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date: 15 July 2018

Health Care Access for Migrants in Europe

Summary and Keywords

Migration is a reality of today’s world, with over one billion migrants worldwide. While many choose to move voluntarily, others are forced to migrate due to economic reasons or to flee war, conflict, or persecution. Such migrants often find themselves in precarious and marginalized situations—particularly asylum seekers, refugees, and undocumented or irregular migrants. While often viewed as a single group, the legal status and entitlements of these three groups are different. This has implications for their ability to access health care; in addition, rights and entitlements vary across the 28 countries of the European Union and across different parts of national health systems. The lack of entitlement to receive care, including primary and secondary care, is a significant barrier for many asylum seekers and refugees and an even greater barrier for undocumented migrants. Other barriers include different health profiles and awareness of chronic disease risk amongst migrants; awareness of the organization of health systems in host countries; and language and communication. The use of professional interpreters can help to overcome communication barriers, but entitlement to free interpreting services is highly variable. Host countries need to consider how to ensure their health systems are “migrant-friendly”: solutions include provision of professional interpreters; ensuring that health care staff are aware of migrants’ rights to access health care; and increasing knowledge of migrants in relation to the organization of the health care system in their host country and how to access care, for example through the use of patient navigators. However, perhaps one of the greatest facilitators for migrants will be a more favorable political situation, which stops demonizing people who are forced to migrate due to situations out of their control.

Keywords: migration, migrants, asylum seekers, refugees, undocumented migrants, access, access to health care, primary care

Migration is a reality of today’s world, with at least one billion migrants worldwide (International Organization for Migration, 2016). Internationally, there are many routes of migration. Some follow postcolonial lines, for example migration from India to the United Kingdom; others are due to proximity, such as migration routes from Central America and Mexico to the United States. In 2015, 37 percent of all global migration occurred within the global South; this was greater than that from South to North (35 percent), and both exceeded migration within the global North (23 percent) (International Organization for Migration, 2016). It is worth remembering, therefore, that many migrants remain in Africa, particularly in the countries of central and southern Africa, and in South Asia, while many of those fleeing the war in Syria remain in neighboring countries in the Middle East or in Turkey (International Organization for Migration, 2016). However, the focus here will be on the increase in migration in Europe.

Levels of migration in Europe have been increasing steadily over the last decade or more (Eurostat, 2017b; Rechel, Mladovsky, Ingleby, Mackenbach, & McKee, 2013). Population estimates in January 2016 indicate that 35.1 million people were born in countries outside of the 28 Member States of the European Union (EU)—6.9 percent of the EU population. Another 19.3 million (3.8 percent) were EU-born internal migrants (Eurostat, 2017b). However, country of birth is only one way of identifying someone as a migrant—another is by citizenship. This gives a somewhat different picture. Thus in January 2016, there were 20.7 million people, 4.1 percent of the EU population, who were citizens of nonmember countries (Eurostat, 2017b). As will be described next, however, regardless of the definition used, migrants are a heterogeneous group with very different rights and entitlements.

Who Is a Migrant?

There is no internationally recognized legal definition for the term “migrant.” One working definition is that employed by the International Organization for Migration, which defines a migrant as anyone who has moved either across or within state borders away from their habitual residence (Table 1).

Table 1. Key Definitions in Relation to Migration and Migrants (Taken from the International Organization for Migration.)

Asylum seeker

A person who seeks safety from persecution or serious harm in a country other than his or her own and awaits a decision on the application for refugee status under relevant international and national instruments. In case of a negative decision, the person must leave the country and may be expelled, as may any nonnational in an irregular or unlawful situation, unless permission to stay is provided on humanitarian or other related grounds.

Country of origin

The country that is a source of migratory flows (regular or irregular).

