Migrants’ right to healthcare: accepting limits on what European healthcare systems can provideBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2679 (Published 17 May 2016) Cite this as: BMJ 2016;353:i2679
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Let me express my thanks to Dr Paraskevas and Dr Rajmil for responding to my letter. They will not be surprised to learn that I do not accept all their arguments.
Dr Paraskevas writes movingly of the precarious situation of migrants travelling to Europe from Syria, Afghanistan and Iraq. He does not mention the depressingly large size of the global pool of people affected by conflict and poverty and the certainty that migration into Europe is a problem of our time that transcends particular national conflicts. We need to acknowledge that this wider problem will pose huge economic challenges.
As Dr Rajmil says, we need to clarify the factors that might lead policy makers to limit healthcare for some migrants. An in-principle commitment to UHC does not mean that European countries can ignore the problems of low growth, budgetary deficit and debt that have affected so many since the 2008 slump. We need better evidence about the impact of large-scale migration on risk pools, not just in terms of age, but also the resource implications of caring for populations who have had little exposure to preventative or promotive programmes, may present with trauma and raised morbidity(1), and have significant reproductive, maternal and child healthcare needs. Evidence to date suggests that humanitarian migrants face considerable challenges and delays in securing employment and making a new fiscal contribution(2). Moreover the possibilities for cost-sharing to relieve pressure on public budgets are limited; humanitarian migrants will rarely be in a position to co-pay, purchase supplemental insurance or buy access via schemes such as the UK's immigration health surcharge. Probably host populations will shoulder the burden through increased taxes, but acceptance of re-distributive fiscal policies is diminishing even in Europe's most liberal countries(3). German economists who initially said that immigration brought economic benefits are now divided in their views(4). Unsurprisingly then governments try to control demand via restricting access beyond basic care, setting minimum residency periods for full access, and allowing differential degrees of access according to legal status. Against this background I would be surprised if politicians were swayed by claims about the long-term preventive benefits of early care or that unrestricted care for all is cheaper than maintaining border controls.
As somebody who has undertaken primary research on UHC in a developing country(5,6) it seems to me that the way to help underserved populations around the world is to build coverage in the global south rather than encouraging exodus to the north. The Lancet economists' declaration makes the case that UHC is affordable even in lower and lower middle income countries as economic growth and increasing domestic resources allow step-by-step expansion of publicly-funded essential services. Here south-south knowledge transfer and support can be as important as aid from the north, but that does not mean open borders. Developing countries embarking on UHC reforms typically face a testing transition in which political opposition, a divided medical profession and rising costs threaten the new system. They are rarely in a position to treat large numbers crossing from neighbouring countries. In the system I studied – the Thai universal coverage scheme – cross-border pressure on hospitals arising from undocumented migration from Myanmar, Laos and Cambodia has been a major policy concern. The Thai government’s main response has been to help plan and support the development of health facilities in the three neighbouring countries, largely with external development aid, rather than to relax border controls. (7)
And as I argue in my letter, recession and austerity are eroding universal coverage even in parts of Europe. Here too protecting UHC will require some limits on access for those outside the risk pool. Can we really condemn Germany for making asylum seekers wait 15 months for non-emergency dental care (8), or Sweden for tacitly allowing failed asylum seekers to remain but offering no guarantee of free health care(2)? The limits of what is provided will depend on the particular circumstances of different European nations, but there will have to be limits.
1 Buhmann CB. Traumatized refugees: morbidity, treatment and predictors of outcome. Dan Med J. 2014;61(8):B4871. http://www.danmedj.dk/portal/page/portal/danmedj.dk/dmj_forside/PAST_ISS...
2 OECD. Working Together: Skills and Labour Market Integration of Immigrants and their Children in Sweden. May 2016 DOI 10.1787/9789264257382-en. http://www.oecd-ilibrary.org/social-issues-migration-health/working-toge...
3 Traub J. The death of the most generous nation on earth. Foreign Policy February 2016 http://foreignpolicy.com/2016/02/10/the-death-of-the-most-generous-natio...
