Improving access and combating discrimination in healthcare with a focus on vulnerable groups: FRA facts

Speech by FRA Director at the European Health Forum Gastein (EHFG) conference on 3 October 2013.

Ladies and gentlemen,

Thank you for the opportunity to address you today. To frame our discussion, I would like to present the facts, drawing on results from work carried out by the EU Agency for Fundamental Rights focusing on:

  1. health inequalities in the EU;
  2. universal health coverage; and
  3. barriers in access to healthcare.

But before that, let me first set the scene. Health is a fundamental human right, for every man, woman and child and is recognised in international and European human rights instruments, and national laws. Human rights are for all, irrespective of citizenship, residence permit or passport -  the passport to rights stems from the fact that you are a human being.

When focussing on the right to health it should be mentioned that the International covenant on economic, social and cultural rights underscores that States have the duty to address the underlying determinants of health, such as access to clean drinking water and adequate sanitation, as well as healthy occupational and environmental conditions. States also have an obligation to grant equal access to healthcare to all, especially vulnerable or marginalized groups of society. In Europe, the EU’s proposed Horizontal Directive will address this by extending protection against discrimination to healthcare on such grounds as disability, age and sexual orientation.

1) Let me first address health inequalities in the EU.

Fact: People with lower educational levels, job status or income often die younger and are sick more often. Subcategories here include migrants, ethnic minorities and people with disabilities. Often they live and work in poorer conditions, their work is more manual and they receive poorer quality healthcare. This can create health inequalities even in comparison to those from the majority population living under similar socio- economic conditions.  

For example: FRA surveyed the situation of Roma, Europe’s largest minority. What did we find? One third of respondents aged 35 to 54 reported health problems limiting their daily activities. This can affect the chance of finding, or being in, paid work. To put it in perspective, in Italy seven times more Roma than non-Roma report limitations due to health. A pattern we found reflected in other countries.

Let me give you another survey example: Roma women, aged 50 and over, said that they suffer in daily life due to injuries, diseases and other health problems. As problems generally increase with age, this is particularly worrying. Perhaps even more worrying are the inequalities that we found: 79% of Roma women over 50 in Poland suffered limitations due to health compared to 48% of non-Roma women living nearby, in basically the same socio-economic conditions. Again we found the same in other countries.

The EU’s Health Strategy aims to remove health inequalities by closing health gaps. This means paying more attention to the needs of less advantaged people by providing healthcare, but also by tackling the social determinants of health: improving living and working conditions such as better sanitation and housing renewal.

This calls for reliable health statistics including the collection and use of disaggregated data. For instance, data on the health status and access to healthcare among ethnic minorities and people with disabilities is not yet collected systematically. This will help create more targeted strategies.

2) This brings me to my second point, universal health coverage.

Fact: The World Health Organisation believes that universal coverage improves population health overall as also shown by scientific evidence.

In terms of universal health coverage, FRA looked at two groups not covered in some Member States:

  • About 20% of Roma in our survey reported that they are not covered by medical insurance or do not know if they are covered.
  • According to research in 2011, irregular migrants in 19 out of 27 EU Member States are only entitled to emergency healthcare. In 11 of these 19 countries they must pay for emergency healthcare. Not only will they be billed, but often healthcare providers require proof they can pay before treating. This may lead to casualties, even death. We found a case in Brussels where an irregular migrant used to borrow a friend’s medical card to go to hospital. When she was later treated in hospital after a serious car accident, she died following a blood transfusion. Why? Wrong person meant wrong blood group.

Providing access to necessary healthcare to irregular migrants is a public health measure and a human rights obligation. But it can also save costs. Cost effectiveness is one of the main issues in the current debate on access to necessary healthcare for irregular migrants, especially in today’s economic climate of healthcare cuts where people often need more support not less.

FRA research has shown that a lack of evidence on the financial implications of delaying treatment of irregular migrants is blocking policy makers from promoting access to healthcare for this group. FRA has been assessing whether delaying treatment until a health condition becomes an emergency is more expensive compared to a timely intervention. We looked at hypertension and prenatal care. As you know, hypertension, when left untreated leads to cardiovascular disease. And no or delayed prenatal care can result in premature births often requiring medical support. The provisional results show that access to necessary healthcare for irregular migrants saves costs. In the short term it can be cheaper to treat hypertension rather than treat victims of strokes. This further supports the argument that healthcare access should also extend to access to primary healthcare.

3) Which leads me to my final point, barriers in access to healthcare.

Fact: Even when entitlement to healthcare exists, the systems may create barriers in access to or quality in healthcare – often unintentionally. These barriers impact all groups that are protected by anti-discrimination law such as people with disabilities and ethnic minorities.

FRA research has shed light on the barriers which affect minority groups. Take the case of communication barriers. People with an ethnic minority background, for example, may be treated the same way as a country national. But, if they cannot properly communicate because of language, and a lack of interpretation, they may receive inadequate treatment, including a wrong diagnosis. Or informed consent may be rendered meaningless.

For people with disabilities accessibility is a key issue, acknowledged by international conventions as being central to the right to health. For example, the UN Convention on the rights of persons with disabilities, which most EU countries have ratified, sets out wide-ranging obligations for States Parties to ensure accessibility, including medical facilities.

FRA research has also identified stereotyping and degrading treatment in the healthcare system towards members of our society. For example:

  • In our EU LGBT survey, over 93,000 lesbian, gay, bisexual and transgender respondents gave us an indication of what their life is like. 10% of respondents felt discriminated by healthcare personnel in the past year. For transgender respondents discrimination was twice was high. And those who were open about being LGBT with medical staff were more likely to experience problems than those who hid their LGBT identity.
  • We also carried out research on multiple discrimination in healthcare. This ranged from delayed, refused or undignified treatment including discriminatory stereotyping to malpractice, and lack of informed consent, including involuntary treatment. For example, older members of migrant or ethnic minorities are often suspected of feigning health problems just to receive benefits. And Muslim women are sometimes considered too poorly educated to understand and communicate their health problems. Same-sex couples often find difficulties in finding old age care facilities that are willing to host them.

Healthcare providers insist everyone is treated equally under their Hippocratic oath. Nevertheless they are sometimes reluctant to acknowledge that healthcare providers and systems might contribute to discrimination. 

In conclusion,

The facts speak for themselves: discrimination and unequal access in healthcare is a reality for many across the EU. This needs to be acknowledged if we want to further reduce health inequalities and address the needs of vulnerable groups.

Thank you.