Care for Undocumented Migrants in Europe 31their CASO centers (Centers d’accueil, de soinset d’orientation) throughout France in 2005 werepotentially entitled to the AME but did not have theirrights recognized. 66 In this regard, Didier Maille, ofthe organization Comède, estimates that “90% ofundocumented migrants do not have the right toAME recognized. 10% have the rights but they do notwork in practice.”As happens in other countries, there are also manydifferences of implementation and interpretationamong cities and local agencies within the same city.“In small cities, the lack of knowledge is remarkableand the law is interpreted much more restrictively.Some agents even go beyond the law,” said DidierMaille, of the organization Comède.The biggest difficulties encountered in practice byundocumented migrants come from the complexityof the system, its requirements and the lack ofawareness about undocumented migrants’ entitlementsamong different actors: health care providers,health administrations, social workers andundocumented migrants themselves.To obtain the AME, undocumented migrants haveto present a valid identification document. In manycases, this requirement constitutes an obstacle.“Before, the applicant declaration was enough. Today,sworn declarations concerning this requirement arevery rare and are only accepted when organizationslike Médecins Sans Frontières (MSF) make them.It is not the same when undocumented migrantsgo alone,” explains Samuel Hanryon of MSF. “Nowthere are also cases where agents commit abuses,for example, by sending undocumented migrantsto the consulate to ask for a passport. Sometimes,this entails big problems particularly when undocumentedmigrants do not have contacts with theconsulate or when they do not have the money to paythe fees to obtain a new passport.”Applying for the AME also requires providing anadministrative address which entails a significantbarrier for many undocumented migrants. Accordingto the above-mentioned report by Médecins duMonde, the situation is worsening every year. In 2005,the number of migrants with precarious administrativestatus in need of an administrative address wastwice higher than that of other residents. 67There are also many difficulties facing undocumentedmigrants needing to prove their residence inFrance for more than three months. Given their poorhousing conditions, it is not always easy for undocumentedmigrants to provide electricity, gas, or otherbills that are required by the regulations. Althoughsome caisses primaires expressed that they arequite flexible as regards this and other conditions,there have also been cases where health administrationswent too far imposing conditions contrary tothe applicable legislation.The organizations GISTI and Médecins du Mondehave informed that some caisses primaires wererequesting undocumented migrants to prove theirpresence in France for each of the three months ofresidence. Some applicants were unable to do so.To avoid these incidents, the national fund CaisseNationale d’Assurance Maladie reminded in 2005 thatthe caisses primaries should not request one documentfor each month that precedes the request. 6866Médecins du Monde, Rapport 2005 de l’Observatoire de l’Accès aux Soins de la Mission France de Médecins du Monde(Paris: MDM, 2006), p. 34. Available at :http://www.medecinsdumonde.org/thematiques/l_observatoire_de_l_acces_aux_soins.67Ibid., pp. 37-39.68Circulaire du ministère de la santé et de l’emploi du 27 septembre 2005. See GISTI, Sans-papiers mais pas sans droits, p.11. Available online at: http://www.gisti.org/doc/publications/2006/sans-papiers/index.html


32 PICUMSimilarly, there have been cases in which undocumentedmigrants were asked to inform about theeconomic resources of their hosts, something thatis illegal, according to the organization GISTI. 69Although there are cases of direct refusals, manydenials by public administrations are informal andtherefore hidden (refus cachés). Undocumentedmigrants arrive to the administration desk to startthe procedure for the AME. There, administratorsask them to bring further documents. Undocumentedmigrants end up leaving and public officialsdo not keep their files. In practice, since manyundocumented migrants do not come back, it is asif they had never applied for the AME. “This way ofrefusal is unwritten, thus it is very difficult to bringa claim against this decision using the complainantmechanisms provided by administrative law,”explains Samuel Hanryon of MSF.Health care professionals and pharmacies mayalso deny treatment or medicine to undocumentedmigrants. A survey conducted in 2005 by Médecinsdu Monde revealed that 37% of 725 general practitionersinterviewed in ten French cities refused toprovide health services to beneficiaries of AME. 70 Inthe opinion of the Observatoire du droit de la santé desétrangers (ODSE), “these discriminatory practicesare justified neither by the risk of late reimbursementnor by the freedom that general practitionershave to choose their patients. All doctors, generalpractitioners and specialists are bound by medicalprofessional ethics and by public health considerations.Therefore, they must always provide medicalhelp to everyone regardless of their nationality,economic situation or administrative status.” 71There are many aspects of the Aide Médical d’Etatthat are still failing and have to be solved. TheNational Human Rights Commission (Commissionnationale consultative des droits de l’homme)has acknowledged this and recommended that “itis necessary to bring to an end all the difficultiesassociated with the granting of the AME in orderto avoid the failure of the system of health protectionand prevention that would be unacceptablefrom a humanitarian as well as from an efficiencyperspective.” 72There are also problems with the mechanismscreated to facilitate access to hospitals for the mostmarginalized groups, including undocumentedmigrants who do not have the AME recognized. Asreported by the organization Comède, in most publichospitals “it is still impossible to know where thePermanence d’Accès aux Soins de Santé (PASS) islocated. It is also difficult to find a staff member ableto explain what PASS means.” 73Comède also denounces violations of the law inan attempt to avoid the risks associated with theso-called “health tourism” in which some hospitalsgive instructions to their PASS to reject foreignerswho have been living in France for less than threemonths. 7469Ibid.70Médecins du Monde (2006 :47).71ODSE, Halte aux refus de soins contre les plus démunis! L’ODSE saisit la HALDE. Available online at : http://www.actupparis.org/article2799.html72Assemblée Plénière de la Commission Nationale Consultative des Droits de l’Homme, Avis sur la préservation de la santé,l’accès aux soins et les droits de l’homme. January 2006, p.4. Available online at:http://acatparis5.free.fr/telechargement/CNCDHsante.pdf73COMÈDE, ‘Acces aux Soins, Acces aux droits’, (Paris : Comède, 2006), p.175.74Ibid.


Access to Health Care for Undocumented Migrants in Europe 33The PASS was created precisely to facilitate allpeople experiencing social exclusion to accessmainstream hospitals and health care since partof its mission is to accompany these patients andhelp them to achieve the full exercise of their rights.Nonetheless, the public services still has a limitedimpact.4.The Role of Civil Society and Local ActorsAlthough the law seems to be rather extensive, it hasbeen shown that there are still failures in the system.This fact explains why organizations working withundocumented migrants feel obliged to intervene tomake the system work.Practice shows that in most cases the interventionof organizations helps to solve problems arisingduring the administrative process. By making telephonecalls to social security centers or to caissesprimaires, NGOs manage to overcome many of theproblems faced by undocumented migrants whentrying to go through the necessary procedure to getthe AME. As explained by the Paris-based organizationComède, “without such help it is most of thetime impossible for applicants to tackle the obstaclesencountered.”Since 1979, the organization Comède (Comitémédicale pour les exilés) has provided medical,social and psychological assistance to asylumseekers and migrants with precarious status.Comède consists of 35 professionals includingdoctors, nurses, physiotherapists and socialworkers. It is assisted by a group of interpretersand also works in cooperation with manyother health care providers, hospitals and publichealth centers. Among its main activities are:i)prevention and health education;ii) help to access the CMU or AME;iii) provision of health care, including psychologicalassistance and medicine free of charge;iv) legal advice and protection against removalon medical grounds;v)information and training for individuals,professionals, activists and NGOs.In the past 27 years, Comède has providedassistance to 85,000 patients of 130 nationalities,including refugees, asylum seekers, unaccompaniedminors and migrants with precariousadministrative status.http://www.comede.orgMany undocumented migrants face serious marginalizationas regards access to health care. Dueto isolation or language barriers, they are oftenunaware of their rights and only try to obtain theAME when they are severely ill. Given this lack ofinformation, many are reluctant to use hospitalservices because they think that they will not ableto afford medical costs. In addition, they often areafraid to approach any kind of public administrationsince they confuse the different level of administrationsand wrongly believe that the police have a linkwith them.


Access to Health Care for Undocumented Migrants in Europe 35Many organizations active in the field of access tohealth care in France belong to the OSDE - Observatoiredu droit à la santé des étrangers (Observatoryon Foreigners’ Right to Health Care), a groupof organizations aiming at denouncing the obstaclesfaced by foreigners when they try to access healthcare or to obtain a residence permit for medicalreasons.OSDE demands equal treatment for nationals andforeigners in regular or irregular status in the fieldof health. In their opinion, this implies the provisionof real universal health coverage and the effectiveimplementation of the right to stay for foreignerswho are ill.The OSDE - Observatoire du droit à la santédes étrangers started in 2000 as a group oforganizations committed to advocate universalhealth care and to follow up on laws in the fieldof health insurance, AME and residence permitson medical grounds. The founding members areACT UP Paris, Aides, Arcat, Cimade, Collectifnational contre la double peine, Comède, GISTI,Médecins du Monde, Mrap and Sida info service.Other organizations have also joined (Afvs, AidesÎle de France, Catred, Creteil-Solidarité, Fasti,Ftcr, Pastt and Solidarité Sida).It is a shared opinion among organizations in Francethat with the introduction of the AME and its requirements,the system has become particularly stigmatizing.The National Commission for Human Rights(Commission Nationale Consultative des Droits del’Homme) has also acknowledged this by stating that“the requirement of so many justification documentswhich are difficult to gather goes against the spirit ofthe act aimed at challenging social exclusion.” 76These reasons are behind the strong advocacycampaign developed by numerous NGOs to changethe current system in place which makes undocumentedmigrants’ access to health care subject toa specific administrative mechanism with a highdegree of complexity.The observatory makes statements on the basisof data provided by the different organizations.http://www.odse.eu.org76Assemblée Plénière de la Commission Nationale Consultative des Droits de l’Homme, pp. 19-20. Available online at :http://acatparis5.free.fr/telechargement/CNCDHsante.pdf


36 PICUM4. GERMANYAs a result of living in an irregular administrative situation and in complete physicaland mental exhaustion, an undocumented woman collapsed on the street in Munich andhad to get treated in a psychiatric hospital. During the long therapy in the hospital,the police stopped in almost every week to ascertain if she was fit enough for deportation.While doctors tried to provide adequate treatment, the hospital administration informedthe registration office about the uncertain residence status of the woman.» Terms:Bundesländer - states of the Federal Republic ofGermanyDuldung - temporary suspension of deportationLandkreise - administrative districtsGENERAL HEALTH CARE SYSTEMHealth care for the majority of the German populationis organized via a contribution-financedobligatory health insurance system, characterizedby a separation of public and private health insurancesunique in Europe. While most people living inGermany are covered by the Statutory Health InsuranceSystem, 77 existing private health insuranceonly insures those whose income is above a certainthreshold for compulsory insurance (47,700.00 EURin 2007), as well as self-employed persons, freelancersand civil servants.For the long-term unemployed, homeless people,asylum seekers and refugees who neither havehealth insurance nor can afford it, the social welfareoffice covers the costs for health care, either bypaying (part of) their health insurance fees or bydirectly paying for medical treatment confirming themedical necessity of treatment. In 2003, 87% of theGerman population received health care throughstatutory health insurance, an additional 10% tookout private health insurance and 2% were coveredby governmental schemes. An estimated 0.3% of theregistered German population had no health insuranceof any kind. 78A fundamental facet of the German political system– and the health care system in particular – is thesharing of decision-making powers amongst thesixteen states (Bundesländer), the federal governmentand authorized civil society organizations. Inhealth care, governments traditionally delegatecompetencies to membership-based, self-regulatedorganizations of payers and providers.77Gesetzliche Krankenversicherung – GKV78The German health care system is predominantly financed by insurance fees. A recent reform introduced funds partlycontribution funded and partly tax funded, thus breaking the principle of a contribution financed system and turning evenfurther away from a system financed in equal parts by employers and employees. Also, a proceeding privatization of healthrisks can be noticed throughout the whole health care system. The reform measures, which went into effect on January2003, require patients to pay an increasing portion of their health care separately (for example co-payment for outpatientvisits) and there is a trend towards merely very basic provisions being taken over by the insurances combined with thepossibility to separately insure further provisions (e.g. dental care). Additionally, provisions have been made that allowfor greater competition in the health care system. All of these reforms have drastic consequences for the character of theGerman health care system. They lead further away from the “principle of solidarity” which is said to be at this system’sbasis. See Große-Tebbe S. and Figueras J., (2004:25-26). Available online at http://www.euro.who.int/document/e85400.pdf.


Access to Health Care for Undocumented Migrants in Europe 37Typical for the German health care system is a sharpdivision between mobile and stationary health care.Besides the mobile medical treatment (with decentralizedphysicians’, dentists’, psychologists’ etc.,surgeries) and in-patient medical treatment (athospitals) there is also the public health service,which has offices in administrative districts (Landkreise)and in bigger cities. Among their tasks arepreventative health care like medical check-ups atschools, counseling of pregnant women and mothers,some arrangements for psychiatric and social-psychiatriccare, surveillance and counseling arrangementsin the fields of hygiene, infectious diseasesand medication, and, sometimes even treatment ofsexually transmitted diseases and tuberculosis. Thepublic health service may also provide informationand carry out some vaccinations. 79HEALTH CARE FOR UNDOCUMENTEDMIGRANTS1. Legal Entitlements to Access Fully orPartially Publicly Subsidized Health CareThe Asylum Seekers Benefits Law regulates theentitlement of refugees, asylum seekers, personswho hold a residence permit for humanitarianreasons and persons with a Duldung (temporarysuspension of deportation) to state subsidies formedical care. 80 In theory, this law is also applicablefor undocumented migrants, who are considered“persons obligated to leave the country.” 81The Asylum Seekers Benefits Law reduces entitlementsto health care services compared to regularhealth insurance or provisions made by socialwelfare for German nationals and migrants notfalling under the Asylum Seekers Benefits Law. 82Uninsured persons in financial distress are obligedto go to the social welfare office before the date onwhich they wish to receive health care services inorder to be referred to a hospital, a physician oranother health service provider. This obligation isonly waived in cases of emergency.Access to the emergency system for undocumentedmigrants is provided by the Penal Code which statesthat in cases of emergency, everyone should receivehelp. 83The Law for Infectious Diseases 84 provides for anonymouscounseling and check-ups in cases concerningtuberculosis and sexually transmitted diseases,which are either organized at public health offices orin private medical centers collaborating with theseoffices. Accordingly, these services are accessiblefor undocumented migrants. In particular cases, ifdeemed necessary in order to prevent the spreading79Bundeszentrale für politische Bildung. Die wichtigsten Akteure im deutschen Gesundheitswesen. Teil 1: Staat undPolitik. Bonn: BPB, 2007; Betriebskrankenkassen (BKK) Bundesverband. Gesundheit Hand in Hand. Das deutscheGesundheitssystem – Ein Wegweiser für Migrantinnen und Migranten. 2005. Available online at:http://www.bkk.de/bkk/common/download/infomaterial/gesundheit_hand_in_hand_-_ein_wegweiser_fuer_migrantinnen_und_migranten.pdf80Asylbewerberleistungsgesetz of 5 August 1997, last modified on 31 October 2006 – AsylbLG.81§ 1 para. 1 No. 5 AsylbLG.82Sinn A., Kreienbrink A. and von Loeffelholz H. D., Illegally resident third-country nationals in Germany Policy approaches,profile and social situation, (Nürnberg: Bundesamt für Migration und Flüchtlinge, 2005), p. 56. Boundaries are set tothis reduced eligibility by medical ethics and by the German Grundgesetz (Basic Law), in which every person’s right to amaximum of human dignity and to life and physical inviolability are codified. Classen thus holds that, in fact, the extentof treatment should for those reasons equal that granted to a German national. See Classen G. Krankenhilfe nach demAsylbewerberleistungsgesetz – aktualisierte und ergänzte Version 2007. Available online athttp://www.fluechtlingsrat-berlin.de83Strafgesetzbuch of 13 November 1998, last modified on 13 April 2007 – StGB.84Gesetz zur Verhütung und Bekämpfung von Infektionskrankheiten beim Menschen of 20 July 2000, last modified on 31October 2006 – IfSG.


38 PICUMof sexually transmitted diseases or tuberculosis,mobile treatment by a physician of the publichealth office may also be included. 85 Undocumentedmigrants with HIV/AIDS can receive free and anonymoustesting at public health offices.According to the Asylum Seekers Benefits Law,asylum seeking pregnant women have access topreventive medical check-ups, services concerningdelivery, care, etc. 86 For undocumented women,however, access to maternity care and health carefor children is only possible if they successfullyapply for a Duldung, which is usually only grantedduring the so-called “period of maternity” (from 6weeks prior to delivery to 8 weeks after delivery; 12weeks in cases of multiple or pre-term births) forthe reason that mother and child are deemed unfitfor travel during this period and can thus not bedeported.Finally, statutory accident insurance has to coverpayments in cases of accidents in the workplace oron the way to the workplace even if the employerhas never paid social security contributions andthe injured person has neither a work or residencepermit. The insurance company has the right torecover its expenses from the employer. 872. The Procedure and the Financing of theSystemIn Germany, access to publicly subsidized medicaltreatment for undocumented migrants in financialdistress is limited to very few cases. Due tothe public authorities’ obligation to report undocumentedmigrants to the Ausländerbehörde (ForeignersOffice), it is impossible for an undocumentedmigrant to gain access to public subsidies forsecondary health care. The undocumented migrantwould have to apply for such subsidies in person atthe social welfare office, which is under a duty todenounce them to the Foreigners Office.In cases of emergency, undocumented migrantscan seek health care directly at a hospital or from ageneral practitioner who is obliged by law to providemedical treatment. However, there is still a greatrisk that their whereabouts become known to theauthorities. The possibility exists for the serviceprovider to attain reimbursement for the costs ofemergency treatment from the tax-funded socialwelfare office according to the regulations of theSocial Code. 88 In order to obtain such a reimbursementthe service provider must have made sure thatthe patient is neither insured nor can he/she pay forthe treatment by his/her own financial means. 8985§19 IfSG.86§ 4 para. 2 AsylbLG.87See Classen G., p.2. Available online at: http://www.fluechtlingsrat-berlin.de and Sinn A. et al. (2005:56) Accordingto the Social Code (According to § 211 SGB VII Sozialgesetzbuch Siebtes Buch (VII) – Gesetzliche Unfallversicherung- of 7 August 1996, last modified on 20 April 2007 – SGB VII) the insurances are obliged to work together with, amongothers, the immigration authorities, so that again there is a real risk that the undocumented stay of the migrant willbecome known. Another frequent problem in cases of injuries at work places is that undocumented migrants are oftenimmediately fired if they are injured and cannot go on working, which makes it difficult for them to prove that theyreally have been working, which is a prerequisite for claiming benefits from the accident insurance. See Spieß K. DieWanderarbeitnehmerkonvention der Vereinten Nationen. Ein Instrument zur Stärkung der Rechte von Migrantinnen undMigranten in Deutschland. (Berlin: Deutsches Institut für Menschenrechte, 2007), p. 58.88Sozialgesetzbuch Zwölftes Buch (XII) - Sozialhilfe - of 27 December 2003, last modified on 20 April 2007 – SGB XII.“Complicated administration procedures and the reluctance of the social welfare centers to cover these costs make thisinquiry very time consuming and of an uncertain outcome. Furthermore, not every hospital administration seems to knowabout this possibility” quoted from PICUM (2001:41). Available online at:http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdf89§§ 4 and 6 AsylbLG.


Access to Health Care for Undocumented Migrants in Europe 39Once the social welfare office has been notified, itis obliged to establish the residence status of thepatient and, in case of irregularities, is held by lawto inform the Foreigners Office which will begin theprocedures for the individual to receive an order fordeportation. 90For any medical treatment other than emergencytreatment, including HIV treatment or pre- andpostnatal care, undocumented migrants have tosuccessfully apply for a Duldung (temporary residencepermit) in order to be eligible for publicsubsidies from the social welfare office. Both do noteliminate the possibility of deportation but temporarilysuspend it. 913.The Situation in PracticeAlthough access to limited medical provisions isguaranteed for undocumented migrants accordingto the Asylum Seekers Benefits Law, the existenceof both legal and practical obstacles renders theexercise of these rights impossible without riskingdeportation. The two major legal barriers in Germanyare the “duty to denounce” 92 and the “penalization ofassistance.” 93a) Duty to DenounceAccording to German legislation, “any public institutionimmediately has to inform the Foreigners Officeif it gains knowledge of the stay of a foreigner whodoes not possess the necessary residence permitand whose deportation has not been suspended.” 94If they neglect to report to the Foreigners Office ontheir own initiative they risk penalization.Consequently, although undocumented migrantsare not exempt from applying for benefits at thesocial welfare office, this entity (like all other publicinstitutions) has the duty to denounce them to theForeigners Office, which will immediately try andend the undocumented migrant’s stay in Germany. 95It is uncertain what the expression “to gain knowledge”of undocumented stay in Germany actuallymeans in this context. The German Ministry of theInterior has recently tried to clarify the situation.It states that there is a differentiation to be madebetween knowledge gained “within the scope of theinstitution’s duty” and information acquired “at theopportunity of carrying out its duty.” 96 The duty todenounce would only apply in the first case. However,with no legal definition of these terms, there can onlybe “relative legal certainty” for everyone involved. 9790See Classen, p. 6. Available online at: http://www.fluechtlingsrat-berlin.de91Flüchtlingsrat Thüringen. Guidebook for Refugees in Thuringia, pp.10. Available online at:http://www.tguv.de/fluechtlingsrat-thr.de/infoheft/Ratgeber_englisch-web.pdf92§ 87 para. 2 AufenthG.93§ 96 AufenthG. See PICUM, (2002: 43-45)94§ 87 para. 2 No. 2 AufenthG.95Classen G., “Sozialleistungen für MigrantInnen und Flüchtlinge. Grundlagen für die Praxis”, in Zeitschrift fürFlüchtlingspolitik in Niedersachsen. Hildesheim: Sonderheft 106/107 2005, p. 67 and Groß J., Möglichkeiten und Grenzender medizinischen Versorgung von Patienten und Patientinnen ohne legalen Aufenthaltsstatus, (2005b), pp.9. Availableonline at:http://www.medibuero.de/attachment/39b520617b75d0e45fa5eb4f5da202aa/e98aee3b56b36b349988096301dc1c23/Faltblatt.pdf96“Kenntniserlangung im Rahmen der Aufgabenerfüllung” resp. “Kenntniserlangung bei Gelegenheit derAufgabenerfüllung”. See Bundesministerium des Inneren. Illegal aufhältige Migranten in Deutschland - Datenlage,Rechtslage, Handlungsoptionen. (Berlin: Bundesminmisterium, 2007), pp.38. Available online at:http://www.emhosting.de/kunden/fluechtlingsrat-nrw.de/system/upload/download_1232.pdf97According to Groß, institutions “gain knowledge within the scope of their duties” of a fact if this fact is vital to theaccomplishment of their tasks. See Groß J., Medizinische Versorgung von Menschen ohne legalen Aufenthaltsstatus,(Berlin, 2005a), Available online at:http://gesundheitspolitik.verdi.de/gesundheit_von_az/migration/medizinische_versorgung_von_menschen_ohne_legalen_aufenthaltsstatus


40 PICUMDoctors and nurses are bound by the medical codeand professional secrecy and are thus not obligedto denounce undocumented migrants, a fact that theGerman Medical Association has repeatedly asserted.98 Matters are less clear, however, in cases involvingpublic hospitals, where it is disputed if thesehospitals are bound by legal regulations, concerningprotection of patients’ personal data or if they,just like any other public institution, must submitrelevant data to the Foreigners Office. 99If a hospital seeks reimbursement for emergencytreatment from the social welfare offices and wantingto make credible its specifications, it may wish toalso include the residence status of the patient inquestion. In such cases, the social welfare officein turn has the obligation to inform the ForeignersOffice. In practice, this process mostly occurs aftertreatment has been completed. 100Sometimes hospital administrations wish to avoidcosts, leading to the denunciation of undocumentedmigrants to the Foreigners Office. Some hospitals donot hesitate to call the police at the point of admissionin order to clarify a patient’s residence andinsurance status before they commence treatment.In many such cases, the threat of being deportedafter treatment is very real, often resulting in situationsin which hospitalized undocumented migrantsdischarge themselves from hospitals before thetreatment is completed. 101These legal and practical obstacles reduce theentitlement of undocumented migrants to very fewcases, and undocumented migrants may receivehealth care if their deportation is not feasible oris legally impermissible 102 or if a severe acute orchronic illness deems necessary an undeniablemedical treatment, which leads to the certifying ofan inaptness to travel by a physician. 103b) Penalization of AssistanceAnother legal hindrance opposing undocumentedmigrants’ right to access health care is the penalizationof assistance. The Residence Act stipulatesthat anyone who assists undocumented migrantswill be penalized if acting for financial gain, if theydo it repeatedly or for the benefit of several foreigners.104 People providing assistance to undocumentedmigrants may be sentenced to a fine or imprisonedfor up to five years if they entice or assist undocumentedmigrants to irregularly stay or overstay. 10598Since 1995 the German Association of Doctors (Deutscher Ärztetag) has taken a firm stand against the Asylum SeekersBenefits Law and confirmed that doctors have the obligation to treat people independently of their residence status.See Deutscher Ärztetag. “Medizinische Behandlung von Menschen in Armut ohne legalen Aufenthaltsstatus“ inBeschlussprotokoll des 108. Deutschen Ärztetages vom 03.-06. Mai 2005 in Berlin. Available online at:http://www.bundesaerztekammer.de/page.asp?his=0.2.20.1827.1832.1909.191399Classen G., Available online at http://www.fluechtlingsrat-berlin.de and Spieß K., (2007: 59)For legal expert Rolf Fodor it is clear that the residence status of a person is irrelevant for the completion of the maintask of a public hospital that is to provide medical assistance. Therefore, “hospitals are not obliged to ask for informationabout the residence status of their patients and accordingly they are not subject to the Duty to Denounce”. See Fodor R.,“Rechtsgutachten zum Problemkomplex des Aufenthalts von ausländischen Staatsangehörigen ohne Aufenthaltsrechtund ohne Duldung in Deutschland”, in Alt J. and Fodor R., Rechtlos - Menschen ohne Papiere, (Karlsruhe: LoeperLiteraturverlag, 2001), pp. 175. See also Anderson P., “Dass sie uns nicht vergessen…”, Menschen in der Illegalität inMünchen: Eine empirische Studie im Auftrag der Landeshauptstadt, (München: Landeshauptstadt, 2003), pp. 37-38.Available online at: http://www.gruene-muenchen-stadtrat.de/seiten/pdfs/studie_illegalitaet.pdf100Spieß K.,(2007:59)101See PICUM (2001:40). Available online at: http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdf102This occurs when the country of origin refuses to take back a migrant, there are no transport links, a stop of deportationhas been issued for a particular country, maternity protection, etc.103Classen G., p. 1. Available online at: http://www.fluechtlingsrat-berlin.de104§ 96 AufenthG.105Ibid.


