© Olmo CALVO/ Médicos del Mundo © Olmo CALVO/ Welcoming refugees in Europe Access to healthcare for people facing multiple vulnerabilities in health in 31 cities in 12 countries C : 100 M : 60 J : 0 N : 0 NovemberMédecins du monde - Identité visuelle ANGLETERRE 08/07/2009 2016 TABLE OF CONTENTS 3/ ACKNOWLEDGMENTS 27/ BARRIERS IN ACCESS TO HEALTHCARE 4/ EXECUTIVE SUMMARY Overview 27 5/ 2015 IN FIGURES Giving up seeking medical European survey results (11 countries) 5 advice or treatment 30 Key figures for Turkey 5 Denial of access to care by a health provider 30 Focus: Pregnant women 5 Discrimination in healthcare facilities 30 Focus: Children 6 Fear of being arrested 30 Focus: Violence 6 31/ SELF-PERCEIVED HEALTH STATUS 7/ EUROPEAN NETWORK AND INTERNATIONAL OBSERVATORY 32/ HEALTH STATUS 7/ THE SOCIAL, ECONOMIC Health problems 32 AND POLITICAL CONTEXT IN 2015 Contraception 32 Urgent care 32 10/ RECENT LEGAL CHANGES, Acute and chronic health conditions 33 FOR BETTER OR WORSE Necessary treatment 33 France 10 Patients had received little or Germany 10 no care before visiting our clinics 33 Greece 10 Chronic conditions: Luxembourg 10 no access, no continuity 34 Norway 10 Infectious disease screening 34 Spain 10 Sweden 11 36/ FOCUS ON PREGNANT WOMEN Switzerland 11 Geographic origin of pregnant women 37 Turkey 11 Administrative status 37 United Kingdom 11 Living conditions 37 Isolation 37 12/ 2015 INTERNATIONAL Limiting movements 37 OBSERVATORY SURVEY HIV and hepatitis screening 38 Methodology 12 Access to healthcare 38 Statistics 12 Pregnant women and non-access Limitations 12 to antenatal care 38 Participating programmes 13 39/ FOCUS ON CHILDREN 14/ DEMOGRAPHIC Children and vaccination 40 CHARACTERISTICS Unaccompanied migrant children 40 Sex and age 14 Nationality and geographical origin 14 42/ FOCUS ON VIOLENCE Focus on nationalities in Greece 16 Global figures and Reasons for migration 17 consequences for health 42 Reasons for consulting MdM Experiences of violence in medical history 42 and partner clinics 19 45/ 8 NGOS IN 11 COUNTRIES 19/ ADMINISTRATIVE SITUATION TO SUPPORT MIGRANTS Administrative status 19 IN TRANSIT PROGRAMME Overview 46 Focus on asylum seekers 21 Greece 46 22/ LIVING CONDITIONS Italy 46 Housing conditions 22 Slovenia 47 Social isolation and family situation 23 Germany 47 Work and income 25 48/ CONCLUSION 26/ ACCESS TO HEALTHCARE 49/ ACRONYMS Coverage of healthcare charges 26 49/ AUTHORS AND CONTRIBUTORS 50/ RECOMMENDATIONS 2 / ACKNOWLEDGMENTS First and foremost we would like to thank the 30,534 patients who generously took time to speak with us and respond to our questions about the realities of their lives, the difficulties and pain they have encountered along the way, despite the social and health problems they were facing at the time we met each of them. This report would not have been possible without the contribution of all the coordinators and teams of volunteers and staff from the various Doctors of the World – Médecins du monde programmes and partner programmes: ASEM in Turkey and the Health Centre for Undocumented Migrants in Norway, who collected data as part of the European Network to reduce vulnerabilities in health. This work received support from the Ministry of Health (France), the European Programme for Integration and Migration (EPIM), a collaborative initiative of the Network of European Foundations (NEF) and the European Commission – DG Health and Food Safety / CHAFEA under a grant from the European Union’s Health Programme (2014-2020). The authors of this report are entirely responsible for the content of this document and the content does not necessarily reflect the positions of the NEF-EPIM or partner foundations, Ministry of Health (FR) and DG Health and Food Safety / CHAFEA. The content of this report represents the views of the authors only and is their sole responsibility; it cannot be considered to reflect the views of the European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains. 3 / © Olmo CALVO/Médicos del Mundo © Olmo CALVO/Médicos “Healthy migrant” effect: not always a reality – Athens EXECUTIVE SUMMARY reveals exclusion from mainstream healthcare systems. Within the data collected in face–to-face interviews with over In Europe, 2015 will stay in all our memories as the year where 30,000 patients during 89,000 consultations, we analysed international solidarity with migrants and refugees showed “only” the full interviews, including social and medical data of its strength and weaknesses. This strength was seen in the 10,447 patients seen in 38,646 consultations in 12 countries. thousands of individuals of all nationalities responding to people’s needs and