Table Of ContentAccess to heAlthcAre And living
conditions of Asylum seekers
And undocumented migrAnts
in cyprus, mAltA, polAnd
And romAniA
CJMN : : 0: : 1 06000
Médecins du monde - Identité visuelle FRANCE 08/07/2009
Acknowledgments
First of all, we would like to thank all the people who accepted to answer the
questions of the feld survey of this report by giving some time to it and sharing
their diffcult experience. Their answers to the questionnaire and testimonies
allow having new and comprehensive data as regards the diffcult questions
such as their conditions of life and access to healthcare.
We would like to thank also all the HUMA partners, ARCA, KISA, Association
for Legal Intervention (SIP) and SKOP: their staff and volunteers were very
committed and spent a lot of time in 2010 to work on this report, on the legal
analysis as well as for the feld survey; the commitment of the surveyors in the
preparation of the feld work and during the feld work has been very strong.
ACCESS TO HEALTH CARE FOR UNDOCUMENTED MIGRANTS AND ASYLUM SEEKERS
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ACCESS TO HEALTHCARE AND LIVING
CONDITIONS OF ASYLUM SEEKERS
AND UNDOCUMENTED MIGRANTS
IN CYPRUS, MALTA, POLAND AND ROMANIA
ACCESS TO HEALTH CARE FOR UNDOCUMENTED MIGRANTS AND ASYLUM SEEKERS
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ACCESS TO HEALTH CARE FOR UNDOCUMENTED MIGRANTS AND ASYLUM SEEKERS
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CONTENTS
INTRODUCTION ......................................................................................................................................... 5
Methodology ....................................................................................................................................... 7
Terminology in the framework of this report ..................................................................................... 11
Map of investigated countries: .......................................................................................................... 12
CYPRUS.................................................................................................................................................... 13
KISA (Action for Equality, Support, Antiracism)................................................................................ 13
Introduction – Context in Cyprus ...................................................................................................... 13
Part 1: Legal analysis........................................................................................................................ 15
Part 2: Field survey in Cyprus........................................................................................................... 31
I. Demographic characteristics ....................................................................................................................32
1. Sex and age.........................................................................................................................................32
2. Regions of origin and nationalities .......................................................................................................33
II. Migration experience ................................................................................................................................34
1. Asylum procedures attempted by undocumented migrants .................................................................34
2. Reasons for migration..........................................................................................................................35
3. Time period since migration.................................................................................................................36
4. Living in fear ........................................................................................................................................37
III. Living conditions ......................................................................................................................................38
1. Family and social network....................................................................................................................38
2. Housing conditions ..............................................................................................................................40
3. Sources of income and working conditions..........................................................................................42
IV. Perceived health and access to healthcare.............................................................................................46
1. Perceived health status .......................................................................................................................46
2. Entitlements to health coverage...........................................................................................................47
3. Access and recourse to healthcare: case study...................................................................................48
4. Difficulties and barriers in accessing healthcare ..................................................................................51
5. Healthcare refusals.............................................................................................................................53
6. Abandoning healthcare........................................................................................................................54
V. Access to healthcare for pregnant women and children...........................................................................55
1. Pregnant women: access to antenatal and postnatal care ..................................................................55
2. Access to healthcare for children.........................................................................................................57
Conclusion Cyprus............................................................................................................................ 59
Recommendations - Cyprus ............................................................................................................. 62
MALTA ...................................................................................................................................................... 64
SKOP ................................................................................................................................................ 64
Introduction - context in Malta........................................................................................................... 64
Part 1: Legal analysis........................................................................................................................ 65
Part 2: Field study in Malta ............................................................................................................... 71
I. Demographic characteristics ....................................................................................................................72
1. Sex and age.........................................................................................................................................72
2. Nationalities .........................................................................................................................................73
II. Migration experience ................................................................................................................................73
1. Time period since migration.................................................................................................................73
2. Reasons for migration..........................................................................................................................75
3. experience of detention and fear ........................................................................................................76
III. Living conditions in Malta ........................................................................................................................76
1. Income and working conditions............................................................................................................76
2. Housing conditions .............................................................................................................................79
3. Access to emotional support................................................................................................................81
IV. Perceived health and access to healthcare.............................................................................................82
1. Perceived health status .......................................................................................................................82
2. Entitlements to health coverage...........................................................................................................83
3. Access and recourse to healthcare: case study...................................................................................84
4. Barriers in accessing healthcare..........................................................................................................88
Conclusion - Malta ............................................................................................................................ 92
Recommendations - Malta................................................................................................................ 93
