PICUM Expert Roundtable: Access to Sexual and Reproductive Health Services as Part of the Right to Health Care

By Tara Ohl, PICUM Trainee and Alyna Smith, PICUM Advocacy Officer

Among the obstacles undocumented migrants face in realising their fundamental rights are the multiple barriers to access health care, including sexual and reproductive health services.

Most EU member states limit access to emergency care only for undocumented migrants, while a limited number provide access to primary care. Where there is an entitlement to care, it tends to be for specific services – maternal care, or treatment for HIV and other communicable diseases – that are disconnected from any right to access primary care.

To draw attention to states’ duties under international and EU law with regard to the right to health, and the reality as well as the impact of undocumented migrants’ extremely limited access to health services in practice, PICUM launched a report entitled “The Sexual and Reproductive Health Rights of Undocumented Migrants: Narrowing the Gap Between Their Rights and The Reality in the EU”.

Together with Doctors of the World (MdM), International Planned Parenthood Federation (IPPF) European Network and the Center for Reproductive Rights, PICUM also invited key partners to meet in Brussels to discuss challenges needing urgent attention and strategies to address them in order to improve access to health services, generally, and to sexual and reproductive health care in particular, for undocumented migrants.

Photo: Informal Stakeholder Discussion on the Sexual and Reproductive Health Rights of Undocumented Migrants in the EU, Brussels, 27 April 2016. To view more photos of the event, click here.

Sexual and reproductive rights as part of the right to health care

International and European human rights laws are clear: access to sexual and reproductive health services is a component of the right to health. States that deny undocumented migrants access to essential health care act contrary to their international obligations.

Under international human rights law, the right to health means that health services must be available, accessible, acceptable and of good quality. These conditions equally apply to sexual and reproductive health.

All EU member states have ratified international human rights treaties, which guarantee the right to health, and thus to sexual and reproductive health. In addition, the principle of non-discrimination applies in the area of health care, which means that states have a duty to guarantee the right to health for everyone residing within their territory. Restrictions, in law or in practice, that limit access to essential health services on the basis of migration status may breach the principle of non-discrimination.

The contradiction at the national level between law and practice

At the national level, three major hurdles in access to sexual and reproductive rights emerged from the meeting: (1) ignorance, (2) complexity and (2) the lack of a ‘firewall’ – that is, a clear separation between immigration law enforcement and health care provision.

Ignorance – because many undocumented migrants, health care practitioners and health administrators are unaware of undocumented migrants’ right to access health care, even as defined under their own national laws and policies. For example, in Belgium, undocumented migrants are, in principle, entitled to a range of health service under national law. However, lack of awareness on the part of all actors as to what irregular migrants have a right to under the law, and about the many practical steps they must take to gain access to the system, means there is a sizable gap between their rights in theory and their ability to benefit from those rights in practice.

Complexity – because health care systems are often difficult both to understand and to navigate. Health care systems in EU member states are often very bureaucratic and replete with obscure rules, including about who pays the cost of care. In the UK, for instance, the cost of giving birth can range between £2244 and £3282, and in case a longer stay in hospital is necessary after the birth of a child, the cost rises considerably. With constantly changing rules on charging applied to migrants in the UK, undocumented women may be wrongly turned away when seeking maternity care in the hospital setting, or may be burdened with enormous debts for procedures they are charged for afterwards – with implications for their ability to later regularise or renew their migration status.

Complexity can also exist when it comes to the reimbursement of health professionals or of hospitals, and can lead to irregular migrants being turned away.

The lack of firewall – because the absence of a clear separation between health care provision and immigration law enforcement means that the risk – or the worry – of being detained and deported deters undocumented migrants from going to the doctor. This is also why pregnant women do not go for check-ups during their pregnancies or wait until symptoms can no longer be ignored to seek care, leading to higher risks for themselves and for their child. It is true in Germany, where hospital administrations have a duty to denounce migrants who are undocumented to immigration authorities, and where there are reported cases of women being detained or handcuffed in hospital right after giving birth.

Photo: Participants of the roundtable debate.

What next?

As underscored by the meeting’s participants, limiting access to health care to emergencies for undocumented migrants is irrational as a matter of health policy, and unacceptable as a matter of fundamental human rights and medical ethics. These policy and rights deficits are not overcome by carving out entitlements for pregnant women and for certain communicable conditions, divorced from access to primary health services. Such fragmented care denies the critical role of primary care in health promotion and disease prevention, in identifying and addressing health conditions as well as risk factors, before they become emergencies – with costly financial and human consequences.

In light of international obligations of states and the many barriers restricting access to care in practice, what must be done?

Data and information about the stark realities confronting irregular migrants at the national level need to be systematically collected and shared among all stakeholders, including the impact of existing laws and policies on indicators such as maternal and infant mortality.

Health care has to be addressed in the migration debate to effectively challenge existing restrictive policies and the absence of a firewall, to demonstrate the economic cost to health systems, and the human cost to communities and individuals of using the provision of basic services such as health as a tool for migration control.

Fragmentation must give way to integration, which means that well-established evidence on the critical importance of primary care should drive policies that ensure access to integrated care, rather than piecemeal entitlements for specific sub-groups or conditions. Models, such as those used by health practitioners at the University of Ghent, that recognise the role that social factors play in determining health status as well as health outcomes, and therefore include social workers among the specialists assigned to provide assistance and support to patients, should be given greater attention.

PICUM’s report further recommends perhaps the most obvious step: that authorities at the national, regional and local levels reform legislation and policy so that access to health services, including those essential to guaranteeing sexual and reproductive health, are available on the basis of need and not on the basis of residence status. Where entitlements do exist, states should work to address the many bureaucratic barriers that stand in the way of access to care in practice.

Policy makers should remove fear as a barrier by creating a firewall separating the provision of sexual and reproductive health services from immigration control. No one should ever worry that going to the doctor could result not only in being turned away because of one’s administrative, but in one’s arrest and deportation.

Finally, the report also recommends the implementation of measures ensuring undocumented migrants’ access to support and services, in cases where they have suffered from sexual and gender based violence, recognising that the right to sexual and reproductive health encompasses elements of health that extend beyond reproduction.

Ultimately, the only way to guarantee the right to sexual and reproductive health for undocumented migrants is to ensure a fulsome entitlement to health services, including primary health care. External hurdles such as the rise of xenophobia, racism and populist discourse create a less favourable context for the promotion of the rights of undocumented migrants in general. But irrational policies and the degradation of rights of no answer: members of the public should be included in efforts to raise awareness of the situation of irregular migrants, and the damaging effects of their exclusion from health services on individuals and families, as well as social cohesion and our shared values.

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