4 Reuters. Four in 10 German economists see migrants as drag on economy: poll. Feb 17, 2016.
5 Hughes D, Leethongdee S. Universal coverage in the land of smiles: lessons from Thailand’s 30 baht health reforms, Health Affairs, 2007;26(4), 999-1008. http://content.healthaffairs.org/content/26/4/999.short
6 Evans TG et al. Thailand’s Universal Coverage Scheme: Achievements and Challenges. An Independent Assessment of the First 10 Years. Synthesis Report. Nonthaburi: HISRO, 2012. http://www.jointlearningnetwork.org/uploads/files/resources/book018.pdf
7 Samsamak, P. Pradit floats idea for a regional health fund. The Nation, June 15, 2013. http://www.nationmultimedia.com/national/Pradit-floats-idea-for-a-region...
8 Stuttgarter Nachrichten. Flüchtlinge in Baden-Württemberg: Zahnersatz könnte Milliarden kosten. 23 January 2016. http://www.stuttgarter-nachrichten.de/inhalt.fluechtlinge-in-baden-wuert...
Competing interests: No competing interests
The discussion concerning migrants' rights and healthcare is of great interest. 1, 2 Controversy between “economy” and “rights” is crucial but it should be clarified what kind of economic policy applies to decide on the limits of healthcare coverage. Looking at epidemiological data, economists from 44 countries stated recently that the UN proposal on sustainable development should include universal healthcare coverage (UHC). 3 They based their proposal on the fact that health systems oriented toward UHC produce benefits, mitigate the effects of shock and produce more cohesive societies. This statement includes healthcare access without restrictions, and concludes that greater investments in health can result in lower overall costs to the system when allocated efficiently.3
On the other hand, besides cutting public healthcare budget, discourses on austerity are proving to be an excuse to introduce privatization and neoliberal measures instead of producing economic growth.4 Reduced budgets lead to diminish the resolution capacity of public health systems. In Spain, the Decree Law 16/2012 that changed back to the old healthcare system and excluded undocumented migrants5 led to increase inequities and geographical variability in the access to healthcare services. 6 As a consequence, higher costs are expected in the short, medium, and long term derived from the public health impact of these measures, and the rising cost of bureaucratic administrative controls, as in other countries.7 Several examples can be found reinforcing these ideas; cuts in the provision of the interpretation services for patients who speak foreign languages in the Netherlands lead to inappropriate use of emergency departments as an alternative, which is more costly in the middle and long term.8 People without coverage impose hidden costs on their country, and UHC sits at the intersection of social and economic policy.9
Other factors, such as the lack of criteria in the management of resources and the introduction of costly interventions and new technologies implemented before checking their effectiveness have more influence on the probability of systems collapsing than facilitating access to healthcare services to migrant people in most needs. Moreover, those systems that strengthen primary healthcare provision have been shown to have better outcomes at lower costs;10 and also better results will be achieved when interventions with proven efficacy and excluding those with potential adverse effects and non-added value are carried out.11, 12
As was stated by Clarke,1 several European countries have taken measures to be restrictive and unattractive for undocumented immigrants and refugees. Moreover, another pending question is how much money does Europe invest to maintain closed borders instead of investing this money to cover migrant people in most need.
It seems that at the moment the winner on the controversy between “economy” and “rights” is the “austerity and neo-liberal” economy.
1 Clarke JM. Stop denying migrants their fundamental right to healthcare. BMJ 2016;353:i1971 doi:10.1136/bmj.i1971.
2 Hughes D. Migrants’ right to healthcare: accepting limits on what European healthcare system can provide. BMJ 2016;353:i2679 doi:10.1136/bmj.2679.
3 Summers LH. Economists’ declaration on universal health coverage. Lancet 2015; 386: 2112–13.
4 Krugman P. The austerity delusion. Guardian Newspaper, 29.04.2015 accessed 20.05.2016 at http://www.theguardian.com/business/ng-interactive/2015/apr/29/the-auste... 20.