ACCESS TO HEALTH CARE FOR UNDOCUMENTED MIGRANTS AND ASYLUM SEEKERS
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POLAND.................................................................................................................................................... 95
SIP .................................................................................................................................................... 95
Introduction – context in Poland ....................................................................................................... 95
Part 1: Legal analysis........................................................................................................................ 99
Part 2: Field survey in Poland......................................................................................................... 109
I. Demographic characteristics ..................................................................................................................111
1. Sex and age.......................................................................................................................................111
2. Nationality and citizenship .................................................................................................................112
II. Migration experience ..............................................................................................................................113
1. Time period since migration...............................................................................................................113
2. Reasons for migration........................................................................................................................114
III. Living conditions in Poland ....................................................................................................................115
1. Family and social network..................................................................................................................115
2. Housing conditions ...........................................................................................................................116
3. Sources of income and working conditions........................................................................................119
IV. Perceived health and access to healthcare...........................................................................................121
1. Perceived health status .....................................................................................................................121
2. Assistance with health formalities ......................................................................................................124
3. Most recent health problem - access and recourse to healthcare......................................................125
4. Difficulties and barriers to access healthcare.....................................................................................127
V. Access to healthcare for pregnant women and for children ...................................................................132
1. Pregnant women: access to ante / postnatal and delivery care .........................................................132
2. Children of asylum seekers and undocumented migrants: the difficulties and barriers encountered
trying to access healthcare for the children ...........................................................................................135
Conclusions – Poland ..................................................................................................................... 138
Recommendations - Poland ........................................................................................................... 141
ROMANIA................................................................................................................................................ 142
ARCA - Romanian Forum for Refugees and Migrants ................................................................... 142
Introduction – context in Romania .................................................................................................. 142
Part 1: Legal analysis...................................................................................................................... 144
Part 2: Field study in Romania........................................................................................................ 154
I. Demographic characteristics ..................................................................................................................155
1. Sex and age.......................................................................................................................................155
2. Region of origin and nationality..........................................................................................................156
II. Migration experience ..............................................................................................................................157
1. Time period since arrival....................................................................................................................157
2. Former asylum seekers .....................................................................................................................158
3. Reasons for migration........................................................................................................................159
4. Experience of detention and fear .......................................................................................................160
III. Living conditions ....................................................................................................................................161
1. Family and social networks................................................................................................................161
2. Housing conditions ............................................................................................................................163
3. Sources of income and working conditions........................................................................................165
IV. Perceived health and access to healthcare...........................................................................................168
1. Perceived health status .....................................................................................................................168
2. Entitlements to health coverage.........................................................................................................169
3. Recourse to healthcare: the action taken during the most recent health problem .............................170
4. Difficulties and barriers in accessing healthcare and the refusals......................................................173
V. Access to healthcare for pregnant women and children.........................................................................177
1. Pregnant women: access to antenatal and postnatal care ................................................................177
2. Access to healthcare for children.......................................................................................................180
Conclusions - Romania................................................................................................................... 183
Recommendations - Romania ........................................................................................................ 186
GENERAL CONCLUSION ...................................................................................................................... 187
GENERAL RECOMMENDATIONS......................................................................................................... 200
Bibliography............................................................................................................................................. 201
Index of tables and figures ...................................................................................................................... 206
Appendices .............................................................................................................................................. 210
ACCESS TO HEALTH CARE FOR UNDOCUMENTED MIGRANTS AND ASYLUM SEEKERS
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INTRODUCTION
This report presents the results of multi-disciplinary research into access to healthcare for asylum
seekers and undocumented migrants in four European Union countries: Cyprus, Malta, Poland and
Romania. It reports on legal rights and entitlements and presents the findings of a quantitative
survey conducted in 2010 by HUMA network members in these four countries: KISA in Cyprus,
Skop in Malta, the Association for Legal Intervention (SIP) in Poland, and ARCA in Romania.
The main purpose of this report is to provide insight into the precarious situation and health
problems of two of the most vulnerable groups living in Europe, asylum seekers and undocumented
migrants, in Cyprus, Malta, Poland and Romania. In more concrete terms, it provides an overview of
the legal systems regulating access to healthcare for undocumented migrants, asylum seekers and
their children in these countries, as well as comprehensive data about their living conditions,
perceived health status and difficulties in accessing healthcare.
