Major differences emerge in immigrants’ healthcare coverage and ability to access services between countries; Policies often fail to take their specific health needs into account.
Is the health system responsive to immigrants’ needs?
Attention to migrants’ health needs is fairly recent in integration policies. On one end, health systems are usually more ‘migrant-friendly’ in countries with a strong commitment to equal rights and opportunities. Policies are at least slightly favourable in most English-speaking countries (NZ, US, AU, UK), the Nordics (NO, SE, FI) and major regions of destination in CH, IT and AT. On the other end, health systems are rarely inclusive or responsive in countries with restrictive integration policies, such as in most of Central and Southeast Europe. Exceptionally in a few countries, migrant health policies are much more or much less favourable than the country's integration policies in other areas. The healthcare system may more actively target migrants' specific needs due to adaptations in regions with many immigrants (AT, IT, CH). Where numbers of migrants are very low (BH, RO, BG, JP, PL, KR, SK) little or nothing may be done to adapt service delivery to their needs. Austerity measures also play a major role (GR, PT, ES).
Targeted migrant health policies are usually stronger and services more responsive in countries with greater wealth (GDP), more immigrants and tax-based as opposed to insurance-based health systems. For example, 8 of the 9 countries with the most responsive policies to achieve this change have national health systems (AU, DK, IE, IT, NZ, NO, ES, UK), the only exception being the US. Links also emerge between migrant health policies across most countries. First, the most responsive services are found in countries with good mechanisms for promoting change (UK, NZ, US, AU). Nevertheless, such countries do not necessarily grant migrants the best entitlements. Some countries offer migrants legal entitlements to healthcare, but make little effort to adapt services to their needs (JP, FR, EE and most Southeast European countries), while others seem to have the opposite priorities (AU, US, UK).
- Although the law may grant migrants certain entitlements to healthcare coverage, administrative procedures (e.g. requirements for documentation or discretionary decisions) often prevent them from exercising these rights
- Wide discrepancies exist for legal migrants, despite the EU’s declared aim to harmonise their entitlements. CY scores lowest, with an integrated system of health coverage for nationals still under development. ES and PT have cut back some entitlements as part of austerity policies. UK has introduced new restrictions for migrants. Precise entitlements in MT are not legally formalised, while Central European countries with few migrants offer only limited entitlements. By contrast, countries such as BE, FR, NL, SE and CH grant virtually the same entitlements to migrants as for nationals
- Entitlements for asylum seekers also show wide variations. KR, LV, DE, MT and LT offer only limited rights or impose administrative barriers, while CA has abolished entitlements for certain categories of asylum seekers. In many countries, entitlements require that asylum-seekers remain inside reception centres or designated areas. On the other hand, TU and FR offer virtually the same entitlements as for nationals, while GR, RO, AT and CZ are not far behind
- Coverage for undocumented migrants remains a controversial issue in most countries. BG, NO, NZ, KR, LV, AU, BH, PL, CZ and TU do not even cover emergency care, although some treatments may be provided on public health grounds. By contrast, CH, SE, IT, NL, LU, CY and FR provide partial or complete healthcare coverage under certain conditions. In many countries, administrative barriers prevent undocumented migrants from exercising their legal entitlements
- Multiple methods and languages are used to inform all categories of migrants about entitlements and the use of health services in FR, IS, IE, JP, PT, ES, CH, BE, NZ and SI; in contrast, HU and BG do little or nothing. There is strong support for health education and promotion in IS, IE, JP, PT, CH, NZ, AT, SE, FI and US, but these activities seem to be ignored in CZ, LV, GR, HR and HU
- Cultural mediators or trained patient navigators are provided to a certain degree in 18 countries
- Healthcare providers are required to report undocumented migrants in SE, BH, SI, UK, HR and DE, whereas this is forbidden in CZ, DK, FR, IS, IT, NO, PT, ES, CH, NL and US (either by law or by professional codes of conduct). In HR, DE, GR and TU, legal sanctions are possible against providing care to them, and organisations may discourage staff from doing so in AU, BE, CA, LT, LU, NL, NZ, SI, UK, US
- Most effort made to adapt services to the needs of migrants in UK, NZ, US, AU, AT, while in LT, TU, SI, SK, PL, EE, BG, LV, GR, HR do little or nothing in this direction
- Language support is provided where necessary in 14 countries (UK, NZ, US, AU, AT, CH, DE, SE, IE, NO, IT, FI, BE, LU), but hardly at all in most Central and Southeast European countries (RO, BH, CY, LT, SK, PL, EE, BG, LV, GR, HR)
- In 21 countries, migrants are involved to some extent in information provision, service design and delivery – most actively in AT, AU, IE, NZ, UK
- Staff are only prepared for migrants' specific needs at national level in UK, NZ, CH, NO. In 17 countries no training modules are regular available
Mechanisms for change
- Active measures promoting change in AU, NZ, NO, UK, US, and promising efforts in IE, with little policy support to achieve change in HR, FR, LV, LU, SI, IS, PL
- Most countries have the research and data they need to address migrants' specific health needs
- Action plans on migrant health have been developed in 22 countries though rarely involving measures to implement them (AU, NO, IE, KR) or migrant health stakeholders
Best Case & Worst Case
This is a composition of national policies found in 2014 in at least one of the 38 countries
All residents have the same healthcare coverage as nationals in law and in practice. To access their entitlements, all residents can get information in various languages and through various methods, including cultural mediators. Healthcare providers are informed of these entitlements, allowed to serve all residents and equipped to meet their needs, through training, various interpretation methods, adapted diagnostic methods and a diverse staff. Health policies are supporting these changes and also equipped to respond to the needs of an increasingly diverse society.
Legal migrants, asylum-seekers and undocumented migrants cannot access the healthcare system without any exceptions, except perhaps emergency care. Even then, their access may depend on providers’ discretion and burdensome documentation. Migrants do not know how to access the health system or address major health issues. Service providers are forced to report undocumented migrants and sanctioned for serving them. Providers do not have the training or staff to serve migrant clients and their health needs. Policy is hindering these changes, as migrants are ignored in health policy, data and research, while health is ignored as an area of integration policy.
Note: The MIPEX health strand was developed in a three-way collaboration between MPG, IOM and COST Action ADAPT (Adapting European Health Services to Diversity). COST is the EU Association for European Cooperation in Science and Technology. The normative framework underlying the health strand was provided by the Council of Europe’s (2011) Recommendations on mobility, migration and access to health care (see http://bit.ly/rKs2YD and http://bit.ly/xF0g6U ). These recommendations were formulated during a two-year process of consultation with researchers, health professionals, national and international organisations, as well as NGOs serving or run by migrants.
Financing of the additional costs of the Health strand was provided by the IOM in the framework of its project ‘Equi-Health’ (Fostering Health Provision for Migrants, the Roma, and other Vulnerable Groups) (see http://equi-health.eea.iom.int/ ). This project is co-financed by the EU’s Directorate-General Health and Food Safety (DG SANTE) through the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA). The process of developing and piloting the questionnaire was undertaken by ADAPT, which is a network of 120 experts on migrant health working in 30 countries. Data collection was organised by the IOM. Most of the experts and peer reviewers responsible for completing the Health strand questionnaire were members of ADAPT, while the rest were recruited from or through MPG’s network of integration policy experts. Scientific coordination was provided by Prof. David Ingleby of the University of Amsterdam’s Centre for Social Science and Global Health. Towards the end of 2015, detailed Country Reports on the European countries covered by MIPEX will be published by the IOM as part of its ‘Equi-Health’ project.