5 Legido-Quigley H, Otero L, la Parra D, Alvarez-Dardet C, Martin-Moreno JM, McKee M. Will austerity cuts dismantle the Spanish healthcare system? BMJ 2013;346:f2363 doi:10.1136/bmj.f2363.
6 Cimas M, Gullón P, Aguilera E, Meyer S, Freire JM, Perez-Gomez B. Healthcare coverage for undocumented migrants in Spain: Regional differences after Decree/Law 16/2012. Health Policy 2016; accessed 20.05.2016 at http://dx.doi.org/10.1016/j.healthpol.2016.02.005 .
7 Cutler D, Wikler E, Basch P. Reducing administrative costs and improving the health care system. New Engl J Med 2012;367:1875-8.
8 O’Donnell C, Burns N, Dowrick C, Lionis C, MacFarlane A, on behalf of the RESTORE team. Health-care access for migrants in Europe. Lancet 2013;382:393.
9 Frenk J, de Ferrati D. Universal health coverage: good health, good economics. Lancet 2012;380:862-4.
10 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83(3):457-502.
11 Choosing wisely. Addressing waste in healthcare accessed 20.05.2016 http://www.choosingwisely.org/ .
12 Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS). Projecte Essencial. Departament de Salut. Generalitat de Catalunya accessed 20.05.2016 http://essencialsalut.gencat.cat/ca/ .
Competing interests: No competing interests
As a result of the Syrian Civil War and the ongoing violence in Afghanistan and Iraq, in 2015 more than 1,011,700 immigrants/refugees fled from countries of the Middle East and Africa to Europe.1,2 Of these, 872,938 immigrants arrived by sea via Turkey to the Greek islands Kos, Chios, Lesvos and Samos.2 Their journey then continued north via Bulgaria, Albania or the Republic of Macedonia, until they reached Germany, Sweden, Great Britain or some other Central/North European country.2
In an attempt to prevent the overflow of migrants, in November 2015 the Republic of Macedonia began erecting fences at its borders with Greece and eventually closed its borders on March 9, 2016,3 leaving 12,000-13,000 refugees stuck in Idomeni refugee camps in Greece.1
The European refugee crisis had a considerable impact on Greece and the Greek Healthcare system, which has been in financial meltdown after years of austerity.4 State-run hospitals have slashed their budgets by as much as 50% in this time. Basic supplies in gloves, syringes, cotton wool, catheters and paper towels have long been in low supply.4
The refugee camps in Idomeni are an insult to European Union (EU) values.5 Thousands of unwashed, hungry, exhausted women and children, waterlogged tents, piles of rubbish, sodden clothes and soaked blankets in mud-soaked land and rising cases of fever, pneumonia, septicaemia and psychotic breaks comprise a true public health emergency.5
The European immigration crisis causes social, cultural and demographic changes that demand political and administrative solutions from EU Member States. Providing primary healthcare to immigrants should become a priority in the agenda of EU Member States affairs, as it reflects the humanitarian, social and cultural aspects of the EU itself.
1. European migrant crisis. Wikipedia - The Free Encyclopedia. Available at: https://en.wikipedia.org/wiki/European_migrant_crisis. Accessed on March 27, 2016.
2. BBC News. Migrant crisis: Migration to Europe explained in seven charts. Available at: http://www.bbc.co.uk/news/world-europe-34131911.Accessed on February 26, 2016.
3. Macedonian border barrier. Wikipedia - The Free Encyclopedia. Available at: https://en.wikipedia.org/wiki/Macedonian_border_barrier. Accessed on April 23, 2016.
4. Chrysafis A. Greek debt crisis: ‘Of all the damage,healthcare has been hit the worst’. The Guardian, July 9, 2015. Available at: http://www.theguardian.com/world/2015/jul/09/greek-debt-crisis-damagehea.... Accessed on April 24, 2016.
5. Smith H. Migration crisis: Idomeni, the train stop that became ‘an insult to EU values’. The Guardian, March 17, 2016. Available at: http://www.theguardian.com/world/2016/mar/17/migration-crisis-idomenicam.... Accessed on April 24, 2016.
Competing interests: No competing interests