Mig-HealthCare Database

Relevant links

Ministry of the Interior

Austrian Integration fund

The most prominent nationalities among migrants/refugees in Austria are

Afghanistan, Syria, Iraq, Iran, Pakistan

The (3) main challenges in terms of healthcare access and/or health issues of migrants/refugees identified are:

• Language barrier
• Communication with healthcare providers is difficult due to language barriers. False diagnoses, misunderstandings and wrong medication are the consequences. Children are often used as interpreters. Often, a bad state of health, inaccessible information, inadequate care and insufficient prevention result from language barriers.
• Access to information
• Appointments in the health sector are problematic, since participants do not know how to find the right doctor or where to look up specific information.
• Lack of information also due to language barrier
• Lack of knowledge about Austrian health system
• ExampleIn terms of the health system, they face difficulties because they do not know when to call an ambulance, when to contact a GP, when to go to the emergency department or when to see a private physician.

Brief description of the legislation concerning access to health care for migrants/refugees

Migrants (and asylum seekers) have access to the health system without any limitations.

Asylum seekers: An initial medical examination of asylum seekers is done within 24 hours after admission to one of the reception centers. If necessary, they have the right to see specialists or staff at hospitals. People receiving Basic Care are automatically entitled to health insurance. However, certain treatments or private doctors are not covered and must be paid. If asylum seekers are not entitled anymore to Basic Care (e.g. due to violent behavior, absence from initial reception center for more than two days), they can still make use of emergency care and essential treatment. In reality however, the Basic Care provision is not easy to put into use.

Relevant links

aref.government.bg/bg/aktualna-informacia-i-spravki

The most prominent nationalities among migrants/refugees Bulgaria

Afghanistan, Syria, Iraq, Pakistan

The main challenges in terms of healthcare access and/or health issues of migrants/refugees identified are

Serious language barrier. For Arabic and Kurdish, the problem is almost solved, but with the rare languages – Farsi and Pashtun, there are still difficulties.

Short stay in the country. During the stay at the refugee centers, until receiving refugee status, all are insured at the expense of the state budget. After receiving refugee status and leaving the refugee centers, the refugees have to find work in order to be health insured. However, due to their short stay in Bulgaria, this rarely a case.

Medical supplies for refugees who received refugee status. Upon receiving refugee status, medications for uninsured persons are at their expense. This is a problem especially for elderly and chronically ill refugees.

Need for prolonged health, social and cultural mediation

Brief description of the legislation concerning access to health care for migrants/refugees

According to Bulgarian low, foreigners who are in process of granting international protection have the right to health insurance, accessible medical care, free use of medical care under the conditions and procedure for the Bulgarian citizens.

According to Bulgarian low, foreigners who are in process of granting international protection have the right to health insurance, accessible medical care, free use of medical care under the conditions and procedure for the Bulgarian citizens.

The medical examination of persons seeking international protection shall be carried out in the health offices of the Territorial Units of the State Agency for Refugees at the Council of Ministers and the following activities shall be carried out:

• initial investigations when registering applicants for protection;
• continuous medical supervision;
• first aid;
• Control of the hygiene status of the persons;
• ongoing control of compliance with hygiene requirements;
• preparation and maintenance of medical records for each person.

Social experts at the State Agency for Refugees at the Council of Ministers support access to healthcare for persons seeking international protection by: advising persons on health issues; record them to a GP; accompany the persons to hospitals; issue official notes to National revenue agency for health insured persons, etc.

Relevant links

Source 1, Source 2, Source 3, Source 4, Source 5

* Number of Persons who acquired refugee and subsidiary protection status within the year.

** Statistical data as of 31 July 2016.

Latest statistical information can be found at the:

• Website of the Civil Registry and Migration Department, Ministry of Interior
• Asylum Information Database, Cyprus Country Report
• Website of the UNHCR Office in Cyprus

The most prominent nationalities among migrants/refugees in Cyprus:

In 2016, the main countries of origin of migrants who applied to enter and reside in Cyprus were: Bangladesh, China, India, Nepal, Philippines, Russia and Sri Lanka.

