Ευρωπαϊκή Διακήρυξη των επαγγελματιών υγείας Για μία πρόσβαση χωρίς διακρίσεις στην υγειονομική περίθαλψη

The main international legal instruments which tackle health issues recognise an indiscriminate right for each and every person to have access to health care. In spite of this recognised right to equality in health care access, numerous national legislations, in Europe and elsewhere, restrict – sometimes strongly – health care access for persons with no residency permit.

The International Covenant on Economic, Social and Cultural Rights(1) foresees that “The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” (article 12). All the Member States of the European Union are signatories of this pact.

The Committee for Economic and Cultural Rights, instituted to monitor the application of this Covenant, underlined that “States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative health services”(2).

Children, like pregnant women, are specifically protected by the International Convention on the Rights of the Child (see question below).

(1) For an overview of the international legal instruments linked to health rights, please consult this page.
(2) General observation n#14, 2000, par. 34.

Depending on the country, the right of undocumented migrants to medical coverage varies widely. The gap, at the legislative level, is considerable. Thus, in Spain, undocumented migrants, as soon as they have been domiciled by inscription in the municipal register of the town in which they reside, can benefit from a total coverage of the cost of medical consultations (not medicine) – even if this ease of domiciliation is currently being challenged. In other countries, such as France and Belgium – where a specific coverage system has been put into place - or Portugal, coverage is also almost total. Elsewhere, as in the Netherlands, free coverage is at the discretion of the doctor. In other countries, like Great Britain, a law only allows for the coverage of primary health care.

Some countries do not guarantee access to health care or even limit it. In Sweden, there is no free access, even for emergency or maternity care. In Germany, the limited entitlements are overridden by the legal obligation to denounce undocumented migrants imposed in most public administrative institutions, except for hospitals.

And even in countries where persons have the right to access care, there are huge gaps between their rights and what actually occurs in practice. In these countries, according to Médecins du Monde’s 2009 report(1), 70% of undocumented migrants have the right to medical coverage but only 36% benefit from it.

In the countries in which the law is very restrictive for undocumented migrants, practitioners, associative or public facilities/organisations, are mobilising to improve health care access for patients. Thus, in Sweden, the city of Stockholm has implemented a medical coverage system for pregnant women, as their situation has become untenable.

In the end, the situation of undocumented migrants is often catastrophic: according to the results of Médecins du Monde’s report(1) which surveyed 1,218 patients in 11 European countries, a third of the health problems which require essential treatment are not covered at all. Amongst them, a third of the men and a quarter of the women perceived their state of health to be poor or very poor. This is 3 times higher than in the general EU population. A third of the patients surveyed were affected by at least one chronic health problem.

(1) Médecins du Monde European Observatory on access to healthcare, ‘Access to healthcare for undocumented migrants in 11 countries in Europe’, Chauvin P., Parizot I., Simonnot N., September 2009, pp.83-93.

Certain countries in Europe, such as Cyprus, do not provide any specific protection for the children of undocumented migrants, and some go as far as demanding that they be denounced, like their parents, whenever they use health services. This is for example, the case in Germany.

In other countries, such as the Netherlands, or in Greece, access to health care for these children is in theory more favourable than that of their parents. In practice, however, this access is often no better due to the residency situation of their parents and the lack of knowledge of their rights by doctors.

Nevertheless, the International Convention on the Rights of the Child, ratified by all the Member States of the European Union, foresees the protection of health of all children. Its article 24 sets forth the universal rights of children to “have the right to the best health conditions possible and to granted medical and rehabilitation services”, and the right of States to carry out the appropriate measures in the field of health. Its article 26 specifies that “the States Parties recognise the right for all children to benefit from social security’”.

Health care access for persons in detention centres is not regulated at the European level, and thus it differs greatly from country to country, both in theory and in practice. Thus in the Netherlands, “Detainees can access medical services through a written request which is passed on by security personnel, who sometimes wait too long before acting properly. There is no freedom of choice between medical doctors, who can only be accessed after referral by a nurse. In practice, it seems that some forms of health care (e.g. dental care, prosthesis and extramural care) are postponed during the detention period. Patients often complain that they received Paracetamol instead of adequate medication. Mental health care has proven to be a very complicated issue, since the problems are often related to the detention itself. In addition, many detainees do not trust the psychologists who work in the detention centres. There is no prior medical examination which can indicate that patients’ medical conditions allow them to remain in detention”.

Conditions of confinement, often very poor, have serious consequences on the physical but also and especially on the psychological state of health of the detainees.

The detention centres are often kept isolated from society, which favours the risks of the rights of the retained persons’ rights being violated. To fight against this tendency, the, ‘Droit de regard’ (Right to view), initiated by the Migreurop Network, encourages people from ‘mainstream’ society to intervene and raise awareness about the reality and the conditions of confinement of foreigners in these centres. Its aim is that these actions will serve as a warning signal and help defend the rights of the foreign detainees, as well as testifying about the consequences of this confinement and how these situations can lead to the violation of the rights of migrants.

Restricting the nature or the scope of health care for undocumented migrants can obviously have an unfavourable impact on their health. But this can also affect the public health of a population, the general sanitary services, or the administration of health care services. For example, follow-up and prenatal care, care linked to childbirth and care during childhood are essential for preventing or reducing the number of ill persons or the handicaps and the associated costs (1). Thus, regular monitoring of pregnancy reduces the risk of premature births, foetal contamination of infectious origin (rubella, flu, etc…) and enables preventative health coverage in order to avoid malformations. More generally, access to preventative care helps prevent contaminations, such as hepatitis.

