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?
The inclusion of migrants into the health system of destination countries is coming to be seen as an essential component of their integration. Migrant health relates to 15 Target Areas of the UN’s Sustainable Development Goals Agenda, with its imperative of ‘Leaving No One Behind’.
At the top end of the MIPEX scale, 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 (Australia, Canada, Ireland, New Zealand, US, UK), the Nordics (Finland, Norway, Sweden), major regions of destination in Austria, Italy, Spain and Switzerland, and in Belgium, Chile and Turkey.
At the other end of the MIPEX scale, health systems are least inclusive in countries with restrictive integration policies, such as most of Central and Southeast Europe as well as Brazil, China, India, Indonesia and Russia. Across the 8 strands of MIPEX, policies on Health are positively related to policies in most other strands. In only a few countries were migrant health policies markedly more favourable than the country’s overall MIPEX score (Austria, Chile, Ireland, Spain, Switzerland, Turkey) or less favourable (Albania, Brazil, Estonia, Korea, Poland and Ukraine).
Migrant health policies are related to countries’ experience of immigration and financial resources. In countries with smaller immigrant populations (e.g. Albania, Brazil, China, India and Indonesia, where international migrants make up <2% of the population), little or nothing may be done to promote their inclusion in the health system. In contrast, migrant health policies tend to be better developed in countries with more international migrants. Within countries, health services in regions with large immigrant populations tend to be more responsive to migrants' health needs (e.g. in Austria, Italy, Spain and Switzerland). A country’s wealth, as measured by GDP per capita, also strongly influences scores on the Health strand. Countries that have difficulty providing adequate health services to national citizens seem reluctant to adapt service delivery to the needs of migrants and are more likely to adopt a “one size fits all” approach.
It is sometimes assumed that tax-based health systems are more inclusive for migrants than insurance-based ones. No link is found with entitlements to healthcare coverage, but tax-based systems are more likely to adapt service delivery to migrants’ needs. Though good entitlements usually go hand in hand with responsive services, there are exceptions: in 2019 many less wealthy countries, as well as France, prioritised entitlements over responsiveness, while the opposite was true for Australia, Austria, Canada, Ireland, New Zealand, Portugal, Spain, the UK and US.
The 2020 core MIPEX updated and averaged together 12 core ‘migrant health’ indicators from the full 23 questions (comprising 41 indicators). Two indicators were chosen from dimension A, measuring entitlements for legal migrants, asylum seekers and undocumented migrants (UDMs) separately. Two indicators were also chosen from each of the dimensions B, C and D, making 12 core indicators in all. Indicators were selected on the basis of their correlation in the 2015 round with the total of the dimension they belonged to. The correlation (r) between the averages of all 12 core indicators and of all 41 original indicators was .95, meaning that the core indicators were able to account for 90% of the variance in the full scores. The core indicators selected in each dimension were averaged to provide the score for that dimension. These core indicators give a fairly reliable estimate of the results that would be obtained by using the full questionnaire, although they are obviously less precise and need to be interpreted with caution.
Although migrants’ entitlements to healthcare coverage are laid down by law in all MIPEX countries except Malta, exercising these rights is often hampered by administrative barriers. These obstacles include requirements for documents that may be difficult for migrants to obtain, or discretionary decisions about how urgently their treatment is needed and whether they are able to pay for it themselves.
- Legal migrants: The conditions vary significantly across countries: in some countries, legal residents may have unconditional entitlements but limited only to emergency care, while in others, they have conditional access to the same range of services as those for national citizens. Beyond these legal conditions, 25 MIPEX countries present no administrative barriers to legal migrants: the corresponding figures for asylum seekers and UDMs are 14 and 2.
- Asylum seekers: Conditions of coverage may include remaining in an assigned location or having inadequate financial resources. Germany imposes the condition that entitlement to more than emergency care is only granted to asylum seekers or refugees who have been in the country for longer than 15 months. Only 14 countries impose no administrative barriers for asylum-seekers: Austria, Chile, Czechia, France, Greece, Indonesia, Japan, North Macedonia, Poland, Romania, Serbia, Slovakia, Switzerland and Turkey.
- Undocumented migrants: This group faces the greatest legal and administrative barriers to obtaining coverage. Although not all aspects of their entitlements were measured in 2019, there are few signs that they have improved since 2015. Only two countries--Chile and Switzerland—impose no administrative barriers for undocumented migrants: where coverage for this group is limited to emergency care, a barrier always exists in the form of a discretionary judgement about whether the migrant’s health problem constitutes an emergency.
Accessibility of health services
- Legal migrants, asylum seekers and undocumented migrants are regularly reached with targeted information on entitlements and use of health services in only 19 of the 52 MIPEX countries.
- In 22 countries, all three groups are regularly reached with targeted information on health education and health promotion.
- Qualified interpretation services for patients with inadequate proficiency in the official language(s) are provided free of charge in 18 countries, but not regularly available in 18 countries. In the other 16 countries, interpretation can be arranged, but the migrant must pay for it.
- In 30 countries, immigrant patients and communities are involved to some extent in designing and providing health information and services – most actively in Austria, Australia, Czechia, Ireland, New Zealand, Spain and UK.
Policies to promote change
- Most countries (42/52) have funding bodies that have supported migrant health research in the past five years. The most extensive support is found in Western European and traditional destination countries.
- Comprehensive policies to mainstream migrant health have emerged in Australia, Ireland, Norway, Sweden, UK, and US, while in 31 countries the health system does not systematically address migrant or ethnic minority health issues.
Policies and integration outcomes: What do we learn from robust studies?
The major gaps within countries’ policies have major and direct implications for immigrants’ health. While more research is needed on the different targeted migrant health policies, the potential impacts of integration policies have been analysed by around a dozen MIPEX studies, including several reviewed in The Lancet, one of the world’s most prestigious medical journals.
How governments treat immigrants strongly influences how well immigrants feel both in terms of their mental and physical health. Under inclusive integration policies, immigrants and non-immigrants end up with similar health outcomes in terms of their reported health, chronic illnesses, elderly diabetes and frailty and, even, mortality. Under restrictive policies, immigrants are much more likely than non-immigrants to suffer from these poor health outcomes. For immigrants’ health, a country’s overall approach to integration seems more determinant than any specific area of integration policy.