The top ten nationalities of asylum seekers in 2017 were: Syria, India, Vietnam, Bangladesh, Egypt, Pakistan, Sri Lanka, Somalia, Cameroon and Philippines*

Main challenges in terms of healthcare access and/or health issues of migrants/refugees identified:

• Challenges in accessing healthcare
• Difficulties and delays with acquiring the medical card for free medical care for asylum seekers. This challenge is significant when a newly arrived person is in need for immediate medical care.
• Great difficulties in communication with doctors in a language they understand when the refugee or asylum seeker does not speak Greek or English.
• In the case of refugees, complying with the provision of having contributed for 3 years at the social insurance fund in order to be eligible for free medical care poses challenges in certain cases.
• Access to healthcare services for migrant workers, especially prevention services and annual tests. Migrant workers have a very limited insurance coverage for healthcare treatment, which does not cover issues such as annual health tests and preventive services. The costs for private healthcare services are very high and preventive for migrant workers who receive very low salaries, while visiting public hospitals is not always possible – and is also restricted by the working hours of migrants.
• Transportation costs for asylum seekers to reach the medical centres.
• Key priority areas in relation to addressing health issues
• Women health issues, especially for pregnant women and toddlers / children.
• Psychological support for refugees and asylum seekers

Brief description of the legislation concerning access to health care for migrants/refugees

Asylum Seekers
Asylum seekers without adequate financial resources are allowed to free medical care at public hospitals. This applies directly to those that reside in the refugee reception centre and welfare beneficiaries. For the rest, they have to apply for a medical card in order to access free medical care. The procedure for the medical card sometimes creates challenges, especially when asylum seekers are not aware of the exact procedure and when they need immediate medical assistance. However, the majority of asylum seekers do get the medical card. The healthcare is not entirely free – there is a small fee € 3–6 to visit the doctor, €0.50 for each medicine and €10 to visit the emergency room(2).

Refugees
Refugees and persons with subsidiary protection have the same rights to access the Cypriot public healthcare system as nationals and EU citizens. This includes the responsibility to have contributed to the social insurance fund for at least 3 years(3). However, this does not include the scheme with which a Cypriot national is allowed to state support for healthcare outside Cyprus in the situations where such healthcare services do not exist in Cyprus. For emergency care, everyone is required to pay a registration fee of €10.

Migrants / Third Country Nationals
Beyond asylum seekers and refugees, other third country nationals legally residing in Cyprus mainly fall under two categories: foreign workers and students. In order for them to receive a visa, migrants falling within any of these categories need to have a private insurance, with which they can visit mainly private hospitals and doctors. For migrant workers, the cost for the insurance is covered half by them and half by their employer. The government has agreed with insurance companies on an insurance package for migrant labour workers, which covers basic medical needs, including inpatient care with a ceiling reimbursement threshold and child birth(4) .

Source : DGEF - DSED / AGDREF

• Migrants’ health issues
• According to our results on both literature review and focus groups discussion with health providers, the main health issues that newly arrived migrants face in France are diseases related to poor living conditions (TB, scrabies, injuries, etc) and mental health issues.
• According to health providers, migrants do not have specific diseases, but the journey for getting to Europe as their living conditions in France (especially accommodation and resident titles issues, including for applying on asylum) impact their health at arrival, but also in long terms. This is in coherence with what we found in the literature review: the importance of poor living and employment conditions and poor social network, impact negatively their health.
• On mental health, health providers declare few psychiatric diseases, but a lot of stress, depression, related to their living conditions, the trauma of the journey and what they experienced in their country of origin.
• Migrants’ healthcare access issues
• The lack of institution willingness, and so, the lack of coordination,
• Even if most of migrant population should have access to health coverage, in practice it is an issue to access to this right,
• The lack of cultural mediators and translators,
• Health providers, as well as researchers mention as a barrier to health access the poor living conditions that some migrants have to face: when people do not have stable accommodation, and/or have fear of being deported, health is not their priority. They are not on demand to access healthcare.

Brief description of the legislation concerning access to health care for migrants/refugees

Health coverage

The Universal Health Coverage was created in 1999 (Couverture Maladie Universelle) for French or regular resident in France which have resources under a specific amount. For Irregular residents, it exists the State Medical Assistance (Aide Médicale de l’Etat). These two schemes ensure free health care for these populations. Nevertheless, some health professionals deny the beneficiaries. The reasons identified for denying care to these patients were mainly about delays in payments and minimal payments.

thelancet.com/journals/

Access to healthcare

Inside hospital, the Health Service Access Point (Permanence d’Accès aux Soins de Santé) was created in 1998 for people who have difficulties to access care (no health coverage, no complementary insurance etc). This mission is funded by the Regional Health Agency and payed to the hospital as a mission of general interest.