(1) Bustamante J., “Migration and health; a human rights approach”, note prepared by the WHO Global Consultation, 3 - 5 March 2010, Madrid. Jorge Bustamante is the United Nation’s Special Rapporteur on the human rights of migrants.

There are many common discourses on the cost of health coverage of undocumented migrants; Opposite to this, not many studies focus on the costs linked to the lack of access to health care (1).

A simplistic vision of the issue could lead us think that, in the case of undocumented migrants, a health problem which has not been treated is one less problem to deal with and pay for, in the sense that undocumented migrants are supposed to leave the country.

But the reality is completely different. There are many undocumented immigrants who cannot leave the country for such and such a reason or due to legal reasons: the question regarding their health care coverage therefore remains intact.

In this framework, allowing for restricted access, limited for example only to emergency care, can lead, by the accumulation of pathological episodes, to an aggravation or chronification of illnesses which are screened or cared for belatedly. These illnesses will therefore need to be treated and covered and even lead to the hospitalisation of the patient, which would be more costly for the health system (2).

Furthermore, limiting access to preventative care or complicating access to the general practitioners of these populations favours a non-adapted and frequent use of services which are particularly expensive, such as emergency services (3).

(1) See for example: Lu MC, Lin YG, Prietto NM, Garite TJ. Elimination of public funding of prenatal care for undocumented immigrants in California : a cost/benefit analysis. Am J Obstet Gynecol. 2000;182:233–239.
(2) Albrecht, H.J., “Fortress Europe? Controlling illegal immigration”, European Journal of Crime, Criminal Law and Criminal Justice, 2002, 10 (1), p. 7. Norredam M., “Access to health care for asylum seekers in the EU – a comparative study of country policies”, European Journal of Public Health, Vol.16, N°3, 285-289.
(3) Chan TC, Krishel SJ, Bramwell Kj, Clark RF: Survey of illegal immigrants seen in an emergency department. West J Med 1996; 164:212-216.

Surveys carried out amongst undocumented migrants shows that ‘immigration for health’ is above all a myth. In the survey carried out by Médecins du Monde’s European Observatory on access to health care, ‘Access to health care for persons without any residency authorisation in 11 countries in Europe’(1) only 6% of respondents cited health as one of their reasons for migration(2). After France, respondents were most likely to cite health as one of their reasons for migration in Greece (9%) and in Sweden (8%), even though there is no possibility of getting their health care costs covered in either country.

(1) Médecins du Monde European Observatory on access to healthcare, ‘Access to healthcare for persons without any residency authorisation in 11 countries in Europe’, Chauvin P., Parizot I., Simonnot N., September 2009, pp. 49-51 www.mdm-international.org
(2) These persons were questioned in the framework of Médecins du Monde programmes.

In the 2009 Médecins du Monde report ‘Access to health care for undocumented migrants in 11 countries in Europe’(1), only 9% of the people questioned(2) wished to return to their country of origin. Refusing or limiting health care access to undocumented immigrants is an inefficient measure for inciting them to leave the country in which they are residing. Indeed these persons have generally come to Europe for different reasons, other than sanitary ones: to flee from war, poverty, dangers, the loss of liberty, to work and to ensure a better future for their children.

Furthermore, there are numerous undocumented migrants who cannot leave the country for such and such a reason or due to legal reasons. In these conditions, the laws and measures aiming to restrict their access to care are inefficient, as they cannot leave the country, and also discriminatory. This clearly indicates the absurdity of submitting sanitary considerations to immigration policy considerations.

(1) Médecins du Monde European Observatory on access to healthcare, ‘Access to healthcare for undocumented migrants in 11 countries in Europe’, Chauvin P., Parizot I., Simonnot N., September 2009, pp. 49-51 www.mdm-international.org
(2) These persons were questioned in the framework of Médecins du Monde programmes.

The World Medical Association is an association which groups together close to 100 national medical associations, and represents more than 2 million doctors. This association adopted, in 1981 at Lisbon, a Declaration on the rights of patients (amended in 1985 and then revised in 2005).
This declaration recognises that “every person is entitled without discrimination to appropriate medical care” and that “physicians and other persons or bodies involved in the provision of health care have a joint responsibility to recognize and uphold these rights. Whenever legislation, government action or any other administration or institution denies patients these rights, physicians should pursue appropriate means to assure or to restore them”(1).
(1) World Medical Assembly Declaration on the Rights of the Patient, preamble.

The fear of being denounced arrested or refused care, constitutes a major obstacle towards the access and the continuity of care for undocumented persons. Amongst the participants of the survey carried out by Médecins du Monde European Observatory on access to healthcare(1), 41% of them renounced care during the past 12 months.
For health professionals, this criminalisation provokes fear, complicates the assistance and the care given to patients and even leads to the refusal of care in certain countries where legislative measures are particularly tough on the issue.

In 2002, a EU directive (2) defined the facilitation of unauthorised entry, transit and residence. According to this directive, Member States were required to adopt appropriate sanctions against “any person who, for financial gain, intentionally assists a person who is not a national of a Member State to reside within the territory of a Member State in breach of the laws of the State concerned on the residence of aliens.” Despite this definition, numerous countries in the European Union have designed measures which are in violation with regard to the aid given to undocumented migrants in their countries, even when this aid is given charitably.

(1) Médecins du Monde European Observatory on access to healthcare, ‘Access to healthcare for undocumented migrants in 11 countries in Europe’, Chauvin P., Parizot I., Simonnot N., September 2009, pp. 49-51 www.mdm-international.org
(2) COUNCIL DIRECTIVE 2002/90/EC of 28 November 2002 defining the facilitation of unauthorized entry, transit and residence