Within the framework of the United Nations, immigrants are considered as a vulnerable group of the population, is especially subject to a different set of vulnerabilities, such as the access to healthcare services. Health is a central aspect of individual and collective life. Thus, to think in the integration process of immigrants necessarily encompasses health. The socioeconomic inequalities that are associated with contexts of poverty, social exclusion, and precarious employment situations can be translated into reduced opportunities to access healthcare services. Despite Portugal have opted for a universal health system that covers all people, including a regulation that allows immigrant’s access to healthcare services, inequalities still persist. Using the revision of literature, Portuguese official documents, and specific determinants of health, we identify immigrant’s main constraints regarding the access to healthcare services in developed countries, such as Portugal, and then we propose good practices and intervention methods to reduce the vulnerability of immigrants and, at the same time, allow them to achieve better living conditions.
Keywords: Good Practiceshealthcare servicesimmigrationPortugalsocial inclusionvulnerability
Immigrant population is currently considered one of the major challenges worldwide, appearing as a source of reflection for most countries. In this context, there is a recognized need to understand immigrant’s population and its vulnerabilities, especially in the health sector. This article aims to identify immigrants as a vulnerable group of the population; analyse immigrant’s main constraints regarding the access to healthcare services in Portugal, and to propose good practices and intervention methods that can contribute to reduce immigrant’s vulnerabilities in the access to health services in Portugal and, at the same time, to promote their social integration.
Immigrant’s access to healthcare services continues to be an under-researched area. Given the increasing presence of immigrant’s groups in our societies, governments are challenged to adopt policies, strategies and good practices to promote their social inclusion in all sectors, and especially in the health sector. Providing easily accessible and quality health services to immigrants simultaneously contributes to social inclusion and protects the health of host communities. Thus, addressing this challenge and turn health systems more inclusive, is critical to health security. This is also defended by the 2030 Agenda for Sustainable Development with the principle “leave no one behind”. The achievement of the health target 3.8 Universal Health Coverage requires evidence-based inclusive policies that facilitate access to equitable and quality health services by immigrant’s groups.
Looking to international and national literature and Portuguese official documents, especially from the Health Ministry, our study is oriented by the following research questions: are the immigrants a vulnerable group of the population? What are the immigrant’s main constraints in the access to healthcare services in Portugal? What good practices and intervention methods can be developed to reduce immigrant’s vulnerabilities?
The article is divided into three parts. In the first part, we identify immigrants as a vulnerable group of the population. Then, we analyse their main constraints regarding the access to healthcare services. And finally, in the third part, we propose good practices and intervention methods to reduce immigrant’s vulnerabilities in the health sector and, at the same time, allow them to achieve better living conditions. We then conclude that there are several aspects of the management of healthcare services in Portugal that can be better adapted to the immigrant population and contribute to its social inclusion.
This work raises the problem of immigrant’s access to healthcare services in developed countries such as Portugal and, by extension, in the countries of the European Union. It is, in short, a conceptual and essayistic approach, assessing the legal and institutional references that raise the consideration of the right to access healthcare services by the immigrant’s population, in a time of profound economic, social and cultural changes within the framework of Europe. In this article we purpose good practices and some intervention methods that can contribute to reduce immigrant’s vulnerabilities in the health sector and, at same time, promote their social inclusion.
This study is oriented by the following research questions: are the immigrants a vulnerable group of the population? What are the immigrant’s main constraints in the access to healthcare services in Portugal? What good practices and intervention methods can be developed to reduce immigrant’s vulnerabilities?
Purpose of the Study
This study aims to propose good practices and intervention methods that can contribute to reduce immigrant’s vulnerabilities in the access to health services in Portugal and, at the same time, to promote their social integration. To achieve this purpose, we divided the article in three parts. In the first one, we identify immigrants as a vulnerable group of the population. Then, review the literature and several official studies, we analyse their main constraints regarding the access to healthcare services in Portugal. Finally, in the last part we purpose good practices and intervention methods that can promote immigrant’s social inclusion.
The set of reflections that are exposed in this paper have in common an essayistic and qualitative approach. It looks to international and national literature about immigrant’s access to health care services to take some conclusions regarding their main constraints in Portugal. Within this literature we mention some authors and their quantitative studies concerning specific characteristics of immigrant’s groups, such as their nationality. Although it was not our purpose to focus these nationalities, this literature was important due to their findings and conclusions, and in order to defend our point of view in the Portuguese case. We also used Portuguese official documents, especially from the Health Ministry to obtain some important data and conclusions regarding the issue.
Vulnerabilities of the immigrant population
The World Health Organization (WHO, 1946, p. 1) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The preamble to the WHO constitution stipulates that it is a fundamental right of every human being, without any form of distinction or discrimination, to be able to enjoy the highest attainable standards of health (Idem).
Health is the result of a complex network of determinants involving, biological and genetic (Gravel & Battaglini, 2000), psychological and social factors, but also, lifestyles and behaviours, and physical, socioeconomic and cultural environment. In this context, several studies defend that socioeconomic conditions, such as social position, access to the consumption of goods, participation in the labour market, values and norms and access to information explain the health and the well-being of the immigrant (Bäckström, 2006, 2010; Germov, 1998; Organización Internacional para las Migraciones, WHO & Oficina del Alto Comisariado de los Derechos Humanos de Naciones Unidas, 2003).