Each Regional Health Agency has a Regional Program for Access to Prevention and Care (PRAPS – Programme Régional d’Accès à la Prévention et aux Soins). Its objective is to define actions for combating diseases worsen by poverty or exclusion.

In the French health system there is not special programs for migrants’ health. Mostly because of a universal way of thinking (a part of migrants became French). Vulnerable migrants are over represented in Health Service Access Point and NGOs health centers. It exists few community health NGOs. Those NGOs receive some funding from PRASP program from the Regional Health Agency.

The State has also in charge the child protection, meaning insuring care, education and housing for those children. Unaccompanied minors belong to this population. Departmental Council is ensuring this mission.

For accommodation programs (for asylum seekers, homeless etc) Social Cohesion services are in charge to assure it.

The most prominent nationalities among migrants/refugees in Germany are:

Migrants(8)

2017: A breakdown of the most prominent nationalities among migrants is represented in the latest data provided by the German statistics for migrants. In total 18.6 million migrants were registered, whereas migrants from Turkey (1.5mill.), Poland (783.058) and Syria (637.845) were the most prominent.

Refugees

2017: Most prominent refugee seeking nationalities in 2017 were: Syria/Arab. Rep., Iraq and Afghanistan, Eritrea and Iran(9)

(1) http://www.bamf.de/SharedDocs/Anlagen/DE/Downloads/Infothek/Statistik/Asyl/aktuelle-zahlen-zu-asyl-maerz-2018.pdf?__blob=publicationFile

(2) https://www.bamf.de/SharedDocs/Anlagen/DE/Publikationen/Broschueren/bundesamt-in-zahlen-2015.pdf?__blob=publicationFile

(3) https://www.bamf.de/SharedDocs/Anlagen/DE/Publikationen/Broschueren/bundesamt-in-zahlen-2016.pdf?__blob=publicationFile

(4) http://www.bamf.de/SharedDocs/Anlagen/DE/Publikationen/Broschueren/bundesamt-in-zahlen-2017-asyl.pdf;jsessionid=4A8AF91DF04176475A405AF32F904157.1_cid294?__blob=publicationFile

(5) http://ec.europa.eu/eurostat/statistics-explained/images/c/c5/Immigration_by_citizenship%2C_2015_YB17-de.png

(6) http://ec.europa.eu/eurostat/statistics-explained/images/f/f6/Immigration_by_citizenship%2C_2016_.png

(7) https://ec.europa.eu/home-affairs/sites/homeaffairs/files/11a_germany_apr_part2_en.pdf

(8) https://www.destatis.de/EN/FactsFigures/SocietyState/Population/MigrationIntegration/MigrationIntegration.html

The main challenges in terms of healthcare access and/or health issues of migrants/refugees identified are:

General barriers for migrants may potentially exist in regard to communication problems. Insufficient German language skills may e.g. hamper access to health care and hinder migrants from acquiring an adequate health literacy (Schaffler 2016). There is also no general legal regulation in regard to the cost coverage for the use of interpreters in medical/therapeutic settings. Further barriers may exist due to cultural differences regarding health issues (e.g. taboos, different

Data on migrant health status in Germany is fragmented and scarce. Nevertheless, there is some evidence, that specific sub groups depending on their social status, living conditions or depending on the country of origin are facing more difficulties than non-migrants in regard to specific health issues like adiposities in children stemming from Turkey etc . The vast majority of asylum seekers in Germany is being limited in entitlement towards healthcare- above all chronic diseases and mental health issues (Razum et al., 2008; Knipper and Bilgin, 2009, Lindner 2015, Macherery, Bozorgmehr et al., 2015). There is evidence that up to 40-50 % of refugees may have experienced traumatic events with potential high prevalence rates of PTSD, depression etc.

Undocumented migrants are a vulnerable sub group which is in risk of deportation due to health care assistance duty to report their stay. In consequence, there exists a very heterogeneous support system in Germany regarding treatment of undocumented migrants, dependent on individual and local decisions and commitment (e.g. single NGOs like e.g. Malteser/Medinetz or single doctors providing treatment).

Brief description of the legislation concerning access to health care for migrants/refugees.

There are no differences in regard to legislation concerning access to health care between non-migrants and legal migrants.

Asylum seekers access to medical care is limited by the German ‘Asylum Seekers Benefits Act’ (AsylbLG) §4 and §5 with restricted coverage of the first 15 months of their stay in Germany or at least as long their application is not accepted. This coverage only includes necessary medical and dental treatment (only acute pain and illness), selected vaccinations and maternal care in case of pregnancy and maternity. After this period of 15 months (or in case their application is granted) asylum seekers get access to the same welfare services as regular residents and get access to a GKV statutory health insurance card.