hopes, organising themselves to help; Among those surveyed, 94.2% were foreign citizens, with it was also seen in all the NGOs who concentrated their 24.7% migrant EU citizens and 69.5% migrant citizens of volunteers and staff to provide help all along the migratory route. non-EU countries. Weaknesses were seen in the coordination between individuals Half of patients seen had permission to reside in the country and NGOs, between NGOs, between state initiatives, NGOs where we met them (50.6% in Europe). and individuals. Nevertheless, the solidarity of all these people and organisations worked. And it worked everywhere thanks Multiple barriers to accessing healthcare were described, to the strength and determination of the migrants and refugees including lack of health coverage for 67.5%, need for to survive and live in a protective environment. interpreting for 40.8% and financial barriers for 24.3%. In the previous 12 months, 21.5% had given up seeking medical The real deception came from most European governments, care or treatment, 9.2% had been denied care in a health who were unable to translate this solidarity into reality, facility and 39.6% of the patients without permission to unable to share common rules, in order to provide a positive, reside limited their movements for fear of being arrested. respectful response to the needs of the people fleeing wars, conflicts and life-threatening circumstances. As a consequence, most health conditions had not been treated properly before arriving at MdM or a partner clinic, At the same time, the population in Greece is still afflicted by even if most patients had been living in the host country for the social and economic crisis. And the austerity measures a year or more. In addition, among the reasons mentioned are harsh in their impact on everyday life. As the new for migration, only 3.5% said that they left their country of president of the International Federation for Human Rights, origin for personal health reasons, among others. These Dimitris Christopoulos, said: “The violation of social rights figures show that migration for health reasons is not a reality [education, health, work] resulted in my country […] in an concerning the people we meet and that this myth should be almost systematic violation of individual rights. The austerity erased from political discourse. policies reinforce the idea that social cohesion is not so much an obligation of the state but an act of charity”. Pregnant women still do not have access to perinatal care in Europe, with 43.6% of pregnant women interviewed not able The Médecins du monde (MdM) – Doctors of the World to access antenatal care before attending an MdM or partner International Network’s report Access to healthcare for clinic, 38.9% receiving care after the 12th week of pregnancy people facing multiple vulnerabilities in health, based on and 67.8% having no health coverage and having to pay. medical and social data collected throughout 2015 in 31 cities in 12 countries (Belgium, France, Germany, Greece, Another example concerns children under 18 years old, as Luxembourg, the Netherlands, Norway, Spain, Sweden, unacceptably high levels of non-vaccination were reported: Switzerland, Turkey and the United Kingdom), once more 29.8% for tetanus, 35.8% for hepatitis B virus, 40.0% for 4 / measles, mumps and rubella and 34.4% for whooping 73.7% required necessary treatment cough. Protecting children against such avoidable illnesses 51.1% had at least one chronic condition should be possible everywhere, for all children, all the more that had not received medical attention for those who live in high-risk environments. 54.7% had at least one health problem that Many patients reported experiences of violence, including had never been treated or followed-up violence perpetrated by the police or armed forces for more than 18% in Europe, sexual violence including rape for almost 17.7% perceived their general and their physical 15% of them, and psychological violence for 26% of the health as poor and 19.8% perceived their mental patients. Violent experiences occurred in the country of origin, health as poor but also during the journey and in the host country (particularly BARRIERS TO ACCESSING HEALTHCARE experiences of hunger and psychological violence). There is a significant lack of mental health support in the “host” 67.5% of the people seen in Europe had no countries. These figures show clearly the response needed in health coverage (no coverage or only access to term of protection, security and access to care. emergency care) 40.8% required an interpreter 2015 IN FIGURES 24.3% reported financial barriers 14.2% reported administrative problems