Thematic focus: Healthcare

FRA data on the current migration flows – covering March 2016 – show the great risks to people’s health and lives during their journeys into and then across the EU, as well as the high level of vulnerability among arrivals. Therefore, particular attention is given to the provision of healthcare to newly arrived migrants and persons in need of international protection. As FRA findings show, these people can access healthcare services to varying extents across the EU Member States covered by FRA’s monthly data collection.

This thematic focus examines the healthcare practices in five key areas:

The right to health is a basic social right. The Charter of Fundamental Rights of the European Union (Charter) enshrines the right to healthcare in Article 35, stating that

“[e]veryone 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”.

The Charter’s application is limited to those matters that fall within the scope of EU law. It does not make any distinction on the grounds of nationality, but it does make the exercise of the right to healthcare subject to national laws and practices.

The UN International Covenant on Economic, Social and Cultural Rights (ICESCR), which all 28 EU Member States have ratified, recognises in its Article 12 “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. Core obligations deriving from this right apply to everyone, regardless of status.

Main findings

  • The majority of the EU Member States covered in this data collection conduct health screenings of newly arrived migrants and/or persons in need of international protection. In most cases, health screenings target persons in need of international protection; in a few Member States, they target all newly arrived migrants.
  • In some Member States, the health screening only aims to identify cases of communicable diseases; in a few others, it also serves to identify individual health needs and people belonging to vulnerable groups.
  • The main health issues affecting newly arrived migrants and persons in need of international protection are dermatological infections, respiratory diseases, colds and psychological issues.
  • None of the Member States covered collects systematic data on the health status of newly arrived migrants and persons in need of international protection, nor on their use of the healthcare system.
  • The main challenges identified about healthcare provision at reception centres are:
    • limited entitlements to healthcare;
    • practical/administrative barriers;
    • cost of treatment and/or medicines;
    • limited availability of healthcare professionals;
    • poor sanitation conditions and overcrowded spaces; o a lack of interpreters.
  • Most Member States do not have specific mechanisms in place to prevent violence against women at reception or detention centres.

Initial health screening

According to Article 13 of the Reception Conditions Directive, EU Member States may require health screenings for applicants for international protection on public health grounds. There is, however, no obligation to undertake such screenings. As shown in the following Table, all Member States covered conduct health screenings (Austria, Bulgaria, Germany, Greece, Slovenia, Italy, Sweden, Croatia and Hungary). In most cases, health screenings target persons wishing to apply for international protection in the Member State; in a few Member States they target all newly arrived migrants. There is a legal obligation to offer health screenings in Austria, Germany, Slovenia and Sweden; it is a routine practice in other Member States despite not being legally prescribed. In some countries, such as Germany, the health screening is mandatory.

In Italy and Greece, newly arrived migrants and persons in need of international protection undergo medical screening. In Italy, the government’s roadmap, approved in September 2015, sets out rules for procedures to be implemented to manage arrivals of persons in need of international protection and migrants; it explicitly imposes a health screening upon arrival at ports. In Greece, health screening is conducted for new arrivals after the registration procedure is completed in the hotspots. It is not mandatory and is conducted where necessary.

In the other Member States, there is no systematic health screening of new arrivals. For example, in Austria, during the registration process at the borders, and in Hungary, in the transit zones, the border guards (Austria) and the police (Hungary) refer everyone who explicitly requires medical assistance or shows symptoms of illness to a health professional.

Health screenings of persons in need of international protection and newly arrived migrants
EU Member State Initial health screening
AT Yes, health screening of  applicants for international protection (provided by law)
BG Yes, health screening of persons in need of international protection
HR Yes, health screening of newly arrived migrants
DE Yes, health screening of foreigners who are in a reception or accommodation centre (provided by law)
EL Yes, health screening of newly arrived migrants
HU Yes, health screening of persons in need of international protection
IT Yes, health screening of all newly arrived migrants
SI Yes, health screening of persons in need of international protection (provided in law)
SE Yes, health screening of applicants for international protection (provided by law)

The purpose of the health screening differs between the EU Member States covered in this data collection. Whereas some Member States only carry out a health screening to identify cases of communicable diseases (Germany and Hungary), others use the health screening for several purposes at once (Greece, Italy, Sweden). For example, according to the Greek Ministry of Health, the health screenings aim to provide, where necessary, appropriate therapeutic intervention and to ensure the referral of those in need of medical care to competent health structures. Furthermore, such screenings seek to protect public health against communicable diseases and to ensure the health of third-country nationals arriving without legal documents.