Not explicitly covered are chronic diseases and mental illnesses, though §6(1) emphasizes on special needs of medical care to prevent (dangerous) exacerbation which in individual cases may grant access to treatment.

Persons in special conditions and children, victims of sexual/psychological violence etc. are also covered by §6 and may get access to treatment.

Undocumented migrants are theoretically also covered by AsylbLG but this bears the risk of being detected. They are dependent on the charity of individual health care staff or NGOs willing to treat undocumented persons. (MIPEX).

(1) on access itself also see on access itself also see https://publications.iom.int/system/files/mrs_52.pdf

Relevant Links:

http://asylo.gov.gr/en/wp-content/uploads/2018/03/Greek_Asylum_Service_Statistical_Data_EN.pdf

50.800 refugees and migrants are in Greece, according UNHCR estimation as of 28 February 2018, of those who arrived and remained since the 2015-2016 mass flow.(1)

The situation changed regarding the sea arrivals between 2015, 2016, 2017 of refugees and migrants as follows(2):

The most prominent nationalities among migrants/refugees in Greece are:

Top Nationalities of arrivals as of November 2017

Source: UNHCR, Greece Sea Arrivals Dashboard, November 2017, https://data2.unhcr.org/en/documents/download/61395

(1) UNHCR Fact Sheet, February 2018, p.1 https://data2.unhcr.org/en/documents/download/62950 [3/4/2018]

(2) UNHCR, Greece Sea Arrivals Dashboard, February 2018, p.1, https://data2.unhcr.org/en/documents/download/62547 [3/4/2018]

The main challenges in terms of healthcare access and/or health issues of migrants/refugees, identified are:

Mental Health & Psychosocial Needs

It is underlined that there is a very high demand for mental health services. According the 154 first assessments that MSF carried out in Lesbos between January and mid - June 2017, 79% met their criteria of severity, over a third had symptoms of Post-Traumatic Stress Disorder, a third had symptoms of depression, another third suffered from anxiety and 4% from psychotic disorders. On average close to a third of these patients had to be referred to a psychiatrist.(3)

Moreover, according to the “Rapid Assessment of Mental Health, Psychosocial Needs and Services for Unaccompanied Children (UAC) in Greece”, commissioned by UNICEF to the Institute of Child Health, was identified that UAC suffer from increased levels of depression, anxiety disorders and post-traumatic stress. Among key contributing factors to the increased distress of UAC are the uncertainness about their future, feelings of hopelessness, the loneliness due to separation from family and community, as well as the long delays in asylum procedures, the absence of an individual to advise and provide them with continuous support cohabitation in shelters, the limited opportunities to access education or vocational training and limited autonomy.(4)

Physical Diseases & Pregnancy

A systematic risk assessment carried out for Greece (Table 1) in accordance with the World Health Organization guidelines for identifying priority vaccine-preventable diseases resulted that there is evidence of vaccination of children for measles, poliomyelitis, diphtheria, b-type haemophilus influenza infection and possible indication vaccination for pneumococcus.(5)

Table 1: Risk Assessment Summary for Preventive Vaccination Diseases in Greece in view of the refugee flows in Greece, 2016

G.Nikolaidis, A. Ntinapogias and M. Stavrou, Institute of Child Health, Executive Summary, Rapid Assessment of Mental Health, Psychosocial Needs and Services for Unaccompanied Children in Greece, October 2017, https://data2.unhcr.org/fr/documents/download/60380, [01/11/2017]

Report Vaccination in refugee / immigrant accommodation, February 2017 https://government.gov.gr/wp-content/uploads/2017/02/Ekthesi-emvoliasmos-prosfygon-2017-02.pdf, [03/01/2018]

Source: Report Vaccination in refugee / immigrant accommodation, February 2017

Furthermore, a mapping exercise in 5 camps by MSF, held in August 2016, identified that the percentage of physical vulnerabilities (asthma, diabetes, kidney problems, cardiac problems, gynecological problems, neurological problems, etc.) including pregnant women of vulnerable people was as following: Softex (39,8%), Derveni-Alexil (52,4%), Sindos-Frakaport (63,2%), Kalochori (38,1%) and Kavalari (51,8%).(6)

Moreover, must be assured for all pregnant women the access to Comprehensive Emergency Obstetric and Newborn Care (CEmONC).(7)

Difficulties regarding the access to public health services

Refugees and migrants access to public health services is not without difficulties. Financial crisis has impact on the health services provided and the function of hospitals (insufficient personnel, drugs etc.). Moreover, lack of cultural mediators worsens the situation due to the existence of cultural differences. Also, translations services must be improved because of the great significance of the communication between the patient and the doctor.