Access to Health Care for Undocumented Migrants in Europe 41After years of uncertainty, the German Ministry ofthe Interior has now explicitly exempted medical(emergency) aid from the forms of assistance toundocumented migrants that are punishable underthe Residence Law. 106Even though there have been no examples of penalizationof medical assistance, the mere existenceof the penalization of assistance under the ResidenceAct has caused unrest among humanitarianorganizations, health care providers and otheradvocates of undocumented migrants’ rights inGermany. For instance, several persons working incenters for refugees and migrants in Munich and inBerlin declared that staff are obliged to take homeall folders containing confidential data of undocumentedmigrants on a daily basis in order to keepthis data safe.It is very difficult for undocumented migrants toaccess health care at hospitals even in cases ofemergency. If a person does not show an insurancecard, hospital administrations usually try tofind a substitute person or institution to bear themedical expenses, often before they begin treatment.Hospitals may retain personal documentssuch as passports in order to guarantee payment.Also, some physicians and hospitals admit thatthey had decrease their standards of treatment incases where insurance status could not be clarifiedin advance, for example by treating a fracture witha plaster dressing rather than fixing the fracturedbone surgically. 107Planned surgeries or treatment of chronic diseasesare generally not available for undocumentedmigrants since they are very expensive. 108 Still,in cases where emergency treatment is directlyfollowed by an operation or long-term hospitalization,the patients may receive very high bills, such asin the following case:A 30-year-old undocumented Latin Americanman came to the emergency unit of a hospitalin Berlin, suffering from severe stomachpain. The physician diagnosed a perforatedstomach ulcer, which had to be operatedurgently. As it was an emergency situation,his family had signed documents to agree topay the costs. Some days later they receiveda bill of about 10,000 Euros. 109For secondary health care, most undocumentedmigrants visit general practitioners, specialists anddentists and pay them in cash or use another person’shealth insurance card. In the opinion of Médecins duMonde Germany (Ärzte der Welt), undocumentedmigrants can realistically receive medical care onlyfrom doctors willing to forego payment of fees andagreeing not to report them. Still, there are limits tomedical care, even if some physicians are willing toprovide medical treatment free of charge. Problemsarise particularly when laboratory diagnoses, X-rayexaminations or further consultations of specialistsare needed.106See Bundesministerium des Innern, pp. 43. Available online at: http://www.emhosting.de/kunden/fluechtlingsrat-nrw.de/system/upload/download_1232.pdf107See PICUM, (2001:40). Available online at: http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdf108There are however few exceptions of hospitals that have created social funds or special agreements for undocumentedmigrants. Ibid., p.41.109Ibid., p.40. Available online at: http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdf


42 PICUMThe fear of being discovered and deported alsoprevents undocumented migrants with tuberculosisor other serious contagious diseases to seektreatment in public health offices. Undocumentedmigrants with HIV/AIDS are only eligible for freetreatment if they successfully apply for a temporaryresidence permit. 110 If not, they are faced with exorbitantcosts that, according to Antje Sanogo, GeneralCounsellor specialised in migration at Aids-Hilfe inMunich, can amount to up to 1,300.00 Euros/month.In 1984 Münchner Aids-Hilfe e.V. (Munich Helpfor Aids) became the first regional HIV/AIDShelp-centre founded as a non-profit association.Over time it developed a comprehensive infrastructurecomprised of voluntary and paid work.Today almost 100 voluntary workers and 60 paidpersonnel offer assistance, ranging from informationand counseling to care and questions ofhousing and employment.According to their principles they offer help toeveryone who turns to them for help. The organizationseeks to provide individual help to peoplewith HIV/AIDS, gay men, drug users, women andmigrants, while also concentrating on structuralissues and challenging the social framework.http://www.muenchner-aidshilfe.deIn addition to the risk of deportation once the temporaryresidence permit has expired, another problemis that undocumented migrants who are not in need ofimmediate treatment have very little chance of receivinga temporary residence permit. Antje Sanogo andPeter Wiessner of Aids-Hilfe in Munich have statedthat “the situation of undocumented migrants withHIV/AIDS thus poses an ethical dilemma for doctors:On the one hand treatment should be started as lateas possible since there are only a certain amount ofefficient drugs to protract the course of disease. Buton the other hand the early start of treatment andtherewith the possibility of receiving a temporaryresidence permit can constitute a measure againstthe deportation of undocumented migrants with HIV/AIDS.”For undocumented pregnant women, the situation isextremely sensitive as well. They have the right toapply for a Duldung and therefore to receive pre- andpostnatal care, however this temporary limitation ofa Duldung entails that both mothers and childrenlose their status at the end of the legally protectedmaternity and since the authorities are informedabout their names and addresses, they run a seriousrisk of deportation. 111Moreover, the newborn child will only receive a birthcertificate if the mother holds a valid residence permitor a Duldung. If a pregnant woman does not apply for aDuldung and delivers her child at home or as a privatepatient in a hospital, the child will be born into “illegality”as it is impossible to get a birth certificate for achild whose mother is unregistered. However, withouta birth certificate, the mother cannot prove parenthoodand it is possible that the child is taken awayfrom her, for example in the deportation process. 112110A temporary residence permit for HIV/AIDS is granted if treatment cannot be obtained in the undocumented migrant’scountry of origin. In some rare cases, when additional conditions apply, undocumented migrants with HIV/AIDS mayreceive temporary residence permits even if treatment could be provided in the country they would be deported to. Suchconditions may include the developing of a second severe illness like hepatitis, which needs to be treated, the developingof diabetes as an adverse reaction to the medication given for HIV/AIDS, or a resistance to certain drugs. Telephoneinterview with Antje Sanago of Münchner Aids-Hilfe (Munich Aids-Aid) on 25 May 2007 on HIV/Aids and residence permitsin Germany.111See Anderson, P., (2003: 67) and Braun T., Brzank P. and Würflinger W. “Gesundheitsversorgung illegalisierterMigrantinnen und Migranten - ein europäischer Vergleich“, in Borde T. and David M. (eds.) Gut versorgt? Migrantinnenund Migranten im Gesundheits- und Sozialwesen, (Frankfurt am Main: Mabuse Verlag, 2003), pp. 119-141.112See PICUM (2001: 49). Available online at: http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdf


Access to Health Care for Undocumented Migrants in Europe 43The choices available to undocumented pregnantwomen are very limited: they go back to their countriesof origin to have the baby there, get an abortion,give birth at home, find a midwife or a hospitalwilling to help or else opt for an “anonymous birth”in certain hospitals which may entail the obligationto give their newborn babies up for adoption. 113In some cities, special arrangements exist betweenorganizations and hospitals that allow for pregnantwomen to give birth without having a Duldung.One example can be found in Berlin. The Büro fürmedizinische Flüchtlingshilfe as well as the MalteserMigranten Medizin have an agreement withthe DRK Klinik Westend, a private hospital of theGerman Red Cross. Both organizations refer undocumentedmigrants to this hospital for maternal careor delivery. The organization referring the patientpays a major part of the costs for care (including apreparatory visit with the doctor) and delivery (345EUR per delivery). This cost does not however coverthe hospital’s total expenses (costs for a normalbirth are at least 800.00 EUR; for a Caesarean theyamount to approximately 1,500.00 EUR), especially incases when complications arise. The remaining costamounts to a financial loss for the hospital’s gynecologicaldepartment. If the treatment is very expensive,social workers at the hospital try to convincepregnant women to apply for a Duldung. On average,two undocumented pregnant women are taken careof each month.The Malteser Migranten Medizin (MMM - MalteserMedicine for Migrants) is a project of the CatholicMalteser organization that offers medicalcounseling and treatment to undocumentedmigrants and other people without health insurance.The MMM provides primary medical checkups,emergency health care and pre-natal carefor women without health insurance during theirpregnancy and provides the possibility of givingbirth in hospital. The main medical reasons forwhich people seek help at the MMM are pregnancies,accident-related problems, acute dentalproblems, tumors and infectious diseases. Apartfrom the first contact point of MMM in Berlin,which was opened in 2001, new medical centershave been established in Munich, Darmstadt andCologne. Further contact points are planned forFrankfurt, Hamburg, Hanover and Stuttgart.Malteser Migranten Medizin has received twoawards from the German federal government.The Botschafter der Toleranz 2004 (Ambassadorof Tolerance) award by the Federal Ministersof Justice and of the Interior was offered tothe whole organization, while the Federal Orderof Merit bestowed by the German PresidentHorst Köhler went to Dr. Adelheid Franz, directorof MMM Berlin, in 2006. The physician Dr.Herbert Breker, head of MMM Cologne, receivedthe Honorary Post-Award of the state of NorthRhine-Westphalia in 2006.http://www.malteser-migranten-medizin.deThe extremely restrictive legal framework and all ofthe existing risks compel ill undocumented migrantsto seek alternative, informal routes for treatment.Self-medication and consulting community networksseem to be the first steps undocumented migrantstake when getting ill. Only if these strategies fail,113See Anderson P., (2003: 67). Available online at:http://www.gruene-muenchen-stadtrat.de/seiten/pdfs/studie_illegalitaet.pdf


44 PICUMwill undocumented migrants consider looking foradditional professional help, sometimes borrowingthe health insurance card of a family member or afriend.The delay in seeking professional help often occursat the expense of the patient’s health, and in casesinvolving infectious diseases placing others at risk. Inaddition, the costs incurred from delayed treatmentare usually considerably higher than if treatmentwas given immediately. Nevertheless, alternativeroutes often constitute the only feasible possibilitiesfor ill undocumented migrants, as actively seekingmedical help always carries the risk of discoveryand deportation. 1144.The Role of Civil Society and Local ActorsUndocumented migrants unable to access anotherperson’s health card and who are not in touch withmedical professionals offering treatment free ofcharge often rely on assistance provided by aidorganizations. 115In recent years, the number of such solidarity initiativestowards undocumented migrants has grownsignificantly. Most seek to provide direct medicalassistance and medication to undocumentedmigrants, to pay treatments and to refer them todoctors and hospitals that are prepared to treatundocumented migrants.Organizations such as Büro für medizinischeFlüchtlingshilfe, Malteser Migranten Medizin andCafé 104 constitute good examples of these initiativesfor undocumented migrants in the field ofhealth care. Their contribution is remarkablealthough they certainly cannot compensate undocumentedmigrants’ lack of access to the public healthcare system. Because of their restricted resources,the capacities of non-governmental networksand individual health care providers reach theirlimits before long, particularly if cost-intensive orin-patient treatment is required.Café 104 is a non-governmental organization thatwas founded in Munich in 1998 by people who hadpreviously worked on asylum related issues on aprofessional or voluntary basis and who felt thegrowing need to address the issue of health carefor undocumented migrants. The organizationoffers medical advice and legal support to thosewithout access to the public health care systembecause of their irregular residence status. Itcollaborates with a network of volunteer doctorsand nurses who provide medical treatment forfree. All staff members work without pay andindependently from governmental institutions. In2002, “Café 104” was offered the “Lichterkette”(Chain of Light) anti-racism award.Since July 2006, “Café 104”, in cooperation withÄrzte der Welt (Médecins du Monde Germany),has offered direct health care for people withouthealth insurance in Munich twice a week. Thisrecent cooperation provides the opportunity tocombine direct medical treatments with socialand legal counseling. An emergency telephoneline assures daily accessibility.http://www.cafe104.de/114Scott P., “Undocumented Migrants in Germany and Britain: The Human ‘Rights’ and ‘Wrongs’ regarding Access to HealthCare”, in Electronic Journal of Sociology, 2004. Available online at:http://www.sociology.org/content/2004/tier2/scott.html. Also, Alt J., (1999) and Anderson P., (2003: 34). Available onlineat: http://www.gruene-muenchen-stadtrat.de/seiten/pdfs/studie_illegalitaet.pdf.115PICUM (2001: 37). Available online at: http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdf; SinnA. et al, (2005:65); Schmitt E., (2006: 34). However, a great number of undocumented migrants are not reached by thoseorganizations, because they are mainly present in the urban centers. Additionally, many undocumented migrants lackinformation not only about their legal entitlements to access health care in the host country but also about the existenceof medical centers linked to organizations or private institutions where health care is provided free of charge.


Access to Health Care for Undocumented Migrants in Europe 45The strong resistance of the federal and stategovernments to recognize the presence of undocumentedmigrants and address their basic socialneeds is opposed to the social reality encounteredby health officials at the local level. Left to witnessthe experiences and difficulties confronting undocumentedmigrants in need of care, health professionalsface serious dilemmas when enforcing the lawand therefore at times feel obliged to break the law.There have been some institutional attempts atthe local level to explore possibilities to improvethe social situation of undocumented migrants inGermany. A good example is the initiative taken in2001 by the City Council of Munich that commissioneda study on the housing, working and health conditionsof undocumented migrants. 116 Following somerecommendations proposed by the study, the city ofMunich decided to take some steps to improve thesituation of undocumented migrants. One of themwas the establishment of a medical contact point for“uninsured people” that was opened by the MalteserMigranten Medizin in July 2006. This first initiativetaken by a municipality in Germany awoke the interestof other local departments dealing with legal,social and humanitarian aspects of undocumentedmigrants in Germany.The Gesundheitsamt Stadt Düsseldorf (DüsseldorfPublic Health Service) offers medical checkupsand social counseling for migrant womenworking in prostitution, regardless of their residencestatus. Five days a week they provide counselingand support on health related concerns(especially on HIV/AIDS and sexually transmitteddiseases) and contraception, but also onpartnership and family related problems, debts,drug addictions, human trafficking, professionalre-orientation and problems concerning theSocial Code. They offer assistance with contactingpublic authorities and institutions.They provide free contraception and checkupsfor venereal diseases and other sexuallytransmitted diseases as well as gynecologicalexaminations. 117http://www.duesseldorf.de/buergerinfo/Some other public health services offer anonymousconsultation hours making it possible for undocumentedmigrants to make use of their services.Two examples are the Düsseldorf Public HealthService and the Department of Health of the City ofFrankfurt.116The study also deals with police controls and undocumented migrants’ experiences with the authorities, the specificsituation of undocumented women and children and the dilemma faced by people who were trying to assist them. SeeAnderson P. (2003) Available online at: http://www.gruene-muenchen-stadtrat.de/seiten/pdfs/studie_illegalitaet.pdf117http://www.duesseldorf.de/frauen/download/migrantinnen.pdf


46 PICUMThe Gesundheitsamt der Stadt Frankfurt(Department of Health of the City of Frankfurt)offers anonymous medical consultation andtreatment, justifying these services due to therisk of epidemics. The City of Frankfurt hascalled for the opening of an intercultural healthservice, as the residence status of migrants inaddition to the fear of undocumented migrantsof being detected should be taken into accountwhen planning such health care services.Five days a week they offer consultation hoursto prevent the spreading of sexually transmittablediseases, mainly directed at women workingin prostitution. 118 Every Thursday there is theAfrikasprechstunde (Africa consulting hours) inwhich medical and psycho-social consultationis offered 119 and every Wednesday there is theRoma-Sprechstunde (Roma consulting hours). 120http://www.frankfurt.de/sixcms/detail.php?id=2996&_ffmpar[_id_inhalt]=102326These public and private initiatives indeed contributeto ease some of the terrible consequences thatinsufficient access to the public health care systemhas for undocumented migrants and society ingeneral. It is clear for German civil society initiativesthat a situation in which the bulk of responsibility fortackling the problems remains on their shouldersis no longer sustainable. The state must assumeresponsibility concerning public health and ensurethat undocumented migrants’ basic human rightsare protected – instead of merely giving awards torecognize the humanitarian work of organizationslike Malteser Migranten Medizin.The Büro für medizinische Flüchtlingshilfe, forinstance, goes beyond providing medical assistanceand advice to undocumented migrants and has heldseveral actions to protest against discriminationand racism as well as to raise awareness about thesituation of undocumented migrants. Also involvedin the activities of the Federal Working Group onAccess to Health Care for Undocumented Migrants,they publicly protest against discriminatory practicesof hospitals and co-organize anti-racismdemonstrations. 121118http://www.frankfurt.de/sixcms/detail.php?id=2999&_myvars(_id_listenartikel)=102351.119http://www.frankfurt.de/sixcms/media.php/738/seiten_aus_afrika_gesund.brosch.pdf.120http://www.frankfurt.de/sixcms/detail.php?id=2999&_myvars(_id_listenartikel)=177411121Büro für medizinische Flüchtlingshilfe Berlin. 10 Jahre Büro für medizinische Flüchtlingshilfe. Eine Erfolgsgeschichte?,pp.36. Available online at:http://www.medibuero.de/attachment/39b520617b75d0e45fa5eb4f5da202aa/f0763d7d937829c0768bc96fd03c1f82/MBBrosch%C3%BCreWeb.pdf


Access to Health Care for Undocumented Migrants in Europe 47The Büro für medizinische Flüchtlingshilfe(Bureau for Medical Aid for Refugees) in Berlinarranges anonymous and free medical treatmentby qualified medical personnel for peoplewithout residence status and health insurancetwice a week. The Büro is a non-governmental,self-organized project within the anti-racismmovement. All staff work on a non-fee, voluntarybasis. Additional costs for medication,X-rays examinations, glasses, etc. are coveredby donations.The Büro was founded in 1996 with the aim ofcombining practical solidarity with politicalactivism. People working in the Büro share theopinion that every human being must be allowedto choose freely where to live and work. Apartfrom providing health care for ill people, theyalso take part in various actions against thediscrimination of foreigners by national or localauthorities and legislation, as well as againstracist attitudes and actions.The Federal Working Group on Access to Health Carefor Undocumented Migrants, set up by the GermanInstitute of Human Rights 122 and the KatholischesForum Leben in der Illegalität 123 (Catholic ForumLiving in Illegality) in early 2006, have also clearlyexpressed the urgent need for political action. Theworking group is made up of experts from academia,political parties, medical practice, churches, welfareorganizations and NGOs.Stressing that the lack of medical treatment forundocumented migrants has serious consequencesboth for the health of the concerned persons andfor public health, the working group also points outthat delayed treatment often creates higher costs.Taking into account the difficulty to address theseproblems under the existing administrative, legaland political structures, they strongly recommendthe abolishment of the penalization of assistancefor humanitarian reasons and the duty to denounceas well as the creation of a specific public fund thatwould cover the costs for medical treatment forundocumented migrants. 124Apart from Berlin, Medibüros exist in Bochum,Bonn, Bremen, Freiburg, Göttingen, Halle,Hamburg, Hanover, Cologne, and Munich (Café104). All Medibüros have office hours once ortwice a week for 1-2 hours, and also have permanentphone lines and answering machines.http://www.medibuero.de122http://www.institut-fuer-menschenrechte.de123http://www.forum-illegalitaet.de124Koch U., Kranksein in der Illegalität. Statement im Rahmen der Anhörung zum Recht auf Gesundheit am 7. März 2007 imBundestagsausschuss für Menschenrechte und humanitäre Hilfe. Available online at:http://www.forumillegalitaet.de/Materialien/Ute_Koch/MenschenrechtsausschussStatement_Ko.pdf


48 PICUM5. HUNGARYEven if the Hungarian Constitution declares the right of everybody living inHungary “to the highest possible level of physical and mental health,” with theexception of stateless persons, undocumented migrants are not entitled tobenefits of the Hungarian health insurance scheme.» Terms:HIF - National Health Insurance FundGENERAL HEALTH CARE SYSTEMHungary introduced a compulsory social insurancesystem in 1990. Entitlement to health care isbased mainly on participation in the social insurancescheme (with compulsory membership) and for afew services it is based on citizenship.The National Health Insurance Fund (HIF) providesuniversal population coverage with a benefit packagethat applies throughout the country without disparities.The HIF only covers the recurrent costs of serviceswhile tax revenues are used to cover the deficitof the HIF as well as certain special services (e.g.public health) and co-payment for certain medicineand therapeutic devices for the socially disadvantaged.The owners of health care facilities, mainlylocal governments, are obliged to cover the capitalcosts of services, which usually come from generaland local taxation. 125The most applicable law is the Health Act which setsgeneral rules in the field of health care. It coversall health services providers operating and healthactivities pursued in Hungary. The Act on LocalGovernments assigns responsibility for arrangingthe provision of primary health care services to localgovernments while placing county governments incharge of providing specialist health care. 126While in principle entitlements are linked to payingcontributions, in practice coverage is universal sinceentitlement is not checked by the providers. In thecontext of health system reform, there is a tendencyto reduce access to publicly financed health careeven for Hungarians. Revision of the entitlementsto health care is currently under consideration byexpanding the scope of services to all emergencycare for which every citizen is eligible. The remaininghealth services will be provided on the basis ofparticipation in the social insurance scheme, but itwill be checked whether the patient is in fact entitledto health services. 127Finally, there is a lack of medical personnel in Hungary,especially in small villages and rural areas wherepeople are obliged to travel to see a doctor. As the RomaPress Center of Budapest informed, “many membersof the Hungarian Roma community are suffering fromthis lack of access to the health system.”125Gaal P., “Benefits and entitlements in the Hungarian health care system”, in European Journal of Health EconomicsSupplement 1, 2005, p. 37.126Hungarian Ministry of Health, Legal and operational environment of the health care system, (2004b), available at:http://www.eum.hu/index.php?akt_menu=3550.127Ibid.


Access to Health Care for Undocumented Migrants in Europe 49HEALTH CARE FOR UNDOCUMENTEDMIGRANTS1. Legal Entitlements to Access Fully orPartially Publicly Subsidized Health CareEven if the Hungarian Constitution declares theright of everybody living in Hungary “to the highestpossible level of physical and mental health,” 128 withthe exception of stateless persons, undocumentedmigrants are not entitled to benefits of the Hungarianhealth insurance scheme. 129 Therefore, they donot have access to any publicly subsidized healthcare in Hungary besides emergency care that isalways free of charge.When granting the right to emergency care, theHealth Act does not refer expressly to undocumentedmigrants but to the general term “non-citizen” byproviding that “a non-citizen in need of emergencycare within the borders of the Republic of Hungaryshall receive immediate treatment.” In addition, itstates that “a non-citizen requiring medical interventionwithin the borders of the Republic of Hungaryshall have access to the said intervention under thesame conditions as a Hungarian citizen.” 130 Since itdoes not provide any conditions on grounds of residencestatus, it may be assumed that undocumentedmigrants are covered by this provision.Therefore, costs incurred for providing emergencycare to undocumented migrants are covered by theNational Health Insurance Fund.As regards other medical services, undocumentedmigrants, as with any other person without a nationalhealth insurance identification card, must pay theconventional fees established for each category ofservices. After treatment they will receive an invoicelisting all services or treatments received with theprice applying. The billing system has been compulsorysince 2006.2. The Situation in Practice and the Role of CivilSociety and Local ActorsIn the absence of a clear-cut definition of “emergencycare”, it falls to health providers to interpretwhat constitutes an “emergency”. There are manydifferences of interpretation among hospitals. Nonetheless,as explained by Dr. Ferenc Falus, Directorof the Nyíro Gyula Kórház hospital in Budapest, “inHungary, hospital staff have the tendency to interpretthis concept quite widely, especially if the patient isan ethnic Hungarian or speaks the language.”This situation may sometimes entail that the healthcare providers report doubtful “emergency” casesto the competent authority in order to receive reimbursement.The payment usually takes place quitelate and on occasion the authority does not have thesame appraisal concerning what can be consideredan “emergency.”Very few undocumented migrants seek healthcare in Hungarian public hospitals. Most probably,undocumented migrants use their own informalnetworks and may even use health insurance cardsfrom family members or friends, making it verydifficult for hospitals to know their real administrativestatus. In opinion of Dr. Ferenc Falus of the NyíroGyula Kórház hospital, this is likely a regular occurrenceamong the Chinese community in Budapest.The situation is best explained by the fact that manyof the undocumented migrants residing in Hungaryare temporarily present in the country, which is whythey rarely seek health care in public hospitals. Thisis also the experience of private hospitals like theOLTALOM-Hospital, the only hospital in Budapestproviding access to health care to everyone free ofcharge, including undocumented migrants. The vastmajority of their patients are homeless, have notbeen accepted by public hospitals or returned frompublic hospitals to die. According to Dr. Iványi Tibor,128Section 70/D Paragraph 1 of the Hungarian Constitution (Act 20 of 1949).129Hungarian Ministry of Health, Beneficiaries of health care in Hungary with special regard on foreigners, (2004a),Available online at: http://www.eum.hu/index.php?akt_menu=3550130Act CLIV of 1997 on Health, promulgated on 23 December 1997, section 243.


50 PICUMthe hospital has been treating no more than 30 or40 uninsured persons a year and most of them wereRomanians. “They are mostly men coming for not soserious problems such as the flu and skin diseasesdue to poor living conditions. Others are directlycoming from the detention centers.”The OLTALOM-Hospital is the only hospital providingdirect medical assistance to uninsured peoplein Budapest completely free of charge. Togetherwith the shelters, the hospital constitutes one ofthe main activities of the Oltalom Charity Society,an organization created in 1989 and linked to theMethodist Church whose main aim is to supportpeople in need. The hospital is partially financedby the National Health Insurance Office as wellas by private donations. The hospital has around70 beds and 30 staff members including nurses,social workers, psychologists, physiotherapistsand medical doctors with specialization in pediatrics,psychiatry, neurology, surgery, vascularsurgery, plastic surgery, anesthesiology, intensivetherapy, radiology, dental and oral affection,dermatology, bacteriology, pathology, publichealth and medical science.Hospital staff hope that they will soon be entirelyfinanced by the state since, as Dr. Iványi Tiborsaid, “the hospital faces major pressure giventhe fact that many homeless people are sentto us by public hospitals, in many cases, due toclear discrimination practices. Sometimes wehave to go back to our informal networks to sendour patients back to public hospitals for specificspecialized treatments. Even in those cases,sometimes patients are returned here again justto die”.Within the current global and European context, it isunlikely that the number of undocumented migrantspresent in Europe will decrease. Thinking of futurescenarios, where the presence of undocumentedmigrants in Hungary may become much moresignificant, civil society organizations have seriousdoubts about the approach of Hungarian society tothis problem. They think that Hungarians will mostlikely show great resistance to freely grant accessto the national health system. There is a big concernabout “sharing” access to social services in Hungary.This resistance has also been shown largely amongthose with the same ethnic origin since one of themain reasons that Hungarians voted against a referendumwhich proposed granting Hungarian nationalityto ethnic Hungarians was the opposition to “footthe bill” for their access to social services.Since 1995, the organization Menedék – HungarianAssociation for Migrants has operated inBudapest as a non-governmental organization.Its main mission is to represent refugees, asylumseekers and migrants’ vis-à-vis the wide societyand promote their legal, social and cultural integration.Their main activities are project-basedand include information and counseling, trainingof interpreters, awareness raising and networkbuilding. They also help undocumented migrants,mainly rejected asylum seekers.http://www.menedek.huhttp://www.oltalom.hu/


Access to Health Care for Undocumented Migrants in Europe 516. ITALY“The Chinese community is quite self-sufficient. They use their own networksto solve even medical problems. Nonetheless, we had always suspected thatsomething else was preventing Chinese from visiting our charity clinic. We decided toapproach them through a cultural mediator. After some time, our clinic started to bevisited daily by Chinese undocumented migrants. How can you explain this?By looking at their eyes one can easily realize how afraid they are. In addition, theyface enormous language and cultural barriers.”Doctor at an NGO providing health care to undocumented migrants in Rome» Terms:A.S.L. (formerly U.S.L.) - local health administrationFondo sanitario nazionale - National Health FundStato di indigenza - indigence statusSTP (Stranieri Temporaneamente Presenti) - temporarily residing foreignerGENERAL HEALTH CARE SYSTEMThe Italian National Health Service is a public systemaiming to grant universal access to a uniform levelof health care throughout the country.According to the principle of subsidiarity, the centralgovernment and the regions share responsibility forthe provision of health care. The state is responsiblefor defining the basic benefit package (LivelliEssenziali di Assistenza) and guarantying accessto health care for everyone throughout the country.The twenty regions must implement these objectivesand have the exclusive competence to regulateand organize the health care system. Local healthauthorities are responsible for the delivery of healthcare services at the local level.Universal coverage has been achieved although thereare many differences in services and expenditureamong regions. This aspect constitutes preciselyone of the remaining challenges of the Italian healthcare system.The system is financed by general taxation (direct andindirect taxes). Local health care administrations alsoreceive payment of the moderating fee - the so-called“ticket” - and the payment of other health servicesdelivered at cost. 131HEALTH CARE FOR UNDOCUMENTEDMIGRANTS1. Legal Entitlements to Access Fully orPartially Publicly Subsidized Health CareUndocumented migrants do not have the rightto register in the Italian National Health Service.However, since 1998 the state has subsided (fullyor partially) their access to the following types ofhealth care:i)ii)“urgent” and “essential” medical care (bothincluding continual treatment);preventive care;iii) care provided for public health reasonsincluding:131Große-Tebbe S. and Figueras J., (2004:41). Available online at: http://www.euro.who.int/document/e85400.pdf


52 PICUMa)b)c)prenatal and maternity care;care for children;vaccinationsd) diagnosis and treatment of infectious diseases.The treatments can be received at a districtpublic health center or at a public hospital(cure ambulatoriali et ospedaliere). 132Whilst some of these treatments are provided freeof charge to undocumented migrants who have a“STP code” (Stranieri Temporaneamente Presenti- temporary residing foreigner) and an “Indigencestatus” (stato di indigena), others are only providedupon payment of the “ticket,” a fee established bythe regions and that is paid also by nationals andregular residents.Care always provided free of charge (without the“ticket” payment) to undocumented migrants is thefollowing:i) emergency care ( cure urgenti);ii) “basic” essential care (i.e. primary care and allkinds of inpatient hospital care, including inpatienttreatment of contagious diseases such astuberculosis and chronic diseases such as HIV/AIDS); 133iii) maternity care;iv) any care for the elderly (over 64 years);134v) any care for children (under 6 years).Nevertheless, undocumented migrants have to paythe “ticket” in case they seek:i)“specialized care” (i.e. outpatient care to becarried out on the general practitioner’s request);andii) outpatient treatment of contagious and chronicdiseases, including HIV/AIDS. 135The Italian legislation provides definitions forthe terms “urgent” and “essential” medical care.“Urgent medical care” is defined as care that cannotbe deferred without endangering the patient’s life ordamaging his/her health. 136132Note, however, that the implementing regulations were only adopted some years later. See Article 35(3) of the Decree-Law No. 286 of 25 July 1998 known as the “The Single Text” regulating immigration (Decreto Legislativo n. 286, 25Luglio 1998, Testo Unico delle disposizioni concernenti la disciplina dell’immigrazione e norme sulla condizione dellostraniero, Gazzetta Ufficiale n. 191 del 18 agosto 1998 – Supplemento Ordinario n. 139): “Ai cittadini stranieri presenti sulterritorio nazionale, non in regola con le norme relative all’ingresso ed al soffiorno, sono assicurate, nei presidi pubblicied accreditati, le cure ambulatoriali ed ospedaliere urgenti o cumunque essenziali, ancorché continuative, per malattiaed infortunio e sono estesi i programmi di medicina preventiva a salvaguardia della salute individuale e collettiva. Sono,in particolare, garantiti: a) la tutela sociale della gravidanza e della maternità, a parità di trattamento con le cittadineitaliane (..); b) la tutela della salute del minore (..); c) le vaccinazioni secondo la normativa e nell’ambito di interventi dicampagne di prevenzione collettiva autorizzati dalle regioni; d) gli interventi di profilassi internazionale; e) la profilassi,la diagnosi e la cura delle malattie infettive ed eventuale bonifica dei relativi focolai”; See also Article 43 (1) and (2) ofthe Decree of the President of the Republic No. 394 of 31 August 1999, implementing the Decree-Law No. 286 (Decretodel Presidente Della Republica 31 agosto 1999, n. 394. Regolamento recante norme di attuazione del testo unico delledisposizioni concernenti la disciplina dell’immigrazione e norme sulla condizione dello straniero a norma dell’articolo1, comma 6, del decreto legislativo, 25 luglio 1998, n. 286, Gazzetta Ufficiale n. 190 del 3 novembre 1999 – SupplementoOrdinario n. 258).133HIV screening is also provided anonymously and free of charge.134For this summary and interpretation of the Italian legislation, see Panizzut D. and Olivani P. Il diritto alla salute- Come ePerché. (Siena: NIE, 2006), p. 52. See also Article 35(4) of the Single Text and Section II B of the Circular of the Ministry ofHealth No. 5 of 24 March 2000, implementing the Decree-Law No. 286 (Circolare 24 marzo 2000, n. 5 del Ministerio dellaSanità).135Ibid. For chronic and infectious pathologies defined as “exonerated pathologies”, access occurs through the outpatientspecial department and the exoneration of the ticket for the special performances in the public or operating within theNHS sanitary structures.136See Section II B of the Circular of the Ministry of Health No. 5 of 24 March 2000.


Access to Health Care for Undocumented Migrants in Europe 53The concept of “essential medical care” as definedby law is both diagnostic and therapeutic, related topathologies which are not dangerous in the immediateor short-term, but which could subsequently leadto serious damages and risks for the patient’s health(complicanze, cronicizzazioni, o aggravamenti). 137The concept of “essential care” is rather wide andincludes “essential” primary and secondary care,hospitalization and medicine that may be defined as“essential.” 138The law also establishes the principle of continuationfor “urgent” and “essential” treatments. Accordingly,undocumented migrants in need of “urgent” or“essential” treatment will receive health care untilthe moment that their whole therapeutic and rehabilitationperiod is completed. 1392. The Procedure and the Financing of theSystemTo enjoy the entitlements of accessing health careand medicine necessary for “urgent and essentialcare,” undocumented migrants must obtain theanonymous “STP code”. The document providingthis anonymous code is issued by a specific publichealth authority and is valid throughout Italy.The code is issued by a hospital administration orby the local health administration (A.S.L., formerlyU.S.L.). Undocumented migrants may receive the“STP” any time, even before they get ill. They obtainit free of charge. The code has a validity of six monthsand can be renewed.When an undocumented migrant requests the “STP”from the administration, they normally also applyfor the “Indigence status” (stato di indigenza) bydeclaring their situation of poverty and filling in anofficial form. This status does not render undocumentedmigrants exempt from paying the “ticket”when required so by law.The cost incurred for providing “urgent” or “essential”medical care to undocumented migrants iscovered by the Ministry of Interior. The hospital orthe district health center administration whereundocumented migrants have been treated informthe local heath administration (A.S.L.) which is inturn reimbursed by the Ministry of Interior. To thisaim, they provide the anonymous code correspondentto the patient (assuring non-traceability), thediagnosis, the care provided as well as the sum tobe reimbursed. 140As regards preventive care and care provided forpublic health reasons as defined by the Italian legislation,costs covered by the so-called “NationalHealth Fund” (Fondo sanitario nazionale) follow asimilar procedure. 1413.The Situation in PracticeGenerally speaking, the system of health care forundocumented migrants in Italy is viewed very positivelyby many organizations working with undocumentedmigrants because good health coverageis provided by law to these migrants. Nonetheless,many NGOs also denounce that the law is notuniformly implemented throughout Italy. Importantdifferences still exist between regions as well aswithin regional health centers and hospitals.137Ibid.138Medicines are distributed by those chemist shops that have made an agreement with the health care system.139Section II B of the Circular of the Ministry of Health No. 5 of 24 March 2000.140See Article 43(4) and (5) of the Single Text; See also section II B of the Circular No. 5 of 24 March 2000.141See Article 35(6) of the Single Text; Article 43 (3-8) of the Decree No. 394 of 31 August 1999; section II B of the CircularNo. 5 of 24 March 2000.