Freedom of movement

A human right comprising three basic elements: freedom of movement within the territory of a country (Art. 13(1), Universal Declaration of Human Rights, 1948: “Everyone has the right to freedom of movement and residence within the borders of each state.”) and the right to leave any country and the right to return to his or her own country (Art. 13(2), Universal Declaration of Human Rights, 1948: “Everyone has the right to leave any country, including his own, and to return to his country”). See also Art. 12, International Covenant on Civil and Political Rights. Freedom of movement is also referred to in the context of freedom of movement arrangements between States at the regional level (e.g., European Union).

Irregular migration

Movement that takes place outside the regulatory norms of the sending, transit, and receiving countries. There is no clear or universally accepted definition of irregular migration. From the perspective of destination countries, it is entry, stay, or work in a country without the necessary authorization or documents required under immigration regulations. From the perspective of the sending country, the irregularity is for example seen in cases in which a person crosses an international boundary without a valid passport or travel document or does not fulfil the administrative requirements for leaving the country. There is, however, a tendency to restrict the use of the term “illegal migration” to cases of smuggling of migrants and trafficking in persons. N.B. Irregular migrants are often referred to as undocumented migrants.

Migrant

Any person who is moving or has moved across an international border or within a state away from his/her habitual place of residence, regardless of (1) the person’s legal status; (2) whether the movement is voluntary or involuntary; (3) what the causes for the movement are; or (4) what the length of the stay is. IOM concerns itself with migrants and migration‐related issues and, in agreement with relevant states, with migrants who are in need of international migration services.

Migration

The movement of a person or a group of persons, either across an international border, or within a state. It is a population movement, encompassing any kind of movement of people, whatever its length, composition, and causes; it includes migration of refugees, displaced persons, economic migrants, and persons moving for other purposes, including family reunification.

Refugee

A person who, “owing to a well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinions, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country. (Art. 1(A)(2), Convention relating to the Status of Refugees, Art. 1A(2), 1951 as modified by the 1967 Protocol). In addition to the refugee definition in the 1951 Refugee Convention, Art. 1(2), 1969 Organization of African Unity (OAU) Convention defines a refugee as any person compelled to leave his or her country “owing to external aggression, occupation, foreign domination or events seriously disturbing public order in either part or the whole of his country or origin or nationality.” Similarly, the 1984 Cartagena Declaration states that refugees also include persons who flee their country “because their lives, security or freedom have been threatened by generalized violence, foreign aggression, internal conflicts, massive violations of human rights, or other circumstances which have seriously disturbed public order.”

Resettlement

The relocation and integration of people (refugees, internally displaced persons, etc.) into another geographical area and environment, usually in a third country. In the refugee context, the transfer of refugees from the country in which they have sought refuge to another state that has agreed to admit them. The refugees will usually be granted asylum or some other form of long-term resident rights and, in many cases, will have the opportunity to become naturalized.

Trafficking in persons

“The recruitment, transportation, transfer, harboring, or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation” (Art. 3(a), UN Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the UN Convention against Transnational Organized Crime, 2000). Trafficking in persons can take place within the borders of one state or may be transnational.

While useful, one unintended consequence of such a generic definition is that migrants are often referred to as if they are one single group. However, there are many different groups covered by the term “migrant” (Ingleby, 2012). This may include, for example, students moving to a country for a few years to study; individuals moving for work; or spouses and families coming to join someone already settled in that country. In 2013, 28 percent of non-EU migrants to the EU came for family reunification; 23 percent for work; 20 percent for education; and 29 percent for other reasons (see Immigration in the EU.) Within those classified as moving for “other reasons” are those leaving for economic reasons and those fleeing war, conflict, and persecution, often seeking asylum in another country. The terms “refugee” and “asylum seeker” are often used synonymously when describing these people; in reality, however, these are two distinct populations with different legal status and entitlements (Table 1).

This means that migrants can find themselves in very different situations, in terms of the degree of freedom in the decision to move, the journey to get to another country, and their legal status once they arrive (Permanand, Krasnik, Kluge, & McKee, 2016; Zimmerman, Kiss, & Hossain, 2011). The focus in this chapter will be those migrants who find themselves in marginalized situations—namely asylum seekers, refugees and undocumented migrants.

