The European Journal of Public Health Advance Access originally published online on January 5, 2007
The European Journal of Public Health 2007 17(5):483-485; doi:10.1093/eurpub/ckl266
Health Inequalities |
Health care provision for illegal migrants: may health policy make a difference?
A.M. Torres-Cantero1, A.G. Miguel2, C. Gallardo2 and S. Ippolito3
1 Department of Health and Social Sciences, Medical School, Murcia University, Murcia, Spain
2 Department of Health Sciences and Public Health, Rey Juan Carlos University, Alcorcón, Madrid, Spain
3 Project Coordinator, Institution Building for Asylum in North Africa, UNHCR Geneva
Correspondence: Dr Alberto M. Torres, Department of Health and Social Sciences, Medical School, 30100 Murcia, Spain, tel: +34 968 364657 fax: +34 968 363947, e-mail: amtorres{at}um.es
Received May 13, 2006, accepted November 3, 2006
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Abstract |
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Illegal migrants in Europe are, generally, only entitled to emergency care and services for children and pregnant women. In 2002 legal changes in Spain made accessible medical cards and free medical care for illegal migrants in similar terms than the legal migrants or the Spanish population. We interviewed 380 migrants to assess whether there were differences on health services utilization by legal status. We did not find differences in the utilization of health services when ill between legal and illegal migrants. However, a significantly lower utilization of health services was associated with less education (RP = 0.4; 95% CI: 0.2–0.9).
Keywords: Access to health care, Equatorian migrants, health services utilization, illegal migrants, Spain
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Introduction |
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National health systems of European societies have been under pressure in recent years to respond to two parallel issues: tackling health care needs of increasingly multicultural and multiethnic societies and providing health care to persons who are not legally entitled to receive it, namely illegal migrants. Legal migrants are entitled to use health services in equal terms than the host country population, but in spite of their poorer health they do not always use health services accordingly.1,2 Nonetheless, health care for illegal immigrants is an issue of even greater concern and debate in Europe and elsewhere.3,4 Illegal migrants are, generally speaking, not entitled to receive public health care, being exceptions to this rule emergency care and services for children and pregnant women.5 Unsurprisingly, utilization of health services in cases of need appears to be lower in illegal than in legal migrants.6,7 Lack of access to health services in cases of need may be questioned on the basis of ethical as well as public health grounds.5 It is unclear, however, whether improving access to health care increase utilization in illegal migrants, as lower utilization of health services might still occur in illegal migrants as a result of fear, discrimination or poor integration in the host country. In 2002 legal changes in Spain made feasible for illegal immigrants to receive medical cards and free medical care in equal terms than the legal migrants. The objective of this study was to assess whether sick legal and illegal migrants are now using health services with similar frequency irrespective of their legal status. This article is a follow-up of a previous work conducted in Madrid in 1997 using similar methodology.7
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Methods |
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A cross-sectional study was conducted in a District of the City of Madrid targeting Equatorian migrants, older than 15 years of age, who had lived in Spain for more than 3 months and resided in the study District. Madrid host about one-third of the migrants in Spain, and Equatorians are currently the largest national group of migrants in Spain. Intercept interviews were conducted during the first semester of 2005, from early in the morning to late at night. Eligible subjects were approached in the streets and health services and their immediate surroundings were specifically excluded as potential places for recruitment. Two trained surveyors conducted data collection. In total, 380 Equatorian migrants were interviewed. Persons who reported having ever been ill in Spain were asked whether they sought medical care for their last episode of illness. Administrative legal status was ascertained by one open question: ‘what is your current administrative status in Spain?’ Illegal status was defined as a person who did not have a valid residency permit. Analyses were conducted in SPSS.
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Results |
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In total, 226 persons reported having ever been ill in Spain, and 86% had used medical services the last time they were ill. No differences were observed in the utilization of health services between legal or illegal migrants in the univariate analyses (table 1). There were no differences in the utilization of health services between legal or illegal migrants when stratified by sex, education, living conditions, problems with health services or self-perceived health status (table 2). However, 12 or more years of schooling, having University education, having lived in Spain for five or more years, and having a stable contract as compared to a temporal or no work contract, were all associated with higher utilization of health services (table 1). In the multivariate analyses, having completed primary education or less was associated with lower utilization of health services (RP = 0.4; 95% CI: 0.2–0.9).