54 PICUMIn practice, access to health care appears less guaranteedin towns where the immigrant population orthe pressure of NGOs is relatively low. The samesituation applies to many agricultural regions in thesouth of Italy. A report by Medici Senza Frontiereabout the living and health conditions of seasonalmigrant workers in agricultural regions of southernItaly notes:“The lack of access to health care and diagnosesof these migrants is very serious.Besides their extremely precarious livingand working conditions and the lack of basicsanitary facilities (water, electricity, toilets,etc.), there are in fact no ASL’s district healthcenters in the migrants’ proximity. Consequently,they seek health care only in veryextreme emergency situations. The healthadministration must provide a solution to thisproblem, facilitating access to health care forexample by opening a center compatible withworking schedules.” 14288.6% of undocumented migrants interviewed withinthe MSF project did not have any access to healthcare although all of them had been living in Italyfrom one to three years. 143Since 1999, Medici Senza Frontiere (MSF) hasmanaged health and legal assistance projects tohelp migrants and asylum seekers in Italy.During the summer of 2003, MSF became awareof the conditions facing immigrants working withtomato crops in the area of Foggia in Puglia. MSFstarted a broader project with the aim of inquiringon the reality of migrant seasonal workersin the south of Italy and help all the people theycould. The findings have been published in areport. 144During the 2004 season (from April to December)a team seven health care providers and culturalmediators went to Calabria, Puglia, Campania,Basilicata and Sicily. They provided legal adviceas well as direct medical assistance from amobile unit. MSF managed to help and interview770 people out of an estimated 12,000 immigrantseasonal workers employed in the south of Italy,51.4% of whom were undocumented.Living and hygienic conditions were unacceptableand led to dramatic consequences for theimmigrant workers’ health conditions. Only 5.6%out of 770 people had been diagnosed as having“good health conditions.” All the others had atleast one health problem, more or less serious.50% had infectious diseases and 63.6% hadchronic diseases. MSF has also informed that theso-called “well-being laps” (time passed betweenthe arrival in Italy and the onset of illness) wasgetting shorter: 10% of the immigrants neededmedical care one month after their arrival inItaly and 39.7% showed this need within a periodvarying between one to six months.http://www.msf.it/142Médecins Sans Frontières, Il Frutti dell’ipocrisia. Storie di chi l’agricoltura la fa. Di nascosto, (Roma: Sinnos Editrice,2005b), pp. 60 and pp.143.143Ibid.144Ibid.


Access to Health Care for Undocumented Migrants in Europe 55In areas where there are not so many immigrants,many civil servants are familiar with the “STPsystem” resulting in extremely restrictive interpretationsof the terms “urgent and essential care.”An example of this has been provided by Médecinsdu Monde: “In some regions, like Lombardia, childrenhave to pay tickets because pediatricians arewrongly categorized as secondary health care. Thispractice is taking place in clear violation of Italianlegislation and of the Convention of the Rights of theChild,” explained Marco Zancheta.In the opinion of some experts, the lack of clarity ofthe concept of “essential care” could be behind all ofthese problems. In this sense, Caritas recommendsofficial clarification of the definition in order to avoidnew barriers contrary to the spirit of the law.Strict interpretations of the law do not only occurin small towns or agricultural areas; it has alsobeen observed that within individual cities, levels ofawareness and information about access to publichealth services for undocumented migrants mayvary greatly among the relevant actors.Even in cities like Rome, with a significant immigrantpopulation, authorities in charge of the STP systemcontinue establishing conditions and requestingdocuments from undocumented migrants notprovided by the law. For instance, some local healthadministrations (ASL) unlawfully ask undocumentedmigrants to present their passports or evenresidence permits to get the STP code, thus ignoringthat regular migrants have access to healthcare through the general National Health Service.Caritas has informed that in Rome there is a clinic(policlinico) that in an attempt to “avoid abuses” hasbeen requiring migrants to demonstrate that theyhave been living in Italy at least three months.The lack of knowledge is not only experienced byadministrations and providers. There is evidence thatshows that in Italy many undocumented migrantsare not aware of their rights.This lack of awareness is particularly evident incertain immigrant communities like the Chinese.Following a very pro-active approach, the “PoliambulatorioVia Marsala” clinic of Caritas Roma, whichtreats numerous undocumented migrants in thearea of the Termini train station in Rome, realizedthat although very numerous and present for asignificant number of years, there were almost noChinese migrants seeking health care at the Caritasclinic. This was particularly evident when comparedto the large number of migrants from other communitiescoming daily to the clinic. As Dr. SalvatoreGeraci of the health department of Caritas Romestated, “it is true that the Chinese community is quiteself-sufficient. They use their own networks evento solve medical problems. Nonetheless, we hadalways suspected that something else was preventingChinese from visiting our clinic. We decided toapproach them through a cultural mediator. Aftersome time, our clinic started to be visited daily byChinese undocumented migrants. How can youexplain this? By looking at their eyes one can realizehow afraid these people are. In addition, they faceenormous language and cultural barriers.” Thanksto this initiative, 589 Chinese patients visited theCaritas clinic from 2000 to 2004, of which 63% wereundocumented. 145145Geraci S., Maisano B. and Marceca M. Accesso e fruibilità dei servizi: scenari nazionali ed esperienze locali,(Unpublished, 2005), pp.6.


56 PICUMThe Area Sanitaria of Caritas Rome started in1983 with the aim of providing basic health care topeople not accessing public and free health carein Rome. Providing social and health support toimmigrants is becoming one of its main priorities.Most of its medical and administrative staffare volunteers.Health services (basic and specialised) areprovided through three clinics and a number ofcenters:a) Poliambulatorio Via Marsala di MedicinaGenerale that provides general medicine andsome specialised health care;b) Poliambulatorio Alessandro VII and thePoliambulatorio San Paolo providing alsodifferent specialised health services;c)d)The dentistry center;The pharmaceutical center.The area sanitaria also seeks to raise awarenessamong health care providers and administrationsabout marginalized people and makes recommendationsfor improving accessibility to the healthsystem. To this aim, they also have a center forstudies and documentation on health and immigrationthat publishes studies and statistics aboutimmigrants and health in Italy.http://www.caritasroma.it/settori/sanita/sanita.asp#As shown by this example, language, cultural barriersand the fear to be discovered also impedeundocumented migrants residing in Italy fromaccessing health care even at clinics run by volunteerorganizations.This fear to be denounced and expelled is also veryreal as regards women who arrive in Italy irregularlyand wish to give birth in safety. There is oftenthe mistaken assumption that, once they have madeuse of the public services, they will be made knownto the authorities and therefore deported. 146Italian legislation does not impose any duty onhealth administrations to denounce undocumentedmigrants. On the contrary, the law clearly states thatauthorities should not be informed whenever thesemigrants seek health care but only if their illnessfalls under the categories of illnesses that have tobe reported to the authorities on equal grounds withItalians. 147Another obstacle encountered by undocumentedmigrants to access health care in Italy is the paymentof the moderating fee, the “ticket”. As reported byCaritas Roma, “it is difficult for those with a precariouseconomic situation to pay the ticket since the ratesare sometimes high. This can even prevent some Italiansfrom seeking health care. The system of healthand social protection should be better adjusted to thedifferent economic situations so that it facilitates realaccess to health care, also for people who are sufferinga high degree of marginalization. 1484.The Role of Civil Society and Local ActorsAs illustrated by all these examples, the existence ofgenerous legal entitlements does not automaticallyguarantee the enjoyment of rights by undocumentedmigrants. It is necessary to improve accessibility asregards this group of socially excluded persons andto this aim more active accompanying public policiesand measures have to be adopted at local and regionallevels. The important role that NGOs continue to playin this field shows that the system is not fully addressingthe specificities of this population.146PICUM, Book of Solidarity. Providing assistance to undocumented migrants in France, Spain and Italy, Vol. 02 (Brussels:PICUM, 2003), p. 36. About the fear to be denounce see also IDOS – National Contact Point EMN (eds.), Illegally residentthird country nationals in Italy: state approaches towards them and their profile ad social situation, (Rome: EMN, 2005).147See Article 35(5) of the Single Text: “L’accesso alle strutture sanitarie da parte dello straniero non in regola con le normesul soggiorno non può comportare alcun tipo di segnalazione all’autorità, salvo i casi in cui sia obbligatorio il referto, aparità di condizioni con il cittadino italiano”.148Caritas Diocesana di Roma, Il diritto alla salute degli immigrati. Scenario nazionale e politiche locali, (Rome, July 2002), p. 20.


Access to Health Care for Undocumented Migrants in Europe 57In many cases, the intervention of NGOs helps totackle barriers encountered by undocumentedmigrants when trying to access public health services.This is particularly evident, for instance, whenundocumented migrants need specialised care.In Italy, general practitioners act as gatekeepersto secondary care. Sometimes they refuse toprovide undocumented migrants with the necessaryprescription. Many civil society organizationsusually intervene in these kinds of situations to solvethe malfunctioning of the system by directly contactinghealth care providers and administrations.Some health administrations are already aware ofthis gap between law and practice and make effortsto address these issues by publishing and disseminatinginformation guides, targeting specific groupsand building partnerships with NGOs. An example ofthis kind of cooperation scheme is a project funded bythe city of Rome and carried out jointly by the healthadministration (ASL) of the “Rome B” district withthe organization Opera Nomadi. The project’s mainpurpose is to guarantee minimum health coverageand preventive care to the Roma community residingin the referred area. To this purpose, a multidisciplinaryteam (composed by health care providers,social workers and cultural mediators) is currentlyworking with the help of a mobile unit that is presentevery day in all Roma camps providing informationand direct medical assistance.It is very common that NGOs publish guides withcontact information and brochures explaining therights and procedures to access medical assistanceand where to go to seek health care in a particulardistrict or city.Some organizations like NAGA in Milan and CaritasRoma also have clinics where they provide healthcare and diagnoses free of charge to undocumentedmigrants and other marginalized persons.These clinics do not seek to run alternative healthservices competing with the public ones but ratheraddress those specific needs and problems relatedto migrants’ health that are not always taken intoaccount by public authorities.NAGA is an organization based in the region ofLombardy giving social and health assistance toforeigners and temporary residing persons. A highpercentage of people seeking NAGA’s help areundocumented.In the region of Lombardy, civil society organizationsplay a fundamental role given the particular organizationof the system to provide access to health carefor undocumented migrants. The general legislationregarding health care for undocumented migrantsis not properly applied in this region. The publicservices only provide specialised care, diagnosisand hospital care to undocumented migrants. Toaccess this type of health care, patients must obtaina prescription from a general practitioner. For basichealth care and prescriptions for secondary care,undocumented migrants must therefore seek helpfrom one of the volunteer organizations’ clinics, forexample, one operated by NAGA which is the onlyone to provide basic health care and which they dofree of charge.NAGA provides basic health care as well as somespecialized care, including cardiology, surgery,dermatology, gynecology, orthopedics, psychiatry,psychology, ultrasound scanning and electrocardiograms.They do so, as Dr. Pierfranco Olivani of NAGAexplains, because there is not yet any evidence thatthe public health service is satisfactorily guaranteeingaccess to secondary care.NAGA opened its clinic for temporary residingforeigners with the intention that it would be a shorttermproject, capable of resolving the issues it wouldaddress. Even if the clinic does close, the organizationremains committed to vigilantly ensuring healthcare entitlements are implemented and respected.


58 PICUMNAGA, Asociazione Volontaria di AssistenzaSocio-Sanitaria e per I Diritti di Stranieri eNomadi, began its work in Milan in 1987. It countson more than 300 volunteers, most of whom aredoctors, nurses and psychologists.Its mission is to promote solidarity and providesocial and medical assistance to guaranteetemporary residing migrants’ health rights.During working days, NAGA’s medical clinicprovides general and specialised health care torefugees and temporary residing immigrants,including undocumented migrants. Most oftheir patients face a situation of serious exclusionand marginalization. Since 1987, the clinichas provided health care to more than 100,000foreigners (around 80 people per day).In recent years, NAGA’s work has been extendedto cover many other areas beyond direct medicalhelp: migrant women, refugees and victims oftorture, ethnic psychiatry, pharmacy, researchand documentation, legal advice and returnand training for intercultural mediators andvolunteers.NAGA is also very active in organizing campaignsto target public opinion vis-à-vis undocumentedmigrants’ specific health and social needs. Itswebsite provides a full range of information aboutthe legal system and useful contact addresses.http://www.naga.it/The situation in Rome seems to be very differentsince the STP system is better implemented. Nonetheless,the existence of clinics like those run byCaritas Rome show that many health care needs ofmarginalized people are still not fully met.The San Gallicano Hospital is an example of apublic hospital which has developed a very friendlyapproach towards undocumented migrants. Thehospital is known for the promotion of health andmedical services relating to migrants. Besides healthcare, it provides social and psychological assistanceto documented and undocumented migrants. Theresult has been a high reliance on this hospital fromundocumented migrants living in Rome and many ofthem seek health care there.This hospital has also accumulated a high level ofexpertise on immigrants’ health needs since it alsohas a research center for preventive medicine ofimmigration, tourism and tropical dermatology.Since its foundation by Pope Benedict XII, SanGallicano Hospital has had a long tradition in theprovision of assistance to travelers and temporaryresiding in the city of Rome.The Center for Preventive Medicine of Immigration,Tourism and Tropical Dermatology startedin 1985 and was the first public health centeroffering free medical assistance to marginalizedItalians and foreigners.By 2003, the hospital had treated about 65,000documented and undocumented migrant adultsand children coming from 120 different countries.The hospital provides basic as well as specialisedhealth care (dermatology, internal medicine, touristmedicine, gastroenterology, infectious and tropicaldiseases, podiatry, preventive oncology, gynecology,ethnic psychiatry and psychology, nutritionmedicine, hematology, neurology, infant psychiatry,surgery, etc.).The hospital counts on the presence of socialworkers and intercultural mediators to coverbasic needs and facilitate access to health care.The welcoming service assists undocumentedmigrants in nine languages: Arabic, English,French, Polish, Portuguese, Rumanian, Russian,Spanish and Turkish.The San Gallicano Hospital also organizes trainingsessions on health and migration, interculturalmediation and international medicine. Itconstitutes a centre of reference for the cityof Rome and for the different district healthadministrations.http://www.00100roma.com/it,servizi,ospedali_all,00153_5109,ospedale+san+gallicano.html


Access to Health Care for Undocumented Migrants in Europe 59Given the relatively recent implementation of regularizationin this area (2001), the help provided bycivil society has revealed itself as indispensable andled to a substantial accumulation of expertise in thefield of immigration and health.Generally speaking, organizations have been veryactive concerning analysis and research activitiesto the extent that the government invited many oftheir experts to give advice on the drafting of thelaws concerning health care for undocumentedmigrants.In addition, some doctors realized that there was aneed to regularly exchange information among thedifferent experts in the field. This was precisely theidea behind the foundation of the Società Italiana diMedicina delle Migrazioni (S.I.M.M.) (Italian Associationfor Migration Medicine). This association goesbeyond strictly scientific and epidemic issues; it isvery active at the structural level. S.I.M.M. plays acrucial role in monitoring the right to health in Italyby making sure that the law is effectively appliedand that migrants’ cultural aspects are also consideredby health authorities when organizing publicservices.The Società Italiana di Medicina delle Migrazioni(S.I.M.M.) (Italian Association for MigrationMedicine) was founded in 1990 by a group ofdoctors, many of whom were providing directvoluntary assistance to immigrant patients indifferent Italian cities. The purpose was to createa forum for regularly exchanging experiencesand knowledge.Nowadays, the association consists of about 100members including doctors, nurses, psychologists,anthropologists, sociologists, socialworkers and health-related staff. S.I.M.M. hasorganized several national and internationalconferences on health and migration.S.I.M.M. also monitors the correct implementationof the regulation of immigrants’ access tohealth care, acts at the structural level to promotethe right to health in general and to raise awarenessabout the importance of taking into accountthe aspects related to health and culture.http://www.simmweb.it/Besides national advocacy campaigns, S.I.M.M. hasalso been acting at the European level by urgingEuropean institutions to promote the right to accesshealth care for every resident in the EU, includingundocumented migrants. To this aim, they haveprepared and presented the text of a draft resolutionof the European Parliament and a draft Councildirective based on the Italian model as well as apetition to the president of the European Parliament.This initiative occurred with the support of differentItalian institutions and health administrations,scientific institutes and civil society organizations.The campaign on the non-expulsion of seriouslyill undocumented migrants has been also veryactive. 149149This campaign was promoted within the S.I.M.M. by three Italian organizations: NAGA, Area Sanitaria Caritas and OIKOS.More information is available at http://www.simmweb.it/.


60 PICUM7. NETHERLANDS“Why should I care so much about these patients? These people do not existin our country. There is no place where I can send them, whereas for those whohave a legal status and are poor, I can at least send them to social services.I cannot send undocumented migrants anywhere.”General practitioner in Amsterdam» Terms:GGD (Gemeetelijke Gezondheidsdienst) –public health serviceGENERAL HEALTH CARE SYSTEMThe Netherlands has an insurance-based healthsystem operated since 2006 by private health insurancecompanies. The new Health Insurance Act 150has, however, set some public limiting conditionsin order to guarantee that health care insurance isaffordable for all, including those on low incomes orwith high care costs.All regular residents in the Netherlands are obligedto take out health insurance covering a standardpackage of essential health care. Anyone who failsto do so will be fined. The content of the standardpackage is determined by the government andincludes practically all essential care, from a visitto the general practitioner to hospital admission, aswell as prescription charges. 151The insurers are obliged to accept everyone residingin their area of activity irrespective of age, gender orhealth status, in order to prevent discrimination onthe basis of risk.The insured person pays a fixed nominal premiumto the health insurer. The Health Insurance Act alsoprovides for an income-related contribution to bepaid by the insured and by the employer. 152 Childrenup to 18 years old pay no premium. In addition, thosewho cannot afford the full standard premium canapply for a care allowance. This amount is paid asa monthly tax credit and is financed by the governmentfrom general tax revenue.Adult insured parties will have part of their fixedpremium reimbursed if during a year they have usedless than 255 EUR in health care costs.150Zorgverzekeringswet (entered into force on 1 January 2006).151The standard package reimburses the costs of: general practitioners, specialists and hospitals; dental care forchildren until the age of 18; specialised dental care and dentures; medical appliances, such as medical stockings;medicines; maternity care and obstetrics; health care transport (ambulances, wheelchair taxis, etc.); limited access tophysiotherapy, remedial therapy, speech therapy and occupational therapy; and advice on nutrition and diet.152Employers contribute by making a compulsory payment towards the income-related insurance contribution of theiremployees.


Access to Health Care for Undocumented Migrants in Europe 61For care not included in the standard package (e.g.dental care for adults), there is the option to take outsupplementary insurance whose premium is freelydetermined by private insurers who are entitled topursue profits. 153Although the government claims that the new systemis a good balance between a solid social basis andthe dynamics of the market, it is expected to increasethe number of uninsured people in the Netherlands.There is a fear that those who cannot afford thecontributions could fall outside the system. Accordingto Doctors of the World, many people cannotafford the premium of 92 EUR per month and willnot be supported enough with the health insuranceallowance.In addition, there is also the fear that some peoplewill not take any insurance or when taking it, theywill not seek health care in order to receive the reimbursementof the no-claim. Finally, it may be pointedout that people suffering from chronic diseases orhandicaps will be confronted with a higher premium,as the standard package will not be sufficient.HEALTH CARE FOR UNDOCUMENTEDMIGRANTS1. Legal Entitlements to Access Fully orPartially Publicly Subsidized Health CareUndocumented migrants are not entitled to take outhealth insurance in the Netherlands.In 1998, with a clear intention to discourage undocumentedmigrants from establishing themselvesin the Netherlands, the Benefit Entitlement Act,or Linkage Act 154 , linked certain rights, such asthe right to state medical insurance to the conditionof authorized residence. Before that date,undocumented migrants had the right to access thepublic insurance system. The Linkage Act can beseen as the centerpiece of migration control in theNetherlands. 155However, undocumented migrants can still receive“care that is medically necessary.” In principle, theyshould always bear the costs of medical treatment.Nonetheless, if undocumented migrants cannotpay, the cost will be covered by a special fund whichdirectly reimburses the health care provider, butnever the patient.The Aliens Act (2000) embedded the principle of theLinkage Act; however, it referred to two exceptionsrelated to health care: “the provision of care that ismedically necessary” and “the prevention of situationsthat would jeopardize public health.” 156153See “The new care system in the Netherlands”, available online at: http://www.minvws.nl/en/themes/health-insurancesystem/default.asp.Before 2006, there were two types of health insurances: compulsory and voluntary. Employees,people entitled to social benefits and self-employed people with incomes up to a certain level were compulsorily insuredunder the Social Health Insurance Act (Ziekenfondswet). People with a higher income could choose to either take out aprivate health insurance or to be uninsured.154Koppelingswet 1998.155Since the introduction of the Linkage Act, the entitlement or access of immigrants to secondary or higher education,housing, rent subsidies, facilities for the disabled, health care and all social security benefits has indeed becomedependent on their residence status. Entitlement to these public services is restricted to immigrants with a regularresidence status. Only publicly funded legal assistance, necessary medical care and education for children up to the ageof 18 remain accessible to all immigrants, including undocumented migrants. See PICUM (2002:35).156Article 10 of the Alien Act of 23 November 2000 (Vremdelingswet, 2000): “An alien who is not lawfully resident maynot claim entitlement to benefits in kind, facilities and social security benefits issued by decision of an administrativeauthority”. (…) The first subsection may be derogated if the entitlement relates to education, the provision of care that ismedically necessary, the prevention of situations that would jeopardize public health or the provision of legal assistanceto the alien”.


62 PICUMThere is not a clear-cut definition of the concept of“medically necessary care.” Since the Linkage Actwas passed, discussions have taken place and therehave been several attempts to define the concept.In 1999, the Ministry of Health stated that this termconcerns research, treatment and care that areneeded according to acknowledged medical-scientificgrounds and judged by the treating doctor whohas an obligation to help anybody regardless of his orher position in society, race and belief. Care will beconsidered “necessary” in the following situations:i)in cases – or for prevention – of life threateningsituations, or in cases – or for prevention – of situationsof permanent loss of essential functions;ii) if there is a danger for a third party, e.g. certaincontagious diseases (in particular tuberculosis)and for psychological disturbances and consequentaggressive behavior;iii) in cases of pregnancy (before and during birth);iv) if related to preventive care and vaccinations forchildren.In 2005, The National Committee on Medical Aspectsof Immigration Policy 157 interpreted the conceptof “medically necessary care” as comprising careprovided in the (former) basic national health carepackage. This package encompassed practically thesame types of health services as the new standardpackage.A positive aspect of this system is that it requiresmedical professionals to determine when the provisionof care for undocumented migrants is “necessary.”This was established by the Ministry of Healthfollowing strong resistance to the Linkage Law fromorganizations representing human rights advocatesor medical physicians. 158The particular role that health care providers havebeen playing as regards the day-to-day definition ofthis concept has created a rather flexible conceptallowing undocumented migrants to access – atleast potentially - a wide range of services providedby individual health care providers and hospitals,including HIV/AIDS treatment and medicine. 159 Aspractice shows, since there are no laws expressivelymentioning it, only mental health care (unlesscausing disturbances and aggressive behavior)and rehabilitative treatments seem to be regularlydenied to undocumented migrants. 160The concept is again currently under discussionby a committee of health care professionals157This committee was set up in the Netherlands in May 2001 by the Ministry of Justice and the Ministry of Health, Welfare andSport. The committee was charged with the responsibility of investigating the influence of medical aspects upon the influxof aliens into the Netherlands. The main conclusion of this committee was that contrary to the views of the parliament andmedia, it was not true that a lot of asylum tourism to the Netherlands was taking place on medical grounds.Concerning the concept “medically necessary care”, the committee stated that “from a medical and ethical pointof view, no reasons exist for a further limitation of the concept in addition to the limitation, introduced by the healthinsurance scheme, that already applies to all (other) residents in the Netherlands, nor does there exist any reason todeviate from the practice that a doctor determines whether or not health care is necessary, based on the principle thatall patients are equal”. See National Committee for Medical Aspects of Aliens Policy, Medical aspects of Aliens Policy,(Staatscourant 11 mei 2001, nr. 91/ pag.8). An English version can be downloaded at http://www.aidsmobility.org/inc/pdf.cfm?pdf=Conclusions report Smeets-ENG1.pdf; See also AIDS & MOBILITY Europe, (2006:30-34). Available online at:http://ws5.e-vision.nl/systeem3/images/WG%20IV%20-%20You%20can%20speak.pdf158See PICUM (2001:52). Available online at: http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdf159As regards medicines, they will have to pay a contribution.160Mental health care is financed by the Exceptional Medical Expenses Act (AWBZ). The Linkage Act excludes undocumentedmigrants from these services. Most psychiatric carers refuse to treat undocumented migrants until they become areal danger to society. However, follow-up care after acute diagnosis is usually not existent. An increasing numberof undocumented migrants need treatment but are not able to receive it and it is also very difficult to place them inemergency shelters.


Access to Health Care for Undocumented Migrants in Europe 63working under the auspices of several medicalassociations. 161Finally, regarding patients with tuberculosis,the “secret code” system allows undocumentedmigrants to remain anonymous when receivinghealth care in order to prevent these individualsfrom stopping their treatment, creating a risk forpublic health. There is also the possibility to obtaina residence permit for medical reasons that allowsthem to stay during the length of the treatment. 1622. The Procedure and the Financing of theSystemWhen undocumented migrants get sick, they can godirectly to a general practitioner or to a hospital.Health care providers or hospital administrationswill request payment for the cost of treatment. If thepatient cannot pay, they will provide health care andclaim for reimbursement afterwards from the fundsset aside to cover the cost incurred for providinghealth care to uninsured persons without residencepermit.In the Netherlands, the costs resulting from providinghealth care to undocumented migrants arecovered through two different systems, dependingon whether care is provided by general practitioners,midwives, pharmacists and dentists on the onehand, or by hospitals on the other hand.The “Linkage Fund” 163 compensates general practitioners,midwives, pharmacists and dentists. Thisfund does not serve to pay the bills of patients, butrather to reimburse doctors for their earning losses.These service providers cannot declare “unpaid bills”of their patients. Applying for refunds has to be seenas applying for “subsidies.” To be reimbursed, theymust, however, fill in a standard form requestingtheir date of birth and nationality. In practice, theseprofessionals are also asked to provide the identityand evidence of the insolvency of the patient.General practitioners, midwives, pharmacists anddentists then have to prove that: i) their patient wasactually undocumented and therefore, the cost ofhealth care cannot be claimed in any other way (e.g.insurance); and ii) the financial burden on them wasexcessive. 164 Nevertheless, it is important to keepin mind that reimbursement is simply a possibility.Medical professionals do not have a recognized rightto claim a refund. 165The request is made through a form submitted tothe Gemeetelijke Gezondheidsdienst (GGD) (publichealth service) of the province concerned who will:i)examine the request – paying special attentionto the economic situation of the patient by evencontrolling bank accounts;ii) ask the Linkage Fund to reimburse a certainamount if the requirements are met; andiii) directly pay to the provider of health services.The second category of providers - hospitals, rehabilitativecenters and ambulance services - has abudget line within their own budget (0.1% of their totalannual budget) arranged with insurance companiesnamed “dubious debtors.” This is in fact the remitof the existing hospital funds, extended in order to161The Royal Dutch Medical Association (KNMG, Koninklijke Nederlandse Maatschappij tot Bevordering der Geneeskunst),the National Association of General Practitioners (LHV=Landelijke Huisartsen Vereniging), the Dutch Society of MedicalSpecialists (Orde van Medisch Specialisten) and the Netherlands Society of Psychiatry (NVvP=Nederlandse Verenigingvoor Psychiatrie).162PICUM (2001: 57). Available online at: http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdf163This fund (Koppelingsfonds) is a public institution created in 1998. In 2006, it consisted of 5.5 million EUR. It is fundedfrom tax revenue and managed by a public entity.164See PICUM (2001: 54). Available online at: http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdf165The Ministry of Health is, however, considering the possibility of reviewing the system as to recognise by law that healthcare providers have the right to get reimbursed any time they provide a health service to undocumented migrants.


64 PICUMinclude the payment of unpaid bills. These providersalso use this fund to cover expenses generated by theprovision of services to undocumented migrants.3. The Situation in Practice and the Role of CivilSociety and Local ActorsThe Dutch system is very complex and the complicatedprocedures, lack of clear definitions and lackof information among all actors involved entailsconsiderable barriers for undocumented migrantsto access health care in practice.There has been, and still is, much misunderstandingabout the meaning of “medically necessarycare.” This is particularly evident as far as healthcare providers and hospital administrations areconcerned.The absence of a clear-cut definition of this term hasallowed many health care providers to broadly interpretthe concept. This circumstance as well as pressurefrom civil society organizations has contributedto a move towards a rather flexible concept of“necessary care” in the Netherlands.Nevertheless, the uncertainty about the meaningof “medically necessary care” and reimbursementfrom the fund has also created a remarkable degreeof confusion resulting in denials to undocumentedmigrants to access health care, particularly athospitals.Given the fact that what constitutes “necessarycare” is decided upon by each individual medicalpractitioner, it is not inconceivable that in practice,serious differences of interpretation will occur,resulting in a situation in which one undocumentedmigrant receives a particular type of treatment,whilst the same treatment is denied to another.As recommended by the Advisory Committee forAliens Affairs, “this situation is undesirable. Theterm ‘medically necessary care’ requires a precisedefinition, a definition that is as consistent as possiblesince in cases where major differences exist,‘medical shopping’ could occur.” 166General practitioners (GPs) are generally accessible.However, in certain areas of big cities with arelatively high concentration of foreigners (morethan 10%), a limited percentage of GPs (5%) regularlyreceive undocumented patients in theirconsultations. There are often a few GPs who havea reputation for rendering services to undocumentedmigrants and who are overloaded withmany patients. Undocumented migrants are becomingincreasingly dependent on those few doctorswho are willing and able to provide health services.One of the reasons for this is that GPs are free toaccept or reject undocumented migrants as patientswithout any possibility of a complaint being lodged toa public institution. 167Access to hospitals is becoming more and moredifficult. Health administrations usually preventundocumented migrants from accessing healthcare if they cannot pay, particularly in cases wherethere is no clear or external evidence that their lifeis at risk when they arrive at the hospital. Accordingto a study conducted by Prof. Engbersen in thecity of Rotterdam in 1999, it is more likely that careis refused in outpatient clinics rather than in theemergency departments, where care is normallyprovided.In most of the cases where undocumented migrantshave an appointment with a health care professionalin a hospital, they are firstly transferred to the financialadministration to arrange the payment. If theyare unable to guarantee payment, access is denied.166See Advisory Committee for Aliens Affairs (ACVZ), National Aspects of Return (2005).167See PICUM (2001:55). Available online at: http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdfand NIVEL. Illegalen aan de ‘poort’ van de gezondheidszorg: Toegankelijkheid en knelpunten in de zorg van huisartsen,verloskundigen en spoedeisende hulpafdelingen. (Utrecht: NIVEL, 2000).