Accurate estimates of the number of marginalized migrants in the 28 countries of the EU are hard to find. The European Council on Refugee and Exiles estimated that there are approximately 1.5 million recognized refugees in the EU (i.e., people given the legal status of “right to remain” in an EU country—see ECRE.) Much of the focus of politicians and wider society, however, has been on those seeking asylum in Europe. Asylum applications to the EU slowly increased until 2013, when the number of applications began to rise rapidly, peaking at over one million in both 2015 and 2016 (Eurostat, 2017a). The three countries accounting for the largest number of asylum applicants were Syria, Afghanistan, and Iraq, reinforcing the reasons why people are most likely to flee their own country—namely war, conflict, and persecution. In 2016, the EU countries receiving the largest number of asylum seekers were Germany, Italy, France, and Greece (Eurostat, 2017a).

Although harder to obtain accurate estimates, there are also large numbers of undocumented or irregular migrants in Europe, including victims of trafficking. One project estimated the number of undocumented migrants living in the EU in 2008 as between 1.9 and 3.8 million people (0.4 percent to 0.8 percent of the total EU population—see PICUM). Finally, one often overlooked group is those who work in low-paid, often seasonal employment.

Such movement of people into new countries presents particular challenges for the health care systems of the host countries. Challenges include rights and entitlements to care; health needs and the potential for different disease profiles from the “settled” population; different cultural concepts and understandings of the structure and organization of the health care system in the host country; and communication and language barriers between migrants and health care practitioners. These issues will also vary across different groups of migrants, depending on their status and migration journey. These issues will now be considered in turn, with particular reference to those migrant groups who find themselves in more marginalized situations—namely refugees, asylum seekers, and undocumented migrants.

Legal Entitlements to Health Care

Regardless of one’s status in relation to migration, all individuals have a fundamental right to health as supported by various international and European instruments (such as Article 12 of the International Covenant on Economic, Social and Cultural Rights.) and the European Charter of Fundamental Rights (European Union, 2012). As a minimum requirement, this should guarantee access to “essential primary healthcare” as well as emergency medical care and antenatal care (European Union Agency for Fundamental Rights, 2011). Other organizations, in particular the World Health Organization, have also recognized the rights of migrants to be able to access not only emergency or reactive health care, but also proactive care, including health promotion and disease prevention programs (World Health Organization, 2010; World Health Organization Europe, 2015). In practice, however, access to health care is often dependent upon the legal status of migrants with undocumented migrants facing the biggest challenges in accessing health care (O’Donnell et al., 2016; Rechel et al., 2013; WHO Regional Office for Europe, 2010). This was highlighted by Dauvrin and her colleagues, who mapped health care entitlement for irregular migrants across a range of European countries as part of an EU-funded project called EUGATE, which explored health services for migrant populations (Deville et al., 2011; Priebe et al., 2011). Dauvrin’s work identified three categories of health care entitlement for irregular migrants: (a) no rights to health care; (b) minimum rights, where emergency care could be accessed; and (c) rights, where primary and secondary care could also be accessed (Dauvrin et al., 2012). Access is, however, often dependent on the ability to pay, as illustrated in Table 2, which for populations with little or no financial support becomes a major barrier.

Table 2. Entitlement to Health Care for Irregular Migrants in the 28 Countries of the EU, as of 31 December 2015. (From: http://fra.europa.eu/en/theme/asylum-migration-borders/healthcare-entitlements)