The information and analysis contained in this report are aimed at policy makers, health
professionals, NGOs and the general public in the hope of bringing about an improvement in the
health situation of asylum seekers and undocumented migrants by guaranteeing full protection of
their right to access healthcare.
This report adopts the same approach as that used by the Médecins du Monde European
Observatory on access to healthcare and by the HUMA network in previous workings. The
Médecins du Monde European Observatory has already published two reports of findings from field
studies into the living conditions, access to healthcare and health status of undocumented migrants
in first 7 and then 11 European countries, in 2007 and 2009 respectively.1 In 2009, the HUMA
network published a comparative analysis of legal entitlements to healthcare for undocumented
migrants and asylum seekers in 10 EU countries.2
Undocumented migrants and asylum seekers are highly vulnerable population groups. In Romania,
the tolerance holders are also particularly vulnerable as no rights are attached to their permission to
stay; they will also be taken into account in this study.3 The difficulties experienced by these
migrants in their home countries and that determined their decision to migrate, compounded by an
often extremely arduous journey into exile, can have very long-lasting effects on their health.
Furthermore, once living in Europe, in a so-called "host" country, the majority endures very difficult
living and working conditions due to or aggravated by their administrative situation. These factors
are all potentially harmful to their health over the medium to long term, all the more because the
status of asylum seeker and the lack of status of undocumented migrants provide respectively little
or no entitlements to healthcare. This makes their situation extremely preoccupying, both in human
rights terms and from a public health perspective.
According to international Human Rights instruments, healthcare is a fundamental right for every
human being. The United Nation's International Covenant on Economic Social and Cultural Rights
requires that states recognise “the right to the enjoyment of the highest attainable standard of
physical and mental health”4, and this by “refraining from denying or limiting equal access for all
persons, including prisoners or detainees, minorities, asylum seekers and illegal migrants to
preventive, curative and palliative health services; abstaining from enforcing discriminatory practices
1 Médecins du Monde European observatory on access to healthcare, Chauvin, P., Parizot, I., Simonnot, N. (2009), op. cit.; See
also Médecins du Monde European Observatory on access to healthcare, Chauvin, P., Parizot, I., Drouot, N., Simonnot, N.,
Tomasino, A. (2007). First European survey on undocumented migrants’ access to healthcare. Paris, Médecins du Monde.
Available at: www.mdm-international.org.
2 HUMA network (2009). Access to healthcare for undocumented migrants and asylum seekers in 10 EU countries. Law and
practice. Paris, Médecins du Monde. Available at: www.huma-network.org
3 For a legal definition of asylum seekers and undocumented migrants, as well as of holders of a tolerance, please look at the table
on the terminology at the end of the introduction.
4 Article 12 (1) of the International Covenant on Economic Social and Cultural Rights, Resolution 2200A (XXI) of 16 December
1966.
ACCESS TO HEALTH CARE FOR UNDOCUMENTED MIGRANTS AND ASYLUM SEEKERS
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5
as a state policy” . In addition to this treaty, other international instruments protect the healthcare
6
rights of specific populations, such as the Convention on the Rights of the Child , or the
International Convention on the Protection of the Rights of All Migrant Workers and Members of
Their Families, although this convention has not been not ratified by any of the countries targeted in
7
this report or by the European Union.
The European Union is supposed to promote health systems based on principles of universality,
solidarity and equity. However, as EU member states remain individually competent to determine
who should benefit from their public health system, legal entitlements to healthcare for
undocumented migrants and asylum seekers depend on national legislation. At the EU level,
8
regulations are in place on healthcare for asylum seekers , imposing access free of charge to
9
emergency care and the necessary treatment of illnesses as a minimum provision. However, as far
as undocumented migrants are concerned, no aspect of European hard or soft law protects or
addresses their fundamental right to healthcare. This is hardly surprising as debate on
undocumented migrants continues to focus on the “fight against illegal migration”, and no discussion
has yet been launched into the need to protect undocumented migrants’ rights at EU level.
10
As highlighted in the first HUMA legal report , most EU countries fall far short of offering the level of
protection foreseen in international instruments with regard to healthcare coverage for
undocumented migrants and, to a lesser extent, asylum seekers. Many current legal frameworks
are highly discriminatory, and in addition, there are still enormous barriers to accessing health
services in practice. The last survey by the Médecins du Monde European Observatory on access
11
to healthcare revealed that undocumented migrants encounter numerous problems, including no
effective access to healthcare entitlements, administrative and language barriers, a lack of
information, unaffordable medical treatment and the fear of being reported or refused healthcare. As
a consequence, 72% of the pathologies of the undocumented migrants interviewed in the survey
went without treatment or follow up.