Access to Health Care for Undocumented Migrants in Europe 65Whilst there are hospitals accepting payment ininstallments after treatment or not actively pursuingunpaid bills, it may happen that a person who did notpay previous bills is refused further treatment. 168In addition, since the new insurance system enteredinto force, undocumented migrants are requestedto show an identification card and insurance cardat the administration desk. There are cases whereaccess to health care has been denied to undocumentedmigrants because they were unable to showan identification card or passport, and the organizationLampion has also informed of cases wherecare was refused due to the impossibility of showinga health insurance card. 169Many civil society organizations, health care providersand local authorities stress that one of the biggestproblems in the Netherlands is the existing lack ofinformation about how the system works: individualhealth care providers are not well informed abouttheir duties or how to reclaim their fees; hospitaladministrations are not given clear instructions onthe impossibility of making health care dependanton the affordability to pay; not all GGD (public healthservices) are flexible enough regarding the reimbursementof costs to doctors providing health carefor undocumented migrants.The existing confusion and aptitude of some healthcare providers, particularly hospitals, is also creatinga misconception among undocumented migrantswho, contrary to their legal entitlements, think thatthey do not have the right to seek health care theycannot pay for. This fact, together with the fear thatundocumented migrants have to be identified andsent to the police, means that they postpone or evendo not seek needed health care.Research conducted by the Netherlands Institute forResearch in Health Care at the request of the Ministryof Health in 2004 revealed that health needs ofundocumented migrants are generally more serious,i.e. life threatening, than those people consulting adoctor on a regular basis. In addition, it was shownthat undocumented migrants are most likely to postponetheir visit to the doctor. 170A concrete example illustrating this was provided bya study conducted in 2000, which revealed that manyundocumented migrant women may not seek healthcare during pregnancy. This finding was based onthe fact that half of the interviewed midwives statedthat they have, at least once in their career, beencalled to assist pregnant women during deliverywho had not received any pre-natal check-up. 171 Asimilar conclusion was reached by the organizationLampion since one third of the total number ofundocumented women as well as a relevant numberof social workers contacting its “e-help desk”service in 2006 (150 callers) were asking questionsabout pre-natal care.On many occasions, the only way undocumentedmigrants safely seek health care is through informalstrategies such as the use of insurance cards of familymembers or friends. This informal method of receivinghealth care has, however, already caused manyproblems since doctors insert medical data correspondingto the patient in the file of the card holder.168PICUM (2001:56). Available online at: http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdf169Lampion Report 2006, available at http://www.lampion.info.170The number of undocumented migrants seeking health care in serious life-threatening situations was three times higherthan the figure applying to regular migrants and six times higher than the rate relating to general reference population.See National Committee for Medical Aspects of Aliens Policy, Medical aspects of aliens policy, (2004). Available at:http://www.justitie.nl/Images/jaarnota_integratiebeleid_2004_tcm74-38880.pdf, visited on 10 February 2006. See alsoMinistry of Justice, Illegal resident third country nationals in the EU member states: state approaches towards them andtheir profile and social situation, research conducted by the Netherlands contact point within the European MigrationNetwork (2005), available at: http://www.european-migration-network.org/.171NIVEL (2000:54) and PICUM (2001:56). Available online at: http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdf


66 PICUMApart from this method, undocumented migrantsmay also receive treatment by trying to pay the fullcost of the care received, negotiating with doctors orgoing to organizations delivering medical assistancefree of charge.Some organizations like Lampion-Pharos, Doctorsof the World or Gezonheidszorg Illegalen Leiden(GIL) make remarkable efforts to provide accessibleinformation to all, to record incidents whereundocumented migrants do not successfully receivemedical treatment and inform local health inspectorsand other actors.One of the objectives of Lampion-Pharos is to makethe health system more accessible to undocumentedmigrants residing in the Netherlands.To this aim, it conducts research, develops newmethods for providing assistance, sets up preventionand information activities, designs trainingprogrammes, collects information from daily practiceand disseminates it through its wide network ofactors. The Lampion “e-helpdesk” project intendsto solve questions related to access to health carefor undocumented migrants in the Netherlands. In2006, the system was contacted 538 times mainlyby undocumented migrants and family members,social workers, grassroots organizations and healthcare providers. Most of the questions were directlyrelated to the financing of health care, pre-natal andhealth care for children, as well as mental healthcare. Project staff have been trained to answer thequestions by themselves; however, they also referthe cases to other organizations within their networkwhen the request is too specific. 172LAMPION is a platform for cooperation on healthissues in the Netherlands. The network includesthe National Mental Health Organization (GGZ),the National Primary Care Organization (GGD),the General Practitioners Association (NHV), theSOA/AIDS organization, the Dutch Council forRefugees, the General Health Inspectorate andthe Linkage Fund (Stichting Koppeling).The Lampion helpdesk constitutes a nationalinformation and advisory service (website andhelp desk) for undocumented migrants. Healthcare workers, volunteers and undocumentedmigrants themselves consult the Lampion helpdesk.Lampion provides information and adviceand refers to relevant partner organizationsif necessary. The high number of questionsreceived by Lampion in 2006 confirms the lackof information on health care issues from undocumentedmigrants and shows that Lampionfulfils a need. Lampion plays an important rolein drawing attention to bottlenecks and trendsregarding access to health care for undocumentedmigrants in the Netherlands.http://www.lampion.info172Frequently asked questions regarding financial issues, legal matters, housing and basic medical rights can be found athttp://www.lampion.info.


Access to Health Care for Undocumented Migrants in Europe 67PHAROS is the independent center of expertiseof LAMPION, and aims at providing qualitativehealth care and making the system more accessibleto refugees, asylum seekers and undocumentedmigrants. PHAROS is inspired by thedefinition of health used by the World HealthOrganization (WHO), according to which “healthis a state of complete physical, mental and socialwell-being and not merely the absence of diseaseor infirmity.”To this general aim, PHAROS collaborates andbuilds partnerships with different categories ofactors at the national and international levelsand transfers in-depth and applicable knowledgeon health care to individuals and organizationsworking with refugees, asylum seekers andundocumented migrants, such as general practitionersand physicians, nurses, mental healthprofessionals, social workers, psychotherapists,outreach workers, staff in medical care servicesfor asylum seekers, primary and secondaryeducation teachers, child welfare personnel,immigration and naturalization officials, andother relief workers and supervisors.http://www.pharos.nlThe organization GIL (Gezonheidszorg IllegalenLeiden) took the initiative to establish a protocol forall hospitals in the region to guarantee accessibilityand quality of care for all undocumented migrants.It also developed a procedure for referrals, whichenables general practitioners to more easily referundocumented patients to hospitals. Finally, itcreates newsletters addressed to health care staffin the region, explaining the procedures.Some other partnerships are being built at the locallevel involving cooperation amongst NGOs, health careproviders and local authorities. For example, in thecity of Amsterdam, a platform composed of the publichealth services (GGD), the Linkage Fund and severalrepresentatives from the local General Practitioners’Federation and from the Academic Medical Center hasbeen established to distribute money from the LinkageFund. The added participation of Doctors of the Worldensures that the platform surpasses mere considerationsof a financial nature and takes into account otherconcerns relating to undocumented migrants and thebarriers they encounter when seeking health care.In Rotterdam, the program of the GGD on vaccinationsconstitutes an interesting practice in a fieldwhere administrative barriers are not infrequent. Inthe Netherlands, those migrants who want to vaccinatetheir children must register in the “burgerlijkestand” (County Clerk’s office) for which they mustprovide their names, country of origin as well as thechild’s name and date of birth.The city of Rotterdam facilitates the vaccinationof children whose parents are not registered byaccepting them on referral by midwives, generalpractitioners or schools. In these cases, they providevaccinations free of charge.


68 PICUMThe Gemeetelijke Gezondheidsdienst (GGD)Rotterdam is the public health service of the cityof Rotterdam.GGD mainly acts in the field of prevention, intervention,coordination, research and health policyissues. This public service is also responsiblefor access to health care for undocumentedmigrants. Public health services act as intermediariesbetween health care providers and theLinkage Fund.They carry out activities in the following fields:a) infectious diseases - help is provided toundocumented migrants without verificationof identity;b) mental health - mentally ill undocumentedmigrants are sent either to clinics (if there isa risk for public order) or to charity organizationsand shelters;From July 2005 to June 2006, Doctors of the Worlddeveloped another project in Amsterdam called the“Pilot Project: MEDOC, Medical Document for UndocumentedMigrants.” It was formulated to respond toone of the persistent problems affecting undocumentedmigrants’ health care throughout Europe,that is, the absence of sound medical records.This organization provided undocumented migrantswith a record they could bring with them wheneverthey visited a doctor in order to keep recordof their medical history. The document was a kindof template presented in four languages (Dutch,English, French and Spanish) on which doctors couldrecord medical visits and specific data related to theundocumented patient: allergies, serious illnessesand surgeries, vaccinations, infectious diseases,psychosocial problems, pregnancies and deliveries,chronic diseases, current medication, etc.c)health care for children - a support unitprovides advice, organizes activities anddevelops specific policies; there is also avaccination program;d) access to health care - health service providesinformation and monitors refusals by hospitalsto provide health care;e)cooperation with relevant actors - a platformexists to gather professional organizations toexchange information about current trends inthe population and in the health system.http://www.ggd.rotterdam.nl/


Access to Health Care for Undocumented Migrants in Europe 69Dokters van de Wereld – Netherlands (Médecinsdu Monde) based in Amsterdam.As part of Médecins du Monde, the mission ofDokters van de Wereld is to provide medicalassistance to vulnerable groups and improvetheir access to health care. This organizationhas special projects in different European statesaddressing the specific needs of high risk groupssuch as the homeless, undocumented migrants,prostitutes and people with substance abuseproblems.The “Pilot Project MEDOC: Medical Document forUndocumented Migrants” of Doctors of the Worldin Amsterdam was developed between July 2005and June 2006. The project aimed to ameliorateaccess to health care for undocumented migrantsand contribute to the continuation of care.Within this project, several activities weredeveloped:a)informing undocumented migrants abouttheir rights and duties under the Dutch healthcare system;b) raising awareness among health care provid-ers about the need to improve health care forundocumented migrants;c)d)developing and disseminating “MEDOCs,”a medical document for undocumentedmigrants;gaining deeper knowledge of the problemsfaced by undocumented migrants.The first evaluations of the project showed thatMEDOC was indeed an important tool for undocumentedmigrants, allowing them to better informand communicate with health care providersand also ensure the continuation of treatments.This initiative was very positively received inAmsterdam as well as in other cities across theNetherlands.http://www.doktersvandewereld.org


70 PICUMThe Dutch physician Dr. Joost den Otter summarizes:“Access to health care for undocumentedmigrants is getting more restrictive in the Netherlands.Hospitals are refusing patients more andmore… we should thus continue working to makehealth care accessible and affordable for undocumentedmigrants.”This was also the line of reasoning expressed in2004 by the National State Committee for MedicalAspects of Aliens Policy when it recommended thatthe government needed to (i) explicitly acknowledgeresponsibility for the health care of each personresiding in the Netherlands; and (ii) continue to guaranteetheir right to necessary health care, leavingmedical professionals in charge of setting indicationsand continued monitoring in the years aheadaccess to necessary care for both uninsured aliensand uninsured Dutch citizens.” 173Dominique van Huijstee of the organization StichtingLOS in Amsterdam finds that “everything willfunction a bit better if the government assumes itsresponsibility to inform about the system and theprovisions applying to undocumented migrants toall actors involved: undocumented migrants, healthcare providers, hospital administrations or healthlocal authorities.” Similar recommendations aremade by Erik Vloeberghs and Marjan Mensinga ofLampion, who remind of the importance of disseminatingclear information about pregnant women andchildren’s entitlements to health care.In recent years, many complaints have beenexpressed by organizations in relation to the existenceof two different funds for primary and secondaryhealth care. In their view, the government shouldcreate a unique fund to solve all problems related,particularly those arising from the “dubious debtorsystem” that make hospitals excessively careful oftheir potential budget losses.Fortunately, the Ministry of Health has shown certainopenness to insert some reforms in the system inorder to simplify the funding system by creatinga sole fund for all types of care and to clarify theprovisions entitling individual health care providersand hospitals to claim for reimbursement. A concretizationof this step is still expected.173National Committee for Medical Aspects of Aliens Policy, Medical aspects of aliens’ policy (Amsterdam: Ministry ofJustice, 2004), p. 12. Available online at: http://www.justitie.nl , visited on 26 January 2006.


Access to Health Care for Undocumented Migrants in Europe 718. PORTUGALA 43-year-old undocumented woman from Angola went to an NGO seeking healthcare. The laboratory tests requested by the volunteer doctor showed a strong anemiademanding an immediate blood transfusion. She went to the emergency unit; however,before treating her, the hospital administration asked her for immediate payment ofan old debt. She was turned away, even though the law allowed her to gain accessto treatment. Only after the medical office of the National Center for Migrants (CNAI)called the hospital upon the request of the NGO, was the mistake corrected and thewoman finally accessed the treatment needed.» TermsInscrição esporádica - temporary registrationJuntas de Freguesia - local borough councilsGENERAL HEALTH CARE SYSTEMThe universal right to enjoy health protection andcare is laid down by the Portuguese Constitution.In Portugal everybody – at least in theory – “hasthe right to health care and the duty to defend andpromote it.” 174The Portuguese health system is characterizedby three co-existing systems: the National HealthService (NHS), special social health insuranceschemes for certain professions and voluntaryprivate health insurance. The NHS provides universalcoverage and is predominantly funded throughgeneral taxation. The health subsystems, whichprovide either comprehensive or partial health carecoverage to about a quarter of the population, arefunded mainly through employees’ and employers’contributions (including state contributions as anemployer). A large proportion of funding is private,mainly in the form of direct payments by the patientand to a lesser extent in the form of premiums toprivate insurance schemes and mutual institutions,which cover respectively 10% and 6.5% of thepopulation.The Ministry of Health is responsible for developinghealth policy as well as managing the NationalHealth Service. Five regional health administrationsimplement the national health policy objectives,develop guidelines and protocols and supervisehealth care delivery. They also have some budgetarycompetences in the field of primary care.Within the NHS, health care is subsidised, takinginto account the social and economic situation ofthe users. For each health check or service used(including diagnostic tests), the user must pay anamount known as a moderating fee, although thereare exceptions provided by law. 175 The moderatingfees are relatively low. For instance in 2004, forgeneral health checks in health centers, patientscontributed 2 EUR and in emergency services, 6.10EUR if in a hospital.174See Article 64(3)(a) of the Portuguese Constitution: “Todos têm direito à protecção da saúde e o dever de a defender epromover”.175These exceptions are: i) children up to twelve years; ii) young people when given an adolescent consultation; iii) pregnantwomen and women in sixth to eighth week after giving birth; iv) women receiving a family planning appointment; v)unemployed persons and their dependents (registered at the Employment Office); vi) recipients of welfare provision froman official body; vii) persons with certain legally recognised chronic diseases; viii) foreigners who whilst not makingSocial Security payments have a member of the family unit paying; and ix) persons who are in need of welfare provisionor find themselves in a situation where there is a risk for public health (infectious diseases; maternity care, child careand family planning; and vaccination).


72 PICUMDespite the remarkable achievements in healthpolicy, a number of challenges remain such as theneed to improve access to health care services, toreduce health inequalities and to modernize theorganizational structure and management of theNational Health Service. 176HEALTH CARE FOR UNDOCUMENTEDMIGRANTS1. Legal Entitlements to Access Fully orPartially Publicly Subsidized Health CareUndocumented migrants’ entitlements to accessthe NHS in Portugal depend on the time they havebeen residing in Portugal, with the exception of childrenwho have access to public health care on equalgrounds as national and documented children.To guarantee access to health care and education forundocumented children, there is a national registryof foreign undocumented children managed bythe High Commissioner for Immigration and EthnicMinorities (ACIME). This registry cannot be accessedby the authorities with the aim to obtain proof of theirregular stay of their parents. 177Those undocumented migrants able to prove thattheir residence in Portugal exceeds 90 days haveaccess to health care, medicine and tests upon presentationof a document called “temporary registration”(inscrição esporádica) which allows, accordingto practice, access to health care on single or multipleoccasions. A moderating fee is charged, withexceptions in place for the following care: diseasesof mandatory notification (such as tuberculosis, HIV/AIDS and sexually transmitted diseases), maternitycare, vaccination and family planning.If the competent authority does not officially recognizethat an undocumented migrant has been livingin a specific district for more than 90 days, they mayonly be entitled to access emergency care in publichospitals upon payment of the full cost of treatment.Nonetheless, emergency care cannot be refusedif the patient lacks the means. The bill will only bereceived after the care has been given. In addition,the law stipulates that the economic situation ofthe patient will always be taken into account by theauthorities when charging the expenses incurred. 178Nonetheless, many administrative obstacles preventundocumented migrants from final exemption. 1792.The ProcedureUndocumented migrants residing in a particulardistrict area for more than 90 days may accesshealth facilities and services of the National HealthService only after compliance of two conditions.First, they have to get a document issued by the localborough council (Junta de Freguesia) 180 officiallycertifying that they have been residing in the areafor more than 90 days. This document is renewable.176See Große-Tebbe S. and Figueras J., (2004:25). Available at: http://www.euro.who.int/document/e85400.pdf and BentesM., Dias C.M., Sakellarides C. and Bankauskaite V. Health Care Systems in Transition: Portugal. (Copenhagen: WHO,2004).177Regarding children, see Decree-Law No. 67/2004 of 25 March 2004 (Decreto Lei N.° 67/2004 de 25 de Março, Diário daRepública – I Série A – N.° 72); See also Portaria n.° 995/2004 de 9 de Agosto, Diário da República – I Série B, N.° 186.178Alto Comissariado para a Imigração e Minorias Étnicas (ACIME). Immigration in Portugal 2004/2005, pp. 54-82.Available online at: http://www.acime.gov.pt/docs/Publicacoes/brochingl/EmigPort_Ingles.pdf. See also Despachon.° 25 360/2001 (2 série), Diário da República N.° 286 12.12.2001; Circular 14/DSPCS of 02/04/02 from the DirectorateGeneral Health (Circular Informativa. Direcção-Geral da Saúdeo, N.° 14/DSPCS); Circular 48/DSPCS of 30/10/02 from theDirectorate General Health (Circular Informativa. Direcção-Geral da Saúdeo, N.° 48/DSPCS); Decree-Law No. 34/2003 of25 February 2003 (Decreto-lei n.° 34/2003 de 22 Abril).179See Jesuit Refugee Service, Report on Destitute Forced Migrants (Brussels: JRS, 2007), p. 79.180There are around 4200 “Junta de Freguesia” in Portugal. The average population is 2,300 inhabitants. See “L’accès desétrangers en situation irrégulière au système de santé », Les documents de travail du Sénat Français. Série Législationcomparée n° LC 160 (March 2006), http://www.senat.fr/lc/lc160/lc160.html, Accessed on 15 May 2007.


Access to Health Care for Undocumented Migrants in Europe 73The document can be obtained upon presentation oftwo witness statements by local registered residentsconfirming the undocumented migrant’s residence inthe neighborhood. They may be private individuals orpeople working in a commercial establishment suchas a hostel or a shop. The law also provides for thepossibility for undocumented migrants themselvesto make a signed declaration about their residencebut, according to Portuguese NGOs, this provision israrely valued in practice. 181Secondly, after this document has been issued,undocumented migrants must then go to a healthcenter in their geographical area to register as apatient there and, when possible, also register witha family doctor. 182As its name indicates, the “temporary registration”(inscrição esporádica) has only very limited validity.In most cases practice shows that every time undocumentedmigrants need to receive medical treatment,they have to be registered. This implies thatthey will have to continuously strive to overcomereoccurring administrative barriers to successfullyaccess health care.If undocumented migrants cannot pay the moderatingfee, they will have to apply to the Social Securityservices or to the local borough councils (Juntas deFreguesia) for a document officially certifying theirprecarious economic situation.3.The Situation in PracticeThe practical enjoyment of legal entitlements inPortugal depends to a great extent on overcomingall of the administrative steps and complicatedbureaucracy needed to get the inscrição esporádica.Nonetheless, given the limited and unbalancedhuman resources structure of the NHS, even thoseundocumented migrants in possession of thisdocument can face serious problems in effectivelyaccessing health care in Portugal, especially athospitals. These problems are common to all NHSusers, including nationals. Emergency rooms areoften overcrowded and there are waiting lists especiallyto visit a family doctor.Moreover, as many Portuguese actors have clearlyexpressed, the applicable legislation regardingundocumented migrants’ entitlements to healthcare is highly ambiguous. This has led to theprogressive development of a wide and complexset of implementing norms and informative notesthat are very difficult to understand. “I even triedto establish a legal working group that could helpNGOs to better understand how the system worksfor undocumented migrants, however, even they donot have clarity on this. The only explanation I find tothis uncertainty is that it responds to a real politicalchoice,” explains Camila Rodrigues, social worker atthe Jesuit Refugee Service Portugal in Lisbon.This circumstance makes the daily work of all actorsinvolved at local level even more difficult, namelysocial workers, NGOs, local administrations, healthcenters, hospital administrations and medicalpersonnel. The ambiguity reinforces the existingremarkable lack of information among healthadministrator and migrants themselves. As a result,an increasing number of direct and indirect obstaclesto access health care are created.181See Article 34 of Decree-Law No. 135/99 of 22 April 1999 (Decreto-lei n.° 135/99 de 22 Abril): “Os atestados de residência(..) devem ser emitidos desde que qualquer dos membros do respectivo executivo ou da assembleia de freguesia tenhaconhecimiento directo dos factos a testar, ou quando a sua prova seja feita por testemunho oral ou escrito de doiscidadãos eleitores recensados na fregresia ou, ainda, mediante declaração do próprio”.182See Article 34 of Decree Law No. 135/99.


74 PICUMThe system for registration is extremely complexsince it entails numerous administrative steps andinvolves different administrations. Practice showsthat it is very difficult for undocumented migrants toget the document which recognizes their residencein Portugal issued by the local borough council. Infact, many undocumented migrants do not succeedin getting declarations from two witnesses mainlybecause they feel forced to move from one addressto another. The situation is particularly hard forhomeless undocumented migrants.The law also provides that undocumented migrantsmay make a signed declaration to affirm their residence,but as reported by JRS Portugal and CentroPadre Alves Correia (CEPAC), “this right is notalways respected or even known by the competentauthorities (Juntas de Freguesia).” 183 In addition, toaccept the declaration signed by an undocumentedmigrant, the latter must present a valid identitydocument. This creates another remarkable barriersince many undocumented migrants do not havesuch a document and the administration tends toonly accept passports.These organizations also inform that some Juntasde Freguesia refuse to issue the attestation usingjustifications that do not have any legal basis. Thus,some go beyond the legal requirements requestingthe provision of further documents or the complianceof some conditions not provided by the law.Sometimes, there are also problems to registerat health care centers and hospitals. As IsabelSardinha, a retired nurse from the regional healthauthority in the area of Lisbon explains, “clericalstaff often refuse to take in undocumented migrantsunder false pretexts in ignorance of the law and oftheir superiors.” Despite their entitlements, in somecases undocumented migrants are simply turnedaway from health centers because they would notpay for the treatment they sought to receive. Thereare, however, many differences among healthcenters’ knowledge of undocumented migrants’entitlements to access health care. As reportedin an IMISCOE study, “some health care centersseem unaware that basic nursing care and vaccinationswere free services, while others knew andassumed it as a daily practice.” 184 In addition, accessdepends to a large extent on the good will of theadministrative and medical staff. There have beencases where undocumented migrant women havereceived medical assistance in one health center butwere systematically refused medical assistance inanother health care center. 185Although there have been a number of cases whereaccess to emergency care was denied, undocumentedmigrants are generally accepted in emergency units.Pressure from NGOs has positively influenced theiraccess to emergency rooms but this does not implythat undocumented migrants frequently seek healthcare. As happens all over Europe, “they only turnto the hospital emergency ward when their state ofhealth is truly threatened.” 186183Ibid., paragraph 2.184IMISCOE (International Migration, Integration and Social Cohesion), Social Integration & Mobility: Education, Housing &Health. (Lisbon: Universidad de Lisboa, 2005), pp.115. Available online at:http://www.imiscoe.org/research/clusters/b5.html185See Jesuit Refugee Service (2007:79), Available online at: http://www.jrseurope.org/EPIM/intro.htm186Ibid.


Access to Health Care for Undocumented Migrants in Europe 75In cases where emergency care is provided to recentarrivals or homeless undocumented migrants,hospitals often send the bills to NGOs. Since in mostcases undocumented migrants cannot afford to pay,“many of these bills remain unpaid, thus in the end,it is the state finally covering the costs for treatingundocumented migrants,” said Camila Rodrigues ofJRS.The inexistence of a clear system of social assistanceand health care for all people present in Portugal,regardless of the length of stay, leads to furtherproblems with implications for all NHS users. “Forinstance, sometimes after medical discharge, homelessundocumented migrants stay at hospitals, thuscontributing to fill already overcrowded hospitals. InPortugal, to leave the hospital, you also need to bedischarged by the hospital social service. Nonetheless,in many other cases, homeless undocumentedmigrants are sent back to the street straight afterreceiving serious medical treatment,” states MárioFaria Silva, director of the Centro Padre Alves Correiain Lisbon. “Sometimes this happens to people withchronic diseases or health problems that need strictfollow up.”As happens in other countries, undocumentedmigrants living in Portugal face a number of additionalbarriers linked to language, health cultureand the lack of information. All these circumstancescontribute to complicate their access to health care.In relation to this, JRS and CEPAC state that “ingeneral, health centers and hospitals do not haveinterpreters or cultural mediators. Consequently,undocumented migrants not only face difficulties togo through all the bureaucracy but also to communicatewith key actors such as medical personnel.”Finally, undocumented migrants often fear thatseeking health care could lead to a risk of deportationeven if, in principle, authorities in Portugaldo not have access to patients’ medical recordsand health professionals are subject to a code ofconfidentiality. 1874.The Role of Civil Society and Local ActorsIn a country where there is a big gap between lawand practice, the role of civil society is of significantimportance. As has been largely explained, theuncertainty regarding applicable norms and procedureshas raised numerous barriers against accessinghealth care in Portugal.The remarkable lack of knowledge about undocumentedmigrants’ rights amongst local boroughcouncils has forced institutes, such as the immigrantgovernment body, the High Commissionerfor Immigration and Ethnic Minorities (ACIME), topublicly announce to all local borough councils thatthey must cooperate in correctly implementing thelaw.ACIME plays a significant role in directly informingundocumented migrants by publishing informativebrochures and booklets. Some brochures seek toexplain undocumented migrants’ entitlements toaccess health care, the different steps to take whenseeking medical treatment, and contact addressesof NGOs and health centers providing support.ACIME is also very active concerning the promotionof cooperation amongst actors involved and thefunding of partnerships and NGO initiatives.187Article 68 of the Statue of the Portuguese Medical Association, approved by Decree-Law No. 282/77 of 5 July 1977:Doctors are forbidden from revealing “all facts which have become known to the doctor during the course of carrying out,or because of, their profession”.


76 PICUMThe Alto Comissariado para a Imigração e minoriasétnicas - ACIME (High Commissioner forImmigration and Ethnic Minorities) is an governmentalinterdepartmental support and advisorystructure concerning immigration and ethnicminorities. Its mission is to promote the integrationof immigrants and ethnic minorities inPortuguese society, to ensure the participationand collaboration of associations which representimmigrants, social partners and institutionsof social solidarity in the definition of social integrationpolicies and combat against exclusion,as well as to accompany the application of legalinstruments to prevent and prohibit discriminationin the exercise of rights for reasons based onrace, color, nationality or ethnic origin.The High Commissioner provides informationabout organizations and institutions providingassistance to migrants and edits numerousbrochures, booklets and videos to directly informmigrants about immigration law, family reunion,voluntary return, access to education, access tohealth care and legal means of fighting racism.ACIME also has an observatory on immigration.ACIME recently changed its name to ACIDI - HighCommissioner for Immigration and InterculturalDialogue (Alto Comissariado para a Imigraçãoe Diálogo Intercultural). Among its new competenceswill be the definition and implementationof horizontal and specific public policies toenhance the social integration of immigrants andethnic minorities and to promote dialogue amongdifferent religions, cultures and ethnic groups.http://www.acime.gov.ptThe existing confusion and lack of informationtogether with inefficiency of the Portuguese healthsystem to meet the health care demand has largelycontributed to the mobilization of actors. Similarly,it has furthered formal and informal cooperationschemes and partnerships between NGOs, localadministrations and the social and administrativepersonnel of hospitals.Local actors confront difficult situations on a dailybasis. They are challenged by the need to find quicksolutions whenever ill undocumented migrants cometo them seeking medical care. “Many times, when illundocumented migrants who encounter difficultiesin gaining access to the system come to our offices, Iphone some of our contacts at the social departmentof a hospital or of a health center here in Lisbon andit normally works,” explains Camila Rodrigues ofJRS.Many actors in fact take the initiative to help undocumentedmigrants. Even neighborhood social centersreact to this situation and adopt measures to guaranteeaccess to health care for undocumentedmigrants. A good example is the Centro SocialBarrio 6 de Maio in Lisbon that primarily mediatesbetween the patients and the health service providersto facilitate access.The solidarity of Portuguese civil society towardsundocumented migrants’ needs is also reflectedin the work carried out by many organizations andreligious institutions. They indeed play a crucialrole in helping migrants to access the public healthsystem. Many of these organizations also makegreat efforts to establish parallel medical centerswhere, besides basic health care, medicine, foodand clothes are provided. These initiatives usuallymonitor the health situation of the migrant overa period of time and even pay bills when migrantswho are not holders of the health card need specialtreatments or diagnoses.