EU Member State

Emergency Care

Primary Care

Secondary Care

Austria

Yes, with payment

Yes, with payment

Yes, with payment

Belgium

Yes, free

Yes, free

Yes, free

Bulgaria

Yes, free but only in centers for emergency medical care

Yes, with payment

Yes, with payment

Cyprus

Yes, with payment, but low fee

Yes, with payment, but with exceptions

Yes, with payment

Czech Republic

Yes, with payment

Yes, with payment

Yes, with payment

Germany

Yes, free

Yes, with payment

Yes, with payment

Denmark

Yes, free

Yes, with payment

Yes, with payment, but exceptions possible

Estonia

Yes, free

Yes, with payment

Yes, with payment

Greece

Yes, unclear in law whether for free

Yes, with payment

Yes, with payment

Spain

Yes, free

Yes, with payment

Yes, with payment

Finland

Yes, with payment

Yes, with payment

Yes, with payment

France

Yes, free

Yes, free

Yes, free

Croatia

Yes, with payment

Yes, with payment

Yes, with payment

Hungary

Yes, with payment

Yes, with payment

Yes, with payment

Ireland

Yes, free

Yes, with payment

Yes, with payment

Italy

Yes, free

Only in some regions, for free

Yes, free

Lithuania

Yes, free

Yes, with payment

Yes, with payment

Luxembourg

Yes, with payment

Yes, with payment

Yes, with payment

Latvia

Yes, with payment

Yes, with payment

Yes, with payment

Malta

Yes, unclear in law whether for free

Unclear in law

Unclear in law

Netherlands

Yes, free

Yes, free

Yes, free

Poland

Yes, free when provided by ambulance teams

Yes, with payment

Yes, with payment

Portugal

Yes, free

Yes, free

Yes, free

Romania

Yes, free

Yes, with payment

Yes, with payment

Sweden

Yes, with payment, but low fee

Yes, with payment

Yes, with payment

Slovenia

Yes, free

Yes, with payment

Yes, with payment

Slovakia

Yes, free

Yes, with payment

Yes, with payment

United Kingdom

Yes, free

Yes, free

Yes, free

Table 2 demonstrates that many countries limit access to health care, especially for those in undocumented or irregular situations, by setting financial barriers which many migrants are unable to meet (Dauvrin et al., 2012; European Union Agency for Fundamental Rights, 2011; Medecins du Monde, 2016). The recent Medecins du Monde report highlighted that, regardless of the legal situation in each country, many undocumented migrants had little or no actual access to health care (Medecins du Monde, 2016). As well as financial barriers, other barriers included administrative problems, often due to a lack of documentation, lack of knowledge of the health care system, and communication barriers (Medecins du Monde, 2016; Woodward, Howard, & Wolffers, 2014). These barriers not only create difficulties for patients, but also for the health care professionals caring for them, especially if health care professionals are expected to ask about migrant status before initiating treatment (Hargreaves et al., 2016).

Health Needs

Research often refers to the “healthy migrant” effect—namely that migrants are often younger and, relative to the native population, healthier (Rechel et al., 2013). This can be true initially, especially if part of a voluntary group such as students or highly skilled workers. By contrast, migrants in marginalized situations are often leaving countries where health care systems have broken down, may have experienced trauma on their journey to Europe, and may have preexisting chronic disease and physical ill health, as well as mental ill health (Medecins du Monde, 2016; Rechel et al., 2013). Country of origin, reasons for migration, socioeconomic status, age, and gender are also factors that influence their health (Salt, 2011). As a result, migrants can suffer from poorer health than the native population of the country they have moved to (Kuehne, Huschke, & Bullinger, 2015; Newbold & Danforth, 2003; Nielsen & Krasnik, 2010), particularly when the migration journey and related trauma is taken into account (Carswell, Blackburn, & Barker, 2011; Permanand et al., 2016). Once in a host country, the precarity and uncertainty of their situation continues to add to their ill health.