Another big issue is the transfer of refugees and migrants in accordance with the accessibility to the public health services (distance to the nearest health facility) and the lack of referral systems. The Greek Ministry of Migration Policy closed many of the sites that were unsuitable for long-term human habitation, and intends to close many of the remaining ones that are also remote.(8)

Besides, the lack of proper accommodation for people with medical vulnerabilities, such as victims of violence or other form of ill-treatment, people with psychiatric disorders, people with physical disabilities, patients who require a special diet (e.g. diabetic patients or patients with hypertension), pregnant women and new-borns, can often worsen their health conditions.(9) Furthermore, the identification of vulnerable people by the authorities is crucial and sometimes is not effective.(10)

Administrative difficulties have been observed in some cases regarding the access to the health care system, which mainly concern difficulties in the issuance of a Social Security Number (ΑΜΚΑ) or the fact that staff in hospitals or health care centers are not always aware of the 4368/2016 law(11) in accordance with the limited information of the population regarding the procedures of documents issuance(12). Also, certain challenges have been observed during a transitional period on the islands with the handover of activities to the national authorities.(13)

It is stated that the existence of different sub-systems and organizational models, combined with a lack of clear mechanisms for coordination, creates significant difficulties in the planning and implementation of national health policy.(14)

Another issue of great significance is the coordination among the National Health Operations Centre (EKEPY) which is part of the Ministry of Health and has a lead role in the humanitarian health response and decision making and the international and national NGOs, UN agencies and other health partners. Moreover, it is important to support the roll out and implementation of the Health Management Information System (HMIS) for surveillance purposes within sites, providing an early alert for epidemics.(15)

(6) MSF, Greece in 2016: Vulnerable People Get Left Behind, October 2016, p.16, http://www.msf.org/sites/msf.org/files/report_vulnerable_people_201016_eng.pdf, [10/12/2017]

(7) UNHCR, Regional Refugee and Migrant Response Plan for Europe, op. cit., p.51

(8) UNHCR, Greece Factsheet, May 2017 https://reliefweb.int/sites/reliefweb.int/files/resources/58264.pdf, [17/12/2017]

(9) MSF, Greece in 2016: Vulnerable People Get Left Behind, op.cit., p.p. 11-13

(10) Ibid, p.p. 14-16

Brief description of the legislation concerning access to health care for migrants/refugees

According to the national legislation(16):

• Everyone who is granted international protection status has access to health care.
• Αsylum seekers are entitled free of charge to necessary health, pharmaceutical and hospital care, on condition that they have no health insurance and no financial means. Issuance of a Social Security Number (AMKA) is needed in order refugees and migrants to have access to public health. According to the Article 14 PD 220/2007, such health care includes:
• a) clinical and medical examinations in public hospitals, health centers or regional medical centers
• b) medication provided on prescription
• c) hospital assistance in public hospitals, hospitalization at a class C room
• Regarding people who are not asylum seekers and they have not granted international protection, the Article 33 of Law 4368/2016 provides free access to public health services to persons without social insurance and with vulnerabilities (pregnant, children, chronically disabled, mentally ill), who are entitled to the Alien Health Care Card (KYPA). In all cases, emergency aid shall be provided to applicants free of charge.

(11) Solidarity Now, Issues in the issuance of AMKA, 10 November 2016,http://bit.ly/2ltg9Ql [02/01/2018]

(12) MSF, Greece in 2016: Vulnerable People Get Left Behind, op.cit., p.17

(13) UNHCR, Fact Sheet, Aegean Islands 1-30 June 2017, https://data2.unhcr.org/en/documents/download/58588 [21/12/2017]

(14) UNHCR, Regional Refugee and Migrant Response Plan for Europe, op.cit.,p.51

(15) Ibid

(16) Aida, Asylum Information Database, Healthcare, Greece http://www.asylumineurope.org/reports/country/greece/reception-conditions/health-care[02/01/2018]

Asylum Service, Frequently asked questions, http://asylo.gov.gr/wpcontent/uploads/2016/11/final_QA_GR_06_2016fv1.pdf [02/01/2018]