Access to Health Care for Undocumented Migrants in Europe 77In the medical support unit GAMI (Gabinate de ApoioMédico para Imigrantes) of the Jesuit Refugee Servicein Lisbon, volunteer doctors provide health care freeof charge to undocumented migrants. They providebasic health care and medicine and, when necessary,refer patients to two specialist doctors withinthe unit’s network (a gynecologist and a dentist) whotreat undocumented migrants free of charge. Theunit treats many homeless undocumented migrants,mainly from countries in Eastern Europe (that didnot recently join the European Union) and Brazil. 188From January to June 2005, 70% of the total numberof patients (83) were undocumented. Some of theundocumented patients who sought health care atthis center had chronic diseases.Medicine, donated by pharmaceutical companies,pharmacists and private donors, is distributed afterconsultation at the medical center or upon presentationof a prescription. The organization tries to takeinto account the economic situation of the patients.Sometimes, they receive requests for medicinefrom hospital’s social services although the limitedresources of their dispensary make it impossible tosatisfy all the queries.Jesuit Refugee Service (JRS) is an internationalCatholic organization founded in 1980 with themission to accompany, serve and defend therights of refugees and forced displaced persons.JRS Portugal began working in Lisbon in 1992providing different services free of charge torefugees, asylum seekers and migrants, includingundocumented migrants. Besides assistanceprovided in its Centro de AcolhimentoPedro Arrupe shelter, this organization providesfood and clothes (donated by private donors) aswell as social, legal, medical and psychologicalassistance. They also support migrants inseeking work and accommodation, organizePortuguese language courses and have a specialprogram to support immigrants who are healthcare providers.In 2003, the social service of this organizationprovided assistance to 157 persons of which 109were undocumented migrants. In 2005, 139 outof 243 social interventions were made to helpundocumented migrants.JRS Portugal is a very active organizationconcerning awareness raising campaigns andnetwork building. They often participate indebates, conferences and occasionally also inevents promoted by the media. Similarly, theyhave developed initiatives in primary and secondaryschools to increase awareness about thesituation of migrants in Portugal.This organization works in strong cooperationand partnership with many other local, nationaland international organizations and institutionsinvolved in the work with undocumentedmigrants.http://www.jrsportugal.pt188For more information on homeless undocumented migrants in Lisbon, see Rodrigues C., “The Changing Profile of RoughSleepers: Immigrants from Eastern Europe Sleeping Rough in Lisbon”, in Homeless in Europe (Winter 2005), pp.18-20,available online at: http://www.feantsa.org/files/Month%20Publications/EN/EN_winter_2005_social_emergency.pdf,accessed on 15 May 2007.


78 PICUMA similar initiative has been put in practice by theCentro Padre Alves Correia (CEPAC) which since2005 has maintained a health unit to treat undocumentedmigrants. The center also provides food,clothes and medicine. They mainly treat people fromPortuguese speaking countries in Africa and Brazil.The Centro Padre Alves Correia (CEPAC) is areligious social solidarity institution foundedin 1992. Its fundamental mission is to supportimmigrants, promoting their integration throughthe provision of several social services freeof charge. Although the organization does notexclude anyone, they focus their work on undocumentedmigrants coming from Portuguesespeaking African countries and Brazil. Undocumentedmigrants represent 28.4% of the personshelped by this center, many of whom are homelessand do not have strong networks.CEPAC provides food and clothes, social andlegal assistance as well as medical assistanceand medicine through its medical unit. Theyalso have a nursing unit which is run jointly withMédecins du Monde.The medical unit started its work in October 2005and does not yet have relevant statistics available.CEPAC also treats family members of permitholders to receive medical assistance in Portugalaccording to health agreements between Portugaland certain countries.http://www.espiritanos.org/cssp/correia.aspAnother example of an organization which has beenworking in this field in Lisbon is the Obra CatólicaPortuguesa de Migrações (OCPM). 189 From 1993to 2005, this organization helped undocumentedmigrants in accessing the mainstream health caresystem as well as direct medical and psychologicalassistance and medicine. This organization hasundertaken these activities individually and in partnershipwith other civil society organizations andtemporary immigrant shelters.The Obra Católica Portuguesa de Migrações(OCPM) is a religious organization that providesdirect assistance to migrants and also carriesout advocacy activities in Portugal.In the medical and psychological units (Gabinetemedico e psicosocial) volunteer specialists helpundocumented migrants by providing healthcare, medicine and economic support for diagnosistests. To this aim, a solidarity fund of about600 to 900 EUR per month was created to sustainthese activities.From 2003 to 2005, the OCPM was one of the partnersof the temporary shelter for immigrants S.João de Deus. They were in charge of the medicalunit of the shelter.http://www.ecclesia.pt/ocpm/Portuguese organizations are increasingly bringingcomplaints before the government claiming thatundocumented migrants’ health needs are not beingmet and urging the government to take the necessarysteps to make the system work better.Many reasons are behind the failure of the systemin Portugal. No matter if it is due to the excessivebureaucracy or to the general inefficiency of theNational Health System, the reality is that an urgentsolution is needed since, as described by Mário FariaSilva of CEPAC, “the situation of ill undocumentedmigrants in Portugal, many of whom are living in thestreets, is a real drama.”189http://www.ecclesia.pt/ocpm/


Access to Health Care for Undocumented Migrants in Europe 799. SPAINJoaquín arrived in Spain from Argentina in 2002. Since he overstayed his tourist visaand became undocumented, he thought that if he registered at the city hall to receivehis health card it could negatively affect his chances of receiving a residence permit.“I knew that to get the health card I had to register at the town hall, but I was afraid.Therefore, I waited to get ill to seek health care in the emergency system. They treatedme well there and a social worker at the hospital advised me to register at the city halland get the health card,” he said.» Terms:Tarjeta Individual Sanitaria - Individual Health CardGENERAL HEALTH CARE SYSTEMIn Spain, there is a tax-based national health system.The system has been largely decentralized to theautonomous communities. Whilst the Ministry ofHealth defines the minimum standards and requirementsfor health care provision, the autonomouscommunities’ health departments have the powerto decide how to organize or provide health servicesand implement the national legislation. The localcouncils’ role is limited to complementary publichealth functions linked to health and hygiene aswell as collaboration in the management of publicservices.The universal right to enjoy health protection andcare is laid down by the Spanish Constitution and theGeneral Health Act. Spain provides free and holistichealth care to “all Spanish citizens and foreignnationals residing in the national territory.” 190According to data from 1997, more than 99% of thepopulation is in fact covered, including the low-incomeand immigrant population. 191The health care system is financed by general taxationsuch as VAT and income tax as well as regionaltaxes. Public financing is complemented by out-ofpocketpayments to the public system (for exampleco-payments for pharmaceuticals) as well as to theprivate sector (for example private outpatient care)and contributions to voluntary insurance. 192Despite the different reforms accomplished, citizens’satisfaction regarding waiting times andadministrative procedures for accessing hospitalcare remains low. 193 In addition, the sustainability ofsuch a “generous” system of universal coverage iscoming under increasing discussion in Spain. Thistendency is explained by existing perceptions aboutthe increased rate of the pharmaceutical and hospitalexpenditure, the raise of demands coming notonly from immigrants, but also from an aged populationand from so-called “health tourists.”190See Article 42 of the Spanish Constitution of 1978: “The right to health protection is recognized”. See also Article 1(2) ofthe General Health Act 14/1986 of 25 April.191Große-Tebbe S. and Figueras J., (2004:53). Available online at: http://www.euro.who.int/document/e85400.pdf.192Ibid. See also information available at: http://www.msc.es/en/organizacion/sns/docs/proteccion.pdf.193Ibid.


80 PICUMHEALTH CARE FOR UNDOCUMENTEDMIGRANTS1. Legal Entitlements and Procedure to AccessPublicly Subsidized Health CareAccess to the emergency system in Spain is generallyguaranteed free of charge to all documented andundocumented foreigners present in the countrywho become severely ill or have an accident, for theduration of their treatment.Regarding undocumented migrants’ access toother health services and medicine, a distinctionis made between pregnant women and children onthe one hand and other categories of undocumentedmigrants on the other.Undocumented children under the age of 18 andundocumented pregnant women are entitled toaccess the Spanish national health system freeof charge under the same conditions as nationals.However, the remaining undocumented migrantsonly enjoy this right if they are registered in the localcivil registry of their habitual residence. 194The document allowing them to gain access to thehealth system is called “Individual Health Card”(Tarjeta Individual Sanitaria) and, besides womenand children, they only get it if registered at the cityhall. There are, however, some conditions to meetfor being registered by the municipal authorities.Registration is free of charge but the precondition isto be in possession of a valid passport. Similarly, itis necessary to provide proof of habitual residencethorough a housing contract, an authorization forregistration signed by the landlord or co-tenant or acontract for water, gas or electricity. If the individual ishomeless, s/he can provide a valid address to receivecorrespondence. In these cases, however, the police orthe local social services will have to visit the place inadvance to certify that the person does in fact live atthe declared address. Finally, in order to retain validityof the health card, the registration must be renewedevery two years. 195This is the most common situation in Spain. Nevertheless,the high degree of decentralization ofpowers has allowed several autonomous communitiesto develop less restrictive systems. For instancein Andalusia, thanks to a special joint agreement196 made by the regional department of health,NGOs and trade unions, undocumented migrantscan access the health centers directly or via theso-called “referral card” obtained at a participatingorganization.Other examples are Valencia, where free medicineis provided to immigrants without resources 197 andMurcia, where, thanks to the pressure of NGOs likeMurcia Acoge, the so-called “solidarity health card”has been recently put in place for migrants who arenot registered at the town hall.194See Article 12 of the Act 4/2000 of 11 January 2000 on the Rights and Freedoms of Aliens in Spain according to which:“1. Los extranjeros que se encuentren en España inscritos en el padrón del municipio en el que residan habitualmente,tienen derecho a la asistencia sanitaria en las mismas condiciones que los españoles.2. Los extranjeros que se encuentren en España tienen derecho a la asistencia sanitaria pública de urgencia ante lacontracción de enfermedades graves o accidentes, cualquiera que sea su causa, y a la continuidad de dicha atenciónhasta la situación de alta médica.3. Los extranjeros menores de dieciocho años que se encuentren en España tienen derecho a la asistencia sanitaria enlas mismas condiciones que los españoles.4. Las extranjeras embarazadas que se encuentren en España tendrán derecho a la asistencia sanitaria durante elembarazo, parto y postparto.”195See Article 16(1) and (2) of the Act 4/2000 as amended by the Act 14/2003 of 20 November. See also Resolution of 4 July1997 from the presidency of the National Institute of Statistics and the General Director of Territorial Cooperation ontechnical instructions to municipalities to update the local registry (“padrón”).196“Convenio de colaboración entre la Consejería de Salud, la Asociación Médicos del Mundo, Federación Andalucía Acoge,la Cruz Roja Española en Andalucía y la Fundación Progreso y Salud, en materia de salud pública para el colectivo deinmigrantes”, signed in Almería on 19 March 1999. The agreement has been recently renewed.197The general system consists of a general reduction of 40% and 90% for certain categories of medicines with theexception of some categories of persons who receive them free of charge.


Access to Health Care for Undocumented Migrants in Europe 81In 1999, the Department of Health of the governmentof the Autonomous Community of Andalusiasigned, along with several NGOs and trade unions(UGT and CC.OO.), a special agreement to guaranteeand facilitate immigrants’ access to the healthcare system (Convenio andaluz de atención sanitariaa inmigrantes).According to this agreement, undocumentedmigrants residing in Andalusia do not have to bein possession of the health card to access healthcare. They can directly access the health systemor receive an official document from any of thecollaborating entities. The partner organizationscommit themselves to inform and accompanyundocumented migrants seeking health care ata public health center or hospital. The agreementalso sets up a monitoring committee at theregional level and other monitoring commissionsat the county level.Another outcome was the issuing of some publicationsand other information materials:i)for immigrants - a brochure with informationabout health centers in Andalusia in severallanguages as well as a “portable medicalhistory,” a document presented in differentlanguages where health professionalscan write down background information andactions taken on immigrants’ health such asvaccinations, treatments, etc.;2. The Situation in Practice and the Role of CivilSociety and Local ActorsMany practical obstacles prevent undocumentedmigrants from gaining access to the health systemin Spain. Contrary to legal provisions, the publichealth system does not cover all medical needs of arelevant number of undocumented migrants residingin Spain. Therefore, the right to access publiclysubsidized health care regardless of administrativestatus is limited in practice.Although there is a lack of precise figures about thenumber of people who do not access health care inSpain, some studies conducted by relevant NGOsreveal the entity of the problem. The organizationMédicos del Mundo reports to have provided 14,857social and medical services to 9,558 undocumentedmigrants in nine of the seventeen Spanish autonomouscommunities in the year 2005 alone. 6,354of these services consisted of direct medical andmental health consultations and 8,503 consistedof social assistance to receive the health card. 198Similarly, according to a project carried out over tenmonths in 2004 by Médicos Sin Fronteras, in two ofthe Madrid districts with a high immigrant population,65% of the 264 undocumented migrants seekingdirect medical and social assistance at their centersdid not have a health card. 52% of undocumentedmigrants were not registered at the city hall and21%, even if registered, did not follow the necessarysteps to get the health card. 68% were from Sub-Saharan Africa and 24% from North Africa.ii)for organizations - a manual to providemedical assistance to immigrants in Andalusia,an official form to refer people to thehealth system, address lists, a small dictionaryof medical terms, leaflets with informationabout women’s health, etc.http://www.juntadeandalucia.es/servicioandaluzdesalud/principal/default_en.asp?version=En198Médicos del Mundo. Informe de Exclusión Social. Madrid: Médicos del Mundo, (Madrid: MDM, 2005), p.27. Available onlineat: http://www.medicosdelmundo.org/NAVG/pagina/IXInformeExclusionSocial.pdf


82 PICUMThe organization Médicos Sin Fronteras (MSF)has provided medical assistance to undocumentedmigrants in the island of Fuerteventuraand the city of Ceuta and continues monitoringthe situation at the Southern Spanish border.They also use testimonies to advocate undocumentedmigrants’ rights.In November 2004, they started a project aimingat providing assistance to undocumentedmigrants and collecting data about:i)ii)the percentage of persons who were notaccessing the health system in Spain;barriers encountered; andiii) consequences for their health status.This project was carried out in two districts ofMadrid with the highest undocumented population.The majority of these migrants werefrom Sub-Saharan Africa and Magreb. The datacollected showed that 38% of undocumentedmigrants who sought help at MSF centers (264)did not have a health card. In addition, 21% evenif registered at the city hall, did not follow thenecessary steps to get the health card. 68% werefrom Sub-Saharan Africa and 24% from Magreb.After the project, this organization issued areport with the results and policy recommendationswhich was widely distributed in Madrid andSpain.http://www.msf.esThe conditions for registration at the city hall constituteone of the biggest barriers to access healthcare. First of all, the requirement of a valid passportposes serious problems. There are many undocumentedmigrants who enter the country clandestinely,without any kind of identification document.In other cases, undocumented migrants do have avalid passport at the time of registration, however,when the passport expires, they automatically losethe possibility to renew their registration and thusthe health card. This can happen for several reasonssuch as the inexistence of a particular consulate inthe city where the immigrant lives, the impossibilityof complying with the requirements to renew apassport, or the fear to be identified and expelled.There are undocumented migrants who even try toobtain the new passport directly from their familiesin home countries, although it can take months toreceive it. 199It is generally interpreted although not generallyapplied throughout Spain that in cases where individualsdo not have a valid passport they can registershowing their Cédula de inscripción para indocumentados,a document issued by the Spanish authoritiesallowing a foreigner to stay for three months. Thisdocument is however very difficult to get and mostof the time, undocumented migrants are reluctantto apply due to their fear of being deported if theirapplication is denied. In addition, as Cristina Olmedoof the legal department of Red Acoge highlights,“this possibility is excluded for those sub-Saharansarriving in cayucos (small wooden boats) to theCanary Islands. As soon as they arrive, they automaticallyreceive an expulsion order and, accordingto Spanish legislation, this prevents them fromgetting a Cédula.” 200199Ibid., p. 11.200In the opinion of Red Acoge, this “Cédula de Inscripción” should be admitted for registration by authorities throughoutSpain as is the case in Madrid. See also Médicos Sin Fronteras, Mejora en el acceso a los servicios públicos de salud delos inmigrantes indocumentados en el área sanitaria 11 de la Comunidad de Madrid. Informe Final (Madrid, MSF, 2005),pp. 6-7 and 11.


Access to Health Care for Undocumented Migrants in Europe 83Another remarkable obstacle against successfulregistration is the necessity of proving residenceat a particular address. This barrier is linked to thedifficulties encountered by undocumented migrantstrying to access housing in Spain. Due in many casesto the owner’s reluctance, it is very difficult for undocumentedmigrants to provide a housing contract ora contract of provision of water or energy supply asprovided by law. A similar issue occurs when theytry to obtain an “authorization for registration” fromthe owner or from other registered tenants requiredin cases where there are others registered in thesame address. As Médicos Sin Fronteras reports,“sometimes owners deny this authorization as theymay have too many people registered at the sameaddress or because they fear inspections or theloss of social benefits. There have also been caseswhere owners or tenants have asked undocumentedmigrants for extortionate sums to get it.” 201The situation is also very complicated for homelessundocumented migrants. If they live in temporarypublic shelters, they can easily get registeredand obtain the health card, although a health cardissued under these circumstances always has avalidity between 1-6 months and a year. The law alsoprovides the possibility of registering on sub-standardhousing - even under a bridge - however, this ispractically inapplicable since most undocumentedmigrants do not use this possibility or fear visitationfrom the police. 202In some cases, undocumented migrants providethe address of an organization but frequently, theauthorities show a great degree of resistance toadmit it.Since 2003, the police have been able to accessdata of foreigners registered at municipalities. 203Although it appears that the police rarely makeuse of this provision, some NGOs have reportedpolice visits to their offices inquiring why therewere too many undocumented migrants registeredat the address. What is particularly sensitive is themessage received by undocumented migrants: thevery existence of this provision removes the incentiveto register at the municipality. Some may stillregister to obtain health care, but many considerit too risky given the fact that the police may nowaccess their data.All of these considerations refer to the general situationin Spain. There are however many differencesin practice throughout the different regions and alsoamong municipalities. In the view of Elena Ramónof the immigration department of the FederaciónEspañola de Municipios y Provincias, “whilst thereare municipalities implementing the law and facilitatingregistration, others interpret the rules in avery restrictive way. Some even deny registration inclear violation of the law. This is more likely to occurin towns where the national residents complain a lotabout immigrants’ access to social services.”According to Ramón Esteso of Médicos del Mundo,“language barriers also play a role when trying toregister since in some municipalities all the registrationdocumentation to be completed is only inSpanish. This is another reason why one of thebiggest demands of undocumented migrants comingto our centers is to receive support with paperworkand assistance to obtain the health card.”201Ibid., p. 12.202Ibid., p. 11.203Sixth Additional Provision of the Act 8/2000 of 23 December as amended by the Act 14/2003 of 20 November.


84 PICUMMédicos del Mundo (Spain) provides medicalassistance to persons excluded from the publichealth system, including undocumented migrantsin nine Spanish autonomous communities. Theydo this through their “Socio-medical assistancecenters” (Centros de Atención Sociosanitaria)and mobile units. They provide primary healthcare, vaccinations, detection of HIV and sexuallytransmitted diseases, mental health, support formedicine, referring and accompanying people tothe health system. Furthermore they issue anannual “Report on Social Exclusion” where theyalso refer to the situation of exclusion sufferedby undocumented migrants due to lack or insufficientaccess to health care. 204http://www.medicosdelmundo.orgUndocumented migrants in Spain often requireassistance from organizations to obtain or renewthe health card, to get a new passport or the landlord’sauthorization for registration. Organizationsalso arrange appointments with doctors or act asmediators between the doctor and the patient to besure that the patient understands the diagnosis.This fact proves that undocumented migrants aregenerally uninformed about their entitlements andprocedures. Nonetheless, some Spanish authoritiesseem to have understood the need to organizeinformation campaigns and frequently publishbooklets and other printed materials to inform andfacilitate access to health care for undocumentedmigrants. 205Similarly, many public hospitals also take initiativesand develop a number of projects to reach, inform andassist immigrants taking into account their specificneeds. One example is the Hospital Punta de Europa,a public hospital in Algeciras in the South of Spain.Given its location, this hospital has treated numerousundocumented migrants arriving on the Spanishcoast after crossing the Strait of Gibraltar. This facthas made the hospital particularly concerned aboutimmigrants’ health needs. As Antonio Salceda of themanagement department explains, “we are forcedto seriously look at this problem, since we have itliterally in front of us” (referring to the location ofthe hospital, only a few kilometers from the Moroccancoast).Some of its initiatives are addressed to tacklelanguage and cultural barriers, such as the telephonicsimultaneous interpretation system availablefor users and medical staff 24 hours a day and7 days a week in six languages. They also providekey documents in several languages (e.g. the “surgicalconsent form”, the list of rights and duties, andthe international clinic interview sheet) and organizecourses for medical staff to improve their languageskills and the understanding of health and multiculturalism.The hospital is also currently working on theinnovative “immigrant patient support unit” (Unidadde Apoyo al Paciente Inmigrante), a research projectthat will constitute the first phase of the future unitof clinical interpretation and cultural mediation.204Report available at http://www.medicosdelmundo.org/NAVG/pagina/NAVGEstructuraPrpal.jsp.205See, for example, Consejería de Sanidad y Consumo de la Comunidad de Madrid, Médicos Sin Fronteras e Institutode Salud Pública, Manual de Orientación Sociosanitaria para Inmigrantes de la Comunidad de Madrid (Madrid, 2005),available at http://www.publicaciones-isp.org/productos/t024.pdf. See also Consejería de Salud de la Junta deAndalucía, Manual de atención sanitaria a inmigrantes, (Sevilla: Junta de Andalucia, 2004).


Access to Health Care for Undocumented Migrants in Europe 85The Hospital Punta de Europa is a public hospitalbelonging to the Health Service of Andalusia(SAS). It serves an area of 243,000 inhabitantsand provides approximately 180,000 consultationsper year. The hospital provides specialisedhealth assistance through hospitalization, emergencyunit and outpatient services.The Hospital Punta de Europa is a collaboratingpartner in the Andalusian agreement on accessto health care for immigrants (Convenio de atenciónde inmigrantes de Andalucía) and has beenrecently selected as one of the hospitals contributingto design a regional plan to improve preandpostnatal care also within the immigrantpopulation. The hospital is now trying to linkthis initiative to the “Migrant Children Hospital”program of the World Health Organization.In addition, this hospital also took part in theMigrant-Friendly Hospitals project, a Europeaninitiative to promote immigrants’ health.Currently, Hospital Punta de Europa is part of thetask force of Migrant Friendly Hospitals.http://www.juntadeandalucia.es/servicioandaluzdesalud/centros/Detalle.asp?IdCentro=16422The Migrant-Friendly Hospitals project, sponsoredby the DG Health and Consumer Protection(SANCO) of the European Commission, broughttogether hospitals from 12 member states ofthe European Union, a scientific institution ascoordinator, experts, international organizationsand networks. The partners agreed to putmigrant-friendly, culturally competent healthcare and health promotion higher on the Europeanhealth policy agenda and to support otherhospitals by compiling practical knowledge andinstruments. One major strategy to test feasibilityof becoming a migrant-friendly and culturallycompetent organization was implementation andevaluation of three selected sub-projects in thediverse reality of European hospitals, with thelocal implementation financed out of hospitalfunds, but supported in a European benchmarkingprocess.To assure sustainability of the Migrant-FriendlyHospitals movement, a Task Force on MigrantFriendly Hospitals was established in the frameworkof the WHO Network on Health PromotingHospitals.http://www.mfh-eu.net/public/home.htm


86 PICUMNot all undocumented migrants are in the same situationand face the same problems. One of the mostvulnerable groups in Spain are those who are notregistered in the city hall. For them, only the emergencysystem is available. “They are mainly sub-SaharanAfricans who after arriving in Ceuta, Melillaor the Canary Islands without any identification aretransported to the peninsula and left by the authoritieswith an expulsion order that cannot be carriedout. They live without any means, no housing, badnutrition and whenever they get ill they have difficultyaccessing integral treatment for recovery.Even if they manage to stay at a shelter, there areno fixed places for ill persons and they are expelledafter three months, regardless of their health statusand even if they are receiving TB treatment,” saidCarlos Ugarte of MSF-Spain.The fact that they can only receive medical help at ahospital – assistance not exempted from barriers 206- may result in discharge from the hospital withouthaving access to any follow-up treatment.The existence of these problems has sparked someregional authorities to react. For example, theAutonomous Community of Madrid recently changedits rules and has started to provide health cards witha validity of six months to undocumented migrantswithout the need to register in the city hall.Thus far, however, undocumented migrants feelobliged to seek help from NGOs or other health careproviders. An example of an organization working inthis field in Madrid is Karibu – Amigos del PuebloAfricano. This organization assists undocumentedAfricans who do not have the health card by offeringdirect medical care from their team of volunteerdoctors or by making referrals to other centersrelying on their own networks.The organization KARIBU-Amigos del PuebloAfricano through its network of volunteersprovides assistance to the most excluded refugeesand immigrants coming from Africa whoare residing in the Madrid region. They have awelcome service and provide temporary housing,food and clothing. They also offer legal advice,medical assistance, help to access housing andthe labor markets as well as educational activitiesfor children and adults.In the field of health, a big part of their work isdevoted to assisting undocumented migrantswho do not have a health card, providing directprimary medical care and medicine or paying forlaboratory tests and other drugs. When patientsneed specialised treatments, they refer them tocooperating doctors and hospitals.http://www.asociacionkaribu.org/Seasonal workers also have very limited access tohealth care. The recent Report on basic needs andgeographical mobility of the seasonal immigrantpopulation in the counties of Lleida, 207 conducted bythe organization Salud y Familia in Lleida, Catalonia,on the request of the Catalonian government,has clearly shown that seasonal undocumentedimmigrant workers, who are mainly sub-SaharanAfricans, face very serious barriers to access healthcare and urgent action is needed to tackle all theconsequences. “These migrants usually have veryserious physical (muscles, bones, skin, dental…)and mental health problems but they do not seekhealth care at an emergency unit unless they aretotally desperate.” 208 Moreover, the most commonresponse given by hospitals and primary healthcenters is that “this is not the right place, not theright time, you need a health card, you have to be206According to Médicos del Mundo Spain, in some regions they even block the access to the emergency system. Availableonline at: http://www.medicosdelmundo.org/NAVG/pagina/IXInformeExclusionSocial.pdf207Salud y Familia, “Necesidades básicas y movilidad territorial de la población inmigrante estacional en las comarcas deLleida” (Barcelona: Salud y Familia, 2007).208Ibid.


Access to Health Care for Undocumented Migrants in Europe 87on our lists first, etc. In the end, they always postponethe treatment.” 209 After issuing this study, theorganization is seeking to extend its collaborationwith local public authorities with the aim of facilitatingseasonal migrant workers’ access to the healthcard in Lleida.Also remarkable is the insufficient access to reproductivehealth care in Spain by undocumentedmigrant women. The Ministry of Health recentlypublished that 40 to 50% of abortions in Spain areundertaken by migrant women. Elsewhere reportsclaim that more than 50% of those women areundocumented. Most women refer to their precariouseconomic situation as the reason behind theirdecisions and half do not use any contraceptivemethod. 210Salud y Familia is a private non-profit organizationbased in Catalonia that aims to contributeto interdisciplinary analysis, exchange ofideas and the articulation of operative solutionswhich improve health and the quality of familylife as a whole, as well as for each of its individualmembers, especially the most vulnerable.Salud y Familia works in collaborationwith public administrations, NGOs and individualsto develop innovative services and projectsthat involve referrals to the health care system,mediation and direct assistance to women andtheir families. The organization also cooperatesin programmes addressed to immigrants, especiallyin the field of health.Its “From Compatriot to Compatriot” projectseeks to facilitate undocumented migrants’access to health care by providing direct medicalassistance as well as information, mediation andhelp to access the public health care system.http://www.saludyfamilia.esThe fact that some Spanish organizations find noalternatives to the provision of direct medical assistanceshows that despite broad legal entitlements,the health care system is still failing to efficientlyaddress the issues at hand.Most organizations seek to avoid parallel systemsand alternative providers and claim that they preferthat public administration gives real solutions to havethese people covered by the common law system.“The law by itself does not mean anything. Thereis still the need of active public policies that makepossible the enjoyment of these entitlements,” saidCristina Nieto, project coordinator at Salud y Familiain Barcelona. In addition, as MSF has expressedthat financial support by public administrations toorganizations providing direct medical assistance toundocumented migrants is not a good solution eitherfrom an economic point of view or from a medicalperspective.A recent study has shown that immigrants withoutresidence permits use health services significantlyless than documented migrants. The researcherswonder whether in this context the strategy ofhealth care provision through alternative providersis able to effectively meet the health needs of undocumentedimmigrants. In their view, “as the needs ofillegal immigrants are rarely heard specific policieshave remained unquestioned.” 211It is clear then that, regardless of the existence ofa friendly legal system, undocumented migrantsliving in Spain generally face obstacles. Many ofthese barriers are linked to the fear of being discoveredand deported, fear of making contact with anykind of public administration, lack of information andunderstanding about the health system and theirentitlements, language and cultural differences,bureaucracy, and the fear of losing their jobs.209Ibid.210http://www.acaive.com/pdf/boletin%200.pdf. See also El País, 28.07.2006 and El Mundo, 28.11.2006.211Torres A.M. and Sanz B., “Health care provision for illegal immigrants: should public health be concerned?” in Journalof Epidemiology and Community Health, No. 54, 2000, p. 479. The report is based on 300 interviews. The purpose of thestudy was to test whether undocumented immigrants are effectively able to obtain medical treatment when they are ill.


