Huber, Manfred

Stanciole, Anderson E.

Policy Documentation Center

EuropEan CEntrE • EuropäisChEs ZEntrum • CEntrE EuropÉEn
poliCy BriEf may 2009
Access to Health Care for  
Migrants, Ethnic Minorities,  
and Asylum Seekers in Europe
by Anderson E. Stanciole, Manfred Huber
poverty and social exclusion continue to be serious challenges across the 
European union and for health systems in member states. migrants, asy-
lum seekers and illegal immigrants are at high risk of poverty and social 
exclusion and there is evidence that they sometimes do not receive the 
care that best responds to their needs. improved access to general health 
care, including also health promotion and prevention strategies, is there-
fore essential to minimising disadvantage for migrants. this policy Brief 
outlines hurdles of access to health care for migrants and discusses policy 
implications.
the results presented are part of a research project on “Quality in and 
Equality of access to health Care services” (healthQuEst) that was 
financed by the European Commission, DG Employment, social affairs 
and Equal opportunities. this study analysed barriers of access to main-
stream health care services for people at risk of social exclusion as well 
as policies in member states to mitigate these barriers. the study had a 
focus on three groups at risk: people with mental disorders, migrants, and 
older people with functional limitations. Eight countries were studied in 
depth: finland, Germany, Greece, the netherlands, poland, romania, spain 
and the united Kingdom.
Migration and health in Europe
With a substantial and increasing share of foreign-born population, the 
European union faces many challenges on how to achieve better social 
integration and basic human rights for refugees, asylum seekers and illegal 
(undocumented) immigrants. Within the broader issue of advancing access 
to services in general, enhanced access to health care services plays a 
significant role in improving the situation of migrants.
to a large extent, there are significant differences between countries and 
migrant groups, creating the need for tailored policy responses that take 
into account the specific barriers to access to health care in each case. 
Anderson E. Stanciole is a health 
Economist at the Department of health 
systems financing at the World health 
organization, Geneva. this work was 
undertaken while at the European Centre 
for social Welfare policy and research, 
Vienna, stanciolea@who.int
Manfred Huber is Director health and 
Care at the European Centre for social 
Welfare policy and research, Vienna
http://www.euro.centre.org/huber
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While countries differ in their role as host countries (long-standing host 
countries, new hosts, new gateway countries, emigration countries and 
countries with segregated minorities), there are also different types of 
migrant groups, which may include migrants and other ethnic minorities, 
asylum seekers or refugees and illegal or undocumented migrants.
Access barriers and migration
for migrants, barriers to accessing health care represent a complex 
issue. special health risks and access problems affect different groups, 
including newly arriving migrants, people living in temporary reception/
detention centres and undocumented immigrants in general. moreover, 
there are many challenges for providing health care within a multicultural 
setting, some of which can be persistent for migrants who have stayed in 
the host country for some time. some of these challenges are similar to 
those faced by long-established ethnic minorities and may include: lack 
of knowledge about available services; language differences; and varying 
cultural attitudes to health and health care.
analysing the access problems of various groups of migrants is further 
complicated by a widespread lack of information about migrants’ health 
needs and access to services. the difficulty in identifying a person as a 
migrant in administrative records prevents data collection about service 
utilisation and epidemiological patterns of prevalence and incidence of 
disease.
Health and illness patterns
Epidemiological evidence from several countries in the study (Germany, 
the netherlands, and the uK) confirm that the health status of large 
immigrant populations is poorer than that of natives. in general, health 
problems often overlap with deprivation and poor living conditions, high-
lighting the relationship between poverty, poor health and lack of access 
to health care.
in the case of asylum seekers and undocumented migrants, this can be 
further complicated by specific issues, such as physical after-effects of war 
and torture, which may induce stress-related mental health problems, 
depression, high blood pressure, digestive problems, headaches and back 
pains. Depending on their living conditions, they may also be at higher 
risk of infectious diseases (e.g. hiV/aiDs, hepatitis, tB) and malnutrition.