The most prominent nationalities among migrants/refugees in Italy are:

Nigeria, Guinea, Ivory Coast, Bangladesh, Mali, Eritrea, Sudan, Tunisia, Senegal, Marocco(2)

(01) http://www.libertaciviliimmigrazione.dlci.interno.gov.it/it/documentazione/statistica/cruscotto-statistico-giornaliero

http://www.istat.it/it/archivio/208951

(02) http://www.libertaciviliimmigrazione.dlci.interno.gov.it/it/documentazione/statistica/cruscotto-statistico-giornaliero

The (3) main challenges in terms of healthcare access and/or health issues of migrants/refugees, identified are:

• A more efficient coordination among Prefectures (local governmental unit) is necessary, they usually address the problem from an emergency perspective without taking into account socio- health care factors.
• Lack of professional figures with ethno-psychiatric profile.
• Furthermore, intervention protocols (major infectious and transmittable diseases, dermatology, mental health, vaccination, trauma) have to be introduced and shared among the actors involved; doctors must be included in the process and it is necessary to invest more on education in order to create a collecting data system which aims at elaborating and analysing the individual health status, considering also the social factors through the implementation of socio- medical records and a sharing database useful for patients follow-up from their first arrival to their "settlement" at regional level.

Brief description of the legislation concerning access to health care for migrants/refugees

Refugees, and their family members, are equated to any Italian citizen and are registered to the national health system. Referring to asylum seekers: from the landing to the formalization of the asylum application at the Questura, they are equated like irregular migrants in terms of access to services and are given of an ad hoc health card (STP, foreign temporarily present) with whom they receive only urgent and essential treatments, continuative treatments included, free of charge. From the moment of formalization, instead they are equated to any Italian citizen and have the registration to the national health system (for the first 60 days asylum seekers have access to free of charge treatments, then they have to enroll in the unemployment list at the employment centres, in order to keep receiving free of charge medical treatments).

General Information on Migration

While there was a drastic increase in asylum seekers arriving in Malta as from 2002 (mainly Somalis fleeing their country during civil war), Libyans in 2011 during the height of the Libyan crisis and more recently Syrians, the majority of migrants are actually from within Europe. (See table below) http://www.unhcr.org.mt/charts

Generally, a person entering Malta without valid documentation (e.g. visa and/or passport) can be detained in accordance with the Maltese immigration law. However, since 2015, those entering irregularly are having their first processing procedures within an Initial Reception Centre in accordance with the latest EU directive on asylum procedures. When a person has been granted a form of protection status they can either temporarily be accomodated within an open center or choose to integrate into the host community. For trends in regards to numbers of asylum applications received over the last year (2017) and country of origin of asylum seekers kindly refer to tables. (See also http://www.unhcr.org.mt/charts/)

The length of an asylum application process takes between 6 and 21 months. (See also http://www.asylumineurope.org/reports/country/malta/asylum-procedure/procedures/regular-procedure)

Currently many of the new arrivals are part of the European Union (EU) temporary emergency relocation scheme.

2015: Home Affairs ministry stated that around 1,100 people applied for asylum in Malta during 2015 - a 33% increase over the previous year.

2016: Malta recorded 1,735 first-time asylum applicants in 2016, marking a 2% increase over the figures from the previous year, according to Eurostat data. The total included 655 asylum seekers from Libya, 285 from Syria, and 255 from Eritrea.

2017 and beyond: (see also the 3 tables on the right): Recently people are received from Greece or Italy through relocation. As of 24 April 2017, the total number of refugees relocated to Malta since February 2016 is 126 (including 18 families), mostly Syrian and Eritrean nationals. The Government of Malta has committed to relocate 189 persons over 2 years, until the beginning of 2018. (See for further information https://malta.iom.int/relocation-italy-and-greece-malta)

Out of 1352 cases processed in 2017 out of 1830 registered

(See Eurostat http://ec.europa.eu/eurostat/statisticsexplained/index.php/File:Asylum_applicants_(including_first_time_asylum_applicants),_Q4_2016_%E2%80%93_Q4_2017.png)

152 individuals received refugee status, while 169 cases were rejected and a good number of cases were closed. An even higher number of applicants received subsidary protection or temporary protection. (See table below http://www.unhcr.org.mt/charts/)

Compared with the population of each Member State, the highest rate of registered first time applicants during the third quarter of 2017 was recorded in Cyprus (1,577 first time applicants per million inhabitants) and Greece (1,361), followed by Malta (960) and Luxembourg (904).