88 PICUM10. SWEDEN“One day during winter, my daughter had problems breathing. It was late at nightand I really didn’t know what to do. I called a member of the church and he said thatregardless of how much it would cost, we had to get to a doctor. However, I didn’tfeel comfortable going to the hospital. I was so afraid that people would ask for myidentification and would expel us straight away. I tried some syrup for my daughterand she felt a bit better. Although the member of the church told me to go, I neverwent to see a doctor because I was too afraid.”A 28-year-old undocumented migrant woman from Africa 212» TermsGömda 213 - undocumented migrantsGENERAL HEALTH CARE SYSTEMSweden has a compulsory, predominantly tax-basedhealth care system providing coverage for the entireresident population. 214 Sweden’s health system attractsconsiderable resources and is recognized as one of thenation’s vital social institutions. Voluntary insurance isvery limited and typically provides only supplementarycoverage to the public health system.The Health and Medical Services Act establishesthat the goals of health and medical services are toensure the entire population’s good health on equalterms, and that care should be prioritized accordingto need. 215Health and medical care in the Swedish health caresystem is the shared responsibility of the state,county councils and municipalities. The state isresponsible for overall health, medical care policyand ensuring that the system works efficiently.The Health and Medical Services Act gives countycouncils and municipalities considerable freedomwith regard to how their health services are organized.County councils are responsible for providing healthcare, health promotion and disease prevention. 71% ofservices are financed by county council taxes althoughthey also receive revenue from patient charges andthrough central government grants. At the local level,municipalities deliver and finance social welfare servicesincluding health care for children, school careservices, care for the elderly, people with disabilitiesand long-term psychiatric patients. They also providerehabilitation and operate public nursing homes andhome care services. 216HEALTH CARE FOR UNDOCUMENTEDMIGRANTS1. Legal Entitlements to Access Fully orPartially Publicly Subsidized Health CareUndocumented migrants (gömda) - not includingchildren who are rejected asylum seekers - lack anylegal entitlements to benefit from the Swedish publichealth system. In contrast to Swedish citizens and212Médecins Sans Frontières, Experiences of Gömda in Sweden: Exclusion from health care for immigrants living without legalstatus, (Stockholm: MSF, 2005a). Available online at: http://www.lakareutangranser.se/files/ReportGomdaSwedenEn.pdf213This is a general term used to describe this population in Sweden. It means “hidden”. Many organizations are trying topromote an alternative concept to refer to this group of migrants.214Note however, that asylum-seeking adults do not have access to the same health care as adults domiciled in Sweden.215Hälso- och sjukvardslag 1982:763, sects. 2.216Große-Tebbe S. and Figueras J. (eds.), (2004:7). Available at: http://www.euro.who.int/document/e85400.pdf


Access to Health Care for Undocumented Migrants in Europe 89regular residents, undocumented migrants have topay full fees for receiving health care, even in casesof emergency. 217There is no specific legislation regarding access tohealth care for undocumented migrants in Sweden.The only indirectly applicable provision is establishedby the Health and Medical Services Act. 218According to this act, county councils are obliged totreat all persons in need of “immediate health care”regardless of legal status. Even if undocumentedmigrants who seek medical care in a public healthcarefacility receive the treatment required, thisdoes not imply that they are exempt from paying theentire cost of treatment and medicine, costs that aregenerally unaffordable for them.As reported by Médecins Sans Frontières, thereappears to be no official definition of the concept of“immediate health care,” thus “leaving it up to eachhospital manager to set the standards at each healthcare facility.” 219There is a law on disease control 220 whose oldwording (“foreign sailors”) does not specify whethermigrants without residence permits are entitled toreceive treatment in case of very specific contagiousdiseases. Practice seems to show that undocumentedmigrants can access treatment of certainsexually transmitted diseases (STDS), such asgonorrhea, Chlamydia and syphilis, free of chargein specialised clinics. Nonetheless, neither tuberculosisnor HIV/AIDS are included. For the latter, onlyscreening is free of charge provided that undocumentedmigrants go to the specific clinics establishedfor this purpose.In relation to children, in 2000 the governmentagreed to pay a fixed amount to the county councils tocover the costs incurred for providing health care tochildren whose application for asylum failed. Thereis not yet any legislation on this but just a financialagreement. 2212.The Situation in PracticeThe absolute lack of entitlements as well as theinexistence of any publicly funded reimbursementscheme to cover expenses incurred by hospitals forproviding health care to undocumented migrantshas led to numerous and serious consequences forundocumented migrants’ health. Similarly, it has putenormous pressure on health care providers andcivil society organizations.Undocumented migrants constitute one of the mostvulnerable groups in Sweden and failure by theSwedish government to recognize their presenceand their very basic health needs contributes largelyto their stigmatization and discrimination.Very few undocumented migrants attempt toapproach health services in Sweden and mostof them find numerous barriers against accessingappropriate health care. In the framework of asurvey conducted by Médecins Sans Frontières inStockholm from July to September 2005, 82% ofundocumented migrants who had sought healthcare reported to have encountered barriers againstaccess. They reported barriers such as being turnedaway by administrative staff at health care centersas well as indirect obstacles like the high costs ofconsultations and medication, the feeling that theywere not entitled to access health care and the fearof approaching the services and being reported tothe authorities.217This also applies to tourists and temporary visitors.218Sects. 4 of the Health and Medical Services Act : “Om någon som vistas inom landstinget utan att vara bosatt där behöveromedelbar hälso- och sjukvård, skall landstinget erbjuda sådan vård.”219See Médecins Sans Frontières, (2005a: 9). Available at: http://www.lakareutangranser.se/gomda.220Disease control Act, Smittskyddslagen (2004:168).221Överenskommelse mellan staten och Landstingsförbundet om hälsooch sjukvård för asylsökande m.fl. (financialagreement between the State and county councils regarding asylum seekers).


90 PICUMMédecins Sans Frontières is a medical humanitarian organization, working in more than 70 countriesacross the world. Guided by the principles of medical ethics, MSF’s focus is to support people in dangerwho for whatever reason do not have access to health care, regardless of race, religion, politics, or sex.MSF’s work involves provision of direct medical care and awareness raising of the plight of the people inneed of help.Läkare Utan Gränser (Médecins Sans Frontières Sweden) started working with undocumented migrantsin 2004. MSF Sweden is supported by a network of 50 specialised doctors, midwives and other healthprofessionals who work within public and private health services.This organization carried out research over a two-month period (July to September 2005) using: i) a questionnairesurvey on the health and social needs covering basic demographic details, family and socialsituation in Sweden and in their home country and health experiences in Sweden, including health status,medical needs and barriers to access health care; and ii) a mental health questionnaire (the HopkinsSymptom Checklist-25, HSCL-25) used to determine the clinical levels of anxiety and depression.Respondents were either new patients or patients who had previously gone to the MSF network for medicalassistance and who voluntarily agreed to participate. They were selected from a complete list of theservice’s patients. 102 undocumented migrants completed the questionnaire on health and social needs,23 filled in the mental health questionnaire and 6 recounted their personal stories thorough in-depthinterviews.The research describes the wide variety of medical needs for which patients could not access medicalcare and medication, including chronic diseases (diabetes and asthma), communicable diseases (sexuallytransmitted diseases and tuberculosis) and pregnancy. 13.7% were helped by MSF to access publichealth centers or hospitals. The remaining 86.3% were consulted within the volunteer MSF network. Asthe study expressively mentions, the research is “a testimony in itself to gömda’s exclusion from healthcare.”http://www.lakareutangranser.seWhen ill undocumented migrants approach a healthcenter, the first thing they are required to do isprovide their personal identity number. All individualswho are officially residing in Sweden have apersonal identity number that is commonly used tocheck the rights of individuals to access social andeconomic rights. Those without a personal identitynumber are basically denied access to these rightsunless there is special legislation covering particulargroups, such as asylum seekers. In a highly regulatedsociety like Sweden, “you cannot practicallyexist without having a social security number.” 222Undocumented migrants often go to public hospitalsonly when facing an urgent health need and willbe charged the full cost. Generally speaking, publichealth services perceive undocumented migrantsas synonymous with loss of income and therefore222PICUM, (2003b:34).


Access to Health Care for Undocumented Migrants in Europe 91are generally reluctant to treat them, especially ifthey have less urgent health problems. This is notonly the case within hospitals but also primaryhealth care centers and maternity centers where onmany occasions undocumented women are requiredto make advance payments. Consequently, manypregnant undocumented women do not receiveprenatal check-ups and only show up on the day ofdelivery. 223This seems to be different when treating children.Although undocumented children who have neverapplied for asylum are excluded by the law and thereforeonly entitled to “immediate care” at full cost,experience shows that hospitals generally providefree care to all children whatever their status. 224 Theproblem is that in most cases parents do not dareto bring their children to hospitals or even vaccinatethem. Undocumented migrant children’s access tohealth care is thus conditioned to a great extent bythe administrative status of their parents.Despite this, the tendency seems to be changing ashospitals are becoming increasingly aware of thedifference in entitlements of children depending onif they are refused asylum seekers or not. In thissense, as Charlotta Arwidson, Swedish Red Cross’coordinator of a project in the field of health care forundocumented migrants in Stockholm states, “weare noticing a growing awareness about this differenceso more and more parents are calling us abouttheir children.”In Sweden, the cost of health care (even basic) andmedicine is disproportionately higher for undocumentedmigrants than for Swedish nationals (seetable below). The exorbitant prices constitute oneof the most important barriers impeding undocumentedmigrants from seeking medical treatmentin Sweden.Table: Examples of charges for consultations and medication in SwedenCONSULTATION/MEDICATION COSTS FOR SWEDISH NATIONALS COST FOR GÖMDA AND TOURISTSConsultation with a doctor at an 260 SEK (27 EUR) 2,000 SEK (209 EUR)emergency departmentConsultation with a doctor at a 140 SEK (15 EUR) 1,400 SEK (146 EUR)primary health care clinicConsultation with a midwife at a 0 SEK 500 SEK (52 EUR)maternity centerDelivery 0 SEK 21,000 SEK (2,197 EUR)Insulin treatment for diabetes 1,800 SEK (188 EUR) per year 13,200 SEK (1,381 EUR) per year(type 1)Source: MSF Sweden 225223Médecins Sans Frontières (2007a: 9,21).224Ibid., p. 10.225Ibid.


92 PICUMAnother major barrier is the fear of being reported tothe authorities and expelled from Sweden. This factprevents undocumented migrants from requestingmedical assistance even in the most serious cases.In the MSF survey, many undocumented migrantsexpressed that seeking health care was very dangerousand some even reported knowing a close friendor family member who had been arrested by thepolice at the hospital or right after leaving it. 226Although medical personnel do not have an obligationto report to the authorities, 227 they cannotrefuse to cooperate with the police. If the police asksquestions, they are obliged to answer “yes” or “no.”It may happen that the police ask a hospital “Do youhave that person there right now?” If this is the case,the hospital staff must give the information. But thepolice cannot phone up and say “Do you think youmight have any undocumented migrants?” and askthem to give the names.Moreover, the billing can pose problems. Sometimeshospital administrations think that the treatedpatient has perhaps been in the asylum systembefore and thus contact the migration board to checkwhether they will pay for the costs. “This inquiry inrelation to medical costs can lead to the migrationboard alerting the police. So in that way, there’s anindirect threat.” 228For all these reasons, undocumented migrantsseek health care only if they are severely ill. Thus,going to hospital is always the very last resort. AsMSF’s survey shows, more than half of the respondentshad not attempted to visit a doctor since theybecame an irregular resident in Sweden. In theopinion of MSF, the restrictive Swedish system hasled to the near total exclusion of these individualsfrom accessing non-emergency and routine healthcare in Sweden. 229In the meantime, undocumented migrants’ healthstatus continues to worsen. Since their illnesses arenot detected at an early stage, their lives can be inreal danger. In fact, seemingly minor medical conditionscan develop into potentially “life-threateningsituations” if they are left untreated. As a result ofthis situation, patients present themselves at theemergency unit in a very critical state and thusrequire more costly inpatient care.3.The Role of Civil Society and Local ActorsFaced with these difficulties, undocumentedmigrants frequently avoid contact with official healthauthorities and when desperate they turn to a fewmedical clinics that have been opened in major citieson the initiative of NGOs and concerned health careworkers.At these clinics consultation is free and suitablemedicine for common illnesses are available. Sometimes,individuals donate drugs that they no longertake.The first initiatives emerged in the 1990s in Stockholmand Gothenburg. In the Stockholm area, the“refugee clinic” of Médecins du Monde Sweden andthe Asylum Committee have operated since 1995,providing support to undocumented migrants,mainly rejected asylum seekers. The foundersbrought together a team of volunteer doctors andnurses who provide health care support at a secretclinic in Stockholm city center every Wednesday. Theclinic is financed by private donations.226Ibid.227According to the Secrecy Act, general care staff cannot, as a general rule, divulge information of individuals. SeeSekretesslag 1980 (The Secrecy Act).228See PICUM (2003a:35).229See Médecins Sans Frontières,(2005a:9,15,20).


Access to Health Care for Undocumented Migrants in Europe 93Läkare i Världen (Médecins du Monde Sweden) isa humanitarian relief organization that supportsvulnerable populations through preventive andcurative health care in Sweden and abroad.Their activities are supported by volunteers,donations and institutional support fromdonors. Many of their volunteers are health careprofessionals, with doctors, nurses, midwivesand those with international field experienceforming the majority. However, the organizationwelcomes people from other professions. It doesnot support any political party or religion.In 1995, a refugee clinic was established in cooperationwith the Asylum Committee in Stockholm.Patients from the Middle East, Russia,Africa, Asia and the Balkans are treated on aregular basis. The clinic is open on Wednesdays.Amongst the more common diagnoses aretuberculosis, fractures, gynecological ailmentsand psychosomatic conditions caused by traumaticexperiences such as torture and war in thecountry of origin.http://www.lakareivarlden.orgIn Gothenburg, the Rosengrenska Foundationestablished a clinic in 1998 to support undocumentedmigrants. The purpose was also to attendto “hidden” failed asylum seekers’ health needs. Inrecent years, the number of volunteers supportingthis network has notably increased to the extentto allow this clinic to provide medical, psychologicaland dental care assistance to about 60 to 100 illundocumented migrants every week. As happenswith the majority of these charitable medical centersthroughout Europe, volunteer health care providersmake a remarkable solidarity effort considering thatthey provide this assistance after their daily workcommitments.Rosengrenska also uses its expertise to raiseawareness about the extreme exclusion of undocumentedmigrants living in Sweden, pointing out thatthey completely lack entitlements to enjoy minimumrights. To this aim, some staff members organizecampaigns, teach students at university or contactthe media. This foundation is also very involved incooperation with other organizations and hospitalsat the national and international levels.Rosengrenska is a voluntary charity network ofhealth professionals. It started its work in 1998with 25 volunteers aiming at providing medicalsupport to “hidden” migrants overstaying inSweden after their application for asylum failed.Today, Rosengrenska’s network consists of 650volunteers.One of their main activities is the provisionof direct medical assistance within churchesor private offices. Every week, the volunteernetwork of doctors and nurses forming this clinicmeets in order to provide medical, psychologicaland dental care to about 60 to 100 patients.Rosengrenska also holds university lectures forstudents and other groups to increase knowledgeabout undocumented migrants’ lack of accessto the national health system. They also bringattention to particularly vulnerable people suchas rejected asylum seekers with post-traumaticstress disorder.Cooperating with other organizations working inthis field in Sweden, like the Red Cross, MédecinsSans Frontières, Médecins du Monde, “No one isillegal”, Emmaus Bjorka, Amnesty medical group,and other hospitals and churches, Rosengrenskaorganizes public meetings and participates inmedia interviews to raise public awareness.http://www.rosengrenska.org


94 PICUMMore recently, several other initiatives in Malmö(e.g. the Delta Foundation) and in Stockholm havecontributed to reinforce the support provided toundocumented migrants.After an initial assessment which confirmed that thehealth needs of undocumented migrants were notbeing met in Sweden, MSF Sweden set up a projectin 2004 in Stockholm, the Swedish city with probablythe largest concentration of undocumentedmigrants. MSF’s work was supported by a networkof 50 specialised doctors, midwives and other healthprofessionals who work within public and privatehealth services. To access services, undocumentedmigrants contacted MSF through a help line. Wherenecessary, MSF’s nurses arranged a consultationwithin the MSF network. The consultation occuredat the regular working place of the volunteer staff,usually outside of normal working hours.Since 2006, this project has been carried out by theSwedish Red Cross. Services provided to undocumentedmigrants are mostly based on voluntarycontributions from skilled professionals. Thesevolunteers are doctors, midwives, psychologists,psychiatrists and physiotherapists who can independentlyconsult and treat patients, in their ownconsultation or at a hospital, or in the Red Crossrefugee center. The Red Cross also has volunteerswith specific language skills who can accompanyand support patients during a visit. An importantpart of their work is the help line coordinated by twonurses employed by the Red Cross.As explained by Charlotta Arwidson of the Red Cross,“the purpose is not to create a parallel system,however we continue working in this field as long asthe county councils do not take up their responsibilitiesas regards undocumented migrants’ healthcare.”The Swedish Red Cross holds the opinion that inaccordance with human rights principles, everyperson should have access to health care.In 2006, they started a project to provide directassistance to undocumented migrants. It wasin fact a project formerly carried out by MSFSweden. Since the start in 2004, the project hasreceived and treated 750 patients and providedaround 2,000 consultations.A network of about one hundred persons witha medical background work for the Red Cross.They voluntarily receive and provide care toundocumented patients without payment. TheRed Cross also works in cooperation with theprivate (but publicly financed) Ersta Hospital inStockholm and maintains contact with organizationsworking in Gothenburg and Malmö.They also act at the structural level to convincethe Swedish government to change the law. TheRed Cross demands that the government createsa regulation which provides to all people, regardlessof their legal status, access to health care inorder to address their medical needs.http://www.redcross.seWithout the solidarity work undertaken by all thesenetworks of doctors, nurses, priests and nuns tocover very basic necessities, the situation of undocumentedmigrants would be even more precarious.Nonetheless, the geographical coverage and theservices offered are indeed limited.Sometimes, patients require emergency andspecialist care or diagnostic tests such as bloodtests or x-rays. If this occurs, volunteer health careproviders try to refer patients to a regular hospital.


Access to Health Care for Undocumented Migrants in Europe 95In the opinion of Anne Sjögren, a volunteer nurseworking at the Rosengrenska clinic, “many doctorsand nurses help undocumented migrants inside thehospitals and many women give birth secretly insidethe hospitals without paying anything. Until nownobody has been punished as a result of this, but thediscussion is sometimes very hard.”Occasionally, treatment is provided in the privatemedical sector or by retired practitioners who oftenwaive charges for their services or offer lowerrates. 230There are also some hospitals that have developeda very friendly attitude towards undocumentedmigrants. Good examples are the Ersta Hospital inStockholm and the Sahlgrenska University Hospitalin Gothenburg.The Ersta Hospital is a standard Swedish non-profithospital funded by the state. At a certain moment,they made the decision to provide free access tohealth care to everybody, including undocumentedmigrants. “This decision has always been highlysupported by our staff. When Ersta Hospital startedto treat undocumented migrants, many doctors andnurses showed a great interest and concern towardsundocumented migrants,” explains the director,Dr. Henry Nyhlin. The hospital treats around 200undocumented migrants who consider this hospitala “safe place.” Many of these patients are referred toby different NGOs and by the Red Cross. The hospitalprovides generalist medical assistance, gastro andgynecologist consultations as well as certain operationsincluding cancer-related ones. “Although wedo not provide many specialist treatments such asdermatology, contagious diseases, maternity care orhealth care for children, we try to be ‘as generalistas possible.’ Otherwise, we have to arrange somethingwith other hospitals,” said Dr. Henry Nyhlin.Interestingly, the hospital has directly informed theSwedish parliament about its activities with undocumentedmigrants and has managed to have an informalagreement with public authorities according towhich the county council is paying the costs incurredby the hospital for providing health care to undocumentedmigrants. To make this possible in practice,the hospital provides undocumented migrantswith a hospital card containing a personal number.The county council reimburses the hospital basedon this number. Some pharmacies even take partin this informal agreement. Upon presentation ofthe hospital card, undocumented migrants receivepartial subsidization of medicine under the sameconditions as Swedish nationals.Since its foundation in 1853, the Ersta Hospitalhas addressed the needs of excluded people(e.g. homeless). It is a publicly funded non-profithospital with 450 staff members and 150 beds.Some organizations like the Swedish Red Crossregularly remit patients to this hospital whereundocumented migrants are treated at no cost.If the hospital cannot treat the patient, they referthem to other hospitals for more specialisedtreatment.The hospital collects general data about thepatients but never poses questions about theiradministrative status.http://www.ersta.seAcknowledging the results of the MSF’s study“Experiences of Gömda in Sweden,” the SahlgrenskaUniversity Hospital has also recently taken animportant step to raise awareness about the situationof undocumented migrants and their access tohealth care in Sweden. In a statement presented to230PICUM, (2003:19-20).


96 PICUMtheir board, the hospital commits to training its staffmembers about undocumented migrants’ presenceand needs. It also encourages staff to be “generous”when examining possible access to health carefor undocumented migrants, by suggesting ethicalreasons to “provide acute and necessary medicalcare to hidden refugees and patients that are notcovered by insurances or other agreements, regardlessof whether the patient is able to pay the fee at thetime.” They end their statement by upholding manyof MSF’s recommendations such as the call uponthe Swedish government concerning the need forshared rules and regulations that protect undocumentedmigrants’ right to access health care as wellas the establishment of a public system for financialcompensation to hospitals that provide health careand medical treatment to “hidden refugees.”The Salgrenska Hospital provides emergencyand basic care for the Gothenburg area (700,000inhabitants) and specialised care for westernSweden (1.7 million inhabitants). It is one of thesix teaching hospitals with medical education inSweden.It is a religious hospital funded by the State. Theyhave taken a small step: training staff membersabout undocumented migrants’ presence andneeds and also they encourage the staff to be“generous” when examining possible access tohealth care for undocumented migrants. They havemade a statement following some policy recommendationsmade before by MSF in its report.http://sahlgrenska.seSwedish organizations are increasingly raising theirvoices to ask for a formal and real solution to theproblem by bringing the attention of the media,writing shadow reports and trying to change thegovernment’s attitude towards undocumentedmigrants. “So far, the Swedish government hasclaimed that not paying for undocumented migrants’health care does not give the wrong message toundocumented migrants that they can stay. Surprisinglyhowever, one gets to know that they end upproviding some money to specific Swedish NGOsand hospitals to treat undocumented migrants. Theygive some support at the time that they do not wantto hear that these people are here. Is this systemsustainable? Until when can we keep this populationinvisible?” notes George Joseph of Caritas Sweden.In his country visit to Sweden, Paul Hunt, UN SpecialRapporteur for the right to health, clearly stated thatSwedish law and practice regarding access to healthcare for undocumented migrants “is not consistentwith international human rights law.” 231 The SpecialRapporteur also encouraged the Swedish governmentto reconsider its position with a view to offeringall asylum-seekers and undocumented personsthe same health care, on the same basis, as Swedishresidents.In his opinion, there is an urgent need for allowingundocumented migrants to access health care notonly for human rights and humanitarian reasonsbut also for compelling public health grounds. Inhis view, the estimated cost of extending the samemedical services on the same basis to residents,asylum seekers and undocumented individuals isunlikely to be significant.231UN Special Rapporteur on the right to health Paul Hunt, Report of the Special Rapporteur on the right of everyone to theenjoyment of the highest attainable standard of physical and mental health, A/HRC/4/28/Add.2 28. February 2007, p. 20.Available online at: http://daccessdds.un.org/doc/UNDOC/GEN/G07/111/82/PDF/G0711182.pdf?OpenElement


Access to Health Care for Undocumented Migrants in Europe 9711. UNITED KINGDOM“G is an Arab man whose nationality is disputed. He suffers from bowel cancer,and was admitted in an emergency because of uncontrolled bleeding. Theclinicians in A&E (accident and emergency departments) scheduled him foran operation as soon as the bleeding stopped. However, once the hospitaldiscovered G was a refused asylum seeker, he was given a bill for manythousands of pounds and his operation was cancelled. He was discharged fromhospital and told to come back ‘when his condition deteriorates.’” 232» Terms:GPs - general practitionersA&E - accident and emergency departmentsGENERAL HEALTH CARE SYSTEMThe United Kingdom’s health care system is calledthe National Health System (NHS). It is financed bynational taxation and managed by the Department ofHealth under the Secretary of State for Health. 233Recent figures show that only 10.8% of Britons opt forprivate insurance, policies which top-up NHS services,enabling shorter waiting times and a greaterchoice of facilities. 234The parliaments of Scotland, Wales and NorthernIreland implement national health legislationand manage regional health bodies. These NHSTrusts oversee the direct provision of health care. InEngland the system is shared among Primary CareTrusts, Hospital Trusts, Ambulance Trusts, CareTrusts and Mental Services Trusts. Established in2002, Primary Care Trusts are “the corner stone” ofthe health service; they commission and monitor theprovision of health services, manage hospitals andforge links with other NHS services. 235The right to health is not guaranteed by UK domesticlaw; as Britain lacks a codified constitution,fundamental principles governing the state derivefrom written and unwritten sources. 236 The Parliamentholds ultimate sovereignty with ParliamentaryActs, Statutory law and EU law taking the place ofconstitutional legislation. 237 Therefore, while noconstitutional guarantee of the right to health exists,national and supra-state protective mechanisms arein place. 238232Testimony taken from Kelly N., and Stevenson J., First do no harm: denying health care to people whose asylum claimshave failed, (London: Refugee Council, 2006), p.8.233The NHS is funded from a combination of direct taxes, VAT and employees’ income contributions.234Wallis G., The Demand for Private Medical Insurance, (London: Office for National Statistics, 2004), p. 47.235The role of public providers in Scotland is taken by Health Boards. In Northern Ireland they are called Primary CarePartnerships and in Wales Local Health Boards.236The British legal system consists of English law, Northern Irish law and Scots Law. While the first two are based oncommon law principles, Scots Law derives from civil law doctrine.237The 1998 Human Rights Act introduced the tenets of the European Convention of Human Rights into UK law and allowedUK courts to make rulings on its applicability.238However, for undocumented migrants, legal protection of the right to health often requires an innovative application ofthe European Convention clauses against cruel and inhuman treatment and respect for family life in the national courts.


98 PICUMThe NHS is legally bound to provide a “universalservice for all based on clinical need, not ability topay.” Their guiding principles assert “health careis a basic human right…unlike private systems; theNHS will not exclude people because of their healthstatus or ability to pay.” 239The birth of the NHS in 1948 has been described byTony Blair as “an act of emancipation… to a generationbrought up with the jar on the mantelpiece forthe doctor’s fee and dread if a child fell ill.” 240 Establishedon values of equal access and free care at thepoint of delivery, the NHS typified the social citizenshipapproach of state responsibility for the overallwelfare of its inhabitants.Now, almost sixty years after its inception, there isa concerted move by the NHS to consolidate freehealth care with legal residency. For many vulnerableundocumented migrants and their families, theNHS system is failing to alleviate the oppressive fearof illness for those living in poverty.HEALTH CARE FOR UNDOCUMENTEDMIGRANTS1. Legal Entitlements to Publicly SubsidizedHealth CareUnspecified and unrecognized in UK health legislation,undocumented migrants accessing health servicesfall into the category of “overseas visitors.” 241 Recentlegislative amendments have significantly reducedtheir ability to access health care.Undocumented migrants may receive primary healthcare in the UK. This includes first contact treatmentwith medical providers such as general practitioners(GPs). All residents of the UK are entitled to registerwith a GP. Once registered, an undocumented migranthas the same entitlements as other NHS patients: theymay receive NHS primary services free of charge butare liable for prescription charges. Also included in“primary care,” and therefore exempt from charges,are family planning services and compulsory mentalhealth treatment. 242Primary care is currently regulated by the HealthService Circular 1999/18. The circular clarifies that“eligibility to receive free medical treatment shouldrelate to whether a person is ‘ordinarily resident’ inthe UK.” 243Equally however, the circular reconfirms a GP’sright to “offer treatment to all people” and use theirdiscretion in accepting NHS patients. 244 Nevertheless,undocumented migrants may be turned awayfrom a medical center without the opportunity tospeak with a doctor.A public consultation entitled “Proposals to ExcludeOverseas Visitors from Eligibility to Free NHSPrimary Medical Services” closed in August 2004 butthe Department of Health has yet to issue renewedguidelines.239The Department of Health, The NHS in England: Core Principles. Available online at:http://www.nhs.uk/aboutnhs/CorePrinciples/Pages/NHSCorePrinciples.aspx.240The Department of Health, The NHS Plan: A Plan for Investment, A Plan for Reform, (London: Her Majesty’s StationaryOffice, July 2000), p. 8.241Hargreaves S., et al, The identification and charging of Overseas Visitors in Newham, (London: London HealthObservatory, 2007), p. 18.242This applies to those subject to the Mental Health Act 1973 or a court probation order.243Paragraph 1, The Department of Health, Health Service Circular 1999/018, (London: HMSO, 1999). A common law term,“ordinarily resident” is not defined within any of the NHS legislation but derives its meaning from the wide applicationof a House of Lords decision concerning education. Department of Health guidelines offer this interpretation to truststo determine whether a patient is “living lawfully in the United Kingdom voluntarily and for settled purposes as partof the regular order of their life for the time being, whether they have an identifiable purpose for their residence hereand whether that purpose has a sufficient degree of continuity to be properly described as ‘settled.’ See Department ofHealth, Implementing the Overseas Visitors Hospital Charging regulations: Guidance for NHS Hospital Trusts in England,(London: HMSO, 2004), p.13.244Health Service Circular 1999/018. This right is codified in Regulation 4 and 5 of the NHS (Choice of medical Practitioner)Regulations 1998.


Access to Health Care for Undocumented Migrants in Europe 99Emergency care, or treatment considered “immediatelynecessary” by a medical practitioner, should beprovided to “overseas visitors” and therefore, undocumentedmigrants even if they are unable to pay inadvance. Within their practice area, the GP’s term ofservice necessitates the free provision of treatmentthe doctor considers “immediately required owing toan accident or other emergency.” 245“Urgent” and “immediately necessary treatment”may also be provided free of charge to undocumentedmigrants within accident and emergency departments(A&E), walk in clinics and by district nurses employedunder the Primary Care Trust.While all care provided within the location of thehospital A&E department is considered “emergencycare,” emergency treatment administered inanother part of the hospital is chargeable. 246 Therefore,it is the location and not the type of treatmentthat is relevant. 247Undocumented migrants are no longer eligible forfree secondary care in the UK. Since April 2004,the National Health Services (Charges to Overseasvisitors) (Amendment) Regulations have limitedsubsidized secondary care to those able to proveone year’s legal residence in the UK. Those unableto prove this legal residence may only access nonurgentsecondary care on confirming their ability topay. “Immediate” and “urgent” treatment should beprovided without delay but the patient will be issueda bill. 248Under these regulations, NHS trusts, NHS foundationtrusts and primary care trusts are placed undera legal obligation to establish the residency statusof those to whom they provide services. Patientsfailing to pay for billed treatment risk having theirfees passed to a debt collector.Secondary care includes all referrals from firstcontactstaff for outpatient care and hospital treatment(including hospital treatment, in-patient careand out-patient department). Exceptions to chargesare granted in certain cases, such as the “easementclause” where a course of treatment continues tobe provided free of charge if it had begun before therefusal of an asylum claim. 249Of the sexually transmitted diseases and 34 communicablediseases exempt from charges on publichealth grounds, HIV/AIDS is not included as it wasexempt from the original 1989 legislation. 250 For HIV/AIDS patients, care is now limited to a diagnostictest and counseling; those wishing to receive drugsor treatment for their diagnosis are liable for fullpayment. 251Undocumented migrant women seeking maternitycare will be charged but Department of Health guidelinesconfirm that due to the many risks involved,“maternity services should not be withheld if thewoman is unable to pay in advance.” 252 After the carehas been given she will be liable for charges and thedebt “pursued in the normal way,” possibly passed toa debt recovery agency. 253245Paragraphs 4(1)h, 4(4), and 4(5) of Schedule 2 of the NHS (GMS) Regulations 1992 as amended and paragraph 2 of theContracts Directions and reaffirmed in the Health Service Circular 1999/18.246Department of Health (2004:17).247For example, an undocumented migrant involved in a near fatal accident would receive free treatment in A&E ‘but oncetransferred to the intensive care until would begin incurring charges that would ultimately amount to tens of thousandsof pounds’. See Kelly N., and Stevenson J.,(2006:8).248Guidelines state that ‘non-urgent or routine elective treatment…could in fact wait until the patient has returned home’,see Department of Health (2004:5).249For a full list of exceptions see ‘Regulation 4 – specific circumstances when an overseas visitor will be exempt fromcharges’, Department of Health (2004:19 – 24).250Regulation 3 ‘Exempt Services’ in NHS, Guidelines for Overseas visitors, p.17.251However, treatment is still provided free of charge by the Scottish Health Service.252Department of Health (2004:42).253In comparison, women legally residing in the UK, Switzerland or EEA countries are covered for all prenatal and antenatalcare until 15months after the birth.