Within the framework of the United Nations, immigrants are considered as a vulnerable group of the population, subject to a different set of vulnerabilities, such as the access to healthcare services (UNDP, 2014; UNHCR, 2016). According to Mustaniemi-Laakso et al. (2016), although the term ‘vulnerability’ is frequently used in legal and political rhetoric, as a legal concept it remains ambiguous and even contested. In the human rights setting the concept generally refers to groups and persons that ‘require special attention to ensure that they enjoy their human rights, because their perspectives are not automatically included in the actions and thoughts of dominant groups’, that is, ‘the people whose rights are most at risk of being violated’ (Timmer, Majtényi, Hausler, & Salát, 2014, p. 10). This is the case with immigrants, who are exposed to multiple factors that cause or accentuate vulnerability and, sometimes, even subject to prejudice and stigmatization, as well as social disadvantage and material deprivation.
Today, this vulnerability is even being expanded due to the increasingly negative social and political discourse about immigrant’s groups. There has been a rise of anti-migrant sentiment and restrictive policies, and a decreasing public confidence in governments’ ability to manage immigrant population and promote their social inclusion (WHO, 2017, p. 22).
Despite the growing research in this field, there is still a lack of data on the accessibility, use, and adequacy of healthcare services, as well as on the satisfaction of the population of immigrants in healthcare services and on possible problems in the health system. As evidenced by several authors, despite the scarcity of information, research and available health indicators seem to indicate that migrants are more vulnerable to diseases or other health problems (ERS, 2015, p. 15; Matos, Alarcão, Lopes, Oiko, & Carreira, 2015). In fact, many features can influence immigrant’s health, such as life conditions, work stress, adaptation to a new society, and even the travel, when this involves danger. Moreover, the socio-economic inequalities that are associated with contexts of poverty, social exclusion, and precarious employment situations can also be translated into reduced opportunities to access healthcare services by the immigrant’s population (Lussi & Marinuci, 2007, p. 9). Thus, thinking in the integration process of immigrants in a society necessarily encompasses health and the access to healthcare services.
Immigrants access to Healthcare Services
The majority of migrants deals with difficulties in a number of issues, such as lack of information, lack of knowledge of rights and duties, lack of health care coverage and of documents, in case of irregular situation, language barriers and administrative and bureaucratic barriers.
Assuming that immigration is recognized internationally as one of the challenges to public health, some governments and non-governmental institutions have been increasingly concerned about the need to formulate policies and programs, as well as good practices, which can address inequalities in the access to healthcare by regular and irregular immigrants (Organización Internacional para las Migraciones, WHO & Oficina del Alto Comisariado de los Derechos Humanos de Naciones Unidas, 2003; European Union Agency for Fundamental Rights (EUAFR), 2011). At this purpose, the World Health Organization (ERS, 2015, p. 14) have identified four principles that public health should consider in promoting the inclusion of immigrants in the host country:
1. to avoid disparities in health status and access to health care between migrants and the host population;
2. guarantee the right to health of migrants;
3. reduce the mortality and morbidity of migrant populations;
4. minimizing the negative impact of the migration process.
But, although these principles, access to healthcare is often still limited and conditional in many countries (Siriwardhana, Roberts, & McKee, 2017). This is particularly relevant in times of economic crisis, where the scarcity of financial resources puts pressure on health systems and health policymakers.
Currently, immigrant’s main constraints in access to healthcare services in developing countries are:
the lack of information regarding bureaucratic formalities
the difficulty in understanding/using the language of the host country
the lack of individuals with competence in the area of the mother tongue of these populations
the lack of habits in using health services
the establishment of a poor interpersonal relationship with health professionals
the clandestine status and the fear of being reported to the authorities (Fonseca, 2005; Estrela, 2009).
The ‘accessibility’ is a broad concept covering many diverse phenomena, and according to Ingleby (2009) the barriers to access healthcare services fall sometimes into what he defines as “institutional discrimination” (p. 11). This occurs when the system and the procedures are defined considering only the nationals need and not the needs of the different groups that coexist in the community (Ingleby, 2009, p. 13).
Immigrants access to Healthcare Services in Portugal
Legally, in Portugal immigrants have the right to access healthcare services. Portuguese Constitution (República Portuguesa, 1976) establishes the right to health and health protection for all citizens (art. 64), provided by the National Health Service. However, universal systems are being questioned regarding its sustainability. We cannot disregard the fact that, since 2011, Portugal has passed through a very delicate crisis situation involving austerity measures and drastic cuts in wages, pensions and public services, including health services, with obvious consequences in vulnerable groups such as the immigrants.