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Discussion |
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We did not find significant differences in the utilization of health services between legal and illegal Equatorian migrants. Our study suggests that once legal barriers to access health services are removed others issues (such as education level, fear to lose once job, or job instability, among others) may become more relevant, as has been reported for Dutch first generation migrants.8 Although utilization of health services was fairly common in both groups, and were used by 82% of the sick illegal migrants in this study, difficulties to use health services were also reported by about one-quarter of interviewees, ranging from administrative issues to discrimination or denial of medical assistance, but no differences were found in those reports between the two groups.
Migrants were asked about their legal status in the streets and concerns may be raised about the validity of their answers. Pilot studies conducted in 2004 showed that answers were reliable and consistent and that migrants had no special difficulties with these items. The fact that more than 40% of the sample declared that they were illegal is also consistent with the estimations that were made at the time of the survey about the magnitude of illegal migration in Madrid. The main limitations of our study are possible differential recall by legal and illegal migrants, the cross-sectional design and possible selection bias in the selection of the sample of migrants. Differential recall of illnesses might have occurred if illegal migrants tended to recall only more severe episodes of illness, but there were no differences in the causes of illness reported in the two groups. The cross-sectional design might have induced some misclassification as legal status was ascertained at the time of the interview and it might have been different when the illness occurred. However, the utilization of health services is sufficiently high to exclude that this bias, if present, might be important in this case. Finally, people who spent more time on the street looking for a job or just walking were more likely to have been selected. However, it is unlikely that those differences might account for the similarities in the utilization of health services that we find in the study.
Practically all migrants (except two) knew that they were entitled to medical cards, and all (except six) had medical cards. We did not specifically ask about how they knew about the new legislation. However, when asked about their knowledge of NGOs or local migrant associations only 53% had ever visited one, and only 51% could recall the name of at least one NGO or association. Therefore, we may speculate that friends, other migrants or peers might have been the most likely sources of information.
A study conducted in Madrid in the late 90s, using similar instruments and methodology found that illegal migrants were using significantly less health services than legal ones.7 Providing access to medical cards does not guarantee utilization of health services and it cannot be concluded that barriers have been eliminated through those legal changes, as has been clearly shown in other studies.8 Nonetheless, the finding that illegal migrants use health services when ill with similar frequency than other migrants is encouraging, as it suggests that significantly positive improvements can be made once legal barriers are removed, and therefore, public health policies may have a positive impact in reducing health inequalities.
Our study design does not allow us to know whether all health care that might have been needed was indeed used by either group of migrants. Further research is needed to address whether health services are similarly used in severe as well as in less severe cases of illness, by legal and illegal migrants, or whether, in fact, there is an underutilization of health services in some specific illnesses, such as mental diseases in illegal migrants.
Our study also raise a relevant policy research question: why was that legislation approved in Spain? Or, what factors made possible the legal changes that guaranteed access to medical care for illegal migrants? We may speculate that a partial answer may be found in the social mobilization and political climate created around that issue by NGOs, opposition parties and Unions. But why that may have happened in Spain, a country where work migration is a relatively new phenomenon, and not in other European countries undoubtedly deserves further attention.
What this paper adds
This study suggests that when access is provided and is available for all migrants having illegal status may not be an additional limiting factor to health services utilization in cases of need.
Policy implications
Policy changes that remove barriers to health services and improve health care access for illegal migrants may be effective to increase health care utilization by illegal migrants.
This study was funded by a grant from the Norvartis Foundation for Biomedical Research
Key points
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References |
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1 Reijneveld SA. Reported health, lifestyles, and use of health care of first generation immigrants in The Netherlands: do socioeconomic factors explain their adverse position? J Epidemiol Commun Health (1998) 52(5):298–304.[Abstract]
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8 Reijneveld SA. Reported health, lifestyles and use of health care of first generation immigrants in The Netherlands: do socioeconomic factors explain their adverse position? J Epidemiol Commun Health (1998) 52:398–404.
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