In Bulgaria, the main purpose of the initial health screening of new arrivals is to detect infectious diseases, whereas the health screening of asylum seekers aims to identify needs for further medical assistance. The medical staff ask and look for visible signs of injury or any serious diseases, including infectious and chronic ones.

In some Member States, the health screening is also used to identify vulnerable persons (Bulgaria, Greece and Italy). In Bulgaria, unless such identification requires special examinations, medical personnel ask people if they have any health-related vulnerabilities – chronic diseases, other serious diseases, pregnancy. Regarding arrivals to ports in Italy, all vulnerable people should be identified at the docks during the first health screening. Special attention is paid to children and pregnant women. A healthcare assistance facility set up in Pordenone (Friuli-Venezia Giulia) provides initial health screening for people arriving from Slovenia before they are identified and registered.

In Germany, Hungary, Slovenia and Sweden, the health screening is not part of the procedure for identifying vulnerable persons. In Germany, staff members who work at reception centres are usually tasked to identify vulnerable persons. In Sweden, people with disabilities, pregnant women and victims of post-traumatic stress who are in need of emergency care are often identified by other means. The health screenings work as a way of identifying victims of post-traumatic stress of a less obvious nature.

In Austria, in case the health status of a person requires particular care, the medical doctor provides health treatment and reports special treatment requirements to the Federal Ministry of the Interior, which then tries to meet the person’s demands (such as accommodation for persons in wheelchairs or persons with serious war injuries).

Promising practice – Health screening of applicants for international protection in Sweden

In Sweden, health screening must be offered to all applicants for international protection by the county councils/regions in which they reside. The health screening is offered to identify any health problems relating to the individual, but also as a measure for infectious disease control. The health screening is voluntary and an interpreter can be engaged if necessary. The health screening aims to deliver a medical assessment of what kind of healthcare services should be offered to the person in question. The screening must include questions about the person’s immunisation status, his or her exposure to infections, as well as other information that may be needed to discover any infectious diseases. The questions must be based on the epidemiological situation of the places where the person in question has stayed before arriving in Sweden. The health screening must also include a health dialogue (hälsosamtal) concerning the person’s past and present physical and mental health. A part of this dialogue must concern the person’s psychosocial situation or traumatic experiences. A physical examination and tests must be carried out as part of the health screening. They should be based on the findings from the questions asked earlier and the health dialogue.

None of the Member States covered has adopted standardised health screening forms. In Germany, the Robert Koch Institute has, however, provided a health screening form which the responsible authorities can use.

Only a few Member States then give migrants and persons in need of international protection their medical records. In Slovenia, migrants who are in reception facilities and in detention centres receive their medical records when leaving the centre. In Croatia, migrants also receive their medical records but these are only available in Croatian. This can create potential problems as migrants and persons in need of international protection move to other locations, including other countries. It should be noted, however, that in some Member States EU citizens, alongside newly arrived migrants, do not have easy access to their medical records.

Health status and use of the healthcare system

None of the EU Member States covered collects systematic data on the health status of newly arrived migrants and persons in need of international protection, nor on their use of the healthcare system. A database exists in Germany to collect information on whether the mandatory health screening has taken place and whether a vaccination has been carried out. It does not, however, contain individual health records. The purpose of such a database is to prevent double health screenings and double vaccinations. Furthermore, if a foreigner staying in a reception facility or in an accommodation centre has an infectious disease, there is a legal obligation to inform the authorities responsible for the accommodation of asylum seekers and the Federal Office for Migration and Refugees. Finally, municipalities have to collect data concerning the costs of medical treatments of asylum seekers to be reimbursed by the federal states.

Similarly, in Hungary, medical providers have to send the results of health screenings to the National Public Health and Medical Officer Service. The information provided includes the type and number of performed screenings, the number of positive test results, data about pregnancies and vaccinations, the number of migrants treated in hospitals, and the number of surgeries performed. The data are collected at hospital/medical service provider level. The information shared do not contain personal data, and is mainly conducted for epidemiological surveillance. Similarly, in Greece, systematic health statistics on migrants and asylum seekers for all epidemiological diseases, such as Hepatitis B, are collected by the Hellenic Centre for Disease Control and Prevention.

In Sweden, there are no statistics available at national level on the health status and use of the health system by refugees and asylum seekers. Each county council/region registers the number of health screenings performed and each healthcare unit registers the number of appointments with persons who do not have a personal identification number (personnummer), including asylum seekers. However, the substitute number that an asylum seeker receives during a health screening or a doctor’s appointment may differ between two appointments, making it difficult to use the data collected.