100 PICUMUndocumented women requesting an abortionmust pay the charges in advance. Should they lackthe funds, Department of Health guidelines advisehospitals to “decline to provide the service andshould advise the woman to seek termination in herown country.” 254 Should the woman’s life be at risk, atermination may be administered but “she remainsliable for charges and the debt should be pursued inthe normal way.” 255Pregnant undocumented women diagnosed withHIV/AIDS are not eligible for subsidized care whichcan reduce the chance of mother to baby transmissionfrom 33% to 1%.Children of undocumented migrants are entitled tofree health care which is considered “urgent” and“immediately necessary”; their parents or guardianwill be liable for charges regarding any secondarycare. 256 Unaccompanied minors are also “chargeable”;a bill will be handed to the person accompanyingthe child and “copies should be sent to the child’sparents.” 257Since the April 2004 amendments, medical chargesnow apply to those in receipt of “hard case” supportbecause they are unable to leave the UK or have yetto receive a decision regarding their claim to stayin the UK under Article 3 or 8 ECHR. 258 As neithergroup is entitled to a legal source of income, they areeffectively unable to access any secondary care. 259The Secretary of State for Health may grant treatmentto an individual on humanitarian grounds butdecisions are purely discretionary.Before these changes, all NHS care had beenavailable without charge to those who could proveresidence, even irregular, in the UK for the previoustwelve months. 260 While entitlements werecommonly unknown by medical practitioners anddifficult for undocumented migrants to access andwithout any comprehensive evidence of systematicabuse, the government decided to implement additionalbarriers to tackle so-called “health tourism.”2.The ProcedureGPs are allocated according to catchment areas,varying from town, postcode or even street address.The first step for an undocumented migrant wishingto access GP services is to locate surgeries in theirdistrict. 261Once identified, the surgery’s reception staff mustbe contacted for information about available spaceon the NHS practice list. GP practices are under noobligation to register a patient unless they have beenexplicitly assigned by the health authority. Owingto clear misunderstanding, a full patient list, opendiscrimination or perhaps instructions from the GP,reception staff may refuse to register the undocumentedmigrant as a NHS patient. In these cases254Department of Health (2004:46).255Ibid.256Ironically, children rendered ‘unaccompanied’ due their parents remaining abroad while placing them in private boardingschools are exempt from charges for secondary treatment as the school is legally acting in loco parentis. Department ofHealth, (2004:46).257Ibid.258Joint Committee on Human Rights, Tenth Report, para. 125 available at:http://www.publications.parliament.uk/pa/jt/jtrights.htm.259Failed asylum seekers unable to return to their home country may apply for ‘section 4’ or ‘hard case’ support. The fewwho do qualify for support are often unable to travel due to a physical medical reason or factors beyond their control.Applications for support under section 4(2) and 4(3) of the Immigration and Asylum Act 1999 can be made to the HomeOffice who will provide support in the form of accommodation support, and vouchers for food and basic toiletries.260‘NHS Act 1977’ and ‘National Health Service (Charges to Overseas Visitors) Regulations 1989’ with amendments in 1994,1991 and 2004.261The NHS offers a confidential, 24-hour health and information service issuing lists of practices and the GPs they hold.Information on GP and Dental Services are also available through the interactive search on the NHS websitehttp://www.nhs.uk.


Access to Health Care for Undocumented Migrants in Europe 101they may be offered treatment if they register as aprivate, fee-paying patient. 262If the receptionist confirms the surgery will acceptthe applicant as an NHS patient, the registration formGMS1 will be issued. 263 The form contains informationfields for personal details, address and, in order toretrieve any medical records existing in the UK, detailsof previous addresses and GPs visited. Some practicesinquire about medical history and ask registrants todetail their ethnic background and list serious illnesses.264 The receptionist will request proof of addressand identity documents.Surgeries may accept undocumented migrants asNHS patients registering them either as “temporaryresidents” or “fully registered” NHS patients. 265 Onceregistered as an NHS patient, an undocumentedmigrant may receive treatment from the GP free ofcharge, even if not “immediately necessary.” 266In hospital accident and emergency departments(A&E), “urgent” and “immediately necessary treatment”is provided free of charge to undocumentedmigrants. The same applies for emergency care inwalk-in clinics and from district nurses employed bythe Primary Care Trusts. Upon arrival to the A&E,patients are “triaged” by a medic to decide if theyrequire immediate treatment. If their ailment is notan emergency, they will be advised to visit their GP ormake an appointment in another department of thehospital. This process also applies to those arrivingin an ambulance.In situations where the patient is directly admittedto critical care or mental health wards, departmentalguidelines state that questioning regardingentitlement “could be inappropriate” and “admittingstaff should alert the Overseas Visitors Team of anypatient who, on the information before them, couldpotentially be liable for charges.” 267For all other hospital care, including in-patient andout-patient care, undocumented migrants will becharged. It is the legal responsibility of hospitaladministration staff to identify all patients “who arenot ordinarily resident.” 268Department of Health guidelines offer “baselinequestions” (“Where have you lived for the last 12months?” and “Can you show that you have the rightto live here?”) to be posed to every patient beforeeach new course of treatment commences so asto establish whether or not the patient was eligiblefor charges. Unlike in other European countries,no safety net exists in the UK to enable particularlyvulnerable groups such as children and pregnantwomen to access health care.Beginning with a note on “avoiding discrimination,”these guidelines assure staff “it is not racist to asksomeone where they have lived for the last twelvemonths as long as you can show that all patients –regardless of their address, appearance or accent– are asked the same question.” 269 If the patientcannot prove legal residence in the UK for the previoustwelve months, booking-in staff or ward-clerksinform them they may be liable to pay for treatment,refers them to the “Overseas Visitors Manager” andplaces the following note inside their medical file:262Regulations 4 & 5 of the NHS (Choice of Medical Practitioner) Regulations 1998.263Standard version is available online at: http://www.nhs.uk/aboutnhs/howtheNHSworks/doctors/Documents/GMS1.pdf264Example available online at: http://www.burgessroadsurgery.co.uk/pages/Form%20GMS1.htm265NHS, 1999/18, 5(b)(ii).266Charging exceptions for NHS patients may be provided in the GMS’s term of service or the PMS pilot scheme contract.267Department of Health, (2004:10).268Ibid, p.16.269Ibid, p.8.


102 PICUMPATIENT MAY NOT BE ORDINARILY RESI-DENT IN UNITED KINGDOMThis patient may not normally be resident inthe United Kingdom and has been referredfor further interview by the Overseas VisitorsTeam. The patient may be liable to pay forany treatment received. The patient has beeninformed. For further information contact:0113 2545819The interview with Overseas Visitors Managershould occur before treatment has begun unless itis considered “urgent” or “immediately necessary.”The patient is informed they may be eligible forcharges and must then be categorized as either an“overseas visitor” or “ordinarily resident.”If liable, “appropriate charges must be set” by amember of the trust. 270 The responsibility for recoveringcharges is then passed to the finance staffwho issue invoices. Departmental guidelines statethat “Trusts are strongly advised to make use of adebt recovery agency that is experienced in handlingthe recovery of overseas debt if they have significantlevels of unrecovered overseas visitor debt.” 2713.The Situation in PracticeAdministrative staff are the first point of call forthose seeking care in a hospital or medical practice.While a doctor is legally bound to provide “urgent”and “immediately necessary care” to all residents inthe UK, the decision is initially the receptionists whooften guard access to medical professionals. Theregistration system they oversee is inconsistent anddocumentation requirements vary dramatically.While there is absolutely no duty for health carestaff in the UK to denounce, the “overseas visitors’”amendments and administrative checks have ledmany staff, both in GP practices and hospitals, towrongly believe that their duty to check entitlementis also a duty to report to immigration authorities.There are growing reports of staff contacting theHome Office to inform about the immigration statusof current or potential patients.Undocumented migrants may be embarrassed andintimidated by inquiries into their health and residencestatus and reluctant to provide this informationto someone in an official position. “They thinkonce my details are registered onto a computer, thisis seen by immigration officers and they will comeand find you. Therefore, if you start spreading thenews that hospitals and GP surgeries are looking atidentifying people for charging, they are not going tocome forward at all.” 272Restricting access to “overseas visitors” at the pointof call for medical care encourages discriminationbased on color and origin, adversely incongruent withthe ideals of a multicultural Britain. 273 This policyregulation not only causes additional stress and fearamong those in urgent need of care, but adds additionalburden and cost to NHS resources. “I havenoticed that within my own surgery people carry theirpassports around to show their identification and arebeing asked for this by receptionists ‘what passport doyou hold – can we have a copy of this’. It’s quite dauntingwhen you are trying to access health care.” 274The British Medical Association has noted “considerableconfusion about overseas visitors’ eligibilityfor NHS primary medical services; this is largelybecause of a lack of clarity in the NHS regulations.” 275270Ibid., p.16.271Ibid.272Testimony taken from Hargraves (2007:40)273The Joint Council for the Welfare of Immigrants criticized the Department of Health for not conducting a race impactassessment.274Testimony taken from Hargraves (2007:38).275See British Medical Association (BMA), General Practitioners Committee, Overseas Visitors -Who is eligible for NHSTreatment, (London: BMA, 2006), p.1.


Access to Health Care for Undocumented Migrants in Europe 103This growing uncertainty coupled with undocumentedmigrants’ lack of knowledge concerningtheir entitlements has resulted in many unforeseenbarriers to health care access.Language problems also make it difficult to communicatehealth needs, especially for patients requiringconfidentiality, or experiencing mental healthissues. Administrative staff unable to establish thecare an undocumented migrant wishes to accessand with whom communication proves difficult, arelikely to refuse registration. NHS trusts may offertelephonic interpretation whereby the receiver canbe passed between medical or administrative staffand the migrant, however “such services are notalways available.” 276Whilst prenatal and postnatal care provided in thecommunity are free of charge, payment problemsoften arise during hospital visits. The fear of accumulatingdebts forms a major barrier against undocumentedwomen seeking natal care and results inmany giving birth at home alone. There is a consistentfailure to notify them that, under NHS regulations,care is free at the point of delivery. Advancepayment demands are often issued. Furthermore,these women can rarely afford additional treatmentfor abnormalities identified in the screening process.“D, a young Chinese woman, was given an upfrontpayment schedule by the trust. She borrowed £800for the first payment, then was unable to fund thesubsequent payments of £800 and £700. She gavebirth at home, but was still billed by the Trust for thefull amount.” 277Prior proof of solvency may be requested for treatmentsnot considered “immediately necessary.” 278Undocumented migrants who have been approvedfor NHS treatment may apply for financial assistancefor prescriptions and travel but no help is providedto pay for treatment. 279Undocumented migrants have identified the difficultiesin registering with GP surgeries as one of the toughestbarriers they face. 280 A surgery can “decide for itself”that the patient list is full, leaving full decision in thehands of administrative staff. Such a non-transparentand discretionary system provides little challenge tolatent racism and discriminatory practices.Official guidelines advise primary care workers “tooffer private medical treatment if it appears thatthe patient has come to the UK specifically to obtaintreatment.” 281 Such procedures may encourageunfounded judgments regarding the motivations ofnon-nationals accessing health care. “There existsdiscriminatory practices by reception staff. One toldmy client ‘why don’t you learn English’ and ‘why didyou come to this country’…Receptionists and practicemanagers are a big problem…they don’t makeit easy for people who have problems in English orwho need to register.” 282The NHS advises staff “the way to avoid accusationsof bias is to ensure that everybody is treated thesame way,” however for those facing daily racism anddiscrimination, such questioning has a highly negativeimpact. 283 The British Medical Association finds the“uncertainty unsatisfactory and would welcome clear,non-discriminatory guidance” for practitioners. 284276British Psychological Institute, written evidence provided to the Joint Commission for Human Rights, Tenth Report.Available online at : http://www.publications.parliament.uk/pa/jt200607/jtselect/jtrights/81/8115.htm.277Kelly N. and Stevenson J., Available onlin at: http://www.refugeecouncil.org.uk/downloads/rc_reports/Health_access_report_jun06.pdf .278Even for those who have the means to pay, evidence may be hard to find when ill and living in an irregular situation.279Leaflets on the NHS Low Income Scheme entitlements and HC1 forms are available from NHS health care centers.280Traore C., ‘Speaking notes for a workshop at PICUM Conference on Access to Health Care for Undocumented Migrants’held in Brussels 28-29 June 2007, p.5. Available online at: http://www.picum.org.281NHS, Health Service Circular 1999/18.282Testimony taken from Hargraves (2007:37)283Department of Health, (2004:8)284British Medical Association, (2006:1)


104 PICUM4.The Role of Civil Society and Local ActorsAlthough undocumented migrants have increasedhealth needs, they remain “largely hidden to healthservices and public health initiatives.” 285 With theBritish state failing to meet their health care obligations,the duty to protect undocumented migrantsfalls upon NGOs and voluntary health providers.They offer services ranging from advocacy, adviceand medical treatment. Assisting access to mainstreamservices, civil society organizations work toaddress the barriers facing undocumented migrantsand where access is denied, they create alternativesystems of care.A main concern of NGOs is to enable access to mainstreamservices. To this end, Médecins du MondeProject: London advocates on behalf of undocumentedmigrants to ensure they have access toa GP; they contact individual surgeries, organizeinterpretation services and accompany patients onappointments. Support workers will communicatewith reception staff of NHS practices and informthem of undocumented migrants’ rights to accessservices. If registration still proves problematic,they can request the Primary Care Trust to allocatea GP directly.In order to overcome administrative barriers,walk-in clinics have been established which donot require identification or residency documents.Attracting many undocumented migrants and thosein precarious residency status, Project: Londonoffers free and confidential support “whatever yourstatus and wherever you live.” Patients are greetedby a “support worker” who will inform them of theirentitlements under the NHS and provide support inaccessing these services.Médecins du Monde provides health care tovulnerable populations in 54 countries worldwide.Well known for their work in war torn ordeveloping countries, they have been operatingin Europe for the past 20 years and opened theirfirst British Clinic in London January 2006.Project: London is an advocacy project run byMédecins du Monde UK providing information andassistance to vulnerable people. As the projectmakes contact with those who normally avoidmainstream services, they took the initiativeto record the numbers and needs of its serviceusers, providing a vital data source for lobbyistsand advocates.In a notable submission to the Tenth Committeeon Human Rights, Project: London criticizedthe “overseas visitor” amendments for violatingthe right to life by “denying some people vitaltreatment for their survival’. Treating those onvery low income or no income at all and thereforetotally reliant on the community to survive,Project: London considers charging those withpotentially terminal diseases, thousands ofpounds they will never have “effectively a deathsentence.” 286http://www.medecinsdumonde.org.uk/Civil society actors have established their ownsystems of care offering medical assistance throughdrop in clinics and emergency services. The NewhamPrimary Care Trust actively enables vulnerablemigrants to obtain fast and immediate medicaladvice and treatment at their walk-in center. Openfrom 7am to 10pm weekdays, the center providesskilled and experienced care with no appointment,285The Health Protection Agency, ‘Migrant Health: Infectious diseases in non-UK born populations’, (London: HealthProtection Agency, 2007), p.29.286Médecins du Monde, Written Evidence to the Joint Committee on Human Rights N.41, (2006) p, 5. Available online at:http://www.parliament.the-stationery-office.com/pa/jt200607/jtselect/jtrights/81/81we48.htm


Access to Health Care for Undocumented Migrants in Europe 105payment or documentation required. Establishedto complement, but not replace, GP surgeries, thecenter provides transitional services includingscreening and treatment for illnesses and injuries.To bridge language and communication gaps, civilsociety organizations provide multi-lingual informationleaflets to advertise their services and offertranslation to visitors seeking information or treatment.Assistance is also provided to enable communicationwithin GP surgeries.Serving an ethnically diverse borough of London,the Newham Primary Care Trust works toreduce health inequalities and promote publichealth among groups facing existing inequalities,deprivation and ill health. The boroughof Newham has the lowest life expectancy andhighest infant mortality rates in London and theTrust’s 1,050 staff work to reduce health inequalitiesand improve access among the populationof 247,737.Working within a community where 62% of residentsconstitute ethnic minorities, including newand recent arrivals, the Trust voiced seriousconcern regarding the knock on effect recentpolicy changes has had upon other migrantgroups, limiting their entitlement to NHS care.Actively identifying and addressing inequalitiesbetween ethnic groups or geographical areas inNewham, the Trust provides health services inschools, clinics and health centers, GP premisesor in the home. They offer a range of complementaryservices aimed at raising the communities’standard of health such as clinical psychologyand counseling, community dentistry, physiotherapyand, speech and language therapy.The information provision carried out by local actorsis twofold; they not only inform undocumentedmigrants of their entitlements in a language theywill understand, but also work to publicize the situationof undocumented migrants, counteractinggovernment claims of “health tourism” and lobbyingagainst proposed charges for primary health care.Undocumented migrants are not entitled to a legalsource of income in the UK and many find difficultyin affording prescribed medication. This burden iseased by Project: London which offers free medicationto those to whom they have given a prescriptionthrough the use of a partner pharmacy nearby whichis sensitive to the needs and concerns of projectreferrals.The inability of undocumented migrants to accesssecondary care is particularly harsh for thosesuffering from terminal or potentially terminalillnesses. Facing immense barriers against accessto care, those with HIV status already find it hard toregister for NHS services and medical professionalsoften treat them in a brisk and awkward manner.Undocumented migrants lack social and medicalentitlements and face additional discriminationmaking them among the most vulnerable groupsaffected by HIV.The Terrence Higgins Trust is an HIV and sexualhealth charity active in both campaigning and providinga wide range of services. As African migrantsnow constitute the majority of new HIV diagnoses inthe UK, the Trust has formulated innovative projectsto meet their needs. Concerned that the governmentpolicy of non-treatment creates a disincentiveagainst testing and places more individuals at risk,the charity offers additional treatment and a mentoringservice as well as providing basic tests.http://www.newhampct.nhs.uk/


106 PICUMEstablished in 1983, the Terrence Higgins Trustwas the first charity in the UK founded in responseto the HIV epidemic and has been at the forefrontof the fight against HIV and AIDS ever since. Theneeds of people living with, and affected by, HIVhave been fundamental to its development.The charity’s roots were in the gay communityand, for many years, the HIV epidemic in the UKaffected mainly gay men. As the shape of theepidemic has changed, so has the Trust. MoreAfrican people living in the UK are diagnosedwith HIV than gay men each year now. So existingservices have been developed and new servicesintroduced to meet ever-changing needs.In a government briefing paper on undocumentedmigrants’ access to HIV treatment, the Trustdebunks the myth of “treatment tourism.” Theirresearch proves that migrants access HIV treatmenta considerable time after their arrival inthe UK. The Trust strongly condemned the billingand denial of HIV treatment to undocumentedmigrants: “The use of health care as an instrumentof immigration policy is unacceptable. Thewithdrawal of accessible life-saving treatmentsdoes not speed up removals, it hastens deaths.We are simply arguing that while people are herethey should be treated well.” 287The UK has no “sans-papiers” movement challengingstructural social exclusion; replacing collectiveaction are community organizations and adviceagencies. 288 Civil society bodies providing urgentcare must work hard to effectuate policy changesand group linkages. 289The government has yet to provide comprehensiveevidence of the “health tourism” which recent legislationswas set to hamper. The amendments simplyplace an added burden on civil society actors already“propping-up” the inadequacies of the NHS.Calls for reviewing the Overseas Visitors legislationhave come from both health care professionals andNGOs. When professional bodies such as the BritishMedical Association are advising its members tocontact the Refugee Council for assistance in treatingand supporting undocumented migrants, thefailure and distrust in government policy becomeshighly evident. 290http://www.tht.org.uk287Terrence Higgins Trust and National Aids Trust, Note on access to HIV treatment for undocumented migrants and thoserefused leave to remain, available at: http://www.tht.org.uk/binarylibrary/westminsterhallbriefingonaccess.pdf288Frank Duvell (PICUM, 2002:34).289Médecins du Monde offer a good example by working within the premises of Praxis, a partner organisation already closeto undocumented migrants and providing complementary services. Such ‘one-stop-shops’ are attractive to users andenable providers to share resources.290The British Medical Association advise GPs ‘In situations where treatment is not being offered under the NHS, and thepatient is unable to pay privately, GPs may wish to refer the patient to an organization such as The Refugee Council…which may now if there are any other services available in the area’. See BMA (2006:6)


Access to Health Care for Undocumented Migrants in Europe 107Recommendations1. Respect international obligationsEuropean Union member states should comply withinternational obligations and therefore progressivelyguarantee that the right to the highest attainablestandard of physical and mental health is enjoyed byall regardless of administrative status.The right to health care for undocumented migrantsis guaranteed in the following United Nations conventionsand declarations and European conventions:• UDHR - Universal Declaration of Human Rights,Art 25• ICERD - International Convention on the Eliminationof All Forms of Racial Discrimination, Art 5(e-iv)• ICESCR - International Covenant on Economic,Social and Cultural Rights, Art 12 (1) and GeneralComment 14 to the ICESCR, paragraph 34• CRC - Convention on the Rights of the Child, Art24(1), 25, 39• CEDAW - Convention on the Elimination of All Formsof Discrimination Against Women, Art 14 (2b)• ESC – European Social Charter (Revised), Art 13• ECHR – Convention for the Protection of HumanRights and Fundamental Freedoms, Art 3. 291Member states should not deny or limit equal accessfor all persons to preventive, curative and palliativehealth services.2. Particularly vulnerable groups ofundocumented migrantsMember states should especially address the healthcare needs of particularly vulnerable groups ofundocumented migrants (e.g. children, pregnantwomen, the elderly, disabled, people with severechronic diseases e.g. HIV / AIDS) and strive toequally meet their needs on the same basis as forthe comparable national population.3. Ensure implementation ofentitlementsMember states should take the necessary measuresto guarantee that undocumented migrants’ entitlementsto health care are uniformly implemented byregional and local authorities.4. Ensure access to information aboutentitlementsMember states should ensure that information aboutundocumented migrants’ entitlements is accessibleto all actors involved and eliminate all practicalbarriers that prevent undocumented migrants fromenjoying their entitlements to health care.5. Detach health care from immigrationcontrolPatient-related medical confidentiality shouldnot be undermined by direct or indirect reportingmechanisms. Member states should detach healthcare from immigration control policies and shouldnot impose a duty upon health care providers andhealth administrations to denounce undocumentedmigrants.291See PICUM (2007: 12 & 29)


108 PICUM6. Civil society should always play acomplementary roleThe ultimate responsibility in providing health careto undocumented migrants rests on the nationalgovernment. Civil society plays a role of facilitatinghealth care to undocumented migrants, but thisshall only be complementary to the duties of thegovernment.7. No criminalization of humanitarianassistanceProviding humanitarian assistance to undocumentedmigrants should not be criminalized. Member statesshould not criminalize civil society for providinghealth care and health-related assistance to undocumentedmigrants.8. Include undocumented migrants inSocial Inclusion-Social ProtectionProcessMember states and EU institutions should includeundocumented migrants within the European SocialInclusion-Social Protection Process and the NationalAction Plans (NAPs).9. Civil society involvement inconsultation processesCivil society organizations, health care providersworking with undocumented migrants and localauthorities responsible for public health shouldparticipate in regular reporting and consultationprocesses, to inform authorities and policy makersabout barriers encountered by undocumentedmigrants in accessing health care. 29210. Ratify the International MigrantWorkers’ ConventionMember states should ratify and implement theInternational Convention on the Protection of theRights of All Migrant Workers and Members of TheirFamilies, which stipulates in Article 28:Migrant workers and the members of theirfamilies shall have the right to receive anymedical care that is urgently required for thepreservation of their life or the avoidance ofirreparable harm to their health on the basis ofequality of treatment with nationals of the Stateconcerned. Such emergency medical care shallnot be refused them by reason of any irregularitywith regard to stay or employment. 293292PICUM has developed a Self Description of Organization (SDO) and Reporting Template to assist local actors to advocatefor specific and clear actions at the national level in the framework of the European Social Inclusion-Social ProtectionProcess. The SDO and Reporting Template can be used to address undocumented migrants’ social exclusion causedby the lack or insufficient access to health care. These reporting tools are available in nine languages (Dutch, English,French, German, Hungarian, Italian, Portuguese, Spanish and Swedish) at http://www.picum.org.293See PICUM (2007: 5)


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Access to Health Care for Undocumented Migrants in Europe 111Global Commission on International Migration (GCIM), Migration in an interconnected world: New directions for action.Report of the Global Commission on International Migration, October 2005. Available online at:http://www.gcim.org/attachements/gcim-complete-report-2005.pdfGroße-Tebbe S. and Figueras J. (eds.), Snapshots of Health Systems – The State of Affairs in 16 Countries in Summer2004. [Copenhagen: WHO, 2004]. Available online at: http://www.euro.who.int/document/e85400.pdfGroß J., Medizinische Versorgung von Menschen ohne legalen Aufenthaltsstatus. [Berlin, 2005a]. Available online at:http://gesundheitspolitik.verdi.de/gesundheit_von_az/migration/medizinische_versorgung_von_menschen_ohne_legalen_aufenthaltsstatus, Möglichkeiten und Grenzen der medizinischen Versorgung von Patienten und Patientinnen ohne legalenAufenthaltsstatus. [Berlin, 2005b]. Available online at: http://www.medibuero.de/attachment/39b520617b75d0e45fa5eb4f5da202aa/e98aee3b56b36b349988096301dc1c23/Faltblatt.pdfGroupe d’Information et de Soutien des Immigrés Accès à l’Espace Privé (GISTI), Sans-papiers mais pas sans droits, 4thed., June 2006. Available online at: http://www.gisti.org/doc/publications/2006/sans-papiers/index.htmlHargreaves S., et al, The identification and charging of Overseas Visitors in Newham. [London: London Health Observatory,2007].Health Protection Agency, Migrant Health. [London: Health Protection Agency, 2006].Hungarian Ministry of Health, Beneficiaries of health care in Hungary with special regard on Foreigners, [2004a]. Availableonline at: http://www.eum.hu/index.php?akt_menu=3550, Legal and operational environment of the health care system, [2004b]. Available online at:http://www.eum.hu/index.php?akt_menu=3550IDOS (Italian Contact Point), European Migration Network, Illegally resident third country nationals in Italy: stateapproaches towards them and their profile and social situation 2005. Available online at:http://www.emnitaly.it/researches.htmInternational Migration, Integration and Social Cohesion (IMISCOE), Social Integration & Mobility: Education, housing &health. [Lisbon: Universidad de Lisboa, 2005]. Available online at: http://www.imiscoe.org/research/clusters/b5.htmlInternational Organisation for Migration (IOM) – European Network for Co-operation and Exchanges on Social Exclusionand Health Issues for Migrants, National Report Austria: Soziale Exklusion und Gesundheit von MigrantInnen in Österreich.[Wien: Ludwig Boltzmann Institut, 2003].International Organisation for Migration (IOM) – National Contact Point Austria within the European Migration Network, IllegalImmigration in Austria: A Survey of recent Migration Research. [Wien: IOM, 2005]. Available online at:http://www.emn.at/modules/typetool/pnincludes/uploads/FINAL_VERSION_ENG.pdfJesuit Refugee Service, “We Are Dying Silent” - Report on Destitute forced Migrants. [Brussels: Jesuit Refugee Service,2007]. Available online at: http://www.jrseurope.org/EPIM/intro.htmJoint Committee on Human Rights of the House of Lords and the House of Commons, UK, Tenth Report, March 2007.Available online at: http://www.publications.parliament.uk/pa/jt200607/jtselect/jtrights/81/81i.pdfKelly N. and Stevenson J., First do no harm: denying health care to people’s whose asylum claim has failed. Available online at:http://www.refugeecouncil.org.uk/NR/rdonlyres/ 9A4F66C5-2D32-4534-ABE6-FA63C828DF49/0/Healthaccessreport_jun06.pdfLampion, Health Care for Undocumented Migrants; Information and Advice. [Utrecht: Pharos, 2006].Koch U., Kranksein in der Illegalität, Statement im Rahmen der Anhörung zum Recht auf Gesundheit am 7. März 2007 imBundestagsausschuss für Menschenrechte und humanitäre Hilfe. Available online at:http://www.forumillegalitaet.de/Materialien/Ute_Koch/MenschenrechtsausschussStatement_Ko.pdf


112 PICUMMédecins du Monde, First European Observatory on Access to Health Care. [2007]. Available online at:http://www.medecinsdumonde.org/gb/presse/dossiers_de_presse/premier_observatoire_europeen_de_l_acces_aux_soins_septembre_2007, Written Evidence to the Joint Committee on Human Rights N.41, [2006]. Available online at:http://www.parliament.the-stationery-office.com/pa/jt200607/jtselect/jtrights/81/81we48.htm, Rapport 2005 de l’Observatoire de l’Accès aux Soins de la Mission France de Médecins du Monde. [2005]. Availableonline at: http://www.medecinsdumonde.org/thematiques/ l_observatoire_de_l_acces_aux_soinsMédecins Sans Frontières, Accès aux soins en Belgique: Rapport d’activité 2005. [Bruxelles, MSF, 2006]. Available onlineat: http://www.msf.be/fr/pdf/rapport_belg_2006.pdf, Experiences of Gömda in Sweden: Exclusion from health care for immigrants living without legal status. [Stockholm:MSF, 2005a]. Available online at: www.lakareutangranser.se/files/ReportGomdaSwedenEn.pdf, Il Frutti dell’ipocrisia. Storie di chi l’agricoltura la fa. Di nascosto. [Roma: Sinnos Editrice, 2005b].http://www.lakareutangranser.se/files/ReportGomda SwedenEn.pdfMédicos del Mundo, Informe de Exclusión Social. [Madrid: Médicos del Mundo, 2005]. Available online at:http://www.medicosdelmundo.org/NAVG/pagina/IXInformeExclusionSocial.pdf, Informe de Exclusión Social. [Madrid: Médicos del Mundo, 2003]. Available online at:http://www.medicosdelmundo.org/NAVG/pagina/NAVGPopUpInformeExclusionSocial.jspMédicos Sin Fronteras, Mejora en el acceso a los servicios públicos de salud de los inmigrantes indocumentados en elárea sanitaria 11 de la Comunidad de Madrid. Informe Final. [Madrid: MSF, 2005]. Available online at:http://www.msf.es/images/InformeMadrid_tcm3-6019.pdfMedimmigrant, Aide Médicale Urgente pour personnes en séjour illégal. Manuel pour des collaborateurs de CPAS etprestataires de soins. [Brussels: Medimmigrant, 2006a]. Available online at:http://www.medimmigrant.be/DMH%20voor%20MZWV%20handleiding%20voor%20OCMWmedewerkers%20en%20zorgverstrekkers%20basispakket%20FR.pdf, Health Insurance for People without a Legal Residence Permit. [Brussels: Medimmigrant, 2006b]. Available onlineat: http://www.medimmigrant.be/ziekteverzekering.eng.web.pdf, Urgent Medical Care for Illegal Residents. [Brussels: Medimmigrant, 2006c]. Available online at:http://www.medimmigrant.be/DMH%20webversie%20in%20word%20EN.pdf, La loi du 13 décembre 2006 portant dispositions diverses en matière de santé, [Brussels: Medimmigrant, 2006d].Available online at: http://www.Medimmigrant.be/mm.legislation.fr.htmNational Health Service, NHS in England: Core Principles. Available online at:http://www.nhs.uk/England/AboutTheNhs/CorePrinciples.cmsxNational Committee for Medical Aspects of Aliens Policy, Medical aspects of aliens’ policy (Amsterdam: Ministry ofJustice, 2004). Available online at: http://www.justitie.nlNIVEL, Illegalen aan de ‘poort’ van de gezondheidszorg: Toegankelijkheid en knelpunten in de zorg van huisartsen,verloskundigen en spoedeisende hulpafdelingen. [Utrecht: NIVEL, 2000].Nowak M., Pritz C., Weyss B. and Lubich A., Report on the Situation of Fundamental Rights in Austria in 2005. Availableonline at: http://www.univie.ac.at/bim/php/bim/get.php?id=255ODSE, Halte aux refus de soins contre les plus démunis! L’ODSE saisit la HALDE. Available online at:http://www.actupparis.org/article2799.htmlOmega Health Care Center, Graz, Annual Report 2004. [Graz: Druckhaus Thalerhof, 2005]. Available online at:http://www.omega-graz.at/pdf/OMEGA_2004.pdfPanizzut D. and Olivani P., Il diritto alla salute- Come e Perché. [Siena: NIE, 2006].PICUM, Undocumented Migrants Have Rights! An Overview of the International Human Rights Framework. [Brussels:PICUM, 2007].