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roma populations are also confronted with major health challenges, 
which partly reflect poor living conditions, with many living without basic 
utilities and enduring unacceptable environmental and sanitary conditions. 
they face higher than average rates of infant mortality, malnutrition and 
communicable diseases including tB, measles and sexually transmitted 
infections. in recent years the prevalence of chronic diseases (e.g. cardio-
vascular diseases, hypertension and obesity) has also become increasingly 
important.
Do current systems provide  
adequate coverage?
most countries provide some level of coverage for immigrants who have 
acquired a residency status, normally under the same cost-sharing regula-
tions that apply to others in the population. in some cases, however, this 
happens only after they have stayed for a minimum period in the coun-
try, which can severely limit their access to health care. asylum seekers 
are entitled to at least basic treatment for acute diseases at no cost in 
most countries. however, current regulations in some countries limit 
the entitlement of asylum seekers to health care services under public 
programmes.
in many countries, undocumented immigrants have the right to the provi-
sion of emergency and medically necessary health care only. however, the 
decision of what constitutes a medical emergency is usually left to the 
provider. this is particularly problematic for important but non-urgent 
cases such as diabetes and childhood immunisations, which frequently 
pose a dilemma for providers if patients cannot afford to pay. Charges for 
hiV/aiDs treatments are particularly controversial with commentators 
pointing out the often debilitated state of patients from whom payment is 
then meant to be recovered.
Common access barriers
the different groups differ in their patterns of help-seeking behaviour. 
these relate to the difficulties of mobilising the resources necessary 
to access care which (in common with barriers faced by socially disad-
vantaged groups in general) include lack of easily accessible information 
about what is available and difficulties in organising the social and practi-
cal support necessary to facilitate attendance for treatment, especially 
out of opening hours or where services are distant. these are overlaid 
with specific problems related to the challenges faced by those who do 
not speak the national language. reluctance to use family and children as 
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interpreters and fear or lack of confidentiality means that even if transla-
tion is available, it may not be taken up.
for documented migrants, one of the main hurdles for getting coverage 
under public programmes, and consequently access to health care is the 
often complex and time-consuming administrative process for obtaining 
documents, including work and residence permits and health insurance 
papers. similar issues also affect asylum seekers, with several countries 
having recently toughened the requirements for obtaining refugees status 
and the regulations on access to health care for both asylum seekers and 
failed asylum seekers.
Specific concerns about older migrants
past and current migration trends and the ageing of the population sug-
gest that the issue of health and social care for older people from ethnic 
minority groups will become more important. migration is a challenging 
experience for anyone, and more so for older people because of the 
losses not only of a wider family context and of friends, but also of a 
familiar physical, social and cultural environment, which may impose com-
munication barriers. in some cases, language problems and the clients’ 
cultural norms and values can pose additional access barriers for older 
people belonging to ethnic minorities.
What are the policy implications  
of these findings?
the evidence collected in the healthQuEst study suggests a number of 
potentially helpful policy strategies in improving access to health care for 
the different migrant groups and tackling the health challenges that they 
are faced with.
Improving the material conditions  
and economic security of migrants
many health problems affecting migrants, asylum seekers and illegal immi-
grants are heavily associated with poverty and deprivation. improving the 
economic and living conditions should be a central priority for securing 
better health for these groups. this might include measures that improve 
immigrants’ employment situation in addition to providing more support 
in the form of social services and accommodation.
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Providing more responsive services
part of the solution to reduce barriers of access to health care for 
migrants will involve increasing the level of supply-side responsiveness. 
health care providers should strive to take into account the specific 
characteristics of the health care demand among migrants and to provide 
more responsive services. this may include increasing awareness about 
services available, providing translation/interpretation services, promoting 
culturally friendly services and combating discrimination.
Improving access to health care for older migrants  
and elderly migrant women
access to health care for these two special groups is often limited due 
to the existence of multiple barriers, which might include the lack of 
pension-years, high unemployment risk, care responsibilities for other 
family members and social isolation. these problems should be addressed 
by appropriate policy interventions, which also need to take into account 
cultural preferences, for instance those related to long-term care ar-
rangements.
at the same time, information about the overall situation of these groups 
is currently lacking. therefore, more resources should be directed at 
collecting statistics and improving the knowledge about the situation of 
older migrants in Europe.