(See for more information http://ec.europa.eu/eurostat/statistics-explained/index.php/Asylum_quarterly_report)

Highly populated island with migrants not only seeking asylum, but economic migrants originating from Eastern European countries and from within the EU. The health system is particularly stretched due to the additional numbers to attend to.

The National Health System Strategy (NHSS) for Malta (2014-2020) states that: The public health care system provides a comprehensive package of health services to all persons residing in Malta who are covered by the Maltese social security legislation and also provides for all necessary care to special groups such as irregular immigrants or foreign workers who have valid work permits. Only a few services including elective dental services, optical services and coverage of certain formulary medicines are means-tested.

(See for more informationhttps://deputyprimeminister.gov.mt/en/Documents/National-Health-Strategies/NHSS-EN.pdf)

Core state medical care is being provided, especially in the case of vulnerable groups of persons. Dependant members of the family of a person granted subsidiary protection, if they are in Malta at the time of decision, enjoy the same rights.

Currently the government is working on an official entitlement policy for irregular migrants to public health services. Currently irregular migrants are being given the health care required on a humanitarian basis.

(http://www.unhcr.org.mt/who-we-help-in-malta/persons-of-concern/127-subsidiary-protection)

Current (April 2018) discussion: The Government has decided to reform the current Temporary Humanitarian Protection (THP) and Temporary Humanitarian Protection New (THPN) policy framework. THP granted to unaccompanied minors, on medical grounds, or on other humanitarian grounds will be regulated by law. In the coming months, the Ministry for Home Affairs and National Security will be proposing amendments to the Refugees Act in order to include this form of protection in the law.

Annecdotal evidence suggests that generally migrant health status is similar to the rest of the population in Malta, while Mental health concerns rank higher. Refugees and asylum seekers suffering from mental health problems might lack appropriate services while some may not even be identified owing to the absence of a formal identification process or specialists within the Initial Reception Centers and Open Centres. No specialized services exist in Malta for victims of torture or trauma.

Social determinants like, unemployment, social exclusion, stress regarding lack of legal status, can in addition lead to impairment of personal functioning and increase the risks in acquiring a mental illness in the long run.

Communicable disease (e.g. skin disease, TB etc) were noted; migrants (including from European and Easter European Countries) presenting with chronic disease like diabetes, HIV/Aids will need long term supervision and care and potentially could become a burden for the already stretched health system.

Communication between migrants and service providers, while improved, still needs further attention. Investment in expanding training of cultural mediators is needed as well as a joint strategy in funding and placing the same strategically throughout health centers and community centers in Malta.

Lack of knowledge/information by professional service providers and migrants on entitlements can challenge access to health services for individuals and family members and needs to be adressed systematically.

Gender/Age/Diversity While no detailed information is available on the elderly or migrants living with disability in Malta there seems to be a consensus that unaccompanied minors as well as single mothers and pregnant women would benefit from stronger attention and follow up by Social Support Services.

• • The National Health System Strategy (NHSS) for Malta (2014-2020) states serivce provision for migrants
• • The Maltese Ministry for Health set up the Migrant Health Unit in 2008, which is spearheading the training of cultural mediators and translators since 2009 to facilitate timely and culturally appropriate follow ups on health needs of migrants. The Ministry had also set up, shortly after, the Migrant Health Liaison Office (MHLO) which provides information on health care services available in the country. The office can be found in Floriana, 7, Harper Lane, FLR 1940
• • The recently launched integration policy is a first step in focusing on integration holistically
• • A migration policy document to indicate way forward is available online (See https://meae.gov.mt/en/Public_Consultations/MHAS/Documents/Migration%20Policy.PDF)

Malta has a history of migration. Ensuring a strong focus on integration throughout all policy development will allow for the country to bridge gaps.

Relevant links 2015

Link 1

Link 2

Link 3

Relevant links 2016

Link 1

Link 2

Link 3

Relevant links 2017

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The main challenges in terms of healthcare access and/or health issues of migrants/refugees identified are:

After the approval of the Royal Decree-law 16/2012, migrants, especially undocumented, have faced significant problems to access to health care. Undocumented migrants haven’t got the right to access to health care, and they are obligate to pay for themselves if they need any health service, with only a few exceptions such as minors, pregnant women and medical emergencies.

