Healthcare for undocumented migrants
Together with her master’s students, Milena Pavlova is investigating the access to healthcare of undocumented migrants. Her findings give cause for concern: in many countries, this group has no or little access to healthcare. Yet such access is essential, especially during the COVID-19 pandemic, when vaccination is crucial. Politics and policy should be separate, Pavlova argues. Who can enter and stay in a country is a question for politics. Policy must ensure that everyone can access adequate healthcare.
Who is an undocumented migrant?
“This term refers to third-country nationals without a valid permit to reside in the EU. That includes people whose applications for asylum have been rejected and those who have violated the terms of their visas, as well as those who have entered the country illegally. The desire for a better life for themselves and their children leads people to migrate to stable countries, which sometimes results in their living in a country without being legally entitled to do so.”
How many undocumented migrants are there in Europe?
“It’s difficult to say, but there are indications that their number has increased in the last two decades. In 2017 the Pew Research Center estimated that there were about 3.9 to 4.8 million unauthorised migrants, which represented less than 1% of the total EU population and about 10% of its foreign population. But these estimates are based on inaccurate and unreliable data. The numbers are also constantly changing. For example, 137,000 undocumented migrants illegally crossed the Greek border during July and August 2015, a 250% increase compared to May and June of that year. That’s a dramatic rise within just a few months.”
Milena Pavlova is professor of Health Economics and Equity at the Faculty of Health, Medicine and Life Sciences. She is an active member of the Scientific Committee of the Netherlands Red Cross and chair of the ASPHER working group on Economic Evaluation in Healthcare in Europe. She has served as an assessor for the European Commission and a reviewer for the International Health Economics Association.
How big is the problem?
“Undocumented migrants are a major concern in all EU member states, including when it comes to the provision of health services. Because they’re not official residents and have no health insurance, they’re not always entitled to use the full range of public health services. In many countries—including Germany, Denmark and Belgium—they only have access to emergency care and services for specific conditions, like infectious diseases, or specific needs, such as maternity care. In 2017, France, Italy and the Netherlands decided to give undocumented migrants the same access to healthcare as authorised residents. By contrast, Slovenia provides urgent medical assistance only.”
What are the barriers in accessing healthcare?
“The first barrier is at the individual level. They choose the treatment and provider based on their own perceptions of healthcare and their experiences in their own country. They often perceive hospital treatment as ‘good’ and GP services as ‘bad’, preferring to use emergency hospital services even when primary-care services are free of charge. Many countries have no gatekeeping system, so patients can skip the GP and go directly to a hospital specialist. Another problem at the individual level is self-medication, such as the use of over-the-counter drugs for minor symptoms. Many people only seek out a doctor in urgent cases. Others avoid healthcare services if using them somehow contradicts their cultural norms and religious beliefs. We need to offer a more personalised approach to account for all these individual-level factors.
“A very important barrier is the fear of deportation. Undocumented migrants often see visiting a doctor as risky: they might draw attention to themselves and be forced to leave the country. They rarely know who to trust. To avoid deportation, they use a fake registration number or address, or send a legal resident who pretends to be the sick person. Also, they may lack the language skills to access information on health services directly. In some countries they’re entitled to an interpreter, but they may not be aware of that. The fear of deportation needs to be assuaged and communities need to be informed about the potentially harmful effects of self-medication. For some migrants, years of irregular status coupled with negative experiences in their countries of origin can trigger ‘phobias’ of health services. In addition, the need for mental healthcare is high among undocumented migrants. The illegal status, continuous uncertainty and distance from their families can lead to depression and other mental-health issues.
Undocumented migrants are a major concern in all EU member states, including when it comes to the provision of health services.
“Evidence shows that tight government control of access to health services, such as requiring patients to register at GP practices, can be a barrier for this group. One solution could be to leave registration to the discretion of the GP, who is guided by the medical code of ethics and treats patients regardless of their immigration status. If needed, the GP can refer the undocumented migrant to hospital care. Whether there are other barriers at the hospital level depends on the healthcare system. There is a need for unified guidelines for all healthcare practices to avoid confusion regarding undocumented migrants’ entitlement to services. It’s also crucial to keep patient registration data confidential so the authorities can’t use this data to deport them. A number of European countries have chosen to pursue this approach. That will encourage the use of primary care.”
How can we break down these barriers?
“Involve NGOs such as the Red Cross. They can easily identify these people, build trust and provide information. All sorts of needs are met by convincing undocumented migrants to make use of healthcare providers. Systematic involvement of the Red Cross could be a European solution.”
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There is a need for unified guidelines for all healthcare practices to avoid confusion regarding undocumented migrants’ entitlement to services. It’s also crucial to keep patient registration data confidential so the authorities can’t use this data to deport them.