Responding to diversity: An exploratory study of migrant health policies in Europe

Abstract

There has been growing international attention to migrant health, reflecting recognition of the need for health systems to adapt to increasingly diverse populations. However, reports from health policy experts in 25 European countries suggest that by 2009 only eleven countries had established national policies to improve migrant health that go beyond migrants’ statutory or legal entitlement to care. The objective of this paper is to compare and contrast the content of these policies and analyse their strengths and limitations. The analysis suggests that most of the national policies target either migrants or more established ethnic minorities. Countries should address the diverse needs of both groups and could learn from “intercultural” health care policies in Ireland and, in the past, the Netherlands. Policies in several countries prioritise specific diseases or conditions, but these differ and it is not clear whether they accurately reflect real differences in need among countries. Policy initiatives typically involve training health workers, providing interpreter services and/or ‘cultural mediators’, adapting organizational culture, improving data collection and providing information to migrants on health problems and services. A few countries stand out for their quest to increase migrants’ health literacy and their participation in the development and implementation of policy. Progressive migrant health policies are not always sustainable as they can be undermined or even reversed when political contexts change. The analysis of migrant health policies in Europe is still in its infancy and there is an urgent need to monitor the implementation and evaluate the effectiveness of these diverse policies.

Introduction

Migrants comprise a substantial – and growing – proportion of European populations: in 2009, 4.0% of the EU's (European Union's) total population were citizens of countries outside the EU [1]. Europe needs migrants to fill labour shortages arising from falling birth rates and ageing populations, especially among those who care for the growing numbers of older people [2]. Many migrants are young and healthy and make little use of the health systems of the countries they move to, but some have complex needs that existing services address inadequately. Indeed, evidence from across the EU demonstrates considerable, but varied, inequalities between migrants and non-migrants in health and access to health services [3], [4], [5], [6], [7], [8], [9], [10]. While the right to health is enshrined in many international and European legal instruments [11], for many migrants this has little practical meaning. This is partly because of national legislation restricting access by certain groups of migrants such as asylum seekers or undocumented migrants. However, obstacles extend beyond constraints on the legal entitlement to care [12]. For example, migrants, who are more likely to be poor, may be deterred from seeking care where user fees are demanded [13]. They may also lack knowledge of the national language, be unfamiliar with the health system, face administrative obstacles, and be subject to direct and indirect discrimination [14], [15].

Recognising that health systems need to take measures to adapt to the specific needs of migrants, there has been growing international attention to migrant health policy. In 2007 the Portuguese government, then holding the rotating EU Presidency, made migrant health a priority, resulting in a statement by the EU Council of Ministers, while further support came from the Council of Europe in the 2007 Bratislava Declaration on Health, Human Rights and Migration and the 2008 World Health Assembly resolution on the Health of Migrants [16]. However, many European countries have been slow to respond to these international calls for action and there remain considerable differences between countries in the extent to which their health systems have adopted ‘migrant-friendly’ policies.

Several studies have sought to describe and analyse differences in the adoption of national health policies on migrant populations across Europe. Some have raised concern about national differences in the legal entitlement of asylum seekers and undocumented migrants to access health services. In 2004, ten of the then 25 EU member states provided only emergency care to asylum seekers [17], despite the Council of the European Union outlining, in 2003, minimum standards for the reception of asylum-seekers including “emergency care and essential treatment of illness”. Undocumented migrants face even greater restrictions. In 2010, only five of now 27 EU member states (France, Italy, Netherlands, Portugal and Spain) gave undocumented migrants access to virtually the same range of services as nationals of that country [18].

One factor that may have affected access to health care by migrants in the past was the system of financing. It has been suggested that tax based systems, with their emphasis on universal coverage, find it easier to incorporate migrant health policies than do systems based on social health insurance, where entitlement is mainly linked to contributions [19]. However, most countries with social health insurance have now created statutory mechanisms to provide cover based on residence in the country regardless of the ability to pay contributions, meaning that universal coverage, which includes immigrants with permanent residence status, has, in theory, been achieved in most of the EU [20].

Studies have also examined social, cultural and historical factors. One has argued that welfare systems based on a “communitarian” or “difference-based” approach to diversity (such as the United Kingdom and the Netherlands) are more inclined to incorporate migrant-friendly health policies than systems based on a “republican” or “difference-blind” logic (such as Austria, France and Germany), which assume that all citizens should be treated equally and, in some cases, may prevent the collection of data based on citizenship or ethnicity because of the perceived potential to use it to discriminate [19]. Similar categorisations distinguish between two principal approaches to diversity, one based on the provision of mainstream services for all, the other based on the provision of separate services for migrants [14]. Similarly, one can distinguish between “active” approaches (adapting health services) versus “passive” ones (expecting migrants to adapt) [21].

As the issue of statutory entitlement to health services for migrants (i.e. primary and secondary legislation establishing health coverage of immigrants) has been well documented, this study focuses instead on the content of national migrant health policies which seek to improve migrant health through targeted interventions. While statutory entitlements allow migrants to use health services, a second level of policies enacted by the health system is needed to operationalise entitlement and ensure the responsiveness of health services to their needs. The objective of the paper is to compare and contrast the content of this second level of migrant health policies, going beyond statutory entitlement, across Europe. To date there have been few comparative publications on this topic and the literature that does exist either covers a small number of countries and/or does not develop a systematic conceptual framework for comparison of the content of the policies [6], [19], [22], [23], [24], [25], [26]. This study addresses these two limitations by covering 25 countries (although only eleven were found to have developed relevant policies and were included in the final analysis) and comparing policies within an existing conceptual framework [25]. While it is difficult to evaluate the different approaches due to a lack of information about implementation and outcomes (see limitations discussed in Section 2), as well as the potential impact of factors external to the content of the health policy (the broader social, cultural, political and economic context), some general conclusions are drawn about the possible strengths and limitations of the different approaches identified.