Migrants may also come from countries in “epidemiological transition” (i.e., with an increasing prevalence of noncommunicable chronic diseases such as diabetes and cardiovascular disease; mental health conditions such as depression; and lifestyle-related conditions such as obesity) while still experiencing infectious diseases, poor maternal and child health, tuberculosis, and HIV (McKeown, 2009; World Health Organization, 2008). Thus health care professionals must be aware of such chronic diseases, as well as the potential for communicable diseases such as tuberculosis, hepatitis. parasitic diseases, and HIV (Burnett & Peel, 2001; Rechel et al., 2013). Migrants themselves are often unaware of such risks and, perhaps because many are younger, do not consider themselves at risk of chronic disease (Cooper, Harding, Mullen, & O’Donnell, 2012). One clear need across different migrant groups in marginalized situations is in relation to mental health needs (Carswell et al., 2011; Medecins du Monde, 2016). A cohort study in Sweden, comprising 1.2 million native-born Swedes, 24,000 refugees, and 133,000 nonrefugee migrants found that refugees were at increased risk of schizophrenia and other nonaffective psychotic disorders compared to the other two groups (Hollander et al., 2016). Reasons may include migration trajectory, racism, discrimination, and poverty (Carswell et al., 2011; Fleischman, Willen, Davidovitch, & Mor, 2015; Katona, 2016).

Finally, little is known about the prevalence of multimorbidity in migrant populations. Recent work using a population-level disease registry in Norway found that, compared to those migrating for family reunification, multimorbidity was lower for those migrating for work (Men: OR 0.23 [95 percent CI: 0.21–0.26]; Women: OR 0.45 [95 percent CI: 0.40–0.50]) but higher for refugees (Men: OR 1.67 [95 percent CI: 1.57–1.78]; Women: OR 1.83 [95 percent CI: 1.75–1.92]). For all groups, multimorbidity doubled after a five-year stay in Norway (Diaz et al., 2015). One issue that likely contributes to this, particularly for asylum seekers and refuges, is the precarity of their situation, with worry and uncertainty over asylum claims taking its toll on their physical and mental health and reducing their ability to focus on their health and lifestyle-related risk factors (Isaacs, Burns, Macdonald, & O’Donnell, unpublished work).

Access to Health Care

In many countries primary care plays a gatekeeping role to other services, and is often the first point of contact into a health care system for all patients, whether they are migrant patients or members of the settled population. This, alongside its person-centered approach to health care, arguably places it in a unique position to facilitate the health needs of migrants (WHO Regional Office for Europe, 2010). Furthermore, primary health care with its principles of equity, social justice and solidarity would seem well placed to address the needs of migrant groups in society (O’Donnell et al., 2016). However, the strength of primary care within health systems varies across Europe (Kringos et al., 2013; Kringos, Boerma, van der Zee, & Groenewegen, 2013; Macinko, Starfield, & Shi, 2003). Features of a strong primary care system include registration with general practitioners or family physicians; use of appointment systems; gatekeeping to hospital-based secondary care services through a referral system; and entitlement to care based on a system of population taxation, sometimes in combination with social insurance. Weak systems do not exhibit these features and often have high levels of out-of-pocket payments for seeing a general practitioner or family physician, high payments for medicines, and a reliance on private insurance schemes. In 2013, Kringos classified countries of the EU according to the strength of their primary care system (Table 3).

Table 3. Strength of European Primary Care Systems (From Kringos et al. (2013)).

Strong

Medium

Weak

Belgium

Czech Republic

Austria

Denmark

France

Bulgaria

Estonia

Germany

Cyprus

Finland

Italy

Greece

Lithuania

Latvia

Hungary

Netherlands

Norway

Iceland

Portugal

Poland

Ireland

Slovenia

Romania

Luxembourg

Spain

Sweden

Malta

UK

Switzerland

Slovak Republic

Turkey

*Based on a composite indicator addressing the structure of primary care (12 indicators of governance, 11 indicators of economic status, and 16 indicators of workforce development) and the process of service delivery (12 indicators of access, 10 indicators of comprehensiveness of coverage, 9 indicators of continuity, and 7 indicators of coordination).

However, even in systems where primary care is strong, policy changes can quickly change relatively favorable system conditions to situations which are less favorable to migrants. For example, austerity measures in Ireland led to a retraction of a policy of integration while government change in The Netherlands led to changes in the provision of interpreting services for asylum seekers (O’Donnell et al., 2016). More recently, the enactment of the Immigration Act of 2014 in the United Kingdom led to the imposition of a £200 (€280, $315) annual health surcharge on migrants who have not been given refugee status in the country (Gulland, 2015).

