Re: Migrants’ right to healthcare: accepting limits on what European healthcare systems can provide
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.
Rapid Response:
Re: Migrants’ right to healthcare: accepting limits on what European healthcare systems can provide
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.
References
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.
http://www.reuters.com/article/us-europe-migrants-germany-poll-idUSKCN0V...
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