Healthcare is not universal if undocumented migrants are excludedBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4160 (Published 16 September 2019) Cite this as: BMJ 2019;366:l4160
All rapid responses
I noted the issue raised in this article on healthcare access of "undocumented" migrants, apparently a new euphemism for illegal migrants nowadays.
The authors described Universal Health Coverage (UHC) as "a guarantee that all people and communities can access high quality health services, while ensuring that they are not exposed to financial hardship." This is attributed to a World Health Organisation report (ref 1).
Particularly for residents of UK, Australia and some parts of Europe, there is a need to further explain the concept of UHC. The following discussion hails from the same report:
"What UHC does and does not mean
UHC means that everyone – irrespective of their living standards – receives the health services they need, and that using health services does not cause financial hardship.
Progress towards UHC means that more people – especially the poor, who are currently at greatest risk of not receiving needed services – get the services they need. Implicit in the definition of UHC is that the services are high quality, meaning that people are diagnosed correctly and receive the interventions currently agreed to be necessary. Progress towards UHC means a lowering of barriers to seeking and receiving needed care: for example, out-of-pocket payments, distance, poorly equipped facilities and poorly trained health workers.
But UHC also means that getting needed health services is associated less and less with financial hardship; that people receiving health services are still able to afford food and other necessities, and do not place their families at risk of poverty by getting the care they need.
UHC does not mean that health care is always free of charge, merely that out-of-pocket payments are not so high as to deter people from using services and causing financial hardship. Nor is UHC solely concerned with financing health care. In many poorer countries, lack of physical access to even basic services remains an enormous problem. Health systems have a role to play in achieving progress towards UHC. Health systems strengthening – enhancing financing but also strengthening governance, the organization of the health-care workforce, service delivery, health information systems and the provision of medicines and other health products – is central to progressing towards UHC"
There are many who perceive UHC as requiring to be free with no out of pocket cost, and yet a large proportion of OECD countries do not have "free" UHC, particularly those who are also members of G10. Many of these nations have UHC with some form of co-payment and/or user-pay levies. Even the NHS, which is lauded as free UHC, actually has co-payments out of pocket mostly with prescription drugs.
Various healthcare professionals (ref 2) and activists labelled the British government's 2017 move to charge non-UK residents when using NHS service (ref 3) as creating a “hostile environment” for visitors and migrants, insisting that these migrants including those undocumented should have the full gamut of NHS services with no out of pocket costs.
There is a presumption about the migrants' ability to pay for NHS (or private) services, that the best (and only) way that equitable healthcare access is free (= no out of pocket) at point of service.
Experience from several countries with this outlook has revealed this model is increasingly unsustainable, particularly with exponential advances and availability of high tech high cost diagnostic and treatment modalities. This occurs regardless of the country's'GDP, OECD or third world nations.
It is important to consider the possibility of partially subsidised charges by temporary visitors and undocumented migrants instead of charging them 150% NHS costs, allowing healthcare costs to be affordable to individual circumstances without it being free.
Some argue that the recouped health costs from visitors/migrants account at best 0.3% of annual NHS budget but this £300m would have to cover the cost of GP practices delivering childhood immunisation services for the year; it is not some small change which would make no significant difference to the people of the UK.
The idealistic pursuit of UHC through "free at point of service delivery" concept is laudable, but is neither practical nor sustainable.
1. World Health Organization, International Bank for Reconstruction and Development/The World Bank. Tracking universal health coverage: 2017 global monitoring report. WHO, 2017
Competing interests: No competing interests