For many migrants, the concept of primary care is also new and there are important structural, organizational, and interpersonal barriers to be considered. The need to pay for care, health care professionals’ knowledge of the rights of migrants to access primary care, and their ability to communicate effectively with migrant patients all play a role in determining whether primary care represents a barrier or facilitator to migrants’ access and use of primary care (Norredam, Mygind, & Krasnik, 2006). Thus the structure, funding, and governance of primary care systems play an integral role in the accessibility of health care for migrants (O’Donnell et al., 2016). Some of these factors may help to explain why Stagg and colleagues found that migrants in general were less likely to register with general practices (Stagg, Jones, Bickler, & Abubakar, 2012).

A number of studies have explored the barriers to accessing primary care, especially in relation to asylum seekers and refugees. As highlighted earlier, many countries have legal barriers, stipulating which types of service an asylum seeker, refugee, or undocumented migrant has the right to access—typically this would be emergency care and antenatal care (Norredam et al., 2006). This often relates back to the way in which health care is funded—those systems which rely on an insurance system for some or all of its costs may find it more difficult (or may not want) to find ways of providing health care for those who have no insurance. The need, in some systems, to pay toward the cost of consulting with a family doctor or for medications are other obvious barriers, particularly if the individual is not allowed to work and so has limited financial resources.

Another barrier is the perceptions that migrants themselves have of the health care system they find themselves in. Work in Scotland with asylum seekers and refugees revealed that the majority came from countries in which health care was generally provided in the hospital setting and primary care was not a strong system of care (O’Donnell, Higgins, Chauhan, & Mullen, 2007). This led individuals to doubt the effectiveness of primary care to deal with their problems. In particular, there was a view that medical generalists such as are found working in primary care could not have the skills and knowledge to deal with all of the problems they encounter in a primary care setting (O’Donnell, Higgins, Chauhan, & Mullen, 2008). There was also a view that family doctors were trying to block access to hospital-based care through the referral system. Disease patterns in the country of origin at times caused problems. For example, the high incidence of tuberculosis in former Soviet Union countries meant that babies in those countries were immunized very early, unlike the immunization protocol in the United Kingdom. This again led to a lack of confidence in primary care doctors among this group of migrants, as mothers lacked confidence in the system of waiting until the child was older (O’Donnell et al., 2007). Such views can lead those migrants who are in a position to return easily to their own country in order to seek health care there (Sime, 2014).

Many of the structural barriers identified in relation to primary care, in particular entitlements and financial barriers, also apply to accessing accident and emergency departments and mental health services (Agudelo-Suárez et al., 2012; Joshi et al., 2013; Norredam, Nielsen, & Krasnik, 2010; Woodward et al., 2014). There is, however, evidence that migrants may use accident and emergency departments in preference to other parts of the health system. A study in the United States compared patients who did, and did not, require interpreting services and found that the risk of an emergency department visit was 60 percent greater for those who required an interpreter (unadjusted hazard ratio 1.6; 95 percent confidence interval 1.4–1.9) (Njeru et al., 2015). This increase remained even after adjusting for age, sex, medical complexity, residency, and outpatient use. Rates of first hospitalization were also higher in those requiring interpreters. As all patients in the study had health insurance, lack of access due to lack of funds was not an explanation. The authors suggested that help-seeking behavior—perhaps due to unfamiliarity with preventive care of chronic disease management—might be a contributory factor. A systematic review also found evidence of increased accident and emergency use and hospitalizations among migrants (Graetz, Rechel, Groot, Norredam, & Pavlova, 2017). Interviews with health care professionals working in accident and emergency suggested that migrants might find it easier to access care in that setting, as staff were less likely to ask about legal status (Dauvrin et al., 2012). Thus, accident and emergency services may be a more permeable or accessible point of care in the health system (Dixon-Woods et al., 2006; Mackenzie, Conway, Hastings, Munro, & O’Donnell, 2013). However, the other recurrent barrier to access that is highlighted in many studies is that of language and communication difficulties.