Access to Health Care for Undocumented Migrants in Europe 113, Book of Solidarity. Providing Assistance to Undocumented Migrants in France, Spain and Italy, vol. 02. [Belgium:PICUM, 2003a]., Book of Solidarity. Providing assistance to undocumented migrants in Sweden, Denmark and Austria, vol. 03.[Brussels: PICUM, 2003b]., Book of Solidarity. Providing assistance to undocumented migrants in Belgium, Germany, The Netherlands and theUK, vol. 01. [Brussels: PICUM, 2002]., Health care for undocumented migrants – Germany, Belgium, the Netherlands and United Kingdom 2001. [Brussels:PICUM, 2001]. http://www.picum.org/Publications/Sample%20pages%20Health%20care.pdfRodrigues, C., “The Changing Profile of Rough Sleepers: Immigrants from Eastern Europe Sleeping Rough in Lisbon”, inHomeless in Europe [Winter 2005] pp.18-20. Available online at:http://www.feantsa.org/files/Month%20Publications/EN/EN_winter_2005_social_emergency.pdfSalud y Familia, Necesidades básicas y movilidad territorial de la población inmigrante estacional en las comarcas deLleida. [Barcelona, 2007].Sandier S., Paris V. and Polton D., Health care systems in transition – France 2004. Available online at:http://www.euro.who.int/document/e83126.pdfSchmitt E., Gesundheitsversorgung und Versorgungsbedarf von Menschen ohne legalen Aufenthaltsstatus. [Hamburg,Unpublished Master Thesis, 2006].Schumacher S., Fremdenrecht, R., ÖGB Verlag., Analyse der Regierungsvorlage für das Fremdenpolizeigesetz 2005.[Vienna: UNHCR 2003]Scott P., “Undocumented Migrants in Germany and Britain: The Human “Rights” and “Wrongs” regarding Access toHealth Care”, in Electronic Journal of Sociology, 2004. Available online at:http://www.sociology.org/content/2004/tier2/scott.htmlSénat Français, L’accès des étrangers en situation irrégulière au système de santé, Les documents de travail du SénatFrançais. Série Législation comparée n° LC 160. March 2006. Available online at:http://www.senat.fr/lc/lc160/lc160.pdfSinn A., Kreienbrink A. and von Loeffelholz H.D., Illegally resident third-country nationals in Germany Policy approaches,profile and social situation. [Nürnberg: Bundesamt für Migration und Flüchtlinge, 2005].Spieß K., Die Wanderarbeitnehmerkonvention der Vereinten Nationen: Ein Instrument zur Stärkung der Rechte vonMigrantinnen und Migranten in Deutschland. [Berlin: Deutsches Institut für Menschenrechte, 2007].Telephone interview with Antje Sanago of Münchner Aids-Hilfe (Münich Aids-Aid) on 25 May 2007 on HIV/Aids and residencepermits in Germany.Terrence Higgins Trust and National Aids Trust, Note on access to HIV treatment for undocumented migrants and thoserefused leave to remain, February 2006. Available online at:http://www.tht.org.uk/binarylibrary/westminsterhallbriefingonaccess.pdfTorres A.M. and Sanz B., “Health Care Provision for Illegal Immigrants: Should Public Health Be Concerned?”, in Journalof Epidemiology and Community Health, No. 54, 2000.UN Economic, Social and Cultural Rights Committee, General Comment No. 14 (2000): The Right to the Highest AttainableStandard of Health, UN Doc. E/C.12/2000/4. August 2000. Available online at:http://www1.umn.edu/humanrts/gencomm/escgencom14.htmUN Special Rapporteur on the Right to Health Paul Hunt, Report of the Special Rapporteur on the Right of Everyone tothe Enjoyment of the Highest Attainable Standard of Physical and Mental Health, A/HRC/4/28/Add.2 28, February 2007.Available online at: http://daccessdds.un.org/doc/UNDOC/GEN/G07/111/82/PDF/G0711182.pdf?OpenElementWallis G., “The Demand for Private Medical Insurance”, in Economic Trends, No. 606. [Newport: Office for NationalStatistics, 2004].


114 PICUMNational legislationAUSTRIA• Aids-Gesetz (AIDS Act) BGBI Nr 728/1993, last modifiedby federal law BGBl. I Nr. 98/2001.• Tuberkulosegesetz (Tuberculosis Act): BGBl Nr. 127/1968,last modified by federal law BGBl. I Nr. 65/2002.• Bundesgesetz über Krankenanstalten- und Kuranstalten(KAKuG) (Federal Law on Hospitals and Sanatoria):BGBI. Nr. 1/1957, last modified by BGBI. I Nr. 155/2005.• Fremdenpolizeigesetz (Aliens’ Police Act): 2005 BGBl. INr. 100/2005 idF BGBi. I Nr. 99/2006.• Niederlassungs-und Aufenthaltsgesetz (Settlementand Residence Act): 2005 – NAG BGBl. I Nr. 100/2005idF BGBl. I Nr. 99/2006.BELGIUM• Loi relative à l’aide médicale urgente du 8 Juillet 1964(Act on urgent medical assistance of 8 July 1964)• Loi organique des Centers Publics d’Action Sociale of 8July 1976 (Organic Law on Social Welfare Centers).• Arrêté royal relative à l’aide médicale urgente, M.B. du31.12.1996 (Royal Decree of 12 December 1996 on statemedical assistance).• Circulaire of 20 May 1997 clarifying the Royal Order onurgent medical assistance.• Loi de finances rectificative pour 2003 (n° 2003-1312) of30 December 2003• Décret n° 2005-860 du 28 Juillet 2005• Loi du 13 Decembre 2006 portant dispositions diversesen matière de santé (National Health Law of 13 December2006).FRANCE• Act No. 92-722 of 22 July.• Loi Pasqua of 1993 (Loi n° 93-1027 of 24 August 1993relative à la maîtrise de l’immigration et aux conditionsd’entrée et de séjour des étrangers en France, JournalOfficiel de la République Française of 29 August 1993.• Loi n° 98-657 du 2 juillet 1998 d’orientation relative à lalutte contre les exclusions (Fight Against Exclusion Actof 29 July 1998).• Circulaire DH/AF 1/DGS/SP 2/DAS/RV 3 n° 98-736 of17 December 1998 relative à la mission de lutte contrel’exclusion sociale des établissements de santé participantau service public hospitalier et à l’accès aux soinsdes personnes les plus démunies.• Loi n°99-641 du 27 juillet 1999. Loi portant créationd’une couverture maladie universelle, (UniversalHealth Coverage Act), Journal Officiel de la RépubliqueFrançaise of 28 juillet 1999).• Loi n° 2002-1576 of 30 December 2002, Journal Officiel dela République Française of 31 December 2002, p. 22070.• Code of Social Action and Families (Code de l’ActionSociale et des Familles)• Loi de finances rectificative pour 2003 (n° 2003-1312) of30 December 2003.• Circulaire DHOS/DSS/DGAS n°141 du 16 mars 2005 relativeà la prise en charge des soins urgents délivrés à desétrangers résidant en France de manière irrégulière etnon bénéficiaires de l’Aide médicale de l’Etat.• Décret n° 2005-860 of 28 July 2005 relative aux modalitésd’admission des demandes d’aide médicale de l’Etat.• Décret n° 2005-859 du 28 juillet 2005 relatif à l’aidemédicale de l’Etat, J.O. n° 175 du 29 juillet 2005(Decree No. 2005-859 of 28 July 2005 on state medicalassistance).• Circulaire DGAS/DSS/DHOS/2005/407 of 27 September2005 relative à l’aide médicale de l’Etat.GERMANY• Gesetzliche Krankenversicherung – GKV (79)• Asylbewerberleistungsgesetz of 5 August 1997, lastmodified on 31 October 2006 AsylbLG Asylum SeekersBenefits Law• Infektionsschutzgesetz Gesetz zur Verhütung undBekämpfung von Infektionskrankheiten beim Menschenof 20 July 2000, last modified on 31 October 2006 IfSGInfectious Diseases Law• Aufenthaltsgesetz Gesetz über den Aufenthalt, dieErwerbstätigkeit und die Integration von Ausländernim Bundesgebiet of 30 Juli 2004, last modified on 26January 2007 AufenthG Residence Act• Sozialgesetzbuch Siebtes Buch (VII) – GesetzlicheUnfallversicherung - of 7 August 1996, last modified on20 April 2007 SGB VII Social Code• Sozialgesetzbuch Zwölftes Buch (XII) - Sozialhilfe - of27 December 2003, last modified on 20 April 2007 SGBXII Social Code• Strafgesetzbuch of 13 November 1998, last modified on13 April 2007 StGB Penal CodeHUNGARY• Hungarian Constitution (Act 20 of 1949).• Act CLIV of 1997 on Health, promulgated on 23 December1997.


Access to Health Care for Undocumented Migrants in Europe 115ITALY• Decreto Legislativo n. 286, 25 luglio 1998, TestoUnico delle disposizioni concernenti la disciplinadell’immigrazione e norme sulla condizione dellostraniero, Gazzetta Ufficiale n. 191 del 18 agosto 1998 –Supplemento Ordinario n. 139 (Decree-Law No. 286 of25 July 1998, known as the “The Single Text” regulatingimmigration).• Decreto del Presidente Della Republica 31 agosto 1999,n. 394. Regolamento recante norme di attuazione deltesto unico delle disposizioni concernenti la disciplinadell’immigrazione e norme sulla condizione dellostraniero a norma dell’articolo 1, comma 6, del decretolegislativo, 25 luglio 1998, n. 286, Gazzetta Ufficiale n.190 del 3 novembre 1999 – Supplemento Ordinario n. 258(Decree of the President of the Republic No. 394 of 31August 1999, implementing the Decree-Law No. 286).• Circolare 24 marzo 2000, n. 5 del Ministerio della Sanità(Circular of the Ministry of Health No. 5 of 24 March2000, implementing the Decree-Law No. 286).NETHERLANDS• Social Health Insurance Act (Ziekenfondswet) of 1964• Exceptional Medical Expenses Act (AWBZ) of 1968• Koppelingswet 1998• Vremdelingswet (Alien Act of 23 November 2000)• Zorgverzekeringswet (Health Insurance Act, enteredinto force on 1 January 2006).PORTUGAL• Constitução da Repuública Portugeusa, Fourth Revision1997• Decreto-Lei n 282/77 de 5 de Julho (Decree Law No.282/77 of 5 July 1977)97• Decreto-lei n.° 135/99 de 22 Abril (Decree-Law No135/99 of 22 April 1999).• Despacho n.° 25 360/2001 (2 série), Diário da RepúblicaN.° 286 12.12.2001.• Circular Informativa. Direcção-Geral da Saúdeo,N.° 14/DSPCS (Circular 14/DSPCS of 02/04/02 from theDirectorate General Health).• Circular Informativa. Direcção-Geral da Saúdeo,N.° 48/DSPCS (Circular 48/DSPCS of 30/10/02 from theDirectorate General Health).• Decreto-lei n.° 34/2003 de 22 Abril (Decree-Law No34/2003 of 25 February 2003).• Decreto Lei n.° 67/2004 de 25 de Março, Diário da República– I Série A – N.° 72 (Decree-Law No 67/2004 of 25March 2004).• Portaria n.° 995/2004 de 9 de Agosto, Diário da República– I Série B, N.° 186.SPAIN• Spanish Constitution of 1978.• General Health Act 14/1986 of 25 April.• Resolución de 4 de Julio de 1997, conjunta de la Presidenciadel Instituto Nacional de Estadística y del DirectorGeneral de Cooperación Territorial, por la que sedictan instrucciones técnicas a los Ayuntamientossobre actualización del Padrón municipal. (Resolutionof 4 July 1997 from the presidency of the National Instituteof Statistics and the General Director of TerritorialCooperation on technical instructions to municipalitiesto update the local registry).• Ley Orgánica 4/2000 de 11 de enero, sobre derechos ylibertades de los extranjeros en España y su integraciónsocial. Texto consolidado. (Act 4/2000 of 11 January2000 on the Rights and Freedoms of Aliens in Spain andtheir Social Integration as amended by the Act 8/2000 of23 December and the Act 14/2003 of 20 November).• Real Decreto 2393/2004, de 30 de diciembre, por el quese aprueba el Reglamento de la Ley Orgánica 4/2000,de 11 de enero, sobre derechos y libertades de losextranjeros en España y su integración social. (RoyalDecree 2393/2004 of 30 December implementing theAct 4/2000).SWEDEN• Sekretesslag (The Secrecy Act) 1980• Hälso- och sjukvardslag (Swedish Health and MedicalServices Act): 1982:763, sects. 2.• Smittskyddslagen (Disease control Act), (2004:168).UNITED KINGDOM• Mental Health Act 1973• National Health Service Act 1977• National Health Service (Charges to Overseas Visitors)Regulations 1989’ with amendments in 1994, 1991 and2004• National Health System (GMS) Regulations 1992• The Human Rights Act 1998• National Health System (Choice of medical Practitioner)Regulations 1998• Health Service Circular 1999/018• Immigration and Asylum Act 1999


116 PICUMIndex of organizationsINTERNATIONALLocal AuthoritiesEUROCITIESFounded in 1986, Eurocities is a network of major Europeancities that brings together the local governments ofmore than 130 large cities within over 30 European countries.Eurocities provides a platform for its member citiesto share knowledge and ideas, to exchange experiences,to analyze common problems and develop innovative solutions.The network is active across a wide range of policyareas including: economic development and cohesionpolicy, provision of public services, environment, transportand mobility, employment and social affairs, culture,education, information and knowledge society, governanceand international cooperation. One working groupof the social affairs department focuses on research onaccess to health care for undocumented migrants.Contact Information:EurocitiesSquare de Meeûs 181050 BrusselsBelgiumTel: +32/2/552.08.88Fax: +32/2/552.08.89Email: info@eurocities.beWebsite: http://www.eurocities.orgNon-Governmental OrganisationsCARITAS EUROPACreated in 1971, Caritas Europa is a non-governmentalorganisation which brings together 48 organizationsworking in 44 European countries. It is mainly active inthe fields of humanitarian relief, development, health andsocial services. Caritas Europa focuses its activities onissues relating to poverty, social inequality, migrationand asylum, both within the European Union and all otherEuropean countries.Contact Information:Caritas EuropaCommunications DepartmentRue de Pascale 41040 BrusselsBelgiumTel: +32/2/235.03.94Email: amazella@caritas-europa.orgWebsite: http://www.caritas-europa.orgHealth Care ProvidersEUROPEAN PUBLIC HEALTH ASSOCIATION (EUPHA)The EUPHA serves as an umbrella organisation forpublic health associations in Europe. Founded in 1992,the organisation is an international, multidisciplinary,scientific platform bringing together around 12,000 publichealth experts for professional exchange and collaborationthroughout Europe. The main aim of the organisationis to strengthen public health research and practice inEurope.Contact Information:EUPHA OfficeOtterstraat 118-124Postbox 15683500 BN UtrechtThe NetherlandsTel: +31/30/272.97.09Fax: +31/30/272.97.29Website: http://www.eupha.orgAUSTRIANon-Governmental OrganisationsEVANGELISCHES HILFSWERK ÖSTERREICHEvangelic Relief Organization, AustriaThe Evangelisches Hilfswerk Österreich a non-profitassociation that provides, as partial organization of thedeaconry in Austria, all kind of social welfare servicesthrough four kindergartens, a medical center, educationalinstitute and 17 refugee service points. The organizationwas established after the Second World War to provideauxiliary delivery to the suffering Austrian population.Contact Information:Evangelisches Hilfswerk ÖsterreichSteinergasse 3/121170 ViennaAustriaTel: +43/1/402.67.54Fax: +43/1/402.67.54.16Email: gf.efdoe@diakonie.atWebsite: http://www.hilfswerk.diakonie.at/


Access to Health Care for Undocumented Migrants in Europe 117BELGIUMLocal AuthoritiesC.P.A.S BRUXELLESCentre Public d’Action SocialeThe C.P.A.S. Brussels is the local authority for publicwelfare in Belgium. It aims to provide material, social,psychological and medical support to those in need.Frequently confronted with undocumented migrants, itcooperates intensely with non-governmental organisationsto implement a system of urgent medical care.Contact Information:Centre Public d’Action Sociale298A Rue Haute1000 BrusselsBelgiumWebsite: http://www.cpasbru.irisnet.be/Non-Governmental OrganisationsMEDIMMIGRANT(previously Medical Steunpunt Mensen zonder Papieren)Formed 1994, Medimmigrant is a non-governmentalorganization aiming to safeguard access to health carefor undocumented migrants or those with a precariousresidence status.Contact Information:MedimmigrantGaucheretstraat 1641030 BrusselsBelgiumTel: +32/2/274.14.33Fax: +32/2/274.14.48Email: info@Medimmigrant.beWebsite: http://www.Medimmigrant.beFRANCENon-Governmental OrganizationsCOMEDE (Comité médical pour les exilés)Medical Council for the ExiledComède is a non-governmental organization set up in1979 by Amnesty International (French section), ServiceOecuménique d’Entraide (Cimade) and Groupe AccueilSolidarité. Comède promotes access to health care formigrants in France, providing medical, social and psychologicalassistance when needed and striving for a moreinclusive national public health care system. Comèdehas 27 years of experience providing free medical careand psychological counseling for exiles (including asylumseekers, rejected asylum seekers and other undocumentedmigrants, refugees and torture survivors).Contact Information:COMEDEHôpital de BicêtreBP 3194272 Le Kremlin-Bicêtre cedexFranceTel: +33/1/45.21.38.40Fax: +33/1/45.21.38.41Email: contact@comede.orgWebsite: http://www.comede.orgMÉDECINS DU MONDEDoctors Without BordersMédecins du Monde, or Doctors without Borders, is aninternational humanitarian aid organization that recruitsmedical and non-medical volunteers to provide healthcare for vulnerable populations around the world, includingFrance. Established in 1980, by 2004 the organisationled 90 international projects in 50 countries and 115programs in France.Contact Information:Médecins du Monde62 rue Marcadet75018 ParisFranceTel: +33/1/44.92.1515Website: http://www.medecinsdumonde.orgGERMANYLocal AuthoritiesSTELLE FÜR INTERKULTURELLE ARBEIT DER LANDE-SHAUPTSTADT, MÜNCHENCenter for Intercultural Work, City of MunichA department of the local authority, the Center for InterculturalWork, City of Munich is responsible for the integrationof migrants. It takes measures to reduce the social,vocational, educational, religious ethnical and culturaldisadvantages of the foreign population. Munich’s populationis about 1.28 million of which 37% are foreigners.


118 PICUMContact Information:S-III-M/ik(Stelle für Interkulturelle Arbeit der LandeshauptstadtMünchen)Franziskanerstraße 881669 MünchenTel: +49/89/233.405.42Fax: +49/89/233.405.43Email: interkulturellearbeit.soz@muenchen.deWebsite: http://www.muenchen.de/Rathaus/soz/wohnenmigration/interkulti/39732/index.htmlNon-Governmental OrganizationsMEDINETZ BREMENMediNetz is a medical advice and assistance center forpeople without access to the public national health caresystem, especially asylum seekers and undocumentedmigrants. The Bremen branch was established in 1999 aspart of the Refugee Initiative Bremen.Contact Information:MediNetz Bremenc/o FlüchtlingsinitiativeBernhardstr. 1228203 BremenGermanyTel: +49/421/790.19.59Fax: +49/421/790.19.63Email: medinetz-bremen@gmx.netWebsite: http://www.nord-com.net/fluechtlingsinitiative.bremen/medinetz.htmlFax: +36/1/479.02.72Email: menedek@menedek.huWebsite: http://www.menedek.huITALYNon-Governmental OrganizationsNAGA - Associazione Voluntaria di Assistenza Socio-Sanitaria e per i Diritti di Stranieri e NomadiVoluntary Association of Social-Health Care Assistancefor the Rights of Foreigners and NomadsNAGA is an independent, non-profit organisation of volunteersestablished in 1987. It provides health care andsocial services to immigrants, undocumented migrantsand refugees in Milan (Italy) who do not have access tothe public national health care system. Since its creation,NAGA has provided medical assistance (primary andsecondary care) to more than 100,000 people and receiveson average 80 people per day, mainly newcomers facingparticular marginalization (e.g. socio-economic, laborand language barriers).Contact Information:NAGAViale Bligny 2220136 MilanoItalyTel: +39/2/58.30.14.20Fax: +39/2/58.30.00.89Email: info@naga.itWebsite: http://www.naga.itHUNGARYNETHERLANDSNon-Governmental OrganizationsMENEDÉKMenedék, the Hungarian Association for Migrants,operates as a non-governmental organization and wasestablished in January 1995 on the occasion of a civilianinitiative. It aims to represent international migrants(applicants, refugees, foreign employees and immigrants)within society and promote their legal, social and culturalintegration.Contact Information:MenedékJosica Utca 21077 BudapestHungaryTel: +36/1/322.15.02Health Care ProvidersPHAROSPharos is a national refugee and health knowledge centerthat offers knowledge, insight and skills for improving thequality of health care provided to refugees and asylumseekers. Pharos helps health care professionals and teachersto develop an ‘intercultural professional attitude’ andoffers special knowledge, skills and methods directed to thecare needs of refugees. Along with ‘Lampion’, Pharos is anational information and counseling office for health carefor undocumented migrants and rejected asylum seekers.The center was established 2004 and gives information tohealth care professionals, social workers and clinic helpconfronted with the special circumstances of undocumentedmigrants who lack legal access to the public national healthcare system.


Access to Health Care for Undocumented Migrants in Europe 119Contact Information:PharosHerenstraat 35PO Box 133183507 LH UtrechtNetherlandsTel: + 31/30/234.98.00Fax: +31/30/236.45.60Email: pharos@pharos.nlWebsite: http://www.pharos.nlhttp://www.lampion.infoLocal AuthoritiesGEMEENTELIJKE GEZONDHEIDSDIENST ROTTERDAMRotterdam Municipal Public Health ServiceThe Rotterdam Municipal Public Health Service is apublic health body and branch of the local government.This organisation of civil servants works on prevention,intervention, coordination, research and policy for healthissues in an area of 800,000 inhabitants. One of its responsibilitiesis improving access to health care for undocumentedmigrants. The population of Rotterdam is diversewith large groups from Suriname, Turkey, Morocco andCape Verde.Contact Information:Gemeentelijke Gezondheidsdienst Rotterdam Rotterdam e.o.Postbus 700323000 LP RotterdamNetherlandsTel: +31/10/4339966Fax: +31/10/4339595Email: info@ggd.rotterdam.nlWebsite: http://www.ggd.rotterdam.nl/PORTUGALNon-Governmental OrganisationsSERVIÇO JESUITA AOS REFUGIADOSJesuit Refugee Service Portugal (JRS)Jesuit Refugee Service is an international Catholic organisationwith a mission to accompany, serve and defend therights of refugees and forcibly displaced people. Founded1980, Jesuit Refugee Service works at international level(70 countries) within the fields of advocacy, human rights,and research. In Portugal, the Serviço Jesuíta aos Refugiadosbegan national activity in 1994.Contact Information:Serviço Jesuíta aos RefugiadosEstrada da Torre, 261750-296 LisboaPortugalTel: +351/21/754.16.20Fax : +351/21/754.16.25Email: jrs-portugal@netcabo.pt; jrs-portugal@jrs.netWebsite: http://www.jrsportugal.pt/SPAINHealth Care ProvidersHOSPITAL PUNTA DE EUROPAHospital Punta de Europa is a public hospital integratedwith another hospital and ten primary health care centersin the health authority district of Campo de Gibraltar,which belongs to the SAS (Servicio Andaluz de Salud). Thehospital is committed to improving and maintaining anoptimal health level, helping to ease inequalities regardingillness and mortality in accordance with the principlesdefining the Health Policy of the Andalusian PublicHealth System (SSPA). Guaranteeing access to qualityhealth services, Hospital Punta de Europa serves an areawith 253,569 inhabitants and has approximately 290,884consultations per year.Contact Information:Hospital Punta de EuropaDirección del AGSCtra. de Getares S/NAlgeciras (CADIZ)SpainWebsite: http://www.juntadeandalucia.es/servicioandaluzdesalud/centros/Detalle.aspLocal AuthoritiesFUNDACIÓN PROGRESO Y SALUDProgress and Health FoundationThe Fundación Progreso y Salud belongs to the AndalusianRegional Ministry of Health. It is the central entity thatsupports and manages Public Health System research inAndalusia and also effectively promotes health researchand innovation in the region. The organization of biomedicalresearch within the Andalusian Public Health Systemplaces the Fundación in the role of facilitator: an entitydedicated to encouraging, supporting and sharing servicesamong research centers and groups throughout thescientific process, from the development of the necessaryresources (infrastructures, financing, skills development


120 PICUMand mobility) to the implementation and effective executionof scientific production (in methodology, management,etc.), including the transfer of research results toindustry and to society. The Fundación Progreso y Saludis also responsible for the direct management of theRegional Health Department’s strategic projects in thisfield.Contact Information:Fundación Progreso y SaludAvda. Américo Vespucio 5, Bloque 2, 2ª PlantaIsla de la Cartuja41092 SevillaSpainTel: +34/955/04.04.50Fax: +34/955/04.04.57Email: fundacion.progreso.salud@juntaandalucia.esWebsite: http://www.fundacionprogresoysalud.orgSWEDENNon-Governmental OrganizationsROSENGRENSKARosengrenska is a voluntary charity network of healthprofessionals. It was formed in 1998 to provide medicalsupport to hidden migrants (undocumented migrants,hidden refugees or rejected asylum seekers), withoutaccess to the national public health care system inGothenburg, Sweden. Today there are more than 650people working voluntarily within the framework of thischarity.UNITED KINGDOMLocal AuthoritiesNEWHAM PRIMARY CARE TRUSTNewham Primary Care Trust is a national health serviceorganisation that serves the community of the LondonBorough of Newham. It employs around 1,050 staff basedacross 23 sites, and encompasses 65 General Practitioners,69 pharmacists, 55 opticians and 80 dentists in theborough. The Annual Budget is £439,556,000. Newham’spopulation is 247,700. The overall objective of the NewhamPrimary Care Trust is to improve the health of the localpopulation and address health inequalities also concerningdifferences between ethnic groups.Contact Information:Newham Primary Care TrustTrust Board SecretaryWarehouse K2 Western GatewayLondon E16 1DRUKTel: +44/20/858.66.200Email: communications@newhampct.nhs.ukWebsite: http://www.newhampct.nhs.ukContact Information:RosengrenskaGamla Riksvrägen 5142832 KålleredSwedenTel: +46/70/575.34.15Email: kliniken@rosengrenska.orgWebsite: http://www.rosengrenska.org


This report gives visibility to the problems arisingfrom undocumented migrants’ inadequate access tohealth care in the European Union. The situation interms of law and practice is provided through elevencountry profiles; each presenting an overview of themost common problems and obstacles preventinga realization of the right to health. The work of civilsociety organizations in providing assistance to undocumentedmigrants is illustrated, with good policiesand practices highlighted to provide inspirationfor future strategies and actions.In Europe, undocumented migrants face seriousproblems in receiving health care. The climate ofrepression and the existing link between immigrationcontrol policies and access to basic social servicescreate a tremendous fear of discovery amongundocumented migrants, deterring them from exercisingtheir entitlements and seeking health care.While numerous international instruments in humanrights law have been ratified by EU member states andrefer to the right of everyone to health care as a basichuman right (regardless of one’s administrative status),the laws and practices in many European countriesare shown to deviate from these obligations.Undocumented migrants are not yet formally consideredas being one of the most marginalized andsocially excluded groups in Europe. Very few documentsof the European Institutions acknowledgethis fact and there is almost a total invisibility ofthe problem in the member states’ plans to combatsocial exclusion.This report provides expert insight that will proveinvaluable to NGOs and health care providers workingwith undocumented migrants. It will also provea useful tool in convincing the governments of EUmember states to speak more, to do more, and totake on their responsibilities and comply with internationalhuman rights obligations, instead of continuingto rely upon civil society as an alternativeprovider of health care for undocumented migrants.Making a strong case for action, this report may beused as a tool of influence, pressure, empowermentand innovation. Ten practical recommendationsare provided to help national and European policymakersto better address the problems arising froma lack of or an insufficient access to health care forundocumented migrants in the EU.PICUM - Platform for International Cooperationon Undocumented MigrantsGaucheretstraat 1641030 BrusselsBelgiumtel. +32/2/274.14.39fax +32/2/274.14.48www.picum.orginfo@picum.org

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