Thus, although the law ensures access to the National Service of Health, many migrants deal with difficulties in accessing public health services, obtaining a user card or even paying the fees (Chauvin & Parizot, 2007; Estrela, 2009; Padilla, 2013). According to several studies (ERS, 2015; Matos et al., 2015; Padilla, 2013), immigrant’s main constraints in Portugal, regarding the access to healthcare can be ordered in six major features: legislative, economic, structural, organizational, cultural and linguistic barriers. Legislative barriers, due to, on the one hand, the limitation of specific situations for the provision of healthcare and, on the other hand, the knowledge of the legislation and/or its applicability by the health professionals. In addition, health professionals and administrative staff often also encounter linguistic and cultural barriers that may also condition access to information and use of healthcare services (Dias, Gama, Cargaleiro, & Martins, 2012; ERS, 2015). Moreover, immigrant’s attitudes and behaviours in the response to sickness are strongly conditioned by their socio-cultural contexts. Thus, the lack of knowledge regarding these cultural specificities can also constitute a barrier in the access to healthcare services. Other significant features are the economic and financial constraints, as well as the high bureaucracy organizational structure that affects the adequacy and/or effectiveness of responses to the health needs of immigrant populations (ERS, 2015).
Furthermore, from the immigrant side, there are also barriers in the access to healthcare services, such as the unstable and precarious employment situation, the difficulty in obtaining social protection and the cost associated with health care. Linguistic and cultural barriers can also constitute an obstacle to seek healthcare services (ERS, 2015). Additionally, other difficulties can be considered here, such as lower socio-economic levels, poor housing conditions, reduced incomes, precarious jobs, psychological stress associated with social exclusion and the absence of support networks, all related to health, contributing to the unfavourable situation of this population group.
Using the list of good practices suggested by the European Regional Committee of the World (WHO – Europe) (Matos et al. 2015, p. 166), regarding the provision of health services to immigrant’s population, and applying it to the Portuguese case, we underline the following, as being the most important:
monitor the accessibility and quality of the provision of health services to the migrant population
identify and analyse problems, create solutions and assess their effectiveness
reduce language barriers and administrative barriers
increase cross-sectoral cooperation with other services
involve immigrants in the design, implementation, monitoring, and evaluation of health services
These good practices are in conformity with the ethical objective of preventing discrimination and exclusion, as well as assuring the promotion and the protection of human rights to all citizens. Article 35 of the Charter of Fundamental Rights of the European Union (2000) states that everyone has the right of access to preventive healthcare and the right to benefit from medical treatment under the conditions established by national laws and practices. Portugal as a member of the European Union is compromised with the defence of values such as equal opportunities, social justice, and solidarity. Thus, the adoption of policies and strategies in conformity with these good practices is essential.
Access to healthcare is a crucial component of a person’s fundamental right to health. This means that societies are obliged to provide accessible, appropriate and effective services to all individuals, in order to promote social inclusion. In this context, one intervention method that we purpose to reduce the vulnerability of immigrants in the access to healthcare services will be to promote a joint action between state and civil society organizations regarding the implementation of good practices. Share lessons learned, good practices, and research on immigrant’s access to healthcare services, will allow to identify gaps, opportunities and new challenges. Another approach that we suggest requires considering ‘health’ in all governmental policies (education, housing, gender, employment, science, and technology…). This will allow a truly comprehensive approach to the problem. A third intervention method is related with the construction of citizenship, specifically, with the ‘health citizenship’, which means the increasing involvement of the citizen (in the broad sense) in assuming more responsibilities regarding health. As Ingleby (2009) argues at this purpose: “it is necessary for migrants … to learn how people in the host society think about health, how the health care system is structured, and what the formal and informal ‘rules of the game’ are for both staff and patients” (p. 10).
In our final considerations, we underline the implementation of comprehensive social policies to promote immigrant’s social inclusion. Building on partnerships between governmental and non-governmental institutions in the community and adopting preventive strategies, we can contribute to the effective integration of immigrants in our societies, in order to combat stigmatization, discrimination, and vulnerability associated with these populations.
One of these strategies is to improve access to healthcare for all individuals, regardless their legal status. Likewise, a greater participation of people of different ethnic origins in the health services could help to prevent discrimination and facilitate their use by immigrant’s groups. Particular attention should also be paid to health education, with a focus on the younger population, aimed at the prevention, in order to change attitudes and risk behaviors, and promoting healthy lifestyle habits.
Finally, because the lack of knowledge by the healthcare providers, together with the stereotypes associated with it, it becomes necessary to implement the training and education of healthcare professionals in the area of ‘multiculturalism’, to raise their awareness about the importance of cultural diversity. In a global approach, this means a better adjustment and adaptation of health services to the existence of an increasing immigrant population within society and the need to promote its social inclusion.
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09 April 2019
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Multicultural education, education, personal health, public health, social discrimination,social inequality
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Marfil-Carmona, R., & Cierco*, T. (2019). Immigrant’s Access To Healthcare Services. The Portuguese Case. In E. Soriano, C. Sleeter, M. Antonia Casanova, R. M. Zapata, & V. C. Cala (Eds.), The Value of Education and Health for a Global, Transcultural World, vol 60. European Proceedings of Social and Behavioural Sciences (pp. 168-175). Future Academy. https://doi.org/10.15405/epsbs.2019.04.02.21