Addressing the particular barriers faced by asylum seekers
a number of measures, some of which are currently in place in individual 
countries, could be potentially helpful in addressing the needs of asylum 
seekers and improving their situation.
first, because of their high health needs it is important to enlarge the 
health baskets made available to asylum seekers. some countries cur-
rently offer only acute treatments. however, this should be expanded to 
encompass more health care services, particularly mental health services, 
in view of the pressing health care needs of asylum seekers.
second, culturally sensitive training aimed at improving the coping skills 
of asylum seekers is required to improve health and deal with the health 
deterioration and mental health problems frequently observed after ar-
rival. this should take into account the interaction between physical and 
mental health symptoms.
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third, it is necessary to consider the impact of policies of relocation 
and enforced dispersal on stigmatisation. in particular, it is important to 
provide support in the transition to new health care providers for asylum 
seekers who are relocated; this might require, for instance, that patient 
information is appropriately recorded and made available to the new 
provider.
finally, country reports suggest that the information on morbidity and 
mortality risks of asylum seekers is meagre. Considering the very specific 
and pressing health needs of this group, more research is required in this 
area.
Targeting reception centres
it is particularly important to safeguard the special needs of asylum 
seekers in reception centres. some countries provide good examples of 
coverage regulations that can promote greater integration. for instance, 
asylum seekers in poland are covered for indirect costs of treatment and 
in spain they receive information on how to access the health system.
another example of good practice in this area can be found in the neth-
erlands. the central agency responsible for the accommodation of asylum 
seekers also contracts preventive health services for asylum seekers in 
each reception centre.  asylum seekers are always seen first by a practice 
nurse, who acts as a gatekeeper and decides whether access to main-
stream health care is necessary. practice nurses receive special training to 
deal with the special needs of the asylum seekers.
Reducing hurdles in obtaining documents
in some cases, significant improvements in access to health care could 
be achieved through the reduction of bureaucratic hurdles in obtain-
ing documents. in particular, hurdles for obtaining residence and work 
permits, identification documents and health insurance papers should be 
reduced. in the case of roma, the process for obtaining birth certificates 
and identification documents should be facilitated and the costs reduced. 
proper systems should be put in place to provide information and to as-
sist migrants on how to obtain the necessary documents.
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7
Conclusions
Epidemiological evidence from several countries indicates that migrants, 
asylum seekers and illegal immigrants are relatively more affected by cer-
tain health problems. they face multiple barriers to access to health care, 
which can compound and reinforce each other, and are often exposed to 
greater risk of poverty and social exclusion.
the analysis of the main access barriers suggests policy measures of 
relatively low cost that could contribute to improve the situation. a very 
significant access barrier facing migrants and ethnic minorities refers to 
difficulties in obtaining documents, such as residence and work permits 
and health insurance papers. for many roma individuals, the costs for 
issuing birth certificates are considered high and the lack of identification 
documents has been shown to affect infant vaccination and prevention 
activities. in most countries migrants received no assistance for obtaining 
documents.
information on the socio-economic situation, health and illness patterns 
and barriers of access to health care available for all three groups is still 
very limited. the study has illustrated that there often is a lack of re-
search evidence to support policy. in particular, more specific research is 
necessary to accurately determine the demographic and epidemiological 
profiles in different countries in order to guide policy interventions.
Where to find more information
M. Huber, A. Stanciole, K.Wahlbeck, N. Tamsma, F. Torres, E. Jelfs, 
J. Bremner (2008) Quality in and Equality of access to health Care  
services. Brussels: European Commission
for more information, and the full report, see: 
http://ec.europa.eu/employment_social/spsi/studies_en.htm#healthcare 
the views expressed in this policy Brief are those of the authors and do not necessarily 
reflect the views of the World health organization, the European Commission or of their 
member states. neither the World health organization, nor the European Commission 
nor any person acting on their behalf may be held responsible for the use that may be 
made of the information contained in this publication.
poliCy BriEf may 2009
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Access to health care for migrants, ethnic minorities, and asylum seekers in Europe

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