Language and Communication

Communication lies at the core of health care. The increasing diversity of languages spoken in Europe is creating new challenges for health care services which have to deal with this increasing diversity, both in terms of language and cultural understanding (MacFarlane et al., 2012; Phillimore, 2011; van den Muijsenbergh et al., 2014). The inability to communicate within health care consultations has recognizable consequences. Patients visit their health care provider less (Derose, Escarce, & Lurie, 2007); consultations are longer; there is poorer mutual understanding leading to increased noncompliance with medication and treatment advice (van Wieringen, Harmsen, & Bruijnzeels, 2002); and there are fewer referrals to other services, especially psychological services (Bischoff, Perneger, Bovier, Loutan, & Stalder, 2003). Other issues include the increased risk of misunderstanding and misdiagnosis (Flores, 2005; Flores, Abreu, Barone, Bachur, & Lin, 2013; Karliner, Jacobs, Chen, & Mutha, 2007); extensive clinical testing required to compensate for poor communication (Priebe et al., 2011); and prolonged administrative procedures. However, communication and understanding goes beyond just language; health, and our understandings of health, are shaped and informed by one’s cultural background. As the recent Lancet Commission on culture and health stated, “intercultural health communication is not only about language translation, but also situated beliefs and practices about the causation, local views on what constitutes effective provision of health care, and attitudes about agency and advocacy” (Napier et al., 2014). Thus, the “language problem” goes beyond mere translation of words. In addition, emotional expressions and meanings are often not interchangeable across languages (Flores et al., 2013) and nonverbal communication from the patient to the practitioner can be difficult to read, especially if the presence of the interpreter draws the focus of the health care provider away from the patient (Tribe & Lane, 2009). Added to this, the intersection of both culture and migrant status with other structural and societal factors can create and compound difficulties in the health care encounter, including a lack of trust (MacFarlane et al., 2012).

Many studies investigating the use and role of interpreters have been conducted in the hospital setting. Greenhalgh and colleagues conducted work in general practice in the United Kingdom, interviewing a range of health care professionals, interpreters, and patients (Greenhalgh, Voisey, & Robb, 2007). They found that general practitioners were central to the routinization of interpreting in the practice; interpreters, even paid professional interpreters, were relatively powerless to influence practice routine and ways of working. Migrant patients had their own issues, with many wanting to have a professional interpreter rather than a family member or friend interpret for them, as they had concerns about confidentiality and appropriateness of the interpreting when ad hoc interpreters were used (Barron, Holterman, Shipster, Batson, & Alam, 2010; MacFarlane et al., 2009).

To date, there has been little or no work on assessing the cost effectiveness of providing interpreting services. While effort has been put into calculating the costs to the NHS in England of providing interpreting services and translated materials (estimated at £23.3 million in 2011) (2020 Health, 2012), no one has calculated the related costs of not providing such services in terms of late presentation of symptoms or use of more accessible services inappropriate to the clinical need (e.g., using accident and emergency departments for conditions better dealt with in primary care). Recent work from Germany has shown that restricting access to health services for asylum seekers—albeit by restricting entitlement rather than by reducing interpreting services—resulted in higher health care costs when asylum seekers eventually were able to use services (Bozorgmehr & Razum, 2015).

