Presentation by Lilana Keith (Platform for International Cooperation on Undocumented Migrants (PICUM)) on the occasion of the EESC hearing on Better Roma inclusion through civil society initiatives: focus on health and anti-discrimination (Brussels, 12 May 2014)

1. Better Roma Inclusion through
civil society initiatives: focus on
health and anti-discrimination
Brussels, 12 May 2014
Lilana Keith PICUM Programme Officer

2. PICUM’s research on Health Care for
Undocumented Migrants
• 2001 -“Health Care for Undocumented Migrants: Germany, Belgium,
Netherlands, United Kingdom” (Expert seminar).
• 2007 -“Access to Health Care for Undocumented Migrants in Europe” (11
countries).
• 2009 -“Undocumented and Seriously Ill: Residence Permits for Medical
Reasons in Europe” (12 countries).
• 2009 - “Undocumented Children in Europe: Invisible Victims of Immigration
Restrictions” (9 countries)
• 2010 -“NowHereLand project, PICUM country reports on Undocumented
Migrants’ Health Needs and Strategies to Access Health Care” (17 countries).
• 2010 -FRIM (Fundamental Rights of Irregular Migrants in the EU) project,
FRA Project - PICUM health care case studies (10 countries)
• 2011-2013- “Building Strategies to Improve the Protection of
Undocumented Children in Europe” project – Country briefs and
2013 guide “Children first and foremost” (7 countries)

3. Access to Health Care for Undocumented
Migrants in EU: Key challenges
• Access very varied across Europe
• Lack of compliance with international obligations
• No EU member state specifically forbids access BUT:
o Health care used as instrument of immigration control
o Usually excluded from national subsidised health insurance
system
o Numerous barriers → many do not access even when entitled/
only in emergency
• IMPACT: incoherence with public health, social cohesion,
medical ethics, strain on frontline service providers, increased
healthcare costs

4. Examples of levels of access
in legislation
1. All care provided only on payment basis
e.g. Austria, Denmark, Hungary, Ireland (at discretion)
2. Free health care in emergencies
e.g. Estonia, Germany (duty to denounce beyond emergency care), Romania
3. Free access to specific services
e.g. UK (primary, emergency, communicable diseases)
4. Heavily subsidised access to most mainstream health services
- wide interpretation of “medically necessarily”, “urgent” or “essential” care
[but excluded from national health insurance – separate admin. system]
e.g. Belgium, France, Netherlands, Italy
5. Access through national health system
e.g. Portugal (after 90 days of residence)
 Children usually same access as adults, no extra protection
 Same access as nationals only in 4 EU countries: RO, SE, SP,GR
(& PT until 16 years)

5. Summary of PICUM findings
Barriers to access in practice
Many do not receive the care they are entitled to:
• Varied interpretation of urgent/ essential/ immediately
necessary treatment & discretion on the local level
(“gateways” to care)
• Lack of awareness and complex rules
• Fear of detection
• Lack of financial resources
• Prejudicial/ unfavourable attitudes
• Language and communication issues

6. Summary of PICUM findings
UDM use of HC services
• Mainly seek health care only when seriously ill
• A high percentage do not access health care even if entitled
• Most frequently, go to NGO clinics or the emergency system
• Many unable to pay medical fees – prioritise children’s health
• Worsening of health status more likely to occur due to factors such
as poor living and working conditions and insecurity
• Lack of continuous care or medical records
• No access to specialist care inc. dentistry, optometry

7. Civil society responses
Pressure on health professionals and NGOs
• Health professionals – often apply professional code and duties
o BUT: Hospital administration comes first and financial concerns seem to win
as not as bound by medical professional ethics
o Being increasingly expected to check immigration status – beyond duties
o Pressure on some “undocumented migrant friendly hospitals”, mainly
private/religious hospitals and NGO providers
o Invaluable in influencing policy (e.g. Italy “We are doctors, not spies”,
Sweden)
• NGOs – enormous pressure to fill the gaps
o Advice, help and advocacy to gain to access mainstream services
(most of them want to avoid “parallel charity-based systems”)
o Provision of direct and volunteer-based medical assistance
(clinics and mobile units)
o Referrals to other health care providers within networks
o Provision of medicines (mainly from donations, including HIV treatment)
o Payment of bills (health care, medicines, tests and exams)

8. Local initiatives: Sweden
The Right to Health Initiative
• All treatment at cost (exc. refused asylum-seeking children)
• Care provided by civil society e.g. Rosengrenska (since 1998)
o Network of health professionals – volunteers - telephone helpline and clinic
o Goal: to not exist = awareness-raising and advocacy
• Research EU comparison – one of the most restrictive
(PICUM, 2007; HUMA, 2009, FRA, 2011)
• UN SR on health – sharp criticism (2007)
• Right to Health Initiative (since 2007) = common standpoint
64 organisations in 2012
• Several hospitals, city councils & regions - more favourable policies
• Public enquiry – suggests equal access (2011)
• Law reformed (effective from 1 July 2013)
o Equal access to health care for children
o For adults = care “that cannot be postponed”, including dental care, maternity
care, contraceptive counselling and abortions, and related medicines
o County councils can offer better health care provisions

9. Local initiatives: Spain
Regional Communities challenge new restrictions
• Until 1 Sept 2012 – near equal access for all ‘habitually resident’
regardless of status
• Reform – significant restrictions
o Care for pregnant women and children remains equal (in law)
o Otherwise emergency care ONLY
• Regions – autonomy in implementing and providing HC →varied
 Only one implementing in full (Castilla-La Mancha)
 Several restricted but providing more than min. required
 Some refusing to implement
o Continue to issue health cards (Andalucía, Asturias, Catalonia, Basque)
o Legal challenge of constitutionality – Dec 2012 – upheld Basque complaint
• Several initiatives led by NGOs and health professionals
o Evidence base on impacts
o Professionals registering as conscientious objectors/ officially against the law
o Public campaigns and protests

10. PICUM Key Recommendations
1. Respect international human rights obligations,
professional ethics and the demands of public health
2. Protect vulnerable UDM
3. Ensure entitlements are implemented- no arbitrary
decisions at the reception
4. Ensure access to information re: entitlements
5. Detach health care from immigration control and stop the
criminalisation of humanitarian assistance

11. Thank you for your attention
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