National health authorities and medical organisations working on the ground in the selected Member States identified the following main health issues affecting newly arrived migrants and asylum seekers:

  • dermatological infections and diseases such as lice and scabies (Bulgaria, Germany, Greece, Italy and Sweden), and fungal skin infections (Bulgaria), usually caused by poor hygiene during the journey and/or in reception and detention facilities;
  • respiratory diseases (Bulgaria, Slovenia and Sweden), particularly among children;
  • flu and colds (Austria, Bulgaria, Greece, Hungary and Slovenia);
  • psychological and psychiatric disorders and post-traumatic stress (Germany and Sweden);
  • dental problems (Slovenia and Sweden);
  • gastrointestinal diseases (Greece and Italy).

Cases of tuberculosis were reported in Austria (during the first month of arrivals) and in Germany where they mainly concern children. Physical trauma (such as fractures) was frequently reported in Italy.

A few countries reported specific health problems affecting migrant children. While migrant children in Greece are mainly suffering from gastrointestinal diseases and the common cold, they are predominantly affected by respiratory infections in Bulgaria. In Germany, malnutrition and tuberculosis are reported as the main health issues among children. About 10 %-20 % of unaccompanied children are traumatised. Furthermore, children often suffer from nervousness and a feeling of restlessness. In Hungary, migrant children are at high risk of infections due to the poor hygienic conditions during their journeys and the lack of mandatory vaccinations. The authorities also find it difficult to confirm whether a child has been vaccinated or not and against which diseases. In Sweden, Syrian children are reported to have mostly good immunisation, while children from Afghanistan (usually unaccompanied) do not know if they are vaccinated and against which diseases.

Maternity care is an issue in some of the EU Member States covered. In Sweden, maternity healthcare units are put under severe strain as they have to conduct all antenatal tests that pregnant women could not carry out earlier in their pregnancies in a short period of time. There is an increase in early labour and complicated childbirths in Sweden as well as in Greece. In Hungary, the authorities occasionally identify unwanted rape-related pregnancies among migrant women.

Healthcare in first reception and detention facilities

According to Article 19 paragraph 1 of the Reception Conditions Directive, EU Member States shall ensure that applicants for international protection (asylum seekers under the EU asylum acquis) receive the necessary healthcare which shall include, at least, emergency care and essential treatment of illnesses and of serious mental disorders. Additionally, Member States shall provide necessary medical or other assistance to applicants who have special reception needs, including appropriate mental healthcare where needed (Article 19 paragraph 2).

With regard to detention, Article 14 (b) of the Return Directive prescribes Member States to ensure that emergency healthcare and essential treatment of illness are provided to third-country nationals during the period prior to a voluntary return and during the periods for which removal has been postponed. According to Article 16 (3) of the same directive, Member States have to pay particular attention to the situation of vulnerable persons in pre-removal detention.

Ensuring timely access to screening and treatment also has cost saving effects on the healthcare system, as FRA’s 2015 report on the cost of exclusion from healthcare shows.

A number of challenges were reported about the provision of healthcare in reception as well as in detention facilities. The following challenges were identified in reception facilities:

  1. Limited entitlements to healthcare: In some Member States, such as Slovenia, asylum seekers are only granted access to emergency healthcare. Similarly, in Croatia, all treatment beyond emergency, including antenatal examinations for pregnant women, have to be paid for by the asylum seekers themselves.
  2. Practical/administrative barriers when accessing healthcare. In Italy, asylum seekers are entitled to the same healthcare as nationals. However, to access to the National Health Service, asylum seekers need to have a residence address. Unfortunately, not all reception centres can provide it.
  3. Cost of treatment and/or medicines has been raised as a problem in some Member States. In Bulgaria, when asylum seekers have to undergo specific treatments such as surgery, funds have to be sought from NGOs and other sponsors to pay for the cost of treatment. In Italy, asylum seekers and refugees accommodated in reception centres have access to the National Health Service and are exempted from payment of healthcare fees on the basis of their financial situation on the same grounds as nationals. However, the implementation of the exemption from payment of healthcare fees encountered some difficulties due to several legal issues. The Ministry of Health has not yet issued any new guidelines or circular letters, and a range of different practices are observed across regions. In Sweden, asylum seekers with scabies cannot afford to pay for their treatment since the required medicine is not a prescription drug.
  4. Limited availability of healthcare professionals at reception centres was raised as an issue in Germany, Greece and Slovenia. In Germany, for instance, it is difficult to find health professionals and voluntary staff working at weekends. In some reception facilities, only voluntary health staff are available.
  5. Poor sanitation conditions and overcrowded spaces have been reported in Germany, Greece and Sweden. In Sweden, overcrowded reception facilities have led to assaults and in some cases to violent deaths. According to the Swedish Police, the violence rate indicates that some centres are not suitable for vulnerable persons, especially because the police may have to travel long distances to reach a specific accommodation if they are asked to intervene. In Germany, there are poor sanitary conditions in many mass reception centres. In addition, there is often a lack of space to ensure appropriate medical treatment.
  6. Lack of interpreters has been mentioned as an issue in Austria, Slovenia and Sweden. In Austria, For instance, the provision of translation during asylum seekers’ visits to hospitals, general practitioners or specialised doctors poses a problem. NGOs are financially unable to provide this service for all asylum seekers, but try to find solutions in severe cases. In Sweden, a lack of trained interpreters has been reported.