Response of Practitioners to Caring for Migrants

A recent systematic review of providers views of caring for migrants, across a range of international settings, found several recurrent themes, such as challenges with respect to communication with migrant patients and a lack of knowledge of the host country’s health care system (Suphanchaimat, Kantamaturapoj, Putthasri, & Prakongsai, 2015). Health care professionals found the workload of caring for migrant patients was often heavy, but also found ways of circumventing some of the system-level challenges, such as dealing with administrative and financial burdens. The “fit” between the expectations of migrant patients and the professional caring for them was explored by Lindenmeyer et al (Lindenmeyer, Redwood, Griffith, Teladia, & Phillimore, 2016). Many of the health care professionals interviewed believed that both practitioners and systems had to adapt and adjust their usual ways of working in order to be flexible and provide good care for migrants. However, a small number of participants believed that the onus was on migrants to adjust to the health care system they were seeking help and care from (Lindenmeyer et al., 2016). Wider conditions can also impact on health care practitioners ability to provide effective and appropriate health care for migrants. In Greece, service providers operating under conditions of austerity felt unable to fulfil their role efficiently for any of their patients; for some, migrants were perceived to be part of the problem (Papadakaki et al., 2017).

Going Forward—How Can Care for Asylum Seekers, Refugees and Undocumented Migrants Be Improved?

There are a number of areas which are amenable to improvement, both for patients and for the health care professionals providing that care.

There is an ongoing debate as to whether care should be delivered in centers specializing in migrant care. While this might be acceptable at certain points of time in the migration journey, overall health care systems will need to find ways to adapt and deliver migrant-sensitive care within current health care systems. To achieve that, a number of issues should be addressed.

Ensuring All Staff Are Aware of Rights and Entitlements

Health care staff need to be educated as to the rights and entitlements of different groups of migrants within their own national health care system. In all settings—but particularly in primary care—reception and administrative staff, as the first point of contact with patients, are a particularly important target group. Their role is key to welcoming and supporting migrant patients and ensuring that they feel comfortable within the health care system.

Access to Timely, High-Quality Interpreting Services

As described above, professional face-to-face interpreting is the gold standard and—as such—should be the default option for all patients accessing health care. Where there are difficulties with this, for example due to a small number of interpreters in a particular language or due to urgency of need, other options may be sought, for example telephone or video interpreting. The use of ad hoc untrained interpreters or members of staff should be discouraged. To date, there is no high quality evidence comparing the effectiveness of face-to-face interpreting with other forms of interpreting, such as telephone or video. With cost constraints a feature of all health care systems, there is a need for high quality evaluation and comparison of different forms of interpreting provisions.

Education for Patients With Respect to the Structure and Operation of the National Health Care Systems

As described earlier, migrants often find themselves in health care systems that are very different from the system they have known in their countries of origin. Many patients are also often unfamiliar with preventive health care, including such systems as cervical screening or with childhood immunization schedules that differ from their country of origin (Cooper et al., 2012; O’Donnell et al., 2007) (Matthews, Burns, Mair, & O’Donnell, unpublished research). Support and information, for example through the use of peer support or mentor schemes, could help to counteract some of this and improve care for such patients. The potential of patient navigators to support underserved patients is being explored and could, potentially, be developed to support particular groups of migrant patients (Dohan & Schrag, 2005; Natale-Pereira, Enard, Nevarez, & Jones, 2011). Migrants can be involved in the development and co-design of such services, to ensure that services are culturally appropriate and meet the needs of different populations (Lionis et al., 2016; O’Reilly-de Brún et al., 2015).

Conclusion

Many migrants to Europe are currently there as a result of war or conflict in their home country. While such individual country situations may resolve themselves, the reality is that the continued presence of conflict in many parts of the world would suggest that people will continue to have to flee their home countries. Add to that poor economic conditions in many parts of the world and the potential threat of climate change causing mass migration and it is clear that such mass migration will be an ongoing phenomenon. As a result, health care systems will need to develop ways of ensuring equity of access for migrant patients, ensuring that legal entitlement, language, and culture do not act as insurmountable barriers to access health care predicated on need.

Acknowledgments

I would like to thank my doctoral students Dr. Max Cooper, Ms. Anna Isaacs, and Dr. Anna Matthews, whose work and discussions have contributed to this chapter. Also the EU-funded RESTORE project and team led by Professor Anne Macfarlane, University of Limerick (Contract No 257258).

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