Furthermore, there is a huge lack of national coordination in migrant’s health care management. Framed on Decree-Law 16/2012, some regional authorities have developed additional residency requirements, trying to avoid the “health tourism” effect, and this is triggering greater rights inequalities among the regions in Spain. For example, Andalucía and Catalonia are two of the six regions providing universal health care, while Ceuta and Melilla are examples of regions with many restrictions.

The main barriers to guarantee health care access and quality in care for migrant population are the high cost of services, the linguistic and cultural differences, the discrimination against migrants, the administrative and bureaucracy obstacles, and the lack of health literacy.

http://apps.who.int/gb/ebwha/pdf_files/EB140/B140_24-sp.pdf

http://www.mipex.eu/spain#/tab-health

Brief description of the legislation concerning access to health care for migrants/refugees

The Royal Decree-Law 16/2012, of April 20th, on urgent measures to guarantee the sustainability of the National Health System and improve the quality and safety of its benefits, that amended Law 16/2003, of May 28th, establishes that the National Institute of Social Security and the Social Institute of the Navy are competent to decide on the condition of insured or beneficiary of the National Health System.

Additionally to what Law 16/2003, of May 28th established, the third article of the Royal Decree-Law 16/2012, establishes healthcare in special situations, allowing that non-registered or non-official resident migrants in Spain will receive public assistance in case of pregnancy, childbirth and postpartum, and in case of being under 18 years, with the same rights as people who hold the condition of insured.

Furthermore, in relation to migrants who are neither registered nor authorized as residents in Spain, the third article of Law 16/2003, of May 28th, establishes that they will receive healthcare in emergency situations due to serious illness or accident, whatever its cause, up to the medical discharge situation. In these situations, migrants have guaranteed healthcare, and everyone has to be cared by public health.

Finally, as an example of regional development of migrant’s health care legislation, the Royal Decree-Law 3/2015, of July 24th, regulates universal access to health care in the Valencian Community. This Decree-Law responds to the situation of sanitary helplessness in which the groups affected by Royal Decree 16/2012, of April 20th were - mostly migrant population in an irregular and socially disadvantaged administrative situation.

The population of Sweden in January 2018 was 10 128 320 people.

In the last two years, many foreign citizens have been granted Swedish citizenship. By 2017, 68,889 people from more than 160 countries became new Swedish citizens, an increase of 14 percent compared with the previous record of 2016. A large part of the increase can be explained by recent years large immigration from Syria. The Syrian citizens were the largest group which received Swedish citizenship, 8,635 people, which is almost double the number compared with the year before (Statistics Sweden,2018).

During the 2000s, the number of asylum seekers has varied widely over the years. However there has been a high increase in the number of asylum seekers in 2015 (See table below). This was followed by a significant decrease in the number of asylum seekers in 2016 and 2017. An explanation for the reduction in recent years is the stricter border controls introduced by the end of 2015. The increasing trend of asylum seekers was therefore broken in 2016 when almost 29,000 people sought asylum in Sweden, which was the lowest number of asylum seekers since 2009. This decrease continued in 2017 when 25 666 people sought asylum, a decline of 11.3 percent or 3 273 people compared with the year before. The majority, six out of ten, of the asylum seekers were men, which was largely unchanged compared with the previous year (Statistics Sweden,2018).

Figure 1: From Statistics Sweden, 2018

In order to immigrate to Sweden, in many cases you need to apply for a residence permit. This does not apply to Swedish and Nordic citizens who have free movement The Swedish Migration Board has different types of applications for residence permits when it comes to migrants from outside the EU. A person with an approved permit for at least 12 months must be registered in Sweden. In 2017 144 489 migrated and were registered in Sweden, of whom 92 225 were from non-EU / EEA countries. The largest group was family-related persons, which accounted for over 40 percent, of which almost half were relatives of previously immigrated refugees. In 2016, refugees were the largest group of migrants, but in 2017 they decreased from 63,300 to 35,400 people. In addition to relatives, the number of granted permits for labour market reasons and studies increased compared with the previous year.

Table 1: Residency according gender and citizenship

The table below shows the number of migrants among the ten most common born countries 2017

The (3) main challenges in terms of healthcare access and/or health issues of migrants/refugees identified are:

• Communication and language barriers
• Organisational or system barriers, issues such as lack of time to care for migrants, inadequate and contradictory information provided by health care givers; unavailability of interpreters at times
• Racism and prejudice

All children have access to health care in Sweden including undocumented children.

Asylum seekers only have access to what is referred to as “vård som inte kan anstå” translated to care that cannot wait/be postponed. There is no common definition to what that care means and this is left to the judgment of the individual care giver