An additional challenge identified in Bulgaria is the unwillingness of newly arrived migrants to undergo medical treatment or allow treatment of their children due to their wish to leave the country immediately.

Only a few Member States reported specific problems concerning access to healthcare in detention facilities. In Italy, two recent reports identified a number of challenges: it is often difficult for detainees to have access to specialist healthcare assistance outside the centre (i.e. in local hospitals or clinics) because, on the one hand, there are no protocols in place with local health authorities and, on the other, detainees’ transport to hospital facilities is discouraged by the management of the centre because it is expensive and has sometimes provided detainees with the opportunity to flee from the centre. Another problem is that detainees are not provided with adequate information on their right to access primary healthcare, although Italian law grants this right to irregular migrants. In Hungary, civil society organisations have raised concerns regarding healthcare provided in alien police detention facilities (e.g. Nyírbátor) where, despite a general health service being available 24-hours a day, only a basic medical service is provided. Serious medical conditions of detainees are treated with significant delays or not at all.

It has been reported that health professionals are present on a regular basis at the detention centre in Slovenia. In Austria and Sweden, no particular challenges were reported regarding healthcare in detention facilities. No information on access to healthcare at detention centres in Bulgaria, Croatia and Germany was made available. 

Vaccination of children

In Sweden, a national regulation prescribes the vaccination of all children – including asylum-seeking children – for measles (German measles), mumps and rubella, known as MMR, polio, diphtheria and tetanus. Only Hepatitis B is not included in the mandatory national immunisation programme.

In Austria and Germany, vaccinations are not systematic as they are not mandatory. In Germany, however, asylum seekers have the right to receive vaccinations and there are enough vaccines available. Vaccines are provided for MMR, polio, Hepatitis B, diphtheria and tetanus.

In Hungary, children receive vaccinations specific for their age, and vaccines are available and provided for MMR, polio, Hepatitis B, diphtheria and tetanus. In Bulgaria, as a general practice at the reception, registration and pre-removal centres, children may be vaccinated only if their medical file with data concerning previous vaccinations is provided.

During periods of mass influx of migrants, Greece and Slovenia did not identify children in need of vaccination, and vaccines were unavailable. In Slovenia, however, the situation seems to have improved since newborn babies in need of vaccination, who were referred to local community healthcare centres, are now automatically vaccinated. Also, children accommodated in asylum homes are vaccinated before starting school and have, in this regard, the same rights as Slovenian citizens.

Measures to prevent and address violence against women

Most of the EU Member States do not have specific mechanisms in place to prevent violence against women at reception or detention centres. The most common measure to address the special needs of women at reception facilities is to provide separate accommodation for single women (Austria, Germany, Hungary ), sometimes equipped with an intercom in case of emergency (Slovenia ). Alternatively joint accommodation with unaccompanied children is provided (Slovenia ). In Greece, there is one detention facility exclusively for women, while in Italy, only one detention facility has a female section.

In Hungary, women may also be separated from their husbands upon request. The majority of the reception and detention facilities in the country operate a 24-hour camera surveillance system, and security guards are always on duty. Social workers in the open reception facilities and at the detention centres are also trained to identify signs of abuse against women. In Austria, workshops on ‘Austrian values’ are offered to asylum seekers in reception facilities as a way of preventing violence against women.

Identification of potential cases of violence against women takes place during the first interviews with female asylum seekers in Austria, and during the health screening and accompanying dialogue in Sweden. Proactive identification efforts are particularly important considering the generally low reporting rates by women on incidents of violence, shown in FRA’s survey on violence against women.

Some Member States reported the existence of complaint mechanisms at reception centres. A mechanism to report sexual violence against women, called the ‘standard operational procedure’, is in place in Bulgaria, but no complaints have been received so far. In Slovenia, complaint mechanisms are in place in a reception facility (Asylum Home) and at a detention centre (Centre for Foreigners). In Germany, there is no obligation to provide complaint mechanisms in reception facilities for victims of violence against women, and as a result such mechanisms exist only in a few places.

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Monthly data collection on migration situation - April 2016

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