The two reports cited above have also confirmed the current trend to restrict the healthcare
entitlements of these population groups. All over Europe, countries are using healthcare as an
immigration control instrument rather than treating it a human right to be protected or a public health
concern to be addressed. Yet access to healthcare should not only be considered a priority in terms
of human rights, it should also be seen as a key public health issue, as access to healthcare for all
contributes to reduce health inequalities and is a means of ensuring a healthy society. Conversely,
denying healthcare to people with little or no legal status only serves to increase their
marginalisation and leads to increased health inequalities.
Cyprus, Malta, Poland and Romania - the four countries targeted in this report - are each in a quite
similar situation and face similar challenges with regard to managing migration. They all joined the
EU recently (in 2004 for Cyprus, Malta and Poland and in 2007 for Romania) and are all
geographically situated on the external borders of the European Union.
For all of them, joining the EU meant adopting EU immigration policy and so they have all received
instructions and incentives for preventing illegal entries by tightening border controls and for
5
See Committee on Economic Social and Cultural Rights (2000). General Comment n°14. The right to the highest attainable
standards of health, E/C/2000/4, §34. For more details about International Human Rights and the right to health, see www.huma-
network.org
6
See in particular Article 24 of the United Nations Convention on the Rights of the Child. Available at:
http://www2.ohchr.org/english/law/crc.htm
7
See in particular articles 28, 43, 45, 70 of the International Convention on the Protection of the Rights of All Migrant Workers and
Members of Their Families (ICRMW). Available at: http://www2.ohchr.org/english/law/cmw.htm; to date, no EU Member State has
signed or ratified this convention.
8 8
Note that the EU Charter of the Fundamental Rights of the European Union specifically states that health rights (“right of access
to preventive healthcare and the right to benefit from medical treatment”) are recognised “under the conditions established by
national laws and practices” (Article 35).
9
Council Directive 2003/9/EC of 27 January 2003, op.cit.
10
HUMA network, op. cit.
11
Médecins du Monde European observatory on access to healthcare, Chauvin, P., Parizot, I., Simonnot, N. (2009). Access to
healthcare for undocumented migrants in 11 European countries. Paris, Médecins du Monde. Available at: www.mdm-
international.org
ACCESS TO HEALTH CARE FOR UNDOCUMENTED MIGRANTS AND ASYLUM SEEKERS
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managing the reception of asylum seekers. These countries are also all new transit and immigration
countries for asylum seekers and for migrants in general. Although essentially seen as gateways
into the European Union by migrants looking to reach EU countries further west, they are gradually
becoming immigration countries themselves. A growing number of migrants are staying and settling
because of the difficulties involved in reaching or settling in other countries due, among other things,
12
to EU legislation on asylum .
Some trends can be identified as a result of their geographical location. For instance, Cyprus and
Malta are both Mediterranean islands that have seen a rapid inflow of immigrant arrivals over a
short period of time, mainly migrants entering the country illegally (by sea or by air) and planning to
continue to other EU countries. Both Poland and Romania, on the other hand have long been
emigrant nations. Situated on the eastern border of the European Union, they are not yet
considered to be attractive locations for immigrants because of their weak economic situation
compared to that of other EU countries. In both countries, immigration is not yet a noticeable social
phenomenon or a priority in terms of policy or legislation.
These four countries, for which immigration is a very recent issue, are ill-equipped to cope with this
phenomenon, and their legislation on migrants’ rights, including the right to healthcare, is generally
weak.
The current economic crisis now constitutes another excuse for these countries to opt for restrictive
regulations and practices rather than for a friendlier approach to migration and health issues. This
situation is not helped by fact that most of the four countries targeted in this report are currently
engaged in general reforms to modernise their health systems and address the numerous problems
affecting users as a whole.
METHODOLOGY
■ Organisation of the report
This report is divided into 4 main parts, one part for each country namely Cyprus, Malta, Poland and
then Romania. In each part, a first section presents the legal entitlements to healthcare and a
second section presents the findings of a field survey on access to healthcare for asylum seekers
and undocumented migrants. A conclusion is drawn for each country and a general conclusion is
given at the end of the report.
■ Methodology used in the legal section
The legal entitlements for each country are presented in the same way as in the 2009 HUMA legal
report, by type of population: nationals, authorised residents, asylum seekers, undocumented
migrants.
In order to clearly show the specific characteristics of access to care/treatment for each of the
different groups residing in a country, as well as any discrimination with regards to legal
entitlements and administrative conditions, a distinction has been made between: i) nationals,
asylum seekers and undocumented migrants; ii) adults and children; and iii) types of care (primary
and secondary, emergency, inpatient, ante-post natal) and treatments (medicines, treatment of HIV
and treatment of other infectious diseases).
12 Acording to the Dublín II regulation, i.e. the Council Regulation (EC) No 343/2003 of 18 February 2003 establishing the criteria
and mechanisms for determining the Member State responsible for examining an asylum application lodged in one of the Member
States by a third-country national, “Member States have to assess which Member State is responsible for examining an asylum
application lodged on their territory on the basis of objective and hierarchical criteria. (…) Where another Member State is
designated responsible under the criteria in the Regulation, that State is approached to take charge of the asylum seeker and
consequently to examine his/her application. If the Member State thus approached accepts its responsibility, the first Member State
must transfer the asylum seeker to that Member State.” See this summary of legislation on
http://europa.eu/legislation_summaries/justice_freedom_security/free_movement_of_persons_asylum_immigration/l33153_en.htm
ACCESS TO HEALTH CARE FOR UNDOCUMENTED MIGRANTS AND ASYLUM SEEKERS
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The research also describes healthcare entitlements for migrants held in detention centres, as well
as the residence permits or other mechanisms provided for in national legislation to protect from
expulsion any seriously-ill undocumented migrants and asylum seekers who cannot effectively
access treatment in their home countries.
The entitlements are presented in tables to make it easier to compare particular populations or
types of medical care between countries (including countries studied in the 2009 HUMA
publication). For the purposes of the report, it has also been necessary to adopt a common
terminology despite the wide differences in healthcare and legal terminology existing between
13
Member States .
The main source of information for this study was the immigration, asylum and healthcare legislation
in force in the different countries, analysed by HUMA’s legal expert with the help of a legal specialist
from each of the countries concerned. The four HUMA network’s member organisations also
contributed to this task.
■ Methodology used in the quantitative survey: « statistical
testimony »
• Aims and limits of the survey
The field survey conducted to collect the data analysed in this report was coordinated by the HUMA
coordination team and conducted by its members: KISA in Cyprus, Skop in Malta, the Association
for Legal Intervention (SIP) in Poland, and ARCA in Romania.
The objective of this field survey was to provide “statistical testimony” of the situations witnessed by
HUMA network’s member organisations on their programs or within specific groups of asylum
seekers or undocumented migrants. The findings do not attempt to offer a fully representative
picture of access to healthcare as experienced by all asylum seekers and undocumented migrants
in each of the four countries. Indeed, the general sample and the samples taken in all four countries
for each category of population - asylum seekers, undocumented migrants (and, in the case of
Romania, holders of a “tolerance”) - were too small to allow a generalisation of the findings.
Similarly, although the organisations conducting the survey made significant efforts to obtain a
randomised selection of respondents, there were still a number of biases in the recruitment of
respondents in each country due to difficulties in gaining access to migrants.
Furthermore, the fact that the asylum seekers and undocumented migrants were recruited via non
governmental organisations (NGOs) may also have resulted in some bias for two main reasons:
- The people interviewed were already in contact with the NGO sector and so may well have
been beneficiaries of the support provided by these NGOs, i.e. social counselling and, in
some cases, support and translation to facilitate their access to healthcare. Undocumented
migrants and asylum seekers not reached by such programs, and so possibly living in worse
general and health conditions, may well have remained “invisible” in this survey.
- Undocumented migrants and asylum seekers living in slightly better conditions probably do
not seek NGO support services and so were not reached by our survey.
However, as no randomised, representative surveys have yet been conducted amongst the general
undocumented migrant or asylum-seeking population in the countries targeted, the quantitative
findings by country presented in this report at least offer key trends that, although calling for prudent
interpretation, go some way towards illustrating the problems faced by these populations in
accessing healthcare.
It is also important to bear in mind that this survey gathers the asylum seekers' and undocumented
migrants' own descriptions of their living conditions and access to healthcare. So, to a certain
extent, the answers given will reflect their subjectivity.
13
For the terminology used in the legal sections of the report, see HUMA network, op